Saving Normal

Mental health and what is normal.

Don’t People in Chronic Pain Have Enough to Deal With?

A mental disorder diagnosis is adding insult to injury.

Chronic pain is part of the human condition. Our backs didn't have enough evolutionary time to make the full engineering adjustment to upright posture- so low back pain is endemic. Because our ancestors didn't often live beyond age 40, natural selection didn't protect us from the pains that so often come from aging- especially arthritis. And until recently, people usually died from diseases rather than living with them- often in pain.

Surveys suggest that between 20-30% of adults in the general population experience chronic pain, with rates higher for women and rising as we age. Having pain and being worried about having pain is part of normal, expectable life- an inevitable cost of our medically assisted longevity. Now DSM-5 wants to make it a mental disorder.

I have asked Dr. Michael Negraeff to discuss the problems this will cause because he understands pain from every perspective- as an anesthesiologist at Vancouver General Hospital; as a chronic pain patient; and as Chair of Pain BC, a non-profit organization composed of health care providers, people in pain, and health care advocates all dedicated to reducing the burden of pain in British Columbia, Canada.

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Dr. Negraeff writes: "The new DSM-5 diagnosis of “Somatic Symptom Disorder (SSD)” adds an insult to the injury ready experienced by the millions of people suffering the severe hardship of chronic pain."

"Chronic pain can occur after injury, surgery, or a medical illness and can persist for years (or a lifetime). Worldwide, pain is one of the most significant causes of suffering, disability, and impairment."

"To make matters even more difficult for patients, chronic pain often has no external sign or visible symptom; they may appear to be 'fine' to family, friends, and health care providers- despite significant pain and very real disability."

"The skepticism and stigma around this invisible disease can cause feelings of extreme isolation, frustration, hopelessness, and result in a worse quality of life than with other chronic diseases"

"People living with persistent pain are four times as likely to attempt suicide as the general public- no surprise considering they are faced with daily suffering, the breakdown of relationships, the potential for addiction, the loss of productivity and purpose, and the risk of impoverishment."

"The over-inclusive and misguided DSM-5 definition of SSD will harm tens of millions of people in chronic pain by mislabeling their physical problems as psychological. The harmful implications are clear- stigma and inadequate evaluation and treatment. Patients will be dismissed and told that their pain is “all in the head,” best described as a mental disorder. A convenient dodge for clinicians frustrated by hard-to-treat chronic pain conditions, but hurtfu and harmful to his patient.

SSD will apply both to pain arising from well described illnesses (eg diabetes or cancer) and also to conditions with less clear etiology (eg fibromyalgia, irritable bowel syndrome, and migraines)".

"All that is required for an SSD diagnosis is the clinician's subjective, fallible, and inherently unreliable judgment that the patient is having disproportionate thoughts or about the seriousness of the pain, displaying a high level of anxiety about health, or devoting excessive time and energy to their symptoms".

"To those familiar with the experience of people in persistent pain, these are not signs of a mental disorder, rather, they are normal reactions to living with a chronic, painful condition shrouded in skepticism and misunderstanding."

"Shouldn’t our efforts be put towards pain management rather than on providing clinicians with excuses for not taking their patients’ suffering seriously?"

Thanks Dr Negraeff for your excellent advice. It is important that your message be spread as widely as possible. It should scare the living daylights out of anyone who has a medical disorder and doesn't want to be tagged with an inappropriate label of mental disorder.

I am grateful that the British Medical Journal last week published and widely publicized a warning piece that I prepared with the help of Suzy Chapman of Dx Revision Watch that advises clinicians to simply ignore SSD and recommends that it be dropped in ICD 11. http://bmj.com/cgi/content/full/bmj.f1580

DSM 5 represents a wholesale, imperial medicalization of normality. So many new and untested diagnoses; so many reduced thresholds for the old ones. Pretty soon everyone will have a diagnosis and many will have a whole bunch of them.

It makes no sense to turn pain into a mental disorder.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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