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Psychiatry
DSM-5 Has Gone to Press Containing a Major Scientific Gaffe
The APA declined to correct the error despite multiple warnings.
Posted February 8, 2013
When DSM-5 is published three months from now, in May, it will contain at least one major scientific gaffe. The Trustees of the American Psychiatric Association voted to include a definition of Somatic Symptom Disorder (SSD) so broad and over-inclusive, it is certain to include medical patients with an outsized concern about their health, as well as those merely vigilant in trying to maintain it.
Stranger still, and just as perplexing, the APA decided to send DSM-5 to press in full knowledge that the manual contained that glaring, sweeping error. Former DSM editor Allen Frances joined a chorus of psychiatric and medical experts in warning, from the results of the APA’s own field trials, that the newly expanded and renamed disorder would mislabel as mentally ill “1 in 6 people with cancer and heart disease; 1 in 4 with irritable bowel and fibromyalgia; and 1 in 14 who are not even medically ill.”
Yet “for reasons I can't begin to fathom,” Frances recently observed, “DSM-5 decided to proceed on its mindless and irresponsible course. The sad result will be the mislabeling of potentially millions of people with a fake mental disorder that is unsupported by science and flies in the face of common sense.”
Why is Somatic Symptom Disorder even a contender for DSM inclusion? As Frances notes, “There is no substantial body of evidence to support either its reliability or its validity.” In a post appropriately warning “Your Physical Illness May Now Be Labeled a Mental Disorder,” fellow PT blogger Toni Bernhard listed the APA's criteria: “People can be diagnosed with Somatic Symptom Disorder if, for at least six months, they’ve had one or more symptoms that are distressing and/or disruptive to their daily life, and if they have one [only one] of the following three reactions:
Criteria #1: disproportionate thoughts about the seriousness of their symptom(s);
Criteria #2: a high level of anxiety about their symptoms or health; or
Criteria #3: devoting excessive time and energy to their symptoms or health concerns.
“Can you see,” she asks, “how this diagnosis potentially includes everything from a stomach ache to cancer?”
Beyond even these flashing-red warning signs, the APA has chosen to ignore the massive public-health consequences of effectively designating all medically unexplained symptoms signs of a new mental disorder. Because of such criteria, patients can—and now will—be given a psychiatric diagnosis for symptoms that simply lack full medical understanding.
Added to that are the deeply troubling consequences of representing those who are simply vigilant about their health—and skeptical of pronounced causes of their illness—as suffering from a mental disorder.
One of the reasons the field trials for SSD pointed to such a risk of error and misdiagnosis is because the criteria rely on a psychiatrist’s perception that a patient’s concern about his or her medical health is excessive and unwarranted. Yet that perception is itself subjective, fallible, and to a large degree arbitrary. It can also be faulty—a patient’s concern may turn out to be justified. As Frances notes of one such case where he had to revise his initial diagnosis, based on a more-complete medical explanation (he had diagnosed depression when the patient in fact had a brain tumor), “The boundary between medical and psychiatric illness is inherently difficult to draw, especially since many psychiatric disorders do present with prominent somatic symptoms that are often mistaken for medical illness. … The underlying medical illness may take time to declare itself.”
“For the second stakeholder review of DSM 5 draft criteria,” notes Suzy Chapman, a UK health advocate whose Dx Revision Watch monitors all actual and proposed changes to the DSM and the ICD [International Classification of Diseases], “the SSD disorder section attracted more submissions than almost any other section. Yet still the Work Group barreled blindly on with suggestions that were roundly opposed as hurtful to the medically ill—shrugging off criticism from professionals and remaining completely unreceptive to advocacy organization and patient concern.”
Indeed, she adds: "For its third draft, rather than revise in favor of less inclusive criteria, the Work Group's response was to lower the threshold even further—reducing the requirement for 'at least two from the B type criteria' to just one—placing even more medical patients at risk of attracting an inappropriate mental health diagnosis."
Voicing strenuous opposition to the APA’s scientific gaffe, including from concern that the new disorder would be widely misapplied, Frances issued several pleas for eleventh-hour changes, including single-word ones that would have tightened the criteria considerably—pleas that in fact went viral given the size of the audience they reached. Such adjustments, he noted at the time, would make “much clearer that the person's concern about physical symptoms had to be 'excessive', 'maladaptive', 'pervasive', 'persistent', 'intrusive', 'extremely anxiety provoking', 'disproportionate', and 'consuming enough time to cause significant disruption and impairment in daily life.’”
Yet rather than risk appearing as if it were acting on the advice of the DSM’s most recent editor or, indeed, the recommendations of numerous other concerned experts, the DSM-5 Task Force turned a deaf ear and pressed on regardless. The dangers are now all-too-apparent. As Chapman puts it, DSM-5’s "highly subjective, difficult to assess criteria [for SSD] have the potential for widespread misapplication, particularly in busy primary care settings—causing stigma to the medically ill and potentially resulting in poor medical workups, inappropriate treatment regimes and medico-legal claims against clinicians for missed diagnoses.”
Adds Frances: “The definition of SSD is so loose it will capture 7% of healthy people (14 million in the US alone), suddenly making this pseudo diagnosis one of the most common of all 'mental disorders' in the general population."
In light of such bad science and the APA’s fundamental betrayal of first medical principles, including to do no harm, Chapman is fully justified in asking: "Why has the Task Force and APA Board of Trustees been prepared to sign off on a definition and criteria set that lacks a body of rigorous evidence for its validity, safety and prevalence, thereby potentially putting the public at risk? And why is APA prepared to abrogate its duty of care as a professional body and expose its membership, physicians and the allied health professional end-users of its manual to the risk of potential law suits?"
The APA unfortunately has decided to enter a Brave New World in which it’s possible to brand those skeptical of its psychiatric diagnoses as ... suffering from a psychiatric diagnosis. Meanwhile, in the same peculiar dystopia, Psychiatric Times has issued its readers a “Diagnostic Champions’ Challenge,” Go For the Gold, whereby the winner is promised an ounce of solid gold bullion—providing they can diagnose an array of complex symptoms within just one minute.
Unfortunately, this doesn’t seem to be a joke. The newspaper, whose sponsors include the APA, has even issued MD and non-MD tracks to winning such bullion, presumably in hopes of distracting readers from the controversy building around the APA’s latest diagnosis: “Each week,” Psychiatric Times promises, “will feature a set of multiple choice diagnostic dilemmas focused on mental health to test your acumen: we present the problem, you diagnosis it—but you'll only have up to 60 seconds for each question."
Rather than trying to dazzle the psychiatric community with such gimmicks, including to mask its mistakes, the APA should have acted on the advice of its critics and advisors, including those warning with strong justification that Somatic Symptom Disorder sits upon “a treacherous [medical] foundation” (Dimsdale). Instead, the APA has just guaranteed what will be the next pandemic in psychiatry: outsized concern about medical illness. Health fanatics take note—you could soon find yourselves classed among the mentally ill.
christopherlane.org Follow me on Twitter @christophlane
References
Dimsdale, Joel E. “Medically unexplained symptoms: a treacherous foundation for somatoform disorders?” Psychiatr Clin North Am 34.3 (September 2011): 511-13.
