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Why Did DSM 5 Botch Somatic Symptom Disorder?

A closed process, tunnel vision, and time pressure.

This is the third in a series of blogs on the trouble caused by DSM 5's mishandling of the boundary between medical and mental illness.

The first explored how a new and untested DSM 5 diagnosis - 'Somatic Symptom Disorder (SSD)' - would mislabel millions of people as mentally ill when they are really just medically ill.…

The second described my attempt to pressure the DSM 5 work group to tighten its overly inclusive SSD definition. Simple wording changes could have reduced the risk that people with medical illness would receive an inaccurate and harmful SSD diagnosis.…

I failed. The DSM 5 work group did discuss my suggestions, but rejected them, and is moving ahead with their loose definition.

Once it is an official DSM 5 mental disorder, SSD is likely to be widely misapplied - to 1 in 6 people with cancer and heart disease and to 1 in 4 with irritable bowel syndrome and fibromyalgia.

It gets even more ridiculous. 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.

Suzy Chapman sent this email with an interesting question: "Why has DSM-5 stubbornly refused to reappraise its inclusion of the SSD category or at least significantly tighten up the criteria in the face of three years' stakeholder opposition and your own determined efforts to force an eleventh hour review?

"Their decision to risk creating such massive mislabeling is puzzling when you consider these observations by Joel Dimsdale, MD, chair of the SSD Work Group. Clearly, he is aware of the perils of over diagnosing mental illness in the medically ill."

Dr Dimsdale notes:

• 'A number of factors influence the accuracy of diagnoses. Most prominently, one must consider how thorough was the physician’s evaluation of the patient. How adequate was the physician’s knowledge base in synthesizing the information obtained from the history and physical examination?'

• 'The time pressures in primary care make it difficult to comprehensively evaluate patients and thus contribute to delays and slips in diagnosis.'

• 'Similarly, physicians can wear blinders or have tunnel vision in evaluating patients.''

• 'Patients present with an admixture of symptoms, preconceptions, feelings, and illnesses...' [1]"

Ms Chapman continues: "So how do you explain the disconnect between the appropriate cautions contained in Dr Dimsdale's article and the reckless inclusiveness of the DSM-5 criteria set for Somatic Symptom Disorder?"

"Dr Dimsdale describes his group's revision as 'a step in the right direction.' But DSM-5 appears hell bent on stumbling blindly into the quicksand of loose, unvalidated mental disorder diagnosis."

"These highly subjective, difficult to assess criteria 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."

"Given that his own words counsel caution, how come Dr Dimsdale's group has produced a criteria set that is considered so dangerous by diverse patient groups and so strongly opposed by professionals?"

"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?"

Thanks Ms Chapman. I was also astounded by the failure of DSM 5 to correct this glaring problem and can come up with only three possible explanations:

• Closed process: Whenever DSM 5 invited public comments, SSD would attract more criticism than almost any other diagnosis. Any show of DSM 5 openness turned out to be just a public relations stunt.

The work group was also aware that my previous blogs were attracting many tens of thousands of viewers and many hundreds of responses - all in opposition. They never took seriously any outside opinions and opted for the loosest possible definition.

• Tunnel vision: DSMs must find a balance between recommending too much versus too little diagnosis. The DSM 5 work group worried so much about missed patients that they have ignored the harms they are causing for the mislabeled patients. They don't understand how dangerous an inaccurate diagnosis of mental disorder can be to someone struggling with medical illness.

• The DSM 5 rush to press: I think the work group might have done the right thing if only they had sufficient time to fully consider my suggestions. But there wasn't time - and for all the wrong reasons.

The recurring disorganization of the DSM 5 process caused it to miss all of its deadlines - except for the last one: its May publication date.

Publishing in May has been held sacrosanct for one reason only - profits generated by DSM 5 are absolutely crucial to fill a gaping hole in APA's budget.

Squeezed for time, DSM 5 was forced to cancel its planned quality control step and has put together the manual in a hectic, last minute rush. No doubt, the work group was pressured to go with the flow so that DSM 5 could be sent to the presses.

This has been the DSM 5 story from start to finish: excessive ambition, disorganized method, closed process, tunnel vision, and publishing profit taking priority over public trust. The result - an expansion of psychiatric diagnosis that is unsafe and scientifically unsound.…

1) Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatry Clin North Am. 2011 Sep; 34(3):511-3.

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