DSM-5 somatic symptom disorder mislabels medical illness as mental disorder

DSM Digest

Experts in any area of psychiatry always over value their pet interest and feel that it deserves more attention. DSM-5 gave its work groups great freedom and encouraged them to be innovative. The result has been a general loosening of diagnostic thresholds throughout DSM-5 that will increase the sensitivity of psychiatric diagnosis, but at a great loss of its specificity. The corollary of this is that millions of mislabeled false-positive patients will suffer the harmful unintended consequences.

The decisions made by the DSM-5 Somatic Symptom Disorders Work Group are a painful illustration. The DSM-IV problem they felt ‘needed fixing’ was that Somatization Disorder was infrequently diagnosed in clinical practice. It had a very rigorous criteria set specifically: a history of eight or more medically unexplained symptoms from four specified symptom groups (with at least four pain and two gastrointestinal symptoms) beginning before the age of 30 and resulting in treatment or psychosocial impairment. The diagnostic threshold was set high in the spirit of the creators of the concept of somatization disorder who believed in using only validated diagnoses and in avoiding false-positives (Feighner et al., 1972).

DSM-5 went overboard in the other direction, introducing an extremely broad new category that is likely to be wildly over-inclusive (‘somatic symptom disorder’, SSD). A medically ill person will meet the criteria for SSD by reporting just one bodily symptom that is distressing and/or disruptive to daily life and having just one of the following three reactions to it that persist for at least 6 months: (1) disproportionate thoughts about the seriousness of their symptom(s); (2) a high level of anxiety about their health; or (3) devoting excessive time and energy to symptoms or health concerns (American Psychiatric Association, 2012).

These are inherently unreliable and untrustworthy judgments that will open the floodgates to the over diagnosis of mental disorder and promote the missed diagnosis of medical disorder. The application of these overly inclusive DSM-5 criteria greatly increases the rates of diagnosis of mental disorders in the medically ill: one in six patients with heart disease or cancer; one in four with irritable bowel or chronic widespread pain; and an astounding 7% false-positive rate in the general population (Dimsdale, 2012).

The resulting harms include:

• Stigma

• Missed diagnoses through failure to investigate new or worsening somatic symptoms

• Inappropriate prescription of psychotropic drugs with consequent side effects, complications, and costs

• Possible limits imposed on the types of medical tests and treatments offered for patients misdiagnosed as having a mental disorder

• Misdiagnosed patients may be disadvantaged in employment, medical, and disability reimbursement

• An additional diagnosis of ‘SSD’ in a patient’s medical history may negatively influence decisions made by agencies involved with social and medical services, disability adaptations, education, and workplace accommodations

• An inaccurate ‘SSD’ diagnosis will skew the person’s view of herself and her illness and perceptions of family and friends

• In multi-system diseases like multiple sclerosis, Behçet’s syndrome, or systemic lupus erythematosus, it can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable to misdiagnosis as psychiatrically ill

• DSM-5 allows for a diagnosis of ‘SSD’ when a parent is considered ‘excessively concerned’ about a child’s symptoms. A parent caring for a child with any chronic illness may be placed at risk of being diagnosed with SSD, leading to the wrongful accusation of ‘over-involvement’ with their child’s symptomatology or of encouraging ‘sick role behaviour’

• The burden of the DSM-5 changes will fall particularly heavily upon women who are more frequent presenters with physical symptoms such as persistent pain and more at risk of receiving inappropriate antidepressants and anti anxiety medications for them (Leiknes et al., 2007)

The DSM-5 Work Group is taking a flying leap into the unknown. There are no published data on the clinical characteristics or treatment of ‘somatic symptom disorder’, or its validity and safety as a construct. Decisions to code or not to code will hang on the arbitrary and subjective perceptions of DSM end-users who often spend very little time with the patient and lack training in psychiatry.

The golden rule: an underlying medical illness or medication side effect has to be ruled out before ever deciding that someone’s symptoms are caused by mental disorder. And the underlying medical illness may take time to declare itself. Uncertainty is hard to live with, but much better than jumping to false and risky conclusions. There are serious risks attached to over-psychologizing somatic symptoms and mislabeling the normal reactions to being sick − especially when the judgments are based on vague wording that can’t possibly lead to reliable diagnosis. DSM-5 as it now stands will add to the suffering of those already burdened with all the cares of having a medical illness.

We suggest ignoring the DSM-5 ‘SSD’ diagnosis because it will do more harm than good. Adjustment disorder is more accurate and appropriate whenever a mental disorder diagnosis is called for in someone who is medically ill.