Final push: We have till Wednesday to submit comments on the DSM-5 draft criteria

Final push: We have till Wednesday to submit comments on the DSM-5 draft criteria

Post #90 Shortlink: http://wp.me/pKrrB-1bm

“So basically, they’re dumping some little-used, contentious and unpopular categories in a big bucket and stirring them up. The resulting mud could well end up sticking to us!”

If you only do two things online this week make it these:

1] Register to submit feedback via the DSM-5 Development website, here, and submit a letter of concern – however brief: http://tinyurl.com/Somatic-Symptom-Disorders

2] If you know an informed and sympathetic clinician, psychologist, allied health professional, lawyer, educator or social worker, contact them today and urge them to review these criteria and to submit a response as a concerned professional, or ask your state ME/CFS organization to submit a response.

The closing date for comments in the second DSM-5 public review is Wednesday, June 15

How many subscribers are there to the Co-Cure mailing list?

A couple of thousand?

And there are over 4,500 members of Phoenix Rising Forums. These usually very active forums are currently offline. Please use the time and energy you might have spent on Phoenix Rising to submit a comment.

We have the potential for several thousand more responses over the next three days.

OK, the APA issued no prior announcement of its intention to bring forward this second public review of draft criteria and so patient groups could not be alerted in advance. But alerts went out on May 5, the day after the latest criteria were posted on the DSM-5 Development site.

Nevertheless, many international patient organizations have been slow off the mark and some have been lukewarm about the need to submit, this year, or to submit, at all.

I’ve been banging on about the implications for these proposals for ME and CFS patients for two years, now, but where are the responses from our international patient organizations to these latest proposals?

Over two years ago, on May 13, 2009, I first reported on Co-Cure that the conceptual framework the DSM-5 Work Group for “Somatic Symptom Disorders” was proposing would:

“…allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome.” [1]

(“Somatic” means “bodily” or “of the body”.)

The most recent version of the Disorders description document states:

“This group of disorders is characterized predominantly by somatic symptoms or concerns that are associated with significant distress and/or dysfunction…Such symptoms may be initiated, exacerbated or maintained by combinations of biological, psychological and social factors.”

“These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met.”

“The symptoms may or may not be associated with a known medical condition. Symptoms may be specific (such as localized pain) or relatively non-specific (e.g. fatigue). The symptoms sometimes represent normal bodily sensations (e.g., orthostatic dizziness), or discomfort that does not generally signify serious disease.” [2]

 

Psychiatric creep

The APA appears hell bent on colonising the entire medical field by licensing the potential application of a mental health diagnosis to all medical diseases and disorders, if the clinician decides that the patient’s (or in the case of a child, a parent’s) response to their bodily symptoms and concerns about their health are “excessive”, or their perception of their level of disability “disproportionate”, or their coping styles “maladaptive.”

While the media has focussed on the implications for introducing new additions and broadening definitions of existing DSM diagnostic criteria, there has been no media scrutiny of these Work Group proposals nor recognition that this Work Group has been quietly redefining DSM’s “Somatoform Disorders” categories with proposals that will have the potential for a bolt-on diagnosis of a “somatic symptom disorder” for all medical diseases, whether “established general medical conditions or disorders”, like angina or diabetes, or conditions presenting with “somatic symptoms of unclear etiology.”

Yet these radical proposals for renaming the “Somatoform Disorders” category “Somatic Symptom Disorders” and combining a number of existing, little-used categories under a new umbrella term, “Complex Somatic Symptom Disorder (CSSD)”, and the more recently proposed “Simple Somatic Symptom Disorder (SSSD)”, have the potential for bringing thousands more patients under a mental health banner and expanding markets for psychiatric services, antidepressants and behavioural therapies such as CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” for all patients with somatic symptoms, irrespective of cause.

 

Sitting ducks

CFS, ME, Fibromyalgia and IBS patients are likely to get caught by these proposals.

CFS and ME patients already diagnosed or waiting for a diagnosis (which might take months or years) would be especially vulnerable to the highly subjective criteria and difficult to measure concepts like “disproportionate distress and disability”, “catastrophising”, “health-related anxiety” and “[appraising] bodily symptoms as unduly threatening, harmful, or troublesome”, this Work Group is proposing.

Other patient groups bundled under the so-called “Functional somatic syndromes” and “medically unexplained” umbrellas, like Chemical Injury (CI), Chemical Sensitivity (CS), chronic Lyme disease and Gulf War Illness, would also be highly vulnerable to a CSSD label.

These proposals could potentially result in misdiagnosis of a mental health disorder, misapplication of an additional diagnosis of a mental health disorder, misapplication of “rehabilitation” therapies like GET or iatrogenic disease.

Families would be at risk of wrongful accusation of “over-involvement” or “excessive” concern for a child’s symptomatology or of encouraging “sick role behaviour” in a child or young person.

Application of these vague and highly subjective criteria may have considerable implications for the diagnoses assigned to patients, for the provision of social care, payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out.

The application of a diagnosis of CSSD may limit the types of treatment, medical investigations and testing that clinicians are prepared to consider and which insurers are prepared to fund.

 

International implications

This is not a US centric issue. The DSM is used to a varying extent in other countries in clinical settings. DSM criteria are currently used more often for research purposes than ICD-10 and the next edition will shape international research, influence literature in the fields of psychiatry and psychosomatics and inform perceptions of patients’ medical needs throughout the world.

Please make use of these last three days to tell the APA why the Somatic Symptom Disorders Work Group needs to rip up these proposals and start over again.

Links:

Proposed criteria are set out on the DSM-5 Development site here: http://tinyurl.com/Somatic-Symptom-Disorders

The CSSD criteria are here: http://tinyurl.com/DSM-5-CSSD

For examples of last year’s submissions, go here: http://wp.me/PKrrB-AQ

Copies of this year’s submissions are being collated here: http://wp.me/PKrrB-19a  

If you are a patient organization, professional, patient, carer or advocate and have already submitted and would like a copy of your comment added to my site, please send a copy to me.agenda@virgin.net

Submissions published to date for this second public review:

IACFS/ME (US);
ME Free For All.org (UK);
The Young ME Sufferers Trust (UK);
Coalition4ME/CFS (US);

Angela Kennedy, sociology lecturer (UK);
Dr John L Whiting MD, (Australia);

Kevin Short (UK)
Susanna Agardi (Australia)
Mary Barker (US);
Peter Kemp (UK);
Mary M. Schweitzer Ph.D., (US)

[1] “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report” was published in the June 2009 issue of the Journal of Psychosomatic Research. The journal is co-edited by DSM-5 Work Group members, Prof Francis Creed and Dr James Levenson. Full free text: http://www.jpsychores.com/article/S0022-3999(09)00088-9/fulltext

[2] There are two key PDF documents: “Disorders Descriptions” and “Rationale”, which expand on the Work Group’s proposals:

              Disorders Description   Key Document One: “Somatic Symptom Disorders”

              Rationale Document     Key Document Two: “Justification of Criteria — Somatic Symptoms”

Suzy Chapman

IACFS/ ME Statement on DSM-5 Somatic Symptom Disorder

The International Association for Chronic Fatigue Syndrome/ME (IACFS/ME) Statement on DSM-5 Somatic Symptom Disorder

Post #89 Shortlink: http://wp.me/pKrrB-1b6

The closing date for comments in the second DSM-5 public review is June 15.

Register to submit feedback via the DSM-5 Development website here:
http://tinyurl.com/Somatic-Symptom-Disorders

More information on registration and preparing submissions here:
http://tinyurl.com/DSM-5-register-to-comment

Copies of last year’s submissions here: http://tinyurl.com/DSM5submissions

Copies of this year’s submissions here: http://tinyurl.com/DSM5submissions2011

IACFS/ME

Dear Members and Colleagues:

I have submitted the comments below to the DSM-5 Work Group on Somatic Symptom Disorders. We are very concerned about the proposed new diagnosis, Complex Somatic Symptom Disorder, and its potential influence on physicians who see patients with CFS/ME.

Thank you.

Fred

Fred Friedberg, PhD
President
IACFS/ME
www.iacfsme.org

To the DSM-5 Somatic Symptoms Disorders Work Group:

On behalf of the board of directors and the membership of the International Association for Chronic Fatigue Syndrome (IACFS/ME), I would like to express my deep concern about the proposed new category of Complex Somatic Symptom Disorder (CSSD) in DSM-5 scheduled for release in 2013.

The Work Group’s well-reasoned points about DSM-IV somatoform disorders – that they are little used, confusing, and pejorative – do call for a re-evaluation. The question is: What should replace them? The new inclusive CSSD category attempts to offer a simplified and more inclusive diagnosis that may be more user-friendly to physicians and other health practitioners.

Our major concern is that the logic behind the new CSSD category is not informed by empirical data that directly examines the utility of this diagnosis in medical practice.

As stated by your Work Group: “A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. …Predictive validity of most of the diagnostic proposals has not yet been investigated.”

Given the absence of scientific validation of the CSSD diagnosis, the potential for unintended consequences is a serious concern. One such consequence is the possibility of over-diagnosis that may selectively affect patients with illnesses that are already not well understood such as CFS/ME. If the treating practitioner is skeptical about the severity or even  existence of CFS/ME, then the new criteria can be used to diagnose CSSD without reference to an underlying illness.

For instance, the CSSD criteria of (2) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms and (3) Excessive time and energy devoted to these symptoms or health concerns, would allow practitioners skeptical of CFS/ME to diagnosis the illness as an Axis I psychiatric disorder. This new psychological diagnosis may then narrow the physician’s focus and reduce the possibility of more effective management of the CFS/ME illness. Furthermore, the CSSD diagnosis may result in additional stigma for already marginalized patients with CFS/ME.

Over-diagnosis with CSSD may also arise from the broad generality of the new criteria and the absence of clear thresholds for patients to meet the criteria. As with somatization/somatoform disorders, when different criteria are used population prevalence varies from less than 1% for somatization disorder to an astonishing 79% for undifferentiated somatoform disorder (cited from Work Group online document). Arguably, the generality of the criteria for both undifferentiated somatoform disorder and CSSD suggests that CSSD may become a much more common (and potentially misapplied) diagnosis than the somatic symptom disorders that it replaces.

Finally, the CSSD diagnosis will not inform the clinician of CFS/ME-specific issues such as adverse reactions to treatment that are more likely in this hypersensitive population. By contrast, the CFS/ME diagnosis is useful for an array of illness related concerns that will assist the clinician in providing care for these medically under-served patients.

Given the above considerations, we ask that the CSSD diagnosis be omitted from DSM-5. Only when the proper validation studies are done that consider vulnerable populations such as CFS/ME can we know if the use of the CSSD diagnosis has clinical value. In its current form, we believe that the new diagnosis will do more harm than good.

Thank you.

Fred Friedberg

Fred Friedberg, PhD
President
IACFS/ME
www.iacfsme.org

IACFS/ME
27 N. Wacker Drive, #416
Chicage, Illinois 60606
US

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 4)

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 4)

Post #82 Shortlink: http://wp.me/pKrrB-16B

Part 1 of this report can be read here in Post #75:

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 1)

Part 2 of this report can be read in Post #77:

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 2)

Part 3 of this report can be read in Post #80:

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 3)

The second public review of draft proposals for DSM-5 criteria closes on 15th June

Information about registering to submit comment can be found in Post #78: http://wp.me/pKrrB-15q

In Part 3 of this report, I set out extracts from the first of two key PDF documents that accompany the latest proposals of the DSM-5 Somatic Symptom Disorders Work Group, highlighting in yellow why ME and CFS patient representation organizations, professionals and advocates need to register their concerns. Stakeholder feedback in this second public review is being accepted until 15 June.

In Part 4, I am posting all the text from the “Rationale” document, omitting several pages of references to research papers. Both key documents can be downloaded here:

For extracts from the “Disorders Description” document see Post #80

     Disorders Description   Key Document One: “Somatic Symptom Disorders”

     Rationale Document     Key Document Two: “Justification of Criteria — Somatic Symptoms”

Extract from “Rationale” document

Justification of Criteria—Somatic Symptoms

DRAFT 4/18/11

Synopsis:

Because the current terminology for somatoform disorders is confusing and because Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders all involve presentation of physical symptoms and/or concern about medical illness, the workgroup suggests renaming this group of disorders as “Somatic Symptom Disorders.”

Because of the implicit mind-body dualism and the unreliability of assessments of “medically unexplained symptoms”, these symptoms are no longer emphasized as core features of many of these disorders. Because somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder share certain common features, namely somatic symptoms and cognitive distortions, these disorders are grouped under a common rubric of “Complex Somatic Symptom Disorder.”

Introduction and Rationale:

The Somatic Symptoms group was charged with viewing those DSM diagnoses where somatic issues predominate. While somatic symptoms are present in virtually every psychiatric diagnosis, they are clearest in the various somatoform disorders and in psychological factors affecting medical condition (PFAMC).

Contemporary criteria for somatoform disorders give heavy emphasis to the concept of “medically unexplained symptoms.” Such terminology enforces a dualism between psychiatric and medical conditions. It bases a diagnosis on a negative — the absence of something, and, as such, runs the risk of misdiagnosis (Kroenke et al, 2007). With such criteria, these disorders are very common, particularly in primary care settings where they are present in 1 out of 6 consultations (Fink, 1999). High levels of presenting somatic symptoms that are below the diagnostic threshold of somatization disorder are quite common and disabling in primary care and medical settings and tend to be associated with both depression and anxiety disorders (Bridges and Goldberg 1985; Barsky et al 1999; Kirmayer and Robbins 1992; Escobar et al, 1998; Gureje et al, 1999). Similarly, psychological factors which complicate underlying medical disorders constitute the essence of PFAMC and are also very common in medical settings (Levenson 2008; Dimatteo 2004).

Page 2

Despite their prominence in primary care settings, these diagnostic codes are rarely used. In 2008, among 28 million Wellpoint/Anthem Blue Cross Blue Shield members, only 0.04% of the members had a clinical encounter for which the primary diagnosis was any of the somatoform disorders or PFAMC. Similarly, among patients within the Veterans Administration during the years 2002-2008, only 0.18% of inpatient encounters and 0.25% of outpatient encounters had as a primary diagnosis any of the somatoform disorders or PFAMC (Levenson, unpublished). With the possible exception of pain disorders, these disorders are uncommonly encountered in psychiatric practice. There is considerable confusion about the criteria for the disorders and the terms themselves are intensely disliked by patients. A 2009 survey of physicians revealed that somatoform NOS was regarded as unclear by 45%, not particularly useful by 51%, and was regarded as a useful diagnosis by only 6% of patients (Dimsdale, Sharma, & Sharpe, unpublished).

Place of prominence in the group of somatoform disorders is given to somatization disorder, which is relatively rare, using the existing criteria (Escobar et al, 1987). In a systematic review of somatization disorder in population-based samples (10 studies) the median prevalence was 0.4% (range 0.03% to 0.84%) (Creed, Barsky J Psychosom Res 2004). As a result, the majority of patients with somatoform disorders are given a residual category diagnosis (undifferentiated somatoform disorder, or somatoform disorder NOS) (Kumabara et al 2007). There have been very few population studies of DSM-IV somatization disorder, but the most recent in China found a prevalence of 0.03% (Phillips et al, 2009). The number of cases of somatization disorder is so small that these data cannot be used to identify the risk factors or associated features reliably.

Researchers therefore have largely abandoned DSM IV criteria of somatization disorder and developed their own criteria, of which “abridged 4/6,” and “multisomatoform”  have been the most widely studied (Escobar, Kroenke). The low prevalence of somatization disorder, combined with the difficulty of measurement of all of the somatoform disorders has meant that these disorders have not even been included in most national surveys of mental health (see table below). Even liberalizing the criteria in terms of symptom count, fails to reveal a natural ‘cut point’ in diagnosing the disorder (Creed, unpublished).

Perhaps as a reaction to the measurement problems with somatization disorder, the low rates, and the reliance on “medically unexplained symptoms,”  this area of psychiatric diagnosis is understudied, and psychiatrists and health service planners have been accused of neglecting an important group of disorders associated with considerable distress and disability (Saxena 2005, Creed 2006). The absence of somatoform disorders from population-based studies has been described by a German group, which did include somatoform disorders, as “astonishing considering that these disorders are the third most frequent in the general population” (Baumeister, 2007).

There is thus a paucity of epidemiological data on somatization disorder as defined by DSM IV, and the impression is that this disorder is extremely rare. When different criteria are adopted to assess prevalence, one finds very different prevalence estimates. In 119 primary care patients, Lynch (1999) reports that Abridged somatization (4m/6f) was present in 6%, Multisomatoform disorder in 24%, DSM IV somatization disorder in <1%, and DSM IV Undifferentiated somatoform disorder in 74.

Page 3

Given that (a) the reliance on medically unexplained symptoms as a key factor for such diagnoses is intensely problematic, (b) the diagnoses are not used by clinicians, (c) patients find them very objectionable, (d) clinicians find these diagnoses unclear; and (e) there are highly discrepant prevalence estimates using various criteria, the workgroup proposes a number of changes in this important area of psychiatric diagnosis.

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 2)

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 2)

Post #77 Shortlink: http://wp.me/pKrrB-13z

Part 1 of this report can be read here in Post #75:

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 1)

In the first part of this report, I addressed some of the queries that have been raised around the second public review of proposals for the revision of DSM categories and diagnostic criteria. Stakeholder feedback is being accepted now until 15 June and I’ll be giving more information on how to submit feedback via the DSM-5 Development website in a forthcoming post.

In this post, I am setting out the latest proposals (dated 14 April 2011) from the DSM-5 Somatic Symptom Disorders Work Group, as published on the DSM-5 Development website, on 4 May. The next post will set out extracts from the two key documents that accompany these revised proposals and why ME and CFS patient representation organizations, patients and advocates need to register their concerns via this second public review.

Criteria proposals and rationales are expanded upon within the two key documents and the devil is in the detail. Patient organizations will need to review both documents, as changes have been made since last year. And if you are able to do so, I recommend that patients, carers and patient advocates read them, too.

At over a dozen pages long, the “Rationale” document (which is titled: “Justification of Criteria — Somatic Symptoms”) looks potentially daunting, but the text is not as long as it appears since five or six pages of references are included at the end. Edits to the documents since the versions published in January, this year, have been highlighted by the Work Group in yellow.

http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

Somatic Symptom Disorders

Please find below a list of disorders that are currently proposed for the diagnostic category, Somatic Symptom Disorders. This category contains diagnoses that were listed in DSM-IV under the chapter of Somatoform Disorders. The Somatic Symptom Disorders Work Group has been responsible for addressing these disorders. Among the work group’s recommendations is the proposal to rename this category Somatic Symptom Disorders. Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, because of the implicit mind-body dualism and the unreliability of assessments of “medically unexplained symptoms,” these symptoms are no longer emphasized as core features of many of these disorders. Since Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric called Complex Somatic Symptom Disorder. Furthermore, the diagnosis of Factitious Disorder can now be found under the diagnostic chapter Other Disorders. We appreciate your review and comment on these disorders.

J 00 Complex Somatic Symptom Disorder |
J 01 Simple Somatic Symptom Disorder |
J 02 Illness Anxiety Disorder |
J 03 Functional Neurological Disorder (Conversion Disorder) |
J 04 Psychological Factors Affecting Medical Condition |
J 05 Other Specified Somatic Symptom Disorder |   The work group has not yet proposed criteria for this disorder.
J 06 Unspecified Somatic Symptom Disorder |  Pseudocyesis  The patient has a false belief of being pregnant…

Below, I am posting proposal details for categories J 00 thru J 04.

Note that the two key PDF documents, dated 14 April 2011 called: “Disorder Descriptions” (7 pages) and “Rationale” contain full disorder descriptions and rationales for all category proposals in the Somatic Symptom Disorders categories, so you need only download one copy of each PDF.

To compare with criteria for CSSD as they had stood in the February 2010 review see this subpage: DSM-5 Drafts 2: http://wp.me/PKrrB-15d

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368

J 00 Complex Somatic Symptom Disorder

Updated January 14, 2011

Complex Somatic Symptom Disorder   [Criteria for CSSD have been edited since the Feb '10 version]

Proposed Revision Tab  

To meet criteria for CSSD, criteria A, B, and C are necessary.

A. Somatic symptoms:

One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:

(1) High level of health-related anxiety.

(2) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.

(3) Excessive time and energy devoted to these symptoms or health concerns.*

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).

For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:

XXX.1 Predominant somatic complaints (previously, somatization disorder)

XXX.2 Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having Illness Anxiety Disorder.

XXX.3 Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

Open full disorder descriptions here       Disorders Description   Key Document One: “Somatic Symptom Disorders”

* Criteria B is still under active discussion

———————

Rationale Tab

Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism. Alternatively, Factitious Disorders could continue to be listed under the category Other Disorders.

Major change #3: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD)

Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD) which emphasizes the symptoms plus the patients’ abnormal cognitions (Barsky, Lowe, Rief). The term “complex” is intended to denote that in order for this diagnosis to be made, the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as cognitive distortions (criterion B).

This is a major change in the diagnostic nomenclature, and it will likely have a major impact on diagnosis. It clarifies that a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present.

It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.

The proposal is to group together these heretofore separately recognized disorders because in fact, there are 3 diverse sources suggesting considerable overlap among them.

1. A 2009 study found that 52% of physicians surveyed indicated that there was “a lot of overlap” and an additional 38% thought that there was “some overlap” across these disorders. In contrast, less than 2% of physician respondents felt that these were “distinctly different disorders (Dimsdale, Sharma, & Sharpe, unpublished).

2. There are limited data regarding overlap in clinical settings. One primary care study, for instance, found that 20% of somatization disorder patients also had hypochondriasis (Escobar, 1998). In primary care patients, somatization disorder was 5 times ( Fink et al 2004) to 20 times (Barsky et al 1992) more common in hypochondriasis patients as compared to primary care patients without hypochondriasis.

3. Treatment interventions are similar in this group of disorders. Cognitive behavior therapy (CBT) and antidepressant medications appear to be the most promising therapeutic approaches for hypochondriasis, somatization disorder, and pain disorder (Kroenke 2007; Sumathipala 2007). Although several variations of CBT have been employed, they share many elements in common. These include the identification and modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors and promote more effective coping. The literature on the use of antidepressants is more limited, but it too does not suggest any major distinctions in therapeutic response across these different disorders. In addition to these patient centered commonalities of treatment, all of these disorders benefit from specific interventions with the patient’s non-psychiatric physician (e.g. scheduling regular appointments as opposed to prn appointments, limiting testing and procedures unless clearly indicated) (Allen 2002).

A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. A recent systematic review (Lowe, submitted for publication) shows that of all diagnostic proposals, only Somatic Symptom Disorder reflects all dimensions of current biopsychosocial models of somatization (construct validity) and goes beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated.

Open full rationale document here       Rationale Document   Key Document Two: “Justification of Criteria — Somatic Symptoms”

———————

Severity Tab

Clinician rated severity of each of the three criteria

(1) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms

(2) High Level of health-related anxiety

(3) Excessive time and energy devoted to these symptoms or health

Response categories

0 Not at all

1 A little bit

2 Somewhat

3 Quite a bit

4 Very much

PHQ Somatic Symptom Short Form (PHQ-SSS)

 

———————

DSM-IV Tab [current DSM-IV criteria]

This disorder was not listed in DSM-IV; therefore DSM-IV criteria for this disorder does not exist. This disorder includes previous diagnoses of Somatization Disorder (DSM IV code 300.81), Undifferentiated Somatoform Disorder (DSM IV code 300.82), Pain Disorder Associated With Both Psychological Factors and a General Medical Condition (DSM IV code 307.89), and Pain Disorder Associated With Psychological Factors (DSM IV code 307.80). It also includes the vast majority of patients previously diagnosed with Hypochondriasis; the rationale for the slpit [sic] in Hypochondriasis can be found in the report on Illness Anxiety Disorder.

This proposal for a SSSD category had not been proposed at the time of the February 2010 draft review:

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=491

J 01 Simple Somatic Symptom Disorder

Updated May 4, 2011

Simple Somatic Symptom Disorder

Proposed Revision Tab

This diagnosis requires the following 3 criteria:

A. Somatic Symptoms

One or more somatic symptoms that are distressing and/or result in significatn disruption of daily life

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: This diagnosis requires one of the following:

(1) Disproportionale and persistent thoughts about the seriousness of one’s symptoms

(2) High level of anxiety about health or symptoms

(3) Excessive time and energy devoted to these symptoms or health concerns

C. Symptom duration is greater than 1 month

Please see full disorder descriptions here     (see Key Document One: Disorders Descriptions)

———————

Rationale Tab

Please see the full rationale document here     (see Key Document Two: Rationale)

———————

Severity Tab (same as for CSSD)

———————

DSM-IV Tab (same as for CSSD)

While this disorder is not listed in DSM-IV, it includes what was previously diagnosed as Somatoform Disorder NOS, with the exception of Pseudocyesis, which is now included in Somatic Symptom Disorder NOS

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=10

J 02 Illness Anxiety Disorder

Updated January 14, 2011

Illness Anxiety Disorder

Proposed Revision Tab

The following 6 criteria must be met:

A. Somatic symptoms are not present or, if present, are only mild in intensity.

B. Preoccupation with having or acquiring a serious illness. If a general medical condition or high risk for developing a general medical condition is present, the illness concerns are clearly excessive or disproportionate. The individual’s concern is focused not on any physical distress per se, but rather on a suspected, underlying medical diagnosis.

C. High level of anxiety about health or having or acquiring a serious illness. These individuals have a low threshold for considering themselves to be sick and a low threshold for becoming alarmed about their health.

D. The person performs related excessive behaviors (e.g. checking one’s body for signs of illness, repeatedly seeking information and reassurance from the internet or other sources), or exhibits maladaptive avoidance (e.g., avoiding doctors’ appointments and hospitals, avoiding visiting sick friends or relatives, avoiding triggers of illness fears such as exercise).

E. Although the preoccupation may not be continuously present, the state of being preoccupied is chronic (at least 6 months).

F. The illness-related preoccupation is not better accounted for by the symptoms of another mental disorder such as complex somatic symptom disorder, panic disorder, generalized anxiety disorder, or obsessive compulsive disorder.

Please see full disorder descriptions here     (see Key Document One: Disorders Descriptions)

———————

Rational Tab

The DSM-IV category Hypochondriasis is now recognized as 2 disorders. Approximately 80 percent of patients previously diagnosed with Hypochondriasis would now be included within the Complex Somatic Symptom Disorder diagnosis. The remaining patients would be diagnosed with Illness Anxiety Disorder.

Please see full rationale document here     (see Key Document Two: Rationale)

———————

Severity Tab

Recommendations for severity criteria for this disorder are forthcoming. We encourage you to check our website regularly for updates.

———————

DSM-IV Tab [current DSM-IV criteria]

Hypochondriasis

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.

B. The preoccupation persists despite appropriate medical evaluation and reassurance.

C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The duration of the disturbance is at least 6 months.

F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

Specify if:

With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable>

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8

J 03 Functional Neurological Disorder (Conversion Disorder)

Updated May 4, 2011

Functional Neurological Disorder (Conversion Disorder)*

Proposed Revision Tab

Criteria A, B, C, and D must all be fulfilled to make the diagnosis:

A. One or more neurologic symptoms such as altered voluntary motor, sensory function, cognition, or seizure-like episodes.

B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior.

C. The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized neurological disorder.

D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Please see full disorder descriptions here   (see Key Document One: Disorders Descriptions)

* The final name of this disorder is still under active discussion

* Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are discussing how conversion disorder relates to the dissociative disorders.

———————

Rationale Tab

Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism. Alternatively, Factitious Disorders could continue to be listed under the category Other Disorders.

Major change #2: De-emphasize medically unexplained symptoms

Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.

Major change #4: Modify criteria for conversion disorder

Changes are made in an effort to simplify the criteria for conversion disorder. First, we suggest removing the requirement that the clinician actively establish that the patient is not feigning. This is because (a) it is probably clinically impossible to prove that a patient is not feigning (Sharpe, 2003) and (b) there is no evidence that feigning of conversion symptoms is more common than feigning of other mental disorders. However as with other disorders positive evidence of feigning remains an exclusion, thereby differentiating conversion from factitious disorder and malingering.

Second, we suggest removing the requirement that the clinician has to establish that there are associated psychological factors . This is because (a) as with feigning, it is very difficult to reliably establish that relevant psychological factors are present in all cases and (b) the research evidence suggests that psychological factors can often be found but are not specific and have only a weak association with the diagnosis (Roelofs, 2005). The association with psychological factors has therefore been relegated to accompanying text rather than remaining a clinical requirement for diagnosis.

Third, we emphasize the importance of obtaining positive evidence of the diagnosis from appropriate neurological assessment and testing. Current diagnostic criteria require that the symptom, after appropriate medical assessment, is found not to be due to a general medical condition. In contrast to most other somatic symptoms, it can be usually be reliably determined whether neurological symptoms are due to an organic disease (Stone et al 2009). Additionally there are also findings on neurological assessment and investigation that positively suggest the symptoms are those of conversion (such as Hoovers sign for motor weakness or absence of seizure activity on an EEG during apparent seizures for seizures) (Hallett 2005; Reuber 2004; Stone 2005).

We suggest retaining Conversion Disorder in the Somatic Symptom Disorders section of the DSM. Conversion remains a condition defined by a somatic symptom that causes disability or distress and therefore sits comfortably in the new Somatic Symptom Disorders category that replaces somatoform disorders on grounds of utility. The alternative placement of this diagnosis is with dissociative disorders. The argument for moving conversion there is that the mental mechanisms involved are similar. However dissociation is a hypothetical process and moving conversion would (a) risk making an unjustified assumption about cause (b) lose the utility of grouping with other conditions that present with a somatic symptom.

Please see the full rationale document here     (see Key Document Two: Rationale)

———————

Severity Tab

There are few widely employed measures of severity in factitious disorder or conversion disorder.

For conversion disorder, the severity scoring might best be based on the severity of the associated disability (using a simple rating of mild, moderate and severe)

———————

DSM-IV Tab [current DSM-IV criteria]

Conversion Disorder

A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Specify type of symptom or deficit:

With Motor Symptom or Deficit (e.g., impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or “lump in throat,” aphonia, and urinary retention)

With Sensory Symptom or Deficit (e.g., loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations)

With Seizures or Convulsions: includes seizures or convulsions with voluntary motor or sensory components

With Mixed Presentation: if symptoms of more than one category are evident

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=387

J 04 Psychological Factors Affecting Medical Condition

Updated May 4, 2011

Psychological Factors Affecting Medical Condition

Proposed Revision Tab

To meet criteria for Psychological Factors Affecting Medical Condition, both criteria A and B are necessary.

A. A general medical condition is present.

B. Psychological or behavioral factors adversely affect the general medical condition in one of the following ways:

1. the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition
2. the factors (e.g. poor adherence) interfere with the treatment of the general medical condition
3. the factors constitute additional well-established health risks for the individual
4. the factors influence the underlying pathophysiology to precipitate or exacerbate symptoms or to necessitate medical attention.

Please see full disorder descriptions here   (see Key Document One: Disorders Descriptions)

———————

Rationale Tab

Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism. Alternatively, Factitious Disorders could continue to be listed under the category Other Disorders.

Major change #2: De-emphasize medically unexplained symptoms

Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.

Please see the full rationale document here     (see Key Document Two: Rationale)

———————

Severity Tab

For PFAMC, severity scoring might include “1” when the psychological factor only increases risk for medical illness, “2” when the symptoms of medical illness are exacerbated, and “3” when the effect is life-threatening.

DSM-IV Tab [current DSM-IV criteria]

[Specified Psychological Factor] Affecting . . . [Indicate the General Medical Condition]

A. A general medical condition (coded on Axis III) is present.

B. Psychological factors adversely affect the general medical condition in one of the following ways:

(1) the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition

(2) the factors interfere with the treatment of the general medical condition

(3) the factors constitute additional health risks for the individual

(4) stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition

Choose name based on the nature of the psychological factors (if more than one factor is present, indicate the most prominent):

Mental Disorder Affecting . . . [Indicate the General Medical Condition] (e.g., an Axis I disorder such as Major Depressive Disorder delaying recovery from a myocardial infarction)

Psychological Symptoms Affecting . . . [Indicate the General Medical Condition] (e.g., depressive symptoms delaying recovery from surgery; anxiety exacerbating asthma)

Personality Traits or Coping Style Affecting . . . [Indicate the General Medical Condition] (e.g., pathological denial of the need for surgery in a patient with cancer; hostile, pressured behavior contributing to cardiovascular disease)

Maladaptive Health Behaviors Affecting . . . [Indicate the General Medical Condition] (e.g., overeating; lack of exercise; unsafe sex)

Stress-Related Physiological Response Affecting . . . [Indicate the General Medical Condition] (e.g., stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache)

Other or Unspecified Psychological Factors Affecting . . . [Indicate the General Medical Condition] (e.g., interpersonal, cultural, or religious factors)

Related material

Patient organisations, professionals and advocates submitting comments in the DSM-5 draft proposal review process are invited to provide copies of their submissions for this second and current public review for publication on this site.

Read submissions in the last DSM-5 public review, held Feb-April 2010 here:

http://tinyurl.com/DSM5submissions

International patient organisation submissions:

Whittemore Peterson Institute, Steungroep CFS Netherlands, CFS Associazione Italiana, ME Association (endorsing submission by Dr Ellen Goudsmit), Action for M.E., Invest in ME, Mass. CFIDS/ME & FM, The CFIDS Association of America, Vermont CFIDS Association, IACFSME, The 25% ME Group

A number of patient advocate submissions are also published.

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” and why are they problematic? (Part 1)

What are the latest proposals for DSM-5 “Somatic Symptom Disorders” categories and why are they problematic? (Part 1)

Post #75 Shortlink: http://wp.me/pKrrB-12P

DSM stands for Diagnostic and Statistical Manual of Mental Disorders. The DSM is published by the American Psychiatric Association (APA) and contains descriptions, symptoms and criteria for diagnosing mental disorders. It does not include information or guidelines on treatments. DSM is the primary diagnostic system in the US for defining mental disorders and is used to a varying extent in other countries.

As a classification system, DSM does not have quite the significance in the UK as Chapter V: Mental and Behavioural Disorders of the WHO’s ICD-10, which is used more often in Europe for classifying mental health disorders. But the next edition of DSM will shape international research, influence literature in the fields of psychiatry and psychosomatics and inform health care providers and policy makers’ perceptions of patients’ needs for many years to come.

The next edition of DSM, which will be known as DSM-5, is scheduled for publication in May 2013.

Diagnostic criteria defined within the DSM determine what is considered a mental disorder and what is not, what medical treatments individuals receive and which treatments medical insurers will authorise funding for. In addition to use in medical settings, DSM is also used by social services agencies, governments, policy makers, courts, prisons, drug regulation agencies, pharmaceutical companies and in research.

The inclusion or not of a disorder within DSM has revenue implications for pharmaceutical companies seeking licences for new drugs or to expand markets and applications for existing products.

Second public review of proposals for DSM-5

On 4 May, the APA published revised proposals for the 13 Work Groups for the revision of DSM-IV categories and diagnostic criteria on the DSM-5 Development website and issued a news release announcing a second stakeholder review and feedback exercise. According to the DSM-5 Timeline, as it stood in March, this second public review was not expected until August-September.

Q: Is this review and comment process open only to APA members and other professionals?

A: No. All stakeholders are invited to submit comment and feedback on the draft framework and the latest proposed revisions to diagnostic criteria: patients and families, patient advocates and patient representation organizations as well as clinicians, researchers, allied health professionals, lawyers and other end users.

Q: How long will this second review period run for?

A: The DSM-5 Development website is open for commenting now until 15 June.

Q: Is registration required in order to submit feedback?

A: Yes. You will need to register to submit comment to the Work Groups. You can register now on the DSM-5 Development site to participate. Once registered, you can prepare and upload your comment via a WYSIWYG editor anytime until 15 June. More information on registering to submit feedback in Post #78.

Q: Which DSM-5 Work Group proposals have potentially the most implications for CFS and ME patients? 

A: The DSM-5 Work Group which has the most relevance for “Chronic fatigue syndrome”, CFS, “ME”, “CFS/ME”, “ME/CFS”, IBS, Fibromyalgia, Chemical Sensitivity (CS), Chemical Injury (CI), Environmental Illness (EI), GWS and chronic Lyme disease patients is the Somatic Symptom Disorders Work Group (SSD Work Group) which has responsibility for the revision of the categories currently classified in DSM-IV under “Somatoform Disorders”.

Q: Where can I find copies of the comments submitted last year by ME and CFS patient organizations during the first public review?

A: Copies of comments submitted, last year, by international patient organizations to the Work Group for “Somatic Symptom Disorders” are collated here together with some of the feedback submitted by patients and patient advocates: http://tinyurl.com/DSM5submissions

Q: How many submissions did the 13 DSM-5 Work Groups and Task Force receive during the first review?

A: The APA reports having received over 8000 comments across all categories.  After the review period had closed, the Task Force did not publish summaries of key areas of concern brought to its attention by stakeholders and neither has the Task Force nor individual Work Groups published responses to areas of major concern.

Q: How many submissions were received in response to the proposals published last year for the “Somatic Symptom Disorders” categories?

A: The APA did not publish a breakdown of the numbers of responses received by each of the 13 Work Groups.

 

Q: How do the current DSM-IV categories for “Somatoform Disorders” compare with ICD-10?

A: There is a degree of correspondence between the current Somatoform Disorders section in DSM-IV and the equivalent section in ICD-10 Chapter V Mental and behavioural disorders. This simplified table sets out how the two classification systems currently correspond for their respective Somatoform Disorders categories:

Current DSM-IV Codes and Categories for Somatoform Disorders and ICD-10 Equivalents

Source: Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-V. Am J Psychiat. 2005;162:847–855.

Neurasthenia is not categorized in DSM-IV. Neurasthenia is classified in ICD-10 in Chapter V Mental and behavioural disorders, at F48.0, as shown in the table, above.

Chronic fatigue syndrome is not classified in DSM-IV. Chronic fatigue syndrome is indexed in ICD-10 to G93.3, (Chapter VI Diseases of the nervous system – the Neurology chapter), the same code to which PVFS and (Benign) ME are classified.

ICD-10 has “Fatigue syndrome”  [Note: not "postviral"; not "chronic"] coded at F48.0 in Chapter V, which specifically excludes G93.3 Postviral fatigue syndrome.

(Please refer to the “ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines” aka “the Blue Book” and to ICD-10 online for full categories, disorder descriptions, inclusions and exclusions for ICD-10 Somatoform Disorders.) [9] [10]

 

Q: What does “Harmonization” between DSM-IV and the forthcoming ICD-11 mean?

A:  The APA participates with the WHO in an International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and a DSM-ICD Harmonization Coordination Group.

There is already a degree of correspondence between some categories in DSM-IV and their equivalent sections in ICD-10 Chapter V. For their next editions, the APA and the WHO have committed as far as possible:

“To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria.”

with the objective that

“The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.”

The WHO acknowledges there may be areas where congruency between the two systems may not be achievable.

Q: Is ICD Revision intending to harmonize its Somatoform Disorders categories with the current proposals for DSM-5?

A: DSM-5 proposals are a “work in progress”. The proposals of the Somatic Symptom Disorders Work Group for the revision of categories within this section represent a radical restructuring of the current DSM-IV Somatoform Disorders; following fields trials, the Work Group will review and potentially revise their proposals. These proposals may be found to be inoperable in the field or otherwise unacceptable to clinicians participating in field trials. The Task Force may require the Work Group to make substantial modifications to the current proposals. A third public review is scheduled for January-February 2011 prior to the finalization of categories and criteria.

It’s not known how closely the DSM-5 Work Group for “Somatic Symptom Disorders” are collaborating with the ICD Revision working group responsible for overseeing the revision of ICD-10′s Somatoform Disorders categories.

There have been no minutes or summaries of meetings of the International Advisory Group for the Revision of ICD-10 Mental and behavioural disorders, in which the APA participates and which is chaired by DSM-5 Task Force member, Steven E Hyman, MD, published since December 2008 (a point raised recently with the WHO’s Dr Bedhiran Üstün) and the ICD Revision Topic Advisory Group for Mental Health does not issue public reports on its progress.

It is not known whether, to what extent or at what stage in the Alpha/Beta drafting process ICD Revision might seek to achieve congruency between category names, glossary descriptions and criteria for ICD-11 Chapter 5 and those being proposed for the restructured DSM “Somatoform Disorders” section. But the classifications under “Somatoform Disorders” for ICD-11 Chapter 5, according to the iCAT Alpha Drafting platform as it stood in November, last year, did not appear to mirror the proposals of the DSM-5 SSD Work Group:

Chapter 5 (V) Somatoform Disorders (the F codes) F45 – F48.0 (as displaying in the iCAT Alpha Drafting platform in November 2010):

(It is understood from ICD documentation that the child categories F45.40 and  F45.41 are proposed new entities for ICD-11.)

From what is understood of ICD taxonomic and ontological principles, the conceptual framework and radical restructuring of the Somatoform Disorders currently proposed by the SSD Work Group, might prove difficult for ICD-11 to assimilate even if ICD Revision were to consider the proposals, per se, to be valid constructs that could be used reliably.

 

Q: What proposals are being put forward for the revision of the DSM-IV categories currently known as ”Somatoform Disorders”?

A: The SSD Work Group is recommending renaming the “Somatoform Disorders” disorders section of DSM-IV to “Somatic Symptom Disorders”.

The Work Group proposes combining existing categories – Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), Factitious Disorder and Factitious Disorder imposed on another (previously known as Factitious Disorder by proxy) into one group entitled “Somatic Symptom Disorders”. Alternatively, Factitious Disorders would be listed under the category “Other Disorders”.

The Work Group’s summary justification is ‘Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, because of the implicit mind-body dualism and the unreliability of assessments of “medically unexplained symptoms,” these symptoms are no longer emphasized as core features of many of these disorders.’

‘…since Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric under a new category called “Complex Somatic Symptom Disorder” (CSSD).’

There is a relatively recent additional proposal for a category called “Simple (or abridged) Somatic Symptom Disorder” (SSSD).

These proposals would represent a major change in the diagnostic nomenclature for this section of the DSM.

The Work Group also proposes a category “Illness Anxiety Disorder” (hypochondriasis without somatic symptoms) and recommends the existing Conversion Disorder category be renamed “Functional Neurological Disorder”. (‘Somatic’  means of or relating to the body.)

 

Q: Have there been changes since the publication of the initial proposals, in February 2010?

A: Since the first public review, the Work Group has modified the criteria for “Complex Somatic Symptom Disorder (CSSD), added a new proposal for a category called ”Simple Somatic Symptom Disorder” and made revisions to the text of the two key PDF documents. So you will need to review the most recent criteria and the two key documents that accompany these latest proposals if you are intending to submit comment.

I shall be posting the latest proposals for criteria and the two key “Disorder Description” and “Rationale” documents in the next post (Post #77).

 

References

1] APA 4 May 2011  News release No. 11-27  or  http://tinyurl.com/APAnewsrelease4may11

2] “Somatic Symptom Disorders” Work Group Members, Bios and Disclosures

3] Latest proposals for “Somatic Symptom Disorders”

4] Key Somatic Symptom Disorders PDF Document: Disorder Descriptions

5] Key Somatic Symptom Disorders PDF Document: Justification of Criteria

6] Revised DSM-5 Timeline

7] Register on the DSM-5 site to submit stakeholder feedback

8] APA’s FAQ on DSM-5

[9] ICD-10 online (version for 2007) Chapter V: Somatoform Disorders: F45-F48.0 codes”

[10] ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines” (aka “the Blue Book”) PDF format

APA News Release 4 May 2011: New Framework Proposed for Manual of Mental Disorders

APA News Release 4 May 2011: New Framework Proposed for Manual of Mental Disorders

Post #74 Shortlink: http://wp.me/pKrrB-12x

http://tinyurl.com/APAnewsrelease4may11

APA News Release 4 May 2011

American Psychiatric Association

News Release

For Information Contact:                                                            Release No. 11-27
Eve Herold 703-907-8640
press@psych.org

Erin Connors 703-907-8562
econnors@psych.org

FOR IMMEDIATE RELEASE

New Framework Proposed for Manual of Mental Disorders
APA Revisions a Key Step in Development of DSM-5

ARLINGTON, Va. (May 4, 2011) The American Psychiatric Association today released the organizational framework proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). This restructuring of the DSMs chapters and categories of disorders signals the latest scientific thinking about how various conditions relate to each other and may influence care. The APA is again inviting comment from the public and mental health and other professionals who use the manual for both diagnostic and research purposes.

The revisions reflect the knowledge we have gained since the last DSM was published in 1994, said David Kupfer, M.D., chair of the DSM-5 Task Force. They should facilitate more comprehensive diagnosis and treatment approaches for patients and encourage research across diagnostic criteria.

The changes re-order the existing manuals 16 chapters based on underlying vulnerabilities as well as symptom characteristics, which currently result in many patients being diagnosed with multiple disorders within and across disorder groups. The chapters are arranged by general categories such as neurodevelopmental, emotional and somatic to reflect the potential commonalities in etiology within larger disorder groups.

The sequence of chapters builds on what we have learned about the brain, behavior and genetics over the past two decades, noted Steven Hyman, M.D., former director of the National Institute of Mental Health and a member of the DSM-5 Task Force.

Public comment is invited through June 15 on the draft framework and the latest proposed revisions to diagnostic criteria, both available on www.dsm5.org. During an initial public review and comment period last year an unprecedented occurrence in both the field of psychiatry and in medicine the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates. All of the responses were considered as part of the manuals reorganization.

Todays release marks another stage in the development of DSM-5. Rigorous scientific scrutiny is shaping this 14-year project, with the involvement of nearly 500 experts from the United States and abroad. Publication is scheduled for 2013.

The manuals new organization combines certain disorders under more comprehensive chapter headings while breaking others out from their previous categories. One example is obsessive-compulsive disorder (OCD), long considered to be an anxiety-driven disorder. Recent studies have shown that OCD and several related disorders involve distinct neurocircuits, and so they are now listed as a separate grouping a move that could advance understanding of their root causes.

There are other notable changes. Disorders previously listed under a single rubric of infancy, childhood and adolescence have been integrated into other chapters, in line with the goal of making DSM more developmentally focused. In addition, research findings linking schizophrenia and schizotypal personality disorder into a schizophrenia spectrum will be reflected in this next edition.

The schizophrenia spectrum designation is supported by studies showing how these disorders tend to aggregate within families, said Darrel Regier, M.D., M.P.H., vice chair of the DSM-5 Task Force and executive director of the American Psychiatric Institute for Research and Education. It will help clinicians to correctly diagnose patients by making clear the common features that fall within the spectrum.

To date, reports on the deliberations and progress of the task force and 13 work groups have been presented at international conferences, through more than 100 papers and via the DSM-5 website. After last years public comment period, the work groups continued to amend and refine some categories of disorders.

The first round of field trials is now testing the new diagnostic criteria in real-world settings, including at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.

The DSM-5 framework and diagnostic criteria will be determined by 2012 and submitted to the APAs Board of Trustees for review and approval.

At every stage, said Kupfer, DSM-5 is benefiting from a depth of research and a breadth of expertise and diverse opinions that will immeasurably strengthen the final document.

The American Psychiatric Association is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org.

 

Media coverage, APA’s 4 May DSM-5 announcement

MedPage Today

CNN Blog

 

Related information:

Post: 05.05.11 American Psychiatric Association (APA) announces second public review of DSM-5 draft criteria and structure

APA announces second public review of DSM-5 draft criteria and structure

American Psychiatric Association (APA) announces second public review of DSM-5 draft criteria and structure

Post #73 Shortlink: http://wp.me/pKrrB-12k

Second public stakeholder review and feedback period now 4 May to 15 June

APA News Release No: 11-27 PDF: http://tinyurl.com/APAnewsrelease4may11 

or open PDF on this site here: New Framework Proposed for Manual of Mental Disorders

Online posting of draft disorders and criteria proposed by the 13 DSM-5 Work Groups for new and existing mental disorders had originally been scheduled for May-June, this year. According to a revised Timeline on the APA’s DSM-5 Development site, in March, this second public review exercise had been rescheduled for August-September:

“August-September 2011: Online Posting of Revised Criteria. Following the internal review, revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on September 30, 2011.”

But yesterday, 4 May, the APA announced that the second public review period is now open and will run from May to 15 June.

The DSM-5 site was updated yesterday with announcements and revised proposals (dated May 4, 2011) across all categories. The current review period closes on 15th June – just six weeks away.

Note that this is a public and stakeholder review and feedback exercise and is not restricted to professionals or members of the American Psychiatric Association.

There is a Task Force announcement here: http://www.dsm5.org/Pages/Default.aspx

[Extracts]

“What Specifically Has Changed on This Site?

“You will notice several changes to this Web site since we first launched in February 2010. Numerous disorders contain updated criteria…

” ...Is There Opportunity to Provide Further Comments?

“At this time, we are asking visitors to review and comment on the proposed DSM-5 organizational structure and criteria changes. Please note that the current commenting period will end on June 15, 2011. It is important to remember that the proposed structure featured here is only a draft. These proposed headings were reviewed by the DSM-5 Task Force in November 2010…

“…The content on this site will stay in its current form until after completion of the DSM-5 Field Trials, scheduled to conclude later this year. Following analysis of field trial results, we will revise the proposed criteria as needed and, after appropriate review and approval, we will post these changes on this Web site. At that time, we will again open the site to a third round of comments from visitors, which will be systematically reviewed by each of the work groups for consideration of additional changes. Thus, the current commenting period is not the final opportunity for you to submit feedback, and subsequent revisions to DSM-5 proposals will be jointly informed by field trial findings as well as public commentary.

“We look forward to receiving your feedback during the coming weeks and appreciate your participation in this important process.”      [Source: http://www.dsm5.org/Pages/Default.aspx]

There are brief notes on the proposed DSM-5 Organizational Structure here:

http://www.dsm5.org/proposedrevision/Pages/proposed-dsm5-organizational-structure.aspx

The “Recent updates” page for “DSM changes” and “Disorder-specific changes” is here:

http://www.dsm5.org/Pages/RecentUpdates.aspx

 

Registration for submitting feedback

Last year, registration was required in order to submit comment via the DSM-5 Development website. You can register to submit feedback on the DSM-5 Development site home page or on the individual pages for specific category proposals (right hand side under “Participate”).

The revised Timeline can be read here: http://www.dsm5.org/about/Pages/Timeline.aspx

According to the Timeline, a third review and feedback is currently scheduled for January-February 2012, for two months.

 

Latest revisions for “Somatic Symptom Disorders”

http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

I will post  information in the next posting specific to the proposals of the DSM-5  Work Group for “Somatic Symptom Disorders”

 

Media coverage of APA’s 4 May DSM-5 announcement

MedPage Today

CNN Blog

Washington Examiner: Corrupting Psychiatry by Max Borders

Washington Examiner: Corrupting Psychiatry by Max Borders

Post #58 Shortlink: http://wp.me/pKrrB-TU

Interesting commentary from writer Max Borders, last week, on the website of the Washington Examiner around the revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM):

Washington Examiner

Corrupting Psychiatry

By Max Borders 01/18/11 10:22 AM

“The American Psychiatric Association (APA) has gone crazy — like a fox.

“There was a time when we could be more charitable about the vagaries in the APA’s Bible, the DSM. But not anymore. If you’ve never heard of the DSM, it’s the Diagnostic and Statistical Manual series the APA publishes. Psychiatrists all over the world use the DSM as a guidebook for treating people with some form of mental illness. But the APA may test credulity with its upcoming edition.

“I refer specifically to proposed changes in the DSM-V due out in 2013. It’s no accident these changes reflect new political realities about how psychiatric medicine gets paid for and by whom…”

Read rest of article at the Washington Examiner

Commentary in response to “Corrupting Psychiatry” from Dutch philosopher and psychologist, Maarten Maartensz, on Nederlog here More on the APA’s mockery of medicine and morality and here More on the APA and the DSM-5

Comments on Washington Examiner to article “Corrupting Psychiatry” by Max Borders

By: Skeeter
Jan 21, 2011 9:55 PM

Good article, that says things that need to be said, long and loud.

Both the APA, and the broader psychiatric profession, are currently indulging in a seriously unjustified power grab, and they and their claims are in desperate need of much closer and tougher (and ongoing) external scrutiny then they have been subject to date.

Generally speaking, I would have to agree that the profession is becoming much too closely aligned with and mutually reliant on both state and corporate interests, as opposed to the interests of the patient and the science on which they base their claims to authority.

One small point: I would not invoke British psychiatry as any counterbalance to the excesses of their American colleagues. The Brits have their own serious problems. Not least of which is that they are mired deep in the methodological and ethical swamp of somatoform disorders (aka conversion or psychosomatic disorders, and their related ‘treatments’), and a lot of patients are paying a very heavy price indeed for this obsession by certain influential members of the British psych establishment.

By: Suzy Chapman
Jan 22, 2011 7:28 AM

Erasing the interface between psychiatry and medicine

The previous commenter cautions against invoking members of the “British psych establishment”. Two very influential members of the British psychiatry and psychosomatics establishment, Professors Michael Sharpe and Francis Creed, have seats on the DSM-5 “Somatic Symptom Disorders” Work Group.

While many column inches by rightly perturbed journalists and a stream of often acerbic critiques from former DSM Task Force chairs, Allen Frances and Robert Spitzer, have focussed on the implications for introducing new additions into the DSM and broadening the definitions of existing diagnostic criteria, the DSM-5 “Somatic Symptom Disorders” Work Group (Chair, Joel E Dimsdale) has been quietly redefining DSM’s “Somatoform Disorders” categories with proposals that if approved would legitimise the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders.

Radical proposals for renaming the “Somatoform Disorders” category “Somatic Symptom Disorders” and combining a number of existing categories under a new umbrella, “Complex Somatic Symptom Disorder (CSSD)” and a more recently suggested “Simple Somatic Symptom Disorder (SSSD)”, have the potential for bringing millions more patients under a mental health banner and expanding markets for psychiatric services, antidepressants, antipsychotics and behavioural therapies such as Cognitive Behavioural Therapy (CBT) for all patients with somatic symptoms, irrespective of cause.

Professor Creed is co-editor of The Journal of Psychosomatic Research. In a June ’09 Editorial, titled “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report”, which expanded on a brief DSM-5 Work Group progress report published on the DSM-5 Development website that April, Joel E Dimsdale and fellow DSM-5 Work Group member, Francis Creed, reported that by doing away with the “controversial concept of medically unexplained symptoms”, their proposed classification might diminish the “dichotomy, inherent in the ‘Somatoform’ section of DSM IV, between disorders based on medically unexplained symptoms and patients with organic disease.”

If the most recent “Somatic Symptom Disorders” Work Group proposals gain DSM Task Force approval, all medical conditions, whether “established general medical conditions or disorders” like diabetes or conditions presenting with “somatic symptoms of unclear etiology” will have the potential for a bolt-on diagnosis of “somatic symptom disorder”.

Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” the American Psychiatric Association (APA) appears hell bent on colonising the entire medical field by licensing the application of a mental health diagnosis to all medical diseases and disorders.

By: KAL
Jan 23, 2011 1:36 PM

Who else might benefit? Disability Insurance. If you can be shown to have a “mental illness” then disability insurance only pays a maximum of two years of payments vs. a lifetime of payments for an organic disease.

Check the APA website for conflicts of interest for members of the working group for Somatic Disorders.

References:

DSM-5 Development website: Somatoform Disorders
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Proposal: Complex Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

Proposal: Simple Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

The most recent versions of the two key documents associated with the proposals of the “Somatic Symptom Disorders” Work Group are:

Update @ 7 February 2011

The Justification of Criteria document was revised again by the SSD Work Group on 1/31/11 to incorporate the new proposal for SSSD and other revisions and is replaced by:

DRAFT 1/31/11  Justification of Criteria – Somatic Symptoms

Revised Disorder Descriptions: Version 1/14/11

 Previous revised Justification of Criteria: Version 10/4/10

DSM-5: New category proposal “Simple Somatic Symptom Disorder”

DSM-5: New category proposal “Simple Somatic Symptom Disorder”

Post #57 Shortlink: http://wp.me/pKrrB-TA

On 16 January, I reported that the page for current DSM-5 proposals for the revision of the DSM-IV “Somatoform Disorders” categories and diagnostic criteria had been updated on 14 January, with a new category proposal called “Simple Somatic Symptom Disorder”.

This proposal is in addition to the recommendations of the Somatic Symptom Disorders Work Group, published in February 2010, for grouping a number of existing Somatoform categories under a common rubric “Complex Somatic Symptom Disorder (CSSD)” and does not replace “CSSD”.

For full details see previous Post #56: http://wp.me/pKrrB-St 

Simple Somatic Symptom Disorder

Updated January-14-2011

See Tab: Proposed Revision:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Simple (or abridged) Somatic Symptom Disorder (e.g. pain)

To meet criteria for Simple Somatic Symptom Disorder, criteria A, B, and C are necessary.

A. One or more highly distressign [sic] and disabling somatic symptoms

B. One of the following symptoms from CSSD (i.e. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms; high level of health-related anxiety; or excessive time and energy devoted to these symptoms or health concerns)

C. Symptom duration is greater than 1 month

For full proposals for “Simple Somatic Symptom Disorder” open the Tabs on this page:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

 

Key links and documents associated with the proposals of the Somatic Symptom Disorders Work Group:

DSM-5 Development website: Somatoform Disorders
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Proposal: Complex Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

Proposal: Simple Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Update @ 7 February 2011

The Justification of Criteria document was revised again by the SSD Work Group on 1/31/11 to incorporate the proposal for SSSD and other revisions and is replaced by:

DRAFT 1/31/11 Justification of Criteria – Somatic Symptoms

        Revised Disorder Descriptions: Version 1/14/11

        Previous revised Justification of Criteria: Version 10/4/10

I shall be monitoring the DSM-5 Development website and if there are any further revisions to either document before the DSM-5 beta is published I will update this site.

According to the APA’s DSM-5 Development Timeline, the second draft is scheduled to be published by the DSM-5 Task Force in May-June, with a public review period of only around a month. The public review and comment period for the first draft, last year, had been around ten weeks.

The following patient organisations have been alerted to these revisions and sent copies of the key documents:

UK patient organisations:

Heather Walker, Action for M.E.
Neil Riley, Chair, Board of Trustees, ME Association
25% ME Group
Invest in ME
Jane Colby, The Young ME Sufferers Trust

US patient organisations and professionals:

Dr Alan Gurwitt, Massachusetts Chronic Fatigue and Immune Dysfunction Syndrome/Myalgic Encephalopathy and Fibromyalgia Association (Mass. CFIDS/ME & FM)
Dr Kenneth Friedman, IACFS/ME
Jennie Spotila, CFIDS Association of America
Dr Lenny Jason

International patient organisations and professionals:

ESME (European Society for ME)
Dr Eleanor Stein, Canada

Revisions to DSM-5 proposals on 14.01.11: New category proposed “Simple Somatic Symptom Disorder”

Revisions to DSM-5 proposals on 14.01.11: New category proposed “Simple Somatic Symptom Disorder”

Post #56 Shortlink: http://wp.me/pKrrB-St 

DSM-5 Dustbin Diagnosis

For copies of International patient organisation and patient advocate submissions in the APA’s spring 2010 DSM-5 draft proposals review process see: http://wp.me/PKrrB-AQ

The page for current DSM-5 proposals for the “Somatoform Disorders” section of DSM-IV was updated on January 14, 2011 with a new category proposal called “Simple Somatic Symptom Disorder”.

Note this proposal is in addition to the recommendation of the Somatic Symptom Disorders Work Group, in February 2010, for grouping a number of existing disorders under a common rubric “Complex Somatic Symptom Disorder (CSSD)”  and it does not replace “CSSD”.

As I have been highlighting for some time now, under these DSM-5 Task Force proposals, all medical conditions, whether “established” general medical conditions or disorders, or conditions presenting with “somatic symptoms of unclear etiology”, have the potential for qualifying for an additional diagnosis of a “somatic symptom disorder”.

There have also been revisions and additions to some of the text of the “Disorder descriptions” document dated “DRAFT January 29, 2010″ that was first published by the DSM-5 Task Force when draft proposals for revisions to DSM-IV were posted on the APA’s DSM-5 website on February 10, 2010, for public review and comment.

Note also that the key document: “Justification of Criteria-Somatic Symptoms DRAFT 1/29/10″ which is also associated with the proposals of the Somatic Symptom Disorders Work Group has now been revised twice since February 2010.

Update @ 7 February 2011

The Justification of Criteria document was revised for a second time by the SSD Work Group on 1/31/11 to incorporate the new proposal for SSSD and other revisions and is replaced by:

DRAFT 1/31/11  Justification of Criteria – Somatic Symptoms

     Previous revised Justification of Criteria: Version 10/4/10

What are the changes since draft proposals were released in February 2010?

On the APA’s DSM-5 Development web page:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

under “Somatoform Disorders Not Currently Listed in DSM-IV”

are now listed two proposals:

“Complex Somatic Symptom Disorder”

(which was discussed last year when the DSM-5 draft proposals were first released) and a new proposal:

“Simple Somatic Symptom Disorder”

So the APA’s DSM-5 Development site page now reads:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx  

Somatoform Disorders

Please find below a list of disorders related to the diagnostic category, Somatoform Disorders. The Somatic Symptom Disorders Work Group has been responsible for addressing these disorders. Among the work group’s recommendations is the proposal to rename this category Somatic Symptom Disorders. Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, because of the implicit mind-body dualism and the unreliability of assessments of “medically unexplained symptoms,” these symptoms are no longer emphasized as core features of many of these disorders. Since somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric called complex somatic symptom disorder. We appreciate your review and comment on these disorders.

*Somatoform Disorders Not Currently Listed in DSM-IV

Complex Somatic Symptom Disorder |
Simple Somatic Symptom Disorder |

*Somatoform Disorders Proposed for Possible Reclassification in Another Diagnostic Category

300.7 Body Dysmorphic Disorder

*Somatoform Disorders Proposed to be Subsumed Under Other Diagnoses
(No DSM-5 Criteria Proposed)

300.81 Somatization Disorder |
300.82 Undifferentiated Somatoform Disorder |
307.80 Pain Disorder Associated With Psychological Factors |
300.7 Hypochondriasis |
307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition |
Pain Disorder |

Somatoform Disorders

300.11 Conversion Disorder |
300.82 Somatoform Disorder Not Otherwise Specified |

The URL for the new page for the proposal “Simple Somatic Symptom Disorder” is:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Below is the full text available from the various child pages at that link:

Simple Somatic Symptom Disorder

Updated January-14-2011

See Tab: Proposed Revision:
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Simple (or abridged) Somatic Symptom Disorder (e.g. pain)

To meet criteria for Simple Somatic Symptom Disorder, criteria A, B, and C are necessary.

A. One or more highly distressign [sic] and disabling somatic symptoms

B. One of the following symptoms from CSSD (i.e. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms; high level of health-related anxiety; or excessive time and energy devoted to these symptoms or health concerns)

C. Symptom duration is greater than 1 month

See Tab: Severity:

[Ed: This is presented in tabular format.]

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491#

PHQ Somatic Symptom Short Form (PHQ-SSS)

During the past SEVEN (7) DAYS how much have you been bothered by…

[Ed: fields are scored from 1-5]

Not at all; A little bit; Somewhat; Quite a bit; Very much

1. Stomach or problems going to the toilet?
2. Pain in your back?
3. Pain in your arms, legs, or joints
4. Headaches?
5. Chest pain or getting out of breath?
6. Dizziness?
7. Feeling tired or having low energy?
8. Trouble sleeping?

See Tab: DSM-IV:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491#

This disorder is not listed in DSM-IV; therefore DSM-IV criteria for this disorder does not exist.

See Tab: Rationale:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491#

Please see full disorder descriptions here [ Somatic Symptom Disorders Description document 14.01.11 ]

[ or open on this site here:Somatic Symptom Disorders Description document 14.01.11 ]

[Ed: This document is a revised text of the document published by the DSM-5 Task Force in February 2010. That document is no longer available on the DSM-5 site pages but for comparison, a PDF copy is archived on my own site here: APA DSM Validity Propositions 1-29-2010or contact me for a copy of the original text.]

[Full text version follows which includes notes by Suzy Chapman identified as "Ed" indicating revisions and additions to the original text.]

© 2010 American Psychiatric Association. All Rights Reserved. See Terms & Conditions of Use for more information

DRAFT January 14, 2011

Somatic Symptom Disorders

Introduction

This group of disorders is characterized predominantly by somatic symptoms or concerns that are associated with significant distress and/or dysfunction. Somatic symptoms are common in every day life and medical practice. Such symptoms may be initiated, exacerbated or maintained by combinations of biological, psychological and social factors. The diagnostic criteria are applicable across the lifespan, even though developmental differences in the presentation and phenomenology of somatic symptom disorders may exist.

These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis.

[Ed: Note that Chronic Fatigue Syndrome is not specified in this revised text and CFS had not been specified in the original text of the February, 2010 document.]

Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met.

[Ed: The para above is new text.  Note: as I have been highlighting for some time now, under these proposals, all medical conditions - whether "established general medical conditions" and disorders or conditions presenting with "somatic symptoms of unclear etiology" - have the potential for qualifying for an additional diagnosis of a somatic symptom disorder.]

There are other psychiatric disorders, which may present with prominent somatic symptoms such as depression or panic; therefore, not all presentations with somatic symptoms would qualify for these diagnoses.

The presentation of these symptoms may vary across the lifespan. A corroborative historian with a life course perspective may provide important information for both the elderly and for children.

[Ed: The 2 paras above are new text.]

I. Psychological factors affecting medical condition (#316).

The essential feature of this disorder is the presence of one or more clinically significant psychological or behavioral factor that adversely affects a somatic symptom or medical condition by increasing risk for suffering, death, or disability. These factors can adversely affect the medical illness by influencing its course or treatment, by constituting an additional health risk factor, or by exacerbating the physiology that is related to the medical illness.

Psychological or behavioral factors include psychological distress, patterns of interpersonal interaction, coping styles and maladaptive health behaviors such as denial of symptoms or poor adherence to medical recommendations. Common clinical examples are: anxiety exacerbating asthma, denial of need for treatment for acute chest pain, manipulating insulin in order to lose weight.

This diagnosis should be reserved for situations where the effect of the psychological factor on the medical condition is evident, and the psychological factor has clinically significant effects on the course or outcome of the medical condition. Abnormal psychological or behavioral symptoms that develop in response to a medical condition are more properly coded as an adjustment disorder (a clinically significant psychological response to an identifiable stressor).

PFAMC can occur across the lifespan. Particularly with young children, corroborative history from parents or school can assist the diagnostic evaluation.

[Ed: The para above is new text.]

To meet criteria for Psychological Factors Affecting Medical Condition, both criteria A and B are necessary.

A. A general medical condition is present.

B. Psychological or behavioral factors adversely affect the general medical condition in at least one of the following ways:

1. the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition

2. the factors (e.g. poor adherence) interfere with the treatment of the general medical condition

3. the factors constitute additional health risks for the individual

4. the factors influence physiology to precipitate or exacerbate symptoms of the general medical condition

  

II. Complex Somatic symptom disorder (CSSD) (#XXX)

This disorder is characterized by a combination of distressing (often multiple) symptoms and an excessive or maladaptive response to these symptoms or associated health concerns. The patient’s suffering is authentic, whether or not it is medically explained. Patients typically experience distress and a high level of functional impairment. The symptoms may or may not accompany diagnosed general medical disorders or psychiatric disorders. There may be a high level of medical care utilization, which rarely alleviates the patient’s concerns. From the clinician’s point of view, many of these patients seem unresponsive to therapies, and new interventions or therapies may only exacerbate the presenting symptoms or lead to new side effects and complications. Some patients feel that their medical assessment and treatment have been inadequate.

[Ed: Previously read: The hallmark of this disorder is disproportionate or maladaptive response to somatic symptoms or concerns. Patients typically experience distress and a high level of functional impairment. In severe cases, they may adopt a sick role. Sometimes the symptoms accompany diagnosed general medical disorders or psychiatric disorders, and sometimes the disorder occurs alone. There may be a high level of health care utilization, which rarely alleviates the patient's concerns. From the clinician's point of view, many of these patients seem unresponsive to therapies, and new interventions or therapies may only exacerbate the presenting symptoms or lead to new side effects and complications. Some patients feel that their medical assessment and treatment have been inadequate.]

Patients with this diagnosis typically have multiple, current, somatic symptoms that are distressing; sometimes, they may have only one severe symptom. The symptoms may or may not be associated with a known medical condition. Symptoms may be specific (such as localized pain) or relatively non-specific (e.g. fatigue). The symptoms sometimes represent normal bodily sensations (e.g., orthostatic dizziness), or discomfort that does not generally signify serious disease (e.g., bad taste in one’s mouth). Health-related quality of life is frequently severely impaired.

[Ed: Previously read: Patients with this diagnosis typically have multiple, current, somatic symptoms that are distressing; rarely, they may have only one severe symptom. The symptoms may or may not be associated with a known medical condition. Symptoms may be specific (such as localized pain) or relatively non-specific (e.g. fatigue or multiple symptoms). The symptoms sometimes represent normal bodily sensations (e.g., orthostatic dizziness), or discomfort that does not generally signify serious disease (e.g., bad taste in one's mouth) or are incompatible with known pathophysiology (e.g. seeing double with one eye closed). Such patients often manifest a poorer health-related quality of life than patients with other medical disorders and comparable symptoms.]

Patients with this diagnosis tend to have very high levels of health-related anxiety. They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often fear the worst about their health. Even when there is evidence to the contrary, they still fear the medical seriousness of their symptoms. Health concerns may assume a central role in the individual’s life, becoming a feature of his/her identity and dominating interpersonal relationships.

[Ed: Previously read: Patients with this diagnosis tend to have heightened levels of health-related anxiety and a low threshold for alarm about the presence of illness. They appraise their bodily symptoms as particularly threatening, harmful, or troublesome and have a tendency to assume the worst about their health. They believe in the medical seriousness of their symptoms despite evidence to the contrary. Health concerns are diffuse and may assume a central role in their lives, becoming a feature of their identity, a way of responding to stressful events, a topic of interpersonal communication, or a basis for interpersonal relationships]

If all of the somatic symptoms are consistent with another psychiatric disorder (e.g. panic disorder), and the diagnostic criteria for that disorder are fulfilled, then that psychiatric disorder should be considered as an alternative or additional diagnosis. If the patient has worries about health but no somatic symptoms, he/she may be more appropriately considered for an anxiety disorder diagnosis.

In the elderly somatic symptoms and comorbid medical illnesses are more common, and thus a focus on criteria B becomes more important. In the young child, the “B criteria” may be principally expressed by the parent.

CSSD is a disorder characterized by chronicity, symptom burden, and excessive or maladaptive response to symptoms. When patients do not meet criteria for these domains, other diagnoses should be considered such as Simple Somatic Symptom Disorder (SSSD).

[Ed: All 3 paras above are new text.]

Complex somatic symptom disorder (includes previous diagnoses of somatization disorder DSM IV code 300.81, undifferentiated somatoform disorder DSM IV code 300.81, hypochondriasis DSM IV code 300.7, as well as some presentations of pain disorder DSM IV code 307). To meet criteria for CSSD, criteria A, B, and C are necessary.

A. Somatic symptoms:

One or more somatic symptoms that are distressing and/or result in significant disruption of daily life.

[Ed: Previously read: A. Somatic symptoms: Multiple somatic symptoms that are distressing, or one severe symptom]

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:

(1) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.

(2) High level of health-related anxiety

(3) Excessive time and energy devoted to these symptoms or health concerns

[Ed: Previously read: B. Misattributions, excessive concern or preoccupation with symptoms and illness: At least two of the following are required to meet this criterion: (1) High level of health-related anxiety. (2) Normal bodily symptoms are viewed as threatening and harmful (3) A tendency to assume the worst about their health (catastrophizing). (4) Belief in the medical seriousness of their symptoms despite evidence to the contrary. (5) Health concerns assume a central role in their lives]

[Ed: According to the DSM-5 website "Criteria B is still under active discussion"]

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).

For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:

XXX.1 Predominant somatic complaints (previously, somatization disorder)

XXX.2 Predominant health anxiety (previously, hypochondriasis) If patients present solely with health related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having Illness Anxiety Disorder (see V.B below).

XXX.3 Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

[Ed: Previously read: C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent (at least 6 months). The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation: XXX.1 Multiplicity of somatic complaints (previously, somatization disorder) XXX.2 High health anxiety (previously, hypochondriasis) {If patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.} XXX.3 Pain disorder. This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as major depression or adjustment disorder.]

For assessing severity of CSSD, metrics are available for rating the presence and severity of somatic symptoms (see for instance PHQ, Kroenke et al, 2002). Scales are also available for assessing severity of the patient’s misattributions, excessive concerns and preoccupations (see for instance Whiteley inventory, Pilowsky , 1967).

[Ed: New proposal "Simple (or abridged) somatic symptom disorder" is inserted here and subsequent sections are renumbered.]

*************************************************

III. Simple (or abridged) somatic symptom disorder [xxxxxxxx] e.g. pain (#XXX)

To meet criteria for SSSD, criteria A, B, and C are necessary.

A. One or more highly distressing and disabling somatic symptoms

B. One of the following symptoms from CSSD (i.e. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms; High level of health-related anxiety; or Excessive time and energy devoted to these symptoms or health concerns)

C. Symptom duration >1 month.

*************************************************

[Ed: This category is proposed (14.01.11) to replace 300.7 Hypochondriasis.

See:http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=10 ]

IV. Illness Anxiety Disorder

This disorder is characterized by high illness anxiety that is distressing and/or disruptive to daily life with minimal somatic symptoms. The following 5 criteria must be met.

A. Preoccupation with having or acquiring a serious illness. If a general medical condition or high risk for developing a general medical condition is present, the illness concerns are clearly excessive.

B. Somatic symptoms are not present or, if present, are only mild in intensity.

C. The person performs related excessive behaviors (e.g. checking one’s body for signs of illness, seeking reassurance from the internet or other sources), or exhibits maladaptive avoidance (e.g. avoiding traveling far from one’s doctor, avoiding triggers of illness fears such as exercise or visits to those who are ill).

D. Although the preoccupation may not be continuously present, the state of being preoccupied is chronic (at least 6 months)

E. The illness-related preoccupation is not better accounted for by the symptoms of another mental disorder such as complex somatic symptom disorder, panic disorder, generalized anxiety disorder, or obsessive compulsive disorder.

*************************************************

V. Functional Neurological Symptoms (previously, Conversion disorder (#300.11)

The essential feature of this disorder is neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. The symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms (including loss of vision and hearing), or speech and swallowing difficulties. In addition, the diagnosis will usually be supported by evidence of internal inconsistency or incongruity with neurological disease. This evidence may include physical signs (such as, Hoover’s sign of functional weakness) or diagnostic investigations (such as seizure-like behaviour in the absence of simultaneous non-convulsive activity on EEG). The symptoms may be acute or chronic. Whilst psychological factors may be noted to be associated with the onset of symptoms, they are not essential for the diagnosis. Co-morbid neurological disease may also be present and does not exclude the diagnosis.

If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering. When the symptom is limited to pain, fatigue, dizziness, cognitive symptoms or to a disturbance in sexual functioning, it is typically coded elsewhere in the DSM (a different Somatic Symptom Disorder diagnosis or in the Sexual Disorders Section).

[Ed: Previously read (as "III. Conversion disorder"): Patients with conversion disorder typically present with neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. These presentations may be acute or chronic. Typical symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms, dizziness, speech and swallowing difficulties. In addition, the diagnosis will usually be supported by confirmatory physical signs or diagnostic investigations consistent with the diagnosis (such as, Hoover's sign). Psychological factors may be associated with the onset of symptoms, but are not essential for the diagnosis. If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering.]

Criteria A, B, C and D must all be fulfilled to make the diagnosis:

A. One or more symptoms of altered voluntary motor, sensory function, cognition, or seizure-like episodes

B. The symptom, after appropriate medical assessment, is not found to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience.

C. Physical signs or diagnostic findings that provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.

[Ed: Previously read: Criteria A, B, and C must all be fulfilled to make the diagnosis: A. One or more symptoms are present that affect voluntary motor or sensory function. B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience. C. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.]

D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

[Ed: Criteria D above is new text.]

  

IV. Factitious disorder #300

Factitious disorders entail long-term,persistent problems related to illness perception and identity. They can be associated with unexpected and/or unexplained symptoms. Individuals with Factitious Disorders falsify medical and/or psychological impairment in themselves and/or others. The diagnosis requires demonstrating that the patient is taking surreptitious actions to cause or simulate illness in the absence of obvious rewards. While an underlying condition may be present, the deceptive behavior associated with this disorder causes others to view such individuals (and/or their proxy) as more ill or impaired than they are and can lead to excessive clinical intervention.

Those with Factitious Disorder by Proxy have been known to falsify illness in children of any age, adults, and pets. The victim (or proxy) is not given the diagnosis of Factitious Disorder by Proxy. When a Factitious Disorder leads to abuse of another or other criminal behavior, V code designations for the victim may be indicated.

Malingering, defined as intentional reporting of symptoms for personal gain (e.g. money, time off work, etc) is not a psychiatric disorder.

IV A. Factitious Disorder on Self (#300.X)- To make this diagnosis, all 4 criteria must be met.

1. A pattern of falsification of physical or psychological signs or symptoms, associated with identified deception.

2. A pattern of presenting oneself to others as ill or impaired.

3. The behavior is evident even in the absence of obvious external rewards.

4. The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.

IV B. Factitious Disorder on another (#300.X) To make this diagnosis, all 4 criteria must be met. Note that the perpetrator, not the victim, receives this diagnosis.

1. A pattern of falsification of physical or psychological signs or symptoms in another, associated with identified deception.

2. A pattern of presenting another (victim) to others as ill or impaired.

3. The behavior is evident even in the absence of obvious external rewards.

4. The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.

[Ed: Section V. Somatic symptom disorder, NOS (# XXX) is omitted from this revised document.]

 

[Ed: The section VII Pseudocyesis that follows is an addition to the text.]

VII Pseudocyesis

The patient has a false belief of being pregnant that is associated with objective signs of pregnancy, which may include abdominal enlargement, reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. While endocrine changes may be present, the syndrome cannot be explained by a general medical condition that causes endocrine changes (e.g., a hormone-secreting tumor).

Body dysmorphic disorder

This disorder is being reviewed by the Anxiety Disorders workgroup. Depending upon criteria and evidence, it may be relocated to the Anxiety Disorders section of DSM or may be incorporated into CSSD.

[Text of PDF ends]

Key documents associated with the proposals of the Somatic Symptom Disorders Work Group:

The Justification of Criteria document was revised again by the SSD Work Group on 1/31/11 to incorporate the new proposal for SSSD and other revisions and is replaced by this document which was the most recent version at 7 February 2011:

DRAFT 1/31/11  Justification of Criteria – Somatic Symptoms

       Revised Disorder Descriptions: Version 1/14/11

       Previous version of Justification of Criteria: Version 10/4/10

Please also see:

Other Clinical Conditions That May Be a Focus of Clinical Attention

Please find below a list of diagnoses related to the diagnostic category, Other Clinical Conditions that May Be a Focus of Clinical Attention. The Somatic Symptoms Disorders Work Group has been responsible for addressing these disorders. This diagnostic category also includes conditions related to psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. In addition, this category contains a listing of movement disorders related to medication use. The work groups are still discussing whether DSM-5 will contain any revisions to these conditions and diagnoses. We appreciate your review and comment on these disorders.

Psychological Factors Affecting Medical Condition

316 Mental Disorder Affecting Medical Condition

316 Psychological Symptoms Affecting Medical Condition

316 Personality Traits or Coping Style Affecting Medical Condition

316 Maladaptive Health Behaviors Affecting Medical Condition

316 Stress-Related Physiological Response Affecting Medical Condition

316 Other or Unspecified Psychological Factors Affecting Medical Condition

316 Psychological Factors Affecting Medical Condition

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Acccording to the DSM-5 Development Timeline:

March – April 2011: Revisions to Proposed Criteria. Based on results from the first phase of field trials, the DSM-5 Task Force and Work Group members will make revisions to the proposed DSM-5 diagnostic criteria and dimensional measures. These revised criteria and measures will be tested in a second phase of field trials.

April – May 2011: Review of Revised Criteria. Revised proposed criteria will be subjected to internal review, including a review by the DSM-5 Task Force and Research Group and by other relevant work groups.

May-July 2011: Online Posting of Revised Criteria. Following the internal review, revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on June 30, 2011.

 

Submissions 2010

International patient organisation and patient advocate submissions to DSM-5 draft proposals public review process, Feb-April 2010: http://wp.me/PKrrB-AQ