Welcome to DSM-5 Facts (The APA’s new PR site)

Welcome to DSM-5 Facts (The APA’s new PR site)

Post #175 Shortlink: http://wp.me/pKrrB-2cm

There’s just a couple of weeks left until the deadline for receipt of stakeholder comments in the third and final review of DSM-5 proposals but still no sign of the promised “full results of the field trials” from the Task Force.

In the meantime, something else from the APA, or rather its PR firm. A spanking new DSM-5 Facts site launched this week “to correct the record” and provide the public with “a complete and accurate view of this important issue.”

http://dsmfacts.org/

Welcome to DSM-5 Facts

The American Psychiatric Association believes strongly in the work that is being done to revise the Diagnostic and Statistical Manual of Mental Disorders (DSM). In preparation for the release of DSM-5, experts from psychiatry, psychology, social work, neuroscience, pediatrics and other fields have committed much of the last five years to reviewing scientific research and clinical data, analyzing the findings of extensive field trials and reviewing thousand of comments from the public.

We welcome scrutiny, not only of this process but of its results.

Regrettably, news reports and commentators alike are filling the discourse with inaccurate, biased or misinformed criticism of DSM-5. Such information undermines the important changes that are being made to the manual, and provokes unwarranted confusion and fear among the individuals and families who stand to benefit most from essential care based on the strongest available diagnostic criteria.

The APA has created this forum to ensure observers of the DSM-5 development process have the facts.

Posted below are recent news stories, articles and opinion pieces, along with our responses, to correct the record, highlight key omissions — and provide essential perspective so that the public has a complete and accurate view of this important issue….

 

On the DSM-5 Facts Issue Accuracy page you’ll find responses to recent articles and Op-Eds by Allen Frances, Paula Caplan, NYT journalist, Benedict Carey, and Cosgrove and Krimsky.

In a counterpoint to Frances’ May 12, New York Times Op-Ed piece, APA responds:

APA Responds to Allen Frances New York Times Op-Ed

…There are actually relatively few substantial changes to draft disorder criteria. Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.

Unfortunately there is no comment facility on this DSM-5 Fact site.

One section for which substantial changes to disorder criteria are being proposed is the Somatoform Disorders.

The Somatic Symptom Disorder Work Group proposes radical changes to this category: to rename the Somatoform Disorders section to “Somatic Symptom Disorders”; eliminate four existing DSM-IV categories: somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder; replace these discrete categories and their criteria with a single new category – “[Complex] Somatic Symptom Disorder” and apply new criteria.

“…To receive a diagnosis of complex somatic symptom disorder, patients must complain of at least one somatic symptom that is distressing and/or disruptive of their daily lives. Also, patients must have at least two [Ed: now reduced to "at least one from the B type criteria" since evaluation of the CSSD field trials] of the following emotional/cognitive/behavioral disturbances: high levels of health anxiety, disproportionate and persistent concerns about the medical seriousness of the symptom(s), and an excessive amount of time and energy devoted to the symptoms and health concerns. Finally, the symptoms and related concerns must have lasted for at least six months.

“Future research will examine the epidemiology, clinical characteristics, or treatment of complex somatic symptom disorder as there is no published research on this diagnostic category.”

“…Just as for complex somatic symptom disorder, there is no published research on the epidemiology, clinical characteristics, or treatment of simple somatic symptom disorder.”

Source: Woolfolk RL, Allen LA. Cognitive Behavioral Therapy for Somatoform Disorders. Standard and Innovative Strategies in Cognitive Behavior Therapy.

And from the SSD Work Group  Rationale/Validity Document  (as published on May 4, 2011 for the second public review of draft proposals but not revised or reissued for the third review):

“…The presence of CSSD complicates management of all disorders and must be addressed in the treatment plan.

“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 6 diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.

“The B-type criteria are crucial for a diagnosis of CSSD. These criteria in essence reflect disturbance in thoughts, feelings, and/or behaviors in conjunction with long standing distressing somatic symptoms. Whilst an exact threshold is perhaps arbitrary, considerable work suggests that the degree of functional impairment is associated with the number of such criteria. Using a threshold of 2 or more such criteria results in prevalence estimates of XXXX in the general population, XXXX in patients with known medical illnesses, and XXXX in patients who may previously have been considered to suffer from a somatoform illness. {text in development concerning impact of different thresholds for criteria B- from Francis [Creed]}…”

No data on prevalence estimates available for the second review and no data on impact of different thresholds for the B type criteria and prevalence estimates available for the third review.

I will update if a report on the field trials is released.

Commentary from Allen Frances on the launch of this new DSM-5 Fact site.

Huffington Post Blogs | Allen Frances

Public Relations Fictions Trying to Hide DSM 5 Facts

Allen Frances MD | May 31, 2012

Recently APA recruited a public relations guy from the Department of Defense to respond to my concerns that DSM 5 is way off track. He immediately went on the offensive and (in an interview for Time magazine) made the obvious PR mistake of calling me “a dangerous man.” This provided me the opportunity to pose yet again the troubling questions about DSM 5 that APA repeatedly refuses to answer. The DOD guy hasn’t surfaced since.

Instead, APA has adopted a much smoother, soft sell approach. It has hired GYMR — an expensive PR firm. GYMR actually brags in its mission statement that it can “execute strategies that include image and alliance building, public education campaigns or media relations to harness the formidable forces of Washington and produce successful results for clients.”

We now have the first fruits of GYMR’s “image building” misinformation campaign. It has launched a PR website with the claim it will provide “the facts on DSM-5 development process. Read recent news stories & opinion pieces, along with our responses, to correct the record, highlight key omissions — and provide essential perspective, so that the public has a complete and accurate view of this important issue.”

Unfortunately, the site is very short on accurate facts, very long on misleading (or just plain wrong) “image building” fiction. It is all pure PR fluff — a way to avoid answering the substantive questions that need addressing before DSM 5 is prematurely rushed to press. Let’s compare GYMR fiction versus DSM 5 fact:

GYMR Fiction: “We have extensive data from the field trials that on average there is a slight decrease in the overall rates of DSM-5 in comparison to DSM-IV disorders.”

DSM 5 Fact: This is simply wrong — APA has no such data. Except for autism, all of the DSM 5 changes will dramatically raise the rates of mental disorder and mislabel normal people as psychiatrically sick. The field trial provided no data on this crucial question because it made an unforgivable error — not including head to head prevalence comparisons between DSM IV and DSM 5. This makes it impossible to estimate how explosive will be the DSM 5 rate jumps. Moreover, false epidemics are often nurtured in the primary care settings that were untested in the DSM 5 field trials.

GYMR Fiction: The PR claim is that DSM 5 has provided a transparent process.

DSM 5 Fact: DSM 5 has been peculiarly and self-destructively secretive from its early confidentiality agreements (meant to protect intellectual property) to its current failure to make public any of the results of its ‘scientific’ reviews. Real science can never be confidential. None of this secrecy makes any sense.

GYMR Fiction: “APA takes very seriously its responsibility in developing and maintaining DSM and has devoted $25 million to the DSM-5 update process thus far.”

DSM 5 Fact: The $25 million has been a colossal waste of poorly spent money. We did DSM IV for one-fifth the price and never missed a deadline or stirred much controversy. The difference in expenditure and outcome has nothing to do with us being especially competent. It has everything to do with DSM 5 being poorly conceived and organized and spending lavishly on silly things like public relations.

GYMR Fiction: “There are several proposals in DSM-5 that aim to more accurately describe the symptoms and behaviors of disorders that typically present in children.”

DSM 5 Fact: The epidemics of excessive diagnosis in children will be muddled further by DSM 5. The threshold for ADHD is being lowered despite the tripling of rates. Temper Dyregulation (AKA DMDD) is being suggested based on just a few years of work by just one research group — despite the risk it will exacerbate the already inappropriate and dangerous use of antipsychotic drugs in kids. And DSM 5 somehow persists in not understanding how its suggestions will necessarily have a profound impact on rates of autism.

GYMR Fiction: “There are actually relatively few substantial changes to draft disorder criteria.”

DSM 5 Fact: Dead wrong — how did GYMR ever come up with this one? My guess is that the DSM 5 changes would affect the diagnosis of tens of millions of people. APA has no way of refuting this estimate since it unaccountably failed to ask the crucial prevalence question in its $3 million field trial.

GYMR Fiction: “Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.”

DSM 5 Fact: Most of the reviews are poorly done and none of the suggestions would stand up to the kind of impartial, independent scientific review demanded by a petition supported by 51 mental health associations. The APA internal review lacks any credibility because it is done in secret and has somehow found a way to approve DMDD and the removal of the bereavement exclusion — both of which have little or no scientific support. To be credible, APA must both make public its own scientific reviews and also contract for external and independent reviews on all the most controversial topics.

GYMR Fiction: “The APA governance attention to this is far greater than anything that ever occurred with DSM III or DSM-IV.”

DSM 5 Fact: Absurd on the face of it. If there had ever been anything resembling proper internal supervision, DSM 5 would not be in this deep mess and would not require expensive PR fig leaves to try to cover it up.

There is more, but you get the idea. DSM 5 is in a paradoxical position. Publishing profits pressure it toward premature publication, but its close to final draft is the object of almost universal opposition. On one side we have APA and its new hired gun GYMR — on the other side we have 51 professional organizations, the Lancet, the New England Journal of Medicine, the international media and outraged segments of the public. It is far too late for any superficial “image building,” however clever, to restore DSM 5 credibility. Saving DSM 5 requires radically reforming its mistakes, not covering them up with a PR smokescreen of misinformation.

The last and only hope for a safe and credible DSM 5 now resides in the new APA leadership — it is within its power to thoroughly reform DSM 5 before it is too late.

The stakes are high. A DSM 5 at war with its users will wind up losing many of them. Disillusioned members (each of whom has involuntarily sunk almost $1,000 in this lavish but misdirected DSM 5 effort) will speed up the already rapid exodus of APA members. APA will eventually lose its monopoly on psychiatric diagnosis. Psychiatry will be unfairly discredited. And, worst of all, the patients who need our help will suffer.

DSM 5 is in such public trouble now because it heedlessly missed every prior private opportunity to self-correct. The solution is not the production of more public relations pablum. Instead, DSM 5 needs to regroup, solve its problems, and avoid racing over a cliff.

Call to action – DSM-5 comments needed by June 15, 2012

Call to action – DSM-5 comments needed by June 15, 2012

Post #173 Shortlink: http://wp.me/pKrrB-2bO

The stakeholder comment period for the third and final review of draft proposals for DSM-5 categories and criteria closes on June 15. Patients, patient organizations and professional stakeholders have three weeks left in which to submit comments.

US advocate, Mary Dimmock, has prepared a “Call to action”

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is used in the U.S. to categorize mental disorders for patient diagnosis, treatment and insurance. The new version, DSM-5, includes a proposal for Somatic Symptom Disorder (SSD) that will have profound implications for ME/CFS patients. Your input is needed by June 15, 2012 to ensure that the DSM-5 authors understand your concerns…

…SSD can be applied to patients regardless of whether the symptoms are considered to be medically unexplainable or not. Severity is rated by the count and frequency of somatic symptoms. The “Justification for Criteria – Somatic Symptoms”, issued in May 2011, states that CBT, focused on “the identification and modification of dysfunctional and maladaptive beliefs”, is one of the most promising treatments.

Why this matters to ME/CFS patients
A diagnosis of SSD can be “bolted” onto any patient’s diagnosis. All that is required is for the medical practitioner to decide that the patient is excessively concerned with their somatic symptoms and their health. This is done using highly subjective and difficult to measure criteria for which very few independent reliability studies have been undertaken.

For patients with diseases that are poorly understood and misdiagnosed by the medical community, like ME/CFS, this will be disastrous. Once diagnosed inappropriately with SSD, the implications for diagnosis, treatment, disability and insurance will be profound…

Download Mary’s Call to action document here:

Word .docx format DSM-5 Response 2012

Word .doc format DSM-5 Response 2012 (MS 2004)

Somatic Symptom Disorder could capture millions more under mental health diagnosis

Somatic Symptom Disorder criteria could capture millions more under mental health diagnosis

Post #172 Shortlink: http://wp.me/pKrrB-29B

By Suzy Chapman | Dx Revision Watch

While media and professional attention has been focused on the implications for introducing new disorders into the DSM and lowering diagnostic thresholds for existing categories, the Somatic Symptom Disorders (SSD) Work Group has been quietly redefining DSM’s Somatoform Disorders with radical proposals that could bring millions more patients under a mental health diagnosis.

The SSD Work Group is proposing to rename the Somatoform Disorders section of DSM-IV to “Somatic Symptom Disorders,” eliminate four existing  DSM-IV categories: somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder and replace them with a single new category – “Somatic Symptom Disorder.”

If approved, these proposals will license the application of a mental health diagnosis for all illnesses – whether “established general medical conditions or disorders” like diabetes, heart disease and cancer or conditions presenting with “somatic symptoms of unclear etiology” – if the clinician considers that the patient’s life has become “subsumed” with health concerns and preoccupations, or their response to distressing somatic symptoms is “excessive” or “disproportionate” or their coping strategies “maladaptive.”

 

Somatoform Disorders – disliked and dysfunctional

The SSD Work Group, under Chair, Joel E. Dimsdale, says current terminology for the Somatoform Disorders is confusing and flawed; that no-one likes these disorders and they are rarely used in clinical psychiatric practice. Primary Care physicians don’t understand the terms and patients find them demeaning and offensive [1].

The group says the terms foster mind/body dualism; that the concept of “medically unexplained” is unreliable, especially in the presence of medical illness, and cites high prevalence of presentation with medically unexplained somatic symptoms (MUS) in general medical settings – 20% in Primary Care, 40% in Specialist Care, 33-61% in Neurology; that basing a diagnosis of psychiatric disorder on MUS alone is too sensitive.

The Work Group might have considered dispensing altogether with a clutch of disliked, dysfunctional categories.

Instead, the group proposes to rebrand these disorders and assign new criteria that will capture patients with diverse illnesses, expanding application of psychiatric services, antidepressants and behavioural therapies like CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors.”

 

Focus shifts from “medically unexplained” to “excessive thoughts, behaviors and feelings”

The Work Group’s proposal is to deemphasize “medically unexplained” as the central defining feature of this disorder group.

Instead, focus shifts to the patient’s cognitions – “excessive thoughts, behaviors and feelings” about the seriousness of distressing and persistent somatic (bodily) symptoms which may or may not accompany diagnosed general medical conditions – and the extent to which “illness preoccupation” is perceived to “dominate” or “subsume” the patient’s life.

“…[The SSD Work Group's] framework will 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…” [2]

“…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…” [3]

These are the most recent proposals for new category ”J 00 Somatic Symptom Disorder.”

Note that requirement for “at least two from the B type criteria” has been reduced to “at least one from the B type criteria” for the third release of draft proposals, presumably in order to accommodate merging the previously proposed “Simple Somatic Symptom Disorder” category into the CSSD criteria. No revised “Rationale/Validity” PDF document has been issued, but read brief revised ”Rationale” here.

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

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

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 one of the following must be present.

(1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
(2) Persistently high level of anxiety about health or 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 persistent (typically >6 months).

Specifiers
Predominant Pain (previously pain disorder). This category is reserved for individuals presenting predominantly with pain complaints who also satisfy criteria B and C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

Severity specifiers
Somatic Symptom Disorder is a disorder characterized by persistency, symptom burden, and excessive or maladaptive response to somatic symptoms. There is a considerable range of severity. Typically, the disorder is more severe when multiple somatic symptoms are present. In addition to fulfilling criteria A and C, the following metrics may be used to rate severity:

Mild: only 1 of the B criteria fulfilled
Moderate: 2 or more B criteria fulfilled
Severe: 2 or more B criteria fulfilled plus multiple somatic symptoms

 

How are highly subjective and difficult to measure constructs like “Disproportionate and persistent thoughts about the seriousness of one’s symptoms” and “Excessive time and energy devoted to these symptoms or health concerns” to be operationalized?

By what means would a practitioner determine how much of a patient’s time spent “searching the internet looking for data” (to quote the example of the Work Group Chair) might be considered a reasonable response to chronic health concerns and what should be coded as “excessive preoccupation” or indicate that this patient’s life has become “subsumed” or “overwhelmed” by concerns about illness and symptoms?  2 gigabytes a week?  5?  10?

At the APA’s Annual Conference, earlier this month, SSD Work Group Chair, Joel E. Dimsdale, presented an update on his group’s deliberations. During the Q & A session, a questioner expressed concern that practitioners who are not psychiatric professionals or clinicians might have some difficulty interpreting the wording of the B type criteria to differentiate between negative and positive coping strategies.

Dr Dimsdale was asked to expand on how the B type criteria would be defined and by what means patients with chronic medical conditions who devote time and energy to health care strategies to try to improve their symptoms and level of functioning would be evaluated in the field by the very wide range of DSM users and how they would be differentiated from patients considered to be spending “excessive time and energy devoted to symptoms or health concerns” or perceived as having become “absorbed” by their illness.

I am not persuaded by Dr Dimsdale’s reassurances that they will try to make this “crystal clear” in the five to six pages of manual text in the process of being drafted for this disorder chapter. Nor am I reassured that these B (1), (2) and (3) criteria can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have the time or instruction for administration of diagnostic assessment tools, and where decisions to code or not to code may hang on the arbitary and subjective perceptions of DSM end-users lacking clinical training in the use of the manual text and application of criteria.

 

Implications for a diagnosis of SSD for all patient populations

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of a “Somatic Symptom Disorder” could have far-reaching implications for all patient populations:

• Application of highly subjective and difficult to measure criteria could potentially result in misdiagnosis with a mental health disorder, misapplication of an additional diagnosis of a mental health disorder or missed diagnoses through dismissal and failure to investigate new or worsening somatic symptoms.

• Application of an additional diagnosis of Somatic Symptom Disorder may have implications for the types of medical investigations, tests and treatments that clinicians are prepared to consider and which insurers are prepared to fund.

• Application of an additional diagnosis of Somatic Symptom Disorder may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out. It may negatively influence the perceptions of agencies involved with the assessment and provision of social care, disability adaptations and workplace accommodations.

• Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation” with symptoms may be placed at risk of iatrogenic disease.

• For multi-system diseases like Multiple Sclerosis, Behçet’s syndrome or Systemic lupus it can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable.

• Proposals allow for the application of a diagnosis of Somatic Symptom Disorder where a parent is considered excessively concerned with a child’s symptoms [3]. Families caring for children with any chronic illness may be placed at increased risk of wrongful accusation of “over-involvement” with a child’s symptomatology.

Where a parent is perceived as encouraging maintenance of “sick role behaviour” in a child, this may provoke social services investigation or court intervention for removal of a sick child out of the home environment and into foster care or enforced in-patient “rehabilitation.” This is already happening in families with a child or young person with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of a chronic childhood illness + SSD.

 

Dustbin diagnosis?

Although the Work Group is not proposing to classify Chronic fatigue syndrome, IBS and fibromyalgia, per se, within the Somatic Symptom Disorders, patients with CFS – “almost a poster child for medically unexplained symptoms as a diagnosis,” according to Dr Dimsdale’s presentation – or with fibromyalgia, irritable bowel syndrome, chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity may be particularly vulnerable to misapplication or misdiagnosis with a mental health disorder under these SSD criteria.

There is considerable concern that this new Somatic Symptom Disorder category will provide a “dustbin diagnosis” in which to shovel the so-called “functional somatic syndromes.”

 

15% of “diagnosed illness” and 26% of “functional somatic” captured by SSD criteria

For testing reliability of CSSD criteria, three groups were studied for the field trials:

488 healthy patients; a “diagnosed illness” group of 205 patients with cancer and malignancy (some in this group were said to have severe coronary disease) and a “functional somatic” group comprising 94 people with irritable bowel and “chronic widespread pain” (a term used synonymously with fibromyalgia).

Patients in the study were required to meet one to three cognitions: Do you often worry about the possibility that you have a serious illness? Do you have the feeling that people are not taking your illness seriously enough? Is it hard for you to forget about yourself and think about all sorts of other things?

Dr Dimsdale reports that if the response was “Yes – a lot.” it was coded.

15% of the cancer and malignancy group met SSD criteria when “one of the B type criteria” was required; if the threshold was increased to “two B type criteria” about 10% met criteria for dual-diagnosis of cancer + Somatic Symptom Disorder.

For the 94 irritable bowel and “chronic widespread pain” study group, about 26% were coded when one cognition was required; 13% coded with two cognitions required.

Has the SSD Work Group produced projections for prevalence estimates and potential increase in mental health diagnoses across the entire disease landscape?

Has the group factored for the clinical and economic burden of providing CBT for modifying perceived “dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” in patients for whom an additional diagnosis of Somatic Symptom Disorder has been coded?

 

Where’s the science?

Dr Dimsdale admits his committee has struggled from the outset with these B type criteria but feels its proposals are “a step in the right direction.”

The group reports that preliminary analysis of field trial results shows “good reliability between clinicians and good agreement between clinician rated and patient rated severity.” In the trials, CSSD achieved Kappa values of .60 (.41-.78 Confidence Interval).

Kappa reliability reflects agreement in rating by two different clinicians corrected for chance agreement – it does not mean that what they have agreed upon are valid constructs.

Radical change to the status quo needs grounding in scientifically validated constructs and a body of rigorous studies not on pet theories and papers (in some cases unpublished papers) generated by Dr Dimsdale’s work group colleagues. Where is the substantial body of independent research evidence to support the group’s proposals?*

*“...To receive a diagnosis of complex somatic symptom disorder, patients must complain of at least one somatic symptom that is distressing and/or disruptive of their daily lives. Also, patients must have at least two [Ed: now reduced to at least one since evaluation of the CSSD field trials] of the following emotional/cognitive/behavioral disturbances: high levels of health anxiety, disproportionate and persistent concerns about the medical seriousness of the symptom(s), and an excessive amount of time and energy devoted to the symptoms and health concerns. Finally, the symptoms and related concerns must have lasted for at least six months.”

“Future research will examine the epidemiology, clinical characteristics, or treatment of complex somatic symptom disorder as there is no published research on this diagnostic category.”

“…Just as for complex somatic symptom disorder, there is no published research on the epidemiology, clinical characteristics, or treatment of simple somatic symptom disorder.”

*Woolfolk RL, Allen LA. Cognitive Behavioral Therapy for Somatoform Disorders. Standard and Innovative Strategies in Cognitive Behavior Therapy.

 

Where are the professionals?

During the second public review, the Somatic Symptom Disorders proposals attracted more responses than almost any other category. The SSD Work Group is aware that patients, caregivers and patient advocacy organizations have considerable concerns. But are medical and allied health professionals scrutinizing these proposals?

This is the last opportunity to submit feedback. Psychiatric and non psychiatric clinicians, primary care practitioners and specialists, allied health professionals, psychologists, counselors, social workers, lawyers, patient advocacy organizations – please look very hard at these proposals, consider their safety and the implications for an additional diagnosis of an SSD for all patient illness groups and weigh in with your comments by June 15.

Criteria and rationales for proposals for the DSM-5 Somatic Symptom Disorders categories can be found here on the DSM-5 Development site.

 

References

1 Levenson JL. The Somatoform Disorders: 6 Characters in Search of an Author. Psychiatr Clin North Am. 2011 Sep;34(3):515-24.

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

2 Dimsdale J, Creed F. DSM-V Workgroup on Somatic Symptom Disorders: the proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report. J Psychosom Res 2009;66:473–6.

3 DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria-Somatic Symptoms documents, published May 4, 2011 for the second DSM-5 stakeholder review. (Caveat: for background to the group’s rationales only; proposals and criteria as set out in these documents have not been revised to reflect recent changes to revisions or reissued for the third review.)

     Disorder Descriptions   May 4, 2011

     Rationale/Validity Document   May 4, 2011

DSM-5 Somatic Symptom Disorders: Differences between second and third draft for CSSD

DSM-5 Somatic Symptom Disorders: Differences between second and third draft for CSSD

Post #168 Shortlink: http://wp.me/pKrrB-27y

A reminder that the third and final DSM-5 comment period closes on June 15 and that I am collating submissions on this site.

Comments are open to professional and lay stakeholders. Please alert clinicians, researchers, allied health professionals, social workers, lawyers, educationalists, therapists, patient advocacy groups to these proposals.

Full proposals, criteria and rationales for the Somatic Symptom Disorders are set out in this post:

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

According to DSM-5 Task Force Chair, David Kupfer, MD, “After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”

 

Somatic Symptom Disorders Work Group proposals:

Two PDF Disorder Descriptions and Rationale/Validity Propositions PDF documents had accompanied the first and second drafts. There are no revised PDFs reflecting the most recent proposals available on the DSM-5 Development website and the documents published with the second draft have been removed.

I have asked the APA’s Media and Communications Office to clarify whether the Somatic Symptom Disorder Work Group intends to publish revised Disorder Descriptions or Rationale/Validity Propositions documents during the life of the stakeholder review period or whether these documents are being dispensed with for this third draft.

Should updated documents be added to the site during the comment period I will post links.

 

Notes on differences between the second and third draft proposals for CSSD

As with the first and second drafts, the intention remains to rename the Somatoform Disorders section to Somatic Symptom Disorders.

The proposal continues to combine the existing DSM-IV categories:

Somatization Disorder
Hypochondriasis
Undifferentiated Somatoform Disorder
Pain Disorder

into a single new category, Somatic Symptom Disorder.

For the second draft, the work group had suggested two separate diagnoses, Complex Somatic Symptom Disorder CSSD) and Simple Somatic Symptom Disorder (SSSD).

Following evaluation of the results of the DSM-5 field trials, the Somatic Symptom Disorders Work Group has decided that Simple Somatic Symptom Disorder  is “a less severe variant of CSSD.”

The Work Group now proposes merging CSSD and SSSD into a single category called Somatic Symptom Disorder (SSD) and is suggesting dropping the word “Complex” from the category term.

The latest proposed category names for the revision of the DSM-IV’s Somatoform Disorders now look like this:

Somatic Symptom Disorders

J 00 Somatic Symptom Disorder – with the option for specifying:

Mild Somatic Symptom Disorder
Moderate Somatic Symptom Disorder
Severe Somatic Symptom Disorder

J 01 Illness Anxiety Disorder |
J 02 Conversion Disorder (Functional Neurological Symptom Disorder) |
J 03 Psychological Factors Affecting Medical Condition |
J 04 Factitious Disorder |
J 05 Somatic Symptom Disorder Not Elsewhere Classified |

Revised Criteria, Rationale and Severity texts for the above can be found at the links above or on this webpage:

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

These are the criteria for J00 Somatic Symptom Disorder

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

J 00 Somatic Symptom Disorder

Updated April-27-2012

Proposed Revision

Somatic Symptom Disorder

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

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 one of the following must be present.

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

(2) Persistently high level of anxiety about health or 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 persistent (typically >6 months).

Specifiers

Predominant Pain (previously pain disorder). This category is reserved for individuals presenting predominantly with pain complaints who also satisfy criteria B and C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

These are three Severity Specifiers being proposed for SSD: Mild, Moderate, Severe.

The text on the Severity tab reads:

“Somatic Symptom Disorder is a disorder characterized by persistency, symptom burden, and excessive or maladaptive response to somatic symptoms. There is a considerable range of severity. Typically, the disorder is more severe when multiple somatic syptoms are present. In addition to fulfilling criteria A and C, the following metrics may be used to rate severity:

Mild: only 1 of the B criteria fulfilled
Moderate: 2 or more B criteria fulfilled
Severe: 2 or more B criteria fulfilled plus multiple somatic symptoms“

There is a table for the PHQ Somatic Symptom Short Form (PHQ-SSS) which you can view in this file:

http://dxrevisionwatch.files.wordpress.com/2011/05/cssd-severity-short-form.png

Note that the criteria for CSSD in the previous draft, released in May 2011, had read:

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following must be present.”

But for the third draft, this has been reduced to

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.”

This is presumably to accommodate Simple Somatic Symptom Disorder within what had been the criteria for CSSD.

(Last year, for the second draft, the criteria for CSSD had required two from (1), (2) and (3) and a symptom duration of greater than 6 months, whereas the criteria for SSSD had required only one from (1), (2) and (3) and a symptom duration of greater than one month.)

 

Note also that the option for three Severity Specifiers for J00 Somatic Symptom Disorder category: Mild, Moderate, Severe, might potentially be intended to correspond to three newly proposed categories in the ICD-11 Chapter 5: Somatoform Disorders section.

In the ICD-11 Alpha drafting platform (which is a work in progress and comes with caveats), the Somatoform Disorders categories are currently proposed to be renamed to Bodily Distress Disorders. There are three new categories listed:

6R0 Mild bodily distress disorder
6R1 Moderate bodily distress disorder
6R2 Severe bodily distress disorder

These three new category suggestions have no definitions or descriptive parameters visible in the ICD-11 Alpha draft so it isn’t possible to determine at this stage what disorders these newly suggested terms might be intended to capture; nor how they would relate to the existing somatoform disorders categories that still remain listed beneath them in this section of the Alpha draft.

For comparison, this is how the corresponding section of ICD-11 categories currently displays:

ICD-11 Alpha draft:

BODILY DISTRESS DISORDERS [Formerly Somatoform Disorders]

6R0 Mild bodily distress disorder
6R1 Moderate bodily distress disorder
6R2 Severe bodily distress disorder
6R3 Somatization disorder
6R4 Undifferentiated somatoform disorder
6R5 Somatoform autonomic dysfunction
6R6 Persistent somatoform pain disorder
     6R6.1 Persistent somatoform pain disorder
     6R6.2 Chronic pain disorder with somatic and psychological factors [not in ICD-10]
6R7 Other somatoform disorders
6R8 Somatoform disorder, unspecified

Hypochondriacal disorder [ICD-10: F45.2] is currently listed in ICD-11 Chapter 5 as Illness Anxiety Disorder under 6L5 ANXIETY AND FEAR-RELATED DISORDERS > 6L5.6 Illness Anxiety Disorder.

Dissociative (Conversion disorders) [ICD-10: F44] is currently listed in ICD-11 Chapter 5 under Neurotic, stress-related and somatoform disorders > 7A5 Dissociative [conversion] disorders.

There had been discussions by the SSD and Dissociative Disorders work groups for potentially locating Conversion Disorder under the DSM-5 Dissociative Disorders section, for congruency with its location within ICD-10.

For the third draft, it appears that the groups with oversight of the revision of conversion disorder have decided that this category should be renamed to Conversion Disorder (Functional Neurological Symptom Disorder) and classified as a Somatic Symptom Disorder.

In a future post, for ease of comparison, I will post a table comparing DSM-5 third draft proposals with current listings for ICD-11.

 

Links:

1] Somatic Symptom Disorders Third draft proposals:
http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

2] Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?
http://wp.me/pKrrB-1Vx

3] DSM-5 proposals for Somatoform Disorders revised on April 27, 2012
http://wp.me/pKrrB-24D

4] Submissions to SSD Work Group May 2011 are archived here:
http://wp.me/PKrrB-19a

5] Submissions to SSD Work Group May 2012 are being collated here:
http://wp.me/PKrrB-1Ol

More Kappa data from DSM-5 field trials

More Kappa data from DSM-5 field trials

Post #167 Shortlink: http://wp.me/pKrrB-27D

Further data from the DSM-5 field trials results have been released in a report by Deborah Brauser for Medscape Medical News.

You can read Ms Brauser’s report from the American Psychiatric Association’s annual conference here, though you may need to register for the site:

Medscape Medical News > Psychiatry

DSM-5 Field Trials Generate Mixed Results

Deborah Brauser | May 8, 2012

…Members of the task force said they hope to publish the full results “within a month.” However, the third and final public comment period for the manual opened last week and ends on June 15. Although the entire period is 6 weeks long, the public may only have 2 weeks to comment after the publication of the field trials’ findings.

…“No previous field trial had such a sophisticated design. And it has resulted in more statistically significant data for specific disorders,” said Dr. Regier.

The current DSM-5 field trials, as well as field trials for past manuals, use Kappa score as a statistical measure of criteria reliability. A Kappa score of 1.0 was considered perfect, a score of greater than .8 was considered almost perfect, a score of .6 to .8 was considered good to very good, a score of .4 to .6 was considered moderate, a score of .2 to .4 was considered fair and could be accepted, and a score of less than .2 was considered poor.

 At adult sites, schizophrenia was shown to have a pooled Kappa score of .46. However, that is down from the .76 and .81 Kappa scores found in the DSM-IV and DSM-III, respectively, and it is less than the .79 score found in the International Classification of Diseases, Tenth Revision (ICD-10).

“It’s important to realize in some ways that the Kappa in the current field trial was from a totally different design…,” said Dr. Regier

Full report

This table has some of the results:

Reconstructed from data published by A Frances, DSM 5 in Distress, Psychology Today, 05.06.12

 

1 Boring Old Man has updated an earlier table here on his blog which incorporates additional data from the Medscape report: 

updated table
1 Boring Old Man | May 9, 2012

There are further, detailed commentaries from 1 boring old man on the DSM-5 field trial results and Kappa values here:

major depressive disorder κ=0.30?…     May 6, 2012

a fork in the road…     May 7, 2012

Village Consumed by Deadly Storm…     May 8, 2012

box scores and kappa…     May 8, 2012

Included in Ms Brauser’s report are data for “Complex somatic disorder”:

The field trials for the new proposed category Complex Somatic Symptom Disorder (CSSD) were held at Mayo. According to one of several tables within Ms Brauser’s report, the following data have been released for “Complex somatic disorder” [sic]:

Extract from DSM-5 Field Trials Generate Mixed Results, Deborah Brauser,  May 8, 2012

Disorder	DSM-5 (95% CI)	DSM-IV	ICD-10	DSM-III
Major neurocognitive disorder	.78 (.68 – .87)	—	.66	.91
ASD	.69 (.58 – .80)	.59 – .85	.77	-.01
PTSD	.67 (.59 – .74)	.59	.76	.55*
Child ADHD	.61 (.51 – .72)	.59	.85	.50
Complex somatic disorder	.60 (.41 – .78)	—	.45	.42

CI, confidence interval; ASD, autism spectrum disorder; PTSD, posttraumatic stress disorder; ADHD, attention-deficit/hyperactivity disorder

*From the DSM-III-R.

CSSD is a new category for DSM-5 which redefines and replaces some, but not all of the existing DSM-IVSomatoform Disorders categories under a new rubric with a new definition and criteria.

It’s a mashup of the existing categories:

Somatization Disorder
Hypochondriasis
Undifferentiated Somatoform Disorder
Pain Disorder

Following evaluation of the field trials, this new category, Complex Somatic Symptom Disorder is now proposed to drop the “Complex” descriptor, be named Somatic Symptom Disorder and absorb Simple Somatic Symptom Disorder (SSSD) – a separate diagnosis that had been introduced for the second draft, with criteria requiring fewer symptoms than for a diagnosis of CSSD and shorter chronicity.

In order to accommodate SSSD, criteria and Severity Specifiers for CSSD have been modified since the second draft. (More on this in the next post.)

Since CSSS (or SSD, as is now proposed) did not exist as a category in DSM-IV, or in ICD-10 or DSM-III, it’s unclear and unexplained by the table what data for which existing somatoform disorders have been used for Kappa comparison for this new category with data for ICD-10 and DSM-III, and how meaningful comparison between them would be.

You can find out more about how the field trials were conducted on the DSM-5 Development site.

 

Delay in publication of field trial results and no key documents in support of proposals

Stakeholders may not get to scrutinise a report on the field trials until as late as a couple of weeks before the public comment period closes.

There are no Disorder Descriptions and Rationale/Validity Propositions PDF documents that expand on category descriptions and rationales (at least not for the Somatic Symptom Disorders) and reflect revisions to proposals between the release of the second and third draft.

Yesterday, I contacted APA’s Communications and Media Office to enquire whether the Somatic Symptom Disorders work group intends to publish either a Disorder Descriptions or Rationale/Validity Propositions document, or both, to accompany this latest draft during the life of the stakeholder review period or whether these key documents are being dispensed with for the third draft.

I’ll update if and when APA Media and Communications provides clarification.

 

Related post:

Make Yourself Heard! says DSM-5′s Kupfer – but are they listening?

DSM-5 Somatic Symptoms Work Group submissions 2012: Last chance to tell SSD Work Group why it needs to ditch flawed, unsafe and unscientific proposals

DSM-5 Somatic Symptoms Work Group submissions 2012: Last chance to tell SSD Work Group why it needs to ditch unsafe and scientifically flawed proposals

Post #165 Shortlink: http://wp.me/pKrrB-26q

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

 

Last chance to tell the SSD Work Group why it needs to ditch its unsafe and scientifically flawed proposals

The third DSM-5 Development public review of proposals for revisions to DSM-IV categories and criteria runs through May 2 – June 15. This will be the last opportunity for stakeholders to submit feedback.

Register on the DSM-5 Development site to submit comment or use your previous user name and log in details if you submitted during the earlier reviews. For information on registration see this post from 2011.

One again, I’m collating copies of submissions to the Somatic Symptom Disorders Work Group on a dedicated page from international patient organizations, medical, allied health and other professional stakeholders, patients, advocates and professional bodies.

Any consumer groups, medical professionals, allied health professionals, social workers, lawyers etc with concerns for the Somatic Symptom Disorders proposals are welcome to forward copies of submissions for publication here.

If you are looking for submissions for the first and second public reviews, you need these pages:

Submissions to first public review (February 10 – April 20, 2010): http://wp.me/PKrrB-AQ

Submissions to second public review (May 4 – July 15, 2011): http://wp.me/PKrrB-19a

This year’s submissions are being collated here as they come to my attention:

DSM-5 SSD Work Group submissions 2012 

Shortlink for submissions page is: http://wp.me/PKrrB-1Ol

Today I am publishing UK patient and advocate, Peter Kemp’s submission to the SSD Work Group:

Submission from Peter Kemp, UK advocate

How people with M.E. and CFS (and other illnesses) could be misdiagnosed as Somatic Symptom Disorder using DSM-5

Misdiagnosis is a common occurrence by all accounts. Therefore medical definitions or criteria should not only assist diagnosis – they should positively aim to prevent or reduce misdiagnosis.

Somatic Symptom Disorder (SSD) as proposed for DSM-5 allows too many possibilities for misdiagnosis. Misdiagnosis that could have disastrous consequences. This is so readily foreseeable that this must be addressed.

Once a physician diagnoses SSD, they have effectively judged the patient incompetent to interpret their own symptoms. If the patient has an unrecognised disease that progresses, or develops a new disease and reports the new symptoms to the doctor, what will the doctor do? The patient is untrustworthy. The doctor is busy and has ‘real’ patients to treat.

It is inevitable that even patients that are correctly diagnosed with SSD will sooner or later present with actual physical disease. The diagnosis of SSD could predictably obstruct investigation and treatment of their disease. This obstruction could be directly attributed to the use of an SSD diagnosis.

SSD should not be included in DSM-5 unless specific guidance to prevent misdiagnosis are included and these have been proven effective.

Imagine a doctor with a patient presenting in the early stages of MS. MS can be difficult to diagnose. When Professor Poser reviewed 366 MS diagnoses made by board certified neurologists, he found that only 65% had been correctly diagnosed (http://www.cfids.org/archives/2000rr/2000-rr4-article03.asp ).

It can take years before the signs, symptoms and tests are clear enough to make a diagnosis (http://ms.about.com/popular.htm ). The symptoms of ‘pre-diagnosis’ MS can be very distressing and the lack of a laboratory test or firm diagnosis may add to a patient’s worries. The patient may try all sorts of strategies to try and find out about, and improve what is happening to them. They may appear to pester their GP, they may appear neurotic and irrational.

Now imagine that in accordance with DSM-5, a doctor gives them a diagnosis of the proposed SSD. The patient has an official diagnosis in their medical records that amounts to ‘hypochondriac’. What effect will that have on the patient’s chances of getting the necessary investigations as the disease progresses? How is it going to help them to cope with their distressing physical symptoms now they have been explained as psychosomatic? The time it will take for them to get a true diagnosis may be further prolonged, and the years spent waiting could be made even more harrowing because of inaccurate psychological labelling.

Therefore sensible doctors will avoid diagnosing SSD. Foolish doctors risk spending their time at professional disciplinary hearings and in court; and this still might not adequately reflect the amount of suffering their diagnosis of SSD could cause.

The rationale for SSD also states: “The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).”

I believe it safe to say that ‘positive symptoms’ does not mean ‘good symptoms’ or ‘symptoms with the right attitude’. I imagine it means definite, definable, testable and maybe even measurable. But when terms like ‘distressing’ and ‘excessive’ are used to measure symptoms, the definition is not a definition. It is not even a convincing concept.

The idea is right, to base the definition on signs and symptoms that are actually present, as long as these sufficiently differentiate the condition from other conditions and do not lead to too many misdiagnoses. Unfortunately, they would predictably fail to achieve this because the definition proposed is significantly subjective.

The ‘DSM-5 Proposed Revision’ could certainly misdiagnose M.E. This would be a serious matter as M.E. is classified by the WHO ICD as a neurological illness. A doctor whose diagnosis of SSD was contradicted by a doctor that diagnosed M.E could find themselves in an awkward legal situation. The implications to the proper care of a patient, due to misdiagnosing a serious neurological illness as a neurotic illness hardly bear thinking about. Hindering necessary investigations and treatment might only be a small part of the problems this might create.

The latest proposal states:

“Somatic Symptom Disorder

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

“A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.”

The Myalgic Encephalomyelitis: International Consensus Criteria – states:
(http://www.meassociation.org.uk/?p=7173)

“A patient will meet the criteria for post-exertional neuroimmune exhaustion (A), at least one symptom from three neurological impairment categories (B), at least one symptom from three immune/gastro-intestinal/genitourinary impairment categories (C), and at least one symptom from energy metabolism/transport impairments (D).”

The Canadian Expert Consensus Panel Clinical Case Definition for ME/CFS states:
(http://www.cfids-cab.org/MESA/ccpccd.pdf)

“A patient with ME/CFS will meet the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; have two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine and immune manifestations; and adhere to item 7.”

Therefore every patient with M.E. or CFS or ME/CFS will present with ample distressing and disruptive symptoms to satisfy DSM-5 Somatic Symptom Disorder Part A.

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.

(1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
(2) Persistently high level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health concerns”

The NICE Guidelines for CFS/ME state:
(http://www.nice.org.uk/nicemedia/live/11824/36191/36191.pdf )

“People with mild CFS/ME are mobile, can care for themselves and can do light domestic tasks with difficulty. Most are still working or in education, but to do this they have probably stopped all leisure and social pursuits. They often take days off, or use the weekend to cope with the rest of the week.”

Therefore even the mildest form of CFS sees persons who have often greatly reduced or stopped socializing, hobbies, sports etc.; and spend much of the time formerly devoted to these pursuits in resting and recuperating their energy to continue working.

When this level of disruptive illness goes on for more than 6 months, people will naturally and rationally become worried. They will be fearful of what is happening and what is going to happen. They will be anxious about their responsibilities, their job, their family and friend connections – everything. They may quite naturally seek help from their GP. They may be given antidepressants, sleeping medications, pain killers, etc. All these combined with a chronic illness necessitate frequent visits to their GP. They may try alternative therapies (possibly after having found what their GP offered did not help them). They may alter their diet, take nutritional supplements, go for acupuncture, homeopathy or other type of therapy.

And here is the rub; if one does not believe they are actually physically ill, their ‘thoughts, feelings and behaviours’ will certainly appear ‘excessive’. This could apply not just to CFS, but many other high impact and distressing illnesses.

The ‘Rationale’ for SSD states: “Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.”

The proposed definition does not address this problem. It might actually make it worse. If doctors believe that SSD has a valid definition they may start actually using it – then God help us.

If a person with just ‘mild’ CFS is justified in being worried, justified in resting so they can keep working, justified in searching for something that will improve their health – then anyone with the illnesses mentioned could meet the criteria to satisfy DSM-5 Somatic Symptom Disorder Part B.

The only proviso is that to some extent this could depend on interpretation of the subjective aspects of part B (there may be more detailed explanations elsewhere – this essay is based on what is included here). What is ‘excessive’, ‘persistantly’, ‘disproportionate’, ‘seriousness’?*

The same ‘Rationale’ for SSD remarks on: “The lack of positive psychological features in the definition”. Unfortunately the proposed criteria attempt to define “positive psychological features” based entirely upon a physician’s subjectivity. That is not, in any sense, a definition.

This is why I believe the circular-reasoning trap constructed with SSD makes it risible. They construct a concept for SSD. They construct criteria for the concept. Chicken-egg or egg-chicken, take your pick.

The problem with this approach is that it does not IDENTIFY the psychological condition they are trying to define. SSD cannot exist only by differentiating features, this is true. Yet differentiating is an essential step. SSD must discern from other anxiety or depressive disorders. It must be discern from normal or rational anxiety, whether that anxiety is acute, chronic or fluctuating. It must discern from anxiety or depressive disorders due to neurological illness or injury. It must discern from physical illness that has not yet been diagnosed, or from physical illness for which diagnosis is complex or often delayed. It must discern from new or emerging diseases. If SSD cannot discern from these, then misdiagnosis could be a common and predictable result.

The criteria should define the disorder but they don’t. They attempt to define the criteria. The disorder should inform the criteria, but it doesn’t. The disorder is lost in a confusion of subjective terms, ‘excessive’, ‘persistantly’, ‘disproportionate’, ‘seriousness’.

The only way it can work is if someone (and here’s another trap); someone who believes that SSD exists and is defined by the DSM, decides what ‘excessive’ and ‘disproportionate’ etc., mean. Then all they have to do, is reach exactly the same conclusion that every other physician using the DSM would reach in the same position. Bingo. A diagnosis that does not mean anything other than what the ‘diagnoser’ decides that it means. And they better hope they got it right, otherwise a good lawyer will wipe the floor with them.

“C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months).”

This is either synchronicity, or they got this direct from the NICE Guidelines for ‘CFS/ME’. The NICE Guidelines ‘Making a diagnosis’ state:

“The range of presenting symptoms is wide, and fatigue and pain may not always be the prominent disabling features at initial presentation.”

“Symptoms tend to vary in intensity and type over a period of weeks or months (and evolve into what is more clearly CFS/ME with time)”

Mild CFS will satisfy DSM-5 Somatic Symptom Disorder Part C. Therefore every person with M.E. or CFS could get a diagnosis of SSD unless they can convince any psychiatrist they encounter that they are not ‘excessive’, ‘persistent’, ‘disproportionate’, or that they don’t believe they are seriously ill.

A serious anomaly might arise with SSD in both M.E. and CFS. These illnesses can start with only fatigue or just a few symptoms. Extreme fatigue and pain might be all that a patient reports. However, if the illness continues over years, some symptoms may improve whilst new ones appear. Problems such as sensory impairments, bladder and bowel problems, immune dysfunction, and a host of neurological symptoms (to name but a few) can develop.

Will the M.E. or CFS patient then be vulnerable to having their previous diagnosis ‘cancelled-out’ by a new diagnosis of SSD, because they developed too many symptoms and are worried about them?

The SSD development group have repeated previous flaws they identified as creating the need for new definitions. They have not defined anything. Yet there may be some positive outcome from their efforts. I imagine that some medical insurance company executives must be rubbing their hands together in glee, but medical negligence lawyers should be turning cartwheels.

Peter Kemp

*Editor: Accompanying the first and second release of draft proposals for the Somatic Symptom Disorders categories, two quite lengthy PDF documents that expanded on the disorder descriptions and validity/rationales were published in conjunction with the webpage Proposed Revision, Rationale and Severity texts.

For this third draft, no PDFs have been published that reflect the Work Group’s revisons since release of the second draft, last May, or set out its rationales in detail. No draft DSM-5 textual content, more comprehensive disorder descriptions or field trial evaluations are available for public scrutiny other than brief, revised Rationale texts:

Criteria for Proposed Revision J00 Somatic Symptom Disorder

Rationale text for category J00 Somatic Symptom Disorder:

Rationale

The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).
The group considers that the current DSM-IV somatoform diagnoses (Somatization Disorder, Somatoform Disorder NOS, Undifferentiated Somatoform Disorder, Hypochondriasis and the Pain Disorders) are so flawed that complete restructuring of these diagnoses is required. Change is needed as:

- The DSM-IV somatoform diagnoses are used rarely in clinical practice in most countries; the terms cause confusion among doctors and are resented by many patients.

- The criteria for DSM-IV somatization disorder are too restrictive. Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.

- These diagnoses are based on “medically unexplained symptoms,” but this term is unreliable, especially in the presence of medical illness. Doctors disagree on the use of the term and patient recall of such symptoms is variable, so reliability of these diagnoses is low.

- The lack of positive psychological features in the definition of these disorders means they fail to satisfy one of the criteria for a mental disorder.

The new diagnoses of Somatic Symptom Disorder (SSD) is proposed to overcome these problems with relevant DSM-IV diagnoses.

The previous posting proposed diagnoses of Complex Somatic Symptom Disorder (CSSD) and Simple Somatic Symptom Disorder (SSSD). In this revision, we have merged the two disordes [sic], recognizing that SSSD is a less severe variant of CSSD. The work group is considering dropping the adjective “complex” from the name of the resulting disorder and is desirous of feedback.   Accessed May 4, 2012

Related material:

1] DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

2] DSM-5 Development site

3] Somatic Symptom Disorders proposals

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

Post #162 Shortlink: http://wp.me/pKrrB-24D

Update @ May 02, 2012: Since publication of this post, APA has posted its third draft (see Post #163)

Although the American Psychiatric Association (APA) has still to announce the dates for its third review of proposals for revisions to DSM-IV categories and criteria, I discovered, today, that proposals for the revision of the Somatoform Disorders were updated yesterday, April 27.

The APA’s third and final stakeholder review exercise is expected to launch by “end of May at the latest.” This is the only information we currently have and the Timeline remains unspecific – other than “Spring” and “for two months.”

Revisions to other DSM-IV categories may also have been published prior to the launch of the third public review and I would advise readers to check the DSM-5 Development site for potential changes to other categories.

 

Somatic Symptom Disorders

Earlier proposals for two new categories, “Complex Somatic Symptom Disorder” (CSSD) and “Simple Somatic Symptom Disorder” (SSSD); “Functional Neurological Disorder (Conversion Disorder)” and proposed revisions to selected other categories, as they had stood at the time of the second public review (May 4 – July 15, 2011), are archived on Dx Revision Watch site here, for comparison:

http://dxrevisionwatch.wordpress.com/dsm-5-proposals/dsm-5-proposals-sub-page-1/dsm-5-drafts-2/

and in this Dx Revision Watch post from May 10, 2011: http://wp.me/pKrrB-13z

 

From the DSM-5 Development website

Revisions as of April 27, 2012 (J 04 Factitious Disorder was updated on March 22, 2012)

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.*

[*Ed: The Work Group now proposes to merge the previously proposed category, "Simple Somatic Symptom Disorder" with "Complex Somatic Symptom Disorder" and is also considering dropping "Complex" from the name of the resulting disorder and instead, calling it "Somatic Symptom Disorder." Update @ May 02, 2012: The text above has been revised by the Somatic Symptom Disorder Work Group since publication of this post. See Post #163 for revised text.]

[Ed: Note: There have been two key PDF documents associated with the proposals for the "Somatic Symptom Disorders" – the "Disorders Description" and "Rationale/Validity" documents. These have been removed from the webpages, presumably pending updating to reflect changes to proposals for this section of DSM-5. If and when these two documents are republished, I will update this page. These updated proposal texts, below, are littered with typos.]

Instead of the categories as they had stood since May 2011:

Somatic Symptom 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
J 06 Unspecified Somatic Symptom Disorder Pseudocyesis

the proposed categories now read (and note, are now renumbered):

Somatic Symptom Disorders

J 00 Somatic Symptom Disorder
J 01 Illness Anxiety Disorder
J 02 Conversion Disorder (Functional Neurological Symptom Disorder)
J 03 Psychological Factors Affecting Medical Condition
J 04 Factitious Disorder
J 05 Somatic Symptom Disorder Not Elsewhere Classified

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

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

J 00 Somatic Symptom Disorder

Updated April-27-2012

Proposed Revision

Somatic Symptom Disorder

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

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 one of the following must be present.

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

(2) Persistently high level of anxiety about health or 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 persistent (typically >6 months).

Specifiers

Predominant Pain (previously pain disorder). This category is reserved for individuals presenting predominantly with pain complaints who also asatisfy criteria B and C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

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

Rationale

The proposed classification for Somatic Symptom Disorders deemphasizes the central role of medically unexplained symptoms. Instead, it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms).

The group considers that the current DSM-IV somatoform diagnoses (Somatization Disorder, Somatoform Disorder NOS, Undifferentiated Somatoform Disorder, Hypochondriasis and the Pain Disorders) are so flawed that complete restructuring of these diagnoses is required. Change is needed as:

- The DSM-IV somatoform diagnoses are used rarely in clinical practice in most countries; the terms cause confusion among doctors and are resented by many patients.

- The criteria for DSM-IV somatization disorder are too restrictive. Undifferentiated Somatoform Disorder has such a low threshold that it is applicable to a very large proportion of patients attending primary care. The same low threshold issue occurs with Somatoform Disorder NOS.

- These diagnoses are based on “medically unexplained symptoms,” but this term is unreliable, especially in the presence of medical illness. Doctors disagree on the use of the term and patient recall of such symptoms is variable, so reliability of these diagnoses is low.

- The lack of positive psychological features in the definition of these disorders means they fail to satisfy one of the criteria for a mental disorder.

The new diagnoses of Somatic Symptom Disorder (SSD) is proposed to overcome these problems with relevant DSM-IV diagnoses.

The previous posting proposed diagnoses of Complex Somatic Symptom Disorder (CSSD) and Simple Somatic Symptom Disorder (SSSD). In this revision, we have merged the two disordes, recognizing that SSSD is a less severe variant of CSSD. The work group is considering dropping the adjective “complex” from the name of the resulting disorder and is desirous of feedback.

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

Severity

Severity Specifiers (mild, moderate, severe)*

[Ed: Cf with ICD-11 Alpha drafting platform proposals for three (as yet undefined) degrees of Mild, Moderate and Severe "Bodily Distress Disorder." See Post #145: “Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11? February 20, 2012]

Somatic Symptom Disorder is a disorder characterized by persistency, symptom burden, and excessive or maladaptive response to somatic symptoms. There is a considerable range of severity. Typically, the disorder is more severe when multiple somatic syptoms are present. In addition to fulfilling criteria A and C, the following metrics may be used to rate severity:

Mild: only 1 of the B criteria fulfilled
Moderate: 2 or more B criteria fulfilled
Severe: 2 or more B criteria fulfilled plus multiple somatic symptoms

PHQ Somatic Symptom Short Form (PHQ-SSS)*

*Ed: Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 2002;64:258-266.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/11914441
PDF: http://www.psychosomaticmedicine.org/content/64/2/258.full.pdf+html

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

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

J 01 Illness Anxiety Disorder

Updated April-27-2012

Proposed Revision

Illness Anxiety Disorder

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

B. Preoccupation with having or acquiring a serious illness. If another medical condition or high risk for developing a medical condition (e.g. strong family history) is present, the preoccupation is clearly excessive or disproportionate.

C. High level of anxiety about health and a low threshold for becoming alarmed about their health.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checking one’s body for signs of illness), or exhibits maladaptive avoidance (e.g., avoiding doctors’ appointments and hospitals).

E. Although the specific 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 another psychiatric disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, or obsessive-compulsive disorder.

Subtypes

Care-seeking subtype: care-seeking individuals have elevated rates of medical utilization.

Care-avoidant subtype: avoidant individuals rarely seek medical care because seeing a physician and undergoing laboratory tests and diagnostic procedures heighten their anxiety to intolerable levels.

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

Rationale

Studies suggest that patients with hypochondriasis fall into two distinct subgroups. In one subgroup (75% of hypochondriasis patients), somatic symptoms predominate and form the patient’s primary concern. The other subgroup (25% of hypochondriacs) is composed of patients with minimal somatic symptoms but who are highly anxious about and suspicious of the presence of an undiagnosed, serious medical illness.

In our proposal for DSM 5, the former subgroup of patients would be subsumed under the new diagnosis of Somatic Symptom Disorder (SSD), while the latter subgroup would now be subsumed under the proposed Illness Anxiety Disorder (IAD). IAD is closely related to other somatic symptom disorders, anxiety disorders, and depressive disorders, but it is included here because of its close relationship to the other somatic symptom disorders in clinical presentation, phenomenology, and in cognitive, affective and behavioral characteristics.

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

Severity

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

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

J 02 Conversion Disorder (Functional Neurological Symptom Disorder)

[Ed: Previous proposal was for renaming "Conversion Disorder" to "Functional Neurological Disorder (Conversion Disorder)" and to possibly relocate under "Dissociative Disorders" in line with ICD-10. Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

Updated April-27-2012

Proposed Revision

Conversion Disorder (Functional Neurological Symptom Disorder)

A. One or more symptoms or deficits are present that affect voluntary motor or sensory function, with or without apparent impairment of consciousness.

B. Clinical findings provide evidence of internal inconsistency or incompatibility with recognized neurological or medical disease.

C. The symptom or deficit is not better explained by another recognized medical or DSM disorder.

D. The symptom or deficit is associated with clinically significant distress or imapairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

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

Rationale

Name Change: The additional parenthetical “functional neurological symptom disorder” has been introduced as it is more frequently used by neurologists who see the majority of these patients. It is also a term that is more acceptable to patients.

Removal of previous criterion 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” We propose that this criterion be eliminated and discussion of etiologic factors placed in accompanying text. This DSM IV criterion reduces the utility and reliability of the diagnosis in practice because:

(a) It confounds clinical description with a proposed but unproven etiology.

(b) The research evidence indicates that observed psychological factors are often non-specific; that is, they occur in patients with other conditions, often with a similar frequency; this non-specificity makes a judgment of their relevance in an individual case of ‘conversion’ subjective and potentially unreliable.

(c) In a substantial proportion of apparent cases of conversion – as defined by neurological symptoms not explained by disease – psychological factors cannot be convincingly or reliably demonstrated.

Removal of previous criterion C. “The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering)”. This criterion reduces the utility and reliability of the diagnosis because:

(a) It is difficult, and probably clinically impossible, to prove reliably that a patient is not feigning.

(b) While the clinician needs to be aware of the possibility of feigning, and to make an appropriate diagnosis if it is found, there is no evidence that feigning is more common in patients with possible conversion disorder than with other mental disorders. Highlighting it for conversion alone is unnecessarily stigmatizing and may be detrimental to the physician-patient relationship.

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

Severity

- Minor and brief impairment (i.e., non-incapacitating symptom such as aphonia lasting less than 2 days)

- Minor impairment and persistent/recurrent (i.e., from 3 days to 3 months)

- Moderate impairment and brief duration

- Severe and persistent/recurrent (e.g., more than 3 months bedbound with contractures and/or muscle wasting)

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

J 03 Psychological Factors Affecting Medical Condition

Updated April-27-2012

Proposed Revision

Psychological Factors Affecting Medical Condition

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

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

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.

[Ed: Rationale and Severity texts have been revised since May 2011 iteration.]

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

Rationale

The work group recommends retaining the diagnosis of Psychological Factors Affecting a Medical Condition (PFAMC) with only minor wording changes in the criteria.

In DSM-IV, PFAMC had 6 subtypes; since there is no evidence the subtypes have been used, we have recommended eliminating them. Finally, we have advocated moving PFAMC from its obscure place in the back of prior DSM editions into the Somatic Symptom Disorders chapter.

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

Severity

1 = increases medical risk (e.g. inconsistent adherence with anti-hypertension treatment)

2 = aggravates underlying medical condition (e.g. anxiety aggravating asthma)

3 = results in medical hospitalization or emergency room visit

4 = results in severe life-threatening risk (e.g. ignoring heart attack symptoms)

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386

J 04 Factitious Disorder

[Ed: Proposal, Rationale and Severity texts have been revised since the May 2011 iteration.]

Updated March-22-2012

Proposed Revision

Proposed Subtypes:

Factitious Disorder Imposed on Self

To meet criteria for Factitious Disorder Imposed on Self, all four criteria must be met.

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified perception.

B. Presenting oneself to others as ill, impaired, or injured.

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

D. The abnormal illness behavior is not better accounted for by another mental disorder such as delusional disorder or other psychotic disorder.

Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy)

To meet criteria for Factitious Disorder Imposed on Another, all four criteria must be met. Note that the perpetrator, not the victim, receives this diagnosis.

A. Falsification of physical or psychological signs or symptoms or of induction of injury or disease in another, associated with identified deception.

B. Presenting another (victim) to others as ill, impaired, or injured.

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

D. The abnormal illness behavior is not better accounted for by another mental disorder such as delusional disorder or other psychoitc disorder.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386#

Rationale

The Somatic Symptom Disorders workgroup requests that Factitious Disorders be grouped within the Somatic Symptom chapter of DSM V. Such a grouping is more logical than the status quo where factitious disorders appear in their own chapter. Our proposed grouping supports clinical utility and facilitates future research.

Utility: This grouping would help physicians with the differential diagnosis of patients who present with persistent problems related to illness perception, frequently including unexpected and/or unexplained psychological and/or physical symptoms. In making a differential diagnosis, it is conceptually and pragmatically useful to group disorders that show diagnostic overlap with one another in the same section. This grouping will be particularly advantageous in terms of comparing and contrasting Factitious Disorder with Conversion Disorder and, to a lesser extent, with Complex Somatic Symptom Disorder.

Research: The grouping of Factitious Disorders with the other Somatic Symptom Disorders would facilitate research progress on the broad spectrum of symptom reporting phenomena, including the feigning of symptoms. In the status quo, Factitious Disorder is listed in a separate chapter, where it is not routinely considered.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=386#

Severity

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

For factitious disorder, one might grade severity levels as “1” when symptoms alone are reported (“bright red blood in stool”), as “2” when a lab test was modified (e.g. introducing blood into a urine sample), as “3” when patients make themselves sick or as “4” when patients’ actions lead to life threatening illness.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541

J 05 Somatic Symptom Disorder Not Elsewhere Classified

Proposed Revision

Updated April-27-2012

Somatic Symptom Disorder Not Elsewhere Classified

Pseudocyesis A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541#

Rationale

Pseudocyesis is a rare disorder with characteristic somatic features. Because of its prominent somatic presentation, pseudocyesis is included in the NEC section of Somatic Symptom Disorder.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=541#

Severity

The work group has not yet finalized their severity for this disorder. Please continue to check this Web site for updates, as this will be forthcoming.

I will continue to monitor the DSM-5 Development site for any further changes and for the announcement of the third and final stakeholder review.

The six most essential questions in psychiatric diagnosis: a pluralogue: conceptual and definitional issues in psychiatric diagnosis Parts 1 and 2

The six most essential questions in psychiatric diagnosis: a pluralogue: conceptual and definitional issues in psychiatric diagnosis, Parts 1 and 2

Post #161 Shortlink: http://wp.me/pKrrB-248

Below, I am posting the Abstract and Introduction to Parts 1 and 2 of Philos Ethics Humanit Med Review “The six most essential questions in psychiatric diagnosis: a pluralogue: conceptual and definitional issues in psychiatric diagnosis.”

Part 1 of this Review was published on January 13, 2012; Part 2 was published (as a provisional PDF) on April 18, 2012. I will post Part 3 when it becomes available.

Below Parts 1 and 2, I have posted the PDFs for Phillips J (ed): Symposium on DSM-5: Part 1. Bulletin of the Association for the Advancement of Philosophy and Psychiatry 2010, 17(1):1–26 and Phillips J (ed): Symposium on DSM-5: Part 2. Bulletin of the Association for the Advancement of Philosophy and Psychiatry 2010, 17(2):1–75 out of which grew the concept for the Philos Ethics Humanit Med Review Parts 1 and 2.

This is an interesting series of exchanges which expand on conceptual and definitional issues discussed in these two Bulletins but these are quite lengthy documents, 29 and 30 pp, respectively; PDFs are provided rather than full texts.

Review Part One

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3305603/

Philos Ethics Humanit Med. 2012; 7: 3.
Published online 2012 January 13. doi: 10.1186/1747-5341-7-3 PMCID: PMC3305603

Copyright ©2012 Phillips et al; licensee BioMed Central Ltd.
Received August 15, 2011; Accepted January 13, 2012.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

      The six most essential questions Part 1

or: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3305603/pdf/1747-5341-7-3.pdf

Html: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3305603/

or http://www.peh-med.com/content/7/1/3

James Phillips,¹ Allen Frances,² Michael A Cerullo,³ John Chardavoyne,¹ Hannah S Decker,⁴ Michael B First,⁵ Nassir Ghaemi,⁶ Gary Greenberg,⁷ Andrew C Hinderliter,⁸ Warren A Kinghorn,^2,9 Steven G LoBello,¹⁰ Elliott B Martin,¹ Aaron L Mishara,¹¹ Joel Paris,¹² Joseph M Pierre,^13,14 Ronald W Pies,^6,15 Harold A Pincus,^5,16,17,18 Douglas Porter,¹⁹ Claire Pouncey,²⁰ Michael A Schwartz,²¹ Thomas Szasz,¹⁵ Jerome C Wakefield,^22,23 G Scott Waterman,²⁴ Owen Whooley,²⁵ and Peter Zachar¹⁰

 

¹Department of Psychiatry, Yale School of Medicine, 300 George St., Suite 901, New Haven, CT 06511, USA

²Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 508 Fulton St., Durham, NC 27710, USA

³Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 260 Stetson Street, Suite 3200, Cincinnati, OH 45219, USA

⁴Department of History, University of Houston, 524 Agnes Arnold, Houston, 77204, USA

⁵Department of Psychiatry, Columbia University College of Physicians and Surgeons, Division of Clinical Phenomenology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA

⁶Department of Psychiatry, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA

⁷Human Relations Counseling Service, 400 Bayonet Street Suite #202, New London, CT 06320, USA

⁸Department of Linguistics, University of Illinois, Urbana-Champaign 4080 Foreign Languages Building, 707 S Mathews Ave, Urbana, IL 61801, USA

⁹Duke Divinity School, Box 90968, Durham, NC 27708, USA

¹⁰Department of Psychology, Auburn University Montgomery, 7061 Senators Drive, Montgomery, AL 36117, USA

¹¹Department of Clinical Psychology, The Chicago School of Professional Psychology, 325 North Wells Street, Chicago IL, 60654, USA

¹²Institute of Community and Family Psychiatry, SMBD-Jewish General Hospital, Department of Psychiatry, McGill University, 4333 cote Ste. Catherine, Montreal H3T1E4 Quebec, Canada

¹³Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90095, USA

¹⁴VA West Los Angeles Healthcare Center, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA

¹⁵Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams St., #343CWB, Syracuse, NY 13210, USA

¹⁶Irving Institute for Clinical and Translational Research, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA

¹⁷New York Presbyterian Hospital, 1051 Riverside Drive, Unit 09, New York, NY 10032, USA

¹⁸Rand Corporation, 1776 Main St Santa Monica, California 90401, USA

¹⁹Central City Behavioral Health Center, 2221 Philip Street, New Orleans, LA 70113, USA

²⁰Center for Bioethics, University of Pennsylvania, 3401 Market Street, Suite 320 Philadelphia, PA 19104, USA

²¹Department of Psychiatry, Texas AMHSC College of Medicine, 4110 Guadalupe Street, Austin, Texas 78751, USA

²²Silver School of Social Work, New York University, 1 Washington Square North, New York, NY 10003, USA

²³Department of Psychiatry, NYU Langone Medical Center, 550 First Ave, New York, NY 10016, USA

²⁴Department of Psychiatry, University of Vermont College of Medicine, 89 Beaumont Avenue, Given Courtyard N104, Burlington, Vermont 05405, USA

²⁵Institute for Health, Health Care Policy, and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St., New Brunswick, NJ 08901, USA

Abstract

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

General Introduction

This article has its own history, which is worth recounting to provide the context of its composition.

As reviewed by Regier and colleagues [1], DSM-5 was in the planning stage since 1999, with a publication date initially planned for 2010 (now rescheduled to 2013). The early work was published as a volume of six white papers, A Research Agenda for DSM-V [2] in 2002. In 2006 David Kupfer was appointed Chairman, and Darrel Regier Vice-Chairman, of the DSM-5 Task Force. Other members of the Task Force were appointed in 2007, and members of the various Work Groups in 2008.

From the beginning of the planning process the architects of DSM-5 recognized a number of problems with DSM-III and DSM-IV that warranted attention in the new manual. These problems are now well known and have received much discussion, but I will quote the summary provided by Regier and colleagues:

Over the past 30 years, there has been a continuous testing of multiple hypotheses that are inherent in the Diagnostic and Statistical Manual of Mental Disorders, from the third edition (DSM-III) to the fourth (DSM-IV)… The expectation of Robins and Guze was that each clinical syndrome described in the Feighner criteria, RDC, and DSM-III would ultimately be validated by its separation from other disorders, common clinical course, genetic aggregation in families, and further differentiation by future laboratory tests–which would now include anatomical and functional imaging, molecular genetics, pathophysiological variations, and neuropsychological testing. To the original validators Kendler added differential response to treatment, which could include both pharmacological and psychotherapeutic interventions… However, as these criteria have been tested in multiple epidemiological, clinical, and genetic studies through slightly revised DSM-III-R and DSM-IV editions, the lack of clear separation of these syndromes became apparent from the high levels of comorbidity that were reported… In addition, treatment response became less specific as selective serotonin reuptake inhibitors were found to be effective for a wide range of anxiety, mood, and eating disorders and atypical antipsychotics received indications for schizophrenia, bipolar disorder, and treatment-resistant major depression. More recently, it was found that a majority of patients with entry diagnoses of major depression in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study had significant anxiety symptoms, and this subgroup had a more severe clinical course and was less responsive to available treatments… Likewise, we have come to understand that we are unlikely to find single gene underpinnings for most mental disorders, which are more likely to have polygenetic vulnerabilities interacting with epigenetic factors (that switch genes on and off) and environmental exposures to produce disorders. [[2], pp. 645-646]

As the work of the DSM-5 Task Force and Work Groups moved forward, a controversy developed that involved Robert Spitzer and Allen Frances, Chairmen respectively of the DSM-III and DSM-IV Task Forces. The controversy began with Spitzer’s Letter to the Editor, “DSM-V: Open and Transparent,” on July 18, 2008 in Psychiatric Times [3], detailing his unsuccessful effort to obtain minutes of the DSM-5 Task Force meetings. In ensuing months Allen Frances joined him in an exchange with members of the Task Force. In a series of articles and blog postings in Psychiatric Times, Frances (at times with Spitzer) carried out a sustained critique of the DSM-5 work in which he focused both on issues of transparency and issues of process and content [4-16]. The latter involved the Task Force and Work Group efforts to address the problems of DSM-IV with changes that, in Frances’ opinion, were premature and not backed by current scientific evidence. These changes included new diagnoses such as mixed anxiety-depression, an expanded list of addictive disorders, the addition of subthreshold conditions such as Psychosis Risk Syndrome, and overly inclusive criteria sets – all destined, in Frances’ judgment, to expand the population of the mentally ill, with the inevitable consequence of increasing the number of false positive diagnoses and the attendant consequence of exposing individuals unnecessarily to potent psychotropic medications. The changes also included extensive dimensional measures to be used with minimal scientific foundation.

Frances pointed out that the NIMH was embarked on a major effort to upgrade the scientific foundation of psychiatric disorders (described below by Michael First), and that pending the results of that research effort in the coming years, we should for now mostly stick with the existing descriptive, categorical system, in full awareness of all its limitations. In brief, he has argued, we are not ready for the “paradigm shift” hoped for in the 2002 A Research Agenda.

We should note that as the DSM-5 Work Groups were being developed, the Task Force rejected a proposal in 2008 to add a Conceptual Issues Work Group [17] – well before Spitzer and Frances began their online critiques.

In the course of this debate over DSM-5 I proposed to Allen in early 2010 that we use the pages of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry (of which I am Editor) to expand and bring more voices into the discussion. This led to two issues of the Bulletin in 2010 devoted to conceptual issues in DSM-5 [18,19]. (Vol 17, No 1 of the AAPP Bulletin will be referred to as Bulletin 1, and Vol 17, No 2 will be referred to as Bulletin 2. Both are available at http://alien.dowling.edu/~cperring/aapp/bulletin.htm. webcite) Interest in this topic is reflected in the fact that the second Bulletin issue, with commentaries on Frances’ extended response in the first issue, and his responses to the commentaries, reached over 70,000 words.

Also in 2010, as Frances continued his critique through blog postings in Psychiatric Times, John Sadler and I began a series of regular, DSM-5 conceptual issues blogs in the same journal [20-33].

With the success of the Bulletin symposium, we approached the editor of PEHM, James Giordano, about using the pages of PEHM to continue the DSM-5 discussion under a different format, and with the goal of reaching a broader audience. The new format would be a series of “essential questions” for DSM-5, commentaries by a series of individuals (some of them commentators from the Bulletin issues, others making a first appearance in this article), and responses to the commentaries by Frances. Such is the origin of this article. (The general introduction, individual introductions, and conclusion are written by this author (JP), the responses by Allen Frances.

For this exercise we have distilled the wide-ranging discussions from the Bulletin issues into six questions, listed below with the format in which they were presented to commentators. (As explained below, the umpire metaphor in Question 1 is taken from Frances’ discussion in Bulletin 1.)…

Full document in PDF format

 

Review Part Two

(Note: Part Two was published on April 18, 2012 and addresses Questions 3 and 4. The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production. I will replace with the final version when available.)

The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

Philosophy, Ethics, and Humanities in Medicine 2012, 7:8 doi:10.1186/1747-5341-7-8

http://www.peh-med.com/content/7/1/8/abstract

Published: 18 April 2012

      The six most essential questions Part 2 Provisional

The six most essential questions in psychiatric diagnosis: A pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis

James Phillips, Allen Frances, Michael A Cerullo, John Chardavoyne, Hannah S Decker, Michael B First, Nassir Ghaemi, Gary Greenberg, Andrew C Hinderliter, Warren A Kinghorn, Steven G LoBello, Elliott B Martin, Aaron L Mishara, Joel Paris, Joseph M Pierre, Ronald W Pies, Harold A Pincus, Douglas Porter, Claire Pouncey, Michael A Schwartz, Thomas Szasz, Jerome C Wakefield, G Scott Waterman, Owen Whooley and Peter Zachar

Abstract (provisional)

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

 

Symposium on DSM-5: Parts 1 and 2

      Bulletin Vol 17 No 1

Phillips J (ed): Symposium on DSM-5: Part 1. Bulletin of the Association for the
Advancement of Philosophy and Psychiatry 2010, 17(1):1–26

      Bulletin Vol 17 No 2

Phillips J (ed): Symposium on DSM-5: Part 2. Bulletin of the Association for the Advancement of Philosophy and Psychiatry 2010, 17(2):1–75

 

One focus for this site has been the monitoring of the various iterations towards the revision of the Somatoform Disorders categories of DSM-IV, for which radical reorganization of existing DSM categories and criteria is proposed.

As the DSM-5 Development site documentation currently stands (April 27, 2012), the “Somatic Symptom Disorders” Work Group (Chaired by Joel E. Dimsdale, M.D.) proposes to rename Somatoform Disorders to “Somatic Symptom Disorders” and to fold a number of existing somatoform disorders together under a new rubric, which the Work Group proposes to call “Complex Somatic Symptom Disorder.”

Complex Somatic Symptom Disorder (CSSD) would include the previous DSM-IV 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].

There is a more recently proposed, Simple Somatic Symptom Disorder (SSSD), which requires symptom duration of just one month, as opposed to the six months required to meet the CSSD criteria. There is also an Illness Anxiety Disorder (hypochondriasis without somatic symptoms); and a proposal to rename Conversion Disorder to Functional Neurological Disorder and possibly locate under Dissociative Disorders.

There is some commentary on the Somatoform Disorders in DSM-IV in this discussion from Bulletin 1:

Bulletin Vol 17 No 1, Page 19:

Doing No Harm: The Case Against Conservatism

G. Scott Waterman, M.D. David P. Curley, Ph.D.

Department of Psychiatry, University of Vermont College of Medicine

What’s new in the ICD-11 Alpha drafting platform? (CFS, PVFS, ME)

What’s new in the ICD-11 Alpha drafting platform? (CFS, PVFS, ME)

Post #157 Shortlink: http://wp.me/pKrrB-22h

 

Screenshot: ICD-11 Alpha Browser Foundation view selected, logged in at April 10, 2012:

Chapter 6: Diseases of the nervous system

http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fwho.int%2ficd%23G93.3

Apr 09 – 11:02 UTC

 

ICD-11 Beta drafting platform to launch in May?

As reported in previous posts, according to the timeline, the ICD-11 Beta drafting platform is supposed to be launching this May.

ICD-11 Revision Steering Group has yet to announce whether the Beta platform remains on target for a May release and if so, on what date it will be launched – so I cannot give you a date yet.

Like the Alpha Drafting Browser, the Beta drafting platform will be a work in progress – not a final Beta draft. The final Beta isn’t scheduled until 2014, after the ICD-11 field trials have been undertaken.

When it does launch, the Beta platform is intended to be accessible to professionals and the public for viewing.

Registered or logged in users will have greater access to content and will be able to interact with the platform to read comments, comment on proposals and make suggestions, as part of the ongoing drafting process.  

In the meantime, the publicly viewable version of the Alpha drafting platform (known as the ICD-11 Alpha Browser) can still be accessed here:

http://apps.who.int/classifications/icd11/browse/f/en

The various ICD-11 Revision Topic Advisory Groups are carrying out their draft preparation work on a separate, more complex multi-author drafting platform that is accessible only to WHO and ICD Revision personnel.

 

Alpha drafting platform

As before, the publicly viewable version of the Alpha Browser should be viewed with the following caveats in mind:

the Alpha draft is a work in progress; it is incomplete; it may contain errors and omissions; it is in a state of flux and updated daily; textual content, codes and “Sorting labels” are subject to change as chapters are reorganized and content populated; the content has not been approved by Topic Advisory Groups, Revision Steering Group or WHO.

It is possible to register, or sign into the platform using existing accounts with several third party account providers such as Google, Yahoo and myOpenID, for increased access and functionality. Once signed in, Comments and Questions can be read and PDFs of the drafts of the top level linearizations can be downloaded from the Linearization tab.

See the Alpha Browser User Guide for information on how the Alpha Browser functions:

http://apps.who.int/classifications/icd11/browse/Help/en

 

The ICD-11 “Content Model”

ICD-11 will be available in both print and online versions and unlike most chapters of ICD-10, will include descriptive content for ICD terms.

For the online version of ICD-11, all ICD entities will include a definition and a number of additional key descriptive fields – between 7 and 13 pre-defined parameters, populated according to a common “Content Model” (Content Model Reference Guide January 2011).

For example, ICD entity Title, Definition, Synonyms, Narrower Terms, Exclusions, Body Site, Body System, Signs and Symptoms, Causal Mechanisms, and possibly Diagnostic Criteria for some entities.*

*According to the iCAT User Google Group message board, these fields may have been revised since the January 2011 Content Model Reference Guide was published; Content Model parameters in the Beta draft may therefore differ from those currently displaying in the public Alpha drafting platform.

The print version will use a concise version of Definition due to space constraints.

In the Alpha Browser, not all these Content Model parameters display in the Foundation and Linearization views and not all of the parameters that have been listed for individual entities have had their draft text added yet, as some chapters are more advanced for the population of proposed content than others.

So the Alpha draft is still very patchy and many entities have no Definition and little or no other proposed content filled in.

With no “Category Discussion Notes” or “Change history” pop-up windows visible in the public version of the Alpha, the viewer cannot determine the rationales behind the reorganization of terms and hierarchies within the various chapters.

 

Chapter location and hierarchy for CFS, PVFS and (Benign) ME in ICD-11

I have been reporting since June 2010 that the proposals for ICD-11 Alpha Draft, as far as one could determine, appeared to be:

1] That a change of hierarchy had been recorded in a “Category Discussion Note”, dated May 1, 2010, between ICD-10 Title term “Postviral fatigue syndrome” and “Chronic fatigue syndrome”. (“Category Discussion Notes” and “Change History” pop-ups did display in the earlier iCAT version of the Alpha drafting platform.)

You can view a screenshot from June 2010 of that “Change history” record here:

http://dxrevisionwatch.files.wordpress.com/2010/06/change-history-gj92-cfs.png

The Definition field on the “Chronic fatigue syndrome” description panel in the current Alpha Browser is currently blank but in June 2010, the Definition had stood as in this contemporaneous screenshot:

http://dxrevisionwatch.files.wordpress.com/2010/05/2icatgj92cfsdef.png

2] That “Chronic fatigue syndrome” had been designated as an ICD-11 Title term within ICD-11 Chapter 6: Diseases of the nervous system, with the capacity for a Definition and up to 10 additional descriptive parameters.

3] That “Benign myalgic encephalomyelitis” had been specified as an Inclusion term to ICD-11 Title term “Chronic fatigue syndrome” but that the relationships between the three terms, PVFS, (B) ME and CFS had yet to be specified, as in this screenshot from June 2010:

http://dxrevisionwatch.files.wordpress.com/2010/05/2icatgj92cfsterms.png

 

What is currently showing in the Chapter 6 Foundation Component?

It isn’t possible to bring up a discrete ICD Title listing for either “Benign myalgic encephalomyelitis” or “Postviral fatigue syndrome” in either the Foundation Component or the Linearization.

In the Foundation view only, for Chapter 6: Diseases of the nervous system, “Chronic fatigue syndrome” is listed as a Title term with the ICD-10 legacy ID “ID:http://who.int/icd#G93.3″;

the Definition field is currently blank;

a list of terms has recently been added under “Synonyms”;

one term has recently been added under “Narrower Terms”.

(Note: there is a small asterisk at the end of term “Benign myalgic encephalomyelitis” which is listed at the top of the “Synonyms” list. The asterisk “Hover text” reads “This term is an inclusion term in the linearizations.”)

If you want to view the listing directly on the Browser site (note the “Comment” and “Questions” icons which open up pop-up windows next to terms for reading/commenting won’t display unless you have already registered and logged in) go here:

ICD-11 Alpha Browser Foundation view:

http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fwho.int%2ficd%23G93.3

ID:http://who.int/icd#G93.3

Chronic fatigue syndrome

Parent(s)

Selected cause is Remainder of diseases of the nervous system in Condensed and selected Infant and child mortality lists
Selected Cause is All other diseases in the Selected General mortality list
Selected cause is Diseases of the nervous system

Definition

This entity does not have a definition at the moment.

Synonyms

Benign myalgic encephalomyelitis *  [Ed: Hover text over asterisk reads: "This term is an inclusion term in the linearizations."]
akureyri
akureyri disease
cfs – chronic fatigue syndrome
chronic fatigue syndrome nos   [Ed: from current proposals for ICD-10-CM, Chapter 18, R53.82]
chronic fatigue, unspecified   [Ed: from current proposals for ICD-10-CM, Chapter 18, R53.82]
epidemic neuromyasthenia
iceland disease
icelandic disease
me – myalgic encephalomyelitis
myalgic encephalomyelitis
myalgic encephalomyelitis syndrome
postviral fatigue syndrome
pvfs – postviral fatigue syndrome

Narrower Terms

neuromyasthenia

Body Site

Entire brain (body structure)
Brain structure (body structure)

Causal Mechanisms

Virus (organism)

 

What’s new in Chapter 5: Mental and behavioural disorders?

As reported in Dx Revision Watch post: http://wp.me/pKrrB-1Vx,  the category “Somatoform Disorders” in Chapter 5, Mental and behavioural disorders is currently renamed to “BODILY DISTRESS DISORDERS”, under which currently sit three new child categories:

5M0 Mild bodily distress disorder
5M1 Moderate bodily distress disorder
5M2 Severe bodily distress disorder.

Chapter 5 Linearization view:

http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fwho.int%2ficd%23F45

Chapter 5 Foundation view:

http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fwho.int%2ficd%23F45

(Click on the little grey arrows to display the child categories):

Child categories to parent ”BODILY DISTRESS DISORDERS”:

http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fwho.int%2ficd%231905_dd0250d2_e8cd_4c48_a93f_7997cc1c8b07

BODILY DISTRESS DISORDERS

5M0 Mild bodily distress disorder
5M1 Moderate bodily distress disorder
5M2 Severe bodily distress disorder
5M3 Somatization disorder
5M4 Undifferentiated somatoform disorder
5M5 Somatoform autonomic dysfunction
5M6 Persistent somatoform pain disorder
      > 5M6.0 Persistent somatoform pain disorder
      > 5M6.1 Chronic pain disorder with somatic and psycological [sic] factors
5M7 Other somatoform disorders
5M8 Somatoform disorder, unspecified

None of these three new (proposed) categories have had any Definitions or other textual content added to the description panels on the right hand side of the Alpha Browser page since I first reported this change in February.

It is still not possible to determine what disorders ICD-11 intends might be captured by these three new (proposed) terms, should ICD-11 Revision Steering Group and WHO classification experts consider these terms to be valid constructs and approve their progression through to the Beta draft.

Because no “Change Notes” or “Change history” pop-up windows display in this version of the Alpha Drafting browser, it is not possible to determine:

whether ICD-11 is proposing to introduce three new terms – 5M0 Mild bodily distress disorder; 5M1 Moderate bodily distress disorder; 5M2 Severe bodily distress disorder, in addition to retaining existing ICD-10 terms, 5M3 thru 5M8;

how ICD Revision intends to define these (proposed) new terms at 5M0, 5M1, 5M2;

how these three (proposed) new terms would relate to the existing ICD-10 “Somatoform Disorders” categories which remain listed as child categories to “BODILY DISTRESS DISORDERS” (apart from “Hypochondriacal disorder” [ICD-10: F45.2], which is now listed as “5H0.5 Illness Anxiety Disorder” in the ICD-11 Alpha Draft).

(See Page 1 and 2 of my report: “Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?: http://wp.me/pKrrB-1Vx  )

 

References:

ICD-11 Revision: http://www.who.int/classifications/icd/revision/en/

ICD-11 Alpha Browser User Guide: http://www.who.int/classifications/icd/revision/caveat/en/index.html
Alpha Browser Foundation view: http://apps.who.int/classifications/icd11/browse/f/en#
Alpha Browser Linearization view: http://apps.who.int/classifications/icd11/browse/l-m/en#
“Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?: http://wp.me/pKrrB-1Vx

“Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?

“Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?

Post #145 Shortlink: http://wp.me/pKrrB-1Vx

The information in this report relates only to proposals for the forthcoming ICD-11; it does not relate to ICD-10 or the forthcoming US specific “clinical modification” of ICD-10, ICD-10-CM.

Part One

This report contains an important update on proposals for ICD-11 Chapter 5: Mental and behavioural disorders.

In a February 16 report by Tom Sullivan for Health Care Finance News, Christopher Chute, MD, who chairs the ICD Revision Steering Group, warns of a possible delay for completion of ICD-11 from 2015 to 2016. Nevertheless, the ICD-11 Beta drafting platform remains scheduled to launch in May, this year.

The Beta drafting platform will take the form of a publicly viewable browser similar to the Alpha drafting platform that has been in the public domain since last May.

You can view the Alpha Drafting Browser here:

Foundation Component view:

http://apps.who.int/classifications/icd11/browse/f/en

Morbidity Linearization view:

http://apps.who.int/classifications/icd11/browse/l-m/en

The Morbidity Linearization is the view that includes (what may be temporarily assigned) sorting codes. These codes are likely to change as chapter organization progresses. Click on the small grey arrows next to the chapters and categories to display parent > child > grandchildren hierarchies. Click on individual terms to display descriptive content in the right hand frame of the Alpha Browser.

Textual content for ICD-11 is in the process of being written and population of content for some chapters is more advanced than others. Content for some of these “ICD-11 Content Model parameters” may display: ID legacy code from ICD-10 (where applicable); Definition; Inclusions; Exclusions; Body Site; Causal Mechanism; Signs and Symptoms.

(For ICD-11, entities will be defined through up to 13 “Content Model parameters” across all chapters – considerably more descriptive content than in ICD-10 and a significant workload for the Topic Advisory Group members and managers who are generating the content for ICD-11.)

The Alpha Browser User Guide is here:

http://apps.who.int/classifications/icd11/browse/Help/en

This page of the User Guide sets out differences between Foundation view and Morbidity Linearization view.

The various ICD Revision Topic Advisory Groups (TAGs) are carrying out their work on a separate, more complex, multi-author drafting platform. Editing histories and “Category and Discussion Notes” are recorded so the progress of proposals and reorganization of ICD entities can be tracked, as the draft evolves.

When the Beta drafting platform launches, interested stakeholders will be invited to register for increased access and interaction with the drafting process by submitting comments and suggestions on draft content and proposals.

It is also possible to register for increased access to the Alpha drafting platform and for downloading PDFs of drafts for the “Print Versions for the ICD-11 Alpha Morbidity Linearization” for all 25 chapters of ICD-11. These are obtainable, once registered and logged in, from the Linearization > Print Versions tab.

Caveats

I’m going to reiterate the ICD-11 Alpha Browser Caveats because it’s important to understand that the ICD-11 Alpha draft is a work in progress – not a static document – and is subject to change.

The draft is updated on a (usually) daily basis; when you view the Alpha Browser, you are viewing a “snapshot” of how the publicly viewable draft stood at the end of the previous day; not all chapters are as advanced as others for reorganization or population of content; the draft is incomplete and may contain errors and omissions.

The codes and “sorting labels” assigned to ICD parent classes, child and grandchildren terms are subject to change as reorganization of the chapters progresses. The Alpha draft has not yet been approved by the Topic Advisory Groups, Revision Steering Group or WHO and proposals for, and content in the draft may not progress to the Beta drafting stage – so be mindful of the fact that the draft is in a state of flux.

We may have a clearer idea of what is being proposed once the Beta drafting platform is released, but as it currently stands, the Alpha lacks clarity; not all textual content will have been generated and uploaded for terms imported from ICD-10 and there may be no definitions or other textual content displaying for proposed new terms.

Two chapters that are a focus of this site are Chapter 5: Mental and behavioural disorders and Chapter 6: Disorders of the nervous system (the Neurology chapter). (ICD-11 is dropping the use of Roman numerals.)

I won’t be reporting on specific categories in Chapter 6 in this post but will do a follow up post for Chapter 6 in a few days; again, there is a lack of clarity for Chapter 6 and requests for specific clarifications, last year, from the chair of Topic Advisory Group Neurology and the lead WHO Secretariat for TAG Neurology have met with no response.

Continued on Page 2: Somatoform Disorders in ICD-10; Somatoform Disorders to Bodily Distress Disorders for ICD-11?

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