Comparison of Complex Somatic Symptom Disorder (CSSD) criteria between third, second and first public review of draft proposals for DSM-5
DSM-5 criteria for CSSD as they stand in the May 2012 Third public review
Somatic Symptom Disorders Work Group proposals:
Two PDF Disorder Descriptions and Rationale/Validity Propositions 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. But brief Rationale text has been posted and can be read at the end of this section.
I have asked the APA’s Media and Communications Office twice, now, if they would 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. I have received no response.
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 DisorderJ 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.)
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
DSM-5 criteria for CSSD as they stood in May 2011 in the Second public review
The DSM-5 Somatic Symptom Disorders Work Group (originally called the Somatic Distress Disorders Work Group) is proposing a radical reorganization of the DSM-IV Somatoform Disorders section.
As the DSM-5 Development site documentation currently stands, the Work Group proposes to rename Somatoform Disorders to Somatic Symptom Disorders and to run a number of existing somatoform disorders together into a new category, which it 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.
View and compare the criteria for Complex Somatic Symptom Disorder and Simple Somatic Symptom Disorder as they stood, last May, for the second public review and comment exercise, on this Dx Revision Watch Tab page or view all category and criteria proposals on the DSM-5 Development site:
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 |
ARCHIVE MATERIAL
This is how the proposed criteria for Complex Somatic Symptom Disorder had stood in May 2011:
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368
J 00 Complex Somatic Symptom Disorder
Updated January 14, 2011
Complex Somatic Symptom Disorder
Proposed Revision Tab
To meet criteria for CSSD, criteria A, B, and C are necessary.
A. Somatic symptoms:
One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:
(1) High level of health-related anxiety.
(2) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.
(3) Excessive time and energy devoted to these symptoms or health concerns.*
C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).
For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
XXX.1 Predominant somatic complaints (previously, somatization disorder)
XXX.2 Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having Illness Anxiety Disorder.
XXX.3 Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.
* Criteria B is still under active discussion
Key PDF documents as they stood in May 2011 [these are revisions of the January 2010 versions]
Disorder Descriptions: Disorder Descriptions May 04, 2011
This proposal for a Simple Somatic Symptom Disorder (SSSD) category had not been proposed at the time of the February 2010 draft review:
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=491
J 01 Simple Somatic Symptom Disorder
Updated May 4, 2011
Simple Somatic Symptom Disorder
Proposed Revision Tab
This diagnosis requires the following 3 criteria:
A. Somatic Symptoms
One or more somatic symptoms that are distressing and/or result in significant disruption of daily life
B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: This diagnosis requires one of the following:
(1) Disproportionale and persistent thoughts about the seriousness of one’s symptoms
(2) High level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health concerns
C. Symptom duration is greater than 1 month
[Disorder Descriptions and Rationale documents as PDFs for CSSD above]
This is how the proposed criteria for Functional Neurological Disorder (currently known as Conversion Disorder in DSM-IV) had stood in May 2011:
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8
J 03 Functional Neurological Disorder (Conversion Disorder)
Updated May 4, 2011
Functional Neurological Disorder (Conversion Disorder)*
Proposed Revision Tab
Criteria A, B, C, and D must all be fulfilled to make the diagnosis:
A. One or more neurologic symptoms such as altered voluntary motor, sensory function, cognition, or seizure-like episodes.
B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior.
C. The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized neurological disorder.
D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
*The final name of this disorder is still under active discussion
* Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are discussing how conversion disorder relates to the dissociative disorders.
[Disorder Descriptions and Rationale documents as PDFs for CSSD above]
DSM-5 criteria for CSSD as they stood in February 2010 in the First public review
ARCHIVE MATERIAL
This is how the proposed criteria for Complex Somatic Symptom Disorder had stood in February 2010:
Complex Somatic Symptom Disorder [Proposed new classification]
Proposal
Complex Somatic Symptom Disorder (includes previous diagnoses of Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition and Pain Disorder Associated With Psychological Factors )
To meet criteria for CSSD, criteria A, B, and C are necessary.
A. Somatic symptoms:
Multiple somatic symptoms that are distressing, or one severe symptom
B. Misattributions, excessive concern or preoccupation with symptoms and illness: At least two of the following are required to meet this criterion:
(1) High level of health-related anxiety.
(2) Normal bodily symptoms are viewed as threatening and harmful
(3) A tendency to assume the worst about their health (catastrophizing).
(4) Belief in the medical seriousness of their symptoms despite evidence to the contrary.
(5) Health concerns assume a central role in their lives
C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent (at least 6 months).
The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
XXX.1 Multiplicity of somatic complaints (previously, somatization disorder)
XXX.2 High health anxiety (previously, hypochondriasis) {If patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.} *
XXX.3 Pain disorder. This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as major depression or adjustment disorder.
For assessing severity of this disorder, metrics are available for rating degree of somatic symptoms (see for instance PHQ, Kroenke et al, 2002). Scales are also available for assessing severity of the patient’s misattributions, excessive concerns and preoccupations (see for instance Whiteley inventory, Pilowsky , 1967).
*Note: Both the Somatic Symptom Disorders Work Group and The Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are considering the possibility that what was described as Hypochondriasis in DSM-IV may represent a heterogeneous disorder in which some individuals may be better considered to have CSSD and some may be better considered to have an anxiety disorder. There will be ongoing discussion of this issue.
Key PDF documents as they stood in February 2010:
