Page Shortlink: http://wp.me/PKrrB-jZ
Archive content dating from first DSM-5 public review and comment period (February to April 2010), superceded by proposals in the second public review and comment period (May to July 2011) and third public review and comment period (May to June, 2012).
DSM-5 first public review period February 2010:
Proposals for Somatic Symptom Disorders
This material also appears in Dx Revision Watch Post #17: http://wp.me/pKrrB-yJ
The first draft of Proposed Revisions to DSM-IV Disorders and Criteria were published on the APA’s relaunched DSM5.org website on 10 February 2010.
Selected material for revision of “Somatoform Disorders”
A version of this material was published in two parts, via the Co-Cure mailing list, 10 February 2010
Ed Notes:
1] The APA appears to be adopting the use of “DSM-5″ rather than “DSM-V” for the next edition of its Diagnostic and Statistical Manual.
2] CSSD in the text below is an acronym for “Complex Somatic Symptom Disorder”. Do not confuse this with “CISSD Project” (Conceptual Issues in Somatoform and Similar Disorders Project), an unofficial project undertaken between 2003 and 2007, initiated and co-ordinated by Dr Richard Sykes, PhD, former Director of Westcare UK; Principal Administrators, Action for M.E. Four members of the CISSD Project workgroup, Michael Sharpe, Arthur Barsky, Francis Creed and James Levenson have served on the DSM-5 Somatic Symptoms Disorders Work Group since 2007. A fifth member, Javier Escobar, is a member of the DSM-5 Task Force, the DSM-5 Psychiatric/General Medical Interface Study Group and serves as Task Force liaison to the DSM-5 SSD Work Group.
3] I have pubished selected material from the APA’s new webpages below, for the proposed revisions to the DSM-IV categories currently classified under “Somatoform Disorders”. There are also some associated PDFs which will need to be referred to.
There is a degree of correspondence between the current “Somatoform Disorders” section in DSM-IV and the equivalent section in ICD-10: Chapter V. The table below sets out how DSM-IV and ICD-10 currently correspond for their respective Somatoform Disorders classifications.
Note that Chronic fatigue syndrome is not categorized in DSM-IV and neither is Neurasthenia (ICD-10: Chapter V at F48.0) http://www.psychnet-uk.com/dsm_iv/dsm_iv_index.htm
Current DSM-IV Codes and Categories for Somatoform Disorders and ICD-10 Equivalents
Source: Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-V. Am J Psychiat. 2005;162:847–855.
We have no information on how closely the ICD Topic Advisory Group for the revision of Chapter V: Mental and Behavioural Disorders (TAG MH) is collaborating with the DSM-5 Somatic Symptom Disorders Work Group over the revisions of their respective “Somatoform Disorders” sections.
Until the iCAT platform is launched and the ICD-11 Alpha Draft published (ETA May 2010), it is not apparent what changes TAG MH might be proposing for the structure, content and classifications of its corresponding Chapter V: F45 – F48 codes, or to what extent ICD Revision intends that any changes to its own “Somatoform Disorders” codings will mirror Task Force proposals for DSM-5 – if the DSM-5 Task Force were to approve radical changes.
4] The public comment period runs from 10 February to 20 April and an online registration process is required. This comment period will be followed by field trials and beta draft. The current publication date for DSM-5 is May 2013.
Comprehensive DSM-5 Development Timeline
————–
The American Psychiatric Association (APA) released draft proposals for revisions and draft criteria for DSM-5 on 10 February
Draft Proposals for DSM-5 Categories are published here on the APA’s relaunched DSM-5 website:
http://www.dsm5.org/Pages/Default.aspx
The public comment period will be open from 10 February to 20 April. There is an online registration requirement for submitting comments.
Open the APA 10 February News Release here in PDF format: Diag Criteria General FINAL 2.05
http://www.dsm5.org/Newsroom/Documents/Diag%20%20Criteria%20General%20FINAL%202.05.pdf
or read the text of the News Release here in Post #16
APA publishes proposed revisions and draft criteria for DSM-5 (DSM-V) categories
The new DSM-5 webpages are here: http://www.dsm5.org/Pages/Default.aspx
American Psychiatric Association DSM-5 Development
Proposed Draft Revisions to DSM Disorders and Criteria
The draft disorders and disorder criteria that have been proposed by the DSM-5 Work Groups can be found on these pages. Use the links below to read about proposed changes to the disorders that interest you. Please note that the proposed criteria listed here are not final. These are initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups. Viewers will be able to submit comments until April 20, 2010. After that time, this site will be available for viewing only.
Structural, Cross-Cutting, and General Classification Issues for DSM-5
“In addition to revising the diagnostic criteria, task force and work group members are also making recommendations to DSM-5 that are likely to affect many or all disorders. These recommendations include the ways in which the diagnostic categories are structured; use of the multi-axial system to record diagnoses and clinical variables of interest; consideration of factors that cut across all diagnoses (e.g., gender and cultural issues); and the use of dimensional measures to refine diagnostic assessment and treatment planning. For more information on these and other disorder-related revisions, please click the links below. You can leave feedback about these and other non diagnostic specific issues in DSM-5 in the Overall Comments section.”
Classification Issues Under Discussion
Cross-Cutting Dimensional Assessment in DSM-5
Diagnoses Proposed by Outside Sources
Definition of a Mental Disorder
————–
http://www.dsm5.org/about/Pages/OverallCommentsPage.aspx
Overall Comments
“The Overall Comments section is where readers can give feedback about DSM-5 other than commenting on a specific diagnosis. For example, comments about DSM’s organization, use, or other general questions and concerns can be submitted here. Comments about a class of disorders as a whole (e.g., Personality Disorders, Anxiety Disorders) also can be made here. To make comments regarding the diagnostic criteria for a specific disorder, please visit the Proposed Revisions section and leave feedback under the disorder of interest.”
Proposed Revisions section:
http://www.dsm5.org/ProposedRevisions/Pages/Default.aspx
Want to comment?
Register: http://www.dsm5.org/Pages/Registration.aspx
————–
Proposed Draft Revisions to DSM Disorders and Criteria
http://www.dsm5.org/ProposedRevisions/Pages/Default.aspx
“The draft disorders and disorder criteria that have been proposed by the DSM-5 Work Groups for new and existing mental disorders can be found on these pages. Use the links below to read about proposed changes to the disorders that interest you. The disorders below are listed by their DSM-IV diagnostic category. However, you may click here if you are interested in seeing which work groups are addressing which disorders. Please note that the proposed criteria listed here are not final. These are initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups.
“You will also notice for each disorder a section pertaining to the assessment of disorder severity. The severity criteria being proposed differs somewhat across disorders, largely because the work groups are in different stages in their deliberation processes. Therefore, you will notice some variability in the range of options presented across disorders, as well as differences in the severity scales being proposed. However, by DSM-5′s completion, we look forward to presenting a standardized method for assessing severity for all diagnoses, with an emphasis on simplicity and clinical utility.
“Finally, in addition to pages on each of the DSM-IV diagnostic categories, you will notice a section on Structural, Cross-Cutting, and General Classification Issues for DSM-5. This section contains proposed revisions that are not specific to diagnostic criteria and include such items as how DSM-5 plans to address the multi-axial system of classification, a description of dimensional assessments in DSM-5, a revised definition of a mental disorder, a listing of disorders proposed by outside sources that are still under consideration, and more. Please be sure to review this section in addition to the diagnostic-specific sections.
“We encourage you to participate in the review process by registering to the Web site and submitting your comments. The draft criteria will be posted here for your input until April 20th. After this time, the work group members may make revisions based on the input received from this Web site. Revised draft criteria for select disorders will then be subjected to field trials (real-world testing in clinical settings). The draft criteria may also change based on incorporation of dimensional measures and other areas that will affect diagnosis across DSM-5. Once these changes have been implemented and/or tested, we will post the revised criteria on this site to allow commentary once again, before beginning a second wave of field trials.”
*Please note that all input we receive will be reviewed, though we can not guarantee that your suggestions will be incorporated into any revisions.
Adjustment Disorders
Anxiety Disorders
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Dissociative Disorders
Eating Disorders
Factitious Disorders
Impulse-Control Disorders Not Elsewhere Classified
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Mood Disorders
Other Clinical Conditions That May Be a Focus of Clinical Attention
Personality and Personality Disorders
Schizophrenia and Other Psychotic Disorders
Sexual and Gender Identity Disorders
Sleep Disorders
Somatoform Disorders
Substance-Related Disorders
Ed: Source: Academy of Psychosomatic Medicine, Nevada, November ‘09 Annual Meeting slide presentation, Francis Creed, MD, FRCP: Can We Now Explain Medically Unexplained Symptoms? See this posting
[Selected material from Somatoform Disorders]
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx
“Please find below a list of disorders related to the diagnostic category, Somatoform Disorders.
“The Somatic Symptom Disorders Work Group has been responsible for addressing these disorders. Among the work group’s recommendations is the proposal to rename this category Somatic Symptom Disorders. Because the current terminology for somatoform disorders is confusing and because somatoform disorders, psychological factors affecting medical condition, and factitious disorders all involve presentation of physical symptoms and/or concern about medical illness, the work group suggests renaming this group of disorders Somatic Symptom Disorders. In addition, because of the implicit mind-body dualism and the unreliability of assessments of “medically unexplained symptoms,” these symptoms are no longer emphasized as core features of many of these disorders. Since somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder share certain common features, namely somatic symptoms and cognitive distortions, the work group is proposing that these disorders be grouped under a common rubric called complex somatic symptom disorder. We appreciate your review and comment on these disorders.”
*Somatoform Disorders Not Currently Listed in DSM-IV
Complex Somatic Symptom Disorder
Ed: Key Document: Full Disorder Descriptions PDF: APA Somatic Symptom Disorders description January 29 2010
*Somatoform Disorders Proposed for Possible Reclassification in Another Diagnostic Category
300.7 Body Dysmorphic Disorder*Somatoform Disorders Proposed to be Subsumed Under Other Diagnoses (No DSM-5 Criteria Proposed)
300.81 Somatization Disorder
300.82 Undifferentiated Somatoform Disorder
307.80 Pain Disorder Associated With Psychological Factors
300.7 Hypochondriasis
307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition
Pain DisorderSomatoform Disorders
300.11 Conversion Disorder
300.82 Somatoform Disorder Not Otherwise Specified
http://www.dsm5.org/MeetUs/Pages/SomaticDistressDisorders.aspx
The Somatic Symptoms Disorders Work Group is chaired by Joel E. Dimsdale, M.D. Its members and disorders of study are listed below.
Members
Dimsdale, Joel E., M.D.
Barsky III, Arthur J., M.D.
Creed, Francis, M.D.
Frasure-Smith, Nancy, Ph.D.
Irwin, Michael R., M.D.
Keefe, Francis J., Ph.D.
Lee, Sing, M.D.
Levenson, James L., M.D.
Sharpe, Michael, M.D .
Wulsin, Lawson R., M.D.
Disorders
Ed: each APA link below opens a new APA page which has child pages accessible via Tabs for:
Proposed Revision
Rationale
Severity
DSM-IV [Sets out the current classification for that disorder]
In some cases, links for PDFs containing Full Disorder Descriptions and Full Rationale are included.
These Tabs pages set out whether a disorder is proposed to be subsumed into a new disorder; whether a name change is being proposed or if the work group is recommending that this subtype should not be included in DSM-5. I cannot reproduce them all, here, but am reproducing the material for two key examples:
Example [1] Complex Somatic Symptom Disorder [Proposed new classification]
and
Example [2] 316 Psychological Factors Affecting Medical Condition
Disorders
Complex Somatic Symptom Disorder
300.11 Conversion Disorder
300.xx Factitious Disorder
300.19 Factitious Disorder Not Otherwise Specified
300.19 Factitious Disorder with Predominantly Physical and Psychological Signs, Symptoms
300.19 Factitious Disorder with Predominantly Physical Signs and Symptoms
300.16 Factitious Disorder with Predominantly Psychological Signs and Symptoms
300.7 Hypochondriasis
316 Maladaptive Health Behaviors Affecting Medical Condition
316 Mental Disorder Affecting Medical Condition
316 Other or Unspecified Psychological Factors Affecting Medical Condition
Pain Disorder
307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition
307.80 Pain Disorder Associated With Psychological Factors
316 Personality Traits or Coping Style Affecting Medical Condition
316 Psychological Factors Affecting Medical Condition
316 Psychological Symptoms Affecting Medical Condition
300.81 Somatization Disorder
300.82 Somatoform Disorder Not Otherwise Specified
316 Stress-Related Physiological Response Affecting Medical Condition
300.82 Undifferentiated Somatoform Disorder
Example [1] Complex Somatic Symptom Disorder [Proposed new classification]
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368
Complex Somatic Symptom Disorder
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.
Please see full disorder descriptions here.
Key Document: Full Disorder Descriptions PDF: APA Somatic Symptom Disorders description January29 2010
Rationale
Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders
The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.
Major change #3: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD)
Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD) which emphasizes the symptoms plus the patients’ abnormal cognitions (Barsky, Lowe, Rief). The term “complex” is intended to denote that in order for this diagnosis to be made, the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as cognitive distortions (criterion B).
This is a major change in the diagnostic nomenclature, and it will likely have a major impact on diagnosis. It clarifies that a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present.
It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.
The proposal is to group together these heretofore separately recognized disorders because in fact, there are 3 diverse sources suggesting considerable overlap among them.
1. A 2009 study found that 52% of physicians surveyed indicated that there was “a lot of overlap” and an additional 38% thought that there was “some overlap” across these disorders. In contrast, less than 2% of physician respondents felt that these were “distinctly different disorders (Dimsdale, Sharma, & Sharpe, unpublished).
2. There are limited data regarding overlap in clinical settings. One primary care study, for instance, found that 20% of somatization disorder patients also had hypochondriasis (Escobar, 1998). In primary care patients, somatization disorder was 5 times ( Fink et al 2004) to 20 times (Barsky et al 1992) more common in hypochondriasis patients as compared to primary care patients without hypochondriasis.
3. Treatment interventions are similar in this group of disorders. Cognitive behavior therapy (CBT) and antidepressant medications appear to be the most promising therapeutic approaches for hypochondriasis, somatization disorder, and pain disorder (Kroenke 2007; Sumathipala 2007). Although several variations of CBT have been employed, they share many elements in common. These include the identification and modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors and promote more effective coping. The literature on the use of antidepressants is more limited, but it too does not suggest any major distinctions in therapeutic response across these different disorders. In addition to these patient centered commonalities of treatment, all of these disorders benefit from specific interventions with the patient’s non-psychiatric physician (e.g. scheduling regular appointments as opposed to prn appointments, limiting testing and procedures unless clearly indicated) (Allen 2002).
A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. A recent systematic review (Lowe, submitted for publication) shows that of all diagnostic proposals, only Somatic Symptom Disorder reflects all dimensions of current biopsychosocial models of somatization (construct validity) and goes beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated.
Please see the full rationale document here.
Key Document: Full Rationale PDF: APA DSM Validity Propositions 1-29-2010
Severity
Severity metrics are readily available for somatic symptoms (viz PHQ, Kroenke 2002) and for the cognitive distortions and misattributions associated with CSSD (viz Whiteley Index, Pilowsky. 1967).
DSM-IV [Current DSM-IV content]
Complex Somatic Symptom Disorder includes previous diagnoses of Somatization Disorder (DSM IV code 300.81), Undifferentiated Somatoform Disorder (DSM IV code 300.82), Hypochondriasis (DSM IV code 300.7), Pain Disorder Associated With Both Psychological Factors and a General Medical Condition (DSM IV code 307.89), and Pain Disorder Associated With Psychological Factors (DSM IV code 307.80).
Example [2] 316 Psychological Factors Affecting Medical Condition
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=387
Proposed Revision
Psychological Factor Affecting . . . [Indicate the General Medical Condition]
To meet criteria for Psychological Factors Affecting Medical Condition, both criteria A and B are necessary.
A. A general medical condition is present.
B. Psychological or behavioral factors adversely affect the general medical condition in one of the following ways:
1. the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition
2. the factors (e.g. poor adherence) interfere with the treatment of the general medical condition
3. the factors constitute additional health risks for the individual
4. the factors influence physiology to precipitate or exacerbate symptoms of the general medical condition
Please see full disorder descriptions here:
Key Document: Full Disorder Descriptions PDF: APA Somatic Symptom Disorders description January29 2010
Rationale
Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders
The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.
Major change #2: De-emphasize medically unexplained symptoms
Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.
Key Document: Full Rationale PDF: APA DSM Validity Propositions 1-29-2010
Severity
For PFAMC, severity scoring might include “1” when the psychological factor only increases risk for medical illness, “2” when the symptoms of medical illness are exacerbated, and “3” when the effect is life-threatening.
DSM-IV [Current DSM-IV content]
[Specified Psychological Factor] Affecting . . . [Indicate the General Medical Condition]
A. A general medical condition (coded on Axis III) is present.
B. Psychological factors adversely affect the general medical condition in one of the following ways:
(1) the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition
(2) the factors interfere with the treatment of the general medical condition
(3) the factors constitute additional health risks for the individual
(4) stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition
Choose name based on the nature of the psychological factors (if more than one factor is present, indicate the most prominent):
Mental Disorder Affecting . . . [Indicate the General Medical Condition] (e.g., an Axis I disorder such as Major Depressive Disorder delaying recovery from a myocardial infarction)
Psychological Symptoms Affecting . . . [Indicate the General Medical Condition] (e.g., depressive symptoms delaying recovery from surgery; anxiety exacerbating asthma)
Personality Traits or Coping Style Affecting . . . [Indicate the General Medical Condition] (e.g., pathological denial of the need for surgery in a patient with cancer; hostile, pressured behavior contributing to cardiovascular disease)
Maladaptive Health Behaviors Affecting . . . [Indicate the General Medical Condition] (e.g., overeating; lack of exercise; unsafe sex)
Stress-Related Physiological Response Affecting . . . [Indicate the General Medical Condition] (e.g., stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache)
Other or Unspecified Psychological Factors Affecting . . . [Indicate the General Medical Condition] (e.g., interpersonal, cultural, or religious factors)
