Sunday, January 23, 2011

Concerns over proposed new category in DSM-V

As a psychologist, I am most concerned about the introduction of the new category to cover medically unexplained symptoms.  It is not possible to submit a comment to the APA at this stage which undermines the scientific process and is likely to lead to errors.    

From a purely psychological perspective, there are a number of issues with Simple Somatic Symptom Disorder (SSSD).  The rationale is not theory based. It's practical (shorthand for, 'I don't now what's wrong with you and you seem a little too concerned that you might be physically ill so this label will cover it. You need to worry less as it will only make you feel worse. Goodbye'). In my view, the new label could have serious consequences, not only medical (inappropriate advice), but also financial (loss of benefits).  The older diagnosis of somatisation disorder was the term used  for medically unexplained symptoms where there was evidence that they  were a means of expressing emotional distress by those who were not willing to be assertive and verbally communicate their feelings to significant others. This was more common in paternalistic societies where women were discouraged from expressing their displeasure, and that includes  England prior to the 1960s. The rationale was therefore that the symptoms were a sign of distress and served a purpose (e.g. avoidance). Thorough assessment tended to alert the practitioner to the 'gains' associated with the symptoms and that was one reason to consider the diagnosis. The concept came from old Freudian ideas reflected in older diagnoses such as conversion hysteria. 

SSSD does not require evidence that the presence of the symptoms are primarily meant to justify avoidance in people unwilling or unable to express their anger etc  using words.  It's a new concept, it's about symptom counting and about value judgement.  It's the doctor who decides (after a 50 minute consult?) if the anxiety about the symptoms is out of proportion, i.e., it's subjective and therefore likely to be influenced by non-clinical factors such as gender and culture. We already know that communities who express themselves more colourfully, such as the Italians, are at increased risk of a psychiatric diagnosis than less expressive cultures. Likewsie, women are more vulnerable than men. How you use words will colour the professional's decision as much as the nature of the symptoms and the tests which have been done to rule out other conditions.

Which tests are ordered depends on the practitioner's  knowledge and the people working in the pathology department.  I was recently reminded of this when a consultant oral surgeon sent me off to have a blood test for Sjogren's Syndrome (SS).  Eight weeks later, it transpired that the lab had not done the tests.  Someone had decided that they were bound to be positive in a person like me. (No, I don't know what that means either.)  However, the oral surgeon wasn't informed nor was my GP. I therefore remain with toothache  in a diagnostic no-man's land.  If the results had turned out to be positive, I'd meet the criteria for Sjogren's syndrome.  If negative, I'd need a more invasive test to rule out SS.  A practitioner unfamiliar with the diagnostic criteria for SS and the importance of the blood tests might well consider SSSD or CSSD at this point. That would leave me  without  the appropriate treatment or advice and at risk of losing teeth, infection and lymphoma.  Chronic toothache causes stress, so the next doctor who sees me might, if I'm unlucky,  reverse  cause and effect, thus reinforcing the diagnosis of SSSD.   The primary gain would be limited to the money earned by the psychiatrist from the consult. The patient would be left with  primary and perhaps secondary losses.  If they were to take legal action to recoup the losses and win, the medical authorities would also lose. 

To summarise, I cannot see how the new category improves on the older labels used to denote the presence of medically unexplained symptoms plus anxiety which might undermine recovery. Indeed,  I'm at a loss to think of a single good reason meriting its inclusion in DSM-V. CSSD was poorly thought out and SSSD is worse. 

Psychological medicine has improved while I've been in practice, but not enough.


Ellen M. Goudsmit BA, MSc, PhD, C.Psychol. FBPsS

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