Monday, June 13, 2011

Do Before Wednesday!

May be reposted

From Suzy Chapman for http://dsm5watch.wordpress.com

13 June 2011



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


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

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

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

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



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

A couple of thousand?

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

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


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

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

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



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

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

("Somatic" means "bodily" or "of the body".)


The most recent version of the "Disorders description" document states:

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

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

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


Psychiatric creep

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

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

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


Sitting ducks

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

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

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

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

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

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

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


International implications

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


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



Links:

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

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

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


For examples of last year's submissions, go here: http://tinyurl.com/DSM5submissions

Copies of this year's submissions are being collated on my site, here: http://tinyurl.com/DSM5submissions2011


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

Submissions published to date for this second public review:

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

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

Mary Barker (US);
Peter Kemp (UK);
Mary M. Schweitzer Ph.D., (US)

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

[2] There are two key PDF documents: "Disorders Descriptions" and "Rationale", which expand on the Work Group's proposals:
http://tinyurl.com/SSD-Disorders-Description  
http://tinyurl.com/SSD-Justification-of-Criteria


Suzy Chapman
_____________________

me.agenda@virgin.net
http://dsm5watch.wordpress.com
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