WEDNESDAY, March 20, 2013 — Doctors may soon be doling out the diagnosis "somatic symptom disorder" (SSD) in clinical practice, and some mental health experts aren't on board because they fear the "new" disorder will lead to misdiagnoses of patients who have real physical conditions.
Somatic symptom disorder is a new entry in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard reference work for physicians on mental disorders. In the upcoming fifth edition of the DSM, due out in May, a section called "Somatic Symptoms and Related Disorders" will replace one called "Somatoform Disorders." The major difference between the two is that the old guidelines required that there be no medical explanation for a patient's physical symptoms, while the new diagnosis could be applied to someone who has a legitimate physical condition, like heart disease or fibromyalgia.
Somatoform disorders are a group of psychiatric conditions in which people experience symptoms that cannot be fully explained medically. One type of somatoform disorder you have heard of is hypochondria; others include conversion disorder (loss of some sort of function — temporary blindness, for example — due to anxiety) and body dysmorphic disorder (excessive worry about a perceived physical defect, such as thinking you have a big stomach or a misshapen nose when you don't).
Objections to the new category of disorders sound like simple semantics on the surface, but in a paper published in the British Medical Journal, Allen Frances, MD, (a psychiatrist who served as chair of the DSM-4 task force prior to its publication in 1994) says patients could suffer as a result.
With the change, according to Dr. Frances, a person who had a heart attack and worries very much about having another one to the point a doctor deems excessive might find themselves with a second diagnosis. Specifically, he said, "Anyone who has a medical illness of any kind, who becomes distressed by that illness and is worried about it, and spends time and effort trying to take care of it, can be given a psychiatric disorder diagnosis."
Sick With Worry About Real Physical Illness
The shift to somatic symptom disorder, according to the chair of the DSM-5 task force, David J. Kupfer, MD, is indeed to catch patients who would be missed with the old guidelines. "The problem with this exclusion is that it did not take into account some patients who exhibit an unusually negative reaction to their symptoms (like excessively high anxiety) even when symptoms are medically explained. Such patients may benefit from treatment," Dr. Kupfer wrote in an article for the Huffington Post.
To Kupfer's point, a heart attack patient may become overly anxious, and even obsessive, about his or her health, potentially needing anxiety treatment. But the subjective nature of a somatic symptom disorder diagnosis concerns Frances. "Anyone with a medical illness who worries about a physical symptom more than the doctor thinks they should" could get this diagnosis, he said, "like someone with cancer who has a headache and thinks a tumor has metastasized."
Because of this, Frances fears that doctors might mistake a patient who is diligent about tracking his symptoms with someone who needs mental treatment. He noted the potential for false positives and misdiagnoses in his paper, citing evidence from a DSM-5 field trial study reported at the 2012 annual meeting of the American Psychiatric Association.
"Somatic symptom disorder captured 15 percent of patients with cancer or heart disease and 26 percent with irritable bowel syndrome or fibromyalgia, and it had a high false positive rate of 7 percent among healthy people in the general population," Frances wrote, concluding that, "Clinicians are best advised to ignore this new category. When a psychiatric diagnosis is needed for someone who is overly worried about medical problems the more benign and accurate diagnosis is adjustment disorder."
"I think the people who suggested this in DSM-5 mean well," Frances said. "They are worried about patients who might be missed, who could benefit from psychiatric referral, and that makes sense. However they've made the definition so loose it's going to attach a huge population of people who will be harmed and insulted by it."
"It's a big overshoot because it opens up the diagnosis to a large percentage of people who are medically ill and who don't want, and for the most part don't need, a mental health evaluation or treatment," Frances said.
With all that's been written about changes to DSM guidelines — the "bereavement exclusion" in major depression and the switch from gender identity disorder to "gender dysphoria," for example — this seemingly subtle change has largely flown under patient and professional radar until now. But the change has sparked some public reaction, including an online petition to stop the inclusion of somatic symptom disorders in DSM-5 on the platform Change.org.