PHILADELPHIA — Researchers from the Somatic Symptom Disorders Work Group of the Diagnostic and Statistical Manual of Mental Disorders sought to employ terminology that did not demean patients presenting with somatic symptoms, according to Joel E. Dimsdale, MD, professor emeritus in the department of psychiatry at the University of California, San Diego. Dimsdale presented here on behalf of the group at the 2012 American Psychiatric Association Annual Meeting.
His presentation aimed to outline proposed changes in the ways these disorders are conceptualized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
“The first change is in de-emphasizing the centrality of the medically unexplained symptoms and emphasizing instead the importance of somatic symptoms accompanied by excessive thoughts, feelings and behaviors related to these symptoms,” Dimsdale said. “The second is that these symptoms may or may not accompany diagnosed general medical disorders.”
Dimsdale also provided an overview of chronic somatic symptom disorder criteria, which include:
- Somatic symptoms that are distressing and/or result in significant disruption in daily life.
- Overwhelming concerns or preoccupation with symptoms and illness (ie, disproportionate and maladaptive responses).
- Chronicity; typically, more than 6 months.
According to Dimsdale, much focus was placed on the words used to describe the psychopathology of somatic disorders. “We wanted to use terminology that did not demean patients,” he said.
There is overlap within somatoform diagnoses, and data from the clinician and patient groups polled indicated that many of the diagnoses in DSM-IV were categorized as “unclear, very unclear or useless. Many patients don’t like these diagnoses, or think they are completely unacceptable,” Dimsdale said.
Perhaps because of the overlap and unclear definitions, primary care physicians had concerns with diagnosing somatic disorders. “Although primary care physicians commonly encounter somatoform disorders, considerable drawbacks to the status quo criteria limit the utility of these disorders,” he said, highlighting the 19 somatic disorders contained in DSM-IV. “Do we need all of these diagnoses? Is there overlap? Is this a spectrum? Do they belong together? We need to look at this afresh.”
One way to limit these diagnoses was to scale the five variants on factitious disorders down to two categories: on self, and on another. “We’ve condensed the previous diagnosis of factitious disorders,” he said.
Psychiatric epidemiology often ignores somatoform disorders, according to Dimsdale. For example, data from Levenson and colleagues that looked at 1.2 million insurance policy holders in Virginia indicated that only 569 somatoform cases were coded. “Clearly, there are problems with the way we use DSM-IV diagnoses,” he said.
Dimsdale highlighted the mind-body dualism of medically unexplained symptoms, but he said DSM-IV does not lend itself to doctor-patient collaboration. “Patients hate it, and it doesn’t lend itself to agreement of what is medically unexplained.”
He said the relationship between “medically unexplained” and “medically misunderstood” should be investigated further.
Another area of concern is how the new criteria will affect prevalence estimates. “They don’t appear to impact prevalence as yet, but further investigation will be necessary,” Dimsdale said.
He concluded that the current proposals are works in progress and not dictums. “They are evolving and being evaluated by review committees,” he said.
For more information:
Dimsdale JE. Symposium S044-1. Presented at: the 2012 American Psychiatric Association Annual Meeting; May 5-9, 2012. Philadelphia.