Prevent Chronic Pain Conditions From Being Classified as Psychiatric Disorders: Action Alert
The American Psychiatric Association (APA) is proposing an addition to their DSM codes that could potentially allow patients with difficult-to-diagnosis conditions – like fibromyalgia, ME/CFS (aka chronic fatigue syndrome), Gulf War Syndrome, and other chronic pain conditions – to be diagnosed as having a psychiatric disorder. Their deadline for accepting comments on this proposal is tomorrow, June 15, so we have to act fast if we are to have any hope of preventing this new diagnosis.
The Diagnostic and Statistical Manual of Mental Disorders is a list of codes, referred to as DSM codes, which identify each distinct diagnosis used by psychiatrists and other mental health professionals. The last major revision to the DSM codes was the fourth edition (DSM-IV) published in 1994. The APA is currently working on the fifth edition (DSM-V), which is supposed to be published in May 2013.
One of the revisions the APA is planning for DSM-V is the addition of a new diagnostic code called “Complex Somatic Symptom Disorder (CSSD).” Somatic symptoms refer to symptoms for which there is no organic explanation.
As you will see from the APA's description of CSSD below, anyone who is concerned because they have been experiencing chronic pain for six months or more and their doctor can't figure out what is causing their pain could be diagnosed with CSSD and forever labled as having a psychiatric disorder. Personally, I can't imagine how someone who has had unexplained pain for six months would not be concerned.
Complex Somatic Symptom Disorder Diagnostic Criteria
Following is the description of Complex Somatic Symptom Disorder proposed for DSM-V:
“This disorder is characterized by a combination of distressing (often multiple)
symptoms and an excessive or maladaptive response to these symptoms or associated health concerns. The patient‟s suffering is authentic, whether or not it is medically explained. Patients typically experience distress and a high level of functional impairment. The symptoms may or may not accompany diagnosed general medical disorders or psychiatric disorders. There may be a high level of medical care utilization, which rarely alleviates the patient‟s concerns. From the clinician‟s point of view, many of these patients seem unresponsive to therapies, and new interventions or therapies may only exacerbate the presenting symptoms or lead to new side effects and complications. Some patients feel that
their medical assessment and treatment have been inadequate.
“Patients with this diagnosis typically have multiple, current, somatic symptoms that are distressing; sometimes, they may have only one severe symptom. 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 (e.g., bad taste in one's mouth). Health-related quality of life is
frequently severely impaired.
“Patients with this diagnosis tend to have very high levels of health-related anxiety. They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often fear the worst about their health. Even when there is evidence to the contrary, they still fear the medical seriousness of their symptoms. Health concerns may assume a central role in the individual‟s life, becoming a feature of his/her identity and dominating interpersonal
“To meet criteria for CSSD, criteria A, B, and C are necessary.
A. Somatic symptoms:
One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:
(1) High level of health-related anxiety.
(2) Disproportionate and persistent concerns about the medical seriousness of one's symptoms.
(3) Excessive time and energy devoted to these symptoms or health concerns.*
C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).
For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
XXX.1 Predominant somatic complaints (previously, somatization disorder)
XXX.2 Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having Illness Anxiety Disorder.
XXX.3 Predominant Pain (previously 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 adjustment disorder or psychological factors affecting a medical condition.”
My biggest concern is that CSSD will become the junk drawer into which chronic pain patients are thrown when their doctors can't figure out where else to put them. And once that psychiatric diagnosis is on their charts, the chances of getting an accurate diagnosis of a real physical problem will be greatly reduced – as will be the chances of receiving effective treatment.
The only hope we have of preventing this diagnosis from being added is to flood the APA with letters expressing our concerns. But we have to act quickly because the deadline is Wednesday, June 15. If you'd like to write to the APA about this, here are the steps you'll need to follow to provide your input:
1. You have to register on the DSM-5 web site in order to make comments. The “Register Now” link is in the upper right hand corner of the DSM-5 home page under the orange Login button. You will receive a confirmation e-mail with a temporary password and a link that you will have to click on to complete your registration.
2. You can then provide your comments directly on the CSSD page.
If you would like to read some of the letters submitted by different organizations, you can find them on the DSM-5 submissions site.