3. Medically Unexplained Symptoms in DSM-5

The next change proposed for the fifth revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (the DSM-5) is the term Complex Somatic Symptom Disorder (CSSD).  This is intended to include such disparate conditions as Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, and Pain Disorder Associated With Psychological Factors.

To diagnose CSSD, criteria A, B, and C are necessary.

A.  Multiple somatic symptoms that are distressing, or one severe symptom.

B.  Misattributions, excessive concern or preoccupation with symptoms and illness:  At least two of the following are required to meet this criterion:

(1) High level of health-related anxiety.

(2) Normal bodily symptoms are viewed as threatening and harmful.

(3) A tendency to assume the worst about their health (catastrophizing).

(4) Belief in the medical seriousness of their symptoms despite evidence to the contrary.

(5) Health concerns assume a central role in their lives

C.  Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent for at least 6 months.

There are numerous problems with the CSSD concept.  First, it is too similar to the category name Somatic Symptom Disorder, which will make it easy to mistakenly assume that CSSD is simply a complex form of SSD which is not how CSSD is defined.  Second, the conditions lumped together under CSSD are so varied that to be labeled with this would be analogous to a surgeon diagnosing a patient with “abdominal disorder.”  CSSD isn’t specific enough to be a rational basis for treatment or research.

Third, the issues listed under “B” immediately raise the question of who is defining “excessive concern.”  Symptoms in patients with Stress Illness (1) can be just as severe as symptoms in patients with a diseased organ.  Anxiety in Stress Illness often is heightened because of the lack of a positive diagnostic test.  Anyone with a significant and unexplained symptom would be expected to have a high level of concern.  The concern of the physician might decline when tests reveal no abnormality but that doesn’t mean ongoing concern by the patient is “excessive.”  In my practice, a large majority of Stress Illness patients are appropriately anxious about their condition, but not more so, and they would therefore be left out of this definition of CSSD.  Fourth, many Stress Illness patients are ill for less than six months so they, too, would not be appropriate for the CSSD term.  Diagnosis and treatment of those with the acute (short duration) form differs little from the more chronic form so this duration criterion is unnecessary.

What to do?  Read the next post, of course.

1. Stress Illness is my term for physical symptoms not fully explained by diagnostic tests that improve when psychosocial stresses are treated.

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