5. Medically Unexplained Symptoms in DSM-5

In the last post, I proposed a revision of the Somatoform Disorders section for the next edition of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association.  The DSM-5 group has proposed changing the name from Somatoform Disorders to Somatic Symptom Disorders (SSD) but this term neglects the central role of psychological or cognitive factors.  It will also cause confusion with the DSM-5 group’s other new proposal, the term Complex Somatic Symptom Disorder (CSSD).  The term CSSD suggests that it is simply a complex form of SSD but that is not at all how the DSM-5 group has defined it.  This is why I suggest replacing Somatoform Disorders with Psychosomatic Disorders, not as a diagnostic term (patients consider it stigmatizing) but as a name for this category that is well understood by mental health practitioners, medical clinicians and the public.

My second proposal is a new definition of CSSD.  In the United States alone, hundreds of millions of medical office visits annually result from physical symptoms linked to one or more forms of psychosocial stress.  Yet the vast majority does not meet criteria for any condition in the current DSM (1) and still would not after proposed changes for DSM-5.  Consequently, these patients are effectively invisible not only for diagnosis and treatment but for research and teaching as well, resulting in the largest single diagnostic blind spot in our health care system.

My definition of CSSD (see the last post) gives this large group of patients a diagnostic term without stigma that distinguishes them from other, similar groups.  Somatization disorder, for example, is distinct from CSSD because it responds gradually to general supportive care provided during regular office visits that gradually decrease in frequency.  Unlike CSSD patients, somatization patients tend not to respond to treatment directed at specific psychosocial stresses.  Hypochondriac patients have anxiety about their health that is not necessarily associated with symptoms or with any of the conditions listed under “B” in my CSSD definition.  They are also less responsive to treatment.  Patients with Factitious Disorder, unlike CSSD, are intentionally producing or feigning their symptoms.

Changes in Somatoform Disorders terminology currently proposed for the DSM-5 apply best only to the small fraction of these patients treated by mental health professionals.  The terms I am proposing will facilitate accurate diagnosis and treatment of millions of patients who present to medical clinicians, who usually are not managed appropriately and therefore suffer needlessly.

1. Smith RC, Gardiner JC, Lyles JS, et al. Exploration of DSM-IV Criteria in primary care patients with medically unexplained symptoms. Psychosom Med. 2005;67:123–9.

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