While the goal of the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is clear, accurate criteria for diagnosing mental disorders, the motivation behind the book's revision was the improvement of diagnosis and clinical care. Somatoform disorders are one area where definitive progress was made.
Somatoform disorders are characterized by symptoms suggesting physical illness or injury, but which may not be fully explained by a general medical condition, another mental disorder, or by medication or substance side effects. The symptoms are either very distressing or result in significant disruption of an individual's ability to function in daily life. People suffering from somatoform disorders are often initially seen in general medical settings as opposed to psychiatric settings.
The DSM-5 makes a significant change to the diagnostic criteria from previous editions by shifting the emphasis from medically-unexplained symptoms to the impact of those symptoms on a person's thoughts, feelings and actions. In DSM-IV, it was required that somatic symptoms be medically unexplained -- that is, if symptoms could be traced to an identifiable underlying medical disorder like depressive symptoms in hypothyroidism, the diagnosis of somatoform disorder could not be made. 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.
Thus, the DSM-5 diagnosis of somatic symptom disorder (which subsumes several DSM-IV's somatoform disorders, like pain disorder and somatization disorder) removes this requirement and instead focuses on the degree to which patients' thoughts, feelings and behaviors about their somatic symptoms are disproportionate or excessive. However, in cases where somatic symptoms are medically-explained, DSM-5 requires that all other criteria for the disorder be met. In addition, the narrative text notes that it is not appropriate to make a somatic diagnosis solely because the symptoms are medically-unexplained.
In other words, symptoms may or may not be associated with another medical condition, but in order to meet criteria for somatic symptom disorder, they must be accompanied by disproportionate or excessive thoughts, feelings or behaviors. The new narrative text for somatic symptom disorder notes that some patients with physical conditions such as heart disease or cancer will indeed experience disproportionate and excessive thoughts, feelings and behaviors related to their illness and, depending on the severity of symptoms, that these individuals may qualify for a diagnosis of somatic symptom disorder.
This change encourages comprehensive assessment of patients for accurate diagnoses and holistic care, as it recognizes that mental problems can occur in patients with medical problems and ensures that patients get the care they need for both. In this sense, somatic symptom disorder is like depression or anxiety or many other mental disorders; it can occur in the context of a serious medical illness. As with all mental disorders, diagnosis requires clinical training and judgment to recognize when a patient could benefit from focused treatment.
The change to allow diagnosis in the context of symptoms that are medically-explained removes the mind-body separation implied in previous editions and encourages clinical judgment and comprehensive assessment rather than a checklist that may arbitrarily disqualify many people who are suffering from both somatic symptom disorder and another medical diagnosis from getting the help they need.
In addition to this critical change, the chapter as a whole -- termed somatic symptom and related disorders -- clarifies and reorganizes the disorders contained within to reduce overlap and confusion in terminology, both of which were often a source of complaint among non-psychiatrist physicians. Because individuals suffering from somatic symptoms are primarily seen in general medical settings as opposed to psychiatric settings, the criteria in DSM-5 better define terms and reduce the number of disorders and sub-categories to make the criteria more useful to non-psychiatric-care providers.
To ensure that the new criteria would indeed help clinicians better identify individuals who need care, scientists tested them in actual clinical practices during the DSM-5 field trials. The diagnostic reliability of somatic symptom disorder performed very well in these field tests.
The changes, approved by the American Psychiatric Association Board of Trustees in late 2012, better reflect the complex interface between mental and physical health. The DSM-5 will be released this May.
David J. Kupfer, M.D., is chair of the DSM-5 Task Force.
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