Psychosomatic illness and the DSM-5

Among the most fascinating diagnoses in psychiatry are the somatoform disorders; these are characterized chiefly by physical symptoms without a clear medical or biological basis, but which instead are thought to arise from some deeper psychological source.  The field of “psychosomatic medicine” (not to mention many of the most classic cases of in the history of psychiatry and psychoanalysis) illustrates the impact of mental factors on physical illness.  Indeed, most of us have experienced the effects of our moods, thoughts, and attitudes on physical symptoms.  For instance, our headaches intensify when we’re under a lot of stress at work, whereas we can usually ignore pain and fatigue when in the midst of intense and exhilarating competition.  Conversely, intense psychological trauma or prolonged deprivation can contribute to chronic physical disease, while a terminal illness can cause extreme psycholgical suffering.

The somatoform disorders as currently listed in the DSM-IV, the “Bible” of psychiatric diagnosis, are:

  • conversion disorder - unexplained neurological symptoms that are thought to arise in response to psychological conflicts
  • somatization disorder - more widespread physical symptoms (pain, gastrointestinal, sexual, neurological) before the age of 30 and with a chronic course
  • hypochondriasis - excessive preoccupation, worry, or fear about having a serious medical illness
  • body dysmorphic disorder - excessive concern and preoccupation with a perceived (but often nonexistent) physical defect
  • pain disorder - chronic pain in one or more areas, usually exacerbated by psychological factors
  • undifferentiated somatoform disorder - one unexplained physical symptom, present for six months

The planning committee in charge of writing the DSM-5, the replacement to the DSM-IV, wants to scrap this category and create a new one called simply “Somatic Symptom Disorders.”  What makes a “Somatic Symptom Disorder” in the new classification?  According to the APA, “any somatic symptom or concern that is associated with significant distress or dysfunction,” combined with “anxiety” or “persistent concerns” about the symptoms.  Have a nasty, persistent cough?  Frequent headaches?  Concerned about it?  Congratulations, you may now have a mental illness as well.  They also propose a “complex somatic symptom disorder” (CSSD) category in which the symptom(s) is/are accompanied by “excessive or maladaptive response” to those symptoms.  What’s excessive or maladaptive?  As with anything in psychiatry, that’s for you (or, more accurately, your doctor) to decide.

(Specifically, most of the somatoform disorders will be lumped together into the “SSD” category.  They plan to move body dysmorphic disorder into the anxiety group, and the criteria for conversion disorder will be narrowed to describe simply an unexplained neurological symptom– none of the deeper psychological components are necessary for this diagnosis either).

Why would they do such a thing?  In the words of the APA, “clinicians find these diagnoses unclear” and “patients find them very objectionable.”  In other words, doctors just don’t use these diagnoses, and patients think their concerns aren’t being taken seriously.

Whether this justification seems appropriate is certainly debatable.  Maybe these diagnoses aren’t made because we’re just not looking for them.  Maybe we’re afraid of alienating patients.  Maybe it’s because no new drugs have been approved for use in somatoform disorders.  Or maybe it really is just a bogus category.  Nonetheless, the proposed solution may be just as bogus.  Indeed, it seems rather absurd to give a psychiatric diagnosis on the basis of a single unexplained bodily symptom and, of course, one complaint about this proposal is that it continues psychiatry’s gradual march towards pathologizing everyone.

To me, the greatest disappointment is that the richness and complexity of the various somatoform disorders will be disposed of, in favor of criteria that only require a physical symptom and “anxiety or concern” about the symptom.  It may sound condescending or objectionable to remark that an unexplained symptom is “all in one’s head,” but these more user-friendly diagnostic criteria may make clinicians even less likely to “look under the hood,” so to speak, and to uncover the mental and psychological factors that may have an overwhelming, yet hidden, influence on the patient’s body and his/her perceptions of bodily phenomena.
 
We are only beginning to understand the intricacies and wonders of the connections between mind and body.  Such understanding draws heavily on complementary approaches to human health and disease, alongside the findings of conventional medical science.  Hopefully, psychiatric practitioners will continue to pay attention to advances in this field in order to provide comprehensive, “holistic” care to patients, even if the DSM-5’s efforts at diagnostic expediency and simplicity portend otherwise.

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4 Responses to Psychosomatic illness and the DSM-5

  1. moviedoc says:

    The proposed solution is more honest, not more bogus. No one wants to "pathologize everyone." The alternative is to tell that new patient, "You don't have a mental disorder. Insurance won't pay for your treatment. Get out of my office."You mis-characterize the DSM-4TR criteria for conversion which require motor or sensory dysfunction that SUGGEST a neurological disorder. There's no mention of "deeper psychogical components" (whatever that means), or even psychological CONFLICTS, only that psychological FACTORS are judged to play some role because stressors or conflicts (presumably interpersonal, etc) have preceded the dysfunction. The notion of psychological conflict, a throwback to the dark ages of psychiatry when psychoanalytic theory held sway, has been rightly removed from DSM.

  2. Steve Balt says:

    moviedoc, "You don't have a mental disorder. Insurance won't pay for your treatment. Get out of my office." If only we said that more often!! But if he/she leaves MY office, they'll go to someone ELSE's office, and that other doctor will be paid for the "care" that I could have provided. (Not that I think purely in terms of dollars and cents, but if everyone else is…..)Regarding the conversion disorder criteria, thank you for the clarification. However, your explanation runs the risk of reopening the semantic turf war that has plagued psychiatry (and is continuing to do so with the DSM-5) and ignores the patient, who should be the focus of all of our efforts. "Components," "conflicts," "factors," "stressors," etc… For my average patient, they all mean the same damn thing. Or they just don't care, all they want is to have some better understanding of themselves, and ultimately to feel better.

  3. moviedoc says:

    Good point about. It's great to be able to say, "You're really OK. You don't need meds, and you don't need psychotherapy." But the people who don't trust that will keep looking. If we have a rigid cutoff, we risk people who need it not getting care, and if it's to flexible it looks like we're all sick. How do you find the sweet spot?As for conversion, I think physiatrists treat more of it than psychicatrists, mostly be suggestion, certainly not by looking for meaning. Understanding doesn't necessarily lead to change, certainly not to explanation or cure.

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