Allen Frances MD on DSM-5 draft proposals and comment: Psychology Today

Allen Frances MD on DSM-5 draft proposals and comment: Psychology Today

Shortlink: http://wp.me/p5foE-2Ry

Over the past 12 months, Allen Francis MD has published a series of often controversial commentaries on the DSM revision process in the media, via Psychiatric Times website and yesterday, on the site of Psychology Today.

Dr Frances had been chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

I have had a comment published, this morning, in response to his latest piece on Psychology Today.

Blogs
DSM5 in Distress
The DSM’s impact on mental health practice and research.
by Allen Frances, MD

DSM5: An Open Process Or Bust
The next steps need help from the field and public.
Published on April 12, 2010

“The first drafts of DSM5 were posted two months ago, allowing the field and the public a first glimpse into what had previously been an inexplicably secretive process. Today is the last day for public comment on these drafts…”

Read full text here

Comments

Public review process

Submitted by Suzy Chapman on April 13, 2010 – 3:24am.

I would like to thank Dr Frances for his commentaries around the DSM revision process. I hope he won’t mind my highlighting that draft proposals are out for review until Tuesday, 20 April – so there is another week during which health professionals, researchers, patient organisations and the lay public can input into the review process.

For some time now, professionals in the field, interest groups and the media have voiced concerns that the broadening of criteria for some DSM-5 categories would bring many more patients under a mental health diagnosis.

But if the draft proposals of the “Somatic Symptom Disorders” Work Group were to be approved there will be medical, social and economic implications to the detriment of all patient populations and especially those bundled by many within the field of liaison psychiatry and psychosomatics under the so-called “Functional Somatic Syndromes” (FSS) and “Medically Unexplained Syndromes” (MUS) umbrellas, under which they include Chronic fatigue syndrome, ME, Fibromyalgia, IBS, chemical injury, chemical sensitivity, chronic Lyme disease, GWS and others [1].

There is considerable concern amongst international patient organisations for the implications of the “Somatic Symptom Disorders” Work Group proposal for combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders under a common rubric called “Somatic Symptom Disorders” and for the creation of a new classification, “Complex Somatic Symptom Disorder” (CSSD).

They are particularly concerned for patients living with conditions characterised by so-called “medically unexplained symptoms” or with medical conditions for which diagnostic tests are currently lacking that provide evidence substantiating the medical seriousness of their symptoms and the need for provision of appropriate medical investigations, treatments, financial and social support, and in the case of children and young people, the putting in place of arrangements for the education of children too sick to attend mainstream school.

According to “Somatic Symptom Disorders” Work Group proposals:

[Criteria superceded by third draft criteria.]

The CFIDS Association of America has submitted: “As drafted, the criteria for CSSD establish a “Catch 22″ paradox in which six months or more of a single or multiple somatic symptoms – surely a distressing situation for a previously active individual – is classified as a mental disorder if the individual becomes “excessively” concerned about his or her health. Without establishing what “normal” behavior in response to the sustained loss of physical health and function would be and in the absence of an objective measure of what would constitute excessiveness, the creation of this category poses almost certain risk to patients without providing any offsetting improvement in diagnostic clarity or targeted treatment.” [2]

To date, there has been little public discussion by professionals or the media of the medical, social and economic implications for patients of the application of an additional diagnosis of “Complex Somatic Symptom Disorder”.

With a week to go before this initial public review period closes there is still time and I urge professionals and stakeholders to scrutinise the proposals of the “Somatic Symptom Disorder” Work Group and to submit their concerns to the Task Force.

Suzy Chapman, UK patient advocate

[1] Marin H, Escobar JI: Unexplained Physical Symptoms What’s a Psychiatrist to Do? Psychiatric Times. Aug 2008, Vol. 25 No. 9 http://www.psychiatrictimes.com/display/article/10168/1171223

[2] CFIDS Association of America submission to DSM-5 public review:
http://www.cfids.org/advocacy/2010/dsm5-statement.pdf

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Related material:

PULSE Today

Managing medically unexplained symptoms, 07 Apr 10

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The DSM-5 public review period runs from 10 February to 20 April. Members of the public, patient representation organisations, professionals and other end users can submit responses, online.

Please take this opportunity to register comment and to alert and encourage professionals and international patient organisations to participate.

Proposed Draft Revisions to DSM Disorders and Criteria are published here on the APA’s relaunched DSM5.org website: http://www.dsm5.org/Pages/Default.aspx

Somatoform Disorders:
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Proposed new DSM-5 category: Complex Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

Two Key PDF documents are associated with proposals:

 PDF Somatic Symptom Disorders Introduction DRAFT 1/29/10

 PDF Justification of Criteria – Somatic Symptoms DRAFT 1/29/10

The Alpha Draft for ICD-11 is scheduled for May 2010. I shall be posting again shortly around the ICD-11 revision process.

CFIDS Association of America submits response to DSM-5 draft proposals

CFIDS Association of America submits response to DSM-5 draft proposals

Shortlink Post: http://wp.me/p5foE-2Rp

Submissions

Patient organisations, professionals and advocates submitting comments in the DSM-5 draft proposal review process are invited to provide copies of their submissions for collation on this page: http://wp.me/PKrrB-AQ

The CFIDS Association of America

Working to make CFS widely understood, diagnosable, curable and preventable

The Diagnostic and Statistical Manual for Mental Disorders (DSM) is being revised by the American Psychiatric Association for release in 2013. Creation of a new category called “Complex Somatic Symptom Disorder” has generated concern and the CFIDS Association submitted its statement on April 1.

The APA will accept public comments until April 20 at http://www.dsm5.org/Pages/Default.aspx

Open PDF here on the CFIDS site:

or here on ME agenda: CFIDS DSM-5 Statement

The CFIDS Association of America

The CFIDS Association of America

April 1, 2010

DSM-5 Task Force

American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209

Members of the DSM-5 Task Force,

In response to an open request for input on proposed changes to the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the CFIDS Association of America submits the following statement and urgent recommendation.

The CFIDS Association strongly questions the utility of the proposed rubric of complex somatic symptom disorder (CSSD). According to the DSM-5 website

(http://www.dsm5.org/Documents/Somatic/APA%20Somatic%20Symptom%20Disorders%20description%20January29%202010.pdf, accessed March 28, 2010):

[Criteria superceded by third draft May 2012.]

The creation of CSSD appears to violate the charges to DSM-5 Work Groups to clarify boundaries between mental disorders, other disorders and normal psychological functioning

(http://www.dsm5.org/about/Pages/faq.aspx, accessed March 28, 2010). This is especially true with regard to patients coping with conditions characterized by unexplained medical symptoms, or individuals with medical conditions that presently lack a mature clinical testing regimen that provides the evidence required to substantiate the medical seriousness of their symptoms. For instance, all of the case definitions for CFS published since 1988 have required that in order to be classified/diagnosed as CFS, symptoms must produce substantial impact on the patient’s ability to engage in previous levels of occupational, educational, personal, social or leisure activity. Yet, all of the case definitions rely on patient report as evidence of the disabling nature of symptoms, rather than results of specific medical tests. So by definition, CFS patients will meet the CSSD criteria A and C for somatic symptoms and chronicity, and by virtue of the lack of widely available objective clinical tests sensitive and specific to its characteristic symptoms, CFS patients may also meet criterion B-4.

As drafted, the criteria for CSSD establish a “Catch-22″ paradox in which six months or more of a single or multiple somatic symptoms – surely a distressing situation for a previously active individual – is classified as a mental disorder if the individual becomes “excessively” concerned about his or her health. Without establishing what “normal” behavior in response to the sustained loss of physical health and function would be and in the absence of an objective measure of what would constitute excessiveness, the creation of this category poses almost certain risk to patients without providing any offsetting improvement in diagnostic clarity or targeted treatment.

To provide another common example, back pain that is debilitating and severe, with negative MRIs, is still debilitating and severe back pain. A patient in this situation might be concerned about this back pain, might view it as detrimental to his quality of life and livelihood, and might direct time and resources to seeking care from multiple specialists (e.g., neurology, rheumatology, orthopedics, rehabilitation) to relieve it. Each of these specialists is likely to recommend slightly different therapies, compounding the patient’s focus on alternative explanations for and long-term impact of decreased function and diminished health. Such a patient could be diagnosed with CSSD, yet no empiric evidence has been provided by the Somatic Symptoms Disorders Work Group that applying the label of CSSD will facilitate communication with the patient, add clinical value to the patient’s experience, or improve the care any of these various specialists might provide.

The Somatic Symptoms Disorder Work Group states that patients fitting these criteria are generally encountered in general medical settings, rather than mental health settings

(http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368, accessed March 28, 2010), further limiting the usefulness of this classification in a manual written primarily for the benefit of mental health professionals.

The Somatic Symptoms Disorders Work Group conveys considerable uncertainty about the impact of this new label, in spite of the charge to all DSM-5 work groups to demonstrate the strength of research for the recommendations on as many evidence levels as possible. The Somatic Symptoms Disorders Work Group states:

“It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.”

(http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368, accessed March 28, 2010)

The proposed DSM-5 revision correctly does not identify chronic fatigue syndrome (CFS) as a condition within the domain of mental disorders and the DSM. However, past discussions of the Somatic Symptoms Disorder Work Group have included such physiological disorders as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia

(http://www.dsm5.org/Research/Pages/SomaticPresentationsofMentalDisorders%28September6-8,2006%29.aspx)

as “somatic presentations of mental disorders.” None of the research and/or clinical criteria for chronic fatigue syndrome published since 1988 have established CFS as a mental disorder and a continuously growing body of literature demonstrates CFS to be a physiological disorder marked by abnormalities in the central and autonomic nervous systems, the immune system and the endocrine system. The role of infectious agents in the onset and/or persistence of CFS has received renewed attention since the DSM-5 revision process began in 1999. Most recently, the October 2009 report of evidence of a human retrovirus, xenotropic murine leukemia-related retrovirus (XMRV), in CFS patients in Science (Lombardi, 2009) has generated new investigations into this and other infectious agents in CFS.

The conceptual framework for CFS detailed in the “Clinical Working Case Definition, Diagnostic and Treatment Protocols” (Carruthers, 2003) serves as a useful tool for professionals to establish a diagnosis of CFS, address comorbidities that may complicate the clinical presentation and distinguish CFS from conditions with overlapping symptomotology. Research on CFS continues to explore and document important biomarkers. Lack of known causation does not make CFS – or the CFS patient’s illness experience – psychopathological any more than multiple sclerosis, diabetes, or other chronic illnesses with objective diagnostic measures, would be so considered.

For the reasons stated above and the general failure of the proposed creation of the CSSD to satisfy the stated objectives of the DSM-5 without risking increased harm to patients through confusion with other conditions or attaching further stigma, the CFIDS Association strongly urges the DSM-5 Task Force to abandon the proposed creation of CSSD.

Sincerely,

K. Kimberly McCleary

President & CEO

The CFIDS Association of America

IACFSME publishes submission to DSM-5 public review process

IACFSME (International Association for CFS/ME) publishes submission to DSM-5 public review process

Shortlink: http://wp.me/p5foE-2R9

Today, 25 March the IACFSME issued an alert for international CFS and ME professionals and published a copy of the organisation’s own submission in the DSM-5 public review process. 

Notice from IACFSME: DSM-5 May Include CFS as a Psychiatric Diagnosis

“The DSM-5 Task Force of the American Psychiatric Association is asking for public comment to their proposed DSM-5 manual of psychiatric diagnoses scheduled for release in 2013. We are concerned about the possibility of CFS/ME being classified as a psychiatric disorder, based on comments made in their Work Group on somatoform disorders (see letter below). Of course, such an action would be a major setback in our ongoing efforts to legitimize and increase recognition of the illness…”

The IACFSME notice and submission can be read here on DSM-5 and ICD-11 Watch or here on the IACFSME site .

 

Submissions by US patient organisations

The March issue of CFIDSLink-e-News reports that the CFIDS Association of America is seeking input from outside experts into the DSM-5 public review process.

The Whittemore Peterson Institute has announced on its Facebook site that it intends to submit a response.

Submissions by UK patient organisations

On 4 March, I contacted seven national UK organisations.  I will update on responses received, so far, in the next couple of days. The following UK patient representative and research organisations have been contacted:

Action for M.E.
ME Association
AYME
The Young ME Sufferers Trust
Invest in ME
The 25% ME Group
ME Research UK

The DSM-5 public review period runs from 10 February to 20 April. Members of the public, patient representation organisations, professionals and other end users can submit responses, online.

Please take this opportunity to comment and to alert and encourage professionals and international patient organisations to participate in the DSM-5 public review process. 

If the proposals of the “Somatic Symptom Disorders” Work Group were to be approved there will be medical, social and economic implications to the detriment of all patient populations – especially those bundled by many psychiatrists under the so-called “Functional Somatic Syndromes” (FSS) and “Medically Unexplained Syndromes” (MUS) umbrellas, under which they include CFS, ME, FM, IBS, CI, CS, chronic Lyme disease, GWS and others.

Register here: http://www.dsm5.org/Pages/Registration.aspx

Related information:

[1] APA’s new DSM-5 Development webpages: http://www.dsm5.org/Pages/Default.aspx

[2] Somatoform Disorders: http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

[3] Complex Somatic Symptom Disorder (CSSD):
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

[4] Key documents:

 PDF Somatic Symptom Disorders Introduction DRAFT 1/29/10

 PDF Justification of Criteria – Somatic Symptoms DRAFT 1/29/10

CFIDS Association calls for input from experts into DSM-5 review process

CFIDS Association calls for input from experts into DSM-5 review process

Shortlink: http://wp.me/p5foE-2Pa

Image Source: Academy of Psychosomatic Medicine, Nevada, November ‘09 Annual Meeting slide presentation, Francis Creed, MD, FRCP: Can We Now Explain Medically Unexplained Symptoms? See this posting

The March issue of CFIDSLink-e-News reports that the CFIDS Association of America is seeking input from outside experts into the DSM-5 public review process:

Extract:

“Advocacy Counts

“The Diagnostic and Statistical Manual for Mental Disorders (DSM) is being revised by the American Psychiatric Association (APA). The proposed revision, DSM5, has drawn media coverage and close scrutiny since its release on Feb. 10. Creation of a new category called “Chronic Somatic Symptoms Disorder” is of particular concern to CFS patients and organizations. The Association is seeking input from outside experts and will submit a review of the biological abnormalities in CFS to APA. The APA will accept public comments until April 20.”

Note that the proposed new classification is “Complex Somatic Symptom Disorder (CSSD)” and not “Chronic Somatic Symptoms Disorder” as given above; CFIDS has been advised.

The DSM-5 Work Group for “Somatic Symptom Disorders” is proposing that Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders should be combined under a common rubric entitled “Somatic Symptom Disorders” and for a new classification “Complex Somatic Symptom Disorder (CSSD).”

The DSM-5 public review period runs from 10 February to 20 April, so there are just over six weeks during which stakeholders in DSM-5 – that’s members of the public, patient representation organisations, professionals and other end users can submit their responses.

Please take this opportunity to submit a response and to alert and encourage professionals and international patient organisations to participate. Key links are provided at the end of this posting.

The following UK organisations have so far been silent on the DSM-5 proposals:

All seven organisations have been contacted, today, for position statements on whether they intend to submit a response and if so, whether their responses will be published:

Action for M.E.
The ME Association:
AYME
The Young ME Sufferers Trust,
The 25% M.E. Group
Invest in ME: Intend to submit a response and to publish
ME Research UK

I would welcome copies of submissions from any patient organisations, professionals and advocates for publication on a dedicated page, here, on DSM-5 and ICD-11 Watch site:

Go here to read Mary M. Schweitzer’s Submission to the Work Group for Somatic Symptom Disorders.

To submit a comment online register here:

APA’s new DSM-5 Development site: http://www.dsm5.org/Pages/Default.aspx

You can also register via a link at the bottom of each proposal, for example, at the bottom of this key page:

Complex Somatic Symptom Disorder (CSSD)

Note that if you are viewing proposals from this page:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

you won’t see the page for:

“Psychological Factors Affecting Medical Condition”

This is one of the DSM-IV categories that the Work Group is proposing should be combined with several other current categories under “Somatic Symptom Disorders”.

In order to view this page, the Proposed Revision, Rationale and other Tabs, or if you wished to submit a comment specifically in relation to this proposal, this is the URL:

316 Psychological Factors Affecting Medical Condition

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=387

There are two key PDF documents associated with proposals for the DSM categories currently classified under “Somatoform Disorders”:

Key Document: Full Disorder Descriptions PDF: APA Somatic Symptom Disorders description January29 2010

Key Document: Full Rationale PDF: APA DSM Validity Propositions 1-29-2010

These provide an overview of the new proposals and revisions and a “Justification of Criteria” rationale document. I would recommend downloading these if intending to make a submission.

Related information:

[1] APA’s new DSM-5 Development webpages

[2] Somatoform Disorders:
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

[3] Complex Somatic Symptom Disorder (CSSD) [Ed: Proposed new category]
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

[4] Psychological Factors Affecting Medical Condition [Ed: Proposed for revision]
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=387

[5] Key PDF documents:

PDF A] Somatic Symptom Disorders Introduction DRAFT 1/29/10
http://www.dsm5.org/Documents/Somatic/APA%20Somatic%20Symptom%20Disorders%20description%20January29%202010.pdf

PDF B] Justification of Criteria – Somatic Symptoms DRAFT 1/29/10
http://www.dsm5.org/Documents/Somatic/APA%20DSM%20Validity%20Propositions%201-29-2010.pdf

[6] For more information see my DSM-5 and ICD-11 Watch site, DSM-5 proposals page: http://wp.me/PKrrB-jZ