Turning physical illness into mental illness

[firecat]

The DSM-IV had several different diagnoses for people who were distressed about their health (somatoform disorders). The DSM-V will have one. That seems like it might be good, but the criteria for diagnosing people with this condition might have been broadened to the point where the diagnosis might be misapplied.

http://www.psychologytoday.com/blog/turning-straw-gold/201301/your-physical-illness-may-now-be-labeled-mental-disorder

"People can be diagnosed with Somatic Symptom Disorder if, for at least six months, they’ve had one or more symptoms that are distressing and/or disruptive to their daily life, and if they have one...of the following three reactions:

Criteria #1: disproportionate thoughts about the seriousness of their symptom(s);

Criteria #2: a high level of anxiety about their symptoms or health; or

Criteria #3: devoting excessive time and energy to their symptoms or health concerns.

Can you see how this diagnosis potentially includes everything from a stomach ache to cancer?

I'm of several minds about this.

Mind 1: I have chronic physical health issues and chronic mental health issues. When my mood disorder isn't well controlled, I absolutely fret about my health a lot more. So I think the state of mind they are describing is something real for some people.

Mind 2: But does the state of mind really need its own name and diagnosis? Can't they just include this as an aspect of mood disorders or obsessive disorders in general? Do anxiety or obsessive thoughts about your health require special treatments that are different from other anxiety and obsession treatments?

Mind 3: I'm concerned that this diagnosis will be used to deny people tests that could determine why they are having symptoms, or deny them treatments that would help them manage the symptoms of their chronic conditions. I'm concerned that it will be disproportionately applied to women and people of color.

More: http://dxrevisionwatch.com/2012/05/26/somatic-symptom-disorder-could-capture-millions-more-under-mental-health-diagnosis/

To meet requirements for Somatization Disorder (300.81) in DSM-IV, a considerably more rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. The diagnostic threshold was set high – a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain and two gastrointestinal symptoms.

In DSM-5, the requirement for eight symptoms is dropped to just one.

Comments

[amethystfirefly]

Ugh. I cannot even. -sigh-

[sauscony]

Thank you for pointing this out. As a person with Crohn's who was told before my diagnosis that it was probably psychosomatic, this is particularly worrying.

[staranise]

The thing about diagnoses are, of course they can be misapplied. This is why you need education, training, and experience to apply them. There are criticisms to be made for every DSM diagnosis out there. But I'm behind this one, especially as a PWD.

Do anxiety or obsessive thoughts about your health require special treatments that are different from other anxiety and obsession treatments?

They may. The biggest argument for a special diagnosis is that you need a diagnosis to treat something; simply subsuming somatization or preoccupation about health under a different disorder excludes people who are having problems mentally dealing with physical health, but who do not have one of the other disorders.

To be honest, I'm in favour of this shift because it represents a shift in thinking away from biomedical, towards social and functional. The previous diagnosis put an emphasis on people being responsible for their own pain, and on how the illness is psychosomatic, not "real". It is not so much about whether you have ~a disease~; if you get psychosomatic aches, pains, or nausea, the new diagnosis says, well, okay, that happens, but it's not necessarily a problem. This is a shift away from stigmatizing a normal human event.

Instead of just being the wastebin diagnosis for unexplained pain or illness, this is actually about a mental state. It no longer means "patient is in pain, doctor has no frigging clue". Yes, there is a risk that it will be used as, "patient is complaining, doctor wants them to STFU." Absolutely. But there is actually less risk now that peoples' pain will get written off to somatic issues and ignored, because this diagnosis does not preclude a root physical cause.

Instead it's about whether or not a person with a physical complaint handles their problem in a way that unnecessarily disables them. Which is a knife-edge when you say "unnecessary"; pain-management specialists debate hugely about this. But the purpose of this diagnosis is to ask: is the person adaptively dealing with their symptoms? Are they realistically estimating the risks and benefits of what they're doing? Are they, as far as they are able, living a happy and productive life? Or are their thoughts or feelings about the illness getting in the way?

The other reason you don't want these people just lumped into mood or anxiety disorders is that you would treat them differently. If someone told me, "I can't ever go out to the mall with friends because I'm afraid a velociraptor will leap out of a store and kill me," I can act on the assumption that this velociraptor incident will probably never happen, and my client will not be harmed by me saying, "velociraptors don't exist anymore." With "I can't ever go out to the mall with friends because I'm afraid there will be dust somewhere and I will get an asthma attack," a diagnosis of Somatic Symptom disorder tells me: there IS a physical thing somewhere, but it does not need to be dealt with to this extreme. My client will be harmed by saying, "You'll never get an asthma attack, you're just imagining it."

[shehasathree]

Instead it's about whether or not a person with a physical complaint handles their problem in a way that unnecessarily disables them. Which is a knife-edge when you say "unnecessary"; pain-management specialists debate hugely about this. But the purpose of this diagnosis is to ask: is the person adaptively dealing with their symptoms? Are they realistically estimating the risks and benefits of what they're doing? Are they, as far as they are able, living a happy and productive life? Or are their thoughts or feelings about the illness getting in the way?

I agree with this, except for the general ability of medical academics (in particular) to accurately judge whether or not someone is handling their problem in a way that unnecessarily disables them. And often doctors and allied health professionals do not know enough about complex conditions to be able to judge whether the patient is realistically estimating the risks and benefits.

[staranise]

Heh, well, yes. That is the central sticking point, and why I want to punch most pain management psychotherapists in the face. But a new DSM ain't gonna fix that mess.

[shehasathree]

true, true.

[firecat]

I appreciate your take on this a lot. I'm curious whether there are treatments for somatic symptom disorder (which counts as excessive anxiety about real risks) that are different from treatments for, say, social anxiety (which, I'm guessing, also counts as excessive anxiety about real risks). Well obviously the details of any conversation about them would be different. Does it help for therapists and psychiatrists to specialize in one of these fields and not the other? I guess it helps to have a specific diagnosis in order to ask for funding to test whether certain treatments help this specific condition and not others.

[staranise]

Social anxiety isn't actually seen as being about "real risks" inasmuch as being embarrassed or disliked is not likely to kill you. If you are dealing with a social situation that is likely to result in harm or death, it's not classified as social anxiety. So yeah, the competency for treating somatic symptom disorder would explicitly include knowing about the disease(s) one's clients have so they know what's "normal" or "proportionate" and what's not.

[firecat]

So anything that doesn't kill you doesn't count as a real risk? Wow.

[lilacsigil]

What concerns me is "devoting excessive time and energy to their symptoms or health concerns." Managing a complex health condition takes up a lot of time and energy and it would be really easy to view perfectly regular health monitoring and organising medical care to be "excessive" to someone else.

For example, when I go to see a specialist, I'm going to have at least 5 hours in the car. So I carefully plan my activities around that to make sure I have the time and energy to not just attend the appointment, but avoid being sick afterwards. When I had undiagnosed cancer, I went back to the doctors weekly - sometimes more often - trying to find what was wrong with me and it was only that persistence that got me a diagnosis. Was it "excessive"? Did I have "a high level of anxiety"? Yes, but only because the doctors in question were failing to do their jobs.

I think your velociraptor/asthma comparison isn't really comparing the situation, either, because one is imaginary. What about asthma vs car travel? Both are perfectly reasonable concerns that can then interfere with their lives, and I'm not really sure why they would require different treatments.

[staranise]

In which case it really does boil down to how one defines "excessive", since the fact is that in the face of many illnesses, the appropriate and proportionate response is "freak the fuck out until someone takes you seriously." In the face of chronic pain, a reasonable analysis of likelihood can tell you that if you want to function next week, you can't make dinner and do dishes tonight. And it would take a specialist experienced with illness and disability to be able to tell the difference between proportionate and excessive.

The point of the asthma example is that there are people who do disproportionately worry about their symptoms. For the purposes of the example, assume that the person would physically be able to go on these outings without having an asthma attack; they are vastly overestimating the probability out of anxiety and fear. If they are treated with psychotherapy, they are able to make more accurate assessments, and can be more functional. This is a real thing that happens in the real world, and that's somatic symptom disorder. Those people need treatment too. We can't just pretend that problem doesn't exist because it can be overgeneralized.

[lilacsigil]

Those people need treatment too.

Indeed they do, but considering the medical milieu that people with chronic conditions deal with, I cannot make myself believe for a moment that somatic symptom disorder is going to be used appropriately outside, perhaps, at a stretch, the discipline of psychology. I understand why you think it's appropriate to name and treat this problem, but I don't understand why you think it's appropriate to separate it from other disproportionate anxieties that affect daily life.

The broadness of the definition and making it a different thing to other disproportionate but not imaginary anxieties is highly inappropriate considering that it's not just "a specialist experienced with illness and disability" who will be using it. If diagnostic procedures, access to treatment and access to mental health care were all in an ideal state, then I think this disorder might reasonably be classified as a disorder. As it stands, it's another tool to cause harm to any patient who does not suit the doctor's opinions and resources.

[shehasathree]

This is really scary.
I have several systemic diseases/disorders, and several of them have taken many years to diagnose and I have been told many times that my symptoms were "just stress" and in the case of food intolerances they were actually massively improved once I got the right diagnosis and management. It's hard enough to get proper treatment for complex conditions/multiple conditions as it is.

I am also particularly unimpressed with the third bit, which is a perfect example of how we can Never Win, because we're expected to self-manage and 'take control' and responsibility and do healthwork etc but obviously not Too Much.

[firecat]

The second link above specifically mentions the lengthy diagnosis time for some conditions:

For multi-system diseases...it can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable [to being put in the SSD box].

I guess it boils down to whether professionals are going to be capable of maintaining a model of a patient that says "This person has physical health conditions AND mental issues around them" (in which case it might be helpful to have the diagnosis) or whether they're going to be binary and say "oh, somatic symptom disorder, let's not believe anything this patient says."

[badgerbag]

Yeah that's pretty horrible.

[cereus]

"a history of many medically unexplained symptoms before the age of thirty"

Worries me. Because - that's just how things *are* for the many diseases/disorders we *just haven't* figured out yet. Celiac, MS, and many autoimmune disorders were in that category until fairly recently. Hell - Cholera was in that category for a while.

So I'm sure there are lots of people walking around out there with "medically unexplained symptoms".

(Edited to fix capitals)

[amadi]

There's also a difference between "medically unexplained" and "medically inexplicable." A lot of people have "medically unexplained symptoms" because they don't have access to medical care. Diagnostic criteria based upon an assumption of equal and full access to care is, in the US model, pretty terrifying.

[cereus]

Also true! Good point.

[flarenut]

I have very mixed feelings about this. On the one hand, It's really easy to see how this will be used by some doctors to say "shut up and stop whining! Oh, and I'm not going to treat your actual physical symptoms either."

On the other, I've seen people who get caught up in their ailments and make a vocation of managing and worrying about them in ways that make it hard for them to do other things and hard to be around them. And if that can be recognized and treated (to some extent separately from the ailments themselves) there will be benefits, like those people having more time to actually live their lives.

(And I think, with others, than there is a difference here between obsessing about symptoms of illness and obsessing about other stuff -- in particular the fact that the illness is actually there.)

[eggcrack]

As if trying to find solutions to health issues that duck all definitions isn't hard enough already. Fuck this.

[sabotabby]

This is interesting; I'll definitely have to consult my friend who's a psychiatrist about it. Oh, and my psychiatrist, I guess.

Because it's definitely a thing; pre-tumor, I wasn't really all that depressed or anxious, even though I have a clinical diagnosis of depression and anxiety. But having my physical health deteriorate rapidly certainly triggered a depression, and it's good to recognize that as a thing. But I can also see the drawbacks to considering it an actual condition.

[bunnybutt.livejournal.com]

Um. I have all three of those symptoms about my symptoms, and in discussions with my PCP, I *should quite reasonably* be having all three of those symptoms about my symptoms. Additionally, some of those symptoms are, in fact, symptoms of physiological conditions for which I am under treatment (or are side effects to the treatments for physiological conditions). None of which adds up to a diagnosis (in my case) for Somatic Symptom Disorder anywhere except on paper in the DSM.

Any chance of seeing you at Pcon this year?

[firecat]

I'm glad your PCP isn't about to attach a useless-for-you diagnosis.

Which one is Pcon? I'm going to Fogcon and possibly
Wiscon this year.

[sophy.livejournal.com]

Not to mention that just about anyone with undiagnosed symptoms, with a new diagnosis, and with newly worsening symptoms are just naturally going to fit those criteria for awhile.