Journal of Trauma & Dissociation
ISSN: 1529-9732 (Print) 1529-9740 (Online) Journal homepage: http://www.tandfonline.com/loi/wjtd20
Problems With DSM–5 Somatic Symptom Disorder Colin A. Ross MD To cite this article: Colin A. Ross MD (2015) Problems With DSM–5 Somatic Symptom Disorder, Journal of Trauma & Dissociation, 16:4, 341-348, DOI: 10.1080/15299732.2014.989558 To link to this article: http://dx.doi.org/10.1080/15299732.2014.989558
Accepted author version posted online: 11 Mar 2015. Published online: 11 Mar 2015. Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjtd20 Download by: [University of Nebraska, Lincoln]
Date: 06 November 2015, At: 02:39
Journal of Trauma & Dissociation, 16:341–348, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2014.989558
EDITORIAL
Downloaded by [University of Nebraska, Lincoln] at 02:39 06 November 2015
Problems With DSM–5 Somatic Symptom Disorder COLIN A. ROSS, MD The Colin A. Ross Institute for Psychological Trauma, Richardson, Texas, USA
This editorial addresses what I perceive to be conceptual problems with the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5; American Psychiatric Association [APA], 2013), “Somatic Symptom and Related Disorders” section. I both discuss the problems and present some newly analyzed data to support my position. These problems include problems with the differential diagnosis of dissociative disorders and somatic symptom and related disorders; problems caused by the expanded definition of dissociation in DSM–5, which now includes somatoform dissociation; failure to mention dissociative disorders in the differential diagnosis of somatic symptom disorder; and lack of clarity about the relationship between somatic and dissociative symptoms. An additional problem is the manner in which the criterion set for the new somatic symptom disorder leads to an apparent increased prevalence of DSM–5 somatic symptom disorder compared to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ), somatization disorder. The name of the overall section concerning somatic symptoms was “Somatoform Disorders” in DSM–IV but has been changed to “Somatic Symptom and Related Disorders” in DSM–5. In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM–III; APA, 1980), the diagnosis of somatization disorder required 13 symptoms from a list of 33 somatoform symptoms. In addition, the person had to see a doctor and there had to be no physical explanation for the symptom. The diagnostic criteria were modified in DSM–IV (APA, 1994) to require one, two, or four Received 1 May 2014. Address correspondence to Colin A. Ross, MD, The Colin A. Ross Institute for Psychological Trauma, 1701 Gateway #349, Richardson, TX 75080. E-mail: rossinst@rossinst. com 341
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symptoms from each of four different types of symptoms—pain, gastrointestinal, sexual, and pseudoneurological (conversion) symptoms—for a total of eight symptoms. The DSM–III requirement for a visit to a doctor and no physical explanation being found was retained in DSM–IV but has been dropped from DSM–5. In DSM–5, somatization disorder has been eliminated and a new disorder, somatic symptom disorder, has been introduced; only one symptom is required to make the diagnosis, and there is no requirement for a visit to a doctor to rule out organic cause. DSM–5 states that diagnostic sections are placed next to each other to emphasize that those disorders are closely related to each other (APA, 2013, p. 13). Thus, in DSM–5, the dissociative disorders are placed between the “Trauma- and Stressor-Related Disorders” and “Somatic Symptom and Related Disorders” sections, which is a reasonable placement conceptually speaking. For example, posttraumatic stress disorder is included in the differential diagnosis of dissociative identity disorder (DID) and dissociative amnesia in DSM–5 (p. 296); posttraumatic stress disorder includes a dissociative symptom specifier (p. 272) and includes dissociative disorders in its differential diagnosis, and acute stress disorder includes dissociative disorders in its differential diagnosis. This is consistent with the two sections “Trauma- and Stressor-Related Disorders” and “Dissociative Disorders” being placed beside each other. The “Somatic Symptom and Related Disorders” section of DSM–5 comes immediately after the “Dissociative Disorders” section. Consistent with this, DSM–5 states that “conversion disorder is often associated with dissociative symptoms such as depersonalization, derealization, and dissociative amnesia” (APA, 2013, p. 320). Conversion disorder, including pseudoseizures, is said to be common in DID in DSM–5 (p. 298), and conversion disorder is included in the differential diagnosis of DID (p. 297). Pseudoseizures are included as a specifier for conversion disorder in DSM–5 (p. 318), and dissociative disorders are included in the differential diagnosis of conversion disorder (p. 321). In DSM–IV, conversion symptoms were one of the four required symptom domains for a diagnosis of somatization disorder, along with pain, gastrointestinal, and sexual symptoms. That is, conversion symptoms were a subset of somatization disorder. Conversion disorder could be diagnosed as a free-standing disorder if full criteria for somatization disorder were not met. Both diagnoses required a visit to a doctor and no physical explanation for the symptoms being found. DSM–5 states that somatic symptom disorder is “the major diagnosis in this diagnostic class” (APA, 2013, p. 309). This might lead one to expect that somatic symptom disorder is closely related to the dissociative disorders. However, in DSM–5, somatic symptom disorder and conversion disorder have been uncoupled from each other: Conversion disorder still requires a visit to a doctor and no physical explanation being found, and DID
Downloaded by [University of Nebraska, Lincoln] at 02:39 06 November 2015
Journal of Trauma & Dissociation, 16:341–348, 2015
343
and dissociative amnesia are included in its differential diagnosis. Somatic symptom disorder does not require a visit to a doctor or no physical explanation being found; dissociative disorders are not included in its differential diagnosis, and, vice versa, somatic symptom disorder is not included in the differential diagnosis of any of the dissociative disorders. The reasoning behind this uncoupling of somatic symptom disorder and conversion disorder is unclear. In my opinion, the relationship between dissociative disorders and somatic symptom disorder should be addressed in both the text and the diagnostic criteria for somatic symptom disorder in future editions of the manual. Either dissociative disorders should be included in the differential diagnosis of somatic symptom disorder, or an explanation should be provided for why this is the case for conversion disorder but not for somatic symptom disorder. The diagnostic categories in the “Somatic Symptom and Related Disorders” section of DSM–5 are somatic symptom disorder, conversion disorder, illness anxiety disorder, psychological factors affecting other medical conditions, and factitious disorder. Of these, only conversion disorder is related to dissociation, according to DSM–5: Perhaps conversion disorder should be moved to the “Dissociative Disorders” section in future editions of the manual, or the relationship of dissociative phenomena to other somatic symptom diagnoses should be made more explicit. The definition of dissociation in DSM–5 includes disruptions in “consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2013, p. 291); that is, it includes both psychoform and somatoform dissociation (Nijenhuis, 2000; Pullin, Webster, & Hanstock, 2014; Van der Hart, Van Dijke, Van Son, & Steele, 2000). The expansion of the domain of dissociation to include somatoform dissociation in DSM–5 (the DSM–IV definition included only psychoform dissociation) makes the need for a careful discussion of dissociation in the “Somatic Symptom and Related Disorders” section of the DSM even more urgent. A conversion disorder could be regarded as a dissociation in perception, body representation, or motor control and could meet criteria for an other specified dissociative disorder by DSM–5 rules (Subtype 3, p. 306): Subtype 3 can include “transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis)” (APA, 2013, p. 307). There does not seem to be any difference between conversion disorder and some forms of other specified dissociative disorder. The inclusion of two possible diagnoses for similar phenomena is confusing. Expanding the definition of dissociation to include somatoform dissociation makes the need to differentiate dissociative and somatic symptoms more pressing, but DSM–5 does not provide consistent guidance on this problem (Brown, Cardena, Nijenhuis, Sar, & van der Hart, 2007; Nijenhuis, 2014).
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An additional problem with DSM–5 somatic symptom disorder is the reduction in required symptoms from 13 in DSM–III to one in DSM–5, combined with dropping the requirement that there be a physician visit and rule-out of physical cause. This makes the placement of such a disorder in a psychiatric diagnostic manual difficult to understand; as written, the diagnosis implies that a person with a bona fide organic condition would qualify for this diagnosis if more distressed or preoccupied with the illness than would be expected compared to an unspecified standard of normal levels of distress or preoccupation. Because somatization disorder was the major diagnosis in the “Somatoform Disorders” section of DSM–IV, and somatic symptom disorder is the major diagnosis in the “Somatic Symptom and Related Disorders” section of DSM–5, one might think that the new DSM–5 diagnosis replaces the old DSM–IV diagnosis. This does not seem to be the case, however, as the new diagnosis is so different from the previous one. If somatic symptom disorder does not replace somatization disorder, then it is unclear why somatization disorder was not retained in DSM–5 as a distinct and separate disorder from somatic symptom disorder. DSM–5 states that the prevalence of somatic symptom disorder is unknown but says that it should be “higher than that of the more restrictive DSM–IV somatization disorder (
ISSN: 1529-9732 (Print) 1529-9740 (Online) Journal homepage: http://www.tandfonline.com/loi/wjtd20
Problems With DSM–5 Somatic Symptom Disorder Colin A. Ross MD To cite this article: Colin A. Ross MD (2015) Problems With DSM–5 Somatic Symptom Disorder, Journal of Trauma & Dissociation, 16:4, 341-348, DOI: 10.1080/15299732.2014.989558 To link to this article: http://dx.doi.org/10.1080/15299732.2014.989558
Accepted author version posted online: 11 Mar 2015. Published online: 11 Mar 2015. Submit your article to this journal
Article views: 127
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjtd20 Download by: [University of Nebraska, Lincoln]
Date: 06 November 2015, At: 02:39
Journal of Trauma & Dissociation, 16:341–348, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2014.989558
EDITORIAL
Downloaded by [University of Nebraska, Lincoln] at 02:39 06 November 2015
Problems With DSM–5 Somatic Symptom Disorder COLIN A. ROSS, MD The Colin A. Ross Institute for Psychological Trauma, Richardson, Texas, USA
This editorial addresses what I perceive to be conceptual problems with the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5; American Psychiatric Association [APA], 2013), “Somatic Symptom and Related Disorders” section. I both discuss the problems and present some newly analyzed data to support my position. These problems include problems with the differential diagnosis of dissociative disorders and somatic symptom and related disorders; problems caused by the expanded definition of dissociation in DSM–5, which now includes somatoform dissociation; failure to mention dissociative disorders in the differential diagnosis of somatic symptom disorder; and lack of clarity about the relationship between somatic and dissociative symptoms. An additional problem is the manner in which the criterion set for the new somatic symptom disorder leads to an apparent increased prevalence of DSM–5 somatic symptom disorder compared to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ), somatization disorder. The name of the overall section concerning somatic symptoms was “Somatoform Disorders” in DSM–IV but has been changed to “Somatic Symptom and Related Disorders” in DSM–5. In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM–III; APA, 1980), the diagnosis of somatization disorder required 13 symptoms from a list of 33 somatoform symptoms. In addition, the person had to see a doctor and there had to be no physical explanation for the symptom. The diagnostic criteria were modified in DSM–IV (APA, 1994) to require one, two, or four Received 1 May 2014. Address correspondence to Colin A. Ross, MD, The Colin A. Ross Institute for Psychological Trauma, 1701 Gateway #349, Richardson, TX 75080. E-mail: rossinst@rossinst. com 341
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symptoms from each of four different types of symptoms—pain, gastrointestinal, sexual, and pseudoneurological (conversion) symptoms—for a total of eight symptoms. The DSM–III requirement for a visit to a doctor and no physical explanation being found was retained in DSM–IV but has been dropped from DSM–5. In DSM–5, somatization disorder has been eliminated and a new disorder, somatic symptom disorder, has been introduced; only one symptom is required to make the diagnosis, and there is no requirement for a visit to a doctor to rule out organic cause. DSM–5 states that diagnostic sections are placed next to each other to emphasize that those disorders are closely related to each other (APA, 2013, p. 13). Thus, in DSM–5, the dissociative disorders are placed between the “Trauma- and Stressor-Related Disorders” and “Somatic Symptom and Related Disorders” sections, which is a reasonable placement conceptually speaking. For example, posttraumatic stress disorder is included in the differential diagnosis of dissociative identity disorder (DID) and dissociative amnesia in DSM–5 (p. 296); posttraumatic stress disorder includes a dissociative symptom specifier (p. 272) and includes dissociative disorders in its differential diagnosis, and acute stress disorder includes dissociative disorders in its differential diagnosis. This is consistent with the two sections “Trauma- and Stressor-Related Disorders” and “Dissociative Disorders” being placed beside each other. The “Somatic Symptom and Related Disorders” section of DSM–5 comes immediately after the “Dissociative Disorders” section. Consistent with this, DSM–5 states that “conversion disorder is often associated with dissociative symptoms such as depersonalization, derealization, and dissociative amnesia” (APA, 2013, p. 320). Conversion disorder, including pseudoseizures, is said to be common in DID in DSM–5 (p. 298), and conversion disorder is included in the differential diagnosis of DID (p. 297). Pseudoseizures are included as a specifier for conversion disorder in DSM–5 (p. 318), and dissociative disorders are included in the differential diagnosis of conversion disorder (p. 321). In DSM–IV, conversion symptoms were one of the four required symptom domains for a diagnosis of somatization disorder, along with pain, gastrointestinal, and sexual symptoms. That is, conversion symptoms were a subset of somatization disorder. Conversion disorder could be diagnosed as a free-standing disorder if full criteria for somatization disorder were not met. Both diagnoses required a visit to a doctor and no physical explanation for the symptoms being found. DSM–5 states that somatic symptom disorder is “the major diagnosis in this diagnostic class” (APA, 2013, p. 309). This might lead one to expect that somatic symptom disorder is closely related to the dissociative disorders. However, in DSM–5, somatic symptom disorder and conversion disorder have been uncoupled from each other: Conversion disorder still requires a visit to a doctor and no physical explanation being found, and DID
Downloaded by [University of Nebraska, Lincoln] at 02:39 06 November 2015
Journal of Trauma & Dissociation, 16:341–348, 2015
343
and dissociative amnesia are included in its differential diagnosis. Somatic symptom disorder does not require a visit to a doctor or no physical explanation being found; dissociative disorders are not included in its differential diagnosis, and, vice versa, somatic symptom disorder is not included in the differential diagnosis of any of the dissociative disorders. The reasoning behind this uncoupling of somatic symptom disorder and conversion disorder is unclear. In my opinion, the relationship between dissociative disorders and somatic symptom disorder should be addressed in both the text and the diagnostic criteria for somatic symptom disorder in future editions of the manual. Either dissociative disorders should be included in the differential diagnosis of somatic symptom disorder, or an explanation should be provided for why this is the case for conversion disorder but not for somatic symptom disorder. The diagnostic categories in the “Somatic Symptom and Related Disorders” section of DSM–5 are somatic symptom disorder, conversion disorder, illness anxiety disorder, psychological factors affecting other medical conditions, and factitious disorder. Of these, only conversion disorder is related to dissociation, according to DSM–5: Perhaps conversion disorder should be moved to the “Dissociative Disorders” section in future editions of the manual, or the relationship of dissociative phenomena to other somatic symptom diagnoses should be made more explicit. The definition of dissociation in DSM–5 includes disruptions in “consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2013, p. 291); that is, it includes both psychoform and somatoform dissociation (Nijenhuis, 2000; Pullin, Webster, & Hanstock, 2014; Van der Hart, Van Dijke, Van Son, & Steele, 2000). The expansion of the domain of dissociation to include somatoform dissociation in DSM–5 (the DSM–IV definition included only psychoform dissociation) makes the need for a careful discussion of dissociation in the “Somatic Symptom and Related Disorders” section of the DSM even more urgent. A conversion disorder could be regarded as a dissociation in perception, body representation, or motor control and could meet criteria for an other specified dissociative disorder by DSM–5 rules (Subtype 3, p. 306): Subtype 3 can include “transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis)” (APA, 2013, p. 307). There does not seem to be any difference between conversion disorder and some forms of other specified dissociative disorder. The inclusion of two possible diagnoses for similar phenomena is confusing. Expanding the definition of dissociation to include somatoform dissociation makes the need to differentiate dissociative and somatic symptoms more pressing, but DSM–5 does not provide consistent guidance on this problem (Brown, Cardena, Nijenhuis, Sar, & van der Hart, 2007; Nijenhuis, 2014).
Downloaded by [University of Nebraska, Lincoln] at 02:39 06 November 2015
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An additional problem with DSM–5 somatic symptom disorder is the reduction in required symptoms from 13 in DSM–III to one in DSM–5, combined with dropping the requirement that there be a physician visit and rule-out of physical cause. This makes the placement of such a disorder in a psychiatric diagnostic manual difficult to understand; as written, the diagnosis implies that a person with a bona fide organic condition would qualify for this diagnosis if more distressed or preoccupied with the illness than would be expected compared to an unspecified standard of normal levels of distress or preoccupation. Because somatization disorder was the major diagnosis in the “Somatoform Disorders” section of DSM–IV, and somatic symptom disorder is the major diagnosis in the “Somatic Symptom and Related Disorders” section of DSM–5, one might think that the new DSM–5 diagnosis replaces the old DSM–IV diagnosis. This does not seem to be the case, however, as the new diagnosis is so different from the previous one. If somatic symptom disorder does not replace somatization disorder, then it is unclear why somatization disorder was not retained in DSM–5 as a distinct and separate disorder from somatic symptom disorder. DSM–5 states that the prevalence of somatic symptom disorder is unknown but says that it should be “higher than that of the more restrictive DSM–IV somatization disorder (
