DSM-5 And Somatic Symptom Disorder

Under DSM-IV, a “diagnosis” of somatization disorder entailed a history of physical symptoms for which, despite thorough medical evaluation, no satisfactory physical etiology could be established.  In DSM-5, this “diagnosis” was replaced by somatic symptom disorder.  This is essentially similar to DSM-IV’s somatization disorder – with one critical difference.  The newer “diagnosis” can be assigned even if there is an identifiable physical illness.  The essential requirement for the new “diagnosis” – indeed the only requirement – is that the individual is excessively or disproportionately preoccupied with the symptoms.  And who, one might ask, decides if a person’s preoccupation is excessive?  A psychiatrist, of course, whose vast training in drugs and ECT equips him with the wisdom, empathy, and insight to make such judgments.  As the eminent Dr. Biederman proclaimed in a public courtroom on February 26, 2009, a  psychiatry professor is second only to God in status and ability!

During my career, I worked with a great many people who were preoccupied with medical concerns.  Some of these individuals had serious illnesses, and my task essentially was to help them adapt to their medical status and still find ways to have a fulfilling and meaningful life.  In other cases, the matter was less clear cut.  Some didn’t seem to be all that sick, but I stress the word “seem,” because I didn’t know.  My fundamental perspective was that everything a client says should be taken seriously.  I found that in all cases, if I listened carefully, respectfully, and humbly, I could come to an understanding of the client’s perspective. 

I remember working with a young woman in her mid-20’s.  I’ll call her Julie.  She was truly terrified that she had cancer.  She had incurred the irritation of several physicians who accused her of wasting their time, and had been referred to a psychiatrist who gave her a “diagnosis” of hypochondriasis and prescribed an antidepressant.  The young woman chose not to fill this prescription, and instead came to see me.

We talked – or rather, she talked and I listened.  It emerged that during a one-year period, when she was five years old, three family members (an uncle, aunt, and grandmother) had died of cancer!  Obviously the feelings of devastation were crippling – not only for her, but for all the surviving members of the family.  So at the very time when she needed an enormous amount of support, her primary caregivers were themselves reeling in shock and grief.

What made things particularly difficult for Julie was the fact that the impending deaths were never discussed with her.  For her, as a five-year-old child, these individuals were just snatched away into oblivion – by this thing called cancer.  For Julie, there really was a bogey man under the bed.  And when she came to me for help, the bogey man was still there.  For me, whether Julie’s fear of cancer was “proportionate” or otherwise was never an issue.  I started from the simple premise that her fear was valid, from her perspective, and that my task was to help her manage this fear in a way that still allowed her to enjoy life and do the things she wanted to do.

After much discussion, she came to the conclusion that the way forward was: to recognize that because of her family history, she probably did indeed have an increased risk of contracting cancer; to take appropriate counter-measures (including diet and regular medical checks); but to not allow the concern to destroy her life.  Once she had formulated her objectives in these terms, she was remarkably successful in keeping her concerns about cancer in a reasonable balance.  I asked her if she had told the psychiatrist about the three family deaths.  She replied:  “No, he never asked about anything like that.”

The truly appalling thing about this is that the psychiatrist, within the context of his profession’s conceptual framework, was not being negligent.  All he needed for his “diagnosis” at that time was the DSM-III-R list of symptoms:

  • preoccupation with the fear of having a serious illness
  • no actual evidence for the illness
  • the fear is not allayed by medical reassurance
  • the fear has lasted for six months
  • the belief/fear is not of delusional intensity 

For psychiatry, that’s all that was needed to “make the diagnosis” and to legitimize the prescription.

The essential point here is that we humans are strange creatures.  During our childhood years we develop all sorts of ideas and feelings.  Some of them are helpful, others less so.  Some are disastrous.  But they are all understandable, if someone will take the time to listen.  Note that it was no part of my role to “fix” Julie, or even to say that she needed to be “fixed.”   Perhaps the most significant thing I said to her during the time we worked together was:  “If I had walked in your shoes, I would also be terrified of cancer.” My job was to provide an unhurried setting of trust and mutual respect in which Julie herself could explore the sources of her fear, catalog the extent to which it was derailing her goals and her relationships, and formulate remedial action.  At all times, Julie was in the driver’s seat.

But that is not the psychiatric way.  People whom psychiatrists consider excessively preoccupied with these matters are “diagnosed” with somatic symptom disorder, usually on the basis of a short interview and perhaps a five-minute phone consultation with a general practitioner.  And the patient is given neurotoxic pills – to correct the “chemical imbalance” or the “neural circuitry anomaly” or whatever trite and deceptive rationalization is current at the time.  And if, with the passage of years, the hapless client is irreparably damaged by the drugs, then there’s always a locked psych ward and ECT.

  • Anonymous

    There is no human fear that is un-understandable. Szasz often quoted Terence who said ‘I am human, nothing human is alien to me’, Szasz said for the psychiatrist, the thinking goes ‘I am psychiatrist, nothing alien is human to me’.

    When people enter medical school and decide to waste that opportunity by specializing as psychiatric quacks, they voluntarily undergo a commonsense-ectomy during their “training”.

    Such common sense advice as the kind you gave this fearful young woman, is alien to the “alienist”.

    The worthless DSM checklist mentality means that a vending machine full of psych drugs could fulfill the psychiatrist’s role.

    Press the button for Mountain Dew, press the button for Somatic Symptom Disorder, bang, out the drugs come.

    Worthless middle men for the state psychopharma industrial complex.

    We can just be glad we didn’t waste our lives in such a fraudulent and dishonest profession.

  • Phil_Hickey

    Anonymous,

    You’ve touched on something that has often puzzled me. When people graduate from medical school, with presumably a great deal of science and scientific methodology under their belt, how is it that they can’t see through the spurious drivel that underpins their chosen specialty? I guess the answer is: with eyes wide shut.

    Best wishes.

  • cannotsay

    Agreed Anon/Phil partially.

    I have also asked myself many times how is it possible for people who have gone through the most intensive scientific training like Mr Biederman or Lieberman to then go and sell nonsense. Worse, they go on to make a living out of making the lives of others miserable.

    But then I do the exercise to remember my days in graduate school, surrounded by highly educated and smart people, and realize that among the highly educated and highly smart there are also unethical people. In other words, ethics and intelligence/scientific training are completely orthogonal.

    If having a high IQ/being highly educated were to be a bar for engaging in unethical behavior, there would be not such thing as “white collar crimes”. However, “white collar crimes” are committed, by definition, by smart/highly educated people.

    This is not to say that all, or a majority of, smart/highly educated people are unethical, but it helps to think in terms of orthogonality.

    Psychiatrists make a living legally. Do they care that their work is based on nonsense or that people suffer as a result? Well, no, since if they did they would not be psychiatrists!

  • Diana

    If a person has pain immediately after a stressful period, can it be a somatization disorder? Example: pain in the joints after an argument, after stress at work or after a visit in the dentist’s office.

  • Francesca Allan

    I don’t know whether it can be characterized as a somatization disorder but when I am too stressed I have pain all down the left side of my body. It’s my helpful indicator to rearrange my schedule. I wouldn’t dare mention it to a psychiatrist.

  • Francesca Allan

    I wonder about this too. I guess they just write down what the lecturers say without questioning same. Perhaps an introductory course in critical thinking should be added to the curriculum. A prof recently declared in one of my lectures that horses are only born at night. I didn’t write that one down and I hope to God it doesn’t show up on an exam.

  • Adam Martin

    What you are describing sounds like a mental illness. I’ve known a lot of narcissists, but none of them would have wanted to drug millions of people because they were different from their standard of normal.

  • cannotsay

    “Mental illness” you mean of the kind that has not been shown to be scientific http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml ? With respect to “different from their standard of normal”, that is precisely what psychiatry is all about: voting in the DSM what certain members of the APA think deviates from their own standard of normal!

    Spare me from nonsense. You don’t need to appeal to narcissism or any other made up disease to make sense of this.

    I always explain this with an analogy to cheap electronic gadgets. If these gadgets were to be manufactured in the US or other Western countries with high labor standards, they would cost much more than what your average gadget costs now. As a result, the average American consumer could not afford it and companies like Apple or Samsung could not sell them like candy affecting both their revenues and profits. Large multinational companies found the solution: transfer the manufacturing to countries like China where people work in slave-like conditions that would not permitted under American laws.

    Is there a “conspiracy” by the American consumer to slave Chinese workers that manufacture these gadgets? Or maybe the conspiracy is on the side of the companies that manufacture the gadgets? Or perhaps the average American consumer and executives at these companies suffers from “narcissism”? None of that seem plausible to me. Most likely, the situation is the result of the self interest of the corporations and the self interest of the American consumer who couldn’t care less for working conditions of those Chinese workers as long they can make profits and buy cheap electronic gadgets respectively.

    In the case of psychiatrists, same story. Psychiatrists need to make a living (in the case of those who got recently out of medical school, in addition many of them need to pay back loans that could be in hundreds of thousands of dollars). Big Pharma companies need to make a profit. Drugging as many people as the DSM allows is a legal way for psychiatrists and pharmaceutical companies to make money (although through different rationales). So sure they are going to push the drugs (in case of psychiatrists) and manufacture/sell them (case of pharmaceutical companies).

    I don’t think it is very complicated to understand. It would take the average psychiatrist to be more ethical than the average American consumer that buys cheap electronic gadgets to pause for a second and think twice before pushing for drugs they do know harm people (just as it would take a great deal of ethics for the average buyer of a smart phone to pause for a second before condoning child labor by buying said phone).

  • Adam Martin

    I don’t think we are on the same page here. I was pointing out the irony of psychiatry diagnosing people with similar personalities as mentally ill. They go even further by medicating people (involuntarily if needed) to conform. By its own diagnostic manual, psychiatry has narcissistic personality disorder and antisocial personality disorder.

    In fact, here are the adjectives describing ASPD. “Needs to be thought of as infallible, unbreakable, invincible, indomitable, formidable, inviolable; intransigent when status is questioned; over-reactive to slights.”

    The suggestion? Institutionalization along with anti-psychotic drugs. Psychiatry should follow its own guidelines. When should we expect mass arrests of psychiatric professionals?

  • cannotsay

    Sorry for the misunderstanding pal, I do think we are on the same page: anti psychiatry!!!

  • Francesca Allan

    Get used to it, Adam! Why would someone bother reading and understanding your words (much appreciated, by the way) when one can shriek his misunderstanding at you instead? You’re just lucky you got only a few paragraphs.

  • Phil_Hickey

    Diana,

    Any reports of distressing or disruptive pain can warrant a “diagnosis” of somatic symptom disorder – if, in the opinion of a psychiatrist, the person’s thoughts, feelings, or response to the pain are excessive or “disproportionate.”

    The “diagnosis,” like the rest of psychiatry’s labels, is pure nonsense.

  • If I may add a footnote to this very useful and appropriate thread, I have also written on the subjects of Somatic Symptom Disorder (Somatization Disorder) and Psychogenic Pain. See “It’s NOT All in Your Head” on Mad in America, and “Psychogenic Pain and Iatrogenic Suicide” on the Global Summit for Diagnostic Alternatives.

    http://www.madinamerica.com/2013/10/head/
    http://dxsummit.org/archives/1002

    I come to this discussion as a technically trained medical and mental health layman who has worked online with chronic face pain patients for 18 years. In far too many cases that I have witnessed, incompetent medical doctors have written off people whose distress and symptoms they do not understand, in favor of a mental health mythology: “It’s all in your head”.

    Sincerely,
    Richard A. “Red” Lawhern, Ph.D.
    Resident Research Analyst and Moderator
    “Living With TN” – an online community within Ben’s Friends

  • Phil_Hickey

    Red,

    Thanks for coming in with this interesting and helpful perspective.

  • Anonymous

    I would like to add that not all psychiatrists are the same. I worked with one for four and a half months in a treatment program and he took his time to listen and talk with me, to teach me about the brain and my disorders, and sometimes to just tell me about something interesting so that I could have a break from all my thoughts. He prescribed medication to help because he knew that some symptoms could be lessened as there are neurological things going on. He paid close attention for side effects and worked very hard to help me become better. Even when I was so depressed that I barely participated in conversations, he was patient and did not give up on me so that he could go get other work done.

  • Phil_Hickey

    Anonymous,

    Thanks for coming in. I don’t know what your psychiatrist taught you about the brain and your disorders, but what the vast majority of psychiatrists tell their clients in these areas is false.

    Best wishes.