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J O E L D I M S D A L E

J I M L E V E N S O N

M I C H A E L S H A R P E

L A W S O N W U L S I N

From the DSM IVs Somatoform

Disorders to DSM 5s SomaticSymptom and Related Disorders

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DSM-5 Somatic Symptom Disorders WorkGroup, 2007-12

Arthur Barsky, Francis Creed

Javier Escobar

Michael Irwin

Frank Keefe

Sing Lee James Levenson

Michael Sharpe

Lawson Wulsin

Joel Dimsdale (chair)

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Disclosure for Joel Dimsdale, JimLevenson, Michael Sharpe, and Lawson

Wulsin

WITH RESPECT TO THE FOLLOWING

PRESENTATION, THERE HAS BEEN NORELEVANT FINANCIAL RELATIONSHIP

BETWEEN THE PARTIES LISTED ABOVE(AND/OR SPOUSE) AND ANY FOR-PROFIT

COMPANY IN THE PAST 24 MONTHSWHICH COULD BE CONSIDERED A

CONFLICT OF INTEREST.BUT WE WERE MEMBERS OF THE SSD WORKGROUP AND THEREFORE INTELLECTUALLY

INVESTED IN ITS RECOMMENDATIONS

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Overall reasons for change

Reliance on medically unexplained symptoms (MUS)as a key factor is very problematic. Fosters mind-body dualism

Unexplained Psychogenic (IBS, migraine, FM, CF are notpsychiatric disorders)

Unreliable; bases a Dx on absence of something.

Misses those who have organic disease explanation but stillare somatizing.

A psychiatric Dx should rest on abnormal psych Sx.

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Reasons to change Somatization Disorder

Criteria not user-friendly

Rarely diagnosed

Arbitrary cut-offs on a continuum

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Reasons to merge Somatization Disorder,USD, Hypochondriasis, and much of the

pain disorders

Unclear boundaries and frequently comorbid

Arbitrary to give one somatic Sx (pain) its ownDxs

Somatization Disorder too narrow and USD toodiffuse

Similar Tx approaches Desire for a Dx user-friendly for nonpsych MDs

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Chief controversy in creation of SSD

We got rid of MUS.

If criteria too liberal, patients with normalreactions to severe medical illness will be given

this Dx.But if too restrictive, too few qualify for

diagnosis.

Pr o p or t i o n a l i t y i s k ey .

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Why did we eliminate Hypochondriasis?

Hypochondriasis is pejorative and unacceptable touse with patients, hence Illness Anxiety Disorder(IAD).

Most patients (75%) with DSM-IV Hypochondriasissatisfy criteria for SSD.

IAD diagnosed for the ~25% of hypochondriacs whohave health anxiety but no or minimal somatic

symptoms.

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Why did we change Conversion Disorder?

Make diagnosis more usable: practical to apply,suitable for neurologists to use, and acceptable topatients.

Revise in light of new evidence: Conversion not established

Universal role of stressors is not found.

Incorporate examination criteria based on

inconsistency and incompatibility withpathophysiology.

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Changes in Conversion Disorder (Functionalneurological symptom disorder)

Eliminated[Psychological factors judged to beassociated]

Neurologists less skilled in eliciting

Patient may not reveal May only emerge within psychotherapy

Not supported by research

Now included as specifier and discussed in text.

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Changes in Conversion Disorder (Functionalneurological symptom disorder)

Eliminated[The symptom is not feigned]

Not practical, not consistent with other diagnoses

Now referred to in text.

Changed name to CD (Functional neurologicsymptom disorder)

Conversion archaic but provides continuity.

FNSD reflects current usage in neurology and is probably

more acceptable to patients.

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Criterion added to Conversion Disorder

Clinical findings provide evidence of incompatibilitybetween the symptom and recognized neurologicalor medical conditions.

The diagnosis should not be made simply becauseinvestigations are normal or the symptom is bizarre.

Internal inconsistency is one of the commonest ways ofdemonstrating incompatibility.

The other is incompatibility with recognizedneuropathophysiology.