Realidad problemática internacional 16

The Somatic Symptoms Disorders Work Group, chaired by Joel E. Dimsdale of the University of California, San Diego, consisted of 9 members [26]. The group sought to address specific concerns with DSM-IV somatoform diag- noses. First, the group eliminated somatization disorder, undifferentiated somatoform disorder, pain disorder, and hypochrondriasis, due to their often-overlapping diagnostic criteria, which reduced the diagnoses’ valid- ity and clinical utility [27]. The group eliminated many terms included in DSM-IV, such as “somatoform” and “somatization” that patients and pri- mary care physicians often found unhelpful [28]. The group abolished DSM- IV’s use of “medically unexplained” symptoms because they believed this approach perpetuated the concept of mind-body dualism and confounded diagnostic reliability and validity [29, 30]. With no distinction between med- ically explained and medically unexplained somatic complaints in DSM-5, an individual can meet criteria for a somatic symptom disorder despite having a clear medical explanation [31].

Although many somatoform diagnoses changed dramatically from the DSM-IV to the DSM-5, some remained largely unchanged. Previously known as factitious disorder and factitious disorder by proxy, DSM-5 includes facti- tious disorder “imposed on self” and “imposed on another.” These diagnoses remained conceptually intact as falsified physical or psychological symp- toms to assume the sick role. There are now “single episode” and “recurrent episodes” specifiers [2 (p325)]. Psychological factors affecting other medi- cal conditions moved to this chapter from DSM-IV’s chapter titled Other Conditions That May Be a Focus of Clinical Attention, with unchanged crite- ria but newly added severity specifiers.

DSM-5’s somatic symptom disorder (SSD) is a major change from the DSM-IV. Criterion A specifies that an individual has one or more somatic symptoms that are distressing or significantly disruptive. As mentioned above, DSM-5 abolished medically unexplained symptoms (MUS) to estab- lish this diagnosis, so an individual may be diagnosed even when medically explained diseases result in distressing somatic symptoms. Criterion B specifies behavioral and psychological features of the disorder, emphasiz- ing the importance of how patients interpret symptoms. Individuals must demonstrate one or more of the following: “disproportionate and persistent

thoughts about the seriousness of one’s symptoms,” “persistently high level of anxiety about health or symptoms,” or “excessive time and energy devoted to these symptoms or health concerns” [2 (p311)]. The B crite- ria demonstrate the emphasis that the group placed on generating “posi- tive” symptom criteria and eliminating the rule-out “after appropriate investigation” criterion necessary in DSM-IV [32]. The first two B criteria overlap, and some authors have questioned whether the presence of both supplies incremental information; the third B criterion seems valid based on studies involving increased healthcare needs in somaticizing patients, but critics have questioned whether “inappropriate excessive time” devoted to somatic symptoms would be more valid [33]. Criterion C speci- fies that an individual need not have the same somatic symptom pres- ent continuously, but the state of being symptomatic must be persistent “typically more than 6 months” [2 (p311)]. SSD has multiple specifiers, including:  “with predominant pain,” which DSM-5 notes would previ- ously have been pain disorder; “persistent” for disorders characterized by increased severity, impairment, and duration; in addition to “mild,” “moderate,” and “severe.”

The SSD diagnosis has come under considerable scrutiny. First, Frances [34] argued that the diagnostic criteria are overly inclusive and that 15% of patients with cancer and heart disease, plus 25% of patients with irritable bowel syndrome and widespread pain, would be diagnosed with SSD. He esti- mated that DSM-5’s criteria would result in a 7% false-positive rate in the general population. Based on these estimates, he expressed concerns about the mislabeling of medically ill individuals as mentally ill [35].

Illness anxiety disorder is another new disorder in DSM-5. Like DSM-IV’s hypochondriasis, the primary diagnostic feature is a preoccupation with having (or acquiring, in DSM-5) a serious illness. Whereas hypochondriasis required that an individual’s concern arise from “misinterpretation of bodily symptoms” [1 (p507)], Criterion B of illness anxiety disorder specifies that if any somatic symptoms are present, they are mild in intensity and the pre- occupation is “clearly excessive or disproportionate” [2 (p315)] to any risk of acquiring a medical condition. The criteria necessitate that an individual has a high anxiety level about their medical status. “Care-seeking type” and “care-avoidant type” specifiers indicate whether individuals obtain fre- quent medical attention or avoid medical attention regarding these health concerns.

Conversion disorder, known as functional neurological symptom disor- der in DSM-5, remains in the chapter, but with multiple changes. Criterion A  still requires one or more symptoms of altered voluntary motor or sen- sory function, but it no longer includes DSM-IV’s requirement to “suggest a neurological or other general medical condition” [1 (p498)]. Rather, Criterion B now indicates that clinical findings suggest incompatibility between the

symptom and recognized neurological or medical conditions. Eliminated are the DSM-IV’s criteria that the deficit be associated with psychological fac- tors (conflict or stress), not be intentionally produced or feigned, and that the symptom cannot be fully explained by a general medical condition, the effects of a substance, or as a cultural experience.

The final major change by this group was moving body dysmorphic disorder from the DSM-IV’s Somatoform Disorders chapter to DSM-5’s Obsessive-Compulsive and Related Disorders chapter. Based on studies comparing the phenomenology, epidemiology, comorbidities, neurobiology, genetics, and treatment of body dysmorphic disorder, the group considered the condition as similar to obsessive-compulsive disorder (OCD) and there- fore more appropriately grouped with that disorder [36].

The following vignette demonstrates a possible implication of the changes to the Somatic Symptom and Related Disorders:

Ms. D is a 43-year-old woman diagnosed with breast cancer two years ago. Twelve months ago she underwent radical mastectomy and adjuvant chemo- therapy. Since then she has complained of excruciating, sharp chest wall pain near the surgical site. She finds herself staying home and avoiding social events with her friends because the pain is disabling. She thinks about the pain con- stantly and experiences considerable anxiety about recurrence of her breast cancer. She has visited her primary care physician at least monthly since the surgery and tried multiple medications for pain with limited improvement.

Based on DSM-IV, Ms. D could have received diagnoses of undifferenti- ated somatoform disorder or pain disorder associated with both psychologi- cal factors and a general medical condition, chronic. Using DSM-5, however, Ms. D instead meets criteria for SSD, given her distressing somatic symp- tom (Criterion A) and the disproportionate and persistent thoughts about her somatic symptom, her persistently high level of anxiety, and the exces- sive time and energy she devotes to the symptom (Criterion B). Because she meets all three B criteria, her disorder has lasted more than 6 months, and her symptom involves predominantly pain, Ms. D would be diagnosed with SSD, with predominant pain, persistent, severe.