The Impact of DSM-5 Somatic Symptom Disorder Diagnoses

The attitude of skepticism and dismissal historically associated with “invisible illnesses” has been compounded by the new DSM-55 diagnosis of Somatic Symptom Disorder (SSD), said Eleanor Stein, MD, Clinical Assistant Professor, Department of Psychiatry, University of Calgary, Canada.

“The concern is that only one physical symptom, such as pain, and only one psychological symptom, such as disproportionate and persistent thoughts, are required to qualify for having a ‘disorder,’” Stein told Psychiatry Advisor.

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Even for patients who have a clearly defined, objectively corroborated medical illness such as hypertension or diabetes, the diagnostic category can be problematic because there is no objective standard of “disproportionate” thoughts.

SSD pathologizes legitimate concerns, according to Stein, whose private practice consists predominantly of patients with ME/CFS, FM, and multiple chemical sensitivities (also known as environmental illness or toxicant-induced loss of tolerance).6 She reports also having patients with pain disorders, Lyme disease, and conditions without medical explanations.

Based on DSM-5 criteria, 15% of patients with cancer or heart disease and 26% of those with irritable bowel syndrome (IBS) or fibromyalgia qualify for a diagnosis of somatic symptoms disorder.7 “This is unacceptably high,” said Stein.

Table 2.
Somatoform/Somatic Symptom Disorders: DSM-IV versus DSM-5
DSM-IV-TR (Somatoform Disorders) DSM-5 (Somatic Symptom and Related Disorders)
Undifferentiated somatoform disorder
Somatic symptom disorder
Body dysmorphic disorder Moved to obsessive-compulsive and related disorders
Hypochondriasis Illness anxiety disorder
Conversion disorder Conversion disorder (functional neurological symptoms disorder)
Origincally included in “Other Conditions That May Be a Focus of Clinical Attention.” Psychological factors affecting other medical conditions
Medically unepxlained symptoms Disorders explained on the basis of positive symptoms (ie, distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms); Remains key feature in conversion disorder
Pain disorder Somatic symptom disorder with chronic pain
Psychological factors affecting other medical conditions
Adjustment disorder
APA, 201515

A Heterogeneous Group

Stein acknowledged that a significant number of patients with invisible illnesses also suffer from coexisting psychiatric symptoms, such as depression and anxiety. It is important not to group them into a single pattern but to recognize three general categories, she said.

Patients with secondary depression or anxiety: “The most common group of patients I see are those with depression or anxiety resulting from the illness and its impact on their lives,” she reported. “Some have lost their employment, are short on money, have been turned down for disability, are unable to buy or prepare food, or have undergone changes in relationships with family, friends, or partners.”