DSM-5 And Somatic Symptom Disorder

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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.

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This article first appeared on Behaviorism and Mental Health,
Philip Hickey’s blog

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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15 COMMENTS

  1. Thank you, Dr. Hickey, for tirelessly pointing out the complete stupidity and lack of validity of the DSM “diagnostic” system. I wholeheartedly agree. I went into a therapist in denial, but with concerns of the abuse of my four year old child; disgust, as a former New Yorker, at 9.11.2001; and suffering from adverse reactions and withdrawal symptoms from a “safe smoking cessation med” / actual dangerous antidepressant, a NSAI, and Ultram. My concerns, drug ADRs, and withdrawal symptoms were misdiagnosed as bipolar – a supposedly “life long incurable, genetic mental illness,” of which I had zero family or personal history.

    Psychiatry should be abolished for turning themselves into an organization whose function is to cover up child sodomy for the religions and easily recognized iatrogenesis for paranoid and incompetent doctors. And because it is now an industry that does nothing but defame and poison it’s patients with major drug interactions for profit. Psychiatry, as an industry, is absolutely corrupt. And, as a kind hearted Christian woman, I now fear for the souls of those fools who still believe in, and utilize, the DSM “bible” to destroy other human beings.

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  2. Dr. Hickey, You develop your description of “Julie” and her complaint really well here. I could relate afresh to the manner in which an unexplored issue–a whole range of feeling–can create an unfreedom within your ability to make sense of something that oppresses you, no matter that you can see all the signs and reconsider the implications. Your client’s getting stuck like this and the implications of the psychiatrist’s leaving her in desperate need of understanding but afixing a label and reducing her to a term in a cheap theory, and talk therapy’s working for her, carry the very encouraging moral that as persons we count for ourselves and have to insist upon the fact if we need to.

    Thanks for the explanations.

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  3. Dr. Hickey,

    You are wise and caring; the smartest thing that a psychiatrists can tell a client is that their emotional distress makes sense considering their distressful experiences. What distressed people need most is an empathetic ear and a path forward; you kindly provided “Julie” with both.

    Empathy is impossible for most psychiatrists because they erroneously believe that emotional distress is a medical problem rather than an experiential problem. I applaud your empathy for the suffering of your clients.

    Thank you for your community service, Steve

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  5. Thank you for posting this. It reminds me of my year of training in a medical hospital for clinical pastoral training. I met a young man on the unit I was assigned to as chaplain who was going to have surgery to remove a huge but benign tumor in his right hip joint. He was 21 years old and angry as hell because of the lack of respect and understanding on the part of the medical community.

    When he began having pain in his hip he went to his GP, who told him there was no reason for the pain. According to that GP there was no problem and he sent the young man on his way. As the pain increased and he began experiencing difficulty walking due to the tumor’s growth he went to one doctor after another who told him there was nothing wrong, that all of this was “in his head.”

    And of course, we all know where he ended up. Yes, in a psychiatrist’s office. The psychiatrist tried to convince him that he was making all the pain up and that he was faking not being able to walk just so he could get peoples’ sympathy! He refused to take the toxic drugs and quit going to the crazy psychiatrist. He finally found a doctor who pointed out the huge tumor in the young man’s hip joint! By the time I met him he was in a wheel chair. Talk about angry! And it all could have been taken care of a year earlier than it was if only someone would have really listened and looked.

    After working as a chaplain in medical and psychiatric hospitals I have more horror stories like this one than you can shake a stick at. It’s made me very gun shy of doctors of any sort but especially psychiatrists who want to label everything in human life as a malady. I let very few docors treat me.

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    • Hi Stephen,

      Did any of the doctors bother to send this guy for further testing or did they all just blow him off? How many doctors did he see?

      Yeah, the psychiatrist deserves blame but so do all the doctors who were negligent. And accusing someone of pretending to not walk? Wow!

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  6. My son believed he had a brain tumor. he also believed he had diabetes and cut himself so that he would feel better. He went through diagnostic testing and no brain tumor was present…however because of his cutting behavior and beliefs (of two months) it was suggested he take antipsychotic medication. When these ‘medications’ made him sick and he refused to take them (without anyone considering underlying reasons for his thoughts) he was forced to go to a psychiatric unit….From the time of ‘forcing’ by six large gloved men and then forced injections for the next four months he was abused by this psychiatric facility. All in the name of psychosis intervention and early recovery.
    That means drugging until your thoughts disappear.
    Until your brain chemistry starts changing in ways we have not yet figured out to repair.
    that means psychiatrists trying to make those thoughts disappear until you start drooling and you can’t move at 16. That means changing ‘meds’ to another type and increasing the dose higher than the drug company recommends because some other doctor said it was okay.
    It still means not connecting..
    My son still had the capacity to try to escape by breaking a window and climbing out.
    We as a family listened to the psychiatrists. For several years we listened as they kept telling us about the revolving door syndrome. As they kept increasing doses.
    As we listened to them.
    Now he is as he is. We go on day by day. We know to try to listen deeply and take each day. There is such a mix up, is it drugs, is it brain change because of drugs, can he get beyond this? I am finding help from Krista McKinnon’s work, Mindfreedom, Dan Mackler, Charlotte LeBlanc (Sidetracked by Schizophrenia)…of course Mad in America (thank you so much), Cindi Fisher….but no one can bring my son back to where he was at 16…before these horrors were inflicted upon him.
    So my goal…I know he must go through this suffering on his own. I can help as possible but it is his path.
    Keep talking about and working on this, it is certainly a civil rights and child abuse issue that we have to keep exposing.

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