plenary dsm 5
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8/12/2019 Plenary DSM 5
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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.
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