Brian Hughes - If you spend 20 years gaslighting your patients, perhaps you should think twice before accusing *them* of trolling *you*

If you are not aware @wigglethemouse (and apologies if you are):

for the WHO's forthcoming ICD-11, the single category replacement for most of ICD-10's Somatoform disorders and F48.0 Neurasthenia has drawn heavily on DSM-5's Somatic symptom disorder construct.

ICD-11's new Bodily distress disorder is conceptually very close to SSD and SSD is listed under Synonyms.


For descriptions and criteria for SSD, see also:

DSM-5 Somatic symptom disorder: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM-5-Somatic-Symptom-Disorder.pdf

Somatic Symptom Disorder
Joel E. Dimsdale, MD, University of California, San Diego
https://www.msdmanuals.com/en-gb/pr...nd-related-disorders/somatic-symptom-disorder

---------------------------------------


Joel E. Dimsdale had chaired the DSM-5 Somatic Symptom Disorders Work Group. In this AJP article, Dimsdale writes (my bolding):

https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2013.13050589

"...Note that the diagnosis of somatic symptom disorder in this case is based on criteria that are present rather than lack of explanation of symptoms; furthermore, these criteria focus on territory familiar to psychiatrists and psychologists—thoughts, feelings, and behaviors. The removal of the emphasis on medically unexplained symptoms allows a focus on patient suffering without questioning its legitimacy or “reality.” Furthermore, finding somatic symptoms of unclear etiology is not sufficient to make this diagnosis. In the absence of abnormal thoughts, feelings, and behaviors, patients with irritable bowel syndrome, chronic fatigue, or fibromyalgia would not qualify for a diagnosis of somatic symptom disorder."


For the APA's SSD field trials, three groups were studied:

488 healthy patients; a "diagnosed illness" group of 205 patients with cancer and malignancy (some in this group were said to have severe coronary disease) and a "functional somatic" group comprising 94 people with "irritable bowel" and "chronic widespread pain" (a term often used synonymously with fibromyalgia).

15% of the cancer and malignancy group met the SSD criteria when "one of the B type criteria" was required; if the threshold was increased to "two B type criteria" about 10% met criteria for dual-diagnosis of a diagnosed general medical condition + Somatic Symptom Disorder.

For the 94 irritable bowel and chronic widespread pain study group, about 26% were coded when "one of the B type criteria" was required; 13% coded when "two B type criteria" was required.

7% of the healthy patient control group were also captured.


Despite the looseness of the proposed criteria set and its reliance on highly subjective and difficult to measure responses like "Disproportionate and persistent thoughts about the seriousness of one’s symptoms" and "Excessive time and energy devoted to these symptoms or health concerns", the SSD Work Group chose to take forward the criteria set option which required only "one of the B type criteria" to meet the diagnosis.

See:

Mislabeling Medical Illness As Mental Disorder Allen Frances (with Suzy Chapman), Psychology Today, DSM 5 in Distress, December 8, 2012

Bad News: DSM 5 Refuses to Correct Somatic Symptom Disorder Allen Frances (with Suzy Chapman), Psychology Today, DSM 5 in Distress, January 16, 2013

Why Did DSM 5 Botch Somatic Symptom Disorder? Allen Frances (with Suzy Chapman), Psychology Today, Saving Normal, February 6, 2013


SSD and BDD license the application of an additional mental health diagnosis for all chronic illnesses – whether "established general medical conditions or disorders" like diabetes, heart disease and cancer, or conditions presenting with "somatic symptoms of unclear etiology" – if the clinician considers the patient is devoting too much time to their symptoms or that their life has become "subsumed" by health concerns and preoccupations, or their response to distressing, chronic, somatic symptoms is perceived as "excessive" or "disproportionate," or their coping strategies "maladaptive."

Furthermore, ICD-11 doesn't use rigid criteria sets like DSM-5 but disorder descriptions and characterizations which allow clinicians more flexibility to use their clinical judgement.

ICD-11's Bodily distress disorder is potentially more problematic than DSM-5's SSD.


References:

Rationale for Proposal for Deletion of proposed new category: Bodily distress disorder Suzy Chapman, Dx Revision Watch, March 01, 2017

Allen Frances¹, Suzy Chapman². DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. 1 Department of Psychiatry, Duke University 2 DxRevisionWatch.com Aust N Z J Psychiatry. 2013 May;47(5):483-4.
doi: 10.1177/0004867413484525 http://www.ncbi.nlm.nih.gov/pubmed/23653063

Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1.
doi: 10.1097/NMD.0b013e318294827c http://www.ncbi.nlm.nih.gov/pubmed/23719325

Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580.
doi: 10.1136/bmj.f1580 http://www.ncbi.nlm.nih.gov/pubmed/23511949

Somatic Symptom Disorder could capture millions more under mental health diagnosis Suzy Chapman, Dx Revision Watch, May 26, 2012

 

Interesting that this is not the usage I am familiar with - so it leaks out into the more general meaning. I have a suspicion that Wessely, with his neo-Freudian background, would prefer to keep secondary gain for hysteria, but the these people are so much like the caterpillar in Alice in Wonderland that I would not guarantee even that.

 

Malingering leads very quickly to Munchhausen disease which brings us to Munchhausen's by proxy which was used for the first wave of families who had their children removed by force. Nowadays they just say it is ME being caused by the parents and that is enough. EC may have moved on by blaming the children with her pervasive refusal disorder but it is all very close to malingering in the sense of claiming disease that is not there.

Central sensitisation sounds neurological but it comes from SWs ideas that we feel normal things, like our heart beat or the usual aches and pains of life but think they are symptoms of disease. This worry makes our brains think there is actually something wrong so it activates pathways to alert us and the whole thing goes out of control and every little ache sets off the alarm signals. CBT helps us bring things back to normal.

 

By the way, the DSM-5 Somatic Symptom Disorders Working Group had comprised the following members (I have highlighted the two UK members):

DSM-5 Somatic Symptom Disorders Work Group

Dimsdale, Joel E., MD
Barsky III, Arthur J., MD
Creed, Francis, MD.
Frasure-Smith, Nancy, Ph.D
Irwin, Michael R., MD
Keefe, Francis J., Ph.D
Lee, Sing, MD
Levenson, James L., MD
Sharpe, Michael, MD
Wulsin, Lawson R., MD


Frances Creed, MD was a key player on the 17 member ICD-11 S3DWG sub working group that was responsible for making recommendations for the revision of the ICD-10 Somatoform disorders.

Javier Escobar, MD, Director of the University of Medicine and Dentistry of New Jersey (UMDNJ) – Robert Wood Johnson Medical School (RWJMS) Medically Unexplained Physical Symptoms (MUPS) Research Center, which has been supported with over $4M in funding by the US National Institute of Mental Health (NIMH), was a member of the DSM-5 Task Force. Dr Escobar had served as Task Force liaison to the Somatic Symptom Disorders Work Group.


In September 2006, in collaboration with WHO and NIH, the APA convened a diagnosis-related research planning conference in Beijing focusing on “Somatic presentations of mental disorders”. Twenty-eight international researchers were invited to participate – the eighth in a series of thirteen conferences convened by the APA between 2004 and 2008.

Amongst those presenting at the 2006 Beijing Symposium were:

Ricardo Araya (Bristol, UK); Simon Wessely (KCL, London, UK); Javier Escobar (New Jersey, US)*; Richard Mayou (Oxford, UK)*; Michael Sharpe (Edinburgh, UK)*; Winfried Rief (Marburg, Germany)*, Norman Sartorius (WHO, Geneva, Switzerland) and Kurt Kroenke (Indianapolis, US)*.

At the time of the symposium, the five asterisked presenters were also members of the international CISSD (Conceptual Issues in Somatoform and Similar Disorders Project) workgroup, that had been convened and co-ordinated by Dr Richard Sykes, PhD, between 2003 and 2007, Principal administrator: Action for M.E.,* Principal collaborator: Professor Rachel Jenkins, Director, WHO Collaborating Center, Institute of Psychiatry, London. (Dr Sykes was later engaged in the “MUPSS Project”, administered by the Institute of Psychiatry.)

Professor Kurt Kroenke and Professor Michael Sharpe had served as the CISSD Project’s international and UK chairs [1][2].


Cosy, eh?

*Action for M.E. inherited the administration of the Sykes' project as a condition of AfME's absorbing of Westcare. Sykes obtained 3 years funding for his project, after retiring from Westcare.

1 Summary of work of CISSD Project provided by Dr Richard Sykes, October 2008: CISSD Sykes Summary

2 18 Proposals submitted by Dr Richard Sykes to ICD Update and Revison Platform, March 2008: CISSD Sykes ICD Proposals

 

Sharpe’s contribution - ch12, ‘Distinguishing malingering from psychiatric disorders ‘ is quite revealing I think. In it he explains why he feels the most important factor to consider when distinguishing “a feigned subjective illness from a ‘genuine’ subjective illness” is inconsistency. This might take the form of inconsistency in accounts of symptom history - or inconsistency between reported symptoms and observed behaviour.

On pages 166/167 he gives a case study of observing inconsistency in cases of “Somatoform disorders, conversion, dissociation, and functional somatic syndromes” and - wouldn’t you know it - the condition he chooses to use as an example is chronic fatigue syndrome. It’s worth quoting here in full.

“A 35-year-old woman was seen in the clinic saying that she had ‘ME’ and requesting a report for the benefits agency. She gave a history of severe disabling fatigue for 5 years following a viral infection. She said that she had not worked and admitted that she had found her previous employment as a teacher very stressful. She was now receiving substantial state benefits and her partner had given up his work to look after her. The mental state and physical examinations were unremarkable. The patient walked very slowly to the waiting room and was collected by her partner who pushed her to the car park in a wheel chair. A diagnosis of chronic fatigue syndrome was made based on the history. Subsequent to the assessment one of the nursing staff reported that she had seen the patient walking out to the shops appearing unaffected by fatigue. When the patient was challenged about this on a future appointment, she said that she had ‘good and bad days’. The fluctuation was accepted but the possibility of exaggeration of symptoms noted.

This case illustrates the importance of seeking evidence of inconsistency over time and that the issue of exaggeration is a vexed one in conditions that may fluctuate from day to day.”

So despite studying ME/CFS for years - and presumably being well aware of the fact that symptom variability is extremely common in the condition - Sharpe chose to repeat and endorse the idea that these fluctuations may instead may be an indicator that patients are exaggerating their symptoms. And he did this in a book titled “Malingering and Illness Deception”.

Regardless of the ‘caveat’ (if that’s what it is) at the end of the case study, I don’t think he leaves much room to doubt what he really thinks of us.

 

DSM-5 has:

Factitious disorder

and

Factitious disorder imposed on another

which includes the disorder originally known as Munchausen syndrome by proxy (MSBP).



ICD-11 has:


6D50 Factitious disorder imposed on self

Inclusions

• Münchhausen syndrome

Exclusions

• Excoriation disorder (6B25.1)
• Malingering (QC30)

6D51 Factitious disorder imposed on another

Exclusions

• Malingering (QC30)

All Index Terms

• Factitious disorder imposed on another
• Munchhausen syndrome by proxy
• Munchhausen by proxy syndrome
• Factitious skin disorder imposed on another ⇒
  • Skin disorder resulting from Munchhausen syndrome by proxy

Coding Note
The diagnosis of Factitious Disorder Imposed on Another is assigned to the individual who is feigning, falsifying or inducing the symptoms in another person, not to the person who is presented as having the symptoms. Occasionally the individual induces or falsifies symptoms in a pet rather than in another person.

----------

ICD-11 has not included the term "Pervasive refusal disorder/syndrome" or "Pervasive Arousal Withdrawal Syndrome (PAWS)." As far as I am aware, there are no outstanding proposals in ICD-11 to include a category for "PAWS".

----------

Edited to add:

In ICD-11, 6B60 Dissociative neurological symptom disorder (Functional neurological symptom disorder in DSM-5) also has an Exclusion for Factitious disorder.

 

I am reading a book "Cracked" by James Davies which has a chapter on how the DSM was set up. It quotes an article from the New Yorker which describes how Factitous Disorder made it into the DSM. Spitzer met up with 2 psychiatrists in Washington who had written a paper about 2 patients with 'hysterical psychoses' typified by short episodes of delusion and hallucination after short trauma and the other showing up at emergency rooms with no real physical problems.

Over a 40 minute discussion, Spitzer divided these into 2 disorders "brief reactive psychosis" and 'factitious disorder". He then borrowed a typewriter and wrote a series of diagnostic criteria which made it into the DSM with just a few minor changes.

Read it and weep.

 

As expected wessely is bouncing off the “i never said ME was malingering” stepping stones as his response to Brian Hughes article on Twitter and is now waltzing off to his charming weekend

 

I think that typewriter has been loaned out numerous times.

 

This reminds me of a gardening book, upon which I used to rely, where it was said that taxonomists are not scientists. They merely do work upon which scientists may, or may not, take note. I paraphrase.

 

https://twitter.com/user/status/1108744559931072513

 

I'm also sorry for being so harsh in my previous posts. My motivation was to prevent Wessley and co using the wording of the article against us but as I result I got overly focused on what could potentially go wrong that I forgot to mention the many strengths of the article. In particular I think that highlighting the abusive and insulting nature of the BPS model of CFS is point that really needed to be made as we are always seen as the aggressors in the media narrative when in fact it they started the fight by claiming we can't tell the difference between illness and regular tiredness after exertion.

 

https://twitter.com/user/status/1109027446781808640


oh oh @Brian Hughes you are in trouble now

 

michael sharpe‏ @profmsharpe
Replying to @b_m_hughes
Dear Dr Hughes, you do write some offensive nonsense. Really.

9:42 AM - 22 Mar 2019

 

Sorry Sly Saint, you got there first.

 

The NewYorker article which @Mithriel mentions:

https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder

Annals of Medicine
January 3, 2005 Issue
The Dictionary of Disorder
How one man revolutionized psychiatry.
By Alix Spiegel

 

Is it the author of that article the same Alix Spiegel who was responsible for the Invisibilia podcast?

 

Alix Spiegel
Co-Host, Invisibilia

https://www.npr.org/people/90889243/alix-spiegel

The bio suggests she probably is.

 

Small world.

 

Comment deleted as I don't wish to lower the tone.