Andy
Senior Member (Voting rights)
Introduction
The classification of the so-called “functional” psychiatric disorders has long been debated. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; 1994) retained the “somatoform” psychological-primacy concept but had poorly devised subdivisions with criteria that proved too loose or too tight to be useful.1 The disorders were excluded from major health surveys and clinicians simply did not use the diagnostic categories.2 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; 2013) provided an opportunity for improvement, but instead of primarily addressing the weaknesses of DSM-IV, changes were made in a completely different direction: there was a fundamental shift away from the acknowledgement of psychological mechanisms being of central importance in functional disorders. Criteria requiring the clinician to judge conversion symptoms as being “associated with psychological stressors” were dropped; the transition from “conversion” to “functional neurological” was begun. “Somatoform” became the neutral “somatic symptom disorders”,3 and there was a move away from the idea of “medically unexplained symptoms” (MUS): the DSM-5 workgroup felt that “medically unexplained” was synonymous with “psychiatric” and was thus to be avoided.4–6 There was also a view that “…the MUS approach is not well accepted by patients who feel that MUS implies that their symptoms are inauthentic and ‘all in your head’”.7 Overarchingly, DSM-5 adopted an attitude of agnosticism regarding the causation of these disorders. In the ensuing years this has morphed into a mantra: the idea that psychological factors are integral to these disorders rather than “co-morbid” is now deemed “radical”,8 or “out of date”,9 and psychiatrists are being encouraged to join the agnostic “renaissance”.10
It would be fair to expect such a fundamental change in direction to have been informed by substantial supporting evidence, but that does not appear to be the case. Indeed, there remains much evidence that these conditions have what we would all consider psychological or psychiatric factors at their core, and little or no evidence to the contrary. The changes in approach appear to have been made largely in efforts to “destigmatize” these conditions; to define them as something other than psychiatric disorders. Although arguably well-meaning, we believe that this shift away from the psychological is short-sighted, and, most important, invalid. It hinders a clear understanding of these conditions in clinical settings and thus leads to poorer treatment outcomes. It misdirects research efforts, as we will discuss. And it is doomed to fail as it does not reflect the underlying nature of these disorders. As Feynman says, “Nature cannot be fooled”.11
In this CJP Perspective, we suggest that the DSM-5 agnostic stance has been of detriment to the functional disorder field, from the point of view of patients and clinicians, and in terms of research. We commence by presenting the psychological causation model, which in essence prevailed for more than a century before DSM-5.
Open access, https://journals.sagepub.com/doi/10.1177/07067437241245957
The classification of the so-called “functional” psychiatric disorders has long been debated. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; 1994) retained the “somatoform” psychological-primacy concept but had poorly devised subdivisions with criteria that proved too loose or too tight to be useful.1 The disorders were excluded from major health surveys and clinicians simply did not use the diagnostic categories.2 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; 2013) provided an opportunity for improvement, but instead of primarily addressing the weaknesses of DSM-IV, changes were made in a completely different direction: there was a fundamental shift away from the acknowledgement of psychological mechanisms being of central importance in functional disorders. Criteria requiring the clinician to judge conversion symptoms as being “associated with psychological stressors” were dropped; the transition from “conversion” to “functional neurological” was begun. “Somatoform” became the neutral “somatic symptom disorders”,3 and there was a move away from the idea of “medically unexplained symptoms” (MUS): the DSM-5 workgroup felt that “medically unexplained” was synonymous with “psychiatric” and was thus to be avoided.4–6 There was also a view that “…the MUS approach is not well accepted by patients who feel that MUS implies that their symptoms are inauthentic and ‘all in your head’”.7 Overarchingly, DSM-5 adopted an attitude of agnosticism regarding the causation of these disorders. In the ensuing years this has morphed into a mantra: the idea that psychological factors are integral to these disorders rather than “co-morbid” is now deemed “radical”,8 or “out of date”,9 and psychiatrists are being encouraged to join the agnostic “renaissance”.10
It would be fair to expect such a fundamental change in direction to have been informed by substantial supporting evidence, but that does not appear to be the case. Indeed, there remains much evidence that these conditions have what we would all consider psychological or psychiatric factors at their core, and little or no evidence to the contrary. The changes in approach appear to have been made largely in efforts to “destigmatize” these conditions; to define them as something other than psychiatric disorders. Although arguably well-meaning, we believe that this shift away from the psychological is short-sighted, and, most important, invalid. It hinders a clear understanding of these conditions in clinical settings and thus leads to poorer treatment outcomes. It misdirects research efforts, as we will discuss. And it is doomed to fail as it does not reflect the underlying nature of these disorders. As Feynman says, “Nature cannot be fooled”.11
In this CJP Perspective, we suggest that the DSM-5 agnostic stance has been of detriment to the functional disorder field, from the point of view of patients and clinicians, and in terms of research. We commence by presenting the psychological causation model, which in essence prevailed for more than a century before DSM-5.
Open access, https://journals.sagepub.com/doi/10.1177/07067437241245957
