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Nederlog

 

 September 5, 2010

 

ME + me :  On the DSM-5TM

 

    "The mild and the long-suffering may suffer forever in this world. As long as the patient will suffer, the cruel will kick."
     -- Sidney Smith


I continue being not well, and today I only have a copy of a fine text by Suzy Chapman (aka ME agenda) that concerns the DSM-5. It is copied from her site about the subject: DSM-5 and ICD-11 watch and it consists of her submission in response to DSM-5 draft criteria dated April 22, 2010. (The short link to it is this: http://wp.me/pKrrB-Gd)

I copied it all because I think it is a good text that clarifies the problems that the DSM-5 poses for persons with ME/CFS and indeed for persons with any unexplained disease, and also for moral medical science.

And I have added 21 notes, M1 to M21, in square brackets, to signalize and stress what I think is important - which is not in any way in criticism of Ms. Chapman, but is because I think she is quite right about the importance and dangers of the DSM-5 for persons with ME/CFS, and indeed also for many other diseases, as just stated. Apart from the attribution to Ms. Chapman and my inserted notes, all the text is just as I found it.

The main reasons to include this here and now are that I wrote briefly about the subject in the previous Nederlog, and that I think it is an important subject. (*)
 


In response to:
Somatic Symptom Disorders > Complex Somatic Symptom Disorder

       Submission and text by Suzy Chapman (ME agenda)


Although the Diagnostic and Statistical Manual of Mental Disorders does not have quite the relevance for UK and some European patient populations, since ICD Chapter V is used in some countries in preference to the DSM, diagnostic criteria in the forthcoming edition will shape the international research and literature landscape and influence not only how disorders are defined for international research purposes but how patients and their needs are perceived by those responsible for their medical treatment and social care. It is hoped then, that the views of those submitting responses to the preliminary draft proposals from outside the USA will be afforded due consideration. [M1]

I submit the following comments and concerns with regard to:

Somatic Symptom Disorders > Complex Somatic Symptom Disorder

I welcome the decision of the Task Force to extend review of the preliminary draft revisions to the lay public as well as to APA members, clinicians, health professionals, researchers, administrators and other end users and for the Task Force’s recognition that patients, their carers, families and advocates and the patient organisations that represent their interests are crucial stakeholders in any consultation process. Their input merits particular consideration given the absence of patient representation within the individual Work Groups. [M2]

Since 2007, when the initial Work Groups were first assembled, the infrequency of reports and their brevity and lack of detail has made it difficult for those outside the field and the lay public to monitor the progress of the various Work Groups. Some Work Groups, for example, this group for Somatic Symptom Disorders, have published reports and editorials in subscription journals which are not readily available to those outside the field and without access to journal papers. [M3]

It would have been helpful if the publication of the free access Editorial: Dimsdale J, Creed F: The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report on behalf of the Somatic Symptom Disorders Work Group in the June ’09 edition of J Psychosom Res, 66 (2009) 473–476, which discussed and expanded on the proposals in your brief April ’09 progress update, could have been noted on the Somatic Symptom Disorders Work Group Progress Report page for wider dissemination.

It might be considered a purely tokenistic gesture by the Task Force to extend involvement in the DSM-5 development process to the lay public if they are unable to inform themselves around the deliberations of the groups charged with revision because they are largely excluded from the literature, symposia, conferences and workshops where discussions around proposals are taking place. They therefore rely on more detailed reports, and the paucity and sketchiness of Work Group reports to date has disappointed. [M4]

I acknowledge that the Task Force has had to balance opening up the draft proposals review exercise to a wide range of stakeholders against conducting a more restricted consultation process in which responses are collated, published and responded to. It is, however, disconcerting for both professionals and the lay public to tender responses into which considerable effort may have been invested if there is no feedback on how those comments, concerns and suggestions have been received by the respective Work Groups and in the knowledge that their submissions will not be visible for scrutiny by other stakeholders, since there appear to be no plans for aggregating and publishing summaries of the key areas of concern for each set of Work Group proposals. [M5]

Given that major changes in diagnostic nomenclature are being proposed for the revision of DSM-IV “Somatoform Disorders” categories, does the Work Group plan to publish an update on any reconsiderations and modifications the group intends to adopt before finalising proposals in readiness for field trials and in the interests of transparency, will it also note key areas of concern for which the Work Group does not intend to make accommodations? [M6]

Complex Somatic Symptom Disorder

There is considerable concern amongst international patient organisations and advocates for the implications of the “Somatic Symptom Disorders” Work Group proposal for combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders under a common rubric – “Somatic Symptom Disorders”, and for the creation of a new classification, “Complex Somatic Symptom Disorder” (CSSD). [M7]

Professionals in the field, interest groups and the media have been voicing concerns for the last couple of years that proposals for the broadening of criteria for some DSM categories would bring many more patients under a mental health diagnosis.

But if these major revisions to the “Somatoform Disorders” categories were to be approved there would be medical, social and economic implications to the detriment of all patient populations and especially those bundled by many of your colleagues within the field of liaison psychiatry and psychosomatics under the so-called “Functional Somatic Syndromes” (FSS) and “Medically Unexplained Syndromes” (MUS) umbrellas.

The Somatic Symptom Disorders Work Group’s proposal to redefine “Somatoform Disorders” would legitimise the potential for the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders, whether diagnosed general medical disorders, psychiatric disorders or so-called “unexplained medical symptoms and syndromes”; dual-diagnosing general medical conditions under the guise of “eliminating mind-body dualism.” [M8]

There are significant concerns for the implications for patients with Chronic fatigue syndrome, ME, Fibromyalgia, IBS, chemical injury, chemical sensitivity, chronic Lyme disease and GWS.

In the June ’09 Journal of Psychosomatic Research Editorial “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report”, which expanded on the group’s brief April report, Chair, Joel Dimsdale, MD, and fellow Work Group member, Francis Creed, MD, reported that by doing away with the “controversial concept of medically unexplained”, the proposed classification might diminish “the dichotomy, inherent in the ‘Somatoform’ section of DSM-IV, between disorders based on medically unexplained symptoms and patients with organic disease.” [M9]

The conceptual framework the group were proposing, at that point:

“…will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome.” [M10]

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 National Institute of Mental Health (NIMH) is a DSM-5 Task Force member. It is understood that Dr Escobar serves as a Task Force liaison to the Somatic Symptom Disorders Work Group and is said to work closely with your group [1].

In the August ’08, Psychiatric Times Special Report “Unexplained Physical Symptoms: What’s a Psychiatrist to Do?” [2] co-authors, Escobar and Marin, wrote:

“…Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of ‘medicalized’, specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivity, and many others.”  [M11]

“…These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms.” [M12]

In Table 1, under the heading “Functional Somatic Syndromes (FSS)” Escobar and Marin list:

“Irritable bowel syndrome, Chronic fatigue syndrome, Fibromyalgia, Multiple chemical sensitivity, Nonspecific chest pain, Premenstrual disorder, Non-ulcer dyspepsia, Repetitive strain injury, Tension headache, Temporomandibular joint disorder, Atypical facial pain, Hyperventilation syndrome, Globus syndrome, Sick building syndrome, Chronic pelvic pain, Chronic whiplash syndrome, Chronic Lyme disease, Silicone breast implant effects, Candidiasis hypersensivity, Food allergy, Gulf War syndrome, Mitral valve prolapse, Hypoglycemia, Chronic low back pain, Dizziness, Interstitial cystitis, Tinnitus, Pseudoseizures, Insomnia, Systemic yeast infection, Total allergy syndrome” [M13]

This radical proposal for a “Complex Somatic Symptom Disorder” category will provide a convenient dustbin into which these diverse disorders might be shovelled. [M14]

It will expand the markets for antidepressant and antipsychotic drugs and therapies such as CBT to address perceptions of

           …poor adjustment…disproportionate distress and disability…dysfunctional and maladaptive response…unhelpful illness beliefs…activity avoidance…psychological distress in the wake of a general medical condition…personality traits…poor coping strategies contributing to worsening of a medical condition…sick role behaviour…secondary gains…

and other perceived barriers to “adjustment” or “rehabilitation”. [M15]

It will provide an attractive means of reducing the financial burden to governments and health insurers of providing appropriate medical investigations, medical treatments, financial and social support. [M16]

Whilst the proposals suggest that:

“a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present”

the application of an additional diagnosis of “Complex Somatic Symptom Disorder” will be based on subjective measures of whether the patient is perceived as having “dysfunctional and maladaptive beliefs” or “cognitive distortions” about their symptoms or disease resulting in “Misattributions [and] excessive concern or preoccupation with symptoms and illness”, whether the patient is “catastrophising” or has adopted “the sick role”. [M17]

Misidentification will increase the application of inappropriate treatment regimes – antidepressants and antipsychotic drugs, and therapies such as CBT to modify “dysfunctional and maladaptive beliefs” about the patient’s symptoms and disease, and behavioral techniques and “to alter illness and sick role behaviors and promote more effective coping”.

Get it wrong and patients are exposed to the risk of iatrogenic disease.

Get it wrong and there will be implications for the securing of health insurance, welfare, social care packages, disability and workplace adaptations and provision of education tailored to the needs of children too sick to access mainstream school.

Get it wrong and families will be put at increased risk of wrongful accusation of “factitious disorder by proxy/factitious disorder on other”.

Get it wrong and practitioners are at risk of litigation. [M18]

The CFIDS Association of America [3] has submitted:

“As drafted, the criteria for CSSD establish a “Catch-22″ paradox in which six months or more of a single or multiple somatic symptoms – surely a distressing situation for a previously active individual – is classified as a mental disorder if the individual becomes “excessively” concerned about his or her health. Without establishing what “normal” behavior in response to the sustained loss of physical health and function would be and in the absence of an objective measure of what would constitute excessiveness, the creation of this category poses almost certain risk to patients without providing any offsetting improvement in diagnostic clarity or targeted treatment.” [M19]

and

“This is especially true with regard to patients coping with conditions characterized by unexplained medical symptoms, or individuals with medical conditions that presently lack a mature clinical testing regimen that provides the evidence required to substantiate the medical seriousness of their symptoms. For instance, all of the case definitions for CFS published since 1988 have required that in order to be classified/diagnosed as CFS, symptoms must produce substantial impact on the patient’s ability to engage in previous levels of occupational, educational, personal, social or leisure activity. Yet, all of the case definitions rely on patient report as evidence of the disabling nature of symptoms, rather than results of specific medical tests. So by definition, CFS patients will meet the CSSD criteria A and C for somatic symptoms and chronicity, and by virtue of the lack of widely available objective clinical tests sensitive and specific to its characteristic symptoms, CFS patients may also meet criterion B-4.” 

The UK patient organisation, the 25% ME Group [4] has submitted:

“There is international concern that the proposed diagnostic category of CSSD as it is currently defined will be used to incorrectly diagnose ME/CFS patients with a psychiatric disorder.” [M20]

and

“It is of note that the draft of the proposed new category of CSSD states: “Having somatic symptoms of unclear aetiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptoms disorder diagnosis” (APA Somatic Symptom Disorders, 29th January 2010) but no such assurance is offered with respect to ME/CFS. This needs to be rectified.” [M21]

I call on the Somatic Symptom Disorders Work Group to give urgent reconsideration to their proposal for a new category “Complex Somatic Symptom Disorder” – while there’s still time to put it right.

Suzy Chapman, UK patient advocate

[1] Escobar, Javier I., M.D., M.Sc. DSM-5 Task Force Member Biosketch and Disclosure information:
http://www.dsm5.org/MeetUs/Documents…%201-11-10.pdf

[2] Marin H, Escobar JI: Unexplained Physical Symptoms What’s a Psychiatrist to Do? Psychiatric Times. Aug 2008, Vol. 25 No. 9: http://www.psychiatrictimes.com/disp…/10168/1171223

[3] CFIDS Association of America submission to the DSM-5 public review: http://www.cfids.org/advocacy/2010/dsm5-statement.pdf

[4] 25% ME Group submission to the DSM-5 public review: http://www.25megroup.org/News/DSM-V%20submission.doc  

 

Notes to the above (by MM)

[M1] Quite so - and the crucial point for (potential) patients and health-care personnel is:

the forthcoming edition will shape the international research and literature landscape and influence not only how disorders are defined for international research purposes but how patients and their needs are perceived by those responsible for their medical treatment and social care.

But more seems to me to be involved, to this psychologist and philosopher: In the DSM-5, the APA seems to be thinking first and foremost not of real science, not of creating a fairly clear set of symptoms and criterions to base medical diagnoses on, not of the interests of patients, but seems to have been first and foremost concerned with securing the future incomes of psychiatrists and psychotherapists, mostly by what I only can fairly describe as psychiatric theology, that runs more or less thus:

'There are a body (soma) and a mind/soul (psyche); all diseases have both somatic and psychological sides; and to the psychiatrist/psychotherapist falls in these modern days the lot and task and mission that used to be that of the priest, the pastor or the reverend: The proper care of the soul/psyche'.

From the point of view of rational real science, this is back to the Middle Ages: In real science there only is a brain, and human experiences are processes in a living brain, that are so complex, and take place in such a badly understood complicated organ, that there hardly is a science of human experience. (**)

[M2] The key sentence here, for me, is:

Their input merits particular consideration given the absence of patient representation within the individual Work Groups.

Put otherwise, the psychiatric professionals wanted to redesign their terminology, definitions and claims, but without providing a real possibility of interference or criticism from anybody who would be concerned about these changes in psychiatry who would not profit financially from these 'terminological changes' themselves as psychiatrists, or at least from outside their own interest group of medical professionals working for money: patients and interested medical laymen (or indeed interested medical doctors not closely tied to the APA) were mostly excluded from the start from properly taking part or indeed seeing what was really going on - or so it would seem, from what happened in fact.

For this, see the next paragraph in the text, and the next note:

[M3] Key phrases in this paragraph, sipporting my previous note:

the infrequency of reports and their brevity and lack of detail has made it difficult for those outside the field and the lay public to monitor the progress of the various Work Groups. Some Work Groups, for example, this group for Somatic Symptom Disorders, have published reports and editorials in subscription journals which are not readily available to those outside the field and without access to journal papers.

And this in fact in a project in which a bunch of psychiatrists redefines what medicine is, what illness is, what the relation between the mind and the body is, what mental illness is, with outcomes that clearly benefit their own professional group of mental health-workers, through the terminological device of attaching a mental, psychological component to any disease, in a quite similar way as medieval theologians insisted on there being a soul next to a body, for which these professionals, whether psychatrists or priests, then deserved to be consulted, to be paid, to be somehow involved for money, and indeed in many cases were and are given the medical say so about what really ails the patient, about what manner of cures are appropriate, and about which medicines, researches and technologies are appropriate to treat the ailments.

[M4] In this paragraph the key passage is, with a small change of mine, that preserves grammaticality:

[members of - MM] the lay public [are - MM] unable to inform themselves around the deliberations of the groups charged with revision because they are largely excluded from the literature, symposia, conferences and workshops where discussions around proposals are taking place.

In brief: The psychiatrists and psychotherapists redefine what medicine is, what illness is, what the relation between the mind and the body is, and what mental illness is, which are issues that touch on the immediate personal interests of all persons that may be effected by it, which is most of the earth's human population as far as the influence of the DSM-5 on many medical diagnoses is concerned, but... the APA chooses to theologize medicine and psychiatry without any interference by "lay persons", notably by scientists in other, e.g. more scientific and difficult or more advanced sciences, than psychiatry (of which virtually the only really scientific part relates not to psychiatry but to pharmacology and neurology: medicines).

[M5] Here the key passage is:

It is, however, disconcerting for both professionals and the lay public to tender responses into which considerable effort may have been invested if there is no feedback on how those comments, concerns and suggestions have been received by the respective Work Groups and in the knowledge that their submissions will not be visible for scrutiny by other stakeholders

That is, in less polite terms and more politically realistic terms: The APA has done its best that its redefinitions can not be effectively rationally criticized by anyone without a direct personal financial interest in them - viz. the psychiatrists in the Work Groups, who apparently do not even affirm that they have received or read any submission by someone not belonging to their own interest group - that, let me reassure the reader, is very much financially dependent on finding patients with disorders, and therefore with a definite financial interest for the group as a whole to have definitions of disease that allow or require a paid part for the members of their own professional group of healthworkers, so called.

[M6] These contain two very good questions by Ms. Chapman. I do not know whether she has received any answer, but suspect not.

In any case, it very much seems as if the APA Work Groups for the DSM-5 are set up so as to do most of their work without any effective control by anyone who does not have the interests of American psychiatrists most at heart.

[M7] The reasons for the "considerable concern" are quite good: In fact a total change of what is involved in medical science seems to be at issue - the psychiatrists working for the APA on the DSM-5 are redefining all manner of physical diseases as psychological diseases, that is, or redefining quite possibly only very partially known and understood bodily processes and malfunctions as if they are due to psychological processes and malfunctions, or at least interdepend with these.

Again, that is NOT modern rational science: That is medieval thinking mocked up for consumption of "laymen" and politicians and bureaucrats (incidentally also "laymen", if not psychiatrists) into modern psychiatric terminology, with a lot of added terminological and philosophical and logical confusion, for a good part intentional it seems, as well.

[M8] Here the key passage is right at the beginning of the paragraph:

The Somatic Symptom Disorders Work Group’s proposal to redefine “Somatoform Disorders” would legitimise the potential for the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders,

and the verbal trick by which is done is at its end: It is done by

dual-diagnosing general medical conditions under the guise of “eliminating mind-body dualism.”

This is a verbal trick because it is a fallacy: In fact the APA insists on what they are pleased to call the "mind-body dualism" and they do that by making all complaints that somehow relate to one's body as "Somatoform", which is to say something like "bodily". And the reasoning - damn Ockham's Razor; damn real science; damn real neuroscience - is this, essentially:

If the present state of medical knowledge can not explain one's suffering, then therefore one's suffering has no medical explanation, and therefore - the APA insists, for very clear financial reasons benefitting in principle all and only members of the APA (and other psychiatrists, of course) - the explanation must be that the patients make the symptoms up, and accordingly lies or is deluded.

In the Middle Ages, witch-trials ran along just the same lines: If the priests cannot explain some unpleasant coincidence or strange fearful event, it "must" be witchcraft, the evil eye, or the work of the devil and his incubi and succubi, these days renamed to "complexes, somatizations, neurasthenia, dysfunctional beliefs" etc.

This seems hard do believe in this modern age? See my next note:

[M9] The key passage in the paragraph is:

(..) Joel Dimsdale, MD, and fellow Work Group member, Francis Creed, MD, reported that by doing away with the “controversial concept of medically unexplained”, the proposed classification might diminish “the dichotomy, inherent in the ‘Somatoform’ section of DSM-IV, between disorders based on medically unexplained symptoms and patients with organic disease.”

That is: Frater Maso and Pater Sado propose, very kindly and most rationally, and so as to minimize terminological problems, that whatever is not understood by the kind colleagues of the inquisition therefore is the work of the devil, as this has the great benefit for The Church of getting rid of whatever The Church does not understand: The Church understands everything, and what it does not understand palpably comes from the evil one. (QED in the APA of 2010, it seems, for the explanation I just gave for the Church and the Inquisition applies to the APA and the science of medicine, as perceived by the APA, to be sure.)

[M10] Of course, the proud result

“…will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome.”  

(1) also allows many "a diagnosis of devil-inspired disorder", indeed "in addition to a general medical condition" ('you have a cancer from hell, miss, for thinking evil thoughts') and (2) uses nonsense terms like "a functional somatic syndrome " as if that is anything else but a medical lying label for what medical doctors cannot explain, while (3) guaranteeing that no medical doctor can be ignorant of any medical condition and any medical cure: what a doctor does not know must be, the APA insists rationally and honestly, "a functional somatic syndrome ", which as it happens psychiatrists claim themselves to be THE medical specialist to treat (rather than do some medical research or tests that were not done so far).

[M11] Note that in

“…Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of ‘medicalized’, specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivity, and many others.” 

the noble "scientific" writers of the prose are saying in so many words that whoever is a medical specialist that is not a psychiatrist, let alone any scientist who did not study medicine ipso facto does not understand medical science well or at all, and has in fact created lots of terminological "turf issues", as the honest Escobar and Marin call them.

How the APA, on their writing, is to deal with any science or any argument that disagrees with any statement or interest of the APA is thus: Tell them their language is not psychiatrically correct, and in fact, by implication, tell them they don't know what they're talking about - if they are not lying, of course.

[M12] This quotation of Escobar and Marin is a sequence of falsehoods:

(1) That “…These labels fall under the general category of functional somatic syndromes " is a pretty crazy and pretentious psychiatric prejudice rather than the fact it purports to be;

(2) That these labels "...seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones" is a disingenuous lie, for with the internet any patient can find out that "functional somatic syndrome" among medical doctors and psychiatrists means "We can't explain what ails you, so we insist that you are insane - try to oppose us if you are not a medical doctor, ha, ha, ha";

(3) That "using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms" again is no more than a lie that only describes the practice of some psychiatrists and medical doctors, and besides does not give reasons nor indeed a DSM number.

Besides, it is a piece of astroturf made up of pleonasms or tautologies: If one has a disease with "unknown physical causes", which could happen until the APA started on DSM-IV and DSM-5, then clearly there will be an "absence of reliable markers", and if indeed one's suffering is severe or long, it stands to reason suffering patients will seem to have some "psychiatric symptoms", especially if the psychiatrists insist they cannot have a disease, since all diseases are known to the APA, while all diseases that have not been discovered or causally explained yet therefore cannot exist, according to the APA, for which reason their symptoms must be malingering or delusion, just as psychiatrists told the world about diabetes, peptic ulcers, homosexuality and many more things non-psychiatrists have since established (after God knows how many personal human tragedies) to have physical causes, not psychological or psychiatric ones.

But it is the automatic remit of any graduate of psychiatry, if the course one graduates in is APA-blessed, of course, that the graduate knows all there is medically to be known, now or ever.

[M13] It seems to me that this list has a remarkable overlap with the things WheeWhee, EFT, and LP cure, within 3 days, or one tapping (durations that should worry many a psychiatrist, since this allows very few psychiatrist a living, if this becomes fashionable).

For more on the subject of the postmodern competition to the psychiatric brotherhood, see Get your whee-whees cuddled....

[M14] Ms Chapman's paragraph is, quite correctly

This radical proposal for a “Complex Somatic Symptom Disorder” category will provide a convenient dustbin into which these diverse disorders might be shovelled.

Being a psychologist myself, quite old, quite learned also, but not by far as divinely omniscient as my psychiatric colleagues of the APA, I observe I would have no problem at all with this if only the APA had spoken not of “Complex Somatic Symptom Disorder” to refer to what is unexplained so far by medicine, but rather, and far more honestly, rationally and scientifically of "Unexplained Diseases".

But the APA, it seems, much rather has myriads of prospering psychiatrists in the world, and accordingly much rather insists that what real medical scientists cannot yet explain therefore must be madness, which therefore, including the insurance-money of the patients, belongs to them, for honest medical exploitation.

[M15] Ms. Chapman quite correctly lists these terms of psychiatric abuse that patients with hitherto unexplained diseases must expect from psychiatrists and from medical doctors who believe these psychiatric worthies, if only because they too belong to the medical brotherhood, and colleagues interests, since medical grad school, rank before patients interests:

           …poor adjustment…disproportionate distress and disability…dysfunctional and maladaptive response…unhelpful illness beliefs…activity avoidance…psychological distress in the wake of a general medical condition…personality traits…poor coping strategies contributing to worsening of a medical condition…sick role behaviour…secondary gains…

And indeed: These are simply arbitrary terms of abuse, without any rational justification, and totally dependent on mood or prejudice of the one who mouths them: What CAN "poor",  "disproportionate", "dysfunctional", "unhelpful " etc. MEAN in the case of patients one admits have a disease one does NOT understand?

But this is no rational or ethical problem for the APA, it seems: An APA-psychiatrist knows everything medical science will ever know - as follows by deductive logic from their DSM-5 proposals! - and therefore, if such an APA-approved psy-pro does not seem to know what ails you, the explanation must be that nothing ails you. And if it keeps hurting, you must be deluded. 

[M16] The paragraph reads

It will provide an attractive means of reducing the financial burden to governments and health insurers of providing appropriate medical investigations, medical treatments, financial and social support.

and thus it is, or at least: Thus it is that the APA seems to want that governments and health-insurers believe, namely to the effect that having patients with unexplained conditions treated as if they are madmen (and therefore also don't qualify for health benefits or social help) is the much cheaper option than giving them the help others with diseases do get (so far, and until the DSM-5 is in full force, for after that it may very well depend on whether you please the member of the Fraudian Brotherhood of the APA sufficiently well to be given medicines rather than blah-blah-therapy or forced exercises).

[M17] And indeed

“dysfunctional and maladaptive beliefs” or “cognitive distortions” about their symptoms or disease resulting in “Misattributions [and] excessive concern or preoccupation with symptoms and illness”, whether the patient is “catastrophising” or has adopted “the sick role”.

are all terms of abuse and discrimination rather than of rational science, for the clear reason that they are in reality based on the - terminologically very cleverly hidden - fact that the ailment one has is one that present medical science cannot explain yet (fully).

Note also that all the cited terms pack a solid prejudice: That the ailing patient cannot even describe his or her own symptoms well, if these are not yet medically understood, or indeed must be lying or mad (as with diabetes and ulcers of the stomach, for many decades: One was mad, according to the psychiatrists of that day, if one suffered from these conditions, without immediately dying from them).

[M18] Here I simply repeat the paragraphs, for they sketch the fundamental medical and moral problem, for doctor and patient also:

Get it wrong and patients are exposed to the risk of iatrogenic disease.

Get it wrong and there will be implications for the securing of health insurance, welfare, social care packages, disability and workplace adaptations and provision of education tailored to the needs of children too sick to access mainstream school.

Get it wrong and families will be put at increased risk of wrongful accusation of “factitious disorder by proxy/factitious disorder on other”.

Get it wrong and practitioners are at risk of litigation.

For what happens when the doctor gets it wrong and tells you that you must be insane because the doctor cannot explain what ails you is that your life and your chances will be damaged even more than by the disease you have: You'll be ostracized, discriminated, forced to work, denied benefits, and denied help and support of all kinds.

For - you may find in a few years time - that the APA has determined, somewhere between 2007 and 2010, and without admitting anybody not close to the APA to have a close look at the medical redefinitions, that it is much better for psychiatrists', governments' and health-insurers' bank-balances that you are insane or a malingerer rather than ill. (And "it's the economy, stupid" - but they will lie about that just as they do about their own medical omniscience.)

[M19] The quotation of the CAA is apt and correct, and the Catch 22 amounts to the fact that the ill with a disease that the APA did not know of when the DSM-5 was crafted, or indeed a disease that the APA did not want to know of as disease, are considered to be insane if they say they feel ill, and sane only if they deny the testimony of their own experiences. (Besides, as soon as they start thinking or talking about their disease, or indeed 'disease', and the problems this causes for them, trained APA-specialists will tell them they are indulging in delusions, insanity, inappropriate ideas and acts, dysfunctional beliefs, and besides are weakwilled wimps anyway, having a disease an APA-member cannot recognize, and indeed are thinking themselves ill, just as Faust got himself damned.)

[M20] The 25% ME Group is right in claiming that

“There is international concern that the proposed diagnostic category of CSSD as it is currently defined will be used to incorrectly diagnose ME/CFS patients with a psychiatric disorder.”

although to this psychologist the reasons that there is relatively little such "international concern" must be that (1) the APA does mostly not allow non-psychiatrists to participate in their redefinitions of "medicine", "diagnosis", "rational explanation", and "medical ethics" (all by implication, but quite clearly, if tacitly and in intentional convoluted terminology) and (2) there is not much of investigative journalism left to expose the APA's return to medieval modes of medical reasoning.

[M21] I agree with the claim and concern of the 25% ME Group, who are trying to make the best of a bad proposal, but indeed I also reject the whole proposal.

In fact, while the DSM-I to DSM-III seem to have been more or less based on medical science and to be directed at arriving at somewhat objective diagnoses of the many kinds of psychiatric problems - to my way of thinking, in the end neurological processes, these days often helped by appropriate medicines such as anti-depressives or sleeping tablets - it seems to this psychologist that the DSM-IV and DSM-V are much more about the financial interests and livelihood of psychiatists than they are about real medical science or about effectively helping ill people.

For that is one thing not noted, but quite relevant: The main problem with unexplained diseases is the lack of medicines and cures - but when APA-psychiatrists "explains" one's "disease" as being some form of madness, they have no medicines or cures either. In fact, they insist for the most part that since one is mad, one is not entitled to medicines, and not to health-benefits either, since one is "not really ill", according to their book of definitions, and one will be forced to work or exercise, because that then will do one good, they will say, on what they pretend or stupidly believe to be "scientific grounds", but in fact are wordmagic and devilish presumption: That if the doctor does not know of it, it cannot exist, and that the medical science of the APA covers all there is and will be known in medical science and any other science that may be relevant to medicine.

At which point one has passed far beyond what is moral, medically tenable, professionally correct, legally valid, or humane, and entered deep into the field of medical incompetence, medicalese presumption, and indeed, in some at least, of medical sadism.

Finally, a little note on the existence of madmen, malingerers, and fraudulence that is not part and parcel of psychiatry:

Yes, there are madmen, malingerers, and fraudulent people, and not just in psychiatry (which profession has very many suicides and forced sectionings among its practitioners, as the reader may not know, but is true - and this psychologist's explanation for it is that it is precisely what attracts the lesser gifted and the more wacky, problematic or lazy ones who graduated in medicine, for the really gifted etc. will very probably want to study something more demanding and more scientific, than the mass of falsehoods with a few insights that forms the library of psychiatry so far (**)).

But malingering or madness is not a valid explanation for millions ill for many years, all with similar symptoms, and nearly all without any objective personal interest in being ill or pretending to be ill. That a certain percentage of those who receive dole must have lied about what made them eligible for dole, moreover, is not a problem of or for psychiatry but of policy, and besides, with payments for the dole as they are in the Western world very few people want to live as poorly and miserably as that allows them to live, even if they were healthy.


P.S. This may need some corrections of typos, that will have to be made later. And please note that the real work was done by Suzy Chapman, whose site about the DSM-5 is under the link, and whose site about ME under the last link.

-- September 6, 2010: Supplied some links and small corrections

P.P.S. It may be I have to stop Nederlog for a while. The reason is that I am physically not well at all. I don't know yet, but if there is no Nederlog, now you know the reason.
 

 

As to ME/CFS (that I prefer to call ME):

1. Anthony Komaroff

Ten discoveries about the biology of CFS (pdf)

2. Malcolm Hooper THE MENTAL HEALTH MOVEMENT:  
PERSECUTION OF PATIENTS?
3. Hillary Johnson

The Why

4. Consensus (many M.D.s) Canadian Consensus Government Report on ME (pdf)
5. Eleanor Stein

Clinical Guidelines for Psychiatrists (pdf)

6. William Clifford The Ethics of Belief
7. Paul Lutus

Is Psychology a Science?

8. Malcolm Hooper Magical Medicine (pdf)

Short descriptions:

1. Ten reasons why ME/CFS is a real disease by a professor of medicine of Harvard.
2. Long essay by a professor emeritus of medical chemistry about maltreatment of ME.
3. Explanation of what's happening around ME by an investigative journalist.
4. Report to Canadian Government on ME, by many medical experts.
5. Advice to psychiatrist by a psychiatrist who understands ME is an organic disease
6. English mathematical genius on one's responsibilities in the matter of one's beliefs:
   "it is wrong always, everywhere, and for anyone, to believe anything upon
     insufficient evidence
".
7. A space- and computer-scientist takes a look at psychology.
8. Malcolm Hooper puts things together status 2010.
 


    "Ah me! alas, pain, pain ever, forever!

No change, no pause, no hope! Yet I endure.
I ask the Earth, have not the mountains felt?
I ask yon Heaven, the all-beholding Sun,
Has it not seen? The Sea, in storm or calm,
Heaven's ever-changing Shadow, spread below,
Have its deaf waves not heard my agony?
Ah me! alas, pain, pain ever, forever!
"
     - (Shelley, "Prometheus Unbound") 


    "It was from this time that I developed my way of judging the Chinese by dividing them into two kinds: one humane and one not. "
     - (Jung Chang)

 


See also: ME -Documentation and ME - Resources


P.P.S. ME - Resources needs is a Work In Progress that hasn't progressed today.


(*) An important subject not only for persons with ME, but for anyone that may become subjected to what I must regard as medical and moral malpractice, in many cases, if the DSM-5 will be instituted as planned, in May 2013.

This topic is also of importance to medical doctors in general, for psychologists, for philosophers (of science, especially), for lawyers, and for other intelligent and educated laymen who fear fashionable nonsense, especially when institutionalized and enshrined in a book as dogma that will guide practice.

(**) This is also why the real experience of people is not to be found in books of psychiatry or psychology, and also not in books of neurology or brain-physiology but in... literature and philosophy. One Shakespeare, one Sophocles, one Montaigne, one Hazlitt, one Chechov explain more about what people really are like, live through, may be like than all the texts of psychiatrists laid end to end. (In my experience.)

And while there are decent psychiatrists and a few useful books in it (mostly for medical people) there is no real science of psychiatry and never was: There is mostly ignorance and pretension, and these days, since the arisal of neuroscience, some useful medications e.g. for depressions and for sleep, and also to deal with some kinds of psychoses. (But nearly all of the things that really work in psychiatry were not the inventions of psychiatrists, as it happens.)

Maarten Maartensz

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