IAPT requests addition of DSM-5's Somatic symptom disorder (SSD) to SNOMED CT for use in Data Set v2.0 to replace "MUS - not otherwise specified"

I have today alerted a mailing list of UK and international clinical psychologists, academics, social workers and mental health advocates that I am member of, some of whom had been involved back in 2010-2013 in organising petitions, position statements, discussion platforms and commentaries opposing DSM-5 and (amongst other new disorders) DSM-5's Somatic symptom disorder.

 

He's wriggling out of giving an opinion on the potential embedding, via the back door, of DSM-5 disorder terms into the NHS:


https://twitter.com/user/status/1229782974637449218

 

I like the idea that most GP's live in the real world. What world, I wonder, does he inhabit, and is it the same one as his patients?

 

https://twitter.com/user/status/1229791170525564936

 

https://twitter.com/user/status/1229820247869415425

 

https://twitter.com/user/status/1229830792030937089

 

https://twitter.com/user/status/1229873530294226950


https://twitter.com/user/status/1229876096008626176

 

Fabulous policing, as always.

Can we clone you? You guys need a team.

 

Photo by Annie Spratt on Unsplash


Mmmm. The first one didn't turn out too badly...not too sure about the second...

 

https://twitter.com/user/status/1230109052987944960


https://twitter.com/user/status/1230110028100784128


https://twitter.com/user/status/1230115339528286208

 

From 2013:

PDF: http://bit.ly/2T37TpR


RCPsych/RCGP Working Group on Medically Unexplained Symptoms

Notes of the meeting held on 7 November 2013 at Wonford House Hospital, Dryden Road, Exeter EX2 5AF


Present
Dr Simon Heyland, Consultant Psychiatrist in Medical Psychotherapy, joint chair
Dr Susan Mizen, Consultant Psychiatrist in Medical Psychotherapy, joint chair
Dr Julian Stern, Consultant Psychiatrist in Medical Psychotherapy
Dr Amrit Sachar, Consultant Liaison psychiatrist – by phone


1 Notes of last meeting
The notes of the last meeting were approved as an accurate representation of the discussion with the following amendment:
The purpose of meeting needed to emphasise that this was a joint venture between Liaison Psychiatry and Medical Psychotherapy Faculties and the RCGP.


2 Matters arising
2.1 Group name
Members discussed whether the group should be renamed SSD (DSM V). It was agreed that MUS had a higher profile nationally and the current name should be retained.

2.2 Training
Members agreed that the group should focus on training for doctors rather than other professions as this is a medical College based initiative.

3 Actions
• Dr Sachar sent Dr Heyland an email with information about medical student training on MUS. (Action: completed)

• Dr Sachar sent Dr Heyland the survey on MUS treatment in IAPT. (Action: completed)

• Dr Sachar had circulated poster presentation re IAPT training.

• Dr Sachar identified a similar piece of work done by Peter Trigwell and would ask him if it could be shared. (Action: Dr Sachar)

• College Report 152, The Management of Patients with Physical and Psychological Problems in Primary Care has been circulated. (Action: completed)

• Dr Heyland to ask Professor Chew Graham about outcomes following the publication of CR152. (Action: Dr Heyland)

• Dr Hashmi to look for a Liaison specialty trainee to undertake a survey of MUS services nationally (Action: Dr Hashmi)

• Inviting colleagues from the medical and surgical Royal Colleges. It was decided that this should be done after the initial three meetings had taken place and the scope of the work had been decided and endorsed by respective Executive Committees. (Action: None required)

• Dr Neil Deuchar, RCPsych commissioning lead had been in conversation with Dr Turner and advised that Professor Sue Bailey, RCPsych President should be made aware of this group so that it could be taken to the Academy of Royal Colleges. Professor Bailey is highlighting the importance of primary care in terms of long term conditions and frequent attenders. Dr Turner and Dr Heyland to contact Dr Deuchar about how best to this raise this with Sue Bailey. (Action: Dr Heyland and Dr Turner)

• The group discussed speaking to Peter Aitken, Liaison Faculty Chair and Kevin Healy, Medical Psychotherapy Chair before taking any paper from this working group to Sue Bailey. However the timescales were short as the paper might be put together in early December.

• Dr Heyland and Dr Mizen to draft a joint position statement before the next meeting. This would be circulated to the rest of the working group for comments with a view to arriving at a draft paper by the end of the calendar year. Dr Sachar suggested that a briefing containing the main points should be signed off on 13 December as Professor Bailey’s timetable might be more urgent. (Action: Dr Heyland and Dr Mizen)

• It was noted that the Liaison Faculty were focussing on workforce and development and MUS would be a work stream within this.

4 Date of next meeting
• Friday 13th December, 11am-1pm, RCPsych, London

[Possibly more of these meeting summaries to follow]

 

From 2013:

PDF: http://bit.ly/3c6fRYe

RCPsych/RCGP Working Group on Medically Unexplained Symptoms (MUS)

Notes of the meeting held by teleconference on 13 December 2013

 

Here speaketh the emperor of byzantium.

Its like he is Henry the 8th...

"Do not listen to those other pronunceres of faith I have the word of god myself all truth must be filtered through myself and my pronouncements"

 

Presumably also he realsies that ME by definition needs a specialist to diagnose it and not a GP. Or even a series of specialists as it is claimed to be to a diagnose of exclusion and is he claiming that "GPs rightly so ignore the DSM the and the APA".

If so should other physicians also ignore them like psychiatrists. What does he even mean?

 

The files are not prepared yet, but there are references to Prof Wessely in the minutes of the RCPsych/RCGP Working Group on Medically Unexplained Symptoms (MUS) meetings on

16 May 2014

and

26 September, 2014

I'll drop the extracts here:


16 May 2014


(...)

2.4 Meeting with RCPsych/RCGP College Presidents
The meeting with Dr Baker and Professor Wessely would be taking place on 16 July. Dr Mizen and Dr Heyland would attend on behalf of the working group. Imran Rafi from the RCGP and Chris Fitch from the RC Psych were also attending. It was noted that there was no RCGP member of the working group attending because the group was yet to be formalised within RCGP structures. Professor Chew-Graham agreed to take this forward. (Action: Professor Chew-Graham)

(...)
2.9 Meeting with Royal College of Physicians President
Dr Richard Thompson had indicated that he was willing to meet with the working group though it was unfortunate that the meeting could not be linked with the meeting with Dr Baker and Professor Wessely. It would be arranged once the working group had been ratified by the RCGP. Dr Turner to get in touch with the President’s PA. (Action: Dr Turner)


and from:

26 September, 2014:

"2.3 Commissioning Guide
In order to progress the development of a commissioning guide through the JCP MH £2000 had to be found. It had now been agreed that this cost would be split between the RCPsych and the RCGP. Dr Heyland had spoken with Chris Fitch from JCP MH and Chris Gush from the RCGP. A two/three page proposal needed to be submitted by 24 October for submission to the JCP on 31 October. The JCP would decide whether the project would go ahead, make recommendations, and set up an Expert Reference Group. Professor Wessely had said that the BPS should also be involved. The output of the group should be a guide of about twenty pages which the JCP would assist in disseminating. The main target would be CCGs. Dr Mizen and Dr Turner were currently members of the commissioning work stream and Dr Heyland would liaise with them to progress the proposal.

(...)

4. Report back on meeting at RCGP on 16 July 2014
On 16 July 2014 a meeting had taken place attended by Maureen Baker, Chair RCGP, Simon Wessely, President RCPsych, Dr Heyland, Professor Chew-Graham, Dr Turner, Dr Mizen and other representatives of the two Colleges. It had been a productive meeting although they had not received all assurances on RCGP involvement that they sought. An important outcome was Simon Wessely’s offer of 50% funding from RCPsych for a JCP commissioning guide. Other outcomes:

• Dr Heyland and Professor Chew-Graham would be updating the position statement to submit to Nigel Mathers for RCGP endorsement (actioned).

• It had been noted that there were no plans to update College Report 152 on the ‘Management of Patients with Physical and Psychological Problems’.

• Professor Wessely asked the working group to ensure the BPS were involved with any work and had contacted the President elect, Professor Jamie Hacker-Hughes.

(...)

• Keeping in touch with Dr Baker and Professor Wessely was identified as an action and Professor Wessely would be invited to join any ERG

 

He's saying that the texts in the DSM-5 manual and in the e-version of the manual are written for psychiatrists and allied mental health specialists - not written for GPs. Which is the case. In 2013, the APA planned to produce an abridged DSM-5 intended for GPs - but I don't think that a primary care version of DSM-5 came to fruition (though a non APA version might have been adapted).

And he's saying that the expanded disorder description texts in the WHO's CDDG guidelines: the ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines (aka the "Blue Book") and the (not yet finalised and released) ICD-11 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines are also intended for mental health professionals - not for GPs.

Of which I am well aware. Which is why I replied with:

"I am well aware of that and await release of the ICD-11 CDDG with interest; my point is: since Somatic symptom disorder is defined and characterised by DSM-5 texts and criteria, by what means does IAPT envisage GPs will identify cases of SSD for referral to IAPT?"

and:

"Or is it the case that IAPT intends to borrow/repurpose a DSM-5 term, and have it added to SNOMED CT UK Edition, because it needs a code, and the ICD-11 codes are not available yet and if its request is successful, SSD will be defined in the UK anyway anyone chooses to define it?"

But he appears to have disengaged, now, and he has not replied to this or to several subsequent points I confronted him with. And he's probably miffed that Allen Frances (who chaired the Task Force for DSM-IV and drafted the much tighter DSM-IV Somatoform disorders criteria sets) has been chipping in.

 

I find this rather worrying, too:

"DSM and the ICD mental heslth secrions were designed to be used by mental heslth professiinals."

but I've seen emails from Wessely similarly littered with typos. Can he not be bothered to check what he writes?

 

@Dx Revision Watch

That's why it sound so convulted when he says this

Is he claiming the DSM and ICD are valid in their mental health constructs or not whomever they are designed for?

Is it just the APA and the WHO which is Byzantine?

 

I think he's possibly saying:

a) DSM-5 texts/criteria and ICD-10/11 texts/disorder descriptions for mental disorders aren't designed for GP use.

b) Even if they were drafted for GPs, GPs would ignore them and get their information/guidance from other sources which don't rely on rigid criteria sets (DSM-5) or on ICD-10/11 disorder descriptions, required features etc. which allow for greater clinical judgement.


and this is what bothers me - if IAPT were successful in obtaining approval for insertion of SSD into SNOMED CT UK Edition - will SSD be defined in the UK anyway anyone chooses to define it?

There is no "generic" SSD – it can’t (or it shouldn’t be) defined and characterised anyway that clinicians and service providers decide suits them; there is only one SSD – and that is the DSM-5’s SSD, as owned by APA and as defined by the DSM-5 SSD criteria set. So it should be a standardised disorder concept wherever it is used. (Although both DSM-5's SSD and ICD-11's BDD rely on highly subjective clinical decision making.)

But what IAPT is doing, is seeking to repurpose a U.S. centric diagnostic disorder term, obtain an ICD-10 code for it (via the SNOMED CT UK Edition to ICD-10 map) then use it in NHS England, where DSM-5 is little used, with no indication of how it intends to define SSD for the purposes of IAPT.

Moreover, IAPT appears to have ignored or overlooked the fact that within a few years, there will be a conceptually very similar disorder to the DSM-5 owned SSD, available within ICD-11 and that the ICD-11 BDD term has already been added to SNOMED CT and has a mapping code to ICD-10.

 

That's what is so bizarre. Either the codes via the DSM, ICD, APA etc are not fit for purpose for anyone or how is it he can relate such organisations to a Byzatine process and then say they are best used by mental health professionals?

ie/ HIM

"None of those codes makes sense and therefore are only used by/designed for mental health professionals?"

??????