Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified, 2020, Geraghty and Scott

Extract from Suzy Chapman's submission to APA in the 2012 draft DSM-5 stakeholder review and comment exercise:

https://dxrevisionwatch.files.wordpress.com/2012/06/scdsm5sub7.pdf

"Although the [SSD] Work Group is not proposing to classify Chronic fatigue syndrome, ME, IBS and fibromyalgia, per se, within the "Somatic Symptom Disorders", patients with CFS – "almost a poster child for medically unexplained symptoms as a diagnosis," according to Dr Dimsdale’s presentation [1][2] – or with fibromyalgia, irritable bowel syndrome, chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity may be particularly vulnerable to misapplication of or misdiagnosis with a mental health disorder under these SSD criteria."​

In his journal article Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? [3] Dr Dimsdale discussed the unreliability of "medically unexplained" as a concept and acknowledged the perils of missed and misdiagnosis:

"...On the face of it, MUS sounds affectively neutral but the term sidesteps the quality of the medical evaluation itself. A number of factors influence the accuracy of diagnoses. Most prominently, one must consider how thorough was the physician’s evaluation of the patient. How adequate was the physician’s knowledge base in synthesizing the information obtained from the history and physical examination? The time pressures in primary care make it difficult to comprehensively evaluate patients and thus contribute to delays and slips in diagnosis. Similarly, physicians can wear blinders or have tunnel vision in evaluating patients.1 Just because a patient has previously had MUS is no guarantee that the patient has yet another MUS. As a result of these factors, the reliability of the diagnosis of MUS is notoriously low..."

"Patients present with an admixture of symptoms, preconceptions, feelings, and illnesses. The task of psychiatric diagnosis is to attend to the patient’s thoughts, feelings, and behaviors that are determining his/her response to symptoms, be they explained or unexplained."​

[Extract ends]

And yet Dimsdale, his fellow SSD work group members (which had included Michael Sharpe and Francis Creed), and the DSM-5 Task Force all signed off on SSD - a "catch-all" diagnostic construct with a criteria set that captures patients with "MUS" but is also inclusive of patients with chronic, distressing somatic (bodily) symptoms associated with, or exacerbated by a diagnosed general medical disease or condition, or diagnosed with one or more of the so-called "functional disorders" and "functional somatic syndromes".*

*The SSD work group's framework "...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." [4]


1 Joel E Dimsdale chaired the DSM-5 Somatic Symptom Disorder work group between 2008 and 2012.

2 Presentation on SSD field trials and field trial evaluation, Joel E Dimsdale, American Psychiatric Association Annual Conference, May 2012.

3 Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatr Clin N Am 34 (2011) 511–513 doi:10.1016/j.psc.2011.05.003

4 Justification of Criteria - Somatic Symptoms, published May 4, 2011 for the second DSM-5 stakeholder review.

 

If the advocates of MUS as effectively a psychiatric diagnosis understood the issues raised above they would insist on collecting systematic data on the levels of misdiagnosis and missed diagnoses.

There is the example I regularly give of a friend told her condition was purely ‘functional’ and sent for psychological treatment for severe pain when bending forward following heart surgery. It took eighteen months for her to find a doctor to agree to the simple X-ray that revealed an eleven inch long surgical instrument left in her chest cavity. Alternatively they are the statistics on missed heart conditions in women, because heart attacks in women can present differently to heart attacks in men.

Given the diagnosis of MUS as a (pseudo) psychiatric condition is based solely on absence of evidence and individual physicians’ clinical judgement but without any evaluated coherent symptom set, even if MUS as a psychiatric condition does exist, it is an inherently risky diagnosis. If its advocates understood these issues they should surely want to know how often they are likely to miss other potentially life threatening diagnoses.

[corrected typos]

 

It's so weird reading the comments on the article about Eysenck in Sense about science, they are all nearly in agreement over how bonkers those ideas are and how is it that they were taken seriously at the time.

Those ideas are currently in their golden age, have never been more popular and never had more influence. And they are worse than ever, more devious, more ambiguous, more vague and yet have more power and influence than they ever had. Ideas that belong straight in the 19th century are somehow managing to impair more progress and cause more harm in the 21st century than at any other time.

It's going to be impossible to counter those who say "the experts make stuff up all the time, even when it hurts people" and point at this nonsense. Congratulations on destroying the very idea of expertise.

 

Elevating the politics of personal gain over science never ends well for everyone but the few.

 

https://twitter.com/user/status/1228091134779559936

 

I may now be having nonverbal unhelpful thoughts.

 

If the promoters of this arrogantly bigoted bullshit actually knew (really knew) people like my wife, then the sheer absurdity of this "unhelpful fear avoidance beliefs" crap would be evident. They peddle their opinionated quackery based on complete ignorance and complete disinterest for any truth. They disgust me.

 

Q for the authors - does the journal use copyeditors? Because it seems to be full of uncorrected errors... The table shown in @Tom Kindlon 's tweet is a bit of a mess - it seems to have been cut and pasted from the NHS IAPT document, including page numbers ("17" at the end of one line) and rogue line breaks. I'd be complaining, given how much it costs to publish in these journals!

 

I think that somewhere on that list are about 1-2 things that are even relevant, and still framed incorrectly, the rest could as well be about astrology for all that it is relevant. Literally most of this list has nothing whatsoever to do with the illness.

It's almost impressive, frankly. Consider how science is supposed to be rigorous and to actually manage to bully through into practice nonsense so complete it actually manages to almost be entirely wrong, even largely irrelevant. Now that's the kind of sales talent that sells bulk freezers in the Arctic circle or tiger-repelling rocks in Bengal.

 

It's quite interesting to see how the other conditions in the NHS IAPT competences doc are treated. Fear avoidance, particularly in regard to exercise, pops up in all sorts of unexpected places.

 

A one trick pony and not a very good one.

 

It fails from the start
"Aims: To be able to demonstrate knowlede of evidence-based interventions"

 

Worth a skim, if you have the time/energy:

https://archive.org/details/influenceofrailw00lond/page/n6/mode/2

The Influence of Railway Travelling on Public Health

Published 1862

A report from The Lancet


Facsimile. It can be downloaded as a PDF.

 

In case anyone wishes to retweet some extracts from the paper:
https://twitter.com/user/status/1228705456765448192

https://twitter.com/user/status/1228689745036922880

https://twitter.com/user/status/1228344029080932353

https://twitter.com/user/status/1228088999669116928

More to follow.

 

Interesting as an example of the recklessness of the DSM-5 Task Force and the DSM-5 Somatic symptom disorder work group.

Please see my earlier comments on DSM-5 in Post #21:

https://www.s4me.info/threads/treat...0-geraghty-and-scott.13501/page-2#post-235557


Let us not forget that in the DSM-5 field trials:

(Extract from: Somatic Symptom Disorder could capture millions more under mental health diagnosis, Suzy Chapman, May 2012)

Dx RevisionWatch Post #172 Shortlink: http://wp.me/pKrrB-29B

"For testing reliability of [C]SSD criteria, three groups were studied for the field trials:

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 used synonymously with fibromyalgia).

Patients in the study were required to meet one to three cognitions: Do you often worry about the possibility that you have a serious illness? Do you have the feeling that people are not taking your illness seriously enough? Is it hard for you to forget about yourself and think about all sorts of other things?

Dr Dimsdale reports that if the response was “Yes – a lot.” then [C]SSD was coded.

15% of the cancer and malignancy group met 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 diagnosed illness + Somatic Symptom Disorder.

For the 94 irritable bowel and “chronic widespread pain” study group, about 26% were coded when one cognition was required; 13% coded with two cognitions required."​

- figures significantly higher than those captured by the old DSM-IV Somatoform disorders.

A 7% false positive rate, too, with 7% of the "healthy" control group also captured by SSD, when only one cognition was required.

"The SSD work group's framework "...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]"​

1 Justification of Criteria - Somatic Symptoms, published May 4, 2011 for the second DSM-5 stakeholder review.


Don't have the paper to hand but I think Wolfe et al concluded a similar figure of around 25% of Fibromyalgia patients would meet the very loose DSM-5 SSD criteria.


Dx RevisionWatch Post #172 Shortlink: http://wp.me/pKrrB-29B

"Nor am I reassured that these B (1), (2) and (3) criteria can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have the time for, nor instruction in administration of diagnostic assessment tools, and where decisions to code or not to code may hang on arbitrary and subjective perceptions of DSM end-users lacking clinical training in the use of the manual text and application of criteria."

 

Given that patients with CFS are considered – "almost a poster child for medically unexplained symptoms as a diagnosis," according to the Q & A following Joel Dimsdale’s (chair SSD work group) presentation on the SSD field trial results at the 2012 APA Annual Conference, I think anything the DSM-5 states needs taking with a very large pinch of salt.

 

I can only skim, but the discussions over fatigue and anxiety are nearly the same as today, it's quite remarkable, actually. It's the speed of society, the fast pace on the nervous urban professional, going full-steam ahead at a blazing... 20m/h! So fast, so nerve-wracking.

The people who discuss this seem to think that everyone but themselves is ready to dissemble into a hysterical mess at a moment's notice, from the tiniest frustration. So weird this obsession over how people are looking out the window if the train unexpectedly stops, frightened for their lives, looking for any threat. Rather than, you know, just curious, or bored, or annoyed because they have stuff to do.

I wonder what those people would think of how bungee jumping is something many people do for fun today. Probably some psychoanalysis over how those people actually seek death, or whatever. There is some seriously bad philosophy going on in medicine, a long line to trace back all the way to Sharpe's and Greco's weird "illness without disease" ponderings over important philosophical issues most patients will never think about for a second of their lives.

 

Posts about IAPT and SNOMED CT have been moved to a new thread.