Somatic Symptom Disorder (SSD): Seriously Stupid Disorder

It's been awhile since I've posted anything, as I have been busy dealing with regular life stuff.

I was having a conversation today with someone who is plodding through the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (We'll just abbreviate to DSM). Since I refuse to spend money on a copy (Waiting for that free ICD-10), this person let me read the Somatic Symptom Disorder (SSD) section in their copy.

*face palm*

Wow, old white psychiatrist people, in what universe do you think this notion is remotely okay?

When I took Psychopathology 101 (graduate level), the class was told that in order to understand the DSM, you need to have some understanding of Freud. I would argue that you need to have both a general understanding of Freud and a general understanding of Emil Kraeplin. Kraeplin is more or less the father of biological psychiatry. In the late 1880's, he identified what are now referred to as the Bipolar Spectrum and Schizophrenia being largely genetic in origin. Unfortunately, he was a German proponent of eugenics and racial hygiene, and so the mental health field ignored him for a few decades.

Freud's primary interest was in the social etiology of mental distress. From early (childhood) social (mother and father) interactions comes a lifelong pattern of emotions and behavior. Per Freud, it was possible for physical symptoms to manifest from emotional difficulties, mainly in the case of people (cough, women, cough) who weren't allowed to express emotions in early life.

When reading the DSM, you can see when Freudian and Kraeplinian psychiatry conflict. SSD is one major conflict. The Workgroup supposedly attempted to remove stigma from "somatization" (The in-your-head term) by acknowledging people can be excessively concerned about their health but still have a medical condition that can be diagnosed. So, it's not "in their head" and often has a biological component - they just worry to the point it's pathological.

Here's the issue:

DSM people, have you been on the Internet lately? Why don't you plunk in "symptom checker" into Google and see what pops up. And when one of the many symptom checkers spits out a possible diagnosis, why don't you find an Internet forum where you can read all about people who had the same symptoms and ended up going a decade until an organ started failing and several joints became deformed, at which point a doctor said, "No, everyone was wrong about this being in your head - you have lupus."

And then you can put in something like "doctor opinions on Internet health information." You can read all about doctors who can't stand it when their patients look up information on the Internet because the Internet has so much misinformation and patients end up asking for expensive and unnecessary testing or taking weird herbal products. There might also be some ranting about fibromyalgia, which seems to come up every time doctors start complaining about patients asking for medical advice.

Wait, doctors complaining about patients looking up medical information because they could misinterpret it? Are those the same patients who were told for years that what turned out to be lupus was "in their heads"? And by the way, anything autoimmune and/or pain related gets the Freudian slap in the medical chart.

Uh huh.

Taking abnormal psychology (undergraduate) years ago, we were warned about "Medical Student Disease." It happens when students read about diagnoses and end up deciding they have one or more when there is no evidence to suggest they do. Um, if medical students (and psychology students) have an issue with reading a textbook in a class, what makes you think the lay public is going to do with information on WebMD?

Uh huh.

Now, let's assume we have someone who has a medical diagnosis, such as lupus. Remember reading about lupus during your Internet search? Lupus is scary. People die from lupus. Often. It's a nasty, nasty disease. What is a reasonable, non-pathological reaction to lupus? Probably reading up on the disease and being concerned about whether or not all medical issues are being addressed, trying to be proactive and communicate with medical providers (Which will be atleast two or three - when you have an autoimmune disorder, you often have a lot of specialists) to ensure treatment is working...oh wait, those can be symptoms of SSD if the person is spending too much time thinking about their disease and too frequently asking for medical advice.

Okay, so the diagnostic criteria for lupus are a tad nebulous. Who cares about those people with lupus? I mean, they end up getting neuropsychiatric symptoms and chronic pain, screw 'em.

How about HIV? What is a reasonable, non-pathological response to being diagnosed with HIV? At any point are you going to diagnose someone with HIV with having an excessive preoccupation with their disease?

Uh huh.

Look, I'm actually supportive of identifying the biological aspects of psych diagnoses. I'm also very supportive of more research on how the brain works and how the brain reacts in times of stress. People are biological, fleshy sorts of things in the same vein as the cat sitting next to me as I type. Stuff happens all throughout the body when watching a funny movie, playing in the snow, being laid off from work, and when living with a medical condition. But just because there are biological goings on in the body doesn't mean someone's emotional response is disordered, no matter how intense the response may seem. And just because someone has an intense emotional response doesn't mean they have problems with emotional regulation from childhood.

Getting sick is scary.

Don't Feel The Burnout

I keep fish. They are my pets. They stare at me when it's their dinner time. They like low light and hiding places. I change their water regularly and they are fed fish flakes. The fish like hiding around this cute little plant. They also like being able to dig in the sand. People tell me I'm a good pet fish owner. I just tell them I pick fish that are hard to kill.

There are several things that make it easy to get burned out when you're in the mental health field. Lengthy education (My Master's program requires 60 credit hours, which of course is a drop in the bucket compared to doctoral programs or medical school/residency), long hours, more education (CEU's and trainings on specific therapies), business expenses, funding cuts from The Powers That Be, managed care, and well, people. Working with people is tough, especially if you like them.

What makes mental health work especially rough is that it's hard to escape. The media is filled with frequently inaccurate portrayals of interventions and people with x, y, and z issues. Read The New York Times, and there will be some criticism of the DSM or something about a newly approved medication or the latest person who fell through the mental health system cracks and killed someone as the result. You might have a friend who wants you to diagnose their ex with something because "He clearly is a sociopath." Flip through a magazine while waiting to get your hair cut and voilà, there is an ad for Pristiq.  

Oy.

I've heard mental health workers say, "What do I do about burnout?" Well, you make time to do something that has nothing to do with mental health (other than your own). I've experienced The Burnout, both in work and in school. It made me an extremely unpleasant person and ineffective worker. I had to learn that time set aside wasn't just the movie I watched or going to a yoga class. It was a mental space, and it's not a space that is easily maintained.

Part of my mental space is taken up by those fish I mentioned. The fish were purchased from a breeder in Oregon, who sent them to me by second day UPS Air - my daughter likes to talk about "the fish we got in the mail." Their "grandparents" were (legally) caught out of Africa's Lake Malawi by the breeder. They can live up to 10 years, and they were three months old when they joined the household. The little plant is supposed to flower underwater when it gets bigger. So yes, I make it a point to keep my fish alive and no, not all aquarium fish come from Petco.

It seems to work. I guess some of my mental space needs to be occupied by something that isn't human.

Life's Instruction Manual

Congratulations. You are now eighteen years old and possess this text, Life's Instruction Manual. Some of this information will be review, but some you have never heard before. The table of contents is below. You have until 12:00 AM to have the book memorized. 

Table of Contents

(In No Order of Importance, Since You are Required to Remember Everything by Tomorrow Anyway)

Chapter 1: Paying the Bills

1. Viable Employment Options: Money Laundering, Drug Trafficking, Stripping, and Porn are Not Included. 
2. Job Searching.
1. How to Not Act Like a Jerk at a Job Interview.
2. Fast Food: You Often Get an Employee Meal.
3. The Temp Agency: Friend or Foe?
4. Putting Out a Shingle: Sorry, Business Skills Are Not Included In This Guide.
3. Where to Store the Cash.
1. The Advantages and Disadvantages of The Bank of Your Mattress.
2. A Real Bank vs. a Credit Union.
3. Cash, Check, Charge, or Debit.
1. Don't Overdraw. Just Don't. 
4. Pay Your Bills On Time. 
5. Taxes.
1. Saving Money on Filing. 
6. Cars: Drains Bank Accounts, Usually Necessary in America.

Chapter 2: Minimizing Disease

1. Exercise: You Can Do It In Your Apartment. 
1. Yoga, Weight Lifting, and Ironmans: Only Good if You Know What You're Doing.
2. Diet: Ramen Noodles Will Not Sustain You for Long Periods of Time.
3. The Doctor:
1. Free Clinics, University Laboratories, Your First Aid Kit, and the ER: The Providers for Medicaid Recipients and the Uninsured.
2. Ice Packs and Heating Pads: Literally the Most Useful Tools in Pain Management.
3. Making the Most of Your Five Minute Physical.
4. Mental Health: Yes, Brains Hurt, Too.
5. Alternative/Complimentary Medicine: Eh, Whatever Works.

I could keep going with a table of contents for a how-to on basic living, but that would take too long and would probably bore everyone who will view this blog entry. But you see where I'm going.

I still remember the first few days after my daughter's birth. Newborns don't know much of anything, but the most striking thing was that she didn't even know how to eat. Of course she had the instinct of, "Hey, this smells like something I should put in my mouth", but she didn't know the most effective way of eating or how her crying resulted in food. Someone who is a few minutes old doesn't know that crying is supposed to get a response - the cry is out of confusion or pain. Babies learn to use crying to communicate as time goes on.

People don't come out knowing anything, but they learn over the years by instruction from adults and imitation of what they see. There is a set of rules that kids are taught, often through mowing lawns or babysitting in return of money, setting aside time for homework, and being prompted to say please and thank you. Discipline, work ethic, and etiquette are the result. The basics.

Here's the problem: some babies aren't fed when they cry. There might not be money to give to a kid for an allowance or in return for chores. A school system might ostracize a kid because they aren't the right race or don't learn the right way or simply the teachers are underpaid and burned out and they don't have the means to be the educators they hoped to be. Not all kids learns "the basics." No one is handed a book called Life's Instruction Manual. We get what we get growing up, and then it's trial and error in adulthood.

We all have the responsibility to take care of ourselves physically and emotionally. But what happens when all of our knowledge of the world is rooted in abuse, poverty, and prejudice? We would need a modified frame of reference. Unfortunately, society isn't exactly set up to help with that.

What Makes That Orange Different Than The Others?

My husband and I have finally gotten around to watching Orange is the New Black. If you haven't heard of it, it's loosely based on the memoir of a woman who went to prison for around a year due to being involved in a drug cartel shortly after college. She stopped being involved, ten years goes by, and then she is named as an accomplice. The statute of limitations was not over, and she was advised to plead guilty and serve time.

In the series, the main character Piper (based on the author) appears to be treated with more respect than the other inmates by Sam, an officer and counselor. Sam seems to have clout in managing the prison. We haven't finished the series, so I don't know how their relationship plays out. After watching the fourth episode, my husband asks, "Why does Sam favor Piper? She's an inmate, too."

The show is sensationalist, but the general social dynamic reminded me of what someone might find in some mental health settings. This is how I explained the Sam/Piper phenomenon:

"Imagine you work in a mental health setting. All day long, you interact with people who yell at you, use drugs, ignore your recommendations, and come from an environment that is socioeconomically disadvantaged. And then, every so often, there is that one person who comes to your office that seems a little like you. They have some sort of education, do what you ask, make polite conversation, are of a socioeconomic class similar to yours, and may even be the same race as you. You click with them. It makes you feel like you're actually making a difference because they seem to be doing well in the grand scheme of things."

Made sense to him.

Behavior occurs as the result of circumstance. In most situations, people have legitimate objections to what goes on in their environments and the recommendations they are given by mental health professionals. Do people always use strategies that are effective and not harmful? No. If people were always skillful and rational, I would not have a career. Some folks go to extreme ends to meet their needs, but at the end of the day meeting needs is what we all do.

I have witnessed the scenario I described above on more than one occasion in multiple health professions. I don't think providers do it on purpose in general, rather they do it unconsciously. Everyone gets along with some people more than others, usually people who have things in common. It's normal. I think the key for professionals is to be mindful of how we act towards the people we work for (The people we serve), and find ways to assist in differing needs as opposed to assuming what works for one person works for everyone.

My generalizations and opinion.

The Triune Mindfulness, Part Unus

The interest in mindfulness-based therapies, a.k.a. third wave behavioral therapies, is "The Thing" in the mental health world right now. For those new to mental health theory, third wave behavioral therapy usually refers to types of therapy that incorporate mindfulness into making changes in thoughts and behavior. Insight into the past and feeling some sort of emotional resolution (catharsis) isn't required, and you're expected to sit upright and look in your therapist's direction, regardless of whether or not there is a couch.


A question that repeatedly comes up is, "What is mindfulness?" Fuzzy responses ensue, usually along the lines of positive lifestyle changes and a sense of mental peace. The next question that comes up is, "How is mindfulness utilized in mental health treatment?" More fuzzy responses. "So how exactly do people learn to change, isn't that what therapy is about?" Fuzz.

Alright, some people give great responses. However, I can see where people get confused about this mystical thing called mindfulness. When practitioners talk about mindfulness in the West, they're talking about three different concepts at the same time: Eastern mindfulness, Western mindfulness, and Western mindfulness used with the intent to improve mental health.

For our first segment, we're going to talk about the exercise commonly associated with mindfulness, meditation:

Meditation is the structured practice of being mindful. One sets aside time to focus on the act of mindfulness, which is typically defined as "Being in the present moment, without judgment." The purpose of meditation is to practice being mindful so that one can implement their mindful abilities during the rest of their waking hours. If you want to know a potential reason why meditation doesn't have all of those awesome benefits people talk about, it might have something to do with failure to translate those skills into "real life."

You can meditate in a chair, sitting on the floor in various positions, laying down (Think "corpse pose" in yoga), staring at candles, visualizing thoughts as bubbles popping, counting, using beads, and probably a slew of other methods I am not aware of. Styles of meditation have traditionally been associated with different sects of South and East Asian religious traditions, but people in the West often pick a style based on what feels natural versus one based on faith.

Oh, that "Being in the present moment, without judgment" thing? The definition of that phrase differs somewhat between Eastern and Western renditions of mindfulness. It generally means to experience the moment without making value judgments.

I made up a guided meditation exercise two seconds ago to illustrate "being in the present moment." Here it is:

Imagine you no longer have words to describe what you are thinking, feeling, doing, or sensing. You no longer introspect, that is, think about yourself. Because there is no "you" to think about, there is no past or future in your mind. You are neither good nor bad, smart nor stupid, beautiful nor ugly, worthy nor unworthy. You are void of description. All you are is your body, and where it is located. Because you are a body, you have the ability to smell, feel, hear, and experience emotions. As you are sitting here, you are welcome to take note of your senses and your feelings. However, avoid placing words on these sensations. You do not think in words. Of course it's okay if you start to think in words during this time - just let the words drift off. Do not pursue them. You cannot be good or bad at this exercise. This is not an exercise of skill. It is an exercise in recognizing that nothing is permanent.

Pop a Pill Culture: The Best Thing Since Sliced Bread

I live in a house that was built in the early 1950's. It's one of the "ticky tacky" houses built in response to men returning from war. The houses on my street have the same architecture, right down to a picture window with a view of the front lawn. It's obvious there were two or three models to choose from on my street: some have garages and some don't, some have a maple tree out front and some don't, and so on.

From time to time I think about what it must have been like in the 1950's. Years of fear, anger, and sadness and their affect on families. Women were expected to stop working and stay at home so that veterans could slip back into employment, giving a sense of meaning and validation for the horrific deaths soldiers saw for years on end.

Houses were expected to be impeccably clean. Food preserved and perfect-looking. Striving for childhood and adolescence to be about play and learning instead of factory work and waiting to die in war not long after turning 18. The comfort of perfection and consistency - when someone wakes up in the morning, the safe routine that was established when the war ended will be maintained.

The '50's was also a time of extensive pharmaceutical research. If you plunk "vintage pharmaceutical ads" into a search engine, scans of advertisements promising improved behavior in women, children, and those with psychiatric diagnoses are prominent. You will also find ads promoting weight loss, ending morning sickness, and improving sleep.

There is a history of these claims, but the '50's actually delivered. Though many drugs were pulled off the market, a significant number are still in use today. Generally at lower doses, and not as indiscriminately, thankfully, as taking amphetamines to control pregnancy weight and almost putting someone into respiratory distress just so a "demented person" would shut up is not remotely okay in any universe.

There is concern that people "just pop a pill" to make their problems go away versus "doing work," like exercising, improving interpersonal relationships, and accepting life has it's problems nowadays. Masking life doesn't make it go away, and I agree.

America has decades of receiving the message, "You don't have to suffer." People are not required to grow their own food, fix their own houses, sew their own clothes, spend all childbearing years pregnant just so a few kids make it to adulthood, personally dig the graves of those they love, and whatever else people needed to do for however many thousand years. That level of suffering isn't the norm. I'm not surprised if people have difficulty tolerating things like work stress, parenting, and grieving. We don't always have the opportunity to practice coping skills because our "first world problems" are considered arbitrary, and we do not teach people how to manage life in order to make up for the teaching moments found in days spent simply keeping oneself alive.

That said, we still have poverty, abuse, war, stigma, and death. It comes in the form of days spent navigating poorly-funded social services to get small amounts of food and medical care, face ridicule for looking or experiencing the world in a different way (Well, that's not new), prolonged deaths with the aid of uncomfortable medical procedures, and unequal pay meant to be kept secret from employees. Those issues are usually minimized and blamed on the person affected. There is no reason to suffer - if you are suffering, you are doing something wrong.

Pills don't make suffering go away. They don't make being discharged from hospitals too early because insurance won't pay out any less harmful. They don't make death less tragic. They don't take away shame from doing work considered of little value to society. They don't take away loneliness, sadness, and anger (Unless we're talking near toxic levels of injected Thorazine, in which case you're probably unable to sit up). They don't take away fighting in marriages or mourning the loss of a child to anencephaly. There is question whether or not psychiatric medication for some of life stressors even has an impact on emotion or thinking. For those who experience a benefit, pills at best are a tool to help focus navigating the problems found in Western life.

Whatever the cause of strife, people's feelings matter. They are important. People do the best they can every day. I can't look at someone and dismiss how they feel just because it's not something I've experienced. Yeah, we all have the responsibility to keep ourselves healthy. But it doesn't mean someone has to witness genocide in order to experience emotions that are valid. If the solution is pills, then so be it - that is where they are at in the moment, and that is where we meet them without moral judgment.

(As an aside, people rarely finish their antibiotic prescriptions. Are those accused of the "pop a pill" even taking what they've been prescribed? I haven't bothered to see if there are studies on that. Another day.)

Gosh Darn Those Doctors, or, A Problem with the DSM-5 Committee That No One Seems to Talk About

The DSM-5 has been out for a few months now, and some articles on the Internet may lead you to believe it's a load of garbage out to ruin what has been known for thousands of years as normalcy. Or at best, a book of codes that allows us mental health people to actually get some money so we can afford light bulbs for our offices and toner for the copy machines we use to duplicate worksheets.

For the those who don't know what I'm talking about - and I wonder if you've only recently gained access to the Internet if that is the true - the DSM-5 is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It's a gigantic book with criteria for psychiatric diagnoses, formed by a committee of psychiatrists in the American Psychiatric Association who have extensive research experience (and maybe one or two psychologists to get some non-physician representation). It's usually called "The DSM." I've also heard it referred to as "The Bible of Psychiatry," despite a lack of detailed portrayals of human nature, potential solutions to human suffering, and divine inspiration. While it was originally written by psychiatrists for psychiatry research (Hence the "Statistical" part of the title), it has now turned into a framework for use by mental health professionals in clinical practice. And insurance companies. And court systems. And school systems. And the Social Security Administration. And..

I haven't read the thing yet. I've read the DSM-IV-TR (previous edition) twice for two different classes - and by twice I mean the whole thing twice. The DSM-5 criticisms in the media sound like criticisms one could make of the DSM-IV-TR: research ranging from solid to questionable, vague criteria with little description of what characteristics look like "in the real world," norms based on people of Western European descent, and a dash of sexism (I'm looking at you, "personality disorder" criteria). I don't plan on reading the thing until I can get a dirt cheap international edition on eBay, and I don't intend to go into great criticism of the latest work until I actually read it.

What I'm going to talk about today is the large number of committee members receiving grants and honoraria from pharmaceutical companies. You know what?

I actually sympathize with the psychiatrists.

Now, pharmaceutical company funding is a problem. Medication has been an effective tool in mental health recovery for many people when used ethically. It was a major contribution to deinstitutionalization and reducing horrendous psychiatric hospital conditions. I don't have a problem with simply the existence of pharmaceuticals or companies that produce medication for a profit. But those little grants influence prescribing Really Expensive Medication, which isn't necessarily anymore effective or tolerable than cheaper medication prescribed at therapeutic (read: not for chemical restraint) doses. Really Expensive Medication tends to contribute to high insurance copays and strapped public mental health entities, and should be reserved for situations in which it is the best choice: someone has had no success with cheaper medications, evidence suggests the Really Expensive Medication is ideal given the person's current challenges, age, sex, etc.

So why do I sympathize with these guys if they are potentially prescribing and diagnosing based on some randomness a drug rep with a medieval studies degree said over sandwiches a few years back as well as a bunch of Pharma grant applications they probably didn't even write?

Well, funding for mental health research, education, and social services isn't stellar. It's hard to do research when you have no money. It's hard to provide education to the public when you have no money. It's hard to implement community programming and medical services when you have no money.

How do we raise money? I don't see any pastel ribbons in our future. Mental health challenges still suffer from stigma, are hard to quantify, and people tend to wonder if they exist at all. Grant funding from nonprofit (and presumably less biased) organizations is limited (I say this as someone who did a stint in fundraising). Why throw money at a nebulous concept, the public cries? And thus Pharma to the rescue.

The idealistic side of me says some of these physicians accept funding from these companies with questionable ethics because they think it is the best means to further our understanding of mental health. They're not going to get enough money elsewhere. Mental health tends to be first cut, last funded when it comes to government priorities. It costs money to do interviews, brain imaging, writing, education, and everything else academic psychiatrists do. Academia doesn't always pay that great, either, and it can take years before one is out of adjunct land after the years of schooling. I think people do the best they can in order survive, and funding is survival for this branch of psychiatry.

That said, why do they put up with the abysmal state of mental health funding? Pharmaceutical grants have produced good at times, but they perpetuate inadequate funding by "picking up the slack" for government entities. Rather than tolerate the current system, could it be better to take periodic breaks from research to focus on advocating for government funding that is on par with funding for other health needs? Psychiatrists are honestly at the top of mental health food chain whether we like it or not, and more of those who are able to advocate need to utilize their acceptance by the government as the authorities on mental health identification and biological treatment in order to put pressure on said government to step up and provide the means to facilitate productive research outcomes.Which should include some more of what those wild psychoneursomethingorother people are doing, light therapy, personality, multiculturalism, and whatever else that could use some of the attention currently occupied by our friends at Pharma.


Rather than cut funding altogether as is current practice, perhaps we should work towards not actually needing current amounts of funding via prevention, education, and providing better treatment based on sound research. Which would initially take more funding, but you have to spend money to make money, right?

I suspect physicians on the DSM committee didn't go into medicine with the intent to become drug company pawns. Again, idealist in me. Maybe it starts with one those dry CME things with GlaxoSmithKline backing resulting in some supernatural entity a la The Ghost of Christmas Future talking about the sky falling if generic lamotrigine is prescribed over Lamictal XR because a 38 hour half-life is just too short, I don't know.

On a final note, other disciplines share responsibility in improving services - not just our friends on the DSM committee. In the spirit of interdisciplinary practice and social justice, all mental health professions should join those already involved in advocacy regardless of their professional identity in order to demand resources to better serve everyone. The more the merrier, right?