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.

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?