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.)