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.

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.