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Language in the Introduction and subsections of CSSD definition is open to misinterpretation

The Draft explanation of Somatic Symptom Disorders both in its Introduction and subsections clearly demonstrates the lack of precision and the resulting conflation of two disparate medical phenomenon. In the explanation of Complex Somatic Symptom Disorder some selection of text will show the difficulty:

"The hallmark of this disorder is disproportionate or maladaptive response to somatic symptoms or concerns." Obviously, the word "disproportionate" is a matter of degree or "portion". The determination of degree cannot be entirely objective, and in cases of actual medical conditions, normal patient response varies across a wide range of factors, including personal, economic, occupational, family, etc. circumstances.

"Patients typically experience distress and a high level of functional impairment." Such a statement is perfectly consistent with a number of medically understood illnesses, and therefore in the problematic context of the CSSD criteria can be disorienting and misleading. "Sometimes the symptoms accompany diagnosed general medical disorders..."

"There may be a high level of health care utilization..." No experienced specialist or general physician is unaware of cases in which patients have had to see five or more doctors before receiving an accurate diagnosis—especially with the more difficult to diagnose illnesses. Endocrine, hematological, circulatory, occult pulmonary conditions come to mind.

"In severe cases, they may adopt a sick role." Now the concept of the "sick role" may infrequently constitute a distinctly categorical "role-type" that is pathological and somewhat separable from a real physiological illness. However, in many chronic illnesses, whose symptoms wax and wane in severity—it would be more accurate to say that the person is chronically sick. Undoubtedly, different individuals or even the same individual will adapt or respond variously, with an attitude of courage, hopefulness, worry, or even despair in different times or circumstances. However, to label such common variations as a "sick role" can often be too superficial and facile—a false engagement in type-casting. To be sure, many patients who are chronically ill need intelligent counseling in coping and in modulation of their attitude and emotions. Hopelessness can creep in and assistance is needed—but to label as a psychiatric disorder a normal spectra of physical disorder with emotional and mental sequelae is a distortion. Again, in some cases the viewpoint is accurate, but in too many others a distortion with consequences.

"Some patients feel that their medical assessment and treatment have been inadequate." In some cases, this statement reflects an adequate further description of a psychiatric problem. In other cases, the statement demonstrates a failing in the criteria.

Again, the dual nature of the criteria is reflected in the following wording: "Patients with this diagnosis typically have multiple, current, somatic symptoms that are distressing...
The symptoms may or may not be associated with a known medical condition. Symptoms may be specific...or relatively non-specific (e.g., fatigue or multiple symptoms.)

Note: The classification or facile diversion of fatigue to the psychological realm can be a very medically dangerous undertaking. A multitude of serious medical, and currently poorly understood biological conditions, manifest fatigue as an early and chronic symptom.

"... Such patients often manifest a poorer health-related quality of life than patients with other medical disorders and comparable symptoms." Unfortunately this statement represents perhaps the nadir of scientific thinking in the entire statement, and therefore puts in relief the lack of rigor which proceeds and follows it. Yes, patients with one medical disorder will often have a poorer quality of life than those with another medical disorder.

In the Introduction to this section in the Draft, there is some clarity in attempting to set a line between the pathological and normal response to medical illness: "Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis." But looking underneath the text raises questions: is the diagnosis of fibromyalgia itself uncertain; or alternatively, is the question the addition of CSSM to some cases of fibromyalgia? By what criteria would CSSM be added: what is a within the range of normal varying responses to a chronic illness, and which responses would add a psychiatric diagnosis? The criteria leave these questions open.