One of the chairs of the current edition of the DSM–IV, commenting in a recent issue of the British Medical Journal, warned that at least one of the included psychiatric disorders, Somatic Symptom Disorder, "may result in inappropriate diagnoses of mental disorder and inappropriate medical decision-making." The key point on which it appears he hung his comment is that this classification no longer requires that the disorder be "medically unexplained." Knowing as little as we do about many areas of medicine, especially those that are in the brain, autoimmune and rare genetic disorders, we can see how easily this may lead to a misdiagnosis of a psychiatric disorder. I once heard of a man who was diagnosed with Major Depression and placed in a day treatment program until he was finally seen by a cardiologist who indicated he has severe cardiac problems, not depression, that caused his fatigue and surley temperament.

While I was writing a continuing education module for healthcare professionals, I came across a voluminous quantity of material in the literature which pointed to problems in psychiatric diagnosing when there was, in fact, a medical disorder. In fact, one article which I read, indicated that the rarity with which psychiatrists perform any type of medical exam to rule out a medical basis for symptoms, was astonishing. In fact, when I worked at several psychiatric hospitals it was common for the staff to separate out the "medical doctors" and the psychiatrists as though both of them were not medical doctors. It was a rather curious thing, but I came to accept the language of the wards.

The physician who  commented in the BMJ on this disorder, Dr. Allen Frances, had support for his concern from even the study that was done for the DSM – V  which found that 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia  and 7% of healthy people had a "very high false positive rate."  Anyone in the healthcare area or consumers of healthcare services should be concerned  by these findings and should also remember that before any psychiatric diagnosis is made all other physical disorders must be discounted. If we don't know of a physical disorder (because research hasn't found it yet) should we be treating for psychiatric disorder? Should we be giving people medications that may cause a variety of problems? Should we in fact be medicating at all as a first attempt to alleviate the problem?

 Are you aware that hypertension can cause something that will be misdiagnosed as Alzheimer's or dementia? Do you know that diabetes and cancer can cause  (not as a psychological reaction) depression and that, in fact, it may be an autoimmune disorder or an infection that may be causing depression? Should a psychiatrist be treating depression when the person has an undiagnosed autoimmune disorder, cancer or diabetes? I have also seen this happen and I was told by a highly respected physician in a medical school that one man had spent years in a psychiatric hospital with undiagnosed diabetes. Another man was having incredible headaches which they assumed were a result of stress or his inability to handle problems in his life. Fortunately, this physician asked a simple question and it was, "Has your hat size changed?"  It had and the man was found to have had a rare form of undiagnosed gout.

It was Dr. Francis' opinion  that, "Clinicians are best advised to ignore this new category. When a psychiatric diagnosis is needed for someone who is overly worried about medical problems, the more benign and accurate diagnosis is Adjustment Disorder." Words well spoken and wise to follow.

I said that I would make a comment or two on the coding system that is used in the DSM. These codes are universally accepted, or I should say accepted in the United States, and used not only for purposes of indicating the diagnosis and several aspects of the disorder but for one other highly important thing; insurance reimbursement. The insurance industry depends on these codes to make a determination regarding whether or not payment will be issued for treatment of the coded disorder. There is a running joke in the medical community that relates to this.

When a  physician or a psychiatrist manages to have all or mostly all of their patients' diagnoses codes accepted for payment, the comment is usually made by their peers, "He/she knows how to code." I believe you will understand what this means without my going on at length regarding coding. Sometimes, especially in the case of family therapy, the mother will, because of this insurance reimbursement difficulty, be seen as the "IP" or the "identified patient." This ensures that someone in the group does have a diagnosable disorder and requires treatment for it.  I'm sure this is not the only example that someone in the medical field might give to you and it doesn't have to be contained to the field of psychiatry.