In the musical Guys and Dolls, the character named Adelaide has a psychosomatic cold. As she explained,
The average unmarried female
due to some long frustration may react
with psychosomatic symptoms
difficult to endure
affecting the upper respiratory tract.
Guys and Dolls is a quaint artifact from the 1950s. Nevertheless, the American Psychiatric Association’s Diagnostic and Statistical Manual still gives doctors permission to say, “It’s all in your head” if they can’t immediately figure out what’s wrong with you. An article of mine that was published in the journal Medical Hypotheses says that doctors cannot make that kind of diagnosis without making an error in reasoning. For that reason, I argue that the APA should remove conversion disorder and somatization disorder from the DSM. The fifth edition of the DSM (DSM-5) is due in 2013.
The APA published the first edition of its DSM in 1952. The DSM-I was based largely on the classification system used by psychiatrists in the military and the Veterans Administration. The DSM-II, which was published in 1968, was similar to the DSM-I but included more ideas from Freudian-style psychodynamic psychiatry. By the early 1970s, however, American psychiatry was facing strong criticism from the scientific community as well as from social activists. Many psychiatric diagnoses seemed to be arbitrary and unscientific and could be used for bad social purposes. In response to this criticism, the APA appointed a task force in 1974 to revise the DSM. The APA published the DSM-III in 1980.
One of the task force’s goals in writing the DSM-III was to make the process of psychiatric diagnosis more scientific. Another purpose was to make sure that a diagnostic label like paranoid schizophrenia meant the same thing in the United States as it did in other countries. To achieve these goals, the task force decided to base the diagnoses in the DSM-III on plain-language descriptions of the patient’s symptoms and signs of illness. In other words, psychiatrists were supposed to base their diagnoses on what they could really observe, not on what they imagined was going on in the patient’s subconscious.
Unfortunately, the APA kept two of the diagnoses that break this rule: conversion disorder and somatization disorder. They appeared in the DSM-III and DSM-IV. They are likely to appear in DSM-5, which is due to be published in 2013. These two diagnoses mean that the psychiatrist thinks that the patient’s physical symptoms are the result of some psychological problem. However, the psychological problem might not be something that anyone can observe. It might not even exist. If the symptoms look like symptoms of a neurological disease, the patient gets the diagnosis of conversion disorder. If the symptoms look like some other kind of problem, the diagnosis is somatization. As I explain at length in my article in Medical Hypotheses, there’s no valid way to establish the cause in these cases. Thus, doctors can’t make these diagnoses without making an error in reasoning.
Conversion disorder and somatization disorder are wastebasket diagnoses that doctors use when they can’t figure out what is really wrong. Doctors diagnose conversion or somatization disorder when the patient’s symptoms seem genuine but the doctor can’t explain them. These diagnoses are the doctor’s way of saying “You are mentally ill” instead of admitting “I don’t know why you are sick.” This kind of fake diagnosis is obnoxious, unproductive, and in my opinion unethical. It has no place in medical practice and should be deleted from the DSM.
Instead of dismissing symptoms as psychosomatic, doctors should work on improving their ability to make correct diagnoses. In particular, they need to learn to listen better to their patients and to do a better physical examination. Often, the vital clues are right there in the examining room. If the patient has any mysterious chronic illness, the patient should be referred to a registered dietitian for an elimination diet protocol. A low-fat, high-fiber diet that excludes all animal foods and a few of the most commonly troublesome plant foods (such as wheat) can often solve the problem.
Why are women far more likely than men to be told that their illness is “all in their head”? There are two possible reasons. One is that the autoimmune disorders that are hard to diagnose are far more common in women than in men. Another possible reason is sexism. Even in the 21st century, some medical doctors evidently still believe that “The average unmarried [or married] female/basically insecure/due to some long frustration may react/with psychosomatic symptoms/difficult to endure.”
Update: I forwarded a copy of my Medical Hypotheses article to Dr. Allen Frances, who chaired the committee that compiled the DSM-IV. He agreed with my analysis. Nevertheless, those diagnoses are included in the DSM-5. I am hopeful that they will excluded from DSM-6!
Although I take issue with somatization and conversion disorder, I think that the APA’s classifications for the personality disorders make a great deal of sense. I explain them in detail in my book Don’t Feed the Narcissists! The Mythology and Science of Mental Health.