Yet Another Way the Medically Ill Will Be Misdiagnosed as Mentally Disordered

DSM-IV includes a section called “Psychological Factors Affecting Medical Condition” (PFAMC) in the part of the manual reserved for conditions that may be of interest to clinicians, even though they are explicitly not to be considered mental disorders.

PFAMC refers to the possible psychological or behavioral factors that may adversely affect a medical illness or interfere with its successful treatment. Some examples-PFAMC might be coded to describe

• someone’s stress precipitating a stroke
• a patient’s noncompliance with treatment
• Type A personality traits that are a risk factor for heart attack
• a sedentary lifestyle predisposing to obesity
• unsafe sexual practices

The idea is to identify a problem, not diagnose a mental disorder. The whole concept of PFAMC and its placement in the manual is that it is not a mental disorder. Clearly, it is definitely not mental illness to feel stress or to disagree with treatment or to be high-strung or to be a couch potato or to be promiscuous. We all do things that are unhealthy-that doesn’t mean we are all mentally ill.

DSM-5 doesn’t see it that way. It has moved PFAMC from the back of the book (where it is not a mental disorder) to front and center in the chapter on Somatic Symptom Disorders (SSD) (where now it will be a mental disorder). The only explanation offered by DSM-5: “We have advocated moving PFAMC from its obscure place in the back of prior DSM editions into the Somatic Symptom Disorders chapter.”

This makes no sense and will further pathologize the medically ill (including children) by giving them yet another opportunity to be stigmatized with an inaccurate and unnecessary diagnosis of mental disorder.

I can think of only 2 possible explanations for the otherwise unaccountable inclusion of PFAMC within the ranks of the mental disorders:

(1) This is a conscious decision to increase the diagnosis of mental illness in the medically ill-yet another example of DSM-5 diagnostic imperialism; or
2) The new placement was a simple and honest error made by a DSM-5 SSD Work Group that did not know the significance of what it was doing.

Neither is reassuring. We have previously discussed how the SSD Work Group has also burdened the medically ill with the decision to introduce a remarkably inclusive SSD that will mislabel as mentally ill many people who are just physically ill.

This is a parlay of really bad ideas. It is burden enough having a medical illness. By piling on fake psychiatric diagnoses, DSM-5 just adds insult to injury.