Director:Nat'l Inst. of Mental Health will walk away from DSM criteria

[HereSince1628]

that lack biological validity. The director of the US' federal research institute on mental health is nixing the DSM's taxonomy for mental disorders and the approach that created it.

Everyone around mental illness knows that the DSM-5 has generated controversy. The 'professional' debate on the DSM-5 may just have opened a sink-hole capable of swallowing the DSM.

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http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
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...While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology (see below). This approach began with several assumptions:
A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
Each level of analysis needs to be understood across a dimension of function,
Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”2 The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories.

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[TM99]

1. Might be an interesting project,

however, it will likely take about 60 to 80 years before it is at the level of accuracy, assessment, use, and experience to replace something like the DSM.

I do not think it will ever fully explain human psychological behavior to reduce us merely to biology, genetics, imaging, etc.

[HereSince1628]

2. First, I don't think the intent is to discard all of psychiatry and start over,

rather, there is an interest in re-organizing the nosology or groupings of mental disorders to reflect causes rather than symptoms.

For the most part, mental illnesses have over the history of psychiatry been labeled and placed into groups simply on the basis of somewhat shared symptoms, rather than underlying mechanisms of causation. This was unavoidable as underlying mechanisms weren't (and actually remain) uncertain or unknown.

The result of that historic approach was construction of over a dozen groups of mental illness such as developmental disorders, substance abuse disorders, mood disorders, somataform disorders, eating disorders, impulse control disorders, personality disorders, etc.

In the last few years, through the application of molecular biology to mental illness it has become apparent that some disorders placed in different categories used in the symptom based DSM actually are associated with the same gene variations.

The basic idea is to form a new taxonomy of mental disorders that uses genetics and underlying shared mechanism to group mental illness into categories that are biologically similar.

The advantage of a such a system would be that biologically similar disorders would likely be caused by problems in similar mechanisms and the disorders would respond to similar classes/types of interventions.

The paradigm that NIMH is moving to envisions mental illness as a hierarchical association of mechanisms. This system begins with genetics endowment, moves through the expression of genes that influence various biological systems that intern contribute to or influence neural modules/function related 'brain circuits' that affect various recognized psychological domains (Cognition, emotions, attractions and aversions, mood etc.).

Within that there is no reason to doubt that a recognizable disorder such as depression will still exist. But what may happen is that it becomes grouped with currently seemingly unrelated illness because of shared underlying biological mechanisms.

It seems unlikely that the new groupings will look very much like the existing groupings--partly because scientists like to leave fingerprints in their disciplines, and nothing does that so much as a reordering of the subcategories considered by a discipline.

However, in a curious in not ironic turn of events, the new domains for research were formed around various groups of symptoms/systems affected by psychopathological processes: Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Systems for Social Processes and Arousal/Modulatory Systems.

[HereSince1628]

3. Second, I somewhat agree that understanding underlying physiology may not capture the entire

breath of psychological influence.

Although my muscles are structured and function exactly like Olympic gymnists, my performance certainly isn't. In addition to genotypic and basic phenotypic variation, I suspect that acquired performance, things learned through exposure and use, is also an important feature of psychological function.

I wouldn't be entirely surprised if it turns out that a brain with normal structure and functioning within physiological norms might also manifest features which are distressing to self or others.

A superficial look at the guiding philosophy of the NIMH project doesn't provide much specificity about where or how mechanisms associated with performance level of acquired features will be located...

[HereSince1628]

4. Boston.com responds:Mental illness still hurts, no matter what you call it

http://www.boston.com/lifestyle/health/blog/inpractice/2013/05/mental_illness_still_hurts_no.html

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... For decades, every medical student purchased one in a series of revisions of the "DSM." Mine was DSM III, which--even if I wanted to lie about my age--places me firmly in the 1980s. The book contains descriptions of dozens of disorders, from schizophrenia to borderline personality to binge eating disorder, each with a menu-style selection of symptoms.

<snipped out criteria table from DSM-IV on depression>

Though this system of diagnosis may seem primitive, it's been felt a superior alternative to no system and its proponents argue that it at least gives clinicians and researchers a common vocabulary and insurance companies a basis for coverage of psychiatric illness.

The DSM's opponents have countered that this system is too subjective, not scientifically valid, and subject to abuse. That abuse can come in the form of mislabeling people as mentally ill (homosexuality appeared in the DSM until 1973) or labeling people in such a way that they are more likely to be prescribed medications. If you have observed that more kids seem now to be autistic, or bipolar--some of that increase is simply from increased diagnosis, guided by the inclusion of these entities in the DSM.

DSM 5 (they've changed over from Roman numerals) is about to be released amid enormous controversy. Many critics, including some psychiatric insiders, feel that the DSM 5 is an even less reliable and more potentially harmful tool than its predecessors. In fact, the National Institute of Mental Health (NIMH) has just announced that it will no longer fund research based on the DSM.

This announcement is nothing short of a cataclysm in mental health. Imagine that you have a child who's been diagnosed with bipolar disorder and is on medication that seems to be working somewhat but which also causes weight gain and puts him or her at risk for suicide. You now have the most powerful scientific organization dealing with mental health (NIMH) at odds with the most powerful psychiatric organization (APA) about whether that diagnosis is valid.

Though the NIMH's bold move will likely be positive in the long run, in the short run it will cause great anguish and confusion for patients and their families, as well as complicating and stalling research funding and insurance coverage for mental illness.

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