The Clinical Picture

When physical illnesses present as psychological problems

How Should Mental Problems be Diagnosed?

Learn About The Controversy: DSM and the Research Domain Criteria.

The Controversy

The elevator dust-up between Jay Z and Beyonce’s sister, Solange, has received much more attention from the general public than the skirmish between the American Psychiatric Association (APA) and Dr. Thomas Insel. Yet, the Jay Z/Solange news concerns only the private conflicts in one celebrity family, while the APA/Insel matter has significant consequences for the future of mental health care.

Dr. Thomas Insel, Director of the National Institute of Mental Health, hopes to find a way to classify mental disorders that is superior to the APA’s current approach. The goal for all of psychiatry is to find better treatments for mental illness.

In April of 2013, just as the APA was about to release its latest revision of the Diagnostic and Statistical Manual (DSM-V) of mental disorders, the NIMH announced that it would be re-orienting funding for research away from studies based on DSM diagnoses. Future grant proposals would use the NIMH’s new Research Domain Criteria (RDoC). nimh-transforming-diagnosis

Sign reads: Warning! Science in Progress
Science -- Always in Progress
By Vera de Kok (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Controversy about the diagnosis of mental disorders is not new. In the 1960’s, Thomas Szaz claimed that mental illness was a myth. Szaz did believe that there were brain diseases (such as syphilis) that produced mental symptoms, but he said that these disorders should not be called mental illnesses. 

Thomas Szas also noted that there were “contemporary psychiatrists, physicians, and other scientists [who held the] view… that some neurological defect, perhaps a very subtle one, will ultimately be found for all the disorders of thinking and behavior.” For Szas, half a century ago, that was a fringe-idea; for today’s scientists it is the reigning paradigm. To quote Dr. Steven E. Hyman, “The term ‘mental disorders’ is an unfortunate anachronism, one retained from a time when these disorders were not universally understood to reflect abnormalities of brain structure, connectivity or function.”

Problems with DSM

The first modern version of the DSM was published in 1980. One important goal was to provide researchers with a standard way to diagnose mental disorders. If everyone utilized agreed-upon definitions, then new findings about a particular disorder could be added to an accumulating body of knowledge about that diagnostic category. DSM has succeeded in this way. Dr. Insel calls the DSM “a dictionary.” It is reliable. 

Now in 2014, the question is no longer whether the DSM is reliable but whether it is valid. In other words, do DSM diagnostic categories sort the varieties of mental problems into categories that are causatively distinct? Do the DSM categories behave as discrete, natural entities? Scientists have been accumulating evidence that they do not.

Clinically, psychotherapists are aware of the limitations of DSM. For example, there are patients who don’t fulfill the criteria for any particular DSM diagnosis but have features of several DSM disorders. Also, behavioral traits vary in the population in a dimensional fashion, and there isn’t a clear distinction between normal and abnormal. These realities are contrary to the general DSM framework.

Biologically also, the evidence is mounting against the DSM schema. For example, there is overlapping genetic susceptibility for altogether different diagnoses such as schizophrenia and bipolar disorder. Also, while it had been hoped that psychoactive medications would be “diagnosis-specific” and provide indirect evidence of a unique biology for each DSM category, it is now clear that these medications are not diagnosis-specific. Antidepressants treat depression and also work for anxiety, for obsessive-compulsive disorder, and, in some instances, for pain.

The DSM diagnoses are no longer considered to be discrete natural entities. So the search goes on for a more fundamental way to define the varieties of mental conditions that we are “heir to.” 

What is RDoC?

Dr. Insel is promoting the Research Domain Criteria (RDoC) for use in research as a step toward finding that more fundamental way to diagnose mental disorders.

The RDoC system is an approach to categorizing objective, measurable information about human behavior. It establishes a matrix, essentially a spreadsheet, with row and column categories. At present there are eight columns, representing different areas of investigation: genes, molecules, cells, neural circuits, physiology, behaviors, self-reports, and paradigm. There are five rows in the spreadsheet, each representing what is believed to be a fundamental domain of behavior: negative valence systems, positive valence systems, cognitive systems, systems for social processes, arousal/regulatory systems. There are sub-domains as well. nimh-research-domain-criteria-rdoc.

Thus, each cell in this spreadsheet contains the intersection of one focus of investigation with one arena of behavior. For example, one cell might be filled in with information about the physiology of “fear” (a negative valence system), or the genetics of “anxiety” (another of the negative valence systems), or the neural circuits associated with “affiliation and attachment” (one of the systems for social processes).

This matrix is a way of organizing data. It is open to modification as research expands our understanding of the best ways to conceptualize human behavior and disease.

The Future

RDoC is already shaping research. And over time, the RDoC approach to research will change the way practitioners organize their clinical observations and their thinking about patients.

But, patients shouldn’t expect to receive a RDoC “clinical diagnosis” any time soon. An evolving DSM has been with us for over 30 years, and shifting away from DSM thinking will not be easy. Our clinicians have been trained using DSM. Insurance re-imbursements have been based on DSM. Research and drug trials, until now, have utilized DSM diagnostic categories.

Like a pair of good hiking boots, DSM has helped us to navigate the trail, but now we notice that our boots have holes. This is what happens to all scientific theories; they take us only so far. Then we find the flaws.

Switching to a new pair of hiking boots is always tough. The old ones still feel comfortable, even when we know they no longer provide good support. It takes work to break in a new pair. It also takes work to integrate new ways of thinking. Even so, it’s worth making the switch.

Barbara Schildkrout, MD is the author of:

Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders

Masquerading Symptoms: Uncovering Physical Illnesses that Present as Psychological Problems

References:

Doherty, J. L. & Owen, M.J. (2014). Review: Genomic insights into the overlap between psychiatric disorders: implications for research and clinical practice. Genome Medicine, 6(29), 1-13. 

Hyman, S. E. (2007). Can neuroscience be integrated into the DSM-V?. Nature Reviews Neuroscience8(9), 725-732.

Szasz, T. S. (1960). The myth of mental illness. American Psychologist15(2), 113-118.

nimh-transforming-diagnosis

nimh-research-domain-criteria-rdoc

Barbara Schildkrout, M.D., an Assistant Clinical Professor of Psychiatry at Harvard Medical School, is the author of Masquerading Symptoms.

more...

Subscribe to The Clinical Picture

Current Issue

Just Say It

When and how should we open up to loved ones?