Saturday, May 04, 2013

National Institute of Mental Health Abandoning the DSM in Favor of a "Brain Disorder" Model

This morning, Mind Hacks posted an article about the decision by the NIMH to abandon the DSM model for diagnosing mental illness - two weeks before its planned publication date. Undoubtedly, the is a major blow to the American Psychiatric Association (APA), the creators and publishers of the DSM.

This may appear to be a good thing on the surface, since the DSM is considered by most of us in the "trenches" to be little more than a coding guide for billing insurance companies. There is also the issue that the DSM, especially in the 5th iteration, is moving closer and closer to a pure medical model and away from its original psychodynamic perspective.

As much as that seems ludicrous to those of us who work with clients - who sit with them and hear about the abuse and neglect they suffered, or the simple lack of nurturing caregivers - NIMH Director Thomas Insel says the DSM lacks validity and that “patients with mental disorders deserve better.” And by better he means a model that can offer a pill, an implant, or a gene manipulation for every mental illness. In essence, he believes (as he said in his recent TED Talk) that all mental illness is a "brain disorder."

Obviously, this is in complete opposition to the piles of research from the interpersonal neurobiological model, attachment theory, and intersubjective systems theory - all of which demonstrate beyond a doubt that much of our mental illness derives from failed relational needs in infancy and childhood.

Those who were fortunate to have relatively happy and healthy childhoods have the necessary resilience to deal with traumas that arise in adulthood - but those with childhood trauma do not.

Here are the most pertinent sections, in my opinion:
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. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.

That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system. The best reason to develop RDoC is to seek better outcomes.

RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning. Many NIMH researchers, already stressed by budget cuts and tough competition for research funding, will not welcome this change. Some will see RDoC as an academic exercise divorced from clinical practice. But patients and families should welcome this change as a first step towards "precision medicine,” the movement that has transformed cancer diagnosis and treatment. RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders. As two eminent psychiatric geneticists recently concluded, “At the end of the 19th century, it was logical to use a simple diagnostic approach that offered reasonable prognostic validity. At the beginning of the 21st century, we must set our sights higher.”3

The major RDoC research domains:

  • Negative Valence Systems
  • Positive Valence Systems
  • Cognitive Systems
  • Systems for Social Processes
  • Arousal/Modulatory Systems
What this means at the research level is that only research in the domains of neurobiology, genetics, and brain circuits are likely to receive funding in the future. Even the most "evidence-based model" we have, CBT, is likely to be defunded under this agenda. While I am not sad to see CBT get pushed aside, it also means there will be no future research into psychodynamic therapies funded by the NIMH.


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