1 Boring Old Man

Only Rip Van Winkle would not to know that academic psychiatry, the American Psychiatric Association [APA], and the National Institute of Mental Health [NIMH] have been united in their assumption that mental illness is a manifestation of brain disease since the introduction of the DSM-III diagnostic paradigm in 1980. They were joined along that journey by the pharmaceutical industry, and have adapted the medical specialty of psychiatry to a practice based on that assumption – with help from another industry, the third party carriers. The inconvenient truth that evidence for this position was lacking weighed heavily on them, so in the early days of the new millennium, the APA took the occasion to use the coming revision of the Diagnostic and Statistical Manual [DSM] to settle the issue – a plan introduced in a book by the future chairs of that revision process in 2002 to solidify that position as part of their DSM revision:

A Research Agenda for DSM-V
^{edited by David J. Kupfer, Michael B. First, and Darrel A. Regier}
Copyright 2002 American Psychiatric Association
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In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syn- dromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.

The efficacy of many psychotropic medications cuts across the DSM-defined categories. For example, the selective serotonin reuptake inhibitors have been demonstrated to be efficacious in a wide variety of disorders, described in many different sections of DSM, including major depressive disorder, panic disorder, obsessive-compulsive disorder, dysthymic disorder, bulimia nervosa, social anxiety disorder, posttraumatic stress disorder, generalized anxiety disorder, hypochondriasis, body dysmorphic disorder, and borderline personality disorder. Results of twin studies have also contradicted the DSM assumption that separate syndromes have a different underlying genetic basis. For example, twin studies have shown that generalized anxiety disorder and major depressive disorder may share genetic risk factors

Concerns have also been raised that researchers’ slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disorders. Few question the value of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM-IV entities, to the point that they are consid- ered to be equivalent to diseases, is more likely to obscure than to elucidate research findings.

All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes be- yond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies.

Psychiatry as a Clinical Neuroscience Discipline
^{by Thomas R. Insel and Remi Quirion}
JAMA. 2005 294[17]: 2221–2224.
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^{One of the fundamental insights emerging from contemporary neuroscience is that mental illnesses are brain disorders. In contrast to classic neurological illnesses that involve discrete brain lesions, mental disorders need to be addressed as disorders of distributed brain systems with symptoms forged by developmental and social experiences. While genomics will be important for revealing risk, and cellular neuroscience should provide targets for novel treatments for these disorders, it is most likely that the tools of systems neuroscience will yield the biomarkers needed to revolutionize psychiatric diagnosis and treatment. This essay considers the discoveries that will be necessary over the next two decades to translate the promise of modern neuroscience into strategies for prevention and cures of mental disorders. To deliver on this spectacular new potential, clinical neuroscience must be integrated into the discipline of psychiatry, thereby transforming current psychiatric training, tools, and practices.}

Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders
^{by Thomas Insel, Bruce Cuthbert, Marjorie Garvey, Robert Heinssen, Daniel S. Pine, Kevin Quinn, Charles Sanislow, and Philip Wang.}
American Journal of Psychiatry. 2010 167:748-751.
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^{… Four decades ago, Robins and Guze suggested five criteria for validating diagnosis [clinical description, laboratory tests, delimitation, follow-up studies, and family data], where the goal was specifying prognosis. Reminiscent of the rationale for developing the Research Diagnostic Criteria in the 1970s that led to the innovative DSM-III for clinical use, the question now becomes one of when and how to build a long-term framework for research that can yield classification based on discoveries in genomics and neuroscience as well as clinical observation, with a goal of improving treatment outcomes. As the major federal research agency funding mental health research in the United States, the National Institute of Mental Health believes the time has arrived to begin moving in such a new direction.}

^{The NIMH is launching the Research Domain Criteria [RDoC] project to create a framework for research on pathophysiology, especially for genomics and neuroscience, which ultimately will inform future classification schemes. The RDoC project is intended to be the next step in a long journey, one that continues the process begun in the 1970s of ensuring diagnosis that has both reliability and validity. While the focus of this journey over the past 30 years has been on refinements in clinically based classification, the time has come to lay the groundwork for the next step in this process: incorporating data on pathophysiology in ways that eventually will help identify new targets for treatment development, detect subgroups for treatment selection, and provide a better match between research findings and clinical decision making.}

Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
^{by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.}
American Journal of Psychiatry 168:672-674, 2011.
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^{In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders,we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…}

Research Domain Criteria: cognitive systems, neural circuits, and dimensions of behavior
^{by Sarah E. Morris and Bruce N. Cuthbert}
Dialogues in Clinical Neuroscience. 2012 14[1]: 29–37.
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^{The RDoC framework has its foundation in three postulates.}

• First, mental illnesses are presumed to be disorders of brain circuits.
• Secondly, it is assumed that the tools of clinical neuroscience, Including functional neuroimaging, electrophysiology, and new methods for measuring neural connections can be used to identify dysfunction in neural circuits.
• Third, the RDoC approach presumes that data from genetics research and clinical neuroscience will yield biosignatures that will augment clinical signs and symptoms for the purposes of clinical intervention and management…

New DSM-5 Ignores Biology of Mental Illness
Scientific American
By Ferris Jabr
April 17, 2013
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This month the American Psychiatric Association [APA] will publish the fifth edition of its guidebook for clinicians, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. Researchers around the world have eagerly anticipated the new manual, which, in typical fashion, took around 14 years to revise. The DSM describes the symptoms of more than 300 officially recognized mental illnesses — depression, bipolar disorder, schizophrenia and others — helping counselors, psychiatrists and general care practitioners diagnose their patients. Yet it has a fundamental flaw: it says nothing about the biological underpinnings of mental disorders. In the past, that shortcoming reflected the science. For most of the DSM‘s history, investigators have not had a detailed understanding of what causes mental illness.

That excuse is no longer valid. Neuroscientists now understand some of the ways that brain circuits for memory, emotion and attention malfunction in various mental disorders. Since 2009 clinical psychologist Bruce Cuthbert and his team at the National Institute of Mental Health have been constructing a classification system based on recent research, which is revealing how the structure and activity of a mentally ill brain differs from that of a healthy one. The new framework will not replace the DSM, which is too important to discard, Cuthbert says. Rather he and his colleagues hope that future versions of the guide will incorporate information about the biology of mental illness to better distinguish one disorder from another.

Cuthbert, whose project may receive additional funding from the Obama administration’s planned Brain Activity Map initiative, is encouraging researchers to study basic cognitive and biological processes implicated in many types of mental illness. Some scientists might explore how and why the neural circuits that detect threats and store fearful memories sometimes behave in unusual ways after traumatic events — the kinds of changes that are partially responsible for post-traumatic stress disorder. Others may investigate the neurobiology of hallucinations, disruptions in circadian rhythms, or precisely how drug addiction rewires the brain. The ultimate goal is to provide new biological targets for medication. “We understand so much more about the brain than we used to,” Cuthbert says. “We are really in the middle of a big shift.”

Circularity: There’s a remarkable circularity in this series. It starts in 2002 with a move to finally put the long awaited biological understructure of mental disorders in place. It ends in 2013 with a move to finally put the long awaited biological understructure of mental disorders in place [the continents move faster that the "big shift" we’re in the "middle" of in psychiatry]. The APA spent $25 M on their "big shift" [that didn’t shift]. Now the NIMH and Cuthbert are after a piece of the $100 M Federal BRAIN Initiative for their go at making the "big shift."
Coordination: The second point is that there is an equally remarkable coordination between the efforts of the various groups involved in this story – the APA, the DSM-5 Task Force, the NIMH, Cuthbert’s RDoC, with academia and PHARMA rolling around in the spaces. One has the feeling one is dealing with a Cartel or a Central Planning Committee rather than autonomous entities. These supposedly separate groups are like the Aspens in the Rockies – all connected through their root systems.
Control: Besides operating in unison, there is a surprising level of control in these groups. Almost all the responses come from the top or through some kind of official channels. This was part of Dr. Spitzer’s original complaint with the DSM-5 Task Force – nondisclosure agreements that came close to loyalty oaths. There are only dissenters and non-dissenters, rather than a wide variety of opinions being bandied about and debated.

So do I think it’s a conspiracy? I do sort of think that, but that’s neither here nor there. What I really think is that all these people are so focused on their institutions that they’ve forgotten the reason those institutions exist; that they’re so busy trying to find a future science that they can’t effectively work with the science they have; that they’re so hungry to be just like other medical physicians that they forget there is a reason they’re not [and if they succeed, they’re going to become extinct]; and that they’re being so controlling right now that they’re probably stifling any creativity they might have – running in circles, chasing fads [and funds]. Dr. Robert Shiller, a Yale Economist, is an expert on financial bubbles [falsely inflated markets]. He wrote a book, Irrational Exuberance, describing the behavior that precedes the bursting of a financial bubble. It’s an apt term for the tone and tenor of much that we hear from Academic Psychiatry, the American Psychiatric Association, the DSM-5 Task Force, and Dr. Tom Insel’s NIMH these days [the above]. We used to hear it from the pharmaceutical industry too, but they already heard the bubble burst, and are moving on to other markets…