1 Boring Old Man

The New Criteria for Mental Disorders
New Yorker
by Maria Konnikova
May 8, 2013

… The director of the National Institute of Mental Health, Thomas Insel, announced last week that the institute would be officially reorienting its research agenda away from the categories in the soon-to-be-published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and toward a new set, the Research Domain Criteria [R.D.O.C.]…

“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.”

In other words, we are still relying on the subjective assessments that lost out to the weight of the case file over half a century ago…

In the intervening decades, however, we’ve developed psychological, biological, physiological, and neuroscientific techniques that have given psychologists unprecedented insight into the mind—advances that the D.S.M.-5 largely ignores. With the R.D.O.C., the N.I.M.H. is now trying to address the growing disconnect between reality—what we now know about mental disorders—and theory…

That sort of dynamism is almost entirely absent from the D.S.M.: not only was the last overhaul almost twenty years ago, in 1994, but the changes between that 1994 version and its 2013 counterpart, however controversial they may have been, are minimal at best. At a time when our understanding of the brain evolves on a nearly constant basis, can we still afford to be tied to a book that changes once every few decades—and refuses to reconceptualize itself in any meaningful fashion?

When the D.S.M.’s approach was conceived, we had to base categorizations on broad observations and one level of data: behavioral. That’s demonstrably no longer the case. In fact, we now know that behavioral data is often at odds with other inputs. Just as a reported pain in the arm can be a radiating effect of a heart condition, a reported psychological problem, like difficultly concentrating, actually be a symptom of an underlying biological or physiological condition. The science has now outgrown the original approach to the point where following such a symptom-based path may undermine the D.S.M.’s original intent. With the introduction of the R.D.O.C., Insel and the N.I.M.H. are trying to ensure that the D.S.M.’s accomplishments evolve with the times, instead of being left behind in a clinical vacuum that hurts research as much as it hurts patients.

Here’s the thing. OUR PATIENTS DON’T MAP ONTO THE DSM-5. The problem right now is that the DSM-5 Task Force didn’t take their decade+ window of opportunity to make the kind of revisions in the clinical diagnostic system that it deserved, that they were assigned. They spent their time trying to turn it into a biologically based system with neither the science to back up the change or any mandate from psychiatrists or the mental health community. Rather than refine our categories into more homogeneous packages of likely candidates [like Melancholia, Catatonia], they took the indefensible position that all mental illness is biological and got nowhere. They proposed a "cross cutting" "dimensional" parallel system but couldn’t bring it off. So we have a DSM-5 that is less the clinical diagnostic system than its predecessor, even less reliable with kappas in the range of the DSM-II. We don’t really know if the neuroscience and genomic information does not map onto our descriptive clinical syndromes is right because OUR PATIENTS DON’T MAP ONTO THE DSM-5 either.

Here’s another thing. This whole RDoC is fine with me. Good think-tank thinking. But it’s irrelevant until it’s relevant, and that’s way down the road, if even then. So it’s the future-think trick. The last future-think is now old hat, passe`. Time to push the next future-think to the fore [like the Soviet 5 year plans]. Tedious.

^{Obviously, not much of what I am saying is new or original. Many science fiction authors have imagined such a dystopia. You can argue that it’s the not the NIMH’s job to consider all the potential consequences decades or centuries away, and you may be right. But I will say this: The risks of biological psychiatry are great, with uncertain payoffs. Directing those billions of dollars to address issues like transgenerational poverty, child abuse/neglect, interpersonal violence, and the housing of mentally ill in jails and prisons, while boring, will almost certainly reduce the burden of mental illness and help make our society a better place.}

^{But the strategy of conducting studies of existing drugs in thousands of patients fails when new drugs are not being invented. So Cuthbert says that the NIMH is very consciously focusing on small studies of new experimental drugs that drug companies have not embraced. The idea is to follow the “de-risking” model that has been successful for disease charities. The best example is Kalydeco, a drug for cystic fibrosis originally developed at Vertex Pharmaceuticals with funding from the Cystic Fibrosis Foundation. Eventually the drug became Vertex’s most important product, demanding lots of resources and generating a high price. The idea is to try to get industry interested in psychiatry again. Changing the diagnostic system, seen as one reason that drugs are failing, is part of the job.}