a little “o”…

Posted on Tuesday 11 March 2014

Several years ago, I wrote a ten part series called the dreams of our fathers that reviewed the coming of the DSM-III and some of its later history. It starts here. It was my attempt to catchup on the history I didn’t know. The short version is that the psychological theories of the analysts had to go, and the group in Saint Louis who wanted to medicalize psychiatry came to the fore. The architect of the system, Dr. Robert Spitzer, wrote:
    The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors…
    Robert Spitzer, in the DSM-III, p 6.
The system was based on descriptive criteria and hinged of inter-rater reliability [substituting for the elusive validity every wanted]. It was based on the Research Diagnostic Criteria [RDC] developed by Spitzer at the NIMH. Besides jettisoning the psychological formulations, it was designed to make communication between clinicians more standardized and to facillitate research in psychiatry. In spite of Dr. Spitzer’s assurances about parsing these diagnoses between disorders of psychological and biological origin, psychiatry became focused on biology, and the that sorting, or even any attempts disappeared. The DSM-5 Task Force began its life in 2002 with the explicit goal of matching the findings of biological research with the diagnostic system, completing the transition to a biology based system, but that enterprise failed – globally.

The objections to the clinical diagnostic system were that the psychiatric drugs were not specific for any particular diagnosis. The neuroimaging findings and genetic studies likewise failed to map onto the clinical diagnostic groups. There were no biomarkers of any clinical entity located along the way, nor any biological targets that showed syndrome specificity. We might add that the pharmaceutical industry had run out of clones of the two major classes – SSRIs and Atypical Antipsychotics – and was moving away from CNS drugs after a quarter century feeding frenzy.

So on the eve of the launching of the DSM-5, the NIMH announced that it was no longer going to fund research based on the diagnostic entities, but would now focus on it’s own NIMH diagnostic system – not quite yet in existence. [sound familiar?]. It was called the RDoC [sounds like RDC?]. Rather than bring science to the diagnoses, it essentially intends to bring the diagnoses to the known science. Here’s Dr. Insel’s brief view:
    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… 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.” The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories…
    Thomas Insel, in Transforming Diagnosis. April 29, 2013

It’s a move supported by the leaders of the DSM-5 task force and other research oriented scientists, for example in this month’s British Journal of Psychiatry:

by Joanne L. Doherty and Michael J. Owen
British Journal of Psychiatry. 2014 204:171–173.

There is increasing concern that a reliance on the descriptive, syndrome-based diagnostic criteria of ICD and DSM is impeding progress in research. The USA’s major funder of psychiatric research, the National Institute of Mental Health (NIMH), have stated their intention to encourage more research across diagnostic categories using a novel framework based on findings in neuroscience…
There are certainly other explanations for the failure of the drugs or the neuroscience findings to map onto the clinical syndromes. Some are compelling:

  • There’s something wrong with the diagnostic system in the first place. We know that’s true with the most common diagnosis of them all – Major Depressive Disorder [MDD]. In the 1970s, there was something of a growing consensus that Melancholic Depression and the Depressions associated with Manic Depressive Illness were prime candidates for biological research. The genetics were right. The clinical syndrome was unique. There were promising biomarkers [DST, REM Latency]. But with the DSM-III, all clinically significant depressions were lumped together and remain so to this day. So maybe the heterogeneity of the patients in that group dilutes out any possibility of pursuing a biological cause. There are other examples but that one is in the center ring.
  • Maybe our medications are symptomatic medications, not "diaease-specific" at all. This is the concept proposed eloquently by Joanna Moncrieff. The analogy might be digitalis for heart disease. It helps with most kinds of heart failure, but no heart disease specificity is conjured up to explain its effectiveness.
  • And where is the evidence that the majority of patients seen by psychiatrists have something wrong with their brains? When I see patients in the clinic tomorrow, I’m not likely thinking that many of them have brain diseases. The colossal failure of the research enterprise to find anything may be that there’s not anything to find. I don’t believe there’s nothing to find myself, but I think it’s way less than indicated by Insel’s ["Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior"]. The only possible way to even hypothesize such a thing would be to severely restrict what he defines as "Mental disorders."
I would claim that my suggestions that we have a faulty diagnostic system badly in need of a different kind of revision; a simple pharmacopeia of symptomatic remedies; and blinders on with a fixation on the brain over mind and life would be at least as likely as Dr. Insel’s Clinical Neuroscience fantasies in explaining their frustrations. He and his associates have lost touch with clinical medicine already, and are proposing we move even further away, based on little concrete evidence. Putting a little "o" in RDC [RDoC] isn’t going to make this attempt any more effective than the 1980 version.

In Charlie Brown’s version of Occam’s razor

    berit bryn jensen
    March 11, 2014 | 7:37 AM

    “He (dr Insel) and his associates” are likely to inflict even more harm and pain and death as they continue on their quest to force reality to conform to their pet beliefs/hypothesis – firmly centered on the golden calf of big pharma money.
    Change will not come from dr Insel and associates, whether in NIMH, APA or WHO, guarding positions, enjoying their loot. As always change depends on ordinary people helping each other, refusing to be fooled and oppressed, eroding the ground beneath the extortionists.

    March 11, 2014 | 8:03 AM

    “Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior”]. The only possible way to even hypothesize such a thing would be to severely restrict what he defines as “Mental disorders.” ”

    It seems to me there is a facile sense in which Insel’s statement is by definition true, since humans are a biological species with brains that do various kinds of things. The problem of course is this is entirely consistent with social psychological perspectives, which these people do not want to face up to.

    March 11, 2014 | 11:32 AM

    while i am not an MD or a PhD, I do feel that the DSM should contain some descriptive criteria about cognitive deficits that should be apparent in any subject with the said mental disorder.

    i believe these shared cognitive deficits will also have shared deficiencies wrt neuropathology.

    it’s a bit of the chicken and the egg. i feel the DSM will need to be updated much more frequently than now, but the criteria for each disorder should be very precise observations/descriptions of the cognitive deficits. medicine is the only true applied science, and imo neuropsychiatry is truly the

    March 11, 2014 | 11:33 AM

    *truly the jewel of all medical practice. neurosurgery even moreso.

    March 11, 2014 | 12:45 PM

    What the usual suspects are up to:
    Update on Treatment-Resistant Depression
    Supported by an educational grant from Otsuka America Pharmaceutical, Inc.

    March 11, 2014 | 4:03 PM

    Gagan, you are scaring me! As far as I am aware (and I’ve studied this a long time), there is absolutely no evidence that what are now conceived as “mental disorders” have any kind of cognitive deficits associated with them. The DSM does not contain these descriptive criteria because they don’t exist. So far, “neuropsychiatry” has been a pretty dramatic failure, at lease if you care about long-term social outcomes like employment, housing, relationships, community involvement, and life expectancy. Neuropsychiatry has, at best, given us some short-term ways to reduce discomfort when we don’t know what is causing it. I regard it more as the stable floor of medical practice, the place where all the crap goes when no one else knows what to do with it.

    As for neurosurgery, I hope you’re talking about removing brain tumors…

    —- Steve

    March 11, 2014 | 4:27 PM

    hi steve, unfortunately you’re misinformed. there IS literature, it is just old and based on measurements of cerebral circulation in the brain.

    i wrote this in a post a few days earlier:
    it’s not new as much as it is a revival of some clinical neurophysiological ideas.
    a lot of their work is lost in the archives or untranslated, but i also suspect the US military has been using these methods for unethical practices:

    essentially you need measurements of cerebral circulation (which requires continuum mechanics) to measure the activity in the brain. it’s been done now with fMRI, and the work above is directly relevant because of the experimental paradigm.

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