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…
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…