When Sigmund Freud was in his 30’s, a young neurologist, he began to try to connect what he knew about the brain and what he saw in human behavior. The end of the 19th Century had seen a flowering of knowledge about the brain anatomy, micro-anatomy, and their correlation with the neurological syndromes. He wrote it as a treatise in 1895 he called The Project for a Scientific Psychology. Soon thereafter, he gave up trying to map behavior and psychic phenomena to the Brain, developing instead a system to define the structure of the Mind. Concurrently Emil Kreapelin in Germany and Eugene Bleuler in Switzerland were building diagnostic classifications of the Mental Diseases – primarily the Psychoses. In 1913, Karl Jaspers wrote his General Psychopathology proposing a fundamental distinction among the ¹Brain Diseases, ²Major Psychoses, and ³Personality Disorders:
by MARIO MAJ
World Psychiatry. 2013 12:1-3.
…In this context, the basic heterogeneity of mental disorders should not be overlooked. “Contemporary neo-Kraepelinian American psychiatry … practices as if there were biological commitments to over 300 DSM-defined entities, while the biological model may apply only to a few mental disorders, for instance, “schizophrenia, manic-depressive illness, melancholic depression and obsessive-compulsive disorder”. These recent statements resonate with Jaspers’ classification of mental disorders into three groups — cerebral illnesses [such as Alzheimer’s disease], major psychoses [such as schizophrenia and manic-depressive illness], and personality disorders [including neurotic syndromes and abnormal personalities] — which are “essentially different from each other” and not equally amenable to biological research [those of the third group may just represent “variations of human nature”]…
While Jaspers himself left Psychiatry for Philosophy, his three part system was followed by the American Psychiatris Association’s first Diagnostic and Statistical Manual [DSM] in 1952 with the section on personality disorders built on the ideas of Adolf Meyer who saw them as "reactions" to Life. In the next revision in 1968 [DSM-III], that third section was organized using the psychoanalytic theory.
The DSM-II revision was unpopular from the start, particularly in the Midwest [Saint Louis] where there was a movement to establish a more medical based biological psychiatry [the NeoKraepelinians]. In 1970, Eli Robins and Samuel Guze published Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia laying out their approach to diagnostic validation. Then in 1972, Washington University senior resident John Feighner, under the tutelage of the Saint Louis group, published the Feighner criteria [Diagnostic Criteria for Psychiatric Research]. Robert Spitzer, tasked with the next DSM revision, used the Feighner Criteria as the starting place for his RDC [Research Diagnostic Criteria: Rationale and Reliability], an NIMH/APA project that produced the DSM-III in 1980. The DSM-III was a radical change, organized by phenomenological criteria without reference to etiology – atheoretical. Robert Spitzer lead a further revision in 1987 [DSM-IIIR] and Allen Frances produced rhe DSM-IV in 1994. Both of these revisions were refinements – variations on the DSM-III theme of atheoretical phenomenology.
By the turn of the century, mainstream, academic, and organized psychiatry were focused on psychopharmacology and neuroscience research – what had formerly been called Biological Psychiatry. David Kupfer and Darrel Regier set out in 2002 to produce a DSM Revision with the clinical syndromes keyed to biologic parameters – a paradigm shift. But by 2011 after a $25M effort, Kupfer and Regier had to announce that the attempt had failed [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5]. The biological correlates just hadn’t materialized. In the quest for the big shift, they had not done much revising and the changes they did make had been heavily opposed by both Drs. Spitzer [DSM-III & DSM-IIIR] and Frances [DSM-IV] and many others. Then the Field Trials were disappoimting with Kappa values in the range of the DSM-II. So the DSM-5 Revision was released in a cloud of controversy. One conclusion clear outcome of that process was that the clinical syndromes as defined did not map onto the neuroscience findings or the effects of the widely used drugs.
As the time for the DSM-5 Revision to be released neared, Dr. Tom Insel announced that the NIMH was abandoning the DSM-5 and moving to it’s own embryonic classification system [Transforming Diagnosis
] – the RDoC [Research Domain Criteria
] – an initiative lead by Drs. Tom Insel and Bruce Cuthbert at the NIMH since in 2009:
The aim of the RDoC initiative is to accelerate the pace of research that translates basic science into clinical settings by understanding the multi-layered systems that contribute to mental function. The RDoC approach emphasizes neurodevelopment and environmental effects, in keeping with modern views about the genesis of mental disorders. “The RDoC unit is the culmination of over five years of effort from the institute and members of the research community,” said RDoC unit Director Bruce N. Cuthbert, Ph.D., who has served as coordinator of the RDoC working group since its inception. “We will now have four full-time staff to coordinate the program and enhance communication with scientists and the public as RDoC grows.” “RDoC represents a significant paradigm shift in the way we think about and study mental disorders,” said Thomas R. Insel, M.D., director of NIMH. “The RDoC approach cuts across traditional diagnostic categories to identify relationships among observable behavior, neurobiological measures, and patient self-report of mental status.”
Most of us sort of know what the RDoC is not. It’s not based on the traditional medical method of using signs and symptoms organized into syndromes that point to an underlying disease entity. Like Dr. Kupfer’s failed attempt to add "Cross Cutting Dimensional Diagnoses" to the DSM-5, it focuses on phenomena that transcend traditional categories. But the RDoC goes much further by ignoring diagnosis as we know it altogether. So what is it?
The Research Domain Criteria [RDoC] project implements Strategy 1.4 of the 2008 NIMH Strategic Plan: “Develop, for research purposes, new ways of classifying mental disorders based on behavioral dimensions and neurobiological measures.” RDoC attempts to bring the power of modern research approaches in genetics, neuroscience, and behavioral science to the problems of mental illness, studied independently from the classification systems by which patients are currently grouped.
The approach provides a framework to develop hypotheses and evaluate results from studies that investigate the mechanisms of psychopathology. The heart of RDoC is a matrix of functional dimensions, grouped into broad domains such as cognition and reward-related systems, examined across units of analysis ranging from genetics and circuit activity to psychology and behavior. Emphasis is placed upon the developmental trajectories through which these functions evolve over time, and the interaction of neurodevelopment with the environment. RDoC research starts with basic mechanisms and studies dysfunctions in these systems as a way to understand homogeneous symptom sets that cut across multiple disorders, rather than starting with clinical symptoms and working backwards.
We have established a multi-study database [RDoCdb] with subject-level data from RDoC research so that accumulating knowledge can be further investigated to identify trans-diagnostic mechanisms. The RDoC Discussion Forum invites input from the scientific community. We expect that the efforts of all involved in RDoC will encourage new ways to think about diagnosis and yield novel treatments and preventions.
Even a brief scanning of the tables reveals how very different the elements are from any existing system.
The RDoC has a Workgroup and a Unit, sub-Workgroups, the Matrix, a Database, and a granting mechanism. By keying future NIMH projects to the RDoC, they hope to populate their database and begin to correlate these basic measurable brain functions with the units of analysis [genes, molecules, cells, circuits, physiology, behavior, self-reports, and paradigms]. How this is exactly going to happen remains somewhat mysterious to me. Obviously, this is part of the NIMH push to quickly develop new treatments, drugs – and their hope is that the drugs, existing and future, will map onto these basic functions, unlike their independence from the traditional clinical symptoms and syndromes.
I don’t know enough neuroscience to evaluate how likely their constructs and sub-constructs are to represent discrete elements of brain function – implemented by genes, circuits, molecules, etc. Nor do I know how they intend to measure many of these parameters in reality. Like all the previous attempts, their assumptions are about the Brain [and not the Mind]. And this statement, "The RDoC approach emphasizes neurodevelopment and environmental effects, in keeping with modern views about the genesis of mental disorders", represents an opinion, stretched very thin after 35 years of disappointing research and theorizing.
I don’t really know what I think about all of this. Like the DSM-5 debacle, they persist in pursuing the idea that mental illness is all biologically determined rather than focusing on only those syndromes where that is likely, once again diluting the kind of directed research that might yield useful results. And it’s hard for me to shake the feeling that this effort is yet another desperate attempt to "realize the dream of Guze, Robins, and the neoKraepelinians" or Tom Insel’s dream that "psychiatry is clinical neuroscience" – and a way of diverting our attention away from the embarrassing collapse of the DSM-5 effort; the failure of the pharmaceutical industry to produce robust drug treatments [the empty pipeline]; and the widespread corruption and conflict of interest revelations in the academic pharmaceutical complex over the last five years. One would think this is a time for reflection and re-evaluation, rather than for racing down a new track full throttle…