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 MAJWorld 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”]…
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.
![Darrel Regier & David Kupfer [DSM-5], Allen Frances [DSM-4], John Feighner, Robert Spitzer [RDC, DSM-III, DSM-IIIR]](http://1boringoldman.com/images/thinkers-1.gif "Darrel Regier & David Kupfer [DSM-5], Allen Frances [DSM-4], John Feighner, Robert Spitzer [RDC, DSM-III, DSM-IIIR]")
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?
![Tom Insel [Director NIMH] & Bruce Cuthbert [Director of Translational Research, NIMH]](http://1boringoldman.com/images/insel-cuthbert.gif "Tom Insel [Director NIMH] & Bruce Cuthbert [Director of Translational Research, NIMH]")
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.
Cuthbert and company at NIMH are making up RDoC as they go along. The Matrix keeps being expanded. Mainly RDoC is a device to ‘keep the game going.’ I have reviewed a couple of papers recently that claimed to be inspired by RDoC. One of these acknowledged NIMH funding. Both amounted to nothing more than scientific churning, with no output that would inspire hope for a breakthrough. Indeed, by following the RDoC advice to ignore diagnoses, each paper enrolled a noisy group of subjects and they found, well, noise.
“… by 2011 after a $25M effort, Kupfer and Regier had to announce that the attempt had failed.”
You wouldn’t know it with so many articles expressing the existence of genetic material being significant in mental illness.
I was reminded while reading this and the comments that Dr. O’Brien directed us to at Psychiatric Times, that psychiatry has always been a profession at war with itself.
Yet, as much as it pains me to see the fractured state of your field, I am grateful there are dissenting voices – and in public no less. There are occupations where this rarely happens, and then behind closed doors with at most a handful of people.
For your dissenting voices, it’s kind of nice to see the wheat among the tares. Gives me hope.
Correct me if I am wrong, but dementia preacox and schizophrenia were hypothetical constructs. The idea was that this was an attempt to identify those with a common pathophysiology or etiology. By examining those who met these criteria we would figure out if these were coherent groupings and then, hopefully, identify the underlying pathophysiology. In our very human attachment to nominalism, these constructs have been reified but let’s face it, it has not panned out. I now will have a colleague say something like,”He is too social for someone with schizophrenia.” The person may meet the criteria in every way but some assumption will be made that the person “really” has a mood disorder since we all know that people who “have” schizophrenia are not social. That is a reification of the notion that schizophrenia – rather than being a construct – is something that actually exists in nature waiting for us to identify it. All of those who have psychotic experiences but are social or recover, for example, are sort of ignored, considered misdiagnosed, or squeezed into boxes that do not really fit. I am not denying that humans experience psychosis or have disabling bouts of dysphoria or extremes of increased energy and mood elevation. I am just saying that our current constructs map sloppily onto the heterogeneity of human experience. Also, by looking at how we now prescribe our drugs (extremely non-specific to our syndromes) and, even more importantly, by examining approaches that seem to be helpful but ignore our diagnostic classification, I am growing increasingly uncertain that it really matters how we define and classify these things.
Diversion is a very old sales technique. If we assume these KOL’s have assumed a sales mentality, then it is not very hard to make the leap that this is just a reworking of their previous ideas.
Remember also that a sales mentality s very motivated by financial gain as well as notoriety. They will try to keep themselves in the public eye for the fees they can generate, but also because they crave that self importance they get from being at the center of something, even if it is not really new or exciting.
Steve Lucas
I don’t understand the neuroscience, but I have a couple of thoughts:
(1.) the willingness to examine attachment patterns looks interesting to me and could potentially provide support for the value of psychodynamic therapy
(2.) I think that there’s value in focusing on some of the individual issues, like attention. It was assumed for a long time that people with mood disorders would be fine once euthymic. If people with, say, bipolar disorder have cognitive difficulties, I think that those ought to be addressed using targeted therapies (psychosocial or pharmacological). Some people with bipolar disorder may have them and others may not. Treating everyone with bipolar exactly the same seems flawed
(3.) As an elaboration of (2.). I’m not as educated about this as you are, Mickey, but, at least superficially, I would think that this was sort of anti-Kraepilinian in that it does not recognize a clear distinction between demntia praecox/ schizophrenia and manic-depressive illness.
It’s all so resolvable if one just thinks, “symptom endophenotypes”…
This nature/nurture thing has become tiresome. It’s as if we were physicists and we we still debating light as a wave or particle, as if an intelligent person couldn’t grasp both.
Yes, Dr. O’Brien, and I suspect that Dawkin’s view on genes still rules in too many circles; the overemphasis on natural selection and reproduction is still generally given much more weight than it deserves. New discoveries (since 1976) in molecular biology indicate that genetics and environment are intertwined to the degree that nature and nurture and environment are inseparable. It seems to me that that should be far more encouraging than damning— our genetic material is geared toward adaptation.
To Sandra Steingard, contrary to your statement, dementia praecox and schizophrenia were not proposed as hypothetical constructs. They were proposed as provisional disorders in a developing nosology, based on close observations of patients. Kraepelin and Jung followed the classical medical model that originated with Thomas Sydenham in the 17th Century. The whole point of the classical medical model was to allow experience-based probability statements about diagnosis and prognosis – for the benefit of patients and their families. From this era came the planks of the modern medical platform: diseases are separate from patients; inductive reductionism from observations trumps deductive scholasticism based on dogma-derived theory; the similarities among patients with a given disease far outweigh any minor differences among them. And while we are on the topic of developing nosologies, we should keep in mind that clinical science is an iterative process, so that nosologies are always provisional, subject to change as new evidence is accumulated. That is what distinguishes clinical science from orthodoxy, dogma, propaganda, and mysticism. Your carping about provisional nosologies from 100 years ago not panning out is irrelevant to today’s debates.
The medical reductionists beginning with Sydenham are often unfairly tagged with the smear that individual patients and their social backgrounds don’t matter. What is social medicine, then? But you make a flat-out, nonsensical category error when you complain that “our current constructs map sloppily onto the heterogeneity of human experience.” And as for your off-hand, airy statements about giving psychotropic drugs to all and sundry, be my guest if you choose in your practice to give any old drug to any old patient with any old diagnosis because it really doesn’t matter. I, for one, would say it is below the standard of care.
You mentioned with disapproval a colleague who said (of a patient) “something like, ‘He is too social for someone with schizophrenia.’ The person may meet the criteria in every way but some assumption will be made that the person “really” has a mood disorder since we all know that people who “have” schizophrenia are not social. That is a reification of the notion that schizophrenia… is something that actually exists.” Here I think you are the one who has reified DSM-5 definitions. It is worth reminding ourselves from time to time of Robert Spitzer’s caution when he introduced the Research Diagnostic Criteria in the late 1970s. Spitzer stated: “The use of specified criteria does not, of course, eliminate clinical judgment. The proper use of such criteria actually requires a considerable amount of clinical experience and knowledge of psychopathology. The criteria involve clinical concepts rather than a mere listing of complaints or observations of atomistic behaviors.” For all we know the colleague you smeared was savvy enough to recognize an important clinical gestalt that you did not.
Dr. Carroll,
Forgive me my imprecision; I consider “hypothetical construct” to be similar to “provisional disorders in a developing nosology”.
As for my “off hand airy statement”, I am just referring to the broadening indications from the FDA for the use of anti-psychotic drugs. It is not MY standard of care, it is what is advertised in our journals and approved of my our regulatory agencies.
I am writing and looking at the request to avoid ad hominem comments. I think I will bid this comment section farewell.
To Sandra Steingard: I think you should walk back your complaint of ad hominem. Indeed, you opened the door for each critique I stated. You might also try to be consistent – if you think it is OK to smear a colleague for disagreeing with you then you have no cause for complaint on the ad hominem score.
I was not talking about a particular colleague but of a way of speaking and thinking that I have generally observed; I had no intent to smear any one. Perhaps you have not had this type of interaction.
I found the tone of your comments to be harsh (“nonsensical”, “airy”). I appreciate learning from you. Perhaps I misread you.
I wish you the best.
Not harsh – rigorous. If you wish to avoid being misunderstood then you would help yourself by thinking more clearly and by writing more clearly. Thank you.
Hi Bernard: Vigorous intellectual discussion in discussion forums, great stuff. Thanks Sandra also for your very useful contributions. Just wondering about this: “inductive reductionism from observations (aka in CBS analytic abstraction) trumps deductive scholasticism based on dogma-derived theory (aka in CBS hypothetico-deductive) ; the similarities among patients (organisms) with a given disease (behavior) far outweigh any minor differences among them.” Sounds a lot like radical behaviorism? Modern version thereof CBS = Contextual Behavioral Science (which btw is where I choose to stand in approaching the science of behavior). See this paper for explication. “Contextual Behavioral Science: Creating a science more adequate to the challenge of the human condition” http://www.sciencedirect.com/science/article/pii/S2212144712000087 Interested in your thoughts… Warm wishes.
I always look out for Sandra’s comments and appreciate her openness and willingness to think aloud. I thought to myself that perhaps I am far too quintessentially British in that I experienced responses to her comments here as offensive – or is it simply that the protocol for academic discussion dispenses with politeness and respect?
Mick,
I am American and totally agree with you. I hope Sandra will chime on future discussions and not let what happened in this thread discourage her.
I, for welcome, welcome the rigor of debate and some disagreement. Too many people think the world and the truth revolve around (possibly) hurt feelings. If you read the editorial policy of the Psychiatric Times, there’s more emphasis on polity that intellectual rigor. And of course menschiness, which is great on the microsocial level and a disaster on the macro level.
As I have often said, looking at academic psychiatry from a five factor personality model, there’s way too damn much agreeableness (and neuroticism) and not enough conscientiousness.
Agreeableness gave us gems like DSM5 and ghostwritten KOL-pharma pseudoscience. On a grand scale agreeableness gave us the real estate bubble and the Iraq War. Getting along (at the macro level) is highly overrated.
Since we’re hashing it out, let me make this suggestion as well–no aliases. One of the biggest themes of this blog is lack of transparency. I think if you are going to demand that of pharma, I think one ought to demand it of oneself and one’s colleagues. I think it is hypocritical to want to hang pharma for lack of openness while throwing stones from behind an unqualified alias. Full disclosure works both ways.
I, for one, ….
I should never post before morning coffee…
I feel that blogs need to achieve a certain level of academic rigor in order to maintain their standing in the community. Blogs also allow us to paint with a broad brush knowing that exceptions exist, and that the ideas we put forward may reflect our personal experience, or a position that may not yet be in the main stream.
This blog has an exceptional group of participants with broad and varied backgrounds. I do not know where, or how, you could put together a group like this in any forum.
A few years ago I took apart a medical doctor that made the mistake of wondering into an area I felt strongly about and also had done some research and I let her know the error of her ways. Upon reflection I realized I had not only been harsh but also very rude, and for that I was very sorry.
My hope here is that everyone understands they may suffer from the remarks of another participant, but they should continue to participate. Every voice has value.
The bar here is shockingly high, let us not forget that fatigue and frustration may make a comment less than our best, and in my case I am running just to keep up. This is a fabulous race, let us all finish together, and not leave anyone behind.
Steve Lucas
Steve, beautifully stated.
For the blog, Dr. Nardo provides a place for dialog here that reminds me of the Island of the Misfit Toys. And, if you understand the meaning of the island from the children’s story, you’ll know that this is not an insult but a high compliment to him esp. but also to those here.
As far as dissenting voices, I came across this article tonight. I almost didn’t link to because it deals with politics, and my comment has nothing to do with politics. However, it also deals with the bigger issue of lack of diversity of thought better than I ever could, so I linked to it anyway.
The most powerful statement to me from the article:
The lack of political diversity in social psychology in no way means the resulting research is bad or flawed. What it does mean is that it’s limited. Certain areas aren’t being explored, certain questions aren’t being asked, certain ideas aren’t being challenged—and, in some cases, certain people aren’t being given a chance to speak up.
I deal with limited thinking in the business world on most days, while being told to “think-outside-the-box” ad nauseam. So now you know why I especially appreciate the dialogs I find on the psychiatry blogs.
Dr. O’Brien makes some great points about how agreeableness has been extremely costly. At the same time, I didn’t think that disagreeing with someone vigorously while still being respectful were mutually exclusive.
And like everyone else, I greatly thank Dr. Nardo for the opportunity to comment here. It is greatly appreciated.
As example A of not being politically correct nor wanting to be a mensch anymore, let me just remind anyone who is being realistic and attentive this one little point to being polite and wanting to keep a pure academic/intellectual tone at blogs:
blogs are meant for opinion at the end of the day, and opinion is not kind and respectful to things that are harsh and self serving as what is now overtly obvious to the zealot ideology of people in power and now they truthfully practice behind the disingenuous smiling at the podiums and dishonest op-ed pieces in professional journals. Attacking the failed one intervention model of psychopharmacology for pure biology to illness will not be received kindly and respectfully by those who profit and control from this agenda. And, those in control use the false pretense of “we should have healthy and honest dialogue and maintain respect” while trying to crush and obliterate dissent.
See Saul Alinsky Tactics to see the illustration to the above point.
And, I agree with AA, it is appreciated that Dr Nardo does allow some dialogue that is a bit harsh at times, as it is the point of what blogs should be promoting. One can be terse, and still be heard, even if not accepted.
The meek perhaps will inherit the earth, but, in what shape will the planet be in to try to reclaim it? It is time to show all who want and need to hear it, the emperor of “Biological psychiatry alone” not only has no clothes, but is carrying a machete! Harsh, yes, but dishonest of me to say, well I hope NOT!
Academia, especially the careerist form, in almost every field is corrupt and insular today and the problem will not be solved by more speech codes and agreeableness. Meehl talked about the buddy buddy syndrome in his famous essay in 1973 and now it is ten times worse.
The subjective feelings of people with titles are not as important as getting close to the empirical truth. Public debate is not group therapy. A wave of conscientiousness in academia implies that certain people are going to have their bubble burst.
But hey, they all loved “deconstruction” and critical theory in the sixties when they weren’t the target of it, let them have a taste of their own medicine.
I don’t think vituperation is necessary in even heated discussion, or Dr. Nardo’s intent when he specifies “But this is not the place for contentious interpersonal dialog. Your opinions are welcomed, but ad hominem comments to or about each other are not.”
If this has been relaxed, I’m sure the participants here will welcome — even praise — my subjective observations of their mental acuity, capacity for empathy, and tendentious political leanings.
One thing about the RDoC that I dislike intensely is that it does not seem to reflect how people see themselves. Can you imagine how patient communication might be done with the RDoC description of dysfunction? Carving up patients and their minds into narrow, isolated domains of functionality and neurophysiology. Ignoring (or at least minimizing) environmental influences on function.
At least with the current diagnostic scheme, we can (if we will) convey a coherent picture of a whole person acting in a complex, historically rich environment and struggling for a meaningful life. I’m not optimistic that this would survive RDoC.
To your point, Alienist, I was wondering how the subjective subdomains would be defined and quantified. They seem to be inherited from studies of rodent behavior. “Approach Motivation” looks positively Skinnerian. This doesn’t show much progress in conceptualization of human behavior.
“Social Processes” are heavily influenced by culture. How would the RDoc take that into account?
I don’t often contribute to these discussions, but I follow them, and learn from them. Being a still-working psychiatrist in his late 60’s, I envy Dr. Nardo his retirement time, a really admire the choice he has made in how to use it. I’m writing now to encourage Sandra Steingard to continue posting, I really value your voice. I also enjoy spirited debate, but prefer that care be taken to respect the persons involved.
A couple of quick thoughts:
* I did feel Dr. Carrol’s critique of Sandra seemed a bit harsh, and I do hope she keeps posting. Whether or not it actually crossed the “ad-hominem” line is debatable, and it’s certainly true that blog posts are not group therapy.
* Carrol’s response veered away from what I thought could have been a more interesting question: Why is it that our definition of schizophrenia seems to be less accurate now than it was in the DSM IV? Why did I have to convince staff members at one of the clinics where I worked that a patient with intense and distracting non-bizarre hallucinations, a part-time job, and an intact social network probably should not be labeled as schizophrenic? I don’t think that’s a question with an easy answer, even if the usual suspects are easily identified and found guilty. There’s some really bad thinking going on, and it scares the crap out of me. I am lucky to have worked with some very talented and understanding supervisors and psychiatrists, and somehow, we developed a good treatment plan and had excellent results at discharge with very minimal use of psychotropics. I just can’t believe how many windmills we had to tilt at before we got there.
* I very much agreed with Dr. O’Brien’s thoughts on aliases and transparency, though I’m not sure it’s always prudent to post our full names as our IDs, mainly because I think it’s easier to hack a user name than a name that appears in the text of a post. So, periodically, I may identify myself: Matthew Jansky, MFT Intern #66278, currently in limbo awaiting licensing exam and continuing extensive literature review on side effects of neuroleptic drugs, primarily SSRIs. I hope that others will post their names from time to time, because I’m very interested to learn more about everyone’s work. This is the first thread where I learned the name of this blog’s author, and I am very grateful for that.
* This is one of the most intelligent and exciting blogs I have ever stumbled across. My colleagues read it frequently, though few of us post, and it really helped spread the word about AllTrials. The only other blog, in any field, that I ever encountered that maintained such high ethical and academic standards was The Oil Drum. (It was more prone to trolling and “crackpottery,” as they say on Physics Forum, but the moderators found really creative and effective ways of dealing with that without shutting down dialogue and debate) When TOD closed its doors, I knew very little about the identities and work of the people who posted. I hope nothing like that ever happens here.
Thanks,
–Matthew