{"id":21803,"date":"2012-04-06T12:36:09","date_gmt":"2012-04-06T16:36:09","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=21803"},"modified":"2012-04-07T07:28:33","modified_gmt":"2012-04-07T11:28:33","slug":"the-eye-of-the-storm-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/04\/06\/the-eye-of-the-storm-2\/","title":{"rendered":"the eye of the storm…"},"content":{"rendered":"
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Research Domain Criteria – RDoC<\/font><\/a><\/strong><\/u>
NIMH – Director’s Blog<\/font><\/strong>
by Thomas Insel
March 06, 2012<\/div>\n

<\/p>\n

While basing diagnosis exclusively on signs and symptoms was typical of mid-twentieth century medicine, by the beginning of the twenty-first century, most disciplines had built many other sources of information, such as biomarkers, into their diagnostic toolkits. Imagine diagnosing heart attack only by characterizing chest pain or using the symptoms of fever to distinguish bacterial from viral pneumonia. A recent report from the National Academy of Sciences, Towards Precision Medicine [see my previous blog on improving diagnosis through precision medicine<\/font><\/strong><\/u><\/a>]<\/em>, described how improving diagnostic specificity for cancer has transformed outcomes by identifying the precise biology of each patient’s tumor and linking this diagnosis to targeted treatments.<\/p>\n

In contrast to these changes in the rest of medicine, for the past century mental disorders have been considered "behavioral," implying that an exclusive focus on symptoms could yield a precise diagnosis. Problems with this narrow approach to diagnosis began to emerge as research demonstrated the inescapable heterogeneity underlying diagnostic labels such as depression or schizophrenia. Even attempts to subdivide these categories by considering additional symptoms, such as anxious depression, failed to give reliably better prediction of treatment response. <\/sup><\/div>\n<\/blockquote>\n

I remember this argument. It sounds like a version of the one that brought us the DSM-III which was going to lead us to a more reliable diagnostic system – by carefully focusing on descriptions of precise symptoms bringing us into sync with the rest of medicine. As I recall, the goal was to find biomarkers then too. The difference is that the great hope in 1980 [symptom lists] is now what’s inadequate in 2012 [symptom lists]: <\/div>\n
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Recent research in genetics and brain imaging suggest that biological measures may help us to understand the heterogeneity within the symptoms of mental illness. Just as with chest pain and fever, by adding more tools to our diagnostic toolkit, current labels such as "depression" or "schizophrenia" might give way to more precise categories. These advances have the potential to revolutionize the way we classify and, importantly, treat mental disorders.<\/p>\n

Last week, NIMH hosted the latest in a series of workshops to launch the Research Domain Criteria [RDoC] project. RDoC is an experimental approach to the classification of mental disorders that incorporates multiple dimensions: behavior, thought patterns, neurobiological measures, and genetics. The immediate aim of the project is not to develop a diagnostic system for clinicians or patients. While I expect RDoC will ultimately transform practice, the near-term goal is to provide a framework for research. For instance, the meeting this week focused on social processes, reviewing what we know and what we need to understand about the deficits in social cognition and social behavior in what we now call autism, schizophrenia, depression, and anxiety disorders in both adults and children. The underlying assumption is that approaching mental disorders along this dimension may yield a more precise, more individualized diagnosis that crosses our current labels. But this is not simply about finding links between the social deficits of people with autism and people with social anxiety. RDoC uses genetics, imaging, and cognitive science for understanding deficits in social behavior…<\/p>\n

This is not as simple as it sounds. Genes identified as conveying risk for mental illness don’t track neatly with any of the currently recognized disorders. Nearly all of the genes associated with risk for schizophrenia also contribute to risk for bipolar disorder and autism. One could use this information to dismiss genetics as "non-specific." But certainly it is more parsimonious to conclude that nature does not define the disorders designated by our current diagnostic labels, all of which were devised by committees of clinicians who were voting on the symptoms. While the impact of individual genes on risk is likely to be small and not specific to any existing current diagnostic category, could genetics be showing us a different way to map the diagnostic landscape?… <\/sup><\/div>\n<\/blockquote>\n

It’s nice to see Dr. Insel admit the obvious in print: "it is more parsimonious to conclude that nature does not define the disorders designated by our current diagnostic labels, all of which were devised by committees of clinicians who were voting on the symptoms<\/font><\/strong>"- a strong indictment of our current Diagnostic and Statistical Manual. I would support what they’re playing with in their Research Domain Criteria <\/font><\/strong>[RDoC<\/font><\/strong>] project. And while I think that "deficits in social cognition and social behavior in what we now call autism, schizophrenia, depression, and anxiety disorders<\/font><\/strong>" might be a bit broad, their deliberations seem sound. I’d settle for the first two. My complaint would be that they didn’t take this approach thirty-two years ago – keeping research and clinical classifications separated until there is adequate evidence from that research to justify the change.<\/div>\n
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Dr. Spitzer’s 1980 DSM-III effort was well justified in removing the psychoanalytic formulations that had been used in sections of the DSM-II. However, the contributions of the psychoanalysts, the the dynamic therapists, the ethologists, and the developmental and behavioral psychologists to our understanding of the human psyche in the first half of the twentieth century were hardly ‘disposable’ – ranking with Kraepelin’s classification of the great psychiatric disorders. The move to a descriptive classification was a move to eliminate speculative formulations from our criteria which was a good idea. But it was so colored by the complaints by the carriers about paying for long costly psychotherapeutic treatments that the general idea of the "mind" was removed as if it were only whimsey [a computer with no operating system or software<\/em>]. The carriers could have simply said, "we are no longer covering long costly psychotherapeutic treatments" without the DSM-III’s implicit denial that non-biological processes could produce a lot of psychic pain and dysfunction – which they can. That decision was also obviously colored by the biologists in the Saint Louis group which had a particular view of mental illness that heavily influenced the whole enterprise [see the prophet…<\/font><\/a><\/strong><\/u>]. Actually, the DSM-II wasn’t really that psychoanalytic<\/em> after all, but I’ll take the point nonetheless:<\/div>\n

<\/p>\n

IV. NEUROSES [300]<\/font><\/strong><\/div>\n
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    300 Neuroses<\/font><\/strong><\/div>\n
    Anxiety is the chief characteristic of the neuroses. It may be felt and expressed directly, or it may be controlled unconsciously and automatically by conversion, displacement and various other psychological mechanisms. Generally, these mechanisms produce symptoms experienced as subjective distress from which the patient desires relief. The neuroses, as contrasted to the psychoses, manifest neither gross distortion or misinterpretation of external reality, nor gross personality disorganization. A possible exception to this is hysterical neurosis, which some believe may occasionally be accompanied by hallucinations and other symptoms encountered in psychoses. Traditionally, neurotic patients, however severely handicapped by their symptoms, are not classified as psychotic because they are aware that their mental functioning is disturbed.<\/sup><\/div>\n<\/ul>\n
      \n
      300.4 Depressive neurosis<\/font><\/strong><\/div>\n
      This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession. It is to be distinguished from Involutional melancholia and Manic-depressive illness. Reactive depressions or Depressive reactions are to be classified here.<\/sup> <\/div>\n<\/ul>\n

      <\/sup><\/p><\/blockquote>\n

      I actually miss it. I think it was closer to the truth than what we have now. But the point here is that Tom Insel’s comment is a scathing indictment of the DSM-5 effort, whether intended or not ["devised by committees of clinicians who were voting on the symptoms<\/font><\/strong>"]. When it’s all said and done, the DSM-III was a mistake. The mistake wasn’t the idea. It was in failing to see what the third party carriers, the pharmaceutical industry, and those among us with challenged morality would do with it. And the category – Major Depressive Disorder<\/font><\/strong> – is at the eye of the storm… <\/p>\n\n\n\n
      DSM II<\/a><\/u> [1968]<\/font><\/strong> <\/p>\n
      <\/td>\n<\/tr>\n
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      III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY [295—298]<\/font><\/strong><\/div>\n
        \n
        296 Major affective disorders…<\/font><\/strong><\/div>\n
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          296.0 Involutional melancholia<\/font><\/strong><\/div>\n<\/ol>\n
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            Manic-depressive illnesses…<\/font><\/strong><\/div>\n<\/ol>\n
              \n
              296.1 Manic-depressive illness, manic type…<\/font><\/strong><\/div>\n<\/ol>\n
                \n
                296.2 Manic-depressive illness, depressed type…<\/font><\/strong><\/div>\n<\/ol>\n
                  \n
                  296.3 Manic-depressive illness, circular type…<\/font><\/strong><\/div>\n
                      296.33 Manic-depressive illness, circular type, manic<\/font><\/strong><\/div>\n
                      296.34 Manic-depressive illness, circular type, depressed<\/font><\/strong><\/div>\n<\/ol>\n
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                    296.8 Other major affective disorder…<\/font><\/strong><\/div>\n<\/ol>\n
                    298.0 Psychotic depressive reaction…<\/font><\/strong><\/div>\n<\/ul>\n
                    IV. NEUROSES [300]<\/font><\/strong><\/div>\n
                      \n
                      300 Neuroses<\/font><\/strong><\/div>\n
                      300.4 Depressive neurosis<\/font><\/strong><\/div>\n<\/ul>\n
                        <\/ul>\n<\/td>\n<\/tr>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

                        Research Domain Criteria – RDoC NIMH – Director’s Blog by Thomas Insel March 06, 2012 While basing diagnosis exclusively on signs and symptoms was typical of mid-twentieth century medicine, by the beginning of the twenty-first century, most disciplines had built many other sources of information, such as biomarkers, into their diagnostic toolkits. Imagine diagnosing heart […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-21803","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21803","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=21803"}],"version-history":[{"count":21,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21803\/revisions"}],"predecessor-version":[{"id":21841,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21803\/revisions\/21841"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=21803"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=21803"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=21803"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}