{"id":35444,"date":"2013-04-17T22:38:32","date_gmt":"2013-04-18T02:38:32","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=35444"},"modified":"2013-04-17T22:38:32","modified_gmt":"2013-04-18T02:38:32","slug":"irrational-exuberance","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/04\/17\/irrational-exuberance\/","title":{"rendered":"irrational exuberance…"},"content":{"rendered":"
"The new framework will not replace the DSM, which is too important to discard…"<\/strong><\/sup><\/em><\/div>\n

<\/p>\n

Only Rip Van Winkle would not to know that academic psychiatry, the American Psychiatric Association [APA], and the National Institute of Mental Health [NIMH] have been united in their assumption that mental illness is a manifestation of brain disease since the introduction of the DSM-III diagnostic paradigm in 1980. They were joined along that journey by the pharmaceutical industry, and have adapted the medical specialty of psychiatry to a practice based on that assumption – with help from another industry, the third party carriers. The inconvenient truth that evidence for this position was lacking weighed heavily on them, so in the early days of the new millennium<\/span>, the APA took the occasion to use the coming revision of the Diagnostic and Statistical Manual [DSM] to settle the issue – a plan introduced in a book by the future chairs of that revision process in 2002 to solidify that position as part of their DSM revision: <\/div>\n
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A Research Agenda for DSM-V<\/a>
edited by David J. Kupfer, Michael B. First, and Darrel A. Regier<\/strong><\/sup>
Copyright 2002 American Psychiatric Association<\/font><\/strong>
[full text online]<\/strong><\/sup><\/div>\n
<\/p>\n

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syn- dromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.<\/p>\n

The efficacy of many psychotropic medications cuts across the DSM-defined categories. For example, the selective serotonin reuptake inhibitors have been demonstrated to be efficacious in a wide variety of disorders, described in many different sections of DSM, including major depressive disorder, panic disorder, obsessive-compulsive disorder, dysthymic disorder, bulimia nervosa, social anxiety disorder, posttraumatic stress disorder, generalized anxiety disorder, hypochondriasis, body dysmorphic disorder, and borderline personality disorder. Results of twin studies have also contradicted the DSM assumption that separate syndromes have a different underlying genetic basis. For example, twin studies have shown that generalized anxiety disorder and major depressive disorder may share genetic risk factors<\/p>\n

Concerns have also been raised that researchers’ slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disorders. Few question the value of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM-IV entities, to the point that they are consid- ered to be equivalent to diseases, is more likely to obscure than to elucidate research findings.<\/p>\n

All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes be- yond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies.<\/div>\n

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In that same year, Dr. Tom Insel became the Director of the NIMH, and soon openly joined the quest with his own addition, the specialty called formerly known as psychiatry<\/font><\/strong> was, indeed, actually clinical neuroscience<\/font><\/strong>, and he laid out a timetable<\/a> for its unfolding based on an array of new technologies: <\/div>\n
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Psychiatry as a Clinical Neuroscience Discipline<\/a>
by Thomas R. Insel and Remi Quirion<\/strong><\/sup>
JAMA<\/font><\/strong>. 2005 294[17]: 2221–2224.
[full text online]<\/strong><\/sup><\/div>\n

<\/p>\n

One of the fundamental insights emerging from contemporary neuroscience is that mental illnesses are brain disorders. In contrast to classic neurological illnesses that involve discrete brain lesions, mental disorders need to be addressed as disorders of distributed brain systems with symptoms forged by developmental and social experiences. While genomics will be important for revealing risk, and cellular neuroscience should provide targets for novel treatments for these disorders, it is most likely that the tools of systems neuroscience will yield the biomarkers needed to revolutionize psychiatric diagnosis and treatment. This essay considers the discoveries that will be necessary over the next two decades to translate the promise of modern neuroscience into strategies for prevention and cures of mental disorders. To deliver on this spectacular new potential, clinical neuroscience must be integrated into the discipline of psychiatry, thereby transforming current psychiatric training, tools, and practices.<\/strong><\/sup><\/div>\n<\/blockquote>\n
As time passed and the DSM-5 Task Force had its series of research symposiums, both the DSM-5 Task Force and the NIMH timelines looked increasingly less likely. Meanwhile, the NIMH came up with an alternative scheme based on the notion that the problem wasn’t with their hypothesis, it was that the presupposed biology didn’t map onto our clinical syndromes. So they set off on a different tack, mapping the patients onto the biology. It was called the RDoC: <\/div>\n
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Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders<\/a>
by Thomas Insel, Bruce Cuthbert, Marjorie Garvey, Robert Heinssen, Daniel S. Pine, Kevin Quinn, Charles Sanislow, and Philip Wang.<\/strong><\/sup>
American Journal of Psychiatry<\/font><\/strong>. 2010 167:748-751.
[full text online]<\/strong><\/sup><\/div>\n

… Four decades ago, Robins and Guze suggested five criteria for validating diagnosis [clinical description, laboratory tests, delimitation, follow-up studies, and family data], where the goal was specifying prognosis. Reminiscent of the rationale for developing the Research Diagnostic Criteria in the 1970s that led to the innovative DSM-III for clinical use, the question now becomes one of when and how to build a long-term framework for research that can yield classification based on discoveries in genomics and neuroscience as well as clinical observation, with a goal of improving treatment outcomes. As the major federal research agency funding mental health research in the United States, the National Institute of Mental Health believes the time has arrived to begin moving in such a new direction.<\/sup><\/strong><\/p>\n

The NIMH is launching the Research Domain Criteria [RDoC] project to create a framework for research on pathophysiology, especially for genomics and neuroscience, which ultimately will inform future classification schemes. The RDoC project is intended to be the next step in a long journey, one that continues the process begun in the 1970s of ensuring diagnosis that has both reliability and validity. While the focus of this journey over the past 30 years has been on refinements in clinically based classification, the time has come to lay the groundwork for the next step in this process: incorporating data on pathophysiology in ways that eventually will help identify new targets for treatment development, detect subgroups for treatment selection, and provide a better match between research findings and clinical decision making. <\/sup><\/strong><\/div>\n<\/blockquote>\n
The DSM-5 Task Force later said that they had realized along the way that their goal of a DSM based on a solid biological footing wasn’t going to happen, but they took their time telling us. Here’s their first public statement that their goal was not going to be reached: <\/div>\n
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Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5<\/a>
by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.<\/sup>
American Journal of Psychiatry<\/font><\/strong> 168:672-674, 2011.
[full text online]<\/strong><\/sup><\/div>\n

In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders,we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder.<\/sup> In A Research Agenda for DSM-V<\/u><\/em>, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…<\/sup><\/strong><\/p>\n<\/p><\/div>\n<\/blockquote>\n

And we began to hear more explicitly about the NIMH RDoC initiative and its basic assumptions, even from the DSM-5 Task Force itself. They passed the baton:<\/div>\n
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We realized from our Research Agenda conference series that we would not be able to accomplish by DSM-5’s deadline all of the things we set out to and, in fact, that portions of that agenda related to advances in neuroscience were already being addressed in other arenas. A logical extension of those discussions, as detailed in our Research Agenda  articles, is the Research Domain Criteria [RDoC] initiative recently launched by the National Institute of Mental Health [NIMH]. A commentary by Insel and colleagues  introduced readers to the working principles behind the RDoC, whose proposed reclassification of mental disorders for research purposes is predicated on a neuroscience-based framework that can contribute to a nosology in which disorders are grouped by underlying pathophysiological similarities rather than phenomenological observations…<\/sup><\/strong><\/div>\n<\/blockquote><\/div>\n
The RDoC assuptions were a bolder statement of the biological hegemony than any previous version: <\/div>\n
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Research Domain Criteria: cognitive systems, neural circuits, and dimensions of behavior<\/a>
by Sarah E. Morris and Bruce N. Cuthbert<\/strong><\/sup>
Dialogues in Clinical Neuroscience<\/font><\/strong>. 2012 14[1]: 29–37.
[full text online]<\/strong><\/sup><\/div>\n

<\/p>\n

The RDoC framework has its foundation in three postulates.<\/strong><\/sup><\/div>\n