{"id":36356,"date":"2013-05-14T22:00:59","date_gmt":"2013-05-15T02:00:59","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=36356"},"modified":"2013-05-15T06:45:04","modified_gmt":"2013-05-15T10:45:04","slug":"a-long-and-winding-road","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/05\/14\/a-long-and-winding-road\/","title":{"rendered":"a long and winding road&#8230;"},"content":{"rendered":"\n<p align=\"justify\"><sup><strong><em><img decoding=\"async\" border=\"1\" align=\"right\" width=\"167\" vspace=\"3\" hspace=\"4\" title=\"the road to Machu Picchu\" alt=\"the road to Machu Picchu\" src=\"http:\/\/www.bugbog.com\/images\/galleries\/peru-pictures\/new-peru-pictures-2\/Machu-Picchu-zigzag.jpg\" \/>I don&#8217;t buy it. We are bombarded by articles making all kind of things out of Dr. Insel&#8217;s blog post, <a href=\"http:\/\/www.nimh.nih.gov\/about\/director\/2013\/transforming-diagnosis.shtml\" target=\"_blank\">Transforming Diagnosis<\/a>, an announcement that the NIMH will move away from the DSM-5 &#8211; coming just a couple of weeks before the DSM-5 even goes on sale. Like everyone else, I&#8217;ve joined in on the speculation and commentary on the reasons for this surprising move [<a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/03\/old-news\/\">old news&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/05\/36061\/\">a flair&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/07\/groundhog-day\/\">groundhog day&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/09\/replaces-with\/\">replaces with&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/10\/damage-control\/\">damage control&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/12\/our-jobs\/\">our jobs&hellip;<\/a>, <a href=\"http:\/\/1boringoldman.com\/index.php\/2013\/05\/12\/said-it-again\/\">said it again&hellip;<\/a>]. When I talk too much about the same thing, it&#8217;s because there&#8217;s something I&#8217;m trying to figure out but I haven&#8217;t gotten there yet. So for the last several days, I&#8217;ve been going over the history and rereading the articles trying to get the story clear in my mind rather than reacting to the media frenzy. I&#8217;ve done that now and here&#8217;s the conclusion. I don&#8217;t buy it. If you don&#8217;t either, and already know why, don&#8217;t bother to read further. It&#8217;s way too long. I just wanted to write it down so I didn&#8217;t have to keep mulling it over in my mind.<\/em><\/strong><\/sup><\/p>\n<div align=\"justify\">Since the release of the DSM-III in 1980, there have always been two versions of the paradigm for the diagnostic manual. The first one was in the DSM-III Manual itself and said:<\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>For  most of the DSM-III disorders, however, the etiology is unknown. A  variety of theories have been advanced, buttressed  by evidence &ndash; not  always convincing &ndash; to explain how these disorders came about. 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. The major justification for the generally atheoretical approach  taken in DSM-III with regard to etiology is that the inclusion of  etiological theories would be an obstacle to use of the manual by  clinicians of varying theoretical orientations, since it would not be  possible to present all reasonable etiologic theories for each disorder.  <\/strong><\/sup><\/div>\n<div align=\"right\"><sup><strong>Robert Spitzer, in the DSM-III, p 6.<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">                The  second version, the background version, was from the group centered at Washington University in  Saint Louis and was called &#8211; <strong><font color=\"#200020\">neo-Kraepelinian<\/font><\/strong>. It professed the same  basis for classification [observed symptoms], but had nothing like the  neutrality of Dr. Spitzer&#8217;s version. Their view has been summarized as  the neoKraepelinian Tenets:                <\/div>\n<ul>\n<div align=\"justify\"><strong><sup>1. Psychiatry is a branch of medicine. <\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>3. Psychiatry treats people who are sick and who require treatment.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>4. There is a boundary between the normal and the sick.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>5. There are discrete mental illnesses.&nbsp; They are not myths, and there are many of them.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>6. The focus of psychiatric physicians should be on the biological aspects of illness.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>7. There should be an explicit and intentional concern with diagnosis and classification.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup>9. Statistical techniques should be used to improve reliability and validity.<\/sup><\/strong><\/div>\n<\/ul>\n<p>                                [<strong><font color=\"#200020\">1. &amp; 2.<\/font><\/strong>]  were directed against psychoanalysis and said that psychiatry was a  medical enterprise, not involved in matters psychological. The next  three [<strong><font color=\"#200020\">3.-5.<\/font><\/strong>] were a counter to the  criticisms from Dr. Szasz and others who said that there was no such  thing as mental illness and that psychiatry was not a medical specialty.  <strong><font color=\"#200020\">Number 6. said that physicians were only to be involved with the biological aspects of mental illness.<\/font><\/strong>  It didn&#8217;t say that all mental illness was biological, just that biology  was the legitimate domain of psychiatric physicians. And the last three  [<strong><font color=\"#200020\">7.-9.<\/font><\/strong>] were a call to use scientific methods in classification.   <\/p>\n<div align=\"justify\">\n<p align=\"justify\">The Spitzer  version [atheoretical, descriptive] was the official version, and under  that definition, the DSM-III was used by mental health professionals of  all disciplines. During the next decades, the other mental health  professions became increasingly covered by health insurance as members  of approved panels by the various insurers and the DSM-III [IIIR and IV]  systems became the standard reporting system for mental health in  America [cross referenced to the ICD-9CM, the official system by  treaty].<\/p>\n<p align=\"justify\">The  neoKraepelinian version was the nucleus for a dramatic change in  academic psychiatry which became rapidly biomedical and  psychpharmacological. Private practitioners in psychiatry increasingly  followed suit with more and more doing &quot;medication management&quot; for the  clients of practitioners in other disciplines. And over the next twenty  years the journals, practice, and focus of American psychiatrists  followed&nbsp; the more neoKraepelinian &quot;biological aspects of mental  illness&quot; definition.                             <\/p>\n<p align=\"justify\">The  DSM-III-R [1988] and DSM-IV [1994] revisions made changes in the  Manual, but stayed with the Spitzer version [atheoretical, descriptive].  Meanwhile, academic and organized psychiatry continued along their  biomedical neoKraepelinian path. The Decade of the Brain at the NIMH  spanned the 1990s and there was a stream of new drugs &#8211; antidepressants  and atypical antipsychotics. The Spitzer version was in the books and  used by non-psychiatrists. The neoKraepelinian version was the stuff of  clinical drug trials, the explosion of psychopharmacology, and psychiatry. <\/p>\n<p align=\"justify\">But in mainstream psychiatry, something subtle had  happened. The distinction between the two versions was becoming  anachronistic. It was no secret that the upper levels of psychiatry were  almost universally biological. I don&#8217;t think in 2000 that most of us  were aware of the extensive connections between academic and organized  psychiatry with PHARMA, particularly the back room connections. In this  next document written  in 2002 in preparation for the next DSM Revision,  there is no distinction. The <strong><font color=\"#200020\">descriptive<\/font><\/strong> approach is now called neoKraepelinian. The <strong><font color=\"#200020\">atheoretical<\/font><\/strong>  aspect is nowhere seen. It looks to me as if they felt that they could finally stop  equivocating and create the biologically based DSM they&#8217;d always wanted:<\/p>\n<blockquote>\n<div align=\"center\"><strong><font color=\"#200020\">Need to Explore the Possibility of Fundamental Changes in the Neo-Kraepelinian Diagnostic Paradigm<br \/>                                            <sup><em>in<\/em> <a href=\"http:\/\/www.unc.edu\/%7Edlinz\/Papers\/A%20Research%20Agenda%20for%20DSM-V.pdf#page=18\" target=\"_blank\">A Research Agenda for the DSM-V<\/a>, 2002<\/sup><br \/>                                            <sup><em>edited by<\/em> David Kupfer, Michael First, Darrel Regier<\/sup><br \/>                                         <sup>[<a href=\"http:\/\/www.unc.edu\/%7Edlinz\/Papers\/A%20Research%20Agenda%20for%20DSM-V.pdf\" target=\"_blank\">full text on-line<\/a>]<\/sup><\/font><\/strong><\/div>\n<p>                                     <\/p>\n<div align=\"justify\"><sup><strong>        <\/p>\n<div>The  DSM-III diagnostic system adopted a so-called neo-Kraepelinian approach  to diagnosis. This approach avoided organizing a diagnostic system  around hypothetical but unproven theories about etiology in favor of a  descriptive approach, in which disorders were characterized in terms of  symptoms that could be elicited by patient report, direct observation,  and measurement. The major advantage of adopting a descriptive  classification was its improved reliability over prior classification  systems using nonoperationalized definitions of disorders based on  unproved etiological assumptions. From the outset, however, it was  recognized that the primary strength of a descriptive approach was its  ability to improve communication among clinicians and researchers, not  its established validity.<\/div>\n<p><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">Dr. Spitzer&#8217;s compromise in 1980 was to settle for inter-rater <strong><font color=\"#200020\">reliability<\/font><\/strong> and let <strong><font color=\"#200020\">validity<\/font><\/strong>  go [since we have no way to determine validity anyway, it was no loss].  They go on to say that the hope had been that the DSM-III groupings  would lead to etiology, but since no biomarkers were yet defined, it  hadn&#8217;t worked out. Notice that biomarkers and etiology are now  connected. The <strong><font color=\"#200020\">atheoretical<\/font><\/strong> is gone for good. The problem at hand was that the expected <strong><font color=\"#200020\">biomarkers<\/font><\/strong> had not been found &#8211; <em>as in <strong><font color=\"#200020\">not <u>yet<\/u> found<\/font><\/strong><\/em>.  The conclusion was that the biological bases of mental illness were not  revealed by the clinical categories of the DSM-III+, and by the way,  the clinical disorders not only didn&#8217;t map to biological findings, but  they didn&#8217;t map to the drug treatments either. As a matter of fact, they  thought the DSM categories may even be hampering research in some way.                          <\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong><\/p>\n<div>  Disorders in DSM-III were identified in terms of syndromes, symptoms  that are observed in clinical populations to covary together in  individuals. It was presumed that, as in general medicine, the  phenomenon of symptom covariation could be explained by a common  underlying etiology. As described by Robins and Guze, the validity of  these identified syndromes could be incrementally improved through  increasingly precise clinical description, laboratory studies,  delimitation of disorders, follow-up studies of outcome, and family  studies. Once fully validated, these syndromes would form the basis for  the identification of standard, etiologically homogeneous groups that  would respond to specific treatments uniformly.<\/div>\n<p>                                    <\/p>\n<div>  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 val- idating 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 syndromes. 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&#8230;<\/div>\n<p>          <\/strong><\/sup><\/p>\n<div align=\"center\"><sup><strong>         <\/p>\n<div><img loading=\"lazy\" decoding=\"async\" border=\"0\" width=\"66\" height=\"18\" src=\"http:\/\/1boringoldman.com\/images\/snip.gif\" \/><\/div>\n<p>         <\/strong><\/sup><\/div>\n<p><sup><strong>          <\/p>\n<div>  Concerns have also been raised that researchers&rsquo; 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 considered to be equivalent to diseases, is more  likely to obscure than to elucidate research findings.<\/div>\n<p><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">Remember,  this is a document from 2002 written by the APA psychiatrists charged with  revising the DSM-IV. What they are saying is that the DSM-III, -IIIR,  -IV paradigm didn&#8217;t pan out. The descriptive <strike>atheoretical<\/strike> system did <u>not<\/u> reveal any disease specific biological markers and so we should change the way we do diagnosis <em><strong><font color=\"#200020\">in order to find them<\/font><\/strong><\/em>. These biological illnesses have yet to reveal their secrets.                          <\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong><\/p>\n<div>  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 beyond our current ways of thinking to attempt to  integrate information from a wide variety of sources and technologies&#8230;<\/div>\n<p><\/strong><\/sup><\/div>\n<\/blockquote>\n<p>                        The <strong><font color=\"#200020\">atheoretical<\/font><\/strong>  part of the system just quietly evaporated. This 2002 book is all  about biology and neuroscience. The possibility that the biomarkers  hadn&#8217;t been found because the Manual was faulty [eg absent Melancholia, etc]  wasn&#8217;t considered. Even odder, there&#8217;s no mention of the possibility  that many of the mental illnesses were not biological in the first place, ergo  had no biomarkers hidden or otherwise. But that&#8217;s an obvious point.  More cogent for the moment is that I couldn&#8217;t find where anyone  considered that the major users of this diagnostic system by actual  count are <u>not<\/u> psychiatrists, <u>not<\/u> people who would be involved with biological diseases or disorders. They are psychologists, social workers, counselors, etc. The content of this <a href=\"http:\/\/www.unc.edu\/%7Edlinz\/Papers\/A%20Research%20Agenda%20for%20DSM-V.pdf#page=18\" target=\"_blank\">Research Agenda for the DSM-V<\/a>  was written from the perspective of biological psychiatrists frustrated  that the confirmation of biomedical psychiatry had not been  forthcoming, and it was being reevaluated to find a more  biological-friendly system. The fact that this&nbsp; tack was incompatible  with the practices of the majority of mental health workers in America  who use the DSM doesn&#8217;t seem to have been on the radar. In my way of  thinking about this, the quiet compromise of the two paradigm versions, Spitzer  vs neoKraepelinian, had been erased. So from 2004-2008, the DSM-5 Task  Force held 13 planning conferences in conjunction with the NIMH, NIAAA,  and NIDA before starting to work on the DSM itself, looking in to going biological. And then, starting  in 2009, the NIMH introduced their RDoC:<\/div>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=102361\" target=\"_blank\">Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders<\/a><br \/>                                    <sup><strong>by   Thomas Insel, Bruce Cuthbert, Marjorie Garvey, Robert Heinssen, Daniel   S. Pine, Kevin Quinn, Charles Sanislow, and Philip Wang.<\/strong><\/sup><br \/>                                    <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong>. 2010 167:748-751.<br \/>                            <sup><strong>[full text online]<\/strong><\/sup><\/div>\n<p align=\"justify\"><strong><sup>Current versions of the DSM and ICD have facilitated reliable clinical diagnosis and research. However, problems have increasingly been documented over the past several years, both in clinical and research arenas. Diagnostic categories based on clinical consensus fail to align with findings emerging from clinical neuroscience and genetics. The boundaries of these categories have not been predictive of treatment response. And, perhaps most important, these categories, based upon presenting signs and symptoms, may not capture fundamental underlying mechanisms of dysfunction. One consequence has been to slow the development of new treatments targeted to underlying pathophysiological mechanisms&#8230;<\/sup><\/strong><\/p>\n<div align=\"justify\"><strong><sup>NIMH plans to maintain liaison with the American Psychiatric  Association and the World Health Organization regarding mutual interests  in psychiatric classification. As an initial step, representatives of  the APA, WHO, and NIMH met in July 2009 to map out common ground. These  organizations have also articulated the importance of adding molecular  and neurobiological parameters to future diagnostic systems, but at our  current state of knowledge this step seems more appropriate for research  than for immediate clinical use. NIMH views RDoC as the beginning of a  transformative effort that needs to succeed over the next decade and  beyond to implement neuroscience-based psychiatric classification.&hellip;<\/sup><\/strong><\/div>\n<\/blockquote>\n<div align=\"justify\">Notice that the APA was there from the start of the RDoC, just like the NIMH has been there through the whole DSM-5 process. Notice that the opening argument is the same one made by the DSM-5 Task Force in 2002, and the one we&#8217;re reading in 2013 in these last couple of weeks. Finally, in 2011, the DSM-5 Task Force announced that they  couldn&#8217;t bring off a biological DSM-5 after all, and they, themselves,  discussed the NIMH RDoC:<\/div>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=115987#B6\" target=\"_blank\">Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5<\/a><br \/>                                            <sup>by David J. Kupfer, M.D. and  Darrel A. Regier, M.D., M.P.H.<\/sup><br \/>                                            <strong><font color=\"#003322\">American Journal of Psychiatry<\/font><\/strong> 168:672-674, 2011.<br \/>                             <sup><strong>[full text online]<\/strong><\/sup><\/div>\n<p align=\"justify\"><strong><sup>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><sup> In <em><u>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&hellip;<\/sup><\/strong><\/p>\n<div align=\"justify\"><strong><sup>We  realized from our Research Agenda conference series  that we would not  be able to accomplish by DSM-5&prime;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&nbsp;  articles, is the Research Domain Criteria [RDoC]  initiative recently  launched by the National Institute of Mental Health  [NIMH]. A  commentary by Insel and colleagues&nbsp; 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&hellip;<\/sup><\/strong><\/div>\n<\/blockquote>\n<div align=\"justify\">So what do I make of this timeline? Well, first, there&#8217;s a piece that&#8217;s not yet on it &#8211; what happened in the gap between the <strong><font color=\"#200020\">Research Agenda<\/font><\/strong> of 2002 and the <strong><font color=\"#200020\">creation of the RDoC<\/font><\/strong> in 2009 &#8211; and it was a lot!:<\/div>\n<ul><sup><strong>                <\/p>\n<li>\n<div align=\"justify\">2002 was at the peak of the psychopharmacology era. The drugs were coming at a steady rate and business was booming. That year, Dr. Insel was a surprise pick to head the NIMH. It was a time of great enthusiasm, the dawn of a new millenium.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">While it probably should&#8217;ve started in 1996 when the Chairman of Psychiatry at Georgia [Dr. Richard Borison] was convicted, the realization that there was corruption afoot in psychiatry came later. In the mid-2000s, problems with conflicts of interest, unreported PHARMA income, and ghost writing increasingly came to the fore culminating in a U.S. Senate Investigation with several psychiatry chairmen &quot;stepping down&quot; and others in high places censured.             <\/div>\n<\/li>\n<li>\n<div align=\"justify\">Around the same time, the corruption in PHARMA reached the public eye. Allen Jones blew the whistle on TMAP, and elsewhere the civil suits began to pile up. In discovery, boxes of internal documents revealed the extensive connections between psychiatric authors a PHARMA, and the ubiquitous deceit in the publication of scientific data, along with a lot of shady drug promotion practices.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">People like Dr. David Healy and others began to report unmmentioned adverse effects like suicidality. The &quot;black box&quot; warning was added to the antidepressants. The reports of adverse effects were joined by charges of inflated efficacy.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">This was the era of large NIMH funded drug trials, and they were pretty disappointing. The new drugs hardly dazzled anyone. <\/div>\n<\/li>\n<li>\n<div align=\"justify\">In that period, we learned the term &quot;pipeline&quot; [drugs headed for approval], and then that there weren&#8217;t any more &quot;me too&quot; drugs on the way or anything to replace them<\/div>\n<\/li>\n<li>\n<div align=\"justify\">After a time of fretting over the &quot;empty pipeline,&quot; the drug companies began to shut down their CNS drug development facilities &#8211; no candidates to work on.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">This was a remarkably non-productive time in research. Lots of new technology and hype, but little in the way of results.       <\/div>\n<\/li>\n<p>                 <\/strong><\/sup><\/ul>\n<div>[just for starters]&#8230; And so the heyday of 2002 slid into a time with one piece of bad news after the other.<\/div>\n<p align=\"justify\">My own read on this narrative is cynical. First, I don&#8217;t accept that the <strong><font color=\"#200020\">American Psychiatric Association<\/font><\/strong>, <strong><font color=\"#200020\">Academic Psychiatry<\/font><\/strong>, the <strong><font color=\"#200020\">DSM-5 Task Force<\/font><\/strong>, and the <strong><font color=\"#200020\">Director&#8217;s office of the National Institute of Mental Health<\/font><\/strong> are separate entities. I see then as a consortium of people in high places who see the future of psychiatry and mental health as a function of new CNS drug development. That means that the entity we call <strong><font color=\"#200020\">PHARMA<\/font><\/strong> is part of the consortium, whether officially or unofficially &#8211; it&#8217;s a big part of the mix.<\/p>\n<p align=\"justify\">What I think happened is that the consensus around the turn of the century was that they could make the move to a solid biological psychiatry that took its place among the medical professions as a solid member.&nbsp; The DSM-III had opened the door, and the DSM-5 was going to complete the process. But as time moved on and the bad news began to accumulate, things weren&#8217;t going as planned, their DSM-5 conferences were going nowhere [I read them so trust me on this point], and they had to do something. The vision of their Research Agenda was handed over to the NIMH who launched the RDoC. Once that was in place and launched, they made their announcement that they couldn&#8217;t bring it off. In the meantime, they&#8217;d ignored the real business of the revision they&#8217;d been assigned, so they got involved in a lot of add-ons [Attenuated Psychosis, Mixed Anxiety Depression, etc]. The original impetus [the future is psychopharmacology] showed in the loosened criteria for any number of diagnoses the dropped bereavement exclusion. It was a lackluster showing at best, because it wasn&#8217;t what they were really aiming for in the first place. Why did Insel jump in at the 11th hour? My guess is that it lets the DSM-5 Task Force off the hook, changing their failed attempt at a biological system into something else &#8211; a noble try, but the clinical syndromes are just not a good-enough basis for drug development or biological discovery.<\/p>\n<p align=\"justify\">I think that all these people really do believe that the only avenue to follow is psychopharmacology and new drug development. What I object to is all the behind the scenes wheeling and dealing, presented to us in carefully prepared sound bytes. I object that they haven&#8217;t listened to Dr. Robert Spitzer, Dr. Allen Frances, and the rest of us who are trying to tell them that their monocular vision is obscuring everything. The roar of criticism about the DSM-5 has all said the same thing, &quot;You&#8217;re supposed to be revising our clinical diagnostic manual! And you&#8217;re doing something else!&quot; Everything has been wrapped around new drug development. It&#8217;s not even about biology because they&#8217;ve ignored repeated calls to reinstate our best candidate &#8211; Melancholia. It&#8217;s just about drug development, finding new targets to entice PHARMA back into the game. They say that outright.       <\/p>\n<div align=\"justify\">So I believe there is a real <em>they<\/em> composed of the groups above, with a fixed goal in mind to the exclusion of any other. <em>They<\/em> really liked the years leading up to 2002, and <em>they<\/em> just can&#8217;t let go of where <em>they<\/em> thought <em>they<\/em> were headed. In 5 days <em>they<\/em>&#8216;re going to publish a book that will enshrine their folly&#8230;<\/div>\n<hr \/>\n<p>and&#8230;<\/p>\n<table cellspacing=\"0\" border=\"0\" align=\"center\" width=\"95%\">\n<tr>\n<td>\n<div align=\"justify\"><sup><strong>    <\/p>\n<p class=\"stamp\">Press Release &bull; <span class=\"date-stamp\">May 13, 2013<\/span><\/p>\n<h1><a href=\"http:\/\/www.nimh.nih.gov\/news\/science-news\/2013\/dsm-5-and-rdoc-shared-interests.shtml\" target=\"_blank\">DSM-5 and RDoC: Shared Interests<\/a><\/h1>\n<p>Thomas R. Insel, M.D., director, NIMH<br \/>    Jeffrey A. Lieberman, M.D., president-elect, APA<\/p>\n<p>NIMH  and APA have a shared interest in ensuring that patients and health  providers have the best available tools and information today to  identify and treat mental health issues, while we continue to invest in  improving and advancing mental disorder diagnostics for the future.<\/p>\n<p>Today,  the American Psychiatric Association&rsquo;s (APA) Diagnostic and Statistical  Manual of Mental Disorders (DSM), along with the International  Classification of Diseases (ICD) represents the best information  currently available for clinical diagnosis of mental disorders  &nbsp;Patients, families, and insurers can be confident that effective  treatments are available and that the DSM is the key resource for  delivering the best available care. The National Institute of Mental  Health (NIMH) has not changed its position on DSM-5. As NIMH&rsquo;s Research  Domain Criteria (RDoC) project website states, &ldquo;The diagnostic  categories represented in the DSM-IV and the International  Classification of Diseases-10 (ICD-10, containing virtually identical  disorder codes) remain the contemporary consensus standard for how  mental disorders are diagnosed and treated.&rdquo;<\/p>\n<p>Yet, what may be  realistically feasible today for practitioners is no longer sufficient  for researchers. Looking forward, laying the groundwork for a future  diagnostic system that more directly reflects modern brain science will  require openness to rethinking traditional categories. It is  increasingly evident that mental illness will be best understood as  disorders of brain structure and function that implicate specific  domains of cognition, emotion, and behavior. This is the focus of the  NIMH&rsquo;s Research Domain Criteria (RDoC) project. RDoC is an attempt to  create a new kind of taxonomy for mental disorders by bringing the power  of modern research approaches in genetics, neuroscience, and behavioral  science to the problem of mental illness.<\/p>\n<p>The evolution of  diagnosis does not mean that mental disorders are any less real and  serious than other illnesses. Indeed, the science of diagnosis has been  evolving throughout medicine. For example, subtypes of cancers once  defined by where they occurred in the body are now classified on the  basis of their underlying genetic and molecular causes.<\/p>\n<p>All  medical disciplines advance through research progress in characterizing  diseases and disorders. DSM-5 and RDoC represent complementary, not  competing, frameworks for this goal. DSM-5, which will be released May  18, reflects the scientific progress seen since the manual&rsquo;s last  edition was published in 1994. RDoC is a new, comprehensive effort to  redefine the research agenda for mental illness. As research findings  begin to emerge from the RDoC effort, these findings may be incorporated  into future DSM revisions and clinical practice guidelines. But this is  a long-term undertaking. It will take years to fulfill the promise that  this research effort represents for transforming the diagnosis and  treatment of mental disorders.<\/p>\n<div>By continuing to work together, our  two organizations are committed to improving outcomes for people with  some of the most disabling disorders in all of medicine.<\/div>\n<p> <\/strong><\/sup><\/div>\n<\/td>\n<\/tr>\n<\/table>\n","protected":false},"excerpt":{"rendered":"<p>I don&#8217;t buy it. We are bombarded by articles making all kind of things out of Dr. Insel&#8217;s blog post, Transforming Diagnosis, an announcement that the NIMH will move away from the DSM-5 &#8211; coming just a couple of weeks before the DSM-5 even goes on sale. Like everyone else, I&#8217;ve joined in on the [&hellip;]<\/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_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-36356","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36356","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=36356"}],"version-history":[{"count":50,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36356\/revisions"}],"predecessor-version":[{"id":42780,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36356\/revisions\/42780"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=36356"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=36356"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=36356"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}