Sunday, May 05, 2013

RDoC Dimensional Approach for Research vs. DSM-5 for Diagnosis

Dr. Thomas Insel, director of the National Institute of Mental Health (NIMH) in the U.S., recently announced that NIMH will be re-orienting its research away from DSM categories:
...While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology...

The dimensional approach to studying mental illness was covered in an excellent new blog post by Dr. Russ Poldrack, who describes ongoing work including the Consortium for Neuropsychiatic Phenomics and the Cognitive Atlas project.

I first wrote about the Research Domain Criteria for Classifying Mental Disorders in 2010:
There is no absolute timeline of when these [research] advances might occur. Instead of providing an immediate replacement for DSM and its clinical diagnoses, RDoC is a long-term project to help the research community by defining more biologically based organizational principles for various psychopathologies...

NIMH has been preparing the RDoC criteria for the past 2-3 years, as you can see in the RDoC Publications and in these Proceedings of RDoC Workshops (scroll down). Requests for applications (RFAs) on Dimensional Approaches to Research Classification in Psychiatric Disorders date back to 2011. The workshops and publications haven't been a secret, they've been available all along.1

Nonetheless, Insel's announcement was treated as a "bombshell", a "potentially seismic move", and a "humiliating blow to the APA." But as 1 Boring Old Man notes, this is old news.

One of the more alarmist posts on the topic was by John Horgan:
Psychiatry in Crisis! Mental Health Director Rejects Psychiatric “Bible” and Replaces With… Nothing

. . .

Now, in a move sure to rock psychiatry, psychology and other fields that address mental illness, the director of the National Institutes of Mental Health has announced that the federal agency–which provides grants for research on mental illness–will be “re-orienting its research away from DSM categories.” Thomas Insel’s statement comes just weeks before the scheduled publication of the DSM-V, the fifth edition of the Diagnostic and Statistical Manual.

Note the foreshadowing here: I do think Dr. Insel's timing in announcing the dimensional RDoC was a deliberate attempt to blunt the media circus that will surround the big DSM-5 release at the APA meeting in 2 weeks.

However, Horgan thinks the timing was more related to President's Obama's ambitious new BRAIN Initiative when he says:
NIMH director Insel doesn’t mention it, but I bet his DSM decision is related to the big new Brain Initiative, to which Obama has pledged $100 million next year. Insel, I suspect, is hoping to form an alliance with neuroscience, which now seems to have more political clout than psychiatry.

This is utterly preposterous, since NIMH has been aligned with "neuroscience" for years (which is apparent when looking at funded projects).2 And by "political clout" I assume he means the Society for Neuroscience has more political clout than the American Psychiatric Association (APA). However, it's not likely that NIMH has abandoned APA.

1 Boring Old Man goes much further and points out that A Research Agenda for DSM-V (2002) was a collaboration between APA and NIMH:
Do they really think that we won’t notice that the APA and NIMH are working in tandem – that their efforts are coordinated? Do they think we won’t notice that the "cross cutting" dimensional scheme for the DSM-5 that got dropped is the same idea as the RDoC? The articles that have been popping up all day are playing this as Insel’s NIMH throwing the DSM-5 under the bus. No need. The DSM-5 is already under the bus where it belongs.

bus image © BrokenSphere / Wikimedia Commons


1 All this activity might not have been apparent to those outside the U.S. funding system, however. Or to the majority of the planet who haven't read old blog posts on the topic.

2 On the front page of NIH RePORTER, search 'NIMH' and '1989' (the oldest date available).

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At May 05, 2013 11:54 PM, Anonymous Vaughan said...

this is old news

The RDoC project has been running for years and the aims have been stated from the start, but the bombshell is not in the fact it exists but the fact that NIMH announced that they will be preferentially funding non-DSM oriented research.

This changes it from and 'interesting side project that we hope will take over from the DSM at some stage' to 'our priority'.

Announcing this, two weeks before the DSM is due to be released is indeed big news, not only for its practical implications but for the rebuke it implies for the APA.

At May 06, 2013 12:00 AM, Blogger The Neurocritic said...

NIMH has been funding non-DSM oriented research since 2011:

"Its dominance notwithstanding, the DSM diagnostic scheme has not assimilated recent breakthroughs in genetics and neuroscience. Most genetic and neural circuit anomalies appear to link either with multiple DSM diagnostic categories or with narrow subgroups within diagnoses. A questionable assumption that the clusters of self-reported symptoms codified in the DSM define unique and homogeneous disorders could be constraining advances in the biology of mental illness. Consequently inadequate understanding of pathophysiology would in turn hamper the development of better treatments. Notwithstanding these difficulties, there is general consensus at this time that the biology of mental illness is insufficiently developed to support a classification scheme based on the integration of genetics, neuroscience, and psychopathology. The purpose of the RDoC project is to promote such integrative science so that advances in genomics, pathophysiology, and psychology can substantially inform diagnosis."

At May 06, 2013 12:53 AM, Blogger The Neurocritic said...

Basically, I don't think it's surprising that NIMH made this announcement. A lot of time and energy and money went into developing the RDoC framework, which presumably is not a finished product. And some of the major players were involved in the DSM-5 revision from the very beginning.

1 Boring Old Man pointed me in the direction of A Research Agenda For DSM V (2002):

"This thought-provoking volume—produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse—represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book...

Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda.

Dr. Bruce Cuthbert, Director of the Division of Adult Translational Research and Treatment Development at NIMH, was part of the Phase 1 development team, who published their white papers in the 2002 volume:

"Preparations for DSM-5 revision began in 1999, when the APA collaborated with the NIMH to stimulate the development of a research agenda that would address emerging opportunities relevant to psychiatric nosology."

The DSM-5 revision committee failed to reach its goal of defining more biologically-based diagnostic categories, so RDoC might be viewed as an extension of that work. From Chapter 2 of the 2002 collection (PDF), Neuroscience Research Agenda to Guide Development of a Pathophysiologically Based Classification System:

"At the risk of making an overly broad statement of the status of neurobiological investigations of the major psychiatric disorders noted above, it can be concluded that the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacologic treatment. A primary purpose of this chapter is to review why progress has been so limited and to offer strategic insights that may lead to a more etiologically based diagnostic system. Such an accomplishment
would represent a highly laudable achievement for psychiatry and would help move the specialty into the mainstream of modern medicine, where etiology and pathophysiology have replaced descriptive symptomatology as the fundamental basis for making diagnostic distinctions.

At May 06, 2013 1:16 AM, Blogger The Neurocritic said...

Finally, this quote from Chapter 1 of the 2002 white paper collection indicates the DSM revision committee didn't exactly expect all of its goals would be reached (PDF):

"Given the relatively short time frame for generating breakthrough research findings between now [1999] and the probable publication of DSM-V in 2010 [2013], it is anticipated that some of the research agendas suggested in these chapters might not bear fruit until the DSM-VI or even DSM-VII revision processes!"

At May 11, 2013 5:41 PM, Blogger katiesci said...

Great post, thanks for the info!


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