RDOCS and DSM 5: Diagnosis and Psychiatry

Peter ForsterDiagnosis

DSM5 and Psychiatric DiagnosisTom Insel, the Director of the National Institute for Mental Health, to celebrate the release of DSM5 in May of 2013, famously announced that the manual was already irrelevant to psychiatric research. This quote from Psychology Today captures the moment fairly well.

Just two weeks before DSM-5 is due to appear, the National Institute of Mental Health, the world’s largest funding agency for research into mental health, has indicated that it is withdrawing support for the manual. 

In a humiliating blow to the American Psychiatric Association, Thomas R. Insel, M.D., Director of the NIMH, made clear the agency would no longer fund research projects that rely exclusively on DSM criteria. Henceforth, the NIMH, which had thrown its weight and funding behind earlier editions of the manual, would be “re-orienting its research away from DSM categories.” “The weakness” of the manual, he explained in a sharply worded statement, “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.”

I have been considering the research diagnostic criteria because I’m in the midst of working with Descartes Lee to revise a part of the diagnosis section of the didactic material for the residents in psychiatry at UCSF. The plan is to focus much more on teaching the research diagnostic criteria then on teaching DSM-5. And so I have been thinking about the pluses and minuses of that approach.

The research diagnostic criteria are designed to focus much more on brain processes than DSM5 (which is really a minor revision of DSMIV, which was, in turn, a relatively minor revision of DSMIII). The idea idea behind RDOCS is that if we can define aberrant brain processes that will help focus our research efforts.

From a practical clinician’s standpoint, the problem is that at this point we have no information that allows us to go from the research diagnostic criteria to prognosis and little information that allows us to specify treatment.

A good friend just recently published a book on trans-diagnostic treatment planning that focuses on psychotherapy. It is an interesting book because it derives from her perspective as a clinician that the trouble with implementing “evidence based treatment” is that most patients have multiple comorbidities and so trying to develop a plan can become a bit like creating a smorgasbord. Instead, she suggests, that treatment planning focus on the aberrant cognitive or behavioral processes.

Again, we see how the mental health community is refocusing its attention more on the underlying dysfunctional cognitive or mental processes and working with those rather than on a purely diagnostic approach to treatment planning.

So Tom Insel is right. But we aren’t quite ready for the new world he proposes, and we have to both prepare residents for the future and also allow them to practice in the present.

And how to create that perfect synthesis is going to be this month’s challenge.