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

Footnotes

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).