Skip to content Skip to navigation

Rethinking psychiatric diagnosis on the eve of DSM-5: A new paradigm for NIMH

May 7, 2013
by Tom Doub, Ph.D., CEO, Centerstone Research Institute
| Reprints
In pursuing this bold research, NIMH must be willing to consider more research of an exploratory nature.
Click To View Gallery

I haven’t even ordered my copy of DSM-5 (for $199, mind you) and it may already be outdated.

As we near publication of DSM-5, the National Institute of Mental Health (NIMH) is reshaping the future of psychiatric diagnosis. NIMH Director Thomas Insel, MD, recently outlined a conceptual framework (first introduced in 2010) for diagnosis that is not necessarily based on current DSM-5 categories (currently defined by symptoms) and begins to transition psychiatry toward a diagnostic model that supplements symptom measures with genetics, objective indicators of brain circuitry and physiology, as well as behavioral and self-report data. This concept is based on the success of “precision medicine” strategies in cancer research, where cancer subtypes are quickly identified using a range of tests so that interventions can be more readily and effectively targeted, thus improving outcomes.

In a bold and controversial decision, NIMH is shifting its research funding away from traditional DSM categories (e.g., depression and schizophrenia) and toward cross-cutting categories of mental functioning and their measures, called the Research Domain Criteria (RDoC). This will be driving the NIMH research agenda, but it is unlikely to impact clinical practice anytime soon.

See NIMH Research Domain Criteria (RDoC) image.

Is this a mistake?

Translation to practice: One problem associated with NIMH divergence from DSM has to do with the already astounding gap that exists between research and practice in mental health. Since most of our treatment interventions are organized around DSM diagnoses, there is risk of further distancing research based on the RDoC framework from practice based on the DSM. If the RDoC model proves to be useful, we will need a solution to translate from RDoC to DSM and vice versa.

Prematurely dismissing what works:  While remarkable advances are being made in genetic and physiological measures of brain functioning, the current toolset of subjective standardized psychological assessments still provides superior validity compared to currently available objective measures, unlike cancer research. In fact, even in more “objective” spheres of medicine, there has come to be a growing appreciation for outcome measures based on the patient’s perspective.

Pages

Topics

Comments

I'm struck by what a historic moment this is, as a field recognizes that its primary diagnostic model is nearing exhaustion and that it must head in a different direction.

Clearly, psychiatric research has just committed to a huge "chasm crossing." The only adequate comparison that I can make for a leap of this type is JFK's call to the nation to "commit itself, before this decade is out, to landing a man on the moon . . . " When he made that call, a considerable body of theory was already in place, though great advances still had to be made.

I'm sure there are better comparisons--do any others come to mind?

Pages

Tom Doub

Chief Executive Officer, Centerstone Research Institute

Tom Doub

@tomdoub

www.centerstoneresearch.org

Thomas W. Doub, Ph.D. currently provides leadership for research...