The winds of change? DSM no longer acceptable for US National Institute of Mental Health

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 windenergy20

The NIMH has caused waves to unsettle the psychiatric establishment after declaring that it will not be using the internationally accepted Diagnostic and Statistical Manual for establishing diagnostic criteria in future research.

 
The introduction of DSM was a game changer for psychiatry.  It describes the signs and symptoms required for all psychiatric diagnoses.  Diagnoses such as schizophrenia and depression had clear defined criteria which meant that clinicians would not be influenced by local habits.  Researchers could collaborate the world over and ensure that the problems they were addressing were the same, allowing clinicians to identify in the field those that had responded well to treatments used in the research.  Its international acceptance in research therefore allowed for improved diagnosis in the clinics and for progress to be made in many areas of psychiatric research increasing our understanding of mental illnesses.  
 

 

But even now DSM is a syndrome based diagnostic system.  All progress in research that has identified potential causes of illness such as genes, environment or neurological contributions are ignored and are not incorporated into the diagnostic model.  This is even the case with the new DSM5 which is due for release this month.  The system is therefore fundamentally similar to the archaic diagnostic systems used in medicine when a problem was identified as “breathlessness”: when in reality the cause could have been due to problems with the lungs or the heart. Failure to take steps to involve the potential causes in any classification would have severely hampered the development of medicine.  Psychiatry is potentially gearing up for a similar plunge.

  The current system (DSM) is completely integrated into diagnostic codes for practice, insurance reimbursements, disability judgments, clinical trials, regulatory agency guidelines, and—particularly in the research perspective—grant applications and journal publications. It is a dilemma that marked change cannot occur until a database is available to offer new perspectives based on genetics and neuroscience, yet such a database cannot be built until research is conducted to explore mechanisms that are independent of current categories. – Bruce Cuthbert 

The NIMH is now using the  Research Domain Criteria in future research.  It is seen as their tool to make the paradigm shift in understanding mental illness.  

The RDoC assumes that mental illnesses are presumed to be disorders of brain circuits. Secondly, it is assumed that the tools of clinical neuroscience, including functional neuroimaging, electrophysiology, and new methods for measuring neural connections can be used to identify dysfunction in neural circuits. Third, the RDoC approach presumes that data from genetics research and clinical neuroscience will yield biosignatures that will augment clinical signs and symptoms for the purposes of clinical intervention and management.

 

The RDoC was developed as a framework for research purposes, to identify new ways of classifying mental disorders based on dimensions of observable behaviour and neurobiological measures.  A research matrix aligns  – “constructs” of these observable behaviours and measures  – with units of analysis such as genes, molecules, circuits and has been developed to “facilitate integration of research and identify gaps” .  

 

The RDoC was developed as a framework for research purposes, to identify new ways of classifying mental disorders based on dimensions of observable behaviour and neurobiological measures.  A research matrix aligns  – “constructs” of these observable behaviours and measures  – with units of analysis such as genes, molecules, circuits and has been developed to “facilitate integration of research and identify gaps” .  

 

As a work in progress the RDoC now has the powerful backing of the NIMH to help it forge forward and gather evidence for structuring psychiatric diagnoses in an alternate manner to the current establishment.  Such research will no doubt take years to gather and corroborate.  But advancement with such a process would lead to great leaps in the management of mental illness.  In the meantime the DSM is still the useful tool that it has always been and should still remain the core diagnostic model  for clinicians within the profession.

  

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