Mental Health Researchers Reject Psychiatry’s New Diagnostic ‘Bible’

  • Share
  • Read Later
Scientific phrenology head
Getty Images

Just weeks before psychiatry’s new diagnostic “bible”—the DSM 5— is set to be released, the world’s major funder of mental health research has announced that it will not use the new diagnostic system to guide its scientific program, a change some observers have called “a cataclysm” and “potentially seismic.” Dr. Thomas Insel, the director of the National Institute on Mental Health, said in a blog post last week that “NIMH will be re-orienting its research away from DSM categories.”

The change will not immediately affect patients. But in the long run, it could completely redefine mental health conditions and developmental disorders.  All of the current categories — from autism to schizophrenia — could be replaced by genetic, biochemical or brain-network labeled classifications.  Psychiatrists, who are already reeling from the conflict-filled birth of the fifth edition of the Diagnostical and Statistical Manual of Mental Disorders, are feeling whipsawed.

Insel, for his part, is lobbying for a more comprehensive approach. For scientific purposes, he argues, the DSM may have outlived its usefulness.  He writes:

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…  Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response…Patients with mental disorders deserve better.

The NIMH has outlined a new diagnostic system — called Research Domain Criteria (RDoC) — that could ultimately replace the DSM, but it’s not yet ready for prime time. For the time being, NIMH and the psychiatrists who use the manual will continue to abide by existing classifications for diagnosing patients and getting treatment reimbursed. “Some people have the idea that we’re trying to ditch or diss the DSM and that’s not a fair assessment,” says Insel.

Dr. David Kupfer, the chair of the APA’s DSM 5 task force said in a statement responding to Insel’s post, “The new manual, due for release later this month, represents the strongest system currently available for classifying disorders…  Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders. But they cannot serve us in the here and now, and they cannot supplant DSM-5.”

But Dr. Eric Hollander, who chaired the DSM research planning agenda for obsessive-compulsive spectrum disorders, says it’s hard to deny that the NIMH appears to be rallying support for a different approach to mental-health classification. “I do think it does represent a lack of interest and faith on behalf of NIMH for the DSM process and an investment in alternative diagnostic systems,” says Hollander, who is director of the autism and obsessive-compulsive spectrum disorder program at Montefiore/Albert Einstein School of Medicine in New York.

Numerous forces currently undermine accurate diagnosis in psychiatry.  To start, researchers have so far been unable to find specific biomarkers like brain scan results or genetic tests to definitively diagnose conditions like depression and to predict which treatments will best help which patients. Secondly, many psychiatric patients have symptoms of more than one disorder and many are clearly ill without meeting any diagnosis precisely. “That tells you we’re not cutting nature at its joints, that it’s not an accurate way to categorize,” says Insel.

Finally, pressures from pharmaceutical companies have led to a massive increase in prescribing of psychiatric medications and labeling of patients to justify that prescribing. Critics of the DSM 5 process have noted that 70% of people serving on its committees to define specific diagnoses have financial ties to pharmaceutical companies, up from 57% for DSM IV.

“People with mild problems are overmedicated and people with severe problems are terribly under-medicated because access to care is terribly  underfunded,” says Dr. Allen Frances, a leading critic of DSM 5, who chaired the DSM IV revision process. He is concerned that the new edition, with its loosening of criteria in several major disorders, will result in even further overmedication.

MORE: DSM-5 Could Categorize 40% of College Students as Alcoholics

“We’ve used a syndromal approach to research for the last 33 years,” he says, “It hasn’t paid off well.”  Indeed, even the pharmaceutical industry seems to be backing away from psychiatry, with almost all of the major players trimming research and development of psychiatric drugs following recent failures.

“I look at the data and I’m concerned,” says Insel. “I don’t see a reduction in the rate of suicide or prevalence of mental illness or any measure of morbidity.  I see it in other areas of medicine and I don’t see it for mental illness. That was the basis for my comment that people with mental illness deserve better.” Adds Hollander, “There’s been a huge gap between some of our basic science information and our ability to develop new treatments because those don’t necessarily map onto DSM diagnoses.”

That’s why NIMH so desperately wants a new system.  Searching the genome for correlates of “schizophrenia” or “ADHD” hasn’t turned up any single gene or group of genes that accounts for most of the risk or has led to a new type of treatment.  Nor have brain scan findings been able to reliably distinguish between psychiatric conditions as now defined or predict which medications or therapies will help.

Instead, RDoC suggests that by precisely targeting one symptom that may occur in multiple disorders— for example, repetitive behavior— it will be easier to find brain and genetic connections than it would be to continue to study a widely varied group of people with a disease like obsessive-compulsive disorder that’s defined by that symptom, plus many others.

Of course, such complex diagnostic issues aren’t unique to psychiatry: classification in areas of medicine as seemingly clearcut as oncology can be fuzzy as well. Recent studies find, for instance, that certain types of severe uterine cancer may share more in common genetically with certain breast cancers than they do with milder uterine disease. The same seems to be true in psychiatry, with new studies finding common genetic roots for ADHD, schizophrenia and autism.

MORE:  Most Common Psychiatric Disorders Share Genetic Roots

With RDoC, Insel wants to bring this same type of what cancer specialists call “precision medicine” to brain disorders, classifying them not simply by symptoms but by genetic analysis and identifying what brain circuits are most affected. Building on a systems approach, RDoC might be able to find a comprehensive regimen that can be individualized for a person’s particular problems, not just an overall classification.

However, just because today’s diagnoses are far from perfect doesn’t mean that mental illness isn’t real or that DSM diagnoses are entirely useless— just as the fact that certain breast and uterine cancers are genetically similar and may require the same treatment doesn’t make breast or uterine cancer “fake” or irrelevant categories.

“We shouldn’t throw out the baby of clinical diagnosis with the bathwater of its limits. It’s still absolutely necessary and often very helpful,” says Frances. “We need to give reassurance for people operating under the current diagnostic system that it makes sense.  It’s not the best way to go forward in research, but it’s the best available form of clinical treatment and planning available now.”

Insel doesn’t object. He says “there’s all kinds of value in using the current [system]” to treat patients whose disorders, whatever they may eventually be called, cause real suffering right now and are dependent upon insurance reimbursement that requires a diagnosis code.”  He adds, “We’ve worked really closely [with the American Psychiatic Association on the] DSM.  This is not meant in any way to be competitive.  We don’t have anything [else] clinicians can use in 2013.”  With any luck, RDoC or some more refined diagnostic system will soon change that and finally offer better treatments for some of medicine’s most painful and debilitating disorders.

MORE: Depressive Thinking Can Be Contagious

32 comments
punkakes13
punkakes13

they create diseases, but not the cure..

punkakes13
punkakes13

i just think first of, these doctor should prescribe brain scans and such things before prescripting any medications or giving diagnosis.. because.. its really insane how they dont use some brain or blood analysis at these things... i think science is first about indentifying the clinical aspects of a disease or syndrome, only then, giving the diagnosis and prescribing certain things to solve it or help it.. but few is done in the first step, a lot is done by ust hearing what the patient have to say.. but the patient is not a doctor.. the patient doesnt know something might be wrong with them that they feel that certain way.. these doctors all they wants is prescribing pills..

why dont they tell u to do all the exams they know out there to show u that everything is fine and u can go home, or that ull take this because its psychological..

i think a lot of people might be receing diagnosis that r not true, just saying

TammyDelbruegge
TammyDelbruegge

I believe change is on the horizon and progress is a wonderful thing; but until then I will use the most current DSM as long as that is what is required of me to get paid for my services.  If someone comes to me and doesn't want to be diagnosed, I don't have a problem with that because I don't subscribe medications but they must pay out of pocket for my services and I cannot consult with a PCP or psychiatrist about medications.  

CoolMint
CoolMint

Psychiatry is trying to employ the paradigm of General Medicine; however, the current paradigm is fatally flawed, because it is based on the primary assumption that biochemical processes are culpable of causing illnesses, both mental and physical. While doctors admit that illnesses can be based on psychological triggers, they have little idea of what they are talking about, because there is no functional paradigm for what a human being is. More often than not, it is a chicken-and-egg problem, so the cause cannot be identified; you are stuck with the psychological and the physical symptoms that happen to elevate each other. What remains is to stick to the only flickering streetlight in the empty dark street in the middle of the night. As long as treatment (forget about healing) is about profit, I do not expect fundamental changes. Doctors who heal their patients, lose their sources of income in the US.

privaterichard
privaterichard

This is the sea change psychiatry and psychology have been waiting for. I am, for the first time, optimistic about the future of mental illness research and classification. Thank you, Dr. Insel, thank you.

cjmone
cjmone

Insel is such a bright guy with such a useful track record, and I couldn't be happier that NIMH has been working on RDoC for the past few years. The constructs make a great deal of sense for any of us who have ill family members or who have struggled ourselves with milder symptoms, and I encourage people to actually read them. My money's on an inflammation process... but real researchers now have a chance to collaborate in a loosely structured matrix that I'm certain will lead us forward in a way the DSM isn't designed to do. With science.

cjmone
cjmone

Insel is such a bright guy with such a useful track record, and I couldn't be happier that NIMH has been working on RDoC for the past few years. The constructs make a great deal of sense for any of us who have ill family members or who have struggled ourselves with milder symptoms. My mother is on an inflammation

goodgrief
goodgrief

Mr. Insel is an idiot. He only brought up OCD in his examples, yet appears to know NOTHING about the disorder. I have OCD, so I think I know what I'm talking about when I say that Mr. Insel was very wrong in trying to re-classify OCD with other disorders that he believes all have a basis in repetition. OCD is based firmly in ANXIETY (hence it is an Anxiety Disorder). Repetitive rituals are one symptom of OCD, but they are not it's raison d'etre - repetitive rituals in OCD are an anxiety-reducer, whereas repetitive rituals in disorders such as Aspergers and ADHD are not (they are used to kickstart the brain's circuitry). Mr. Insel also wrongly suggests that the different types of OCD (being a washer, counter, religious OCD, etc) should not be classified together as the same disorder. In fact, ALL types of OCD stem from a lack of serotonin, constant high levels of anxiety and a base phobia which can change (ie: from germs to safety). All types of OCD also benefit from SSRI medication and ERP cognitive/behavioral therapy. Note that I said "therapy" - Mr. Insel seems to be saying that medication is the one stop answer for all mental illness. This is ridiculous - ERP is the only effective therapy for OCD, works best in concert with SSRIs, however studies have shown that ERP alone is MORE effective than medication alone! It is terrifying that someone who knows so little about OCD and mental illness in general is in charge of the NIHM.

DocJohnG
DocJohnG

Some people suggest we should just move to the ICD system; the ICD system also relies on symptom lists for diagnoses of mental disorders. There's very little objective difference between the two systems in practice (just different codes used). I also find it odd trying to draw a line between how clinicians use a reference manual like the DSM and pharmaceutical interests. If clinicians overdiagnose, how is that the fault of the current DSM-IV? How can a critic with a straight face suggest this is going to get worse with a new edition when the real problem is not the reference book -- but how people use (and misuse) it?

The NIMH's proposition is (a) primarily focused on researchers (which many journalists seem to gloss over); (b) will be decades in the making, given we've been studying biomarkers of mental illness for decades with little progress; and (c) limited to just one area in the NIMH (it's not the entire NIMH that is going down this road at this time). 

The end result is the DSM is not going away any time soon, despite the hype and hyperbole about it.

lost
lost

There is no objective diagnostic test that can either prove or disprove anything in the D$Moneymaker and since both psychiatric drugs and the diagnosis are manufactured for each other by the drug companies, it is quite obvious why profits for this enterprise dwarf those of all other drugs.   

Which brings us to that old Ferengi proverb:

When there is profit to be made in finding Unicorns;

You find Unicorns!


Rototime
Rototime

Taking a physical cause route to psychiatry will cause a tectonic shift for the better. Eventually.

sixtymile
sixtymile

This is pretty much analogous to classifying species according to genetics rather than by what they look like and makes a lot of sense. Eventually, scientific discipline must take priority over the conventional habits of practitioners for any field of advancing knowledge. And the potential for growth in real knowledge of mental illness is -- well, HUGE. That said, the range of options in deciding classification of anything remains inherently subjective and more a matter of convenience than fact. We mostly classify things because as humans we have this inherent urge to classify things -- and then argue about it.

Dontmindme
Dontmindme

It seems like brain scanning would find a true mental illness as apposed to someone who is depressed because of certain things in their lives making them sad. For example, when someone does drugs and goes crazy it can show up in a brain scan. Crystal meth can put holes in the brain. So, there has to be something going on in the brain, weather it was genetics that made a brain form differently or grow differently, or another cause for a brain to have a disorder. Also, I've heard of some anti depressants making patients want to commit suicide! That doesn't sound right at all. The pharmaceutical companies seem to be putting pressure on the medical industry to continue to sell medication rather than take the time to develop promising ways to diagnose a patient. "Not every illness can be treated effectively with medication." I think the medical industry is finally starting to realize this as they further investigate mental illness.

aliberaldoseofskepticism
aliberaldoseofskepticism

The biggest issue is that psychiatric ailments are syndromes (that is, lists of symptoms) more than ailmets. That is, I can't just do a serum test for serotonin and declare you depressed the way I can do a serum test for blood glucose and declare you diabetic. As a result, diagnosis is, ah, intuitive. (No, $cientologists, this doesn't make you "right".)

Maybe we should just adapt the ICD system.

lawrencesene
lawrencesene

I think Dr. Frances summed it up pretty adequately: "“We need to give reassurance for people operating under the current diagnostic system that it makes sense.  It’s not the best way to go forward in research, but it’s the best available form of clinical treatment and planning available now.”


anniethebug
anniethebug

The DSM is one of the big reasons psychiatry is in such a sorry state today.  The profession is weighed down by charlatans, and by ridiculous, psychobabble diagnoses that command top insurance dollars.  People with mental illness DO deserve better. 

Take multiple personality disorder AKA dissociative identity disorder ... a totally made-up diagnosis that remains in the DSM year after year.  It's a huge cash cow for a very small number of doctors who make patients believe they have the illness, but it's made psychiatry a laughingstock legally and morally for 30 years now.  That's just one example where the DSM-defined "truth" causes a lot of harm to society and to the profession.

Whatever good psychiatry is doing is getting lost in the noise of these sorts of nonsense treatments.  The profession needs to reform from within.  The practitioners who have common sense and decency need to stop tolerating the greedy idiots among them. 

That's why Insel is saying, “I don’t see a reduction in the rate of suicide or prevalence of mental illness or any measure of morbidity.  I see it in other areas of medicine and I don’t see it for mental illness. That was the basis for my comment that people with mental illness deserve better.” 

Everyone knows people aren't becoming more mentally well over time, even as more and more money is spent.  I think that some patients, treated by reasonable doctors, probably ARE improving, but that's totally cancelled out by patients harmed by unnecessary or absurd treatments. 

ClaireSaenz
ClaireSaenz

This is quite a stunning development.  Watching the controversy over DSM-V I often wonder why we don't simply adopt the ICD system.

cjmone
cjmone

I encourage you to have an open mind about Insel's human nature and NIMH goals, and read more about RDoC. This is not a compassionless man. Talk therapy will always exist and be helpful for many. Also, I disagree with your firm opinion about the nature of "all" OCD, or about why people with autism may have these behaviors.

goodgrief
goodgrief

It is also disturbing how compassionless and cold Mr. Insels' suggestions are. What we need is more COMPASSION shown toward people with mental illnesses. That's something you CAN get from a therapist, I doubt you'll find the same from a brain scan.

TammyDelbruegge
TammyDelbruegge

@lost so you are saying if we don't diagnose someone with OCD, Asperger's, Depression, etc., they won't have it...well, then, problem solved.  i will explain that to the next person that comes in to my office and see if that takes care of the problem.

cjmone
cjmone

I think we need to remind people that the DSM and IDC mental illness brackets are rough attempts to categorize behaviors, and useful to the person only for insurance billing. The categories themselves have developed from both factual and disproven historical concepts, infighting among psychiatric factions, and the influence of available pharmaceuticals to address various symptoms. People who present with serious illness and get labeled with a DSM diagnosis should be reminded that real research has thus far been limited.

cjmone
cjmone

MPD was Huge in the 90s. Got a psychosis disorder? Must be MPD! It's BPD they're diagnosing everyone with now. These poor kids, being told they have a personality disorder...

lawrencesene
lawrencesene

@anniethebug You raise some good points. However, "The practitioners who have common sense and decency need to stop tolerating the greedy idiots among them." seems a little simplistic. You mean like the banking industry? Your solution is simple enough, it's implementation, not so much. This may not be the last edition of the DSM before it's replaced by RDoC, or something like it.



aliberaldoseofskepticism
aliberaldoseofskepticism

The DSM has a large lay readership. It's actually a major source of the APA's funding.

The biggest issue with the DSM-V is that it seems to begin the diagnostic process with "What mental illness do you have?", rather than "Do you have a mental illness?" The latter is a perfectly legitimate question, since you're going to a psychiatrist. The former is just begging the question.

TammyDelbruegge
TammyDelbruegge

@cjmone Anyone that starts their comment of with "Mr. Insel is an idiot." is not likely to be receptive to your encouragement...keep in mind the author's words tell us about the author himself.

aliberaldoseofskepticism
aliberaldoseofskepticism

Perhaps not, but it would fix the change in the DSM from the DSM-IV's "Do you have a mental illness?" to the DSM-V's "What mental illness do you have?"

Again, it depends on the ailment. There are physical stigmata of autism, but not everyone with a large, brachycephalic skull is autistic.

cjmone
cjmone

That should be ICD, sorry. I hope I won't get a dyslexia diagnosis for that!

TammyDelbruegge
TammyDelbruegge

@cjmone children aren't diagnosed with personality disorders...i don't know what the news dsm says about it but as of right now, PD can't be diagnosed until 18 years of age...which is legally considered an adult.