Rdoc And Dsm-5: The Future Of Diagnosis
The debut of thefifth editionof theAmerican Psychiatric Association’s(APA)Diagnostic and Statistical Manual of Mental Disorders (DSM)at the upcoming APA annual meeting might be regarded as the year’s most anticipated event in the mental health field. Its release has been covered in the media, including theWashington PostandThe New York Times,andexperts have weighed in with their viewof how this publication will impact clinicians, researchers and those diagnosed with mental disorders. However, an initiative underway for several years at theNational Institute of Mental Health(NIMH) could have more far-reaching effects on the diagnosis and treatment of mental health disorders and addiction.
TheNIMH’s Research Domain Criteria(RDoC) project was born of the inability of previous editions of theDSMto achieve both of their ultimate scientific objectives: produce areliable diagnostic codefor clinicians to use, and prove that these diagnoses arevalid(i.e. the measure to which the DSM accurately diagnosis what it claims to diagnose).1On the one hand, theDSM-IIIandDSM-IVachieved the first objective of insuringreliabilityof the diagnostic constructs across different research and clinical settings through the use of diagnostic criteria, providing a “common language” among clinicians and ensuring “that a diagnosis is both accurate and consistent; for example, that a diagnosis of schizophrenia is consistent from one clinician to another, and means the same thing to both of these clinicians, whether they reside in the United States or other international settings.”2
On the other hand, the objective of establishing thevalidityof the diagnostic categories has not been achieved.1Unlike definitions of medical illness, such as heart disease or AIDS, “theDSMdiagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” such as found in genetics and brain imaging research.3
Consequently under the leadership of NIMH DirectorThomas Insel, M.D., the institute concluded that a new strategic framework was essential for generating research–unconstrained by theDSMcategories– that will eventually enable health care professionals to diagnose mental disorders as precisely as identifying strep throat by a throat swab. To achieve this goal, the NIMH will place a priority on collecting the imaging, genetic, physiologic and cognitive data on mental disorders–not just the symptoms–and see how they relate to treatment.3In other words, the emphasis will be on the causes of the disorder, not the symptoms.4
In this light, the utility of neuroscience and genetic studies on disordered gambling for developing treatment strategies becomes clearer. As Dr. Insel has noted, “Symptoms alone rarely indicate the best choice of treatment.”3For example, a study of the brain’s circuitry rather than a focus on symptoms might suggest which areas of brain are implicated in the impulsivity and poor decision-making of disordered gambling and, therefore, offer a region at which drug treatment can be targeted.5,6
One critique of RDoC is that the research base has not developed fully enough to supply the data needed to transform diagnosis and treatment. In response to Dr. Insel’s blog about RDoC andDSM-5,David Kupfer, M.D., chair of APA’sDSM-5Task Force, argued that although “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,’ the RDoC vision of a system based on biological and genetic markers ‘remains disappointingly distant’ and ‘cannot serve us in the here and now.’7It ‘merely hand[s] patients another promissory note that something may happen sometime.”7
What do you think of the RdoC approach? Please leave your thoughts or comments in the section below.
The National Center for Responsible Gaming (NCRG) will also be at the APA Annual Meeting from May 17 to 22 as theDSM-5is released. NCRG staff members Christine Reilly, Nathan Smith and Amy Kugler will be live blogging and updating the NCRG’s Facebook and Twitter pages with news and insights. The NCRG will also be at Booth #2128 in the APA Exhibit Hall. Please follow us online or in person as the events unfold at the APA Annual Meeting!
References
1. DSM-5 and the NIMH Research Domain Criteria Project – Psychiatric Times. 2011. Available at: http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1842906. Accessed May 6, 2013.
2. American Psychiatric Association. DSM-5 Development. 2010. Available at: www.dsm5.org.
3. Insel T. NIMH Director’s Blog.Transform. Diagn.2013. Available at: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.
4. Belluck P, Carey B. Psychiatry’s New Guide Falls Short, Experts Say.The New York Times. http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html. Published May 6, 2013. Accessed May 7, 2013.
5. Balodis IM, Kober H, Worhunsky PD, Stevens MC, Pearlson GD, Potenza MN. Diminished frontostriatal activity during processing of monetary rewards and losses in pathological gambling.Biol. Psychiatry. 2012;71(8):749–757. doi:10.1016/j.biopsych.2012.01.006.
6. Potenza MN. Pharmacological approaches to treating pathological gambling. In:What Clinicians Need to Know about Gambling Disorders.Vol 7. Increasing the Odds: A Series Dedicated to Understanding Gambling Addiction. Washington, DC: National Center for Responsible Gaming; 2012:52–60. Available at: http://www.ncrg.org/resources/monographs. Accessed April 30, 2013.
7. American Psychiatric Association. Psychiatric News Alert.David Kupfer Md Responds Crit. Dsm-5 Nimh Dir.Available at: http://alert.psychiatricnews.org/2013/05/david-kupfer-md-responds-to-criticism.html?spref=tw. Accessed May 6, 2013.
