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NIMH Distances Itself From DSM Categories, Shifts Funding To New Approaches
New submitter Big Nemo '60 writes with news that the National Institute of Mental Health is seeking to modernize the diagnosis of mental illness through the use of neuroscience, genetics, etc. From the article: "The world's biggest mental health research institute is abandoning the new version of psychiatry's 'bible' — the Diagnostic and Statistical Manual of Mental Disorders — questioning its validity and stating that 'patients with mental disorders deserve better.' This bombshell comes just weeks before the publication of the fifth revision of the manual, called DSM-5."
More importantly, they are going to be shifting funding to research projects that seek to define new categories of mental illness using modern medical science, ignoring the current DSM categorizations: "The strength of each of the editions of DSM has been 'reliability' .. 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. ... 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. ... It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the 'gold standard.' ... 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."
I had internal infections misdiagnosed as depression for over 4 years before physical symptoms appeared. This is a good thing to avoid these kind of errors in the future. How the hell can a doctor prescribe SSRI without measuring the actual levels first?
Tomorrow is another day...
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. ...
In the early 1990s, I was prescribed drugs because "there's too much dopamine up there". They didn't measure jack. They just came up with this out of the blue based on how I was behaving.
The absolute lack of measurement was readily apparent to me, even in my state which after decades was most likely undiagnosed autistic spectrum disorder and post traumatic stress from all the crap that happens when spectrum kids get bullied in school.
Dopamine up there? How the hell couuld they know without a measurement.
The other problem with DSM is that it's too normative. Homosexuality is a "disorder", but then when you start treating homosexuals nicely they suddenly become less traumatized, more come out, and you realize that most of them aren't as sick as you thought, and that a lot of the sick ones are like that because you marginalized them in the first place.
First things first though. Come up with something to measure at least before you even pass judgement on it being normal, and then MAYBE you can try to come up with how much deviation from the mean is healthy. Posted AC for obvious reasons...
The New Scientist article -- whoops, guest editorial -- is titled "Psychiatry divided as mental health 'bible' denounced", but 'denounced' is a ridiculous overstatement. NIH/NIMH are simply announcing a new cross-category funding program that will step back and question the field's traditional assumptions.
Either the guest editorialist didn't RTFA, or else is just using the occasion to inject their personal views into public sight.
Or else just trolling.
Sheesh, evil *and* a jerk. -- Jade
I'm really glad this has come about, not because the DSM itself is a useless book but because the attitudes towards it lead to some gross errors of judgement.
The DSM can be useful: if one clinician wants to communicate to another at a fairly high level the symptoms a patient is experiencing, then a DSM-defined disorder can be a reasonably efficient way of doing this. Also, the DSM does group together some symptoms which tend to occur as clusters under labels which can provide cues for looking for related symptoms which might otherwise be missed.
However...
People make the mistake of thinking that because something is listed in the DSM it is somehow a 'real disease'. The Epstein–Barr virus is a real disease: it is caused by a specific virus. Type I Diabetes is a real disease: it is caused by the loss of insulin-producing cells in the pancreas (although there is the more distal cause of the cell loss). Depression is not a real disease, in this sense - at least, not at the moment. It is a cluster of symptoms which when the occur together are referred to as Depression. Nothing more. (That isn't to say a 'disease' will not actually be identified at some point, but I suspect that will be for a specific subtype of depression, not depression as it is currently classified).
On the radio yesterday, I heard an 'aspie' - who under DSM 5 will no longer be an 'aspie' since Aspergers will no longer exist in its current form - talking about how it was great when he was diagnosed because they finally knew what was wrong with him. The problem is this: they didn't and still don't know what's wrong - just that his symptoms fit a commonly observed pattern, and that there are particular interventions to try to address the associated deficits. Having a listing in the DSM doesn't make things any more or less 'real', but some/many people imagine that it does. Just because there isn't a diagnostic criteria for a very shy child (although I imagine one could be found if looking hard enough), that doesn't mean that there aren't programmes to help the child be more comfortable with social interaction.
This becomes most manifestly a problem when conducting genetic, neurobiological, or even treatment research into the causes for 'a disorder'. Because these disorders are symptom clusters, and often have substantial variation in presentation, they are at times artificially grouped for research. This can hinder research into specific subgroups who show more common characteristics. Similarly, if there is a presentation which includes two DSM disorders (e.g. depression and anxiety, which is a very common comorbidity) then these people will tend to be systematically excluded from research because they are defined as 'having comorbidity'. Are both 'disorders' caused by the same underlying cause? Who knows, but being separate DSM disorders means that this group tends to be very underrepresented in research.
On top of this, there is the involvement of vested interests in the development of disorders, there is the interpretation of things as 'wrong' because they are a DSM disorder, etc.
In summary, the DSM can be useful for clinicians to communicate a summary to each other, when accompanied by further detail. It can provide gross groupings for treatment research, but lacks finesse of distinction which could help tailored treatments to individual characteristics rather than the broader presentation. People suddenly seem to think something is 'real' because it appears in the DSM, and so push to have ever more 'disorders' included. This all makes DSM as much of a hindrance as a help to good research and mental health practices.
Nerds opining on psychiatric diagnosis...
This should go about as well as psychiatrists opining on monads...
Da Blog
They could all be Climate Scientists!
No. Then they would need measurements. Lots of them. Millions of them. So much measurement, that some people just sit there, overwhelmed by the sheer number of data points and claim, that no one could ever make any sense of it and thus we should just mind our own business and go away.
I assume you're referring to the common deluded misinterpretation of the "climategate" emails, wherein someone used basic statistical principles to align a dataset, and a bunch of morons, without looking at the actual changes, immediately presume that this somehow negates an entire branch of study supported by basic thermodynamics, satellite observation, thermometer data, ice core samples, sea level measurement, and lots of non-corrected tree data.
Right? That's what you mean?