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Time to revamp psychiatry and mental health in light of modern neuroscience?

mentalhealthpuzzleTrans­form­ing Diag­no­sis (arti­cle by Thomas Insel, Direc­tor of the NIMH): “In a few weeks, the Amer­i­can Psy­chi­atric Asso­ci­a­tion will release its new edi­tion of the Diag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders (DSM-5)…While DSM has been described as a “Bible” for the field, it is, at best, a dic­tio­nary, cre­at­ing a set of labels and defin­ing each. The strength of each of the edi­tions of DSM has been “reli­a­bil­ity” – each edi­tion has ensured that clin­i­cians use the same terms in the same ways. 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. Indeed, symptom-based diag­no­sis, once com­mon in other areas of med­i­cine, has been largely replaced in the past half cen­tury as we have under­stood that symp­toms alone rarely indi­cate the best choice of treatment.

Patients with men­tal dis­or­ders deserve bet­ter. 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…”

No One Is Aban­don­ing the DSM, but It Is Almost Time to Trans­form It (SciAm blog post): “Let me be clear: men­tal ill­ness is real, but the dis­crete cat­e­gories of ill­ness in the DSM might not exist out­side its pages…NIMH has, how­ever, been work­ing on an endeavor known as the Research Domain Cri­te­ria Project, or RDoC for short, which encour­ages psy­chol­o­gists, neu­ro­sci­en­tists and other sci­en­tists to think out­side the DSM box—to begin tran­si­tion­ing away from estab­lished DSM dis­or­ders and instead study fun­da­men­tal bio­log­i­cal and cog­ni­tive processes under­ly­ing men­tal ill­ness. The impor­tant dis­tinc­tion here is between clin­i­cal prac­tice and research. The NIMH is not in any way say­ing that clin­i­cians should stop using the DSM, but it does think that the DSM has con­strained research…

Insel echoed these com­ments in a sep­a­rate e-mail: “We can­not ‘ditch’ or ‘reject’ terms like schiz­o­phre­nia or bipo­lar. We just need to view them as con­structs, per­haps includ­ing many dif­fer­ent dis­or­ders that require dif­fer­ent treat­ments or obscur­ing dis­or­ders than cut across the cur­rent cat­e­gories. A symptom-only sys­tem will not be suf­fi­cient for iden­ti­fy­ing brain disorders—whether the ini­tial label is demen­tia or schizophrenia…”

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