A paradigm shift in psychiatric diagnosis

I cannot yet speak personally to the contents of the soon-to-be-released DSM-5, but it would be difficult to argue that the circumstances surrounding its A paradigm shift in psychiatric diagnosisrelease are anything short of a complete mess. The newest edition of the manual had already elicited severe criticism from psychiatrists and psychotherapists, including one of its biggest former advocates. These dissents are now purchasable in popular book form, as the Times highlights two publications attempting to discredit the DSM-5 on the proverbial eve of its debut.

Most significantly, on April 29th the National Institute of Mental Health (NIMH), the primary source of federal funds for mental health research in the United States, officially denounced the DSM-5. NIMH cites the manual’s “lack of validity” and states bluntly that “[patients] with mental disorders deserve better.” Like the book by Greenberg reviewed in the above Times article, NIMH roots the problem with the DSM in its structuring mental disorders by symptom clusters rather than “any objective laboratory measure” like the myriad tests used in medicine to positively diagnose physical illness. As an alternative, NIMH simultaneously announced the launch of its Research Domain Criteria (RDoC) project, which seeks to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.” This does not simply represent a dismissal of the old diagnostic paradigm that has existed in psychiatry since the third edition of the DSM, but an active move toward a new paradigm that focuses on the brain and deemphasizes symptomatology.

How should clinical psychology feel about this impending shift? McWelling Todman, a clinical psychologist in my department at The New School, sent the following impressions out on a recent listserv email chain:

“I see [the RDoC] enterprise as having two potentially important implications, one of them inevitable and near term, the other increasingly probable, but further away on the horizon. The first implication is the obvious one: It is going to be almost impossible to get NIMH funding unless there is adherence to the proposed brain circuit-based RDoC classification system in the framing of the project. The second implication is arguably more serious, and that is that the training model(s) for clinical psychology will have to be radically transformed if it is going to survive.”

Todman went on to point out that the goals and philosophy of RDoC are very much in line with President Obama’s recently announced brain-mapping initiative.

Moving away from the method of clustering symptoms into artificially designated categorical diagnoses is an appealing prospect. At the same time, the furthering of an agenda to make mental illness an entirely biological concept threatens to devalue or disenfranchise some of the most interesting and clinically useful aspects of clinical psychology and psychoanalysis. This discussion is only just beginning, and it will need voices from all sides to ensure that how we research, diagnose, and conceptualize mental illness moves in a better direction.

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4 thoughts on “A paradigm shift in psychiatric diagnosis

  1. […] Researchers found that they could accurately diagnose bipolar disorder with 72-73% accuracy, depending on sample. Principle investigator Dr. Sophia Frangou said this “level of accuracy… is comparable to that of many other tests used in medicine.” Such findings are a boon to the National Institute of Mental Health’s (NIMH) new initiative for brain-based psychiatric diagnosis. […]

  2. […] Even if we are able to identify biological markers of mental illness (as is the goal of the National Institute of Mental Health’s new Research Domain Criteria initiative), there would be no scientific logic to the conclusion that the illness is purely biological; that […]

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