You may have heard the recent chatter, panic even, within the mental health community surrounding The National Institute of Mental Health (NIMH) and its "abandonment of the DSM." After speaking to Assistant Professor of Clinical Psychology (in Psychiatry) from Columbia University Medical Center, Rachel Marsh, Ph.D., this seemingly shocking and bold news revealed two important messages. One, the DSM is NOT being abandoned by researchers or clinicians, but rather re-examined and developed in a way that redefines the classification of psychopathology. Two, the Research Domain Criteria Project (RDoC) has been launched by NIMH with the intention of understanding mental illness and dysfunction based on dimensions of observable behavior and neurobiological measures. RDoC is meant to eventually help rewrite the DSM, not abolish it.
Since spring of 2009, NIMH researchers have been examining mental illness with a fresh perspective. Research studies are now aimed at exploring and focusing on commonalties across all disorders, studying fundamental biological and cognitive processes underlying mental illness. Thus far, mental health research has been based upon the criteria of the DSM.
The NIMH explains that the current diagnostic system has not integrated recent breakthroughs in genetics, molecular, and cellular and systems neuroscience. According to NIMH, "if we assume that the clinical syndromes based on subjective symptoms are unique and unitary disorders, we undercut the power of biology to identify illnesses linked to pathophysiology and we limit the development of more specific treatments." Moving away from the DSM should allow researchers to study patients based on commonly found issues across illnesses, and consider biologically contributing factors.
The limitations of our current diagnostic system (the DSM) are clear. Many who suffer from mental illness experience significant symptoms, yet fall into a gray area when they fail to meet the rigid criteria for a disorder. Those who suffer from EDNOS (Eating Disorders Not Otherwise Specified) for instance, are lacking in criteria that would catapult them into the group of Anorexia Nervosa. EDNOS patients linger in a space between diagnoses, often reporting that they feel they have "failed" at their eating disorder by receiving this diagnosis. This diagnosis can be particularly frustrating, as most patients do not have "pure forms" of eating disorders, and they may cross over from one disorder to the other over time. Although EDNOS has the highest death rate of any category of eating disorder, it can become much more difficult to access treatment when insurance companies see this diagnosis (as what they might think) is not quite as serious as Anorexia. What can we do to treat the distinct illnesses that exist outside the pages of the DSM?
David Kupfer, MD, Chair of the DSM-5 Task Force, made a statement on the future of mental health research indicating change ahead, "We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting. In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia." He goes on to explain that while the DSM has been universally utilized by clinicians to describe and diagnose the behaviors and symptoms of their patients, modifications to the DSM-5 will encourage other directions in future research. In support of RDoC, Kupfer goes on to say, "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. RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field."
We are hopeful that the modifications made to the DSM-5, and furthermore the implications of the RDoC research, will make it more difficult for insurance companies to deny coverage for mental illness. Relaxing and re-orienting the way we understand the DSM-5 criteria will hopefully improve the way we recognize, diagnose, and describe illness across disorders; as well as improving detection during the early courses of mental illness. This has the potential for more effective intervention and treatment through providing new specific biological targets for medication- and perhaps with this flexibility in definition- greater access to insurance coverage and treatment.
The take home message: thinking outside of the limitations of the DSM could mean revolutionizing the way we diagnose and treat mental illness. This shift in understanding and diagnosing mental illness has been in the works for decades, although it should be quite some time before we can become impacted by the effects of this research.
NIMH has made the RDoC process open and transparent to the community, encouraging any comments or questions about the project. Stay up to date with the RDoC Project here: http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml