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Friday, 3 May 2013

DSM-5 - "WATERSHED MOMENT" - CAN IT SURVIVE SUCH SCATHING CRITICISM FROM A MAJOR AND WELL RESPECTED MENTAL HEALTH RESEARCH BODY?++++ COME TO SEMINAL CONFERENCE (BELOW) AT OLD TRAFFORD ON JUNE 28th 2013 - "American Psychiatry divided as mental health 'bible' denounced by the U.S. National Institute of Mental Health"

Psychiatry divided as mental health 'bible' denounced-  COME TO SEMINAL CONFERENCE (BELOW) AT OLD TRAFFORD ON JUNE 28th 2013 - "American Psychiatry divided as mental health 'bible' denounced by the U.S. National Institute of Mental Health" (The World's biggest MH Research Institute + the results of their Research Criteria Project) - They will no longer use DSM as a research tool - COURTESY OF NEW SCIENTIST MAGAZINE MAY 3rd 2013

Come to seminal conference at Old Trafford on June 28th 2013 with Prof Allen Frances and other great keynotes:

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.

On 29 April, Thomas Insel, director of the US National Institute of Mental Health (NIMH), advocated a major shift away from categorising diseases such as bipolar disorder and schizophrenia according to a person's symptoms. Instead, Insel wants mental disorders to be diagnosed more objectively using genetics, brain scans that show abnormal patterns of activity and cognitive testing.

This would mean abandoning the manual published by the American Psychiatric Association that has been the mainstay of psychiatric research for 60 years.

The DSM has been embroiled in controversy for a number of years. Critics have said that it has outlasted its usefulness, has turned complaints that are not truly illnesses into medical conditions, and has been unduly influenced by pharmaceutical companies looking for new markets for their drugs.

There have also been complaints that widened definitions of several disorder have led to over-diagnosis of conditions such as bipolar disorder and attention deficit hyperactivity disorder.

Now, Insel has said in a blog post published by the NIMH that he wants a complete shift to diagnoses based on science not symptoms.

"Unlike our definitions of ischaemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," Insel says. "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."

Insel says that elsewhere in medicine this type of symptom-based diagnosis been abandoned over the past half-century as scientists have learned that symptoms alone seldom indicate the best choice of treatment.

To accelerate the shift to biologically based diagnosis, Insel favours an approach embodied by a programme launched 18 months ago at the NIMH called the Research Domain Criteria project.

The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behaviour. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.

"We cannot succeed if we use DSM categories as the gold standard," says Insel. "That is why NIMH will be reorienting its research away from DSM categories," says Insel.

Prominent psychiatrists contacted by New Scientist broadly support Insel's bold initiative. However, they say that given the time it will take to realise Insel's vision, diagnosis and treatment will continue to be based on symptoms.

Insel is aware that what he is suggesting will take time – probably at least a decade, but sees it as the first step towards delivering the "precision medicine" that he says has transformed cancer diagnosis and treatment.

"It's potentially game-changing, but needs to be based on underlying science that is reliable," says Simon Wessely of the Institute of Psychiatry at King's College London. "It's for the future, rather than for now, but anything that improves understanding of the etiology and genetics of disease is going to be better [than symptom-based diagnosis]."

Michael Owen of the University of Cardiff, who was on the psychosis working group for DSM-5, agrees. "Research needs to break out of the straitjacket of current diagnosis categories," he says. But like Wessely, he says it is too early to throw away the existing categories.

"These are incredibly complicated disorders," says Owen. "To understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time, but in the meantime, clinicians still have to do their work."

David Clark of the University of Oxford says he's delighted that NIMH is funding science-based diagnosis across current disease categories. "However, patient benefit is probably some way off, and will need to be proved," he says.

The controversy is likely to erupt more publically in the coming month when the American Psychiatric Association holds its annual meeting in San Francisco, where DSM-5 will be officially launched, and in June in London when the Institute of Psychiatry holds a two-day meeting on the DSM.

DSM-5 and the NIMH Research Domain Criteria Project

By James Phillips, MD | 13 April 2011

The NIMH Research Domain Criteria (RDoC) project raises many questions about DSM-5 and future DSMs. The first is, does the project play a role in DSM-5? Answer: no. Another question: Will the RDoC play a role in future DSMs? Certainly yes. And further: Will the project cause major revisions in future DSMs? For sure. And finally: What does this say about the status of DSM-5? Let’s consider this.

But first we had better take a look at the RDoC project. The project has its origin in the failure of DSM-III and DSM-IV to achieve their ultimate scientific objectives. In the planning of DSM-III, the first objective was to insure reliability of the diagnostic constructs across different research and clinical settings through the use of diagnostic criteria. That goal was mostly accomplished and was considered the main achievement of DSM-III and DSM-IV.

A second objective was to achieve validity of the diagnostic categories—that the categories would reflect real disease or disorder entities in the real world. The current consensus is that this goal has not been not been achieved. Warning signs have been the heterogeneity of clinical presentation, high levels of comorbidity, overlapping of categories, and failure to discover biological markers for the diagnostic categories. In a more technical sense, the Robins and Guze criteria for validity1 have not been accomplished. The conclusion from all this is that the current set of diagnostic constructs cannot be considered true phenotypes that in any way match underlying genetic and pathophysiologic findings: “As it turns out, most genetic findings and neural circuit maps appear either to link to many different currently recognized syndromes or to distinct subgroups within syndromes.”2

This stalemate with the DSM categories has led to an entirely different approach to organizing research in psychopathology. In dramatic contrast to the DSM-III/DSM-IV approaches (begin top-down, with reliably established, descriptive diagnostic constructs and then search for the underlying genetic and pathophysiologic foundations), the new approach initiated by the NIMH—called the NIMH Research Domain Criteria (RDoC) project2,3 —starts bottom-up, with smaller, more fine-grained units of behavior or function (called “constructs”) that have been shown to be associated with disruptions of neural circuitry. These constructs are provisionally grouped into 5 larger “Domains.” The domains and constructs are placed in rows in a matrix, with the columns then representing the various ways in which the constructs can be studied: the columns currently listed are genes, molecules, cells, circuits, behavior, and self-reports. In this way any construct can be studied from a variety of perspectives, and the constructs can be studied against one another.
Two points are worth mentioning about the RDoC project. First, the RDoC constructs are not expected to match up with current DSM categories (and will crisscross through them), but are expected to play a significant role in future nosologies. As the NIMH team writes, “The NIMH is launching the RdoC project to create a framework for research on pathophysiology, especially for genomics and neuroscience, which ultimately will inform future classification schemes”4, p 748 Second, despite the matrix columns for behavior and self-report, the project treats psychiatric disorders as brain disorders. To quote the same authors: “First, the RDoC framework conceptualizes mental illnesses as brain disorders.”4, p 749 The project is thus fully in the spirit of the biological impetus that drove DSM-III.
Where does the RDoC project leave DSM-5? In a word: in an odd place. On the one hand, the architects of DSM-5 have been quite aware of the failures to match DSM-IV constructs with genetic and neuroscientific findings.5-8 On the other hand, both DSM-5 and the RDoC project place major importance on dimensional measures. Writing about the evolution of DSM-5 in 2009, Regier and colleagues wrote that “Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V.6,p 649 And Strategy 1.4 of the NIMH Strategic Plan is: “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”3
The coincidence of dimensionality in both the RDoC project and DSM-5 does not reflect an influence of the former on the latter. The difference between dimensions in the RDoC project and dimensions in DSM-5 is that, while the former are part of an effort to further research into constructs with known disruptions in neural circuitry, the latter are more of a fishing expedition to increase the validity of the existing manual (eg, by adding cross-cutting dimensional measures of anxiety and depression to the existing categories). The dimensional measures proposed for DSM-5 are, we might say, an effort to produce a “RDoC-lite.”
In view of the fact that significant scientific progress in understanding mental disorders will have to wait for the results of the RDoC project or of similar work in genomics and neural circuitry,9 it is not hard to support the conservative attitude toward change in DSM-5, especially with respect to the proposed dimensional measures, espoused by Allen Frances and others.10-11
1. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970;126:983-987.
2. National Institute of Mental Health Research Domain Criteria Project (RDoC).
http://www.nimh.nih.gov/research-funding/nimh-research-domain-criteria. Accessed April 13, 2011.
3. National Institute of Mental Health Strategic Plan.
http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml. Accessed April 13, 2011.
4. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748-751.
5. Kupfer DJ, First MB, Regier DA, eds. A Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association Press; 2002.
6. Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. Am J Psychiatry. 2009;166:645-650.
7. Hyman SE. Can neuroscience be integrated into the DSM-V? Nat Rev Neurosci. 2007;8:725-732.
8. Regier DA, Narrow WE, Kuhl EA, Kupfer DJ, eds. The Conceptual Evolution of DSM-5. Arlington, VA: American Psychiatric Publishing; 2011.
9. Akil H, Brenner S, Kandel E, et al. Medicine. The future of psychiatric research: genomes and neural circuits. Science. 2010;327:1580-1581.
10. Frances A. DSM in philosophyland: curiouser and curiouser. Bulletin of the Association for the Advancement of Philosophy and Psychiatry.
http://alien.dowling.edu/~cperring/aapp/bulletin.htm. Accessed April 13, 2011.
11. Phillips J. DSM-5 is a many-dimensioned thing. Psychiatric Times.
http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1696725. Accessed April 13, 2011.


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