Tuesday, 7 May 2013

From DSM-5 to RDoC - From bad to worse?

A personal crisis can remind us of our frailty and increase the wish for a sense of order and meaning; consequently, it can be reassuring when a doctor frames our difficult-to-define experiences in a clear and organised way by using familiar diagnostic criteria - usually beginning with "You are suffering from ..."

Though we may welcome some semblance of order during mental or emotional distress, it is not reassuring to know that the producers of DSM-5 have failed to come up with the scientific evidence to support the diagnostic categories that form the basis of this code book. In truth, these are simply just one way of trying to understand our personal struggles and crises (I write more about this here). Furthermore, the limits and risks of the DSM-5 have been loudly trumpeted by many people, including Dr Allen Frances, such as here in the New Scientist.

With the precise timing akin to an experienced actor entering the stage, Dr Insel (Director of the National Institute of Mental Health – NIMI) has announced that they (NIMI) have the answer. They are developing another new classification system (the Research Domain Criteria, RDoC) that will, he asserts, be far superior and have a more robust scientific basis. And with reference to DSM-5, Dr Insel concludes: “The weakness is its lack of validity”.

When I read Dr Insel’s report, some things didn’t ring true. I mention just one: he explains that the research for this new classification system “began with several assumptions”, including the one that “mental disorders are biological disorders involving brain circuits”.

It’s elementary, isn’t it - if science is an open and unbiased (as far as possible) quest for knowledge (and truth) - research cannot be based on narrow and rigidly predetermined assumptions without prejudicing the outcome. Dr Insel is in effect saying “we have decided mental disorders are biological disorders involving brain circuits, and on this basis we will introduce a new diagnostic approach and treatments to match.” It’s certainly wilful, but I don’t see this as science. As Dr Insel says of DSM-5, here again with RDoC the same applies: “the weakness is its lack of validity”. [...]

Central to the emergence of 17th century Enlightenment thinking was the rejection of myth and dogma - in favour of open, logical and systematic questioning and reason. But this is not possible when the parameters are too narrow. By way of example, there is an enormous gulf between asking: “Why does God exist?” and asking “Does God exist?” 

It is not coincidental that I have strayed from speaking about psychiatry to theology. In one sense the Enlightenment was provoked into being by the dogmatism of aspects of theology, its abuse of power, and a failure to reason and to be reasonable. It seems to me that claiming that “mental disorders are biological disorders involving brain circuits” is far too narrow an assumption and is more akin to an adherence to a belief system than a genuine search to understand.

Clearly, in the sense that all we do - whether we eat, sleep, read, tweet - involves brain circuits, so “mental disorders are biological disorders involving brain circuits”. But this is quite different from implying that these can be shown to be directly causal and then require the development of new drug treatments to rectify the disorders, which is where this article by Dr Insel leads us.

I have become both wary and weary of big claims that fail to understand our lives within their social, cultural, racial, familial, interpersonal and economic circumstances. I share Prof Kendler’s caution when it comes to big claims. With reference to psychiatry he writes:

“We have hunted for big, simple neuropathological explanations for psychiatric disorders and have not found them.  We have hunted for big, simple neurochemical explanations for psychiatric disorders and have not found them. We have hunted for big, simple genetic explanations for psychiatric disorders and have not found them…Our current knowledge, although incomplete, strongly suggests that all major psychiatric disorders are complex and multifactoral…In grieving for our loss of big explanations, we similarly have to give up our hope for simple, linear explanatory models.”

Surely any answers towards understanding and responding to mental and emotional distress lie, not so much in big claims (such as “mapping the cognitive, circuit, and genetic aspects of mental disorders”, as Insel proposes) but rather in looking to the bigger picture within the broader context of our lives. As I have written here:

“Understanding our lives in context does not mean ignoring the findings from genetic research and neuroscience that might shed light on any causes of emotional and mental distress. It does, however, become problematic when these factors are allowed to eclipse the relevance of clues within the circumstances and events of our lives.
I think the complex interplay between social, environmental, genetic and neurological factors is still little understood and it is certainly possible that research will in the future reveal as-yet-not-understood biological factors that impact upon aspects of our psychological well-being. Even so, formative factors such as: the family we grow up in; the schools we attend; the way we are treated; the level of social deprivation experienced; the trauma and distress we encounter; and the relationships we form, will still be key determinants and of primary significance in helping us to understand our lives.”

Whether DSM-5 or RDoC, these detract from what really matters – our personal quest for meaning when hope and meaning can be difficult to find.

“People understand me so little that they fail even to understand my complaints that they do not understand me.”
- Søren Kierkegaard, Feb 1836

6 comments :

  1. Very thoughtful and well-said.

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  2. Great coverage of all the angles in the DSM debate, and the RDoC business is a new one on me - beggars belief! I totally agree with your emphasis on context and would add, if I may, that lived experience cannot be measured, only described, thus I argue for narrative ethnography to be recognised as a valid research method in mental health policy and practice. Thanks for such informative and stimulating work :)

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    1. Thanks Roberta. Central to RDoC is the emphasis on brain circuits as the root of mental health concerns. Some (me included) have grave concerns over the ratio of benefits versus risks of the proposed treatments. I know its a rather lengthy post, but many people seem hoodwinked by newfangled treatments to supposedly correct so-called brain circuit disorders: http://blog.mythsandrisks.info/2013/07/deep-brain-stimulation-treating-or.html

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  3. Thank you and You're spot on there Mick - people put a tremendous amount of faith in bio-medical psychiatric knowledge when in many ways it is pseudo-knowledge, if not downright imagination! Brain circuits are all very well but they are very complex surely, and shaped by experience, diet, many things. I can't understand why they won't just listen to people and focus on outcome research - social support, being listened to, having meaningful activities to focus on - these are what people say help them feel better. I really do recommend Rapley et al (2012) 'Demedicalising Misery'. Joanna Moncrieff, Pat Bracken, Jacqui Dillon etc.. all have chapters, brilliant stuff. Maybe you're aware of that work already, noted your ref to Allen Frances - love his blog on Psychology Today :)

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    1. No, haven't read that one. Yes, Allen Frances speaks a lot of commonsense (though we do have some strong differences of opinion in some regards). I haven't quite forgiven him yet for his part in DSM-IV :)

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