NIMH "re-orienting its research away from" DSM

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I wish they'd have placed less emphasis on neurobiology and the medical model, though.
 
Because I think that the medical model is overly reductionist and neglects other important contributing factors (e.g. psychosocial history).
 
cara susanna said:
I wish they'd have placed less emphasis on neurobiology and the medical model, though.
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Ummmm, Cara? That would be contrary to the whole thrust of their project.

Not that I wish anything but a quick and humiliating death to their project...
 
Well, I meant emphasized it in their project.
 
Another nail in the coffin of the DSM!!!
 
cara susanna said:
Because I think that the medical model is overly reductionist and neglects other important contributing factors (e.g. psychosocial history).
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It's not neglecting any factors, it's describing outcomes. With enough research we may be able to see distinct differences within disorders and further break down umbrellas like major depression into subgroups that are specific to contributing factors and potentially produce literature on which drug works on people with specific backgrounds to their disorder.

It's an amazing move forward, but completely unpractical until imaging and what not is cheap enough.
 
Buzzwordsoldier said:
Ummmm, Cara? That would be contrary to the whole thrust of their project.

Not that I wish anything but a quick and humiliating death to their project...
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I take it a lot of psychologist's attitudes towards neuroscience is antagonistic then?
 
serenade said:
It's not neglecting any factors, it's describing outcomes. With enough research we may be able to see distinct differences within disorders and further break down umbrellas like major depression into subgroups that are specific to contributing factors and potentially produce literature on which drug works on people with specific backgrounds to their disorder.

It's an amazing move forward, but completely unpractical until imaging and what not is cheap enough.
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It's basing a new system of diagnosis entirely on medical and neurobiological factors, which pretty much gives the impression that the other factors are unimportant. Not to mention that we don't have consistent explanations of the biological pathogenesis of these disorders, so NIMH taking this forward seems really premature to me.

No, we don't have an antagonistic view, we just think that the medical model is overemphasized. There are a LOT of problems with neurobiological explanations of even the most obviously biologically-based disorders, such as schizophrenia.

The fact that you specifically mentioned "drugs" demonstrates what is wrong with this project to me.
 
Well I was thinking specifically the move toward neuro imaging for diagnosis and treatment plan development.
The reason I said drugs is because I imagine this being used by psychiatrists who know how to use neuroimaging.
Overall it seems like you seem threatened by this move as you think it somehow signifies a push away from your field's training. I mean I think this if anything will make good psychotherapy even more necessary as we could actually make diagnosis significantly more valid.
 
I dislike this move, because I think it's incredibly premature in terms of the science and I think an over emphasis on neurobiology has the potential to ignore important aspects of functioning and environmental/psychosocial factors--"oh, you're suicidal due to your recent job loss. Well, your MRI is normal, so we can't really help you."

The neurobiology of mental illness is interesting and important but very much in its infancy. Plus, we can't just ignore behavior and functional impairment assessment or treatment.
 
I think it is premature, but at the same time I think it is good that this is at least being initiated. It is going to take along time for the evidence base to catch up to the goals - but the goals are good, nonetheless.

Perhaps there is an overmephasis on things like neuroimaging (talk to any neuropsychologist and they'll likely tell you all about the limits of current neuroimaging techniques), and I wouldn't mind seeing some more emphasis on contextual factors. But ultimately, we are not focused enough (IMO) on some of these important underlying variables for psychopathology. I'm a fan of reconceptualizing diagnoses, because I don't like how diagnoses are presently made. Too much overlap and subjectivity.
 
futureapppsy2 said:
I dislike this move, because I think it's incredibly premature in terms of the science and I think an over emphasis on neurobiology has the potential to ignore important aspects of functioning and environmental/psychosocial factors--"oh, you're suicidal due to your recent job loss. Well, your MRI is normal, so we can't really help you."

The neurobiology of mental illness is interesting and important but very much in its infancy. Plus, we can't just ignore behavior and functional impairment assessment or treatment.
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I'm pretty sure you'd use an EEG and see way abnormal wavelengths in a patient who is depressed to the point of suicide, so I'm not sure whether this is simple ignorance of neurobiology or being a closet dualist.

Also why is everyone suddenly thinking that we're going to reject the social and environment factors? Did you all miss the whole point of the fact that those things transfer and affect the brain structure too? Or whether you think that we're all going to just stop listening to patients? I think some of you are jumping the gun here.
 
Pragma said:
I think it is premature, but at the same time I think it is good that this is at least being initiated. It is going to take along time for the evidence base to catch up to the goals - but the goals are good, nonetheless.

Perhaps there is an overmephasis on things like neuroimaging (talk to any neuropsychologist and they'll likely tell you all about the limits of current neuroimaging techniques), and I wouldn't mind seeing some more emphasis on contextual factors. But ultimately, we are not focused enough (IMO) on some of these important underlying variables for psychopathology. I'm a fan of reconceptualizing diagnoses, because I don't like how diagnoses are presently made. Too much overlap and subjectivity.
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I agree, it's extremely premature both because we know far too little about neuroimaging when there aren't very obvious deficits or an entire chunk missing. But in the future it'll be revolutionary for the mental health field in perfecting more precise individual based treatment plans on both sides.
 
serenade said:
I'm pretty sure you'd use an EEG and see way abnormal wavelengths in a patient who is depressed to the point of suicide, so I'm not sure whether this is simple ignorance of neurobiology or being a closet dualist.

Also why is everyone suddenly thinking that we're going to reject the social and environment factors? Did you all miss the whole point of the fact that those things transfer and affect the brain structure too? Or whether you think that we're all going to just stop listening to patients? I think some of you are jumping the gun here.
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I'm not sure you understand how depression or suicide work. You don't necessarily have to be chronically depressed to be suicidal, and suicidality doesn't have be chronic. I haven't heard any good evidence that depression or suicidality can be reliably dx'ed with any sort of physiological or neurological imaging. If you have actual studies, please cite them--I'd legit love to read them. Also, I'm not against physiological or neurological dx measures--if we had them, great. But we don't--like I said, the science is very in its infancy.
 
futureapppsy2 said:
I'm not sure you understand how depression or suicide work. You don't necessarily have to be chronically depressed to be suicidal, and suicidality doesn't have be chronic. I haven't heard any good evidence that depression or suicidality can be reliably dx'ed with any sort of physiological or neurological imaging. If you have actual studies, please cite them--I'd legit love to read them. Also, I'm not against physiological or neurological dx measures--if we had them, great. But we don't--like I said, the science is very in its infancy.
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http://scholar.google.com/scholar?hl=en&q=eeg+for+depression&btnG=Submit&as_sdt=1,21&as_sdtp=

Choose your pick. We've had many amazing ones since the 90s that can be improvised for psychiatry.

I'm also not sure how the above really plays into any of this, chronic or not you'll have physiological correlates. That being said the time issue is big in dsm diagnoses, you can't even be diagnosed with major depression without having had it for over 6 weeks?
Anyways, you're right. The field is in it's infancy, which is why we should keep the DSM and try to expand on the social and individualistic aspects for the time being while moving forward and expanding on the physiological measuring.
 
Why replace the DSM with anything? Why do we need a disease model at all? My saying that doesn't mean psychologists can't be helpful and psychiatric drugs can't be useful, or that there isn't such a thing as science as regards "problems in living" as Tom Szasz called it...
 
JeyRo said:
Why replace the DSM with anything? Why do we need a disease model at all? My saying that doesn't mean psychologists can't be helpful and psychiatric drugs can't be useful, or that there isn't such a thing as science as regards "problems in living" as Tom Szasz called it...
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I don't know, why have literature on neurological lesion diagnosis and treatment while we're at it?
 
serenade said:
I don't know, why have literature on neurological lesion diagnosis and treatment while we're at it?
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What is this "neurological lesion diagnosis and treatment" you speak of?
 
serenade said:
http://scholar.google.com/scholar?hl=en&q=eeg+for+depression&btnG=Submit&as_sdt=1,21&as_sdtp=

Choose your pick. We've had many amazing ones since the 90s that can be improvised for psychiatry.

I'm also not sure how the above really plays into any of this, chronic or not you'll have physiological correlates. That being said the time issue is big in dsm diagnoses, you can't even be diagnosed with major depression without having had it for over 6 weeks?
Anyways, you're right. The field is in it's infancy, which is why we should keep the DSM and try to expand on the social and individualistic aspects for the time being while moving forward and expanding on the physiological measuring.
Click to expand...

From the first page or so, those seem to be looking at sleep irregularities in depressed (a categorization based, ironically, on the DSM criteria) v. control patients. There's none that I can see that looks at the EEG from a diagnostic POV, and among the studies you've linked to, there are inconsistent results. Interesting research but hardly at the diagnostic phase. Also, I did not see any studies linking suicidal thoughts with EEG patterns (yes, the suicidality and major depression are strongly correlated but *not* synonymous). Yes, the DSM has issues, sometimes serious ones, and clinical interviews are hardly infallible, but to say that we should throw out that diagnostic method for one we *do not yet have* is incredibly premature, IMO.

Also, the NIMH RDoc states that they will be interested in collecting biomarker data across clinical categories--in other words, they'll still be relying strongly on data from clinical interviews and other dx mechanisms (e.g., psych/neuropsych testing, symptom measures) and trying to tie certain symptoms to biomarkers. They just won't relaying strictly on DSM-5 categorization. This, to me, is extremely reasonable, especially because clients/patients in the real world almost never strictly fit into DSM boxes to begin with. FWIW, the DSM has always seemed to me more like a language tool than a strict diagnostic one--something to allow clinicians to communicate in professional shorthand if you will. It's rare, in my experience, to find a client who will fit strictly in and perfectly in a DSM category, but speaking in those categories can convey some reasonable approximation of what a given client may be experiencing.
 
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That being said the time issue is big in dsm diagnoses, you can't even be diagnosed with major depression without having had it for over 6 weeks?
Click to expand...

Two weeks in the DSM-IV (not sure if DSM-V changes this).
 
futureapppsy2 said:
You don't necessarily have to be chronically depressed to be suicidal, and suicidality doesn't have be chronic.
Click to expand...

You don't even really have to be depressed at all. Suicide as a topic varies between cultures. Sometimes it's due to personal issues, global economic pressures, or cultural norms.

Though, EEG biofeedback (neurofeedback) has a growing body of evidence behind it for a variety of conditions IIRC they include depression, anxiety, ADHD, and seizure disorders.
 
I have mixed feelings on this.

On the one hand, I do agree with others it would be nice to see NIMH placing more emphasis on social/environmental factors. Then again social/environmental fields and biological fields are increasingly fusing as our understanding of both continues to expand. I don't know that NIMH is saying they will refuse to fund anything that isn't purely biological (or anything of the sort). This is a large-scale project designed to reshape how we think about these things and advance our understanding of the biological factors. More immediately for me, this completely fits with my conceptualization of disorders (not the biology, but the emphasis on trans-diagnostic processes). I think some folks are neglect that this is the Research Domain Criteria - all the folks involved will agree we aren't anywhere near being able to diagnose based on biology. Years of folks beating their heads against a wall trying to do that indicates its pretty unlikely to happen within the current system. I see this project more as a "shift" in the approach to a system where it seems at least theoretically possible to ascertain stronger brain-behavior links. For instance, while extremely unlikely we'll find a "depression" gene, I think odds are significantly higher we'll find a gene that enhance GABA transmission suppressing reward responses which produces an increased risk for a variety of different disorders.

My interpretation of this is that this is culmination of the realization that biological explanations are NOT working out well and an attempt to reshape the approach so that becomes a possibility. That said, I admit it fits perfectly with my research program so perhaps I'm seeing what I want to see in this. I'm happy to see the DSM being thrown out. Its a necessary evil for some things (e.g. insurance billing, epidemiology/population description) but I think has little value in most research beyond providing some assurance of a common parlance. I think this shift is necessary for breakthroughs to continue to be made on the biological side since (as illustrated in the link Serenade provided) we really aren't doing that great now. I hope to see social/environmental work move in this direction as well and suspect it will in the near future.
 
Ollie123 said:
I have mixed feelings on this.

On the one hand, I do agree with others it would be nice to see NIMH placing more emphasis on social/environmental factors. Then again social/environmental fields and biological fields are increasingly fusing as our understanding of both continues to expand. I don't know that NIMH is saying they will refuse to fund anything that isn't purely biological (or anything of the sort). This is a large-scale project designed to reshape how we think about these things and advance our understanding of the biological factors. More immediately for me, this completely fits with my conceptualization of disorders (not the biology, but the emphasis on trans-diagnostic processes). I think some folks are neglect that this is the Research Domain Criteria - all the folks involved will agree we aren't anywhere near being able to diagnose based on biology. Years of folks beating their heads against a wall trying to do that indicates its pretty unlikely to happen within the current system. I see this project more as a "shift" in the approach to a system where it seems at least theoretically possible to ascertain stronger brain-behavior links. For instance, while extremely unlikely we'll find a "depression" gene, I think odds are significantly higher we'll find a gene that enhance GABA transmission suppressing reward responses which produces an increased risk for a variety of different disorders.

My interpretation of this is that this is culmination of the realization that biological explanations are NOT working out well and an attempt to reshape the approach so that becomes a possibility. That said, I admit it fits perfectly with my research program so perhaps I'm seeing what I want to see in this. I'm happy to see the DSM being thrown out. Its a necessary evil for some things (e.g. insurance billing, epidemiology/population description) but I think has little value in most research beyond providing some assurance of a common parlance. I think this shift is necessary for breakthroughs to continue to be made on the biological side since (as illustrated in the link Serenade provided) we really aren't doing that great now. I hope to see social/environmental work move in this direction as well and suspect it will in the near future.
Click to expand...

That's my take as well. Essentially, the neurobiological/neurophysiological research isn't mapping on very well to the existing/upcoming DSM diagnostic system, so why not do away with said system and see if there are alternative models that better fit the data?

However, in a clinical sense, we're likely years (if not decades) away from having, say, a biologically-based test for mental disorders (at least as far as "mental disorders" are understood today). The existing EEG and neuroimaging research I've seen, for example, is pretty underwhelming (at least in the areas in which I work).
 
From a conversation that I had with a friend...

I like to think of it as NIMH saying "We applaud your effort in establishing reliability, but to this point you have been at best reliably ignorant and at worse reliably wrong."
 
MBellows said:
...and at worse unreliably wrong."
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Fixed it for you🙂 Sadly it even falls short on reliability for some situations...

Seriously though I think its a very good way of looking at it. Psychotherapy Brown Bag just put up a good piece on this and likened the DSM to striving for "good" government instead of choosing complete anarchy, which is one of the better analogies I've heard. Psychometrics generally considers validity to require reliability but reliability to be relatively independent (i.e. its possible to have perfect reliability even in the absence of any validity), but I think the lack of validity contributes to unreliability because people are (understandably and arguably appropriately) much more willing to deviate from protocol and be "flexible" when interpreting off a flawed instrument.
 
Ollie123 said:
Fixed it for you🙂 Sadly it even falls short on reliability for some situations...

Seriously though I think its a very good way of looking at it. Psychotherapy Brown Bag just put up a good piece on this and likened the DSM to striving for "good" government instead of choosing complete anarchy, which is one of the better analogies I've heard. Psychometrics generally considers validity to require reliability but reliability to be relatively independent (i.e. its possible to have perfect reliability even in the absence of any validity), but I think the lack of validity contributes to unreliability because people are (understandably and arguably appropriately) much more willing to deviate from protocol and be "flexible" when interpreting off a flawed instrument.
Click to expand...
Psychotherapy Brown Bag is still active? I go to their webpage and the last posting I see is from July 2012
 
Ignore this post - saw that it was included in a previous discussion a few threads down. My apologies!
 
futureapppsy2 said:
I think this is a really good take on the situation.

http://blogs.scientificamerican.com...he-dsm-but-it-is-almost-time-to-transform-it/
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Why aren't any psychologists or psychology graduate students shaping these issues/debates and publishing articles in major publications? The articles that I see in the Nytimes, Scientific American are all written by psychiatrists or reporters that don't know anything about our field. You guys are making an important points about contextual factors, social/env. factors and the medical model being overly reductionistic. If we continue to sit by the sidelines, we are not going to be defining anything.
 
Ollie123 said:
this is the Research Domain Criteria - all the folks involved will agree we aren't anywhere near being able to diagnose based on biology. Years of folks beating their heads against a wall trying to do that indicates its pretty unlikely to happen within the current system. I see this project more as a "shift" in the approach to a system where it seems at least theoretically possible to ascertain stronger brain-behavior links.
Click to expand...

Agreed, but where does this leave NIMH-funded treatment research? I think a lot of the tension revolves around that issue, especially as treatment makes up a sizable portion of the NIMH portfolio. What do treatment researchers do in the meantime? Are they choosing populations of interest based on the RDoc? Will psychosocial treatment be valued in this climate? (the writing on the wall appears to suggest "no") And are we asking our patients to wait for an indefinite time for this approach to translate into new treatments?

I actually share mixed feelings re: the RDoC, and believe that the constructs are useful and at least face valid in a number of respects. I also think that the RDoC project is not an "all or nothing" endeavor that must be grounded in biological reductionism. It just happens that the folks behind it happen to operate under that paradigm.
 
LM02 said:
Agreed, but where does this leave NIMH-funded treatment research? I think a lot of the tension revolves around that issue, especially as treatment makes up a sizable portion of the NIMH portfolio. What do treatment researchers do in the meantime? Are they choosing populations of interest based on the RDoc? Will psychosocial treatment be valued in this climate? (the writing on the wall appears to suggest "no") And are we asking our patients to wait for an indefinite time for this approach to translate into new treatments?

I actually share mixed feelings re: the RDoC, and believe that the constructs are useful and at least face valid in a number of respects. I also think that the RDoC project is not an "all or nothing" endeavor that must be grounded in biological reductionism. It just happens that the folks behind it happen to operate under that paradigm.
Click to expand...

Agreed RE: concerns about whether psychosocial treatments are valued, though at least in my area I really view that as a separate issue as relative under-valuation of psychosocial treatments long pre-dates release of the RDoc.

That said, while it would perhaps be a larger and more complicated shift for treatment research (versus experimental) there is nothing that says treatment research can't also fit within this paradigm. It would require a dramatic shift in how patients are recruited/trials are run that may not prove easy to achieve (nor potentially easy to publish) but I think the whole point is to push in a new direction when treatment research has clung to the DSM mostly because it is "easy". I know several folks who have grants for treatment research that could easily fit within an RDoc model. For example, developing and re-framing interventions to target impulsivity, cognitive control, emotion regulation, etc. across a wide variety of traditional diagnoses, rather than "Therapy for patients with major depression but not GAD or PTSD or SUDs". In some ways, this could be an easy shift for certain centers (i.e. group-heavy inpatient units where patients rarely have the same diagnoses anyways and this is essentially already being done in a less formalized manner).

Anyways, don't get me wrong, I do share concern about the impact this will have on treatment research. However, I'm perhaps somewhat optimistic that treatment research can also shift to this model and that we don't necessarily need to know details of the inner workings of all these processes beforehand. After all, treatment research has gotten by so far without a solid foundation for how we're defining populations of interest (i.e. the DSM).
 
The DSM 5 is pretty much a joke. Just as Cara stated, it's too caught up with the medical model in regards to diagnosis and treatment. Psychosocial factors are barely taken into account when they can be fundamental in a client's treatment. Moreover, regular human experiences are now more than ever being thought of as mental health disorders. Disruptive Mood Dysregulation Disorder for temper tantrums? Grief becoming a contributing factor in Major Depressive Disorder? Blurred lines between regular anxiety and Generalized Anxiety Disorder?

Don't get me wrong: the DSM 5 is great for clinician communication and there are some parts that help with diagnosis, but as a whole it's just a billing manual. It benefits pharmaceutical and insurance companies, not the client.

Great article to look at with comments from a Duke Psychiatry Professor:

http://www.healthnewsreview.org/201...c-approval-of-dsm-v-a-sad-day-for-psychiatry/
 
Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.
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This pretty much sums it up for me. Throwing out one system when you don't have a workable replacement system (or anything even close to it) in place seems ill advised. We are nowhere near to having a functional biological methodology in place for understanding, diagnosing, and treating most disorders. Not that biological factors aren't important, but how is treatment research going to be impacted as we move forward?
 
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