Tuesday, 14 May 2013

RDoC and the cross-roads of psychiatry

The Irish poet Brendan Behan is, I think, credited with the phrase: "There's no bad publicity except an obituary". One wonders how appropriate this phrase might be to the 'diagnostic Bible' (except that it isn't) which is DSM-V which is poised to make its entrance into the World in the coming days.

The real Homer @ Wikipedia 
Indeed, the story of DSM-V even before it hits the diagnostic shelves of all good psychiatric bookshops, has the makings of an epic piece of poetry or literature, or at least a Storify tale. Drama, intrigue and divisions reminiscent of Good and Evil (I'll let you decide who has taken which role) are all included.

The various debates on the details of the psychiatric diagnoses contained in DSM-5 have seemingly unearthed smouldering questions about the way mental health is classified, and whether such classifications are helpful for those at the receiving end of such diagnoses, the social-medical world and indeed the wider research universe.

Two papers recently published under the heading of 'Current controversies in psychiatry' (understatement of the year) by the BioMedCentral journal series add fuel to the diagnostic debate fire. Ian Hickie and colleagues* (open-access) provide an interesting commentary on clinical classifications in mental health, and how reverse translation "that is, working back from the clinic to the laboratory" might be a direction to think about. Bruce Cuthbert and Tom Insel** (open-access) bring forward the concept album that is RDoC (Research Domain Criteria) and its potential "to transform the approach to the nosology of mental disorders". Their notion of the seven pillars of RDoC harks back to the writings of one T.E. Lawrence.

Both opinion papers acknowledge that the psychiatric labelling systems we have at the moment are not perfect and reflect the feeling of common ground across various diagnostic labels.

I've followed a fair bit of the DSM-V development discussions with autism, sorry the autisms, in mind and how it has morphed into the larger question of how useful labels and tick-box criteria are to the real world. Speaking within the confines of the proposed categorisation of autism spectrum disorder (ASD) it strikes me that much of the debate boils down to the lack of progress made in isolating the biological factors which define conditions like autism. Yes, heterogeneity and maturation have played their part in cloaking autism from biological definition, but despite the seemingly very close relationship between one or two of the gold-standard autism assessment instruments and the new revisions proposed to DSM, one doesn't get the sense that autism will be revealing its definitive biological footprint anytime soon.

Although not a novel idea, I have often wondered whether some simple changes to the way that research is carried out in autism circles might yet yield some knowledge gains. So for example, moving away from autism as a diagnosis as being the primary variable; instead focusing on those all important endophenotypes and their discriminating factors. I've talked about work from the MIND Institute as one example of this direction, but there are others too (yep, branched chain amino acids). Intervention, or rather response to intervention is another possible discriminating factor. Y'know best responders vs. non-responders vs. worst responders to the myriad of interventions out there for conditions like autism. Obviously the question then is: how do you categorise responder status?

Anyhow, I can't see anything happening too quickly despite all this talk about rethinking nosology given that DSM-IV was with us for 19 years. That's not however to say that changes might not already be afoot...

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* Hickie IB. et al. Clinical classification in mental health at the cross-roads: which direction next? BMC Medicine 2013; 11: 125.

** Cuthbert BN. & Insel T. Toward the future of psychiatric diagnosis: the seven pillars of RDoC. BMC Medicine 2013; 11: 126.

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ResearchBlogging.org Ian B Hickie1, Jan Scott, Daniel F Hermens, Elizabeth M Scott, Sharon L Naismith, Adam J Guastella, Nick Glozier, & Patrick D McGorry (2013). Clinical classification in mental health at the cross-roads: which direction next? BMC Medicine, 11