The Future of Diagnosing Mental Disorders
Wayne K. Goodman, MD, discusses the shortcomings of DSM-based diagnoses and how we can use neurobiology to develop a more accurate framework for evaluating psychiatric conditions
Wayne K. Goodman, MD
Message from the Chair
For sixty years, psychiatrists have relied on the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose and treat patients. The diagnostic categories listed in the DSM — which are based on a clinical consensus of symptoms — have served our field well for years. Most notably, this classification system has provided a common language and standardized criteria for communicating important clinical information. Thus, its strength has been inter-rater reliability.
However, more recently, as we continue to learn about the underlying genomics, neurobiology and neurocircuitry of psychiatric conditions, it has become clear that the DSM diagnoses often do not align with the empirical findings. In other words, construct validity has been called into question. And from a clinical perspective, the diagnoses are not necessarily predictive of treatment responses in patients. Consider, for example, that selective serotonin reuptake inhibitors may work, with variable success, across a range of disorders classified separately as anxiety or mood disorders in the DSM-IV.
These concerns are shared by the National Institute of Mental Health, which in 2009, launched the Research Domain Criteria (RDoC) project — an initiative that will create a new framework for evaluating psychopathology based on both clinical observation and neurobiology. The RDoC will define cross-cutting domains of mental functioning, such as fear circuitry or working memory, and study them across several units of analysis from genes to neural circuits to behaviors. While our knowledge of brain function as it relates to pathophysiology and behavior is still relatively basic, the goal of the RDoC is to lay the foundation for the future of psychiatric classifications and understand how research can help inform them. Someday, anxiety and mood disorders, for example, will be evaluated by looking at a combination of genomics, neuroendocrine measures, brain imaging and clinical presentation rather than simply a list of symptoms.
Here, at Mount Sinai’s Department of Psychiatry, we will be at the forefront of implementing this approach in a new consultation program that couples state-of-the-art clinical care with RDoC-guided research principles. Building upon our established specialty clinics for syndromes like mood disorders, we will take a fresh look at patients’ presenting problems with respect to domains of function, such as cognitive functioning, from different levels of analysis, including neuropsychological testing and functional brain imaging, without being prematurely pigeon-holed by DSM diagnoses. For cases with treatment-resistant illness, we will draw upon expertise from across our diagnosis-based centers of excellence to generate treatment recommendations.
With DSM-5 being published in May 2013, there isn’t enough time for the RDoC approach to impact the new version of our clinically-based classification system. When writing a discharge summary or submitting a claim for insurance, the language of the DSM-5 will still prevail. However, at some point in the future, the RDoC process will overtake conventional wisdom and introduce new constructs and a new way of diagnosing psychiatric disorders. At that point, psychiatric practice will more closely resemble other medial specialties. Developing a fresh set of diagnostic criteria based on underlying biology will not only lead to more accurate diagnoses, but will also help us identify novel targets for better treatments. And ultimately, lead to better quality of life for our patients.
Wayne K. Goodman, MD
Chair of the Department of Psychiatry
Esther and Joseph Klingenstein Professor of Psychiatry
The Mount Sinai Medical Center
Thomas Insel & Bruce Cuthbert: Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders. Am J Psychiatry 167:7, 2010.