Above:  Orchid's View of the American Psychiatric Association's Backlash against much needed reforms to psychiatric diagnostics.
Photo Credit:  pwmania.com  


​Dr. Thomas Insel on the DSM

In his blogs 6 years ago & in the 2018 Medscape interview -- 

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Dr. Thomas Insel
Val's Take

     I tend to be the hardest on people who I have put the most "faith" in.

        Insel in the Medscape interview did not renounce all the previous criticism of the DSM -- but he was unwilling to really acknowledge that RDoC [Research Domain Criteria Initiative] was  @ least initially  intended as a replacement of the DSM.

        Further, there were statements @ the  time by APA [American Psychiatric Association] representatives that they thought RDoC would ultimately replace the DSM.

         I'm probably not being fair to Insel, especially since he is the one who really had the courage to bring this issue to the FORE -- BUT the profession has NOT stepped up to the plate to deal with this HUGE issue & we're 6 years out --and they don't even really seem to understand the ramifications of a "diagnostic manual" that "lacks validity."

           I don't know know what it is going to take to light a fire under NIMH, the APA & our Society -- to FIX THIS -- but we seem to have a pretty laid back attitude -- & the fact of the matter is people's lives are @ stake.

            All kinds of decisions are based on these diagnostic categories that "lack validity" -- and some of these decisions involve punishment.

            Ultimately, we know enough to know what we're doing isn't right AND the ANSWERS may be who knows how long into the FUTURE.

             This is really about coming to terms with our ignorance and what that means in the Criminal Justice System.

    
Insel on the DSM -- Initially upon release of the DSM 5 while Director of the National Institute of Mental Health [NIMH]
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  "This approach (RDoC) began with several assumptions:

*A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
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*Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,

*Each level of analysis needs to be understood across a dimension of function,
Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

"It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data.

"In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”

"The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories.

"Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category.

"We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.

"That is why NIMH will be re-orienting its research away from DSM categories. "

 https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml 
After the BACKLASH & in the 2018 Medscape Interview:  

​Dr Insel: A real problem for psychiatry has been the lack of biomarkers, and our diagnostics have been built upon mostly subjective reports.

The DSM is essentially a consensus document, with master clinicians getting together and voting on what criteria we should use as classifiers for major depressive disorder, or for posttraumatic stress disorder (PTSD), and so on.

This process never included any biology or any kind of objective measures other than the consensus.

But I have to say, it worked quite well. I was around before we had a DSM, so I saw that this at least gave us a dictionary.

It gave us a common language in which every term was defined, and that was a huge kind of progress.

I was part of that original process when we formulated the DSM in 1983, and it transformed the field, but by 2010 we should have been able to do a little better than that.

My concern was that we were putting out yet another edition of the same manual without having changed the paradigm at all.

Dr Topol: Your idea didn't go over well.

​Dr. Insel:  But let's be honest about it. In terms of where we are 25 years later, we still do not have the data we need to be able to do this in a more objective, scientific way. Why don't we collect those data?

In 2008, we set up the Research Domain Criteria project, which was not a replacement for the DSM.

It is a framework for research that tells us what kind of data we will need if we want to revise the way we do diagnostics.

By the way, until we fix the diagnostic system, we probably will not be able to fix the therapeutics.

We have to get this right.

That led to this great debate within the field.

Ultimately, I was reassured; most people have agreed that this is a problem.