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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 20  |  Issue : 1  |  Page : 12-15

Current concerns in psychiatric diagnostic process and the paradigm shift: Research domain criteria


Department of Postgraduate Psychiatry, Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom

Date of Web Publication8-Sep-2015

Correspondence Address:
Nilamadhab Kar
Steps to Health, Showell Circus, Low Hill, Wolverhampton, WV10 9TH
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-8990.164801

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  Abstract 

There are many issues around the current approaches in diagnosing psychiatric illnesses. Most of the diagnoses are symptom-clusters and not etiology based. Although they are reliable constructs, their validity has always been debated. It is a common experience that the presentations of patients having even the same diagnosis vary considerably. Recently following the launch of Diagnostic and Statistical Manual of Mental Disorders-5, concerns have been raised about the possibility of over diagnosis and over-treatment of patients who are essentially well. To address these concerns, there is an initiative to move away from traditional diagnoses and study the clinical phenomena based on behavioral dimensions and neurobiological measures, which will support new ways of classifying mental disorders. Research domain criteria (RDoC) are a framework for collecting the information needed for a new nosology. Conceived as a matrix, RDoC is using different units of analysis to study various domains of functions. Without taking into account current diagnoses, it is trying to find out the abnormalities in different parameters from genes to physiology, circuits etc., in a given clinical presentation. This process will improve the understanding of clinical phenomena in a dimensional model and may ultimately help suggest more appropriate interventions leading to better outcomes for psychiatric disorders.

Keywords: Diagnosis, etiology-based, process, psychiatry, symptom-based


How to cite this article:
Kar N. Current concerns in psychiatric diagnostic process and the paradigm shift: Research domain criteria. J Mental Health Hum Behav 2015;20:12-5

How to cite this URL:
Kar N. Current concerns in psychiatric diagnostic process and the paradigm shift: Research domain criteria. J Mental Health Hum Behav [serial online] 2015 [cited 2020 Oct 26];20:12-5. Available from: https://www.jmhhb.org/text.asp?2015/20/1/12/164801


  Introduction Top


While great progress has been made in diagnostic methods for physical disorders, the psychiatric diagnoses are being made based on patient-reported symptoms, clinician assessed psychopathologies and observations. Some may reflect this as diagnosing diabetes without recourse to blood sugar tests or treating chest pains as myocardial ischemia without electrocardiogram or other investigations. Although there are advances in neurobiological understandings in mental illnesses, they have not contributed effectively to the process of making psychiatric diagnoses. As a result, the psychiatric diagnoses are still symptom-clusters, based on polythetic criteria for the diagnoses using International Classification of Diseases (ICD) or Diagnostic and Statistical Manual of Mental Disorders (DSM). [1],[2] It is true that these categories have acceptable reliability in clinical research and field trials. [3],[4] However, there is certain uneasiness about the validity of these diagnostic constructs. [5] Only a few of these diagnoses are etiology-based, whereas all others are still based on the symptom-clusters and presentation.

In this review, current issues in the psychiatric diagnostic systems are being discussed along with the changes that are taking place. The focus is on the new approach taken by National Institute of Mental Health (NIMH) through the research domain criteria (RDoC).


  Use of Diagnostic Systems in Psychiatry Top


There is no confusion whether we need appropriate diagnoses for the psychiatric illnesses, although there are groups who actively oppose this stating it as "myth" or "labeling". [6],[7] Like other medical specialties, in psychiatry, treatment of ailments revolves around proper diagnoses and evidenced-based interventions for those diagnoses. The diagnoses are essential for various other reasons, e.g., they are the means of scientific communications regarding the presentations, studying the response to interventions; developing indications, and for use in the research and clinical trials to share or generalize the findings. They are also needed for the national data for understanding the needs, developing services and for medico-legal issues. In fact, the World Psychiatric Association-World Health Organization Global Survey of 4887 psychiatrists in 44 countries highlighted the purposes of diagnostic system of mental disorders as communication among clinicians, to inform treatment and management decisions, to generate national health statistics more frequently amongst others. [8] It was found that a formal classification system for mental disorders was being used in day-to-day clinical work by most psychiatrists; [8],[9] and ICD-10 is used most commonly. [8] Most psychiatrists prefer diagnostic guidance that is flexible enough to allow for cultural variation and clinical judgment. [8] After around 1-year of DSM-5, a survey in the USA found that around 45% of professionals, including 59% of psychiatrists have started using it. [10] These suggest that although there are controversies and concerns, the current diagnostic systems are being actively used in clinical practice and research.

Current issues in diagnostics in psychiatry

Concerns regarding diagnostic processes in psychiatry and identifying the ill accurately are not new. In an interesting paper way back in 1973 Rosenham highlighted that it may be difficult to distinguish normal from mentally ill. [11] There have been several criticisms of the current diagnosis methods and the diagnoses themselves. Recently, the DSM-5 was criticized for many reasons from various quarters. [12],[13] Division of Clinical Psychologists in the UK has publicly affirmed that there are "significant conceptual and empirical limitations" in the ICD and DSM and have highlighted a need to move away from the disease models in psychiatry. [14] There are voices of concern from psychiatric colleagues as well. Frances, chair of the DSM-IV Task Force in one of his articles advised physicians to use the DSM-5 "cautiously if at all." [12] He highlighted the real danger of DSM-5 being the over-diagnosis and over-treatment of "patients who are essentially well."

The usual criticisms of current psychiatric diagnoses are well-known. They are symptom-clusters and not etiology-based. There are dependent on factors like patients' and carers' reports, clinicians' opinion about presence or absence of a symptom/sign. The clinicians' assessment could be criticized as subjective, dependent on available information and susceptible to bias. Most of these symptom-cluster based diagnoses are not linked to etiology except a few disorders, e.g., the organic, substance-related and stress related disorders. [1],[15]

The heterogeneity of the diagnoses is also highlighted; such that patients with the same diagnosis may have different kind of symptoms and presentation; they may even have a different response to treatment and long-term prognosis. One of the reasons could be the polythetic nature of diagnostic criteria for the current classificatory systems. Although the diagnoses based on the classificatory systems are often quite reliable, there are issues regarding the validity of these diagnoses. [5]

Another major criticism has been that the diagnoses are categorical (present vs. absent) which does not reflect the dimensional (e.g., absent, some, severe) nature of the presentation of the morbidity. [16] It is usual to notice various observations and measures presenting in a continuous, dimensional way which beyond a threshold are observed to be clinically meaningful or become diagnosable entities. For example, the distribution of intelligence quotient (IQ) in population is a continuous one, and although the states of borderline intelligence, mild, moderate, severe, or profound intellectual disabilities are categorically defined they are basically at different levels of the IQ score. Other similar examples in physical diseases could be the blood sugar level that can be traced in a range from low to normal to high levels that are clinically relevant suggesting, e.g., hypo- or hyper-glycaemia. These kind of dimensional observations are not there for most of the current psychiatric diagnoses; although, the concepts of mild, moderate, and severe degrees of illness are incorporated in many psychiatric diagnoses in current classificatory systems. [1],[2]


  Changes in Classificatory Systems Top


There are some changes in the DSM-5 which can be seen as a response to the above concerns. In DSM-5 dimensional approach has been incorporated within the categorical system. It is evident in autistic spectrum disorder, schizophrenia spectrum by eliminating subtypes and replacing dimensions of psychosis symptom severity, and alternative dimensional approach to diagnosis of personality disorder. [17] However, the diagnostic method is essentially the same as before.

It is good to note that DSM-5 and ICD-11 are regrouping the diagnostic classes as much as possible on common underlying etiological factors, e.g., creation of diagnostic grouping of obsessive-compulsive and related disorders and disorders specifically associated with stress. [1],[15]


  Research Domain Criteria Top


Considering these concerns, NIMH in the USA in their strategic plan suggested for a change in approach and planned to develop, for research purposes, new ways of classifying mental disorders based on behavioral dimensions and neurobiological measures. [18],[19],[20] It has launched the RDoC project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. [5] It is a framework for collecting the data needed for a new nosology.

The RDoC is designed as a dimensional system mapping the parameters from normal to abnormal. [18] This is similar to how dimensions are used in other medical specialties (e.g., blood pressure, blood sugar, etc.). It is not considering the current disorder categories; it wishes to find out abnormalities in the basic behavioral neuroscience and other biological parameters regarding the patient reported symptoms. [18]

To achieve this objective, RDoC is considered as a matrix, where dimensions of the function will be studied against multiple variables. [21] Dimensions of function are described as constructs, and related constructs are grouped into major domains of functioning, related to motivation, cognition, and social behavior. Currently, five domains have been considered, which are: Negative valence systems (i.e., systems for aversive motivation), positive valence systems, cognitive systems, systems for social processes, and arousal/regulatory systems. [21] The RDoC will use different classes of variables (or units of analysis) to study the domains/constructs. At present, seven such classes have been specified: Genes, molecules, cells, neural circuits, physiology, behaviors, and self-reports. [21] It is emphasized that these particular domains and constructs are the initial starting points only, [18] with a scope of being updated.

It is interesting to learn that researches are underway to study clinical phenomena based on the RDoC research matrix. It is good to see that studies are building up based on RDoC framework exploring psychopathologies and presentations. [22],[23],[24],[25],[26],[27],[28],[29],[30] For example, a study evaluated hallucinations based on RDoC framework, stepping back from the diagnoses and analyzed it in a spectrum. [22] These kinds of exercises are going to improve the depth of knowledge associated with the phenomena, which will be eventually helpful in intervention.


  Conclusion Top


The RDoC approach is a paradigm shift not only in the diagnostic exercises in psychiatry, but it is probably one of the most important development that will improve understanding and management of mental illnesses. Contributions from genetic, neurophysiological and biological studies will help toward probable regrouping of the clinical presentations into a different diagnostic system which is more precise, valid, verifiable and useful in clinical decision making, and will match up to the diagnostic precision observed in many physical disorders. RDoC is almost a revolution in the making!

Acknowledgment

Quality of Life Research and Development Foundation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.  Back to cited text no. 1
    
2.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 2
    
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6.
Szasz TS. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper and Row; 1974.  Back to cited text no. 6
    
7.
Shackle EM. Psychiatric diagnosis as an ethical problem. J Med Ethics 1985;11:132-4.  Back to cited text no. 7
    
8.
Reed GM, Mendonça Correia J, Esparza P, Saxena S, Maj M. The WPA-WHO global survey of psychiatrists′ attitudes towards mental disorders classification. World Psychiatry 2011;10:118-31.  Back to cited text no. 8
    
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11.
Rosenhan DL. On being sane in insane places. Science 1973;179:250-8.  Back to cited text no. 11
    
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Division of Clinical Psychology. Position Statement on the Classification of Behaviour and Experience in Relation to Functional Psychiatric Diagnoses: Time for a Paradigm Shift; May, 2013. Available from: http://www.bps.org.uk/system/files/Public%20files/cat-1325.pdf. [Last accessed on 2014 Nov 29].  Back to cited text no. 14
    
15.
World Health Organisation. ICD-11 Beta Draft. Available from: http://www.apps.who.int/classifications/icd11/browse/l-m/en. [Last accessed on 2014 Dec 09].  Back to cited text no. 15
    
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American Psychiatric Association. DSM-5′s Integrated Approach to Diagnosis and Classifications. Arlington, VA: American Psychiatric Association; 2013.  Back to cited text no. 17
    
18.
National Institute of Mental Health. NIMH Research Domain Criteria (RDoC). Available from: http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml. [Last accessed on 2014 Dec 09].  Back to cited text no. 18
    
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Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, Quinn K, et al. Research domain criteria (RDoC): Toward a new classification framework for research on mental disorders. Am J Psychiatry 2010;167:748-51.  Back to cited text no. 19
    
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Insel TR. The NIMH research domain criteria (RDoC) project: Precision medicine for psychiatry. Am J Psychiatry 2014;171:395-7.  Back to cited text no. 20
    
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Cuthbert BN. The RDoC framework: Facilitating transition from ICD/DSM to dimensional approaches that integrate neuroscience and psychopathology. World Psychiatry 2014;13:28-35.  Back to cited text no. 21
    
22.
Ford JM, Morris SE, Hoffman RE, Sommer I, Waters F, McCarthy-Jones S, et al. Studying hallucinations within the NIMH RDoC framework. Schizophr Bull 2014;40 Suppl 4:S295-304.  Back to cited text no. 22
    
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Norrholm SD, Glover EM, Stevens JS, Fani N, Galatzer-Levy IR, Bradley B, et al. Fear load: The psychophysiological over-expression of fear as an intermediate phenotype associated with trauma reactions. Int J Psychophysiol 2014. pii: S0167-876001646-8.  Back to cited text no. 23
    
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Kleinman A, Caetano SC, Brentani H, Rocca CC, dos Santos B, Andrade ER, et al. Attention-based classification pattern, a research domain criteria framework, in youths with bipolar disorder and attention-deficit/hyperactivity disorder. Aust N Z J Psychiatry 2015;49:255-65.  Back to cited text no. 26
    
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29.
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