The RDoc vs. DSM5 debate roils on

Note: RDoC is the NIMH official new diagnostic system, set up against the DSM-5 in 2013 by Thomas Insel, director.  The DSM is the well known diagnostic manual used by mental health services for decades.

I was obsessed by a recent, totally innovative article by Alexopoulos and Arean(Molecular Psychiatry 2014) on a new psychotherapy model which is based on the “neurobiology of targeted domains of function.”  What? The argument, out of Cornell University, is simple: figure out which domains (“constructs” in RDoc language) are “dysfunctional” and target interventions specifically.  Personalize psychotherapy, noting that everyone differs in how they cope with stress or express “dysfunction”; by caveat, a label-driven, DSM-5, approach is less precise (i.e. CBT for depression is basically the same across the board?).  They conclude the RDoC nosology (system of diseases) is preferable because of its precision, and they continue the massive rebellion against the Establishment (of the DSM and the APA).

Yet, another article in Medscape Psychiatry (2014) argued the opposite.  They defend the DSM5 against the criticism of RDoC adherents:  labels are just as value-based and subjective in the RDoC as they are in the DSM-5.  Yes, the DSM5 uses social constructs to define disorders, but the RDoC uses a reductionism value system to organize its disorders.  What’s the difference, they ask, either system is biased, and they conclude we are probably “decades away” from really applying the RDoC to clinical matters.  (I hope to be retired by then).

These debates are all so very opinionated; it bothers me how contentious is my field of psychiatry.  When do we get hard facts?  I thought neurobiology was pretty hard, but now I don’t know; I guess the jump from brain to mind is still not established (correlation is not necessarily causation), and a reductionistic view is not necessarily right.

All that said, I think I am going to persevere a bit further with a neurobiologically-informed, RDoC-based, “streamlined” psychotherapy as posited by Alexopoulos and Arean.  That means that the treatment of depression is like this:

  1. Enhance positive valence systems and circuits
  2. Alter negative valence systems and circuits that interfere with 1.

Specifically:  promote activation, pleasant experiences, and socialization; challenge negative biases and cognitions; combating apathy with planning and structure; and improving emotional dysregulation with stress management strategies.

I think it’s old wine in a new bottle, but perhaps a better year?  Note: it certainly does away with the Oedipal Complex!