Table of Contents
Introduction
With the release of the Diagnostic and Statistical Manual 5(DSM-5), the removal of the multi axial system, and the adjustment of organizational structure and criteria content, there was controversy in the catalog base of psychiatric classification. Two weeks before the release of the DSM-5, the largest funding institute for mental health research, the National Institute of Mental Health (NIMH), withdrew support of manual (NIMH, 2013). The director of the NIMH, Thomas Intel, publicly announced the decision in a blog, criticizing the DSM-5 for categorizing diagnosis based merely on subjective consensus of a cluster of clinical symptoms, without objective laboratory measure (Insel, 2013). He forwardly states that the DSM classification system “lacks validity” and does not justify the best assessment measures to provide the most effective treatment.
Insel announced a ‘paradigm shift’ with the emergence of The Research Domain Criteria (RDoC’s), with focus on a ‘precision medicine’ model approach in diagnosis (Insel, 2013). This announcement on such a public forum, hit a large audience and created a domino effect in the mass media, creating further skepticism, criticisms and provoked further investigation into the making of the DSM-5. Headlines from new forums such as the Washington Post read, “NIMH vs. DSM 5: No One Wins, Patients Lose” and others articles critiquing the DSM, such as, “Psychiatry’s bible, the DSM, is doing more harm than good”.
This ground-shaking separation of the two, and criticism of the DSM-5, caused a controversy and a gap between clinicians and researchers. However, though the media suggested a divide between DSM-5 and the RDoC in the foundational assessment models, they both serve to better classify psychiatric conditions to address adequate treatment.
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Controversies
The DSM is a tool that provides a categorical system for clinicians use as a guide for diagnosis of treatment. The principles mechanisms of the diagnostic criteria include indicating symptoms, frequency, severity and duration. The edits that came with the DSM-5 classification criteria, drastically changed content and structure for the previous DSMs and specifically did these edits despite sound methodology. One controversial aspect was in the methods of the review process of the new draft diagnostic criteria with field trials. The field trials showed a prevalence of more false-positive diagnosis, and the revision process that was supposed to follow to address these issues, was dropped to meet the deadline (Welch, S, Klassen, C, Borisova, O, & Clothier, H, 2013).
The lack of quality control and the absence of empirically supported diagnostic rationale, contributes to shift to a research-based model. Another limitation concerning the negligible validity of the DSM-5’s method of classification is the problem of heterogeneity. For example, the criterion of posttraumatic stress disorder (PTSD) was revised in order to address the variety of symptoms that manifest following traumatic stress, by expanding the symptom presentations. Consequently, by expanding the symptoms, it created an ambiguous nature of classification. For example, there is now 636,120 ways to meet diagnostic criteria for PTSD (Galatzer-Levy & Bryant, 2013).
This example suggests that the DSM classification system is too broad, another critique made by the NIMH. Therefore, the launch of the RDoC was to emphasize the need of neuroscience in guiding research practices to best tailor treatment to the individual with laboratory measurements, like genetic testing (Lilienfeld, Treadway, 2016). These tests will more definitely classify the disorder, deepen the understanding of he etiological aspects of the disorder, and set boundaries to diagnosis for over, or under diagnosis.
Conclusion
The RDoC emphases the importance of precise, objective measures and the need to break down symptoms as specific indicators of psychobiological dysfunctions, suggesting that symptoms alone are not sufficient enough understand the best treatment. On the other hand, the DSM-5 clusters works to assign common presenting signs and symptoms to labeled diagnosis. While the two approaches suggest striking differences, both serve to better classify psychiatric conditions to address appropriate treatment response. Specifically, both attempt to establish a level of neuroscience and genetic components into establishing a psychiatric diagnosis. While the DSM-5 does not address the biological aspects into the criteria itself, progressively, the DSM has included text accompanying diagnostic criteria as such in risk and prognosis factors, helping DSM provide a more accurate picture of the clinical realities of psychiatric diagnosis (Kupfer and Regier, 2011).
Lastly, although the withdraw and public statements suggested a division of the two systems, in the end, they set to compliment each other in the classification of mental illness. Overall, the RDoC is not attempting to replace the DSM, but integrate classifications that serve to more objectively understand biological aspects of disorder to create validity and better treatment outcomes (Casey, B. J, 2013). Going forward, the NIMH continues to fund grants for the DSM, however with the emphasis of finding etiological processes (Lilienfeld, Treadway, 2016).
