DSM-5 and RDoC: Perspectives on Diagnosis & Treatment
Summary of Presentation
In this presentation, Doctors Stern and Silverstein discussed the strengths and weaknesses of two recent initiatives to improve diagnosis and treatment of mental illness: 1) the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the NIMH Research Domain Criteria (RDoC) project and covered the rationale, work done so far, and likely future outcomes. The DSM is the standard classification of mental disorders used by mental health professionals in the United States and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system. The previous edition, DSM-IV-TR, has been used by professionals in a wide array of contexts, including psychiatrists and other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors, as well as by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems). DSM is used in both clinical settings (inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care) as well as with community populations. In addition to supplying detailed descriptions of diagnostic criteria, DSM is also a necessary tool for collecting and communicating accurate public health statistics about the diagnosis of psychiatric disorders.
In brief, the starting point of RDoC is that the DSM categories are heterogeneous and often invalid in many respects, and are a hindrance to effective research into the causes and treatments for forms of mental illness. RDoC proposes, as an alternative, the identification of core biological and psychological processes, whose existence is supported by substantial research, and whose alterations can be found in people with psychological symptoms. For example, there are many ways that a person can be diagnosed with Major Depression, and many people can meet diagnostic criteria even though they may have only one symptom in common. In addition, symptoms of Major Depression are found in many other DSM diagnoses. Is it useful to lump all such people together when trying to find the causes of, or treatments for, depression? The same holds true for schizophrenia and many other DSM diagnostic categories. RDoC proposes, instead, that research on mental disorders focus on issues such as mood dysregulation, cognitive disturbance, reactivity to rewarding stimuli, anxiety, arousal level disturbances, psychosis, etc., and that, ultimately, diagnosis should be made based on observable laboratory tests (as is the case in other areas of medicine), with treatments geared towards known biological and psychological mechanisms. RDoC thus promises to integrate science and practice to the mutual benefit of both. However, RDoC is not without its limitations, including that, at present, the effort is too new to judge its eventual impact or to be practical for everyday clinical practice as a sole diagnostic approach.
Steven Silverstein, Ph.D. is Director of Research, and Director of the Division of Schizophrenia Research at Rutgers University Behavioral Health Care (UBHC). He is also Executive Director of the Violence Institute of New Jersey at Rutgers-UBHC; Executive Director of the Predoctoral Internship Program in Clinical Psychology at Rutgers-UBHC; and Professor of Psychiatry at Rutgers’ Robert Wood Johnson Medical School. He is the former Chair of the American Psychological Association’s Task Force on Serious Mental Illness, a member of the executive committee for the NIMH Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS) project, a member of the Adult Psychopathology and Disorders of Aging (APDA) NIH study section, and an Executive Committee member of the Society for Research in Psychopathology. Dr. Silverstein received his Ph.D. in Psychology from the State University of New York at Buffalo in 1989, and completed his internship and fellowship at Cornell Medical College from 1988-1990. Dr. Silverstein’s research interests are in cognitive and perceptual impairments in schizophrenia, rehabilitation of these problems, and psychometric and methodological issues related to their assessment. He has approximately 150 publications related to schizophrenia, is currently Principal Investigator (PI) on 2 NIMH grants, site PI on two other NIMH grants, Principal Mentor on a junior faculty member’s NIMH grant, and PI on a foundation grant to develop a new self-report measure of cognitive difficulties for people with schizophrenia. Dr. Silverstein was the 2008 recipient of the United States Psychiatric Rehabilitation Association’s Armin Loeb Award for research in psychiatric rehabilitation, the 2009 recipient of the New Jersey Psychological Association’s Distinguished Researcher Award, and the 2010 recipient of the American Psychological Foundation’s Alexander Gralnick Research Investigator Prize.
Robert Stern, M.D. is the Director of Treatment Programs at Essex County Hospital Center and is Clinical Associate Professor in the Department of Psychiatry at Robert Wood Johnson Medical School in Piscataway, NJ. For the past 20 years Dr. Stern’s clinical work and research have focused on the treatment of patients with severe mental illness in general and schizophrenia in particular. Dr. Stern has published over 100 articles, book chapters and abstracts. Dr. Stern graduated from Sackler School of Medicine, University of Tel Aviv, and completed his residency training and fellowships at Mount Sinai School of Medicine in NYC. Dr. Stern currently serves as the chairperson of the Public Psychiatry Committee of the New Jersey Psychiatric Association. Most recently, Dr. Stern was inducted in 2013 as a Board Member on the State Board of Trustees for NAMI NJ. He also served on several state wide professional committees focusing on psychiatric care for patients with severe mental illness over the past 10 years.