Controversies in Mental Health Diagnosis: The Future and Beyond Or “You Don’t Need a Weatherman to Know Which Way the Wind Blows”*
*(B. Dylan, 1965)
Current Status of Confusion
Mental health providers are struggling with the changes in how to diagnosis a client’s psychopathology. The American Psychiatric Association introduced the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) summer 2013. In the near future, all insurance companies in the United States can only accept diagnoses from the International Classification of Disease (ICD-10). In awareness of this change, DSM-5 creators included ICD-10 codes with the DSM-5 diagnostic codes (a type of cross-walk). Note, the ICD-10 codes are different numbers, usually presented in alpha-numerical sequence (found in parentheses) with no numerical relationship to the DSM-5 code. Are you confused yet?
DSM-5 is essentially a subset of diagnoses from ICD-10. However, the DSM-5 is reorganized in a completely different way than DSM-IV and has done away with the now familiar Multi-Axial system. (For those who were around when DSM-III came out, the movement to the Multi-Axial system generated huge uproar until it became a habit). Therefore, experienced clinicians need to learn a new approach to writing, thinking, and codifying diagnoses
A criticism of both DSM-5 and ICD-10 is that both systems are atheoretical, symptom-based and marginally connected to neuroscience research. Diagnoses are based on clinical observations and client’s phenomenological self-report. Although DSM-III & DSM-IV included then-recent neurobiological research, all current systems are still based on an atheoretical model and fail to connect brain and behavior together in meaningful ways. Relying on subjective complaints, only limits validity of the diagnosis and assumes that there is a one-to-one relationship between complaint and diagnoses. Experience tells otherwise.
“Times, They Are a Changing” (B. Dylan 1964)
Over the past several decades, an increasingly comprehensive body of research in genetics, neuroscience, and behavioral science has transformed our understanding of how the brain produces both adaptive and maladaptive behaviors. The National Institute of Mental Health (NIMH) wants to directly connect this information transforming it into clinical practice. To accomplish this goal, NIMH developed a strategic plan which is initially focused on research criteria. However, the application to clinical practice is quite clear; albeit in the future.
Beginning in 2011, the NIMH strategic plan calls for clarifying the underlying causes of metal disorders with efforts towards integrating genetic, neurobiological, imaging, behavioral, and clinical data. The main goal is to develop a new way of classifying mental disorders based on dimensions of observable behavior and neurobiological functioning. The working document is called the Research Domain Criteria Project (RDoC). NIMH, in conjunction with others, will develop specific domains with specific definitions. At present, researchers requesting funding for a project from NIMH, must use the RDoC criteria. DSM-5 or ICD-10 criteria will not be accepted for funding.
The newest developments in neuroscience and neurobehavioral indicate that complex disorder found in either DSM-5 or ICD-10 are linked to several different brain circuitries. For example, compulsive hoarding has a different brain circuitry than those with compulsive thoughts; yet in DSM-5 these disorders get the same code.
RDoC is intended as a framework to guide classification of patients for research studies, not as an immediately useful clinical tool. However, the hope is that with continued refinement and development, mental health diagnosis and treatment (including psychotherapy) will be driven by brain-behavior relationships and information gleaned from neuroscience investigation.
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By Dr. P. Douglas Callan, PhD, LP, Core Faculty at MSP
Along with being a Core Faculty member at MSP, Dr. Callan has a clinical/health psychology practice in Fenton, MI specializing in Cognitive Behavioral Therapy (CBT) for adults and older adolescents with complicating psychosocial aspects of medical disorders, depression, anxiety, life changing events, and PTSD. He also is trained as a neuropsychologist performing assessment with an emphasis in pediatric neuropsychology specializing in learning disorders and ADHD assessment.