NIMH dilivers kill shot to DSM-V

[Velvet Elvis]

This is big:

 

http://www.science20.com/science_20/blog/nimh_delivers_kill_shot_dsm5-111138

 

I'm not clear if part of their goal is to get therapists and non-medically trained individuals out of the diagnosis game or not.

 

I'm skeptical.

 

[lifequake]

Wow.  I don't know what to say.

[WinterRosie]

I'm reading a book about trauma responses. The author (who has been researching how various mammals from rats and rabbits up to bonobos and other large primates for about 40 years or so) was fighting to have PTSD changed in the DSM-V.

PTSD is one of those things that you can't exactly find on an MRI all that easily. But that doesn't mean that the DSM-V has it right, either.

 

So... I guess I side with neither of these two forces?

Also, how do they know what to scan for without self-reporting of symptoms? How would they know to check for dissociation vs seizures if you never reported losing time, or out of body experiences, or feeling depersonalized or derealized? How would they know that you heard voices if you never had the opportunity to tell them what you heard?

[Velvet Elvis]

Here's the whole thing spelled out in detail:

 

http://www.nimh.nih.gov/research-funding/rdoc/nimh-research-domain-criteria-rdoc.shtml

[Kaashii]

Wow.  I don't like that at ALL.  I can understand the criticisms of the DSM-V, but this is ridiculous.  Talk about completely dehumanizing things.  I understand that it's for funding research at this point, but if they start using that crap as a diagnostic guideline, even MORE people will be intimidated to the point they fail to seek help or discontinue seeking help for their MI.  Someone comes in seeking help for depression and they want to examine all of THAT?  God, if they wanted to poke and prod at ME like that, I'd be telling them where to stick it.   We're people, not fucking lab rats. 

 

As it stands for funding research, it's disturbing at best.  If they ever turn that into diagnostic criteria?  There are no words for the disgust I'm feeling just thinking about it.

[Luna-]

I am feeling very stupid. I read the links, but I don't understand what they are saying. Can someone explain this or even just the gist of it, please?

[Retromancer]

New Scientist (British science magazine, accessible to the layperson) take on it:
 

Psychiatry divided as mental health 'bible' denounced

[Luna-]

Thanks very much for this; I think I understand it better.

 

So basically the new focus of research is going to be this:

"Insel wants mental disorders to be diagnosed more objectively using genetics, brain scans that show abnormal patterns of activity and cognitive testing."

... ie moving away from diagnosing on the basis of symptoms?

 

Are the various tests sophisticated enough to do that? I realise it's a future-thinking thing.

 

ETA: I thought the problem was that there weren't really objective tests to dx MI. Will we all have to be MRI'd? I mean it'll be great if they get developed obviously, but what happens in the meantime?

Edited May 5, 2013 by Luna-

[WinglessFaery]

I don't know about this. In a way it sounds good when they say mental health patients deserve better and to be diagnosed that way would seriously reduce stigma but on the other hand..

Idk about all mental illness but bipolar for example..well they still have no idea what causes it or why certain medications help. Probably because there has been a significant lack of funding for its reasearch in the past (im otally getting all this info from madness by marya hornbacher and a pamphlet for abilify in case you were wondering lol) so maybe they should fund both before relying on techniques like this. I mean otherwise are they gonna turn people away for treatment if they have symptoms but don't match what they THINK should show up on the brain scan?

Also tests like that are expensive and a lot of us are on dissability...

Edited May 5, 2013 by WinglessFaery

[wj74]

To me this sounds like something private practice drs would do, the ones that don't take insurance... I think most insurance companies aren't going to pay for that. You can't force people to have an MRI if their insurance won't cover it for a mental illness.

[WinterRosie]

The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behaviour. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.

 

For me, this is where we diverge. Some MI have biological basis, sure, but some don't. Some are experiential. Some are situational. Where does someone like me, who is MI due to life experiences (rather than biological basis) fall on this toss-out of the DSM? Does that mean that we are further ignored? Does that make us become stigmatized as untreatable? I hope not.

[Kaashii]

Rosie, you just hit one of the big nails on the head - some MIs can be exogenous (and I would hazard a guess that many others aren't entirely endogenous, either).   There may NOT be a specific biological cause, so forcing someone to endure a barrage of expensive and intimidating tests, then to be told that their MI isn't "real" because the scans come up blank would be completely counterproductive to getting people to want help or believing that their condition is treatable.  (I think we can connect the dots and see where this could potentially lead without me saying it, to avoid being triggery.)   PTSD would be a prime example here - life experiences are something that wouldn't show up on any lab report, and their framework seems heavily weighted against self-reported symptoms. 

 

I'm aware that the documents say that those are "suggestions",  but it's a slippery slope and the effects of it even as such could be very negative.

[WinterRosie]

^ this is the current "problem" with fibromyalgia. In the old days, back when physical ailments were diagnosed based on self-reported symptoms, fibromyalgia was a very real thing. You feel pain? We'll treat the pain.

Now,  because the source of the pain isn't revealed with current diagnostic tools, it's seen as pain without a biological basis. Or, pain that is less real than, say, rheumatoid arthritis where damage to the joints can be seen on a scan.

I'm terrified of MI diagnosis and treatment going in that direction.

[AnneMarie]

 

The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behaviour. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.

 

For me, this is where we diverge. Some MI have biological basis, sure, but some don't. Some are experiential. Some are situational. Where does someone like me, who is MI due to life experiences (rather than biological basis) fall on this toss-out of the DSM? Does that mean that we are further ignored? Does that make us become stigmatized as untreatable? I hope not.

 

 

How do you know that you don't have a biological predisposition or sensitivity? Many people survive trauma without developing (or maybe rather sustaining) serious MI.

[AnneMarie]

I think this is a good research start.

 

If neural imaging leads to effective treatment, insurance should be forced to cover the cost just as they would for a heart condition. The mental health parity laws in the US come into play. The thing is, the link has to first be established and you get to that thru research, which is what RDoC targets. If DSM categories aren't facilitating, then NIMH is right to develop an approach that better fits the known science and aids the best theories on future discoveries.

[kateislate]

I am very hot on this idea. And I'm a person that thinks 90% of my problems are mainly "psychological" and maybe only 10% are innately "biological." (A distinction that may not even mean a whole lot IMO - everything's in the brain). But so little is known about that 10% that instead of there being some targeted treatment for it, I'm on medications from four totally different classes in a sort of blind shot-gun approach that helps, but nobody has any clue why or how. And that with a psychiatrist who is extremely biologically/medically-oriented. He does what he can with the crappy data out there.

 

The structure and premise of the DSM is so bad and creates so much "noise" it's virtually impossible for researchers to find a signal - what causes what and what treats what. It's a major reason there have been no significant advances in the medical treatment of mental illness in what - 20? 30? years??? Pretty much all the new drugs that come out are just refinements of what's been out there for decades. And let's face it - none of them work all that well to begin with.

[Gearhead]

My current meds are doing a good job of keeping me sane. Will I have to go off of them to have a screwed-up brain scan to prove that I should be on the meds I'm taking?

[bluechick]

kateislate-I absolutely disagree with your assessment of MI treatments. My medicine and therapy regime is working very, very well. They saved my life. Without them I'd be dead.

As for what NIMH is doing I think it's misguided. It's not really an either/or proposition. I am saddened that these two schools of thought are at odds rather than working together.

[Kaashii]

Even though my treatment regime is far from perfect, I'm rather along the same lines as bluechick.  It was hard enough for me to ask for help again with the idea of seeing a psychiatrist and a therapist being intimidating enough.  If I was struggling at that junction again and someone was going to force me through all kinds of expensive and even more nerve-wracking tests?  I would have chosen not to get help and I would not be writing this post right now.  You can do all the tests in the world on someone, but if they're having a genuine problem and need help,  having someone treat them like a lab rat for who knows how long and tell them that what's wrong with them isn't real because it doesn't show up on a lab report is going to do anything BUT help them.  You can say what you want about genetics and endogenous factors, but things like that REALLY don't matter when someone is in crisis or on the verge of it. 

 

Both sides can try to talk it up however they want, point fingers at the other side for being wrong and their research being flawed, but in the end, it's the MI community that will wind up feeling the negative effects of it first.  This whole thing is REALLY misguided at best, capable of more harm than it does good at its worst if it somehow makes its way into the field as actual diagnostic criteria down the road. 

[bfff]

Good for science, bad for patients.

[Velvet Elvis]

The problem was that in the past research had to be proposed in terms of DSM criteria to get funding from the NIMH.  That meant that all research findings would be shaped to fall within the DSM paradigm.  This simply outlines new, broader criteria for funding requirements.

 

I expect it to be 20-30 years before there are any noticeable changes in patient care resulting from this so there's no reason for people to freak out about it unless they are researchers active in the field. 

 

I was planning on doing graduate work in cog-sci when my brain broke so I'm pretty happy with this.  In the past people doing work in fields such as cog-sci and philosophy were largely ignored by those working in mental health fields.   Getting all people doing brain research across all disciplines on the same page and working together can only be a benefit to humanity as a whole.  

 

I'm worried the whole project might be too ambitious to be practical though. 

[Luna-]

Here is another article, more geared to the layperson. 

 

Psychology Today

[water]

 

 

I'm worried the whole project might be too ambitious to be practical though. 

 

This is what I was wondering.  my hubby thinks it is a ploy for the insurance companies to get away with something.  who knows.  I do believe that this type of research could possibly help.  But at the same time, my meds have saved my life.  Yes, they are not perfect, but they are working.

 

Also, I keep thinking, now at my late age in life, how in the world could anyone even separate out any physical and psychological components of my disease.

 

Let's say I came into the world with chromosomes for depression.  Perhaps one short and one long, enough to maybe possibly create depression.  Then I grow up in an amazingly emotionally abusive household.  Desolate place.  My depression goes sky high.  And at the same time, I am dealing with two non parents. I am forced to make my own life. Because of my genes as well, I refuse to give up - I have great empathy- an ability to push forward in despair.  Then coupled with my narcissistic parents, some of these qualities turn out to be the very stuff that has led me to this fairly successful functional life of a middle aged depressed mother,wife, artist, videographer.

 

So now, after half a century of living and only a few years on meds, who is to say what is nature and what is nurture? They are all smushed together at this point. So if I look at that chart, the one on this page, those genes molecules cells, are they are result of my pushing through? a result of what was in me out of the womb? If I was born with certain predispositions to depression but lived with somewhat normal parents, maybe my depression would be worse?  who the hell knows.  

 

I definitely see the great importance in this type of study.  I also see  the great importance in the continuance of the DSM-V which has managed to spark a company to make two pills that somewhat successfully help me deal with my smushed together reality. 

 

Until this country starts getting that the physical and the psychological are joined together, that we are body, mind and soul, I don't think we will make much progress.

Edited May 6, 2013 by water

[kateislate]

kateislate-I absolutely disagree with your assessment of MI treatments. My medicine and therapy regime is working very, very well. They saved my life. Without them I'd be dead.

 

I think that's great, really. And I seem to do better on my meds than off. But for a lot of people that's not the case - they don't work, or the results or mixed, or the side effects are bad. Schizophrenia is a perfect example - there are drugs (mostly variations on very old drugs) that treat positive symptoms - improvement in most, remission in some. But for the negative symptoms - which are truly devastating - there are basically zero treatments.

 

And I don't think most people realize how serious the situation with psychopharmacology research is right now. Here are two good articles which explain in part why NIMH is doing what it's doing:

 

Psychopharmacology in crisis (Nature)

No New Meds (Science News)

Some quotes:

 

Not a single drug designed to treat a psychiatric illness in a novel way has reached patients in more than 30 years, argues psychiatrist Christian Fibiger of the University of British Columbia in Kelowna, who described the problem in a 2012 Schizophrenia Bulletin editorial. “For me, the data are in,” says Fibiger, who has developed drugs at several major pharmaceutical companies. “We’ve got to change. This isn’t working.”

 

...many drug companies are retreating. Though some small, targeted efforts remain in place, pharmaceutical giants Glaxo­SmithKline, AstraZeneca and Novartis recently shuttered their main brain drug discovery programs.

 

Cohen says that much of the problem derives from a failure to develop the underlying science. Depression is a complex disease, yet to assess whether drugs work, researchers have to rely on crude tools such as questionnaires.

 

My feeling is that the APA really deserves what it's getting. They basically left NIMH/researchers no choice. After decades of the DSM dominating research - and not much coming out of it - two decades since the last major revision - during which time there have been no important advances in psychopharmacology or psychiatry - and all the very serious problems that everyone knows underlie the whole structure of it - did the APA do any real rethinking for the DSM-V? No...the changes they made are unbelievably trivial - cosmetic.

 

We can't wait for another 20 years for the APA to get its act together.

 

I'm worried the whole project might be too ambitious to be practical though.

 

Yeah, that might be right. Don't know until you try though. And like you said it's a long, long-term thing. I'd be surprised if there were any radical changes in my lifetime. Never know though.

[Alien Navel Cord]

I already had a test done at my psychologist's office that showed how fast my brain is running.. and this concluded that yes, in fact, I do have bipolar disorder. I don't know what it was called but he hooked electrodes to my head and something on my finger and he could see my brain waves. It wasn't being used as diagnostic criteria, but more of a peice of the puzzle on how to structure my therapy. Has anyone else heard of this/taken this test?