Terry Marks-Tarlow

Big Question

“In light of the new DSM-5 release and the NIMH’s proposed RDoC framework – what is the future for mental disorder classification and diagnosis?”


I believe that the future of psychiatric diagnosis is one of the most important contemporary issues within the field of clinical practice and theory. The release of the DSM-5, with the first edition appeared in 1952, has opened up a hotbed of issues. There were rancorous debates of what categories to retain and which to exclude behind the scenes, with high political and economic stakes surrounding each. The elimination of the bereavement exclusion from the category of major depression seems to me utterly unconscionable. By medicalizing normal grief, this winds up pathologizing, if not punishing, healthy attachment. It is a sad trend for economic concerns and social politics to eclipse humanitarian concerns, such that political infighting serve decisions that cater more to money and the needs of pharmacology companies than to people and their mental health. Lots of examples of these trends are documented by Gary Greenberg, both in his 2010 article in Wired article [http://www.wired.com/magazine/2010/12/ff_dsmv/] and in his new book, The Book of Woe: The DSM and the Unmaking of Psychiatry. Another heartbreaking example involves research psychiatrists who received huge kickbacks from pharmaceutical companies for misusing diagnostic categories in order to open up the prescription drug market for children. Greenberg, among others, consider the DSM a work of fiction, due to fuzzy, overlapping, symptom-based, categories lacking definitive biological markers.

While the road to hell may be paved with good intentions, the history of the DSM appears fraught with corrupted ones. I’m hoping we cannot continue down this same path much longer without mutiny in the ranks. With that in mind, efforts of the NIMH to launch a new direction in diagnostic research appear to me at first blush to be a sound alternative. From a conceptual point of view, the main problem with the DSM is that its 100s of categories are based on ubiquitous symptoms that cross-cut too many diagnoses. The use of outward symptoms is simply a poor choice. To understand why, just imagine what it would be like for a doctor to use chest pain alone in order to diagnose an underlying condition. We would feel much more confident if the physician would rely on a number of different tests, screening, and/or scanning tools. So, too, does a multifaceted, multileveled approach make sense for psychiatric diagnoses.

The NIMH is currently releasing the RDoC [http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml], including requests to critique or respond to this document. The RDoC is at the core a matrix approach to psychiatric research, spanning from normal to pathological conditions, as well as including open constructs and units of analysis. As a dimensional system, the RDoC claims to be “agnostic” with regard to its diagnostic categories. Researchers can examine a range of levels—from genes, to molecules, cells, circuits, physiology, behavior, self-report, or whole paradigms. A strength of this approach is its dynamic capability of changing over time, in response to new research and suggestions. In contrast to the symptom-based, top-down approach of the DSM, here all diagnostic categories and criteria for measuring them, will emerge from the bottom-up.

As much of my own previous writing indicates (especially my 2008 book, Psyche’s Veil and my 2011 paper in Psychoanalytic Diaglogues, Merging and Emerging: A Nonlinear Portrait), I am steeped in the paradigm of nonlinear dynamics. Just as nature self-organizes from the bottom-up, so too should our diagnostic categories. This maximizes our possibilities for capturing full complexity, both as a frozen moment in time, as well as changes that occur over time, whether on the developmental time scale of the individual or the historical time scale of culture at large. For clearly, our underlying diagnostic categories tend to morph along with new economic conditions and cultural trends. For example, to my knowledge, no one today receives a diagnosis of “glove anesthesia,” a commonly diagnosed condition during Freud’s era that went hand-in-hand (sorry for the pun!) with wearing gloves (who wears gloves today?). It remains an important empirical issue whether higher incidences of particular diagnoses, such as Borderline Personality Disorder or Autism, indicate an increasingly “sick” population or whether this is an artifact of diagnostic procedures (including corrupt psychiatrist/pharmacology allegiances) themselves.

In looking toward the future of diagnosis, I applaud the use of multiple domains and levels of analyses, as well as the search for underlying biological markers. However, even within an open-ended, modular approach suggested by the RDoC, there remains the danger of biological reductionism. The RDoC is a huge step forward in many ways, including its emphasis developmental factors and environmental effects. But even close attention to these interaction effects could prove misguided, if the overall paradigm continues to fragment complex problems into simple components. I am really glad that whole paradigms are included in this matrix, as I believe the best way to capture the full complexity of psychiatric diagnoses is to take a nonlinear, holistic perspective from the start. This is so because all complex systems are inseparable from their contexts, and diagnoses often emerge from treatment rather than proceeding it (see Marks-Tarlow, 2011).

Physiological variability appears an excellent candidate for holistically capturing diagnostic categories, including personal idiosyncrasies. Only by preserving full physiological variability, rather than collapsing group norms to central means, will diagnoses progress. What is more, psychiatric diagnoses should be made in the context of ordinary life, so that the full range of contexts and responses is included. The importance of this is clear when it comes to emotional dysregulation—people display different responses and symptoms when stress or arousal is low versus high stress/arousal, and when in the midst of familiar circumstances versus novel ones, and when in the middle of an activity or stage of life versus during transitional times. Within a nonlinear paradigm, when variability is compiled over a range of time scales from a variety of different measures, whether using variability in respiration rate, heartbeat, or motor patterns, underlying fractal patterns tend to emerge. If I had a crystal ball, I’d place my bets on fractal dimensionality and power laws as central constructs in new diagnostic trends. One nonlinear researcher who has specialized in these kinds of measures is Bruce West (author of Where Medicine Went Wrong, 2006 and most recently, Complex Worlds: Uncertain, Unequal, and Unfair, 2012). I hope to collaborate with Bruce in the near future to create a “manifesto” addresses psychiatric diagnoses from the perspective of nonlinear dynamics.

Dr. Marks-Tarlow is Teaching Faculty at Reiss Davis Psychoanalytic Child Study Center in Los Angeles, California; Research Associate at Institute for Fractal Research in Kassel, Germany; and on the Advisory Board of the Global Alliance for Transformational Entertainment, also in Los Angeles. Her academic interests include how creativity and intuition interface with nonlinear dynamics and neurobiology. She has a private practice, is an artist, does yoga, dances, and has written the libretto for an opera, “Cracked Orlando”, that premiered in 2010 in New York City with a ballet. She has authored and illustrated several books, including Psyche’s Veil: Psychotherapy, Fractals and Complexity (2008; Routledge) and most recently Clinical Intuition in Psychotherapy: The Neurobiology of Embodied Response (2012; Norton).

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