Beyond diagnosis? Shifting approaches in psychiatry
A blogpost by Martyn Pickersgill, Centre for Biomedicine, Self and Society at The University of Edinburgh
The use of biological ideas and techniques in the study of mental ill-health and the practice of psychiatry is nothing new. But just because it isn’t new doesn’t mean that’s the only thing that’s going on in research and in the clinic: many other notions (psychological, sociological, and so on) interpolate with somatic emphases in psychiatry. One engine powering the late-twentieth century biological turn within US psychiatry was the 1980 launch of the third edition of the American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders: DSM-III. This texted helped to revivify attention to the bodily aspects of mental ill-health, although of course psychiatrists had to be attentive already to this ontological dimension for such a shift to be propelled. The DSM has come to be a major feature within the landscape of mental health research and practice, and not just in the US. Nevertheless, over the last few years criticism of this text has been growing within psychiatry itself.
A key locus of critique has been the former Director of the US National Institute of Mental Health (NIMH): Thomas Insel. The NIMH has traditionally been a major supporter of studies conducted using the DSM – and, indeed, of the production of successive editions of the DSM itself. In 2010, Insel and colleagues launched the NIMH Research Doman Criteria (RDoC) initiative. This was supposed to be a framework for shaping thinking about specific characteristics of what were regarded as psychopathologies, and how these could be better interrogated within laboratory and related settings. The NIMH have called RDoC a “long-term project” that incorporates “genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new mental disorders classification system” (NIMH, 2013). Through its promotion of RDoC, the NIMH has downplayed the import of the DSM. Insel himself wrote in one widely discussed blog post that: “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure” (Insel, 2013). Consequently, NIMH would “be re-orientating its research away from DSM categories” (ibid).
My ongoing research, supported by the Wellcome Trust, is examining epistemological debates such as the ones around RDoC and the DSM so as to generate a sharper image of the ways in which diagnoses are used in research and clinical practice, and with what ontological ramifications. Part of my research has involved interviewing key figures in US and UK psychiatry, and I have explored how they construct the purpose, nature, and implications of the ambiguous RDoC project. My intent is not to provide a broad-brush critique of RDoC as, for instance, biologically reductionist. As my data demonstrates, this is a criticism that psychiatrists themselves are often happy to make. Hence, the sociological focus of any analysis of RDoC needs to be positioned slightly differently. Accordingly, I use discussions about RDoC as a case study in what I have termed the sociology of novelty. In my upcoming SKAPE talk, I will explore how major institutional actors’ accounts of what is new, important, or (un)desirable about RDoC are constituted through institutional context and personal affects. In so doing, I aim to add empirical depth to current understandings about the bio-politics and psy-sociality of contemporary (US) psychiatry, and to contribute to sociological debates about ‘the new’ in technoscience.
Cuthbert, B. N. and Insel, T. (2013) ‘Towards the future of psychiatric diagnosis: the seven pillars of RDoC’, BMC Medicine, 11, 126, https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-11-126.
Insel, T. (2013) ‘Transforming Diagnosis’, NIMH Director’s Blog, 29 April 2013, https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.
NIMH (2013) ‘Introduction to RDoC’, NIMH Science Update, 9 August 2013, https://www.nimh.nih.gov/news/science-news/2013/introduction-to-rdoc.shtml.
Pickersgill, M. (2013) ‘The social life of the brain: neuroscience in society’, Current Sociology, 61, 322-340.
Pickersgill, M. (2014) ‘Debating DSM-5: diagnosis and the sociology of critique’, Journal of Medical Ethics, 40, 521-525.
Pickersgill, M. (forthcoming) ‘Psychiatry and the sociology of novelty: negotiating the US National Institute of Mental Health ‘Research Domain Criteria’ (RDoC)’.