Some thoughts on NIMH's abandonment of DSM

You have almost certainly already seen the news that the National Institute of Mental Health, America's main federal mental health research body, has abandoned the DSM as a guiding framework for mental health research. In a recent blog it's director Thomas Insel explained that the organisation will now seek to support "research projects that look across current categories – or sub-divide current categories – to begin to develop a better system."

This is a hugely important shift in the politics of mental health, and even though, as Vaughan Bell has pointed out at Mind Hacks, it won't effect a sudden change in how people are diagnosed, it will have positive knock on effects for how we conceptualise mental health problems.

Most researchers in clinical psychology (I can't speak for psychiatry) are aware of the limitations of the DSM. The fact that it is written by consensus and is full of categories that are reliable rather than valid is a widely acknowledged source of embarrassment and frustration for people trained in the methodology of a field in which validity is a central theoretical concern.

The problem is that in America, a country which has such an important influence on research around the world, the NIMH is an extremely important source of money for people who wish to do serious long term research into mental health. In the major research universities here, faculty members in clinical psychology departments need to attract serious grants to continue their research and to get tenure. That often means NIMH money.

With even the best intentions it has been difficult to do studies which ignore the boundaries that already exist in psychiatric practice. This is part of how we end up with the perpetuation of terms like "Borderline Personality Disorder". Several academics I know find it an offensive term, and yet they continue to publish papers with the name in the title. Why? Because it is an unfortunate label for a useful concept (i.e. a population of people who's self regulation has been disrupted by traumatic and invalidating experiences) but people's research needs to adopt a common language if studies are to effectively "speak"to one another, so the cognitive dissonance goes on. Perhaps this is why Insel's post explicitly states that the DSM, so often referred to as the "bible" of psychiatry, is better considered a dictionary. What the NIMH propose, with their alternative the "Research Domain Criteria", is a new dictionary.

I've seen some pessimism already from mental health activists, and they might be right. The funds that NIMH disburses have been historically connected to the Federal Government's "decade of the brain" programme, and this ethos is still dominant, not least in the ongoing use of the term "disease". But there is reason for optimism too. The NIMH's strategic vision is broad, and incorporates research which examines gene-environment interactions, environmental risk factors and personalised psychosocial interventions. Most significantly, a move away from automatic acceptance of terms like "OCD" or "Schizophrenia" opens up the conceptual field to research that focuses on mechanisms rather than categories.

It will be a long time before service users see the tangible effects of this; Vaughan Bell compared the time frame to a Mars mission. However, unlike NASA's journey to Mars, this is a research programme that may end up helping us see humans again.