May 24, 2017

What Can the RDoC Offer Clinicians?

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Joel Yager, MD, and Robert E. Feinstein, MD

University of Colorado School of Medicine, Aurora (Drs Yager and Feinstein)​


As practicing clinicians, we’re keenly aware of the limitations of current diagnostic systems. Despite the DSM-5’s many worthwhile features and practical uses, we contend on a daily basis with the need for a richer, more inclusive conceptual framework to adequately describe and encompass the psychiatric intricacies we encounter in our patients. In our outpatient department, virtually no patient receives only one psychiatric diagnosis. Piling on DSM diagnostic labels, each one accurately categorizing only restricted aspects of our psychiatrically multimorbid patients’ pictures, doesn’t adequately capture all of their clinical complexities. Not infrequently, our patients’ diagnostic concoctions consist of hybrid stews in which MDD, PTSD, GAD, ADHD, alcohol and substance use disorders, and borderline personality disorder all blend together; these, in turn, have inspired inventive cross-diagnostic neologisms such as “border-polar” or “border-holic” disorders.

Investigators have had frustrations regarding the limited scientific validity of the DSM system, which stimulated the emergence of the National Institute of Mental Health (NIMH)’s Research Domain Criteria (RDoC). We were eager to see what this new, somewhat reductionist scheme might have to offer in the clinical realm, and our assessment was recently published. Going in, we were keenly aware that, as a provocative and controversial evolving enterprise, RDoC was not intended to serve clinical purposes at its early stages of development.

We found a mixed but generally useful bag. The RDoC domains and constructs offer a new vocabulary—negative and positive valence systems, systems for social processes, approach motivation, reward attainment, and so-forth. These terms are now being applied in neuroscience studies to delineate networks and identify biomarkers, but they generally haven’t bubbled up into clinical work. Reflecting on how these unfamiliar words and formulations might apply to enduring clinical phenomena inevitably shook us out of our cognitive comfort zones, stimulating new considerations and reconceptualizations. We found several comfortably familiar areas in which the RDoC terms basically offered ways of repackaging old wine (eg, depression, anxiety) in new bottles (eg, negative valence systems).

In our article, we listed potential clinical inquiries based on the constructs in the RDoC domains. For example, we found encouragement for clinicians to consider asking patients about important phenomena regarding their values, capacities for effort expenditure, and habits, which might not routinely enter current diagnostic thinking. Constructs in the RDoC that address these areas are the positive valence domain’s motivational states, cue sensitivities, reward and effort valuations, and expectancy prediction errors. Constructs in the social processes domain, such as affiliation and attachment and perception and understanding of others, draw important attention to meaningful phenomena such as attachment styles and capacities for mentalization, considerations that we see as clinically important but insufficiently emphasized in the DSM.

We enjoyed the challenge of mapping clinical questions onto the RDoC domains and believe that several of the questions we’ve delineated can enrich clinical assessment. At the same time, this work underscores the fact that meaningfully assessing all of these complex issues would take considerable time and more technologically advanced information-gathering methods than most clinical practices currently employ.

We have learned that the NIMH, the Delaware Project, and the Association for Behavioral and Cognitive Therapies have been working together to develop a series of webinars designed to explore the pathway from an RDoC-based formulation of psychopathology/pathophysiology of mental disorders to treatment development and on to dissemination and implementation. They’re beginning to address how useful the RDoC might be in bridging the science-to-service gap and, as we’ve discussed above, whether conceptualizing a patient’s presentation in RDoC terms, in addition to the more traditional DSM categories, might help clinicians with assessment and treatment. The first webinar considered generalized anxiety, asking attendees to think of anxiety in terms of threat sensitivity and fear circuitry. You can watch the video on YouTube. The second webinar will focus on depression and ask attendees to consider depression from the perspectives of anhedonia and reward circuitry deficits. Whether the RDoC can ultimately help the field shorten the time to better treatments remains to be seen, but by aiming the webinar series at students, trainees, researchers, and practitioners, the webinar organizers hope to begin to get an answer to this question.

Financial disclosure:Dr Yager has received honoraria from the Massachusetts Medical Society, UpToDate, and West Virginia University. Dr Feinstein has no relevant personal financial relationships to report.

Category: Mental Illness
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