A hopeful future for mental health diagnosis.

Diagnosis carries a certain weight that often marks a pivotal point in an individual’s mental health journey. For many people who have struggled with perplexing, exhausting symptoms it can come as a welcome relief, offering clarity and hope for recovery. For others, it is a ball and chain that threatens to sink them deeper into murkier depths of isolation and stigma, robbing them of freedom, and damning them to a life dependent on medicine, psychiatric care, and ‘the system’. It is often a transformational experience, becoming part of one’s identity for better or for worse. In my previous post ‘Psychosis, a category or continuum?’, I describe how in recent decades psychiatry has shifted more towards viewing mental health conditions as lying on a spectrum with everyday experiences. The deciding point at which one’s experiences and behaviour go from being ‘normal’ to pathological has a lot to do with whether a doctor identifies them as symptoms and provides a diagnostic label.

Mental health diagnosis is arguably one of the most controversial topics of modern medicine. No neuropsychological exam or physiological test exists to determine whether or not someone has a condition. If you visit a doctor with complaints of mental health related issues, you are likely to be presented with a short subjective questionnaire that asks you to rate on a scale the extent to which particular scenarios describe your state of mind. This is usually followed by a more in-depth interview, with a diagnosis provided only if specific medication or therapy is prescribed. Whilst the use of a qualitative questionnaire can be incredibly informative, questions and answers are interpretive and can be ambiguous. First it depends on the individual to report accurately their symptoms and second it depends on the specialist’s ability to correctly identify them and distinguish a correct diagnosis. Whilst common symptoms such as depression or anxiety can be identified relatively quickly, receiving an actual diagnosis of a fully-fledged condition such as Major Depressive Disorder, General Anxiety Disorder, Bi-polar Disorder or a personality disorder, often takes a much longer time. In the case of Bi-polar disorder, receiving a correct diagnosis can take a number of years and often follows an initial misdiagnosis (Cha et al., 2009) and consequently the consumption of wrongly prescribed medicines.

To determine a diagnosis, specialists compare observed symptoms against specific diagnostic criteria. There are two widely used diagnostic manuals – the International Classification of Diseases (ICD) and the Diagnostic Statistical Manual (DSM). The DSM, often mockingly referred to as the ‘Psychiatrist’s Bible’, came into effect in 1952 as a result of extensive collaboration amongst American psychiatrists. Although its conception was rooted in the gallant intention to provide a singular framework upon which practitioners could provide patients with systematic care, the manual has had a controversial history.  Early versions, which included a limited array of conditions with ambiguous diagnostic criteria, garnered considerable critique from the anti-psychiatry movement of the 1960s. Since then the manual has undergone a number of significant revisions and marked improvements, although it continues to be haunted by fierce criticism. For example, whilst the first DSM identified a few dozen different conditions, its fifth and current incarnation recognises over 250. Does this rise in conditions reflect enhanced appreciation for nuance or perhaps an over-medicalisation of everyday experience that seems characteristic of American health-care culture?

Diagnostic manuals have endured their turbulent history and remain an integral tool for psychiatrists, clinical psychologists and researchers. I feel compelled to say that I have personally never met anyone who uses such manuals, taking them at face value alone. Instead of viewing the DSM as a scripture that must be dogmatically adhered to, the view tends to be that it is more like a dictionary, a set of labels with definitions. The growing intuition is that times are a (slowly) changing. This is partly due to staggering developments in technology that will one day contribute to identifying psychiatric conditions based on biomarkers (measurable biological indicators). Could a diagnosis of Bi-polar disorder be determined with a simple blood test? Probably not. Unlike more biological conditions (e.g. cancer, HIV/AIDS, heart disease, diabetes, etc.), it is difficult to believe that a psychiatric diagnosis could be reduced to a single measure. It requires a far more holistic approach that incorporates everything from a person’s genetic makeup, the concentration of specific chemicals in their brain, how different areas of their brain connect to one another, as well as their behaviour and subjective experience.

In the last decade, the National Institute of Mental Health (NIMH) initiated the Research Domain Criteria (RDoC) project in the hopes of revolutionising how we diagnose and treat mental health conditions. It aims to develop “new ways of classifying mental disorders based on dimensions of observable behaviour and neurobiological measures”. For each condition (or symptom) a two-dimensional matrix is constructed that organises information across different domains (psychological constructs that range from normal to abnormal) and classes of variables (units of analysis, which include seven paradigms ranging from genes to self-reports) – see Figure 1. Individual cells of the matrix are then filled in with empirically supported research, helping to provide a comprehensive framework of the constituents that make up a mental health condition. Eventually, biological tests (e.g. DNA screening, blood tests, neuroimaging, etc.) could accompany the current diagnostic interview procedure. Results could then be compared to profiles of conditions developed by the RDoC, enabling practitioners to more carefully distinguish a correct diagnosis.

Microsoft Word - brt_2752_Lilienfeld RDoC Analysis.revised

Figure 1: Research Domain Criteria matrix

Whilst this new approach has caused a considerable buzz within the mental health field, it is still in its early stages. In their 2016 paper, Patrick and Hajcak use a quote from T.S. Elliot to earth the excitement – ‘Between the idea and the reality … Falls the Shadow’ (in science there is always someone who raises a cautionary finger!) They describe a number of challenges that face the RDoC project, including the crisis of replicability that has plagued the fields of psychology and neuroscience in recent years. Translating the promise of this revolutionary framework into actual progress will be no mean feat – but name one thing worth doing in life that isn’t? Underneath our sceptical exterior, scientists are deeply optimistic characters (I promise you, if we weren’t we wouldn’t keep going). At the early stages of my research career, with the privilege of historical hindsight and the potential of advancing technologies, the RDoC project is very exciting. One day mental health diagnosis may well be different – the future is hopeful.

If you are interested in further reading on the topics touched on in this post, here are some suggestions:


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