From RDC to RDoC: a history of the future?
By KWM Fulford
Back in 1963 the New York Times reported enthusiastically that “….a young doctor at Columbia University’s New York State Psychiatric Institute has developed a tool that may become the psychiatrist’s thermometer and microscope and X-ray machine rolled in to one.” The tool in question was a precursor of the Research Diagnostic Criteria (RDC) with its operationally defined criteria for psychiatric diagnosis. The young doctor was of course Robert Spitzer who within a few years was to become chair of the APA task force that produced the equally well received operational-criteria-based DSM-III.
Set against the back drop of discontent that has greeted DSM-5, Thomas Insell’s enthusiastic launch in April this year of the National Institute of Mental Health’s Research Domain Criteria (RDoC) project came as a welcome return to the optimism and proper ambition of the heady days of the RDC. Insell has cause to be up-beat. These too are heady days. Psychiatry once again, as in 1963, has promising new tools to hand: imaging, epigenetics, and the rest. DSM has failed to deliver on the promise of these new tools. Patients, Insell says, deserve better.
But will they get it? Will RDoC succeed where RDC (it seems) has failed? No one doubts the promise of the new neurosciences. RDoC — like RDC in its day — is a step (no more) towards some as yet unspecified future psychiatric diagnostic classification. As such Insell is surely right that RDoC will prove more hospitable to the neurosciences than the 500+ categories of DSM-5. But what hope the product bottom line? Will RDoC in the end prove any more effective than RDC and its successor DSMs in translating new knowledge of brain functioning into tangible improvements in patient care?
One way to improve the odds is to strengthen the voice of experience. The buzz on the service delivery side of mental health in the UK is ‘co-production’: an equal voice for patients and carers as ‘experts by experience’ alongside clinicians and managers as ‘experts by training’. So why should we not have co-production in research? Sure, functional magnetic resonance imaging (fMRI) and the like require high-level specialist training. But psychiatric fMRI is about the brain basis of complex mental states to which the voice of experience alone can ultimately speak. In research, moreover, there is a growing resource of doubly qualified ‘experts by experience and training’. So what’s to lose from co-production in research? And with co-production in research goes by extension co-production in the translation of research back into practice.
Co-production it should be said straight away, presents many challenges. Not the least of these for co-production in neuroscientific research are all the methodological and conceptual challenges of bridging between object (observations of the brain) and subject (the contents of experience).
This is where — as a two-way translational bridge between object and subject — philosophy has a role to play. Philosophy, as no less a neuroscientist than Nancy Andreasen pointed out some years ago, is a natural partner to the neurosciences. The centenary of the philosopher-psychiatrist Karl Jaspers’ General Psychopathology in 2013 is auspicious in this respect. Jaspers’ key message for the (equally new at the time) neurosciences of 1913 was that psychiatry uniquely demands in equal measure object (causes/explanations) and subject (meanings/understanding). Yet psychiatry adopted a predominantly causes-only approach that, mediated by the mid-twentieth century logical empiricism of the philosopher Carl Hempel, led, ultimately, to DSM-5.
Modern philosophy of psychiatry, although developing otherwise in parallel with the new neurosciences, has been throughout strongly practice-oriented. The field has indeed blossomed through a dynamic two-way relationship with practice. Besides traditional areas of phenomenology and the philosophy of mind, a novel philosophy-into-practice development has been the clinical skills-based approach of values-based practice. Building on a series of training and policy initiatives values-based practice has recently been incorporated into the UK’s National Occupational Standards for Mental Health as part of a wider reframing around co-production and recovery. There is co-production too in research. Matthew Ratcliffe’s group at Durham University is running a number of phenomenology-based projects in partnership with service user organizations. In Oxford we have a co-production scoping study underway with the Mental Health Foundation. And expect to hear more in this connection of the young philosopher and cognitive scientist Philipp Koralus’ Erotetic Theory of Reasoning and its potential contribution to the emerging field of ‘computational psychopathology’.
So in 2013 let’s welcome Research Domain Criteria as warmly as Research Diagnostic Criteria was welcomed back in 1963. Let’s welcome too, and engage fully with, the new neurosciences. But let’s also welcome and engage fully with the methodological and conceptual challenges of translating research into practice. Otherwise we risk a history of the future in which the small ‘o’ added by RDoC to RDC ends up as just another big zero.
Bill Fulford is a Fellow of St Catherine’s College and Member of the Philosophy Faculty in the University of Oxford and Emeritus Professor of Philosophy and Mental Health at the University of Warwick. He is lead editor of the Oxford Handbook of Philosophy and Psychiatry, series editor of the OUP book series International Perspectives in Philosophy and Psychiatry, and co-editor of the journal Philosophy, Psychiatry, & Psychology.
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Image credit: Human brain work metaphor made of rusty metal gears. © Andrey_Kuzmin via iStockphoto.