Tuesday, 12 May 2015

The Crisis of Psychiatry and the Promised Neurocognitive Revolution

This post is by Massimiliano Aragona, philosopher at the University of Rome

Massimiliano Aragona
The DSM-5 (American Psychiatric Association 2013) has been published in the midst of unusual controversy. Criticisms had always been advanced, but in the past the DSM system was the dominant paradigm (the 'Bible of Psychiatry'), so they were considered ‘marginal’ complaints by: psychoanalysts, antipsychiatrists, experts of various fields worried about an excessive medicalization of human sufferance, and psychopathologists concerned with the progressive abandonment of deep qualitative phenomenological analysis in favour of superficial quantitative diagnostic criteria. Such criticisms are important per se, but were largely neglected at the time.

Today it is different, because it is the credibility of the DSM itself that is in question. And, along with the DSM, it is a general way to conceive psychiatry which is in crisis: 'the neo-Kraepelinian paradigm established by Robins and Guze and institutionalised in the DSM has resulted in so many problems and inconsistencies that a crisis of confidence has become widespread' (Zachar and Jablensky 2014: 9).

Some years ago I worked on the hypothesis that the DSM nosology could be conceived as a Kuhnian paradigm (Aragona 2006; in English see partial accounts in Aragona, 2009a, 2009b). I was aware that psychiatry and psychology were not, as a whole, Kuhnian paradigms, but my assumption was that such an epistemological model could apply to the subsystem of psychiatric nosology. The consequence was that several ‘concrete’ problems in psychiatric research (internal heterogeneity of mental disorders and lack of prognostic and therapeutic specificity, excessive comorbidity rates, and so on) could be modeled not as merely empirical problems but as Kuhnian anomalies. In this model, ‘anomalies’ are apparently empirical outputs largely dependent upon the way the system is internally structured. In short, the general idea was that such anomalies were suggesting that the system was entering a state of crisis, also showing the main intra-paradigmatic reasons for the crisis and allowing a comparison of possible revolutionary solutions.

A recent paper (Aragona 2014) compared the predictions of the time to what is happening today. Here I will focus just on the part of that paper focusing on a possible revolutionary approach which at that time was unpredicted, while today it represents the most likely scenario for future research. This model is the neurocognitive model proposed by the U.S. Institute of Mental Health (NIMH) and denominated RDoC Project (Insel et al 2010; Cuthbert and Insel 2013).

Early proposals had suggested to reframe psychiatric disorders as ‘breakdowns of neurocomputational mechanisms’ (e.g. Sirgiovanni 2009). The RDoC Project is a development of the neurocognitive perspective, suggesting: 'to shift researchers away from focusing on the traditional diagnostic categories as an organizing principle for selecting study populations towards a focus on dysregulated neurobiological systems' (First 2012: 15). As such, the RDoC is not a diagnosis as we are used to conceive it, but a matrix of basic areas of cognitive functioning to be correlated to corresponding brain circuits, and whose dysfunctions would lead to mental symptoms. Although its long-term future is questionable, the hope is that when the RDoC-based research will have collected enough new findings, then a neurocognitive paradigm shift will occur.

But what exactly would be changed in such a possible revolution?

By shifting from traditional diagnoses to cognitive domains around which available evidence (from different sources, from genes to self-observation) should be trans-nosographically organized, the RDoC Project promises a radically different nosography, based on neurocognitive dysfunctions as organizational kernels of the system. In other words, this model radically changes the direction of the validation process: while in the traditional approach researchers are expected to proceed from phenomenally defined disorders back to the discovery of their etiology, in the etiopathogenic approaches the direction is reversed, i.e. from ‘subpersonal’ dysfunctions ahead to the resulting phenomenal picture.

Would it be for the best? Many conceptual problems need to be addressed, and above all it remains the problem (the same as in the DSM-5) of how to reconcile the hermeneutics of mental symptoms (cp. Berries 2013) with the reductionist stance of these models. But this is another story…

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