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New Thinking on Mental Illness Diagnoses

In a recent New York Times Op-ed, T.M. Luhrmann expands on a recent paper by the British Psychological Association on redefining mental illness.  She makes several important points about mental health symptoms and our strategies for addressing them.

First, rather than thinking of symptoms like anxiety, sadness, and paranoia as simply reflecting defective brain functioning, we can understand symptoms as reactions to life experiences.  Luhrmann highlights traumatic experiences as a likely cause of some psychiatric symptoms.  In fact, some symptoms may be seen as adaptations to these experiences.  She encourages therapists to explore why symptoms may have developed and to better understand their function.  This, of course, is a central tenet of trauma informed care: focusing on ‘what happened’ to individuals rather than ‘what is wrong’ with them.   Talk therapies can be important in this regard.

Second, she notes that the field is, in many ways, beginning to rethink the concept of diagnosis.  Diagnoses are defined by an expert consensus process in which specific groups of symptoms that meet criteria for severity and duration are equated with specific illnesses.  Diagnoses have long been the primary classification variable for mental health research.  This is changing.  The National Institute of Mental Health is now endorsing the use of “Research Domain Criteria” (RDoC) for research classification purposes.  RDoCs are “new ways of classifying mental disorders based on behavioral dimensions and neurobiological measures.” RDocs are grouped into domains like cognition, reward, and social communication.    Particular attention is paid to the process of development over time, as organisms interact with their environments.  This change in research focus may reflect an important readjustment in our field.  We are now moving from thinking of diagnoses as distinct illnesses to recognizing that there is important variability within each diagnostic grouping and overlap between them. Developing successful intervention strategies may be enhanced by a more differentiated understanding of the building blocks of mental health or mental illness.

Third, this redefinition was motivated in part by the lack of major gene effects underlying mental health diagnoses.  We once hoped that the large data sets collected through the NIMH practical trials would allow us to map gene/illness pathways.  Unfortunately, it didn’t work that way.   No simple relationships were found.  Rather, it is the interaction of genetic vulnerability and environmental exposure (toxic stress and trauma, among others) that likely cause mental health problems.  Ongoing research continues to identify these specific interactions that should be further advanced by the RDoC framework.

Most mental illnesses are not simple manifestations of bad genes but are developmental problems.  Understanding them as such opens new possibilities for prevention, treatment and research.  As in other areas of medicine, personalized approaches will become increasingly useful.  Prevention will focus on increasing resilience and reducing risk factors.   These changes may well help to usher in the ‘next major era’ in public health – more effective prevention and treatment.
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