APA: RDoC helps psychiatry ‘use its words’

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”