TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

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.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

APA: RDoC helps psychiatry ‘use its words’