Academic Psychiatry | 2021
Integrating NIMH’s Research Domain Criteria (RDoC) Initiative into Psychiatry Resident Training
Abstract
As the field of psychiatry progresses toward greater foundational understanding of psychopathology and human behavior, psychiatry residency training must adapt to incorporate new knowledge and perspectives. Previously dominated by psychoanalytic theory, psychiatry has undergone tremendous change over the last 40 years, largely due to the publication of the third revision of the Diagnostic and Statistical Manual (DSM-III) in 1980 and subsequent revisions to the DSM. The DSM largely conceptualizes psychopathology as categorical diagnostic constructs, based predominantly on patientor informant-reported symptoms and clinical examination. This approach has increased the reliability of psychiatric diagnosis and led to greater acceptance of the field within the medical community at-large [1]. The DSM framework has also provided psychiatry trainees with a common framework upon which to build their understanding of psychopathology. However, an alternative approach to the DSM has been proposed by the National Institute of Mental Health (NIMH), titled the Research Domain Criteria (RDoC), to classify psychopathology, albeit for research, rather than clinical, purposes at this point [2, 3]. In this paper, we introduce the RDoC framework and propose how RDoC could be incorporated into psychiatry resident training to improve understanding of psychopathological mechanisms. Rather than conceptualizing psychopathology as discreet entities (diagnoses) that are categorically different from “healthy” functioning (and separate from each other), RDoC conceptualizes psychopathology as transdiagnostic dimensions of functioning/behavior that range from functional to dysfunctional. The RDoC initiative proposes a matrix of six domains of neurobehavioral functioning (rows of the matrix) that each comprises constructs (and subconstructs) which represent specific mental functions within the parent domain [4]. RDoC proposes that each (sub)construct can be measured with multiple units of analysis (columns of the matrix) ranging from genes to neural circuits and to self-report. With the different units of analysis, RDoC thus seeks to integrate psychiatrically relevant biomarkers and clinical data into a common flexible framework to advance understanding of underlying neurobehavioral functioning and psychopathology. It is important to note that RDoC views (sub)constructs as occurring within developmental trajectories (arguably, a third dimension to the matrix) that also interact with the environment [5]. The RDoC matrix is also not a definitive nomenclature and is thus open to ongoing modification or addition of new constructs, as new research emerges. While RDoC was not created with the intention of immediately replacing the DSM, others have explored how the RDoC framework could augment clinical practice [6]. Intervention and prevention trials are beginning to adopt the RDoC framework by targeting biomarkers as more specific (and perhaps proximal) outcome variables relative to more general (and perhaps distal) patient-reported diagnostic outcomes [7]. For example, Krystal et al. [8] recently published a randomized, double-blind, placebo-controlled trial using an investigational kappa opioid receptor antagonist. In this novel trial design (termed “fast-fail”), the investigators’ primary outcome was not symptomatic improvement but, rather, successful engagement of the target of interest (reward system functioning using functional magnetic resonance imaging [fMRI]). By showing that the investigational agent hits the target, this trial design provides proof of mechanism of mediation between the drug and an underlying neurobehavioral system. The NIMH continues to encourage researchers to incorporate RDoC into their designs. As psychiatry evolves to integrate the RDoC framework into clinical practice, psychiatry resident education will need to integrate RDoC to prepare residents for the future practice of psychiatry. Others have encouraged the use of the RDoC framework to augment psychiatry resident training * Stewart A. Shankman [email protected]