Diagnostic Classification Systems Research Articles

Recognizing and Effectively Managing Hypermobility-Related Conditions.

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia.

The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement. This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined. Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking. Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

Evaluation of the Applicability and Usefulness of the Latin American Guide for Psychiatric Diagnosis, Revised Version, in Comparison with other International Systems among Latin American Psychiatrists

Background: The Latin American Guide to Psychiatric Diagnosis, Revised Version (GLADP-VR) represents an adaptation of the ICD-10 that seeks through a biopsychosocial approach to better reflect the holistic framework and culture of Latin American countries. This revision of the original GLADP included updated Latin American annotations and a new integrated diagnostic model centered on the person. Objectives: The aim of this study was to evaluate among Latin American psychiatrists the levels of applicability and usefulness of the GLADP-VR in comparison with major international diagnostic classification systems. Method: The survey evaluation instrument included questions about fundamental characteristics of a useful diagnostic guide and comparative questions about the acceptability and usefulness of the GLADP-VR, the original ICD-10, DSM-IV and DSM-5, and suggestions to improve the guide. The sample included 127 Latin American psychiatrists with an interest on Diagnosis and Classification and membership in one of the 17 national psychiatric societies affiliated with Latin American Psychiatric Association (APAL). They were sent the evaluation instrument by e-mail. Thirty-seven (29.1%) responses were obtained. There were no indications of demographic bias among respondents and no-respondents.The vast majority of respondents answered the questionnaire completely. Ninety-two percent reported knowing the GLADP-VR before the survey and 65.6% had actually used it before.Results: The most commonly used diagnostic system was the original ICD-10 (86.5%), followed by the GLADP-VR (56.8%). Regarding applicability, the diagnostic system recognized as the most user-friendly was the ICD-10 followed by the GLADP-VR, with the most difficult being the DSM-5. Concerning diagnostic accuracy, the GLADP-VR was found most useful; and the DSM-5 was least useful. Regarding usefulness for clinical care and professional practice, the ICD-10 was rated highest, followed by the GLADP-VR, and lowest was DSM-5. The least valued in this regard was the DSM-5. Regarding usefulness for yielding a complete view of the clinical situation, the GLADP-VR was best (83.3%), and DSM-5 was the lowest. Concerning cultural and psychosocial contextualization, the GLADP-VR was considered most useful, well above ICD-10 and the DSMs. Furthermore, the GLADP-VR was considered more useful for teaching and research by about 80% of psychiatrists, superior to the other diagnostic systems.Discussion: The findings of this study on the most prevalent use of ICD-10 are consistent with the results of a survey conducted earlier by the World Psychiatric Association across the world. In addition, in the present study less than half of the respondents used regularly the DSMs. The findings of the present study concerning the GLADP-VR were quite consistent with the corresponding findings of an earlier preliminary evaluation of the GLADP-VR. This seems to be related to the GLADP-VR comprehensive personalized diagnostic formulation with various components, including narratives. Conclusions: There are indications that the GLADP-VR is seen in Latin America as having higher diagnostic accuracy, yielding a comprehensive view of the clinical situation and its context, and more suitable for teaching, research, and work in community mental health.

The psycho-periodic cube

The current diagnostic classification systems in psychiatry have been developed primarily for evidence-based clinical decision making with both categorical and dimensional approaches having their own advantages and disadvantages. Efforts have been made to improve these classification systems, and we are now at the point where we must expand beyond the one-dimensionality of these systems. In this paper, we propose that psychiatric disorders can be arranged in a three-dimensional classification system according to the degree of dysfunctions on three specific axes in a way that is similar to the arrangement of chemical elements according to their atomic weights in Mendeleyev’s periodic table. For the three axes, we chose externalization, drive, and attention to represent the three-dimensional descriptions of mental health, namely, well-being in social, motivational, and cognitive areas, respectively. Throughout the paper, we explain our reasons for choosing these three axes and compare our hypothesis with categorical diagnostic systems as well as Cloninger’s dimensional diagnostic system using personality disorders, affective disorders, and schizophrenia as the specific diagnostic samples.

Global Consensus on Definition, Classification, Diagnosis, and Staging of Limbal Stem Cell Deficiency.

Despite extensive knowledge gained over the last 3 decades regarding limbal stem cell deficiency (LSCD), the disease is not clearly defined, and there is lack of agreement on the diagnostic criteria, staging, and classification system among treating physicians and research scientists working on this field. There is therefore an unmet need to obtain global consensus on the definition, classification, diagnosis, and staging of LSCD. A Limbal Stem Cell Working Group was first established by The Cornea Society in 2012. The Working Group was divided into subcommittees. Four face-to-face meetings, frequent email discussions, and teleconferences were conducted since then to obtain agreement on a strategic plan and methodology from all participants after a comprehensive literature search, and final agreement was reached on the definition, classification, diagnosis, and staging of LSCD. A writing group was formed to draft the current manuscript, which has been extensively revised to reflect the consensus of the Working Group. A consensus was reached on the definition, classification, diagnosis, and staging of LSCD. The clinical presentation and diagnostic criteria of LSCD were clarified, and a staging system of LSCD based on clinical presentation was established. This global consensus provides a comprehensive framework for the definition, classification, diagnosis, and staging of LSCD. The newly established criteria will aid in the correct diagnosis and formulation of an appropriate treatment for different stages of LSCD, which will facilitate a better understanding of the condition and help with clinical management, research, and clinical trials in this area.

The NIMH Research Domain Criteria Initiative and Comorbidity in Schizophrenia: Research Implications

Diagnostic classification systems of schizophrenia have changed over time, pointing to their potential lack of reliability and scientific validity. A particular challenge is comorbid presentations, which have made the delineation of clear boundaries difficult and challenging for research applications. There is a need for a new symptom domain approach that is free of traditional diagnostic “attachments.” The National Institute of Mental Health (NIMH) introduced such as system with the Research Domain Criteria (RDoC) initiative in 2013. The system relies on five behavioral dimensions. We present the potential advantage of using the RDoC in the study of behavioral domains within schizophrenia and specifically for comorbid manifestations. Using the RDoC matrix allows researchers to align information from genetic, molecular, cellular, circuit, physiological, behavioral, and self-report levels of a comorbid disorder. Overall, the NIMH RDoc criteria will not displace the International Statistical Classification of Diseases and Related health Problems/Diagnostic and Statistical Manual of Mental Disorders diagnostic systems, but they may be very useful for investigators who want to focus on the systematic underlying molecular, genetic, cellular, and neurophysiological underpinnings for the study of comorbid disorders. [ Psychiatr Ann. 2018;48(12):547–551.]

Manifesto for a European research network into Problematic Usage of the Internet

The Internet is now all-pervasive across much of the globe. While it has positive uses (e.g. prompt access to information, rapid news dissemination), many individuals develop Problematic Use of the Internet (PUI), an umbrella term incorporating a range of repetitive impairing behaviours. The Internet can act as a conduit for, and may contribute to, functionally impairing behaviours including excessive and compulsive video gaming, compulsive sexual behaviour, buying, gambling, streaming or social networks use. There is growing public and National health authority concern about the health and societal costs of PUI across the lifespan. Gaming Disorder is being considered for inclusion as a mental disorder in diagnostic classification systems, and was listed in the ICD-11 version released for consideration by Member States (http://www.who.int/classifications/icd/revision/timeline/en/). More research is needed into disorder definitions, validation of clinical tools, prevalence, clinical parameters, brain-based biology, socio-health-economic impact, and empirically validated intervention and policy approaches. Potential cultural differences in the magnitudes and natures of types and patterns of PUI need to be better understood, to inform optimal health policy and service development. To this end, the EU under Horizon 2020 has launched a new four-year European Cooperation in Science and Technology (COST) Action Programme (CA 16207), bringing together scientists and clinicians from across the fields of impulsive, compulsive, and addictive disorders, to advance networked interdisciplinary research into PUI across Europe and beyond, ultimately seeking to inform regulatory policies and clinical practice. This paper describes nine critical and achievable research priorities identified by the Network, needed in order to advance understanding of PUI, with a view towards identifying vulnerable individuals for early intervention. The network shall enable collaborative research networks, shared multinational databases, multicentre studies and joint publications.

DC:0-5TM Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: An Overview

In 2016, ZERO TO THREE published its newest version of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–5™) for children from birth through age 5 years. DC:0–5 is empirically derived and clinically meaningful with foundations in infant and early childhood mental health. This Workshop will provide participants with an understanding of the background, approach, and content of this diagnostic classification system for mental health disorders in children ages <5 years.

An introduction to the why and how of risk adjustment

Department of Veterans Affairs (VA) health services researchers often adjust for the differing risk profiles of selected patient populations for a variety of purposes. This paper explains the major reasons to conduct risk adjustment and provides a high level overview of what risk adjustment actually does and how the results of risk adjustment can be used in different ways for different purposes. The paper also discusses choosing a diagnostic classification system and describes some of the systems commonly used in risk adjustment along with comorbidity/severity indices and individual disease taxonomies. The factors influencing the choice of diagnostic classification systems and other commonly used risk adjustors are also presented along with a discussion of data requirements. Statistical approaches to risk adjustment are also briefly discussed. The paper concludes with some recommendations concerning risk adjustment that should be considering when developing research proposals.

Association of schizophrenia polygenic risk score with manic and depressive psychosis in bipolar disorder

Bipolar disorder (BD) is highly heterogeneous in symptomatology. Narrowing the clinical phenotype may increase the power to identify risk genes that contribute to particular BD subtypes. This study was designed to test the hypothesis that genetic overlap between schizophrenia (SZ) and BD is higher for BD with a history of manic psychosis. Analyses were conducted using a Mayo Clinic Bipolar Biobank cohort of 957 bipolar cases (including 333 with history of psychosis during mania, 64 with history of psychosis only during depression, 547 with no history of psychosis, and 13 with unknown history of psychosis) and 778 controls. Polygenic risk score (PRS) analysis was performed by calculating a SZ-PRS for the BD cases and controls, and comparing the calculated SZ risk between different psychosis subgroups and bipolar types. The SZ-PRS was significantly higher for BD-I cases with manic psychosis than BD-I cases with depressive psychosis (Nagelkerke’s R2 = 0.021; p = 0.045), BD-I cases without psychosis (R2 = 0.015; p = 0.007), BD-II cases without psychosis (R2 = 0.014; p = 0.017), and controls (R2 = 0.065; p = 2 × 10−13). No other significant differences were found. Our results show that BD-I with manic psychosis is genetically more similar to SZ than any other tested BD subgroup. Further investigations on genetics of distinct clinical phenotypes composing major psychoses may help refine the current diagnostic classification system.

Understanding the pediatric psychiatric phenotype of 22q11.2 deletion syndrome.

The purpose of this article is to provide an overview of current insights into the neurodevelopmental and psychiatric manifestations of 22q11.2 deletion syndrome (22q11DS) in children and adolescents. The pediatric neuropsychiatric expression of 22q11DS is characterized by high variability, both interindividual and intraindividual (different expressions over the lifespan). Besides varying levels of intellectual disability, the prevalence of autism spectrum disorders, attention deficit disorders, anxiety disorders, and psychotic disorders in young individuals with 22q11DS is significantly higher than in the general population, or in individuals with idiopathic intellectual disability. Possible explanations for this observed phenotypic variability will be discussed, including genetic pleiotropy, gene-environment interactions, the age-dependency of phenotypes, but also the impact of assessment and ascertainment bias as well as the limitations of our current diagnostic classification system. The implications inferred by these observations aforementioned bear direct relevance to both scientists and clinicians. Observations regarding the neuropsychiatric manifestations in individuals with 22q11DS exemplify the need for a dimensional approach to neuropsychiatric assessment, in addition to our current categorical diagnostic classification system. The potential usefulness of 22q11DS as a genetic model to study the early phases of schizophrenia as well as the phenomenon of neuropsychiatric pleiotropy observed in many CNV's will be delineated. From a clinical perspective, the importance of regular neuropsychiatric evaluations with attention to symptoms not always captured in diagnostic categories and of maintaining equilibrium between individual difficulties and competencies and environmental demands will be discussed.

Validation of Dodd's Model for Differential Diagnosis of childhood speech sound disorders: a longitudinal community cohort study.

Dodd's Model for Differential Diagnosis is one of the available clinical diagnostic classification systems of childhood speech sound disorders. Yet we do not understand the validity of this system beyond clinical samples, precluding its application in epidemiological or population-based research. This study aimed to determine the prevalence of subgroups of speech sound disorders in a community sample, relative to past clinical samples, in children speaking standard Australian English. We examined speech development in a community-ascertained sample of children at 4years (n=1607). Inclusion for speech sound disorder was a score of less than or equal to 1 standard deviation on a standardized speech test, and/or research assistant concern, and/or three or more speech errors on sounds typically acquired by 4years. Dodd's model was then applied to 126 children. Data revealed proportions of children across Dodd's diagnostic subgroups as follows: suspected atypical speech motor control (10%); inconsistent phonological disorder (15%); consistent atypical phonological disorder (20%); phonological delay (55%); and articulation disorder alone (0%). The findings are in line with known prevalence of these subgroups in clinical populations. Our findings provide additional support for speech-language pathologists to use this system in clinical practice for differential diagnosis and targeted intervention of speech sound disorders in children. Dodd's Model for Differential Diagnosis is the first classification system of speech sound disorders to be applicable to both clinical and community cohorts.

Accounting for Social Processes in the Development of Diagnostic Classification Systems: Commentary on the “Standards and Guidelines for the Development of Diagnostic Nomenclatures and Alternatives in Mental Health Research and Practice”

Diagnostic classifications of mental disorders are complex systems that integrate both scientific and social priorities. The Task Force on Developing Humanistic Approaches to Psychological Diagnosis of the Society for Humanistic Psychology has released a set of guidelines intended to guide the development of mental health classifications. This commentary argues that the attention paid in the guidelines to social processes is a desirable and inherent component of the development of any classification. Social influences regarding the definition of the concepts and the processes by which people develop them are integrally intertwined, contrary to the common view that nonscientific factors should be excluded from classification systems as much as possible. These guidelines offer a much needed resource for developing future mental health classifications.

Bipolar spectrum in major depressive disorders.

Growing evidence for the spectrum concept of most mental disorders, particularly mood disorders, has challenged the arbitrary distinctions inherent in the contemporary categorical diagnostic classification system. Detection of manic symptoms in the context of episodes of depression is particularly important because of the implications for differential treatment of bipolar vs unipolar depression. The purpose of this study is to characterize the magnitude and clinical correlates of subthreshold manic syndromes or symptoms among people with major depressive disorder (MDD) compared to those without a history of manic symptoms. We defined two subthreshold manifestations-manic syndrome or symptoms-that did not include a criterion for duration. In the context of MDD, we found that the clinical correlates of those with the subthreshold manic syndrome were more similar to those with bipolar-II disorder than to MDD alone, whereas those with manic symptoms only were intermediate between those with subthreshold manic syndrome and MDD alone. These results confirm the spectrum concept of mania and suggest that a manic syndrome should be considered when evaluating people with MDD.

Need for an Antipsychotic in a Case of Infective Insanity Between Siblings – A Therapeutic Approach

BACKGROUND: Shared Delusional Disorder is not uncommon and has been included in formal diagnostic classification systems. However, it is not frequently diagnosed. This is a case of a 21 year old female, unmarried, who presented to our OPD with prominent psychotic symptoms, particularly a fixed belief that she was being followed by someone for the last six years. Her elder sister, who was close to her emotionally also developed persecutory delusion of similar content within one year of its onset in the younger sister. Thus when they first presented to the OPD, both sisters had similar type of psychotic presentation. After separation of both sisters, psychotic symptoms improved in elder sister within one month. CONCLUSION: Shared Delusional disorder is not uncommon. The risk of induced delusion is more among those who have high emotional bonding and it disappears following separation of each other. So it is necessary to evaluate the family member of individuals suffering from psychiatric disorder to rule out Induced delusional disorders. The conceptual issues of the problem are also discussed.

Menière and Friends: Imaging and Classification of Hydropic Ear Disease.

Over 75 years ago, endolymphatic hydrops was discovered as the pathologic correlate of Menière's disease. However, this pathologic finding could be ascertained only in postmortem histologic studies. Due to this diagnostic dilemma and the variable manifestation of the various audiovestibular symptoms, diagnostic classification systems based on clinical findings have been used hitherto. A review of the literature of magnetic resonance (MR) imaging of hydropic ear disease. Recent developments of high resolution MR imaging of the inner ear have now enabled us to visualize in vivo endolymphatic hydrops in patients with suspected Menière's disease. The existing knowledge from temporal bone histologic studies and from the emerging evidence on imaging based evaluation of patients with suspected Menière's disease indicate that endolymphatic hydrops not only is responsible for the full-blown clinical triad of simultaneous attacks of auditory and vestibular dysfunction, but also for other clinical presentations such as "vestibular" and "cochlear Menière's disease." As a consequence, we propose the term "Hydropic Ear Disease" as a new terminology which is based on symptomatic and imaging characteristics of these clinical entities to clarify and simplify their diagnostic classification.

Personalized Feedback on Symptom Dynamics of Psychopathology: A Proof-of-Principle Study.

Background and ObjectivesIn the proposed symptom network approach to psychopathology, psychiatric disorders are assumed to result from the (causal) interplay between symptoms. By implementing this approach we explored whether individual feedback on symptom dynamics complements current categorical classification and treatment. The aim of this proof-of-principle case-study was to explore the feasibility, acceptability and usability of this transdiagnostic approach.MethodsA female patient, aged 67, suffering from treatment resistant anxious and depressive symptoms was treated in our tertiary outpatient clinic for old age psychiatry. She participated in ecological momentary assessments (EMA), which involved intensive repeated measurements of mood and context-related items during two weeks. Visualizations of the interplay between the items were provided by network graphs and were discussed with the patient.ResultsNetwork graphs were discussed with the patient. For example, it was hypothesized and discussed with the patient that feeling relaxed increased physical activity, causing physical discomfort in the following hours. Physical discomfort caused stress as its symptoms resembled her feared somatic anxiety symptoms. This increased the patient’s insight that stress, expressed as somatic symptoms, played a central role in her panic disorder. This started a dialogue on how to cope with stress caused by somatic (anxiety) symptoms and provided a rationale for the patient to start an interoceptive exposure intervention she had repeatedly refused before.LimitationsThe observed symptom dynamics may not be generalizable to any other random two weeks.ConclusionsPersonalized diagnosis of psychopathology incorporating complex symptom dynamics is feasible and a promising addition to current categorical diagnostic systems and could guide intervention selection. This merits further exploration.

Pretreatment Cardiometabolic Status in Youth With Early-Onset Psychosis: Baseline Results From the TEA Trial.

To describe pretreatment cardiometabolic constitution in children and adolescents with first-episode psychosis (FEP). Baseline cardiometabolic assessment was performed in youths aged 12-17 years with FEP entering the Tolerability and Efficacy of Antipsychotics (TEA) trial and matched healthy controls. Patients were included between June 10, 2010, and January 29, 2014. ICD-10 was used as the diagnostic classification system. Cardiometabolic risk markers were compared between patients versus controls and antipsychotic-naive versus antipsychotic-exposed patients. Comparing 113 youths with FEP (age ± SD = 15.74 ± 1.36 years, males = 30.1%, schizophrenia-spectrum disorders = 92.9%, antipsychotic-naive: n = 57) to 60 controls, patients had higher waist circumference (WC) z scores (1.13 ± 1.65 vs 0.42 ± 1.27, P = .018), cholesterol (4.10 ± 0.71 vs 3.79 ± 0.49 mmol/L, P = .014), low-density lipoproteins (2.37 ± 0.56 vs 2.13 ± 0.51, P = .012), and non-high-density lipoproteins (2.58 ± 1.60 vs 2.52 ± 0.52, P = .018). More patients than controls (42.9% vs 20.3%, P = .019) and antipsychotic-naive than antipsychotic-exposed (51.9% vs 34.0%, P = .023) had a WC > 90th percentile. Hypercholesterolemia (34.0% vs 12.5%, P = .015) was more frequent in patients, while decreased high-density lipoprotein cholesterol was more frequent in controls (32.5% vs 19.0%, P = .032). Family history of type 2 diabetes mellitus was associated with increased body mass index (BMI) z score (P < .001), WC z score (P = .001), insulin (P = .038), and homeostatic model assessment of insulin resistance (HOMA-IR; P = .025). Dyslipidemia was associated with significantly increased insulin (P = .041), HOMA-IR (P = .032), and low-density lipoprotein cholesterol (P = .041). Previous antipsychotic exposure was not associated with increased cardiometabolic risk. Early age at onset predicted increased BMI and WC z scores, while diagnosis of schizophrenia and higher Clinical Global Impression-Severity score were associated with increased blood lipids. Youths with FEP had significantly greater WC and lipid abnormalities than matched controls, regardless of antipsychotic exposure. In youths with FEP, elevated metabolic risk predates antipsychotic exposure. ClinicalTrials.gov identifier: NCT01119014; European Clinical Trials Database (EudraCT): 2009-016715-38​​​.

Biobehavioral assessment of the anxiety disorders: Current progress and future directions

It is difficult to accurately assess and differentially diagnose the anxiety disorders. The current system of assessment relies heavily on the subjective measures of client self-report, clinical observation, and clinical judgment. Fortunately, recent technological advances may enable practitioners to utilize objective, biobehavioral measures of assessment in a clinical setting. The current body of literature on two of these biobehavioral tools (eye-tracking and electrocardiogram devices) is promising, but more validation and standardization research is needed to maximize the utility of these devices. Eye-tracking devices are uniquely capable of providing data that can be used to differentially diagnose anxiety disorders from both other commonly comorbid and misdiagnosed disorders. Both eye-tracking and electrocardiogram devices are able to provide change-sensitive assessment information. This objective, real-time feedback can assist clinicians and researchers in assessing treatment efficacy and symptom fluctuation. Recently developed wearable and highly portable electrocardiogram devices, like the wearable fitness and behavior tracking devices used by many consumers, may be particularly suited for providing this feedback to clinicians. Utilizing these biobehavioral devices would supply an objective, dimensional component to the current categorical diagnostic assessment system. We posit that if adequate funding and attention are directed at this area of research, it could revolutionize diagnostic and on-going assessment practices and, in doing so, bring the field of diagnosis out of the 20th century.

Research Domain Criteria as Psychiatric Nosology.

Diagnostic classification systems in psychiatry have continued to rely on clinical phenomenology, despite limitations inherent in that approach. In view of these limitations and recent progress in neuroscience, the National Institute of Mental Health (NIMH) has initiated the Research Domain Criteria (RDoC) project to develop a more neuroscientifically based system of characterizing and classifying psychiatric disorders. The RDoC initiative aims to transform psychiatry into an integrative science of psychopathology in which mental illnesses will be defined as involving putative dysfunctions in neural nodes and networks. However, conceptual, methodological, neuroethical, and social issues inherent in and/or derived from the use of RDoC need to be addressed before any attempt is made to implement their use in clinical psychiatry. This article describes current progress in RDoC; defines key technical, neuroethical, and social issues generated by RDoC adoption and use; and posits key questions that must be addressed and resolved if RDoC are to be employed for psychiatric diagnoses and therapeutics. Specifically, we posit that objectivization of complex mental phenomena may raise ethical questions about autonomy, the value of subjective experience, what constitutes normality, what constitutes a disorder, and what represents a treatment, enablement, and/or enhancement. Ethical issues may also arise from the (mis)use of biomarkers and phenotypes in predicting and treating mental disorders, and what such definitions, predictions, and interventions portend for concepts and views of sickness, criminality, professional competency, and social functioning. Given these issues, we offer that a preparatory neuroethical framework is required to define and guide the ways in which RDoC-oriented research can-and arguably should-be utilized in clinical psychiatry, and perhaps more broadly, in the social sphere.