Symptoms, Disorders, Functions, and the NIH Research Domain Criteria

Symptoms, Disorders, Functions, and the NIH Research Domain Criteria

There are historically two basic approaches to evaluation and treatment of mental and emotional disorders, and although they are in some conflict, it is possible to combine them to ensure best practices.  These are the disorder-oriented symptom-based approach, epitomized by the DSM-V and its associated practice and insurance policies, and the function-based approach that focused on underlying principles, and avoids reference to disorders or stereotyped symptoms in its practice model.

In creating assessments and treatment plans, diverse information can be brought into consideration.  This includes the client report, family and other reports, diagnostic interview results, structured test results such as CPT and performance tests, and also tests such as EEG, QEEG, and related physiological data.  There is a need for integration and consensus on how this information can be incorporated in a systematic manner to ensure best decisions and outcomes.  Often, symptoms alone are brought to bear, when a prescribing physician may listen to a parent or child, and then select a medication based on that information alone.  This may be effective in some fraction of cases, but it ignores the simple reality that more than one cause can lead to a particular observation, and a basic 15-minute interview is not enough to make that determination.

It takes little reflection to realize that using a symptom-only approach has serious limitations, and may be considered as a defect in the practice model.  There are many reasons a particular behavior or complaint may appear, and a symptom-only approach neglects this fact.  Indeed, most common disorders such as depression, anxiety, and attention issues, are interactive and complex.  A child may present with agitation and inattention, when the underlying cause is metabolic, or related to a specific learning disability or a sensory processing disorder.

Another issue with a symptom/disorder-based approach arises when a given disorder might contain many different symptoms, some combination of which comprise the diagnosis.  It is possible to have two children with entirely different behaviors and profiles, who share that one diagnosis.  From a functional point of view, this does not make sense.  Two individuals with very different presentations should ideally be differentiated, to ensure suitable assessment and treatment options.  This is not just an academic point.  The different subtypes of ADD, for example, respond very differently to medications and other interventions, so that this clear distinction between types is necessary to help to avoid negative outcomes and abreactions.

Another controversial extreme is to rely heavily on test results, and use data as the driving influence.  While this may be more physiologically based than behavior and self-report, there is the inevitable tradeoff of types of errors that can be made when using data to make a decision.  For example, Type 1 errors occur when a test result is interpreted too liberally, so that there is a likelihood of a false positive, a misdiagnosis.  These lead to stigma, concern, and possibly unnecessary or even harmful treatments.  The other side of this issue is Type 2 error, in which a test result is disregarded for not being extreme enough, resulting in a failure to recognize a bona fide condition in a patient.

There may be a tendency to “treat the brainmap,” which is another form of fallacious reasoning.  If the purpose of the intervention is solely to produce a clean map, all that is needed is white-out, and the map can be cleaned in an instant.  This facetious example nonetheless shows that if you intervene at an inappropriate time in the progression and mechanism of a disorder, you may wipe out external appearance, but can do so without treating the underlying causes.

The integrated model is applied when the practitioner can say “I see these individual functional characteristics, perhaps excesses or deficits, which, within the individual’s environment and demands, are giving rise to the observed thoughts, feelings, and behaviors in this client.”  It must be possible to associate the external observations and reports with physiological data that are consistent with, or commonly seen in cases of, these observations.  Having gone through this process, it is possible to assign a diagnosis without ambiguity, one that is based on a combination of underlying functional considerations, along with the classical symptom checklists.

Overall, the use of convergent information is essential, and the effort taken to ensure multiple directions of assessment is reflected in a clearer, more informative, and more useful understanding of each client.  New technology and clinical science are providing the means to create comprehensive assessments that incorporate behavior, self-report, performance scores, physiological data, and environmental factors.  Convergent information in this way allows practitioners to pinpoint their client’s position and trajectory in a multidimensional manner, incorporating multiple levels of consideration.

This approach is consistent with the National Institutes of Health Research Domain Criteria RDoC Framework.  This model is a four-dimensional space that incorporates the full range of organismic functioning from genetics, chemistry, biology, behavior in a continuum, with circuits being the binding middle structure.

 

 

 

EEG and QEEG do make considerable use of circuit concepts, as they measure and quantify neuronal activation and connectivity in a direct manner, that is not equalled by any behavioral or metabolic or structural measure or mapping method.  EEG/QEEG provide an ideal rapid, cost-effective, and precise approach to capturing neuronal patterns for assessment, and also for neurofeedback and related neuromodulation techniques.

For more details on the National Institutes of Health Research Domains model, see the following article:

https://iacc.hhs.gov/meetings/iacc-meetings/2016/full-committee-meeting/january12/slides_bruce_cuthbert_011216.pdf

 

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