The DSM And NIMH: Why Insel Got It Right And What It Means For Sexology

Margie Nichols, Margie Nichols, Ph. D.

  In a move that is causing consternation among psychiatrists, Thomas Insel, Director of the National Institutes of Mental Health, announced that NIMH will be ‘re-orienting its research away from DSM categories.’  Insel called the Diagnostic and Statistical Manual, the Bible of psychiatry, nothing more than a dictionary at best.  He made it clear that it is founded on symptom-based categories, and that this method of classifying disease has become outmoded in every other area of medicine. He says NIMH will replace the DSM with what he is calling RDoC, or ‘Research Domain Criteria.’  In this new system, mental illnesses will be categorized not by symptoms but by genetic, neural, and cognitive data.  Only problem – the system doesn’t exist yet – because the data doesn’t exist.

In other words, Insel is saying having no category system at all for mental disorders is better than the current DSM.  He did acknowledge that the DSM will still be useful for mental health treatment (although that is questionable) and will certainly be in place for insurance purposes for quite some time.  But he was emphatic in stating that it would be a disaster to base scientific research on the DSM categories. There just isn’t any evidence tying DSM categories to underlying brain/biological based entities.  As Insel said, “Biology didn’t read the book.”

Validity  has been a chronic problem with the DSM.  The first DSM begun in the 1950’s constructed mental illness categories based on psychoanalytic theory.  But the tenets of psychoanalysis have never been proven scientifically and few professionals use that model in their work today.  In 1980 the psychoanalytic system was replaced with a model based on symptoms; DSM III was a major departure from the past.

In other words, the DSM was first based on a theory never backed up with scientific evidence,  and then by a system that  assumed that things that looked alike were the same.  This is like assuming that all illnesses with the symptom of ‘high fever’ were caused by the same pathogen.  As Insel points out, the rest of medicine progressed beyond symptom-based models sometime in the mid-20th century.  Today, most medical diagnosis is based on physical and structural evidence and some on etiology: we know that the HIV virus causes certain changes in the immune system which result in a dizzying array of mostly dissimilar symptoms, we realize that Kaposi’s Sarcoma and PCP pneumoni, despite their dissimilarities, are both the end result of the HIV infection, and we know how the infection is transmitted.  By contrast we merely hypothesize that, for example, Major Depressive Disorder is different from Generalized Anxiety Disorder, because the symptoms are different,  and we then presume that the brain mechanisms underlying the two are different as well.

But we are beginning to accumulate evidence that turns the DSM categories upside down.  For example, the same genetic anomalies found in schizophrenics are also found in some people diagnosed with autism and others with bipolar disorder. The same drugs that treat depression also work for panic attacks and obsessive-compulsive disorder, and medications developed for psychosis also help those with anxiety.   In other words – categories based on symptoms may be very misleading.  And research based on these categories will be both wrong and often irrelevant.  Based on psychopharmacology , it is a reasonable working hypothesis that some underlying structure and etiology are similar in conditions that respond to the same medication.  We should be looking at these similarities, but we won’t do that if our category system, our theory, considers them different and unrelated.

Insel is proposing a system he calls RDoC – Research Domain Criteria – which would be based on genetic, neural, and cognitive data.  Data we are only just beginning to gather.

Basically, Insel is saying until we have the data it is better to have no theory and no categories than to use the DSM.  And he is completely right.  The designers of the DSM actually realized that their categories were basically stabs in the dark, a tentative work-in-progress model.  But the DSM quickly became reified, and now we act like there actually is a distinct disease of ‘Major Depressive Disorder’ that has a precise location in the brain.  And once we do that – we stop looking at the issue with what the Buddhists call ‘Beginner’s Mind,’ or ‘Don’t Know Mind.’

The truth is, we should have ‘Don’t Know Mind’ about psychology and psychiatry because – we really don’t know.  And it’s not just categories of ‘mental illness’ we don’t know about.   Our psychological theories are as flawed as the DSM, but that’s the subject of Part II of this blog.

The implications of the RDoC approach, when applied to sexology ,are profound, particularly the sexology of GSD (Gender and Sexually Diverse) people.  First, RDoC, if it is truly atheoretical, must start with a neutral view, not a disease model.  Without concepts like ‘Gender Identity Disorder,’  and ‘Paraphilias’  we are free to simply investigate the broad diversity of human gender and sexual behavior.  This research has already begun.  There are neuroscientists and biologists examining the role of genetic and epigenetic factors in influencing all aspects of sexuality, especially gender variation and same/opposite sex attraction.   Second, the continuum concept will replace the categorical system we have now, making judgments about ‘normal’ vs. ‘variant’ a matter of judgment and debate.     A new paradigm , being neutral, would have to assume that sex and gender diversity is innocent until proven guilty – i.e., variation, not disease.   And that would have immense social implications: unusual gender presentations and expression, uncommon sexual desires, would not be assumed to be problematic unless evidence is discovered to suggest that they are.

Insel’s system  would radically affect the science of sexology as well.  Few people realize how much the category system we use to look at GSD has been  influenced by modern psychiatry.  We label some people ‘homosexual’ because psychiatry classified same-sex attraction as a ‘perversion:’ historically, the category came into being via psychiatrists.  We label others trans* because psychiatry has categories based on the concept that atypical gender expression is an illness.  Other cultures, and other time periods, have sliced up the GSD pie differently.  Both the DSM and the culture at large draw a bright line between sexual orientation (narrowly defined as same vs. opposite sex attraction) and gender identity. But most cultures have not, and earlier, non-disease sexology models blended the two, as in the concepts of ‘inverts,’ or a ‘third sex.’

As Maria Konnikova explains in the New Yorker, the RDoC system is a dynamic one: as data continues to be accumulated from different sources, inter-relationships between variables will continuously evolve.  Eventually, dimensions and processes that underly the behavior we observe will become clear, and they may have nothing to do with the categories we use now.  Consider the above example, the bright-lining the distinction between same-sex attraction and gender.  The fact is, we don’t actually know if there is a genetic/neural/cognitive difference between gender variation and sexual orientation, we don’t even know what ‘orientation’ is and whether other sexual drives (kink, nonmonogamy) should be considered ‘orientation.’  We have some reason to believe all these things are related:  there is a good deal of overlap among people who are LG or B with those who are T, kinky, and nonmonogamous.   Moreover, research on neuroanatomy, genetics, and prenatal hormonal influences is turning up similar results for transgender people and same-sex oriented people, suggesting some similar developmental pathways for both.

I ran across an obvious example of how the DSM categories hinder sexology very recently.  The April 2013 issue of the Journal of Gay and Lesbian Health  contains two excellent reviews of the current biological science regarding male to female transgender people and gays and lesbians, respectively.  A number of findings turned up in both reviews:   fraternal birth order, for example, and digit ratios.  But neither author seemed aware of the other area of research – because the research parameters were set by the DSM categories of homosexuality and transsexualism, and these two ‘conditions’ are presumed distinct.

If we get rid of our current categories based on the DSM, as Insel suggests, and replace it with a dynamic, atheoretical, data-based paradigm, we can truly investigate the similarities between gender identity, expression, and behavior  and different sexual ‘orientations’, or desires and preferences.  In short, if RDoC is implemented in the study of GSD,  we might actually learn something.


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