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DEBATE

Open AccessToward the future of psychiatric diagnosis: theseven pillars of RDoC
Bruce N Cuthbert1,3* and Thomas R Insel2,3

Abstract
Background: Current diagnostic systems for mental disorders rely upon presenting signs and symptoms, with theresult that current definitions do not adequately reflect relevant neurobiological and behavioral systems - impeding
not only research on etiology and pathophysiology but also the development of new treatments.
Discussion: The National Institute of Mental Health began the Research Domain Criteria (RDoC) project in 2009 todevelop a research classification system for mental disorders based upon dimensions of neurobiology andobservable behavior. RDoC supports research to explicate fundamental biobehavioral dimensions that cut acrosscurrent heterogeneous disorder categories. We summarize the rationale, status and long-term goals of RDoC,
outline challenges in developing a research classification system (such as construct validity and a suitable process
for updating the framework) and discuss seven distinct differences in conception and emphasis from current
psychiatric nosologies.
Summary: Future diagnostic systems cannot reflect ongoing advances in genetics, neuroscience and cognitive
science until a literature organized around these disciplines is available to inform the revision efforts. The goal of
the RDoC project is to provide a framework for research to transform the approach to the nosology of mental
disorders.
Keywords: Diagnosis, DSM, ICD, Psychiatric diagnosis, Psychopathology, RDoC, Research domain criteria

Background
As of this writing, there are three versions of diagnostic
systems for psychiatry in development. By far the most notoriety has been attached to the revision of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, which has
been under revision sufficiently long enough to receive aname change from DSM-V to DSM-5. This attention is
not surprising given the prominence of the DSM for clinical diagnosis both in the US and internationally, its simultaneous role in research, and the number of controversial
issues that have been involved in the revision process such as the debates over autism spectrum disorder [1], bereavement and depression [2], and personality disorders[3,4], to name just a few. The DSM revisions have also
prompted an extensive re-visiting of important issues* Correspondence: bcuthber@mail.nih.gov
1
National Institute of Mental Health, National Institutes of Health, 6001
Executive Boulevard, MSC 9632, Room 7121, Bethesda, MD 20892-9632, USA
3
Express/parcel delivery, Rockville, MD 20852, USA
Full list of author information is available at the end of the article

regarding the nature of mental disorders, and how theyshould be considered scientifically. An excellent summary
and analysis of these topics is represented by the series of
papers that appeared recently in Philosophy, Ethics, andHumanities in Medicine and BMC Medicine ([5-7]; seealso [8]).
The second major revision is that of the Mental and Behavioural Disorders section of the International Classification of Diseases (ICD-11), being developed by the World
Health Organization. This revision effort is being accomplished by an international group of experts, including
some intentional overlap with members from the DSM
committees. (It is worth noting that the ICD represents
the official diagnostic standard in the US as in the rest of
the world.) Although both the DSM and ICD emphasize
clinical utility, the scope of the clinical settings where the
ICD is employed tends to be yet more varied and extensive than that of the DSM. The latter is intended largely
for use by highly trained mental health professionals(though it is employed by many professional groups). By
contrast, the ICD is necessarily designed for health© 2013 Cuthbert and Insel; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

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settings around the world, to be used not only by practitioners with widely divergent levels of expertise but also incultural settings where assumptions about the etiology
and nature of disorders may be highly dissimilar from theWestern milieu of the DSM. Accordingly, the ICD places
stronger emphasis on public health applications than theDSM, and one reflection of this emphasis is the use of definitions that emphasize short text descriptions of each disorder rather than the polythetic symptom lists of the DSM.
Finally, the National Institute of Mental Health (NIMH)
instituted the Research Domain Criteria (RDoC) projectin early 2009. Given its status as a research classification
system rather than one intended for routine clinical use,
this initiative diverges markedly from the others in multiple respects. The seven major differences between RDoC
and the established systems are delineated in the sections
that follow, as its share of this forum.
One caveat is in order at the outset to provide an appropriate context for the remarks that follow. The dictionary
reminds us that the first sense of the noun ‘debate’ is‘a discussion . . . involving opposing viewpoints,’ as appropriate for its Latin root that means ‘to beat’ [9]. However,discussions among the framers of the DSM-5, the ICD-11
revisions and the NIMH RDoC have from their inception
been cordial, and marked by general agreement about therelative emphasis of each respective system and also about
their shared interests. Thus - unfortunately from the perspective of sparking a sharp exchange among divergent
views - the ‘debate’ in this case must proceed more along
the lines of the term’s more elaborated definition, a ‘deliberation’ or ‘consideration.’ In this more congenial sense,
there is indeed much to consider.

Discussion
A diagnostic system can have many purposes. For instance, a major reason for the creation of the ICD wasto establish a comprehensive manual for determining
causes of mortality, thus enhancing efforts at improving
public health. However, perhaps the pre-eminent role ofdiagnosis in medicine is to determine the exact nature ofa patient’s disease in order to administer the optimaltreatment. Yet, very little discussion of this aspect canbe found either in published papers or in the extensive‘blogosphere’ that has sprung up around the DSM-5.
The revisions have renewed debates about the definitionand nature of mental disorders; the various positions in
the philosophy of science that might represent how tothink about mental illness (‘realist,’ ‘essentialist,’ and soon); categorical versus dimensional approaches to disorders; and the role of reductionism and phenomenology[5-8]. Any discussion about the ramifications of thesevarious considerations in actually making a difference on
how we treat our patients, however, has been conspicuously lacking.

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This lack is likely due in no small part to the current nature of treatments for mental disorders. On the one hand,
effective treatments exist. Treatments for major classes ofdisorders such as depression, anxiety disorders, schizophrenia and bipolar disorders are available, and effective
for large numbers of patients. Further, a number of effective treatment modalities - pharmaceutical interventions,
psychosocial or behavioral treatments, medical devices have been established. On the other hand, treatments are
not particularly precise, and tend to affect broad classes ofdisorders. Anti-depressant medications, such as selective
serotonin reuptake inhibitors, are used to treat not only
depression but a wide variety of anxiety, mood and otherdisorders. Anti-psychotic agents are used not only withschizophrenia but in bipolar disorder and sometimes for
personality and other severe disorders. Anxiolytics such as
valium are prescribed widely across the anxiety and moodspectrum. A similar situation prevails for behavioral treatments; for instance, the use of cognitive-behavioral therapy, albeit with many variants, has expanded beyond theinternalizing disorders spectrum for which it was originally developed to the treatment of virtually all mental
disorders (for example, see [10]).
Although decent treatments for mental disorders arethus plentiful, it is instructive to contrast the changes indisease burden for other diseases over the past several
decades with that for mental disorders. For instance, theimpact of research - both clinically and in public healtharenas - has been dramatic for heart disease. Death due
to heart disease climbed steadily from 1950 through1968, at a rate that projected almost 1.8 million deathsin 2007. Instead, because of the rapid progress of research, the actual mortality due to heart disease was only
about one quarter of that number; approximately 1.1
million deaths in 2007 alone were averted according to
the predicted peak rate [11]. Similarly, survival rates forchildren with acute lymphoblastic leukemia have improved over the last several decades from less than 10%
to over 90% [12]. By contrast, mortality has not decreased for any mental illness, prevalence rates are similarly unchanged [13], there are no clinical tests fordiagnosis, detection of disorders is delayed well beyond
generally accepted onset of pathology, and there are nowell-developed preventive interventions.
There are many reasons for this lack of progress in mental disorders. The brain is the most complex organ in thebody, and it is well-accepted that mental illnesses involve
highly complex interactions of genetic factors and experience. The brain cannot be studied directly with the facility
we have for more accessible organs, limiting progress
based on pathology. However, the diagnostic system forpsychiatry has also been increasingly noted as an impediment to progress. The problems have been extensively
documented (for example, [14-18]) and do not need to beCuthbert and Insel BMC Medicine 2013, 11:126
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elaborated here, but include excessive co-morbidity of disorders, marked heterogeneity of mechanisms and reification of disorders. In particular, the underlying validity ofthe disease entities has been questioned, in that the DSM
and ICD categories do not map well onto emerging findings from genetics, systems neuroscience and behavioral
science (for example, [19,20]); as a result, it becomes very
difficult to translate research from basic studies, either inanimal models or in humans, to a systematic understanding of pathology or to systematic treatments directed atmechanisms. Nevertheless, the DSM and ICD system (thetwo nosologies are largely overlapping in terms of theactual listing of disorders) has become the standard to
obtain research grants regarding etiology and pathophysiology, to conduct drug trials at all phases, and to obtainregulatory approvals for pharmaceutical treatments. In behavioral research as well, the need to establish evidencebased treatments has led researchers to copy the lead of
drug trials and conduct trials in terms of DSM and ICD
diagnoses. Thus, issues with the current nosology markedly affect the treatment development arena.
This point is well illustrated in a quotation from a recent
paper by several pharmaceutical industry scientists regarding problems in drug development using the current system: ‘On average, a marketed psychiatric drug is efficacious
in approximately half of the patients who take it. One reason for this low response rate is the artificial grouping ofheterogeneous syndromes with different pathophysiologicalmechanisms into one disorder . . . by increasing the mechanistic understanding of disease and matching the righttreatments to the right patients, one could move from onesize-fits-all to targeted therapy and increase the benefit-riskratio for patients.’ These scientists conclude that a ‘pedestrian’ trial-and-error search of multi-target agents must be
hazarded ‘. . . until clinical trial design and patient segmentation can improve to the point of matching diseasephenotype to circuit-based deficits. . .’ ([21], p. 1276). This
problem is no doubt a not insignificant reason why somany pharmaceutical companies have withdrawn from active development research in mental disorders [22,23].
And the reliance on biologically heterogeneous categories
as the gold standard for diagnosis has clearly precluded
the identification or validation of biomarkers. Although
one could imagine revising the diagnostic categories toalign with biological discoveries, our field has essentiallyexcluded biological findings that do not map on to thecurrent heterogeneous categories of symptom clusters.
In other areas of medicine, trends have increasingly
moved in the direction of ever more precise specificationof the genetic, molecular and cellular aspects of disease.
In specialty after specialty, there has been a realizationthat disease entities that appear to be a single disorderactually have distinct genetic precursors and pathophysiology. For instance, for many forms of cancer, diagnosis

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is no longer defined by the involved organ or even thepathologist’s report, but rather by analysis of genetic
variants that can predict exactly what treatment will be
optimal (for example, [24]). In another domain, perhaps
the most striking example of this trend involves a new
drug, Ivacaftor (Kalydeco), approved by the Food andDrug Administration after an expedited review. The
drug is effective in treating patients with cystic fibrosis
who have a form of the syndrome with a specific mutation of the cystic fibrosis transmembrane regulator gene.
Only 4% of patients with cystic fibrosis have this genetic
mutation, but, for these patients, the compound is highly
effective in correcting the action of the malfunctioning
protein [25].
These new approaches toward individualized treatment
are now generally called ‘precision medicine’, and represent the forefront of medical science. In November 2011,
the US National Academy of Sciences published a majorreport on precision medicine outlining the significance of
this development and calling for new knowledge networks
that can harness the power of promising technologies to
identify and correct specific pathophysiologies that result
from genetic and environmental causes [26]. As yet, thefield of mental disorders research lags badly behind therest of medicine in moving toward precision medicine;yet, knowledge of the central nervous system has exploded
over the last two decades, and new technologies are rapidly eclipsing such well-known methods as positron emission tomography scans and magnetic resonance imaging.
How can these rapid developments in basic science beharnessed in the service of precision medicine for mental
disorders?
Research domain criteria

As a national health ministry, NIMH is committed to reducing the burden of suffering due to mental illness throughresearch. Decades of research have increasingly revealed
that neural circuits and systems are a critical factor in how
the brain is organized and functions, and how genetics andepigenetics exert their influence. However, this knowledge
cannot be implemented in clinical studies as readily as
might be hoped. Any one mechanism, such as fear circuits
or working memory, is implicated in multiple disorders as
currently defined; it is difficult to know which diagnostic
category to select first to explore any promising leads, anda positive result immediately raises the question of whether
the demonstration of efficacy must be extended to all similar disorders (a time-consuming and expensive proposition). Contrariwise, a syndrome such as major depression
clearly involves multiple mechanisms - dysfunction in the
hypothalamic pituitary axis, in brain reward-seeking activities, in emotion regulation circuits, in modulatory neurotransmitter systems, in cognitive systems, and in epigenetic
marks; thus, it is not surprising that studies to establish

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Page 4 of 8‘the cause’ of major depression are equivocal and difficult
to replicate, nor that new treatments directed toward aparticular mechanism are often only marginally effective
and cannot be replicated.
In response to this situation, NIMH established in its
Strategic Plan of 2008 the following goal: to ‘develop, forresearch purposes, new ways of classifying mental disorders based on dimensions of observable behavior andneurobiological measures.’ The instantiation of this goalis the RDoC project, and is NIMH’s effort to develop a
precision medicine approach for mental disorders [27].
RDoC represents a real paradigm shift, by considering
mental disorders from a translational point of view.
RDoC does not take as a starting point the traditionalview of disorders as symptom complexes based largely
on clinical descriptions. Rather, the approach proceeds
in two steps. The first step is to inventory the fundamental, primary behavioral functions that the brain has
evolved to carry out, and to specify the neural systems
that are primarily responsible for implementing thesefunctions. For instance, much is now known about circuits for fear and defense [28], for various aspects of appetitive behavior such as learning to predict reward andmoving toward reward [29], and cognitive functions
such as working memory [30]. The second step then involves a consideration of psychopathology in terms ofdysfunction of various kinds and degrees in particularsystems, as studied from an integrative, multi-systems
point of view.
The four aims of the RDoC project are listed inTable 1, beneath the statement of goal 1.4. The project
began with deliberations among members of an internal
NIMH working group, which served to define the overall
shape of the effort as well as the specific process to befollowed. The workgroup determined that the optimal approach was to establish a hierarchical scheme, with thespecific dimensions nested within five major domains offunctioning (see Table 2 for a listing of the RDoC matrix
as of June, 2012 at the end of the initial conference series).
The project moved forward rapidly once this organizational matrix was established. As called for Aim 1 ofTable 1, the RDoC process involved a series of workshopswith experts in the field to determine the ‘fundamental behavioral components’ to be included in the system. The
five major domains, conceived on empirical grounds fromsuch diverse research areas as temperament, behavior genetics and structural models of mental disorders, also
served as a convenient way to organize the workshops inthat one workshop was conducted for each of the five domains. Approximately 30 to 40 experts convened for each
workshop. Their charge was to determine which dimensions should be included within the domain; provide adefinition for each dimension; and provide a list of the elements for each dimension that could be used to measure
it, at each of several units of analysis (as specified in Aim
4 of Table 1). An important consideration is that the dimensions, as behavioral entities tied to neural systems, arealways dependent upon the march of research to continually refine and evolve a scientific understanding of theirfunction and of their implementing circuits. In this sense,
the dimensions represent ‘constructs’ as classically definedin psychological research [31], and this term was adopted
for RDoC to emphasize that they will (and should) always
be subject to further validation and revision. The RDoC
‘matrix’ thus consists of a series of rows, with the constructs nested within their superordinate domains, andthe columns representing the units of analysis. The
reader is encouraged to consult the RDoC website(http://www.nimh.nih.gov/research-funding/rdoc/index.
shtml), which contains the completed matrices from allof the RDoC workshops.

Table 1 National Institute of Mental Health Strategic Goal
1.4: Develop, for research purposes, new ways ofclassifying mental disorders based on dimensions ofobservable behavior and neurobiological measures

The seven pillars

Aim #

Task

1

Initiate a process for bringing together experts in clinical andbasic sciences to jointly identify the fundamental behavioral
components that may span multiple disorders (e.g., executivefunctioning, affect regulation, person perception) and thatare more amenable to neuroscience approaches.

2

Determine the full range of variation, from normal toabnormal, among the fundamental components to improveunderstanding of what is typical versus pathological.

3

Develop reliable and valid measures of these fundamental
components of mental disorders for use in basic studies andin more clinical settings.

4

Integrate the fundamental genetic, neurobiological,
behavioral, environmental, and experiential components thatcomprise these mental disorders.

The distinctions between RDoC and the DSM and ICD
systems can be captured by seven major points that
include both conceptual and practical differences. First,
the approach incorporates a strong translational research
perspective. Rather than starting with symptom-based
definitions of disorders and working toward their pathophysiology, RDoC inverts this process. Basic science - ingenetics, other areas of neuroscience and behavioral
science -serves as the starting point, and disorders are
considered in terms of disruptions of the normal-range
operation of these systems, with an emphasis on themechanisms that serve to result in dysfunctions of varying
degrees.
Second, RDoC incorporates an explicitly dimensional
approach to psychopathology, as called for in many recent
analyses of psychopathology [32,33]. However, in contrast

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Table 2 Research domain criteria, October 2012 (constructs are listed within each domain)
Negative valence
domainPositive valencesystems

Cognitive systems

Systems for social
processes

Arousal/modulatory
systems

Acute threat (‘fear’)Approach motivation

Attention

Affiliation andattachment

ArousalPotential threat(‘anxiety’)Initial responsivenessto reward

Perception

Social communication

Biological rhythms

Sustained threat

Sustained responsivenessto reward

Working memory

Perception andunderstanding of self

Sleep-wake

Loss

Reward learning

Declarative memory

Perception andunderstanding of others

Frustrative nonreward

Habit

Language behavior
Cognitive (effortful)
control

to views that emphasize dimensionality mostly as a function of symptom severity, RDoC is committed to studying
the ‘full range of variation, from normal to abnormal.’ Insome cases, only one end of a dimension may involve
problem behavior (for instance, one is seldom likely tocomplain of an outstanding memory or keen vision), but
often both extremes of a dimension may be considered as‘abnormal’ – for example, a complete lack of fear may be
associated with aggressive or psychopathic behavior, andthe opposite end of diminished reward-seeking may be
mania. An important consideration regarding dimensionality is that the relationship between increasing disruptions in functional mechanisms and the severity ofsymptoms may be markedly nonlinear, with ‘tipping
points’ that mark a transition to more severe pathology; acritical area of research is to determine the exact locationof such points, and how they are affected in each individual by various risk or resilience factors.
The third distinction follows directly from the second.
Aim 3 in Table 1 includes a call to ‘Develop reliable andvalid measures of these fundamental components.’ Oneof the drawbacks of a pathogen model of illness is thatmost scales developed over the past decades have either
been designed to study normal traits such as personality
or else clinical symptoms of disorder, and thus lack sensitivity at one end or the other of a putative dimension.
In particular, zones of very mild or transient psychopathology, with their potential for understanding proximate
etiology and for indicated prevention, receive shortshrift. Thus, scale development represents a high priority
for RDoC research applications. In fact, well-validated
and psychometrically optimized measures based upon
cognitive neuroscience research are beginning to appear[34]. Consistent with contemporary measurement science,
new scales would (and should) almost invariably incorporate interval or ratio scaling to improve quantification of
the phenomena of interest. As such assessments muster,
it becomes feasible to determine cut-points along the
distribution for varying types of interventions, essentiallysimilar to practices in other areas of medicine where continuous measures are available, such as hypertension or
hypercholesterolemia. A further advantage of this approach is that ongoing research studies about relative risk
at various points along the dimension can inform decisions about changing the cut-points at which interventions are indicated - as has happened repeatedly, such as
in hypertension research [35].
The fourth distinction concerns the types of designs andsampling strategies that RDoC studies must necessarily
follow. In the traditional clinical study, the independent variable is almost always one or more (usually one)
DSM or ICD groups, often versus controls. It is relatively
straightforward to diagnose the patients according to thesymptom-based criteria, excluding those who fail to meetcriteria for the diagnosis under study. The resultant
groups form the independent (grouping) variable. (An important public health issue concerns the unknown number of such patients whose conditions are essentiallyinvisible to research by virtue of failing to meet criteria, although it is well known that for some disorders, such as
eating disorders, ‘not otherwise specified’ is the modal
diagnosis.) RDoC, by contrast, involves a two-step procedure. The investigator must first establish the ‘samplingframe,’ that is, what group of individuals will be enteredinto the study; because this will not be identical to a DSM
or ICD diagnosis, other criteria will have to be applied. In
some cases, this might simply comprise all patients presenting at a certain type of clinic, such as for anxiety disorders or serious mental illness. However, such a samplingframe might fail to meet the goal of studying the ‘full
range,’ and so a control group might also be needed - witha wider range of inclusion, however, rather than the typical‘super-normal’ control group with no psychiatric history.
Then, the second step is to specify the independent variable in the study. To permit investigators freedom in pursuing their hypotheses, the independent variable may bechosen from any unit of analysis. Thus, performance on aworking memory task might be the independent variable

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for a study of working memory in serious mental illness;
dependent variables might comprise neuroimaging ofspecified brain areas, relevant assessments of real-world
dysfunction and an exploration of relevant candidate
genes. For a study of anxiety disorders, fear-potentiatedstartle might be the independent variable, stratified by arelevant genetic polymorphism, and the dependent variables could be overall symptom severity and distress plus
performance on a behavioral fear-avoidance test. Thus,
while more interesting research designs can be created,
the investigator will need to be more thoughtful about
crafting the design of the study to answer the particularexperimental question.
Fifth, and critically important, the system is intended
to provide a structure that places equal weight on behavioral functions and upon neural circuits and their constituent elements - that is, to be an integrative model
rather than one based primarily on either behavior orneuroscience. This integrative approach can be seen in
the way in which goal 1.4 is stated. The criterion for including a construct in the matrix during the workshops
reflects this same priority. Participants were instructedthat there were two requirements for adding a construct
to the matrix: first, ‘There must be strong evidence forthe validity of the suggested construct itself [as a behavioral function]’; second, ‘There must be strong evidence
that the suggested construct maps onto a specific biological system, such as a brain circuit.’ This rule wascarefully followed; over the course of the workshop
series, there were several instances where a nominatedconstruct was not included either because a nominatedfunction could not be paired with an implementing
neural system, or because a consensus could not bereached regarding the function of a nominated circuit.
The NIMH working group’s shorthand expression forthis idea was, ‘Behavioral science studies what the brain
evolved to do, and neuroscience studies how the brain
implements it.’ Thus, claims that the RDoC system simply involves biomarkers or endophenotypes are oversimplified at best.
Following from this consideration, a sixth distinctionis that the RDoC project is intended (at its inception, inparticular) to concentrate on constructs for which there
is solid evidence to serve as a platform for ongoing research. There is no claim to include all of the psychopathology that is listed in the various categories of the
DSM and ICD nosologies. This reflects a deliberate decision by NIMH to constrain the initial scope of the project to elements for which there is considerable data, so
as to provide a solid foundation on which to gain experience and indicate how more provisional constructs may
be studied profitably in the future.
Finally, a research-oriented scheme like RDoC faces
both a luxury and a risk in not being tied to fixed

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definitions of disorders. As many commentators havepointed out, any changes to DSM or ICD criteria prompt
considerable upheaval throughout the mental health system - in officially reported prevalence rates, in possible insurance reimbursement changes, in legal proceedings anddeclarations of disability, in regulatory practice. As an experimental classification, RDoC does not face these liabilities. In fact, a strong goal of a research system ought tobe its flexibility in dynamically accommodating those research advances that it tries to foster. Provision must be
made to delete constructs that have been superseded by
new thinking, to add constructs, to split one construct
into two, and so on. (The NIMH RDoC workgroup has
actively considered the optimal process for consideringsuch changes, which will be disseminated in the near future.) As this consideration implies, and in contrast to
clinical nosologies, the constructs appearing in the RDoC
matrix (Table 2) are not the only ones that can be studied.
A new construct can be added to the matrix only whenreplicated data are furnished to provide evidence that itmeets the two criteria indicated above (a validated construct, and a specifiable neural circuit); it follows that suchstudies could not be conducted if only those constructs
listed in the RDoC matrix were permitted for study. Thus,a critical component of RDoC is to permit research involving well-justified experiments seeking to validate constructs that are not currently part of the RDoC matrix, or
to modify in various ways the extant constructs.

Summary
Psychiatry lags behind other areas of medicine in building avenues toward a precision medicine approach todiagnosis, and will not catch up until a system is available that reflects recent progress in genetics, other areasof neuroscience and behavioral science. However, such asystem cannot be implemented until a database is available that can inform its development. This is the essential rationale for the RDoC project. It is difficult toestimate how long such a project may take. Already,promising developments are being forged by investigators who have probed the circuits from both basic andclinical directions, and have related these findings towell-validated tasks that measure functioning. However,
the integrative approach that RDoC calls for is so newthat unforeseen obstacles surely await the pioneers inthis area. This is only to be expected. In the long run,there seems to be a growing consensus in the field that amore empirically based approach must be developed,
and the inherent qualities of the research process itself
should serve to shape mid-course corrections as the project moves forward. It should be re-iterated, however,that the RDoC framework is explicitly intended to be amoving target, and that the framework should grow andchange with the pace of new research findings. Thus, theCuthbert and Insel BMC Medicine 2013, 11:126
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challenge is not to design an optimal list of relatively
permanent elements, but rather to construct a platformthat can both accommodate and foster continual developments in research knowledge and methods.
It will be quite apparent to the reader that RDoC isneither designed nor intended to be used for practicalclinical purposes at this early stage. The near-term goal of
RDoC, rather, is to build a new framework of research thatcan produce pioneering new findings and approaches toinform future versions of psychiatric nosologies. In particular, the goal is to lay the groundwork for specifying
how diagnosticians can accomplish the goal of precision
medicine for mental disorders - pinpointing with increasing accuracy the precise genetic, neural circuit and behavioral data that can generate tailored recommendations forinterventions that can manage, cure and prevent mental
disorders in the largest possible number of individuals. In
this sense, although the immediate thrust of the RDoC
project sets it apart from the established structures of the
DSM and ICD, the long-term aspirations for all three systems converge on reducing the burden of suffering for
those with mental disorders.
Abbreviations
DSM: Diagnostic and Statistical Manual of Mental Disorders; ICD: International
Classification of Diseases; NIMH: National Institute of Mental Health;
RDoC: Research Domain Criteria.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Both authors have discussed the ideas expressed herein, and contributed to
final versions of the paper. BC provided the first draft and final draft based
upon comments from TI and discussions between both authors. Bothauthors read and approved the final manuscript.

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6.

7.
8.
9.
10.

11.

12.

13.

14.
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16.

17.
18.
19.
20.

21.
Author details
1
National Institute of Mental Health, National Institutes of Health, 6001
Executive Boulevard, MSC 9632, Room 7121, Bethesda, MD 20892-9632, USA.
2
National Institute of Mental Health, National Institutes of Health, 6001
Executive Boulevard, Room 8129, Bethesda, MD 20892, USA. 3Express/parcel
delivery, Rockville, MD 20852, USA.
Received: 23 October 2012 Accepted: 13 March 2013
Published: 14 May 2013

22.
23.
24.
25.

26.
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doi:10.1186/1741-7015-11-126
Cite this article as: Cuthbert and Insel: Toward the future of psychiatricdiagnosis: the seven pillars of RDoC. BMC Medicine 2013 11:126.

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