Since the 1970s, the Diagnostic and Statistical Manual of Mental Disorders, has reigned as the so-called "bible" of psychiatry. But now, with the May 22 release of its fifth edition, the DSM-5 is losing some of the support of its faithful.
For the first time, the National Institutes of Mental Health, the world's largest mental health research institute, has shifted its funding support away from the DSM, citing a "lack of validity" and diagnoses based on "clusters of clinical symptoms, not any objective laboratory measure."
The DSM-5 includes a plethora of new diagnoses, some of which have been contentious: It removes Asperger's syndrome from a larger umbrella of autism spectrum disorders and creates new conditions like social anxiety disorder and somatic symptom disorder, which critics say could label patients who are physically sick as mentally ill.
"Patients with mental disorders deserve better," NIMH Director Dr. Thomas R. Insel said in a recent statement
Instead, NIMH will put more of its research dollars into a new classification system, the Research Domain Criteria (RDoC), to incorporate genetics, imaging and cognitive science that focus more on neurological systems than just a collection of symptoms.
According to Insel, the overriding premise of the 18 months of work developing the RDoC is that the brain is the "alleged seat and cause of psychiatric suffering."
RDoC would classify psychopathology based on observable behavior and neurobiological measures.
The shift comes after President Obama proposed the BRAIN Initiative, a $100 million brain-mapping project designed to promote American innovation and job growth while finding ways to treat and cure diseases such as Alzheimer's and brain damage from strokes.
The RDoC assumes that mental disorders are "biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behavior. It's aim in mapping these circuits is to yield "better targets for treatment," according to Insel.
But Dr. David Kupfer of University of Pittsburgh, chairman of the American Psychiatric Association's (APA) DSM-5 task force, responded to Insel's blog post, saying that the decades-long search for biomarkers associated with mental illness remains, "disappointingly distant. ... We're still waiting."
The DSM revisions are the first in 20 years, a "generation" for clinicians, patients and their families, he said. Numerous conditions have been renamed or recategorized and the 1,000-page manual is now electronic version with references and hyperlinks.
"It is important to understand that it is only a guidebook to help clinicians diagnose behaviors and symptoms, not a treatment guide or research manual," said Kupfer. "I think we need to put that in perspective. ... It's not what many people call the Bible or the 10 Commandments."
The DSM-5 task force included 160 experts from around the world, as well as 400 research advisors. The book went public three times for input on language.
"We are very proud of that," said Kupfer.
Disorders are framed in context of age, gender and cultural expectations.
The revised manual also looks at "commonalities" that may exist between conditions like bipolar disorder, psychosis and schizophrenia, as "clues to early intervention," said Kupfer.
"We laid disorder chapters next to each other so, going forward, we might find genetic or cognitive neuroscience," he said.
The manual also tries to do more to measure the severity of certain disorders.
"We know that in clinical depression, for example, one size does not fit all," he said.
Psychology Today called the funding cuts to DSM-5 research in favor of RDoC, a "humiliating blow to the APA."
But Dr. Bruce Cuthbert, coordinator of the RDoC project and director of the division of adult transitional research at NIMH, said research will continue in both camps.
"Science is changing for the future, and it's not at all a slap to the APA," he said. "We have cordial relations with people who developed the DSM and we have a shared interest in psychiatric diagnosis. It still remains the best instrument for diagnosing medical disorders today and to direct people to effective treatment."
But, he said, the way scientists are looking at mental illness is a "real shift" from the past.
Just as doctors can measure blood pressure, brain researchers hope in the future to have similar tools to measure the circuitry of the brain, which governs so much of behavior. The weakness of the DSM-5 is that it looks at a collection of symptoms, rather than the brain activity behind it.
A good example is the way in which anxiety disorders are classified in a group -- ones like post-traumatic stress disorder [PTSD], specific phobias, agoraphobia, according to Cuthbert. The DSM "assumes" they are all fear disorders. But brain research has found that "the more overall distress and misery" [patients] report, the more blunted their fear activity [in the brain].