Wednesday, February 10, 2010

DSM-V Draft Posted Online

The American Psychiatric Association has posted its proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders on its website, where specific disorders are grouped by category.

Here are the (current, subject to further revision) proposed criteria for Autism Spectrum Disorder in the DSM-V:
Autism Spectrum Disorder

Must meet criteria 1, 2 and 3:

1. Clinically significant, persistent deficits in social communication and interactions, as manifest by all of the following:

a. Marked deficits in nonverbal and verbal communication used for social interaction;
b. Lack of social reciprocity;
c. Failure to develop and maintain peer relationships appropriate to developmental level.

2. Restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least TWO of the following:

a. Stereotyped motor or verbal behaviors, or unusual sensory behaviors
b. Excessive adherence to routined and ritualized patterns of behavior
c. Restricted, fixated interests

3. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).
This category includes everyone who, under current DSM-IV guidelines, would be diagnosed with Autistic Disorder, Asperger's Disorder, Pervasive Developmental Disorder Not Otherwise Specified, and Childhood Disintegrative Disorder. Rett's Disorder is also included in the DSM-IV section on pervasive developmental disorders, but is slated for removal from the DSM-V:
Rett's Disorder patients often have autistic symptoms for only a brief period during early childhood, so inclusion in the autism spectrum is not appropriate for most individuals.

Like other disorders in the DSM, Autism Spectrum Disorder (ASD) is defined by specific sets of behaviors and not by etiology (at present) so inclusion of a specific etiologic entity, such as Rett's Disorder, is inappropriate. To ensure that etiology is indicated, where known, clinicians will be encouraged to utilize the specifier: "Associated with Known Medical Disorder or Genetic Condition." In this way, it will be possible to indicate that a child with ASD has Fragile X syndrome, Tuberous Sclerosis, 22q deletion, etc.
This strikes me as reasonable; autistic-like behaviors that are part of a wider, underlying syndrome should be recognized as part of that syndrome, rather than considered or treated in isolation. Michelle Dawson, noting that "the vast majority of named neurodevelopmental disabilities do not appear in the DSM, past, present, or future", suggests that autism doesn't belong there, either.

Back to the revised criteria for Autism Spectrum Disorder: I noticed that there are now two, rather than three, symptom domains --- communication and social interaction have been merged into one category, leaving a "social communication and interactions" domain and a "restricted interests/repetitive behaviors" domain. The criteria seem to be vaguer, more flexible versions of the earlier autism criteria, which, as Shiva has written about recently, dwell excessively on social and communication impairments while ignoring other areas of difference that are just as important, if not more so, in the lives of individual autistics:
IMO, the existing "triad of impairments" [which the UK's National Autistic Society defines, somewhat differently from the APA's DSM-IV, as "difficulty with social communication," "difficulty with social interaction," and "difficulty with social imagination"], even with the additional "related characteristics" [of, among other things, "sensory sensitivity," "special interests," and "love of routines"] ... fails at defining autism both by inaccuracy in what it does contain and by failing to include what many autistic people consistently report as among the most significant components of what distinguishes us from neurotypical people.
Michelle Dawson criticizes this reductiveness, too, although her criticism deals more with the DSM-V workgroup failing to incorporate any understanding of autism as a separate cognitive phenotype, rather than one fundamentally equivalent to the standard, neurotypical cognitive phenotype, but missing some very important social and communicative bits.

I don't think, nor does much of the research on autistic cognition and perception suggest, that anything like that is the case.


Autism and 14-Monkey Experiment said...

I think this name change would hopefully clarify and make life more easier for people who suffer from autism.

Lindsay said...

Yeah, I just realized this post sounds a lot more disappointed/critical than I really feel about the new autism criteria; I failed to mention my intense satisfaction at all the autism-spectrum conditions being unified into a single category. I think the workgroup was very much right to do this.

I still wish the definition weren't solely focused on social and communication impairments, though.

Emy Augustus said...

hey, just wondering, what other things would you want the definition to focus on besides social and communication impairments?