Left Brain Right Brain

Yes, a new version of the Diagnostic and Statistical Manual (DSM) is in the works. You’ve probably heard “DSM-IV” or read it a number of times. It is the manual used to describe the various “mental disorders” and the criteria for diagnosing them. (Pervasive Developmental Disorders or PDD’s are described there. These include Autistic Disorder, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Asperger Syndrome, Rett Syndrome and Childhood disintegrative disorder. If the proposed changes go into place, all that will be left is Autism Spectrum Disorder.

It isn’t that people with diagnoses of Asperger or PDD-NOS will no longer will no longer be recognized as having a diagnosis. It is just that the diagnosis name will be replaced with Autism Spectrum Disorder.

Here is are the proposed DSM-V criteria for Autism Spectrum Disorder (299.00)

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 routines 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)

Compare this to the DSM-IV criteria

299.00 Autistic Disorder

1. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
1. Qualitative impairment in social interaction, as manifested by at least two of the following:
1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.
2. failure to develop peer relationships appropriate to developmental level
3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
4. lack of social or emotional reciprocity
2. Qualitative impairments in communication as manifested by at least one of the following:
1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
3. stereotyped and repetitive use of language or idiosyncratic language
4. lack of varied spontaneous make-believe play or social imitative play appropriate to developmental level
3. Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as manifested by at least of one of the following:
1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
2. apparently inflexible adherence to specific, nonfunctional routines or rituals
3. stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole body movements)
4. persistent preoccupation with parts of objects
2. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
3. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.

For a good discussion, there is an op-ed piece in the New York Times by Prof. Roy Richard Grinker. Prof. Grinker discusses about how the separate category of Asperger Syndrome really is not necessary in today’s culture. The reduced stigma attached to Autism makes it less helpful to have a separate name for “less severe” autism.

Professor Grinker was also interviewed for the United States’ National Public Radio. You can read or listen on their site.

Autistic Disorder, PDD-NOS, Asperger Syndrome and Childhood Disintigrative Disorder will all be a part of the new “Autism Spectrum Disorder”. Rett Syndrome will not be in the DSM-V at all.

One thing this will change is access to services–or possibly. For example, the State of California has “autism” as an eligibility category in the Department of Developmental Disabilities. This was put in place before the DSM-IV and the diagnosis of Asperger Syndrome was used. The state has interpreted the law to mean that only Autistic Disorder is a qualifying diagnosis, denying people with PDD-NOS and Asperger diagnoses unless they meet the criteria for the “other category”. This has put pressure to diagnose “Autistic Disorder” over PDD or AS.

Given the current budget crisis in the State of California, it isn’t as though having a diagnosis of “autism” is a key to great services anyway.

That all said, it will be interesting to hear the discussion of this change. One point that is interesting is the removal of the age 3 limit. Before, there had to be onset of symptoms before age 3. Now it is a more general statement: “Symptoms must be present in early childhood”. I find it interesting that the lack of imaginary play statement is gone as well.

The DSM is not a checklist. In the end, it will be the diagnostic instruments like the ADOS that will determine whether someone qualifies for a diagnosis. I wonder how they will modify these instruments? The “imaginary play” requirement seems to be in the ADOS as it stands now, with the birthday party section for example.