DSM-IV Controversy
DSM-IV-TR vs. DSM-5
Debate on the Changes in Autism Diagnosis
I. Introduction
A. What is the DSM? According to the American Psychiatric Association the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. The DSM consists of three major components:
1. The diagnostic classification is the list of the mental disorders that are officially part of the DSM system.
2. A set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis.
3. The descriptive text that accompanies each disorder …show more content…
systematically describes each disorder.
B. Why does the DSM change?
1. “Over time, a tension can develop between current diagnostic categories and facts emerging that will eventually lead to the next categories. This tension creates conflict between received certainties of diagnostic authorities and the lived complexity that parents and patients live with, leading eventually to a revision of the authoritative classification system.” (Daniel Gensler, p2)
2. In the first two editions, the closest diagnosis was schizophrenia. It wasn’t until 1980 that Autism received its own diagnosis. (Daniel Gensler, p2) As we discover new things through research and studies, the authorities update the DSM.
II. DSM 5 –
A. Progress is important
1. It has been 2 decades since the DSM IV was published. Twenty years of research, experiments, observations and studies have changed what we know about autism.
2. DSM V has taken four separate disorders of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and the catch-all PDD-NOS and contained them under the umbrella diagnosis of Autism Spectrum Disorder. According to the American Psychiatric Association that publishes the DSM, “Anyone diagnosed with one of the four pervasive development disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5 or another, more accurate DSM-5 diagnosis.”(APA website)
3. Susan Swedo, MD, senior investigator of NIMH, the National Institute of Mental Health states, “A single umbrella disorder will improve the diagnosis of ASD without limiting the sensitivity of the criteria, or substantially changing the number of the children being diagnosed.” (APA website)
B. Under the DSM-IV, the categories now contained in the Autism Spectrum Disorder were listed under the term Pervasive Developmental Disorders. The term Pervasive is incorrect.
1. Webster’s defines the term pervasive as, “existing in or spreading to every part of something.”
2. “Symptoms are not pervasive – they are specific to social-communication domain plus restricted, repetitive behaviors/fixated interests.” (Kaufmann, 19)
C. The DSM-5 recognizes the spectrum nature of Autism
1. “A dimensional approach was incorporated into the DSM to provide greater detail to the clinician and to allow the differentiation of symptoms by measuring number/count, duration, and intensity beyond just the absence or presence of a symptom.” (Pomeroy, 197)
2. “The distinction between the previous categories has been found to be inconsistent and to vary across sites.”(Gibbs, 1751) “The boundaries between different disorder categories often blur, and severity levels wax and wane.” (Pomeroy, 199)
3. Each individual on the spectrum is different with different symptoms and levels of severity of those symptoms and the DSM-5 recognizes that variability.
4. “Scientific evidence and clinical practice show that a single spectrum better reflects the symptom presentation, time-course and response to treatment.” (Kaufmann, 23)
D.
“ Since the inclusion of Asperger’s Disorder in the DSM-IV in 1994, there has been ongoing controversy about the Asperger’s disorder label.” (Kite, 1693)
1. Miller and Ozonoff in 1997 applied DSM-IV Asperger criteria to the four cases described in Asperger’s original paper from 1944. They found that all four individuals met DSM-IV criteria for Autistic Disorder and none met Asperger criteria. This is largely due to the precedent rule that says Asperger’s Disorder is ruled out if the person meets the Autistic criteria. (Ozonoff, e5)
2. Gilchrist and colleagues in 2001 found that 80% of their Asperger group met DSM-IV Autistic Disorder criteria. Their HFA (high-functioning Autism) and Asperger’s groups performed similarly illustrationg the confusion that Asperger’s is really just High Functioning Autism. (Ozonoff, e5) This goes along with the new Spectrum diagnosis.
3. Prior and colleagues in 1998 used a cluster analysis approach to diagnosing autism along the newer Spectrum diagnosis. They identified three clusters differing in their level of impairment, severity of symptoms, and level of cognitive function, NOT in the nature of their symptoms. These results are directly supportive of the DSM-5. (Ozonoff, …show more content…
e5)
4. The ambiguity concerning Asperger’s disorder will be eliminated in two steps.
a. First, the term is eliminated altogether
b. Second, combining the first two of the three primary symptom domains of ASD into one symptom domain – clinically significant, persistent deficits in social communication and interactions.
c. “No longer will there be the necessity to decide whether someone can communicate well but relates poorly, as is the current situation with Asperger’s disorder, because the distinction is collapsed.” (Gensler, 88)
– Rebuttal Question: According to my research, there may be many people that fall under one of the four previous PDD categories that will no longer qualify for a diagnosis of Autism Spectrum Disorder under the new DSM-5. How do you account for their losing their disgnosis and therefore the supports that are currently in place to help them with success in school and their futures?
– Response: “There are a number of behaviors that have long been associated with ASDs that were not formally outlined in the DSM-IV-TR and are now included such as difficulties understanding non-verbal behaviors, hypersensitivity to sensory input, indifferences to pain/heat/cold. The assessment tools used in these studies are based in DSM-IV criteria and may not have been elicited in the assessment process. It is also possible that many of the children who would not meet the new ASD criteria may meet the new DSM-5 Social Communication Disorder.” (Gibbs, 1755) “The American Journal of Psychiatry’s most comprehensive assessment in October 2012 found that 91% of children with clinical DSM-IV diagnoses would retain their diagnoses under the new DSM-5 criteria.” (APA website)
III. – Moving from DSM-IV to DSM-5 is taking one step forward and two steps back.
A. “Unlike the clarity that exists in diagnosing physical ailments, the interpretation of what a mental illness is and how it is defined is subjective.” (Kite, 1692)
1. The DSM system in general by definition assumes that Autism is a mental illness. This excludes the new research into the biomedical side of Autism.
2. While changes are necessary to the existing diagnostic criteria for Autism, the DSM-5 does not meet the necessary reviews and takes away identifiers that should continue to be used.
3. “It is important to remember that autism is not homogenous (all the same) and defining it using the umbrella term ASD risks whitewashing the evident heterogeneity (with distinct differences), which has a substantial impact on research into this condition.” (Lai, 2).
4. In essence this has simply moved us from the level of subgroups, comparing apples to oranges, to the prototypical level of all fruit. We must still recognize the differences within the spectrum to understand each individual child and how their particular “autism” works. The DSM-5 fails to differentiate enough.
B. “DSM-5 criteria is more stringent than DSM-IV, such that some individuals who qualified for PDD will not meet the new ASD criteria.” (Lai, 1).
1. Studies show that the DSM-5 provides better specificity, reducing false-positive diagnoses, but this is at the expense of reduced sensitivity, especially for older children and adults, individuals without intellectual disability, and individuals who previously met the criteria for diagnoses of DSM-IV Asperger’s Disorder or PDD-NOS.” (Lai, 2).
2. In order to meet criteria for ASD under DSM-5, a child must meet all three of the newly combined social communication impairments and at least two of the RRBs (restricted, repetitive patterns of behavior)… A minimum of 5 out of 7 symptoms must be present as compared with DSM-IV criteria for the lowest threshold which is social impairment with no specific count and either communication impairment or RRBs or even sub-threshold presentation across all three areas. (Gibbs, 1751)
3. In 2012, McParland et al. conducted a reanalysis of the 933 participants evaluated under the DSM-IV. They found 39.4% would no longer meet the ASD criteria under DSM-V. Mattila et al found in a study in Finland that only 46% of cases met the new criteria. In another recent study, Worley and Matson (2012) used checklists to compare ASD symptoms in 121 children already classified under DSM-IV. They found that 32.7% lost their diagnosis. Gibbs et al.also conducted a recent study where 26 of 111 children no longer met the criteria for ASD under the new DSM-5. Of those children, 10.2% had been diagnosed with Autistic Disorder, 16.6% with Asperger's Disorder and 50% with PDD-NOS. (Gibbs, 1752-1753)
4. "Therefore, children with clear support needs that are very akin to ASD may have difficulty accessing the necessary funding, supports, and early intervention programs." (Gibbs, 1754) Children who have supports in place in educational settings will lose them. Younger children who need the early interventions will be unable to get them. This will only hurt them.
C. Stigma/Identity Crisis
1. "According to Wallis, the negative connotations associated with the term of 'autism' in the new label of 'Autism Spectrum Disorder', will discourage families of those with milder symptoms of autism spectrum conditions from seeking a diagnosis under the new label… Research has suggested that the term Asperger's Disorder currently has a relatively positive perception in society due to links to "geniuses" like Bill Gates, Albert Einstein and Thomas Jefferson." (Kite, 1693)
2. There has been increasing growth in interest in the topic of Asperger's disorder with a Google search in early 2012 indicating over 9 ½ million topics on the subject. (Kite, 1694)
3. "Dropping the terms Asperger's and PDD-NOS will have major social implications affecting millions of individuals and their families who have identified those labels with themselves or their loved ones for the last 20 years. The change in terminology will also require school systems and insurance companies to change the systems that link children with diagnoses to relevant educational services and to reimbursement entitlements." (Gensler, 89)
4.
Of the 547 health and education professionals participating in Kite et al. study, 93.4% of participants answered that there was a difference between Autism and Asperger's Disorder. (Kite, 1694)
5. Ghaziuddin has researched the differences between the two diagnoses on multiple occasions. His findings have suggested that persons with Asperger's often have a distinct style of social interaction, active but odd rather than that of Autism where the children are passive and aloof. He states that the two conditions differ not only in the degree of severity but also in the quality of their social impairment. (Ghaziuddin, 141) Other distinct Asperger's traits include idiosyncratic interests often sophisticated and intellectual and a communication style that is pedantic and verbose.
6. The new Social Communication Disorder was created to help catch the children who would no longer fall under the new ASD criteria. "It seems logically and internally inconsistent for the DSM-5, which explicitly takes a dimensional approach, to introduce a separate category that is so qualitatively similar to another condition." (Ozonoff, e6) SCD does not fit what we know about Asperger's
Disorder.
D. Recognizing the spectrum nature of Autism with definitive sub-group identifiers.
1. "Within autism there is a huge variability in terms of behavior (symptom severity and combination), cognition (the range of deficits and assets), and biological mechanisms…To understand the biology of "the autisms," it is necessary to clarify not just the similarities but also the differences among subgroups." (Lai, 2)
2. Lai, Lombardo, Chakrabarti and Baron-Cohen state that "Cognition plays a pivotal role linking brain and behavior in ASD, yet curiously remains absent in DSM-5." Their research argues that to make progress in autism research, and ultimately to improve clinical practice, we need to move forward in the identification of subgroups within the autism spectrum. Expanding the list of specifiers and requiring details be recorded to include developmental pattern, sex/gender, clinical phenotypes, genetic correlates, environmental contributors, and a complete cognitive profile including intelligence, language, social cognition, theory of mind, executive function, bottom-up perceptual processing, and top-down information processing. (Lai, 5)
3. "In a world that is moving toward individualized medicine, not incorporating information about such specifiers will be a backward step." (Lai, 6)
- Rebuttal Question: Listening to the information presented in your debate, the DSM-IV isn't the answer and the DSM-V isn't the answer, so what is the answer?
- Response: We need a system that encompasses all the intricacies of what comprises the whole of the Autism Spectrum. "The National Institute of Mental Health (NIMH) will no longer use DSM-based diagnostic categories in its research projects. Director Thomas Insel called the DSM reliable but said that its diagnostic categories, which are based on clusters of clinical symptoms and not laboratory measurements, lack scientific validity. He went on to say NIMH's plan is to create a future replacement diagnostic system that more directly reflects biology and modern brain science via their Research Domain Criteria project." (Pomeroy, 198)
IV. Questions from the Audience
Debate on the Changes in Autism Diagnosis
I. Introduction
A. What is the DSM? According to the American Psychiatric Association the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. The DSM consists of three major components:
1. The diagnostic classification is the list of the mental disorders that are officially part of the DSM system.
2. A set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis.
3. The descriptive text that accompanies each disorder …show more content…
systematically describes each disorder.
B. Why does the DSM change?
1. “Over time, a tension can develop between current diagnostic categories and facts emerging that will eventually lead to the next categories. This tension creates conflict between received certainties of diagnostic authorities and the lived complexity that parents and patients live with, leading eventually to a revision of the authoritative classification system.” (Daniel Gensler, p2)
2. In the first two editions, the closest diagnosis was schizophrenia. It wasn’t until 1980 that Autism received its own diagnosis. (Daniel Gensler, p2) As we discover new things through research and studies, the authorities update the DSM.
II. DSM 5 –
A. Progress is important
1. It has been 2 decades since the DSM IV was published. Twenty years of research, experiments, observations and studies have changed what we know about autism.
2. DSM V has taken four separate disorders of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and the catch-all PDD-NOS and contained them under the umbrella diagnosis of Autism Spectrum Disorder. According to the American Psychiatric Association that publishes the DSM, “Anyone diagnosed with one of the four pervasive development disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5 or another, more accurate DSM-5 diagnosis.”(APA website)
3. Susan Swedo, MD, senior investigator of NIMH, the National Institute of Mental Health states, “A single umbrella disorder will improve the diagnosis of ASD without limiting the sensitivity of the criteria, or substantially changing the number of the children being diagnosed.” (APA website)
B. Under the DSM-IV, the categories now contained in the Autism Spectrum Disorder were listed under the term Pervasive Developmental Disorders. The term Pervasive is incorrect.
1. Webster’s defines the term pervasive as, “existing in or spreading to every part of something.”
2. “Symptoms are not pervasive – they are specific to social-communication domain plus restricted, repetitive behaviors/fixated interests.” (Kaufmann, 19)
C. The DSM-5 recognizes the spectrum nature of Autism
1. “A dimensional approach was incorporated into the DSM to provide greater detail to the clinician and to allow the differentiation of symptoms by measuring number/count, duration, and intensity beyond just the absence or presence of a symptom.” (Pomeroy, 197)
2. “The distinction between the previous categories has been found to be inconsistent and to vary across sites.”(Gibbs, 1751) “The boundaries between different disorder categories often blur, and severity levels wax and wane.” (Pomeroy, 199)
3. Each individual on the spectrum is different with different symptoms and levels of severity of those symptoms and the DSM-5 recognizes that variability.
4. “Scientific evidence and clinical practice show that a single spectrum better reflects the symptom presentation, time-course and response to treatment.” (Kaufmann, 23)
D.
“ Since the inclusion of Asperger’s Disorder in the DSM-IV in 1994, there has been ongoing controversy about the Asperger’s disorder label.” (Kite, 1693)
1. Miller and Ozonoff in 1997 applied DSM-IV Asperger criteria to the four cases described in Asperger’s original paper from 1944. They found that all four individuals met DSM-IV criteria for Autistic Disorder and none met Asperger criteria. This is largely due to the precedent rule that says Asperger’s Disorder is ruled out if the person meets the Autistic criteria. (Ozonoff, e5)
2. Gilchrist and colleagues in 2001 found that 80% of their Asperger group met DSM-IV Autistic Disorder criteria. Their HFA (high-functioning Autism) and Asperger’s groups performed similarly illustrationg the confusion that Asperger’s is really just High Functioning Autism. (Ozonoff, e5) This goes along with the new Spectrum diagnosis.
3. Prior and colleagues in 1998 used a cluster analysis approach to diagnosing autism along the newer Spectrum diagnosis. They identified three clusters differing in their level of impairment, severity of symptoms, and level of cognitive function, NOT in the nature of their symptoms. These results are directly supportive of the DSM-5. (Ozonoff, …show more content…
e5)
4. The ambiguity concerning Asperger’s disorder will be eliminated in two steps.
a. First, the term is eliminated altogether
b. Second, combining the first two of the three primary symptom domains of ASD into one symptom domain – clinically significant, persistent deficits in social communication and interactions.
c. “No longer will there be the necessity to decide whether someone can communicate well but relates poorly, as is the current situation with Asperger’s disorder, because the distinction is collapsed.” (Gensler, 88)
– Rebuttal Question: According to my research, there may be many people that fall under one of the four previous PDD categories that will no longer qualify for a diagnosis of Autism Spectrum Disorder under the new DSM-5. How do you account for their losing their disgnosis and therefore the supports that are currently in place to help them with success in school and their futures?
– Response: “There are a number of behaviors that have long been associated with ASDs that were not formally outlined in the DSM-IV-TR and are now included such as difficulties understanding non-verbal behaviors, hypersensitivity to sensory input, indifferences to pain/heat/cold. The assessment tools used in these studies are based in DSM-IV criteria and may not have been elicited in the assessment process. It is also possible that many of the children who would not meet the new ASD criteria may meet the new DSM-5 Social Communication Disorder.” (Gibbs, 1755) “The American Journal of Psychiatry’s most comprehensive assessment in October 2012 found that 91% of children with clinical DSM-IV diagnoses would retain their diagnoses under the new DSM-5 criteria.” (APA website)
III. – Moving from DSM-IV to DSM-5 is taking one step forward and two steps back.
A. “Unlike the clarity that exists in diagnosing physical ailments, the interpretation of what a mental illness is and how it is defined is subjective.” (Kite, 1692)
1. The DSM system in general by definition assumes that Autism is a mental illness. This excludes the new research into the biomedical side of Autism.
2. While changes are necessary to the existing diagnostic criteria for Autism, the DSM-5 does not meet the necessary reviews and takes away identifiers that should continue to be used.
3. “It is important to remember that autism is not homogenous (all the same) and defining it using the umbrella term ASD risks whitewashing the evident heterogeneity (with distinct differences), which has a substantial impact on research into this condition.” (Lai, 2).
4. In essence this has simply moved us from the level of subgroups, comparing apples to oranges, to the prototypical level of all fruit. We must still recognize the differences within the spectrum to understand each individual child and how their particular “autism” works. The DSM-5 fails to differentiate enough.
B. “DSM-5 criteria is more stringent than DSM-IV, such that some individuals who qualified for PDD will not meet the new ASD criteria.” (Lai, 1).
1. Studies show that the DSM-5 provides better specificity, reducing false-positive diagnoses, but this is at the expense of reduced sensitivity, especially for older children and adults, individuals without intellectual disability, and individuals who previously met the criteria for diagnoses of DSM-IV Asperger’s Disorder or PDD-NOS.” (Lai, 2).
2. In order to meet criteria for ASD under DSM-5, a child must meet all three of the newly combined social communication impairments and at least two of the RRBs (restricted, repetitive patterns of behavior)… A minimum of 5 out of 7 symptoms must be present as compared with DSM-IV criteria for the lowest threshold which is social impairment with no specific count and either communication impairment or RRBs or even sub-threshold presentation across all three areas. (Gibbs, 1751)
3. In 2012, McParland et al. conducted a reanalysis of the 933 participants evaluated under the DSM-IV. They found 39.4% would no longer meet the ASD criteria under DSM-V. Mattila et al found in a study in Finland that only 46% of cases met the new criteria. In another recent study, Worley and Matson (2012) used checklists to compare ASD symptoms in 121 children already classified under DSM-IV. They found that 32.7% lost their diagnosis. Gibbs et al.also conducted a recent study where 26 of 111 children no longer met the criteria for ASD under the new DSM-5. Of those children, 10.2% had been diagnosed with Autistic Disorder, 16.6% with Asperger's Disorder and 50% with PDD-NOS. (Gibbs, 1752-1753)
4. "Therefore, children with clear support needs that are very akin to ASD may have difficulty accessing the necessary funding, supports, and early intervention programs." (Gibbs, 1754) Children who have supports in place in educational settings will lose them. Younger children who need the early interventions will be unable to get them. This will only hurt them.
C. Stigma/Identity Crisis
1. "According to Wallis, the negative connotations associated with the term of 'autism' in the new label of 'Autism Spectrum Disorder', will discourage families of those with milder symptoms of autism spectrum conditions from seeking a diagnosis under the new label… Research has suggested that the term Asperger's Disorder currently has a relatively positive perception in society due to links to "geniuses" like Bill Gates, Albert Einstein and Thomas Jefferson." (Kite, 1693)
2. There has been increasing growth in interest in the topic of Asperger's disorder with a Google search in early 2012 indicating over 9 ½ million topics on the subject. (Kite, 1694)
3. "Dropping the terms Asperger's and PDD-NOS will have major social implications affecting millions of individuals and their families who have identified those labels with themselves or their loved ones for the last 20 years. The change in terminology will also require school systems and insurance companies to change the systems that link children with diagnoses to relevant educational services and to reimbursement entitlements." (Gensler, 89)
4.
Of the 547 health and education professionals participating in Kite et al. study, 93.4% of participants answered that there was a difference between Autism and Asperger's Disorder. (Kite, 1694)
5. Ghaziuddin has researched the differences between the two diagnoses on multiple occasions. His findings have suggested that persons with Asperger's often have a distinct style of social interaction, active but odd rather than that of Autism where the children are passive and aloof. He states that the two conditions differ not only in the degree of severity but also in the quality of their social impairment. (Ghaziuddin, 141) Other distinct Asperger's traits include idiosyncratic interests often sophisticated and intellectual and a communication style that is pedantic and verbose.
6. The new Social Communication Disorder was created to help catch the children who would no longer fall under the new ASD criteria. "It seems logically and internally inconsistent for the DSM-5, which explicitly takes a dimensional approach, to introduce a separate category that is so qualitatively similar to another condition." (Ozonoff, e6) SCD does not fit what we know about Asperger's
Disorder.
D. Recognizing the spectrum nature of Autism with definitive sub-group identifiers.
1. "Within autism there is a huge variability in terms of behavior (symptom severity and combination), cognition (the range of deficits and assets), and biological mechanisms…To understand the biology of "the autisms," it is necessary to clarify not just the similarities but also the differences among subgroups." (Lai, 2)
2. Lai, Lombardo, Chakrabarti and Baron-Cohen state that "Cognition plays a pivotal role linking brain and behavior in ASD, yet curiously remains absent in DSM-5." Their research argues that to make progress in autism research, and ultimately to improve clinical practice, we need to move forward in the identification of subgroups within the autism spectrum. Expanding the list of specifiers and requiring details be recorded to include developmental pattern, sex/gender, clinical phenotypes, genetic correlates, environmental contributors, and a complete cognitive profile including intelligence, language, social cognition, theory of mind, executive function, bottom-up perceptual processing, and top-down information processing. (Lai, 5)
3. "In a world that is moving toward individualized medicine, not incorporating information about such specifiers will be a backward step." (Lai, 6)
- Rebuttal Question: Listening to the information presented in your debate, the DSM-IV isn't the answer and the DSM-V isn't the answer, so what is the answer?
- Response: We need a system that encompasses all the intricacies of what comprises the whole of the Autism Spectrum. "The National Institute of Mental Health (NIMH) will no longer use DSM-based diagnostic categories in its research projects. Director Thomas Insel called the DSM reliable but said that its diagnostic categories, which are based on clusters of clinical symptoms and not laboratory measurements, lack scientific validity. He went on to say NIMH's plan is to create a future replacement diagnostic system that more directly reflects biology and modern brain science via their Research Domain Criteria project." (Pomeroy, 198)
IV. Questions from the Audience