Friday, December 13, 2013

Diagnosed with Asperger’s? Not Anymore: Part 1 of a series on the DSM-5

Today we will feature a post submitted by Rachel Hodas, one of our fantastic program managers in Philadelphia. Rachel is also our "Spotlight Staff" this week on The AHEADD Blog, so be sure to take aminute to read about the author of this great article.


The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), considered to be the “Bible” of modern psychiatry, is the standard diagnostic system used in the United States used to classify mental health disorders. It provides a common language for talking about and classifying psychiatric problems among researchers and clinicians. The original version of the DSM was first published in 1952 after the United States saw sharp increases in mental health problems as soldiers returned home from World War I. Since then, the DSM has gone through many revisions, reflecting and influencing public thoughts about psychiatric disorders.

The newest version of the DSM, the DSM-5, was released this past May, at the 2013 American Psychiatry Association’s annual convention in San Francisco. The DSM-5 is the product of over a decade of development, the formation of a multi-group task force, and years of empirical support.

But some argue that even more research should have been done before publication. Critics of the new DSM claim that the science backing it up is just not strong enough. Frank Farley, Ph.D., a professor at Temple University, is concerned by the research methods used to evaluate the new criteria. “Many of these field trials were conducted in ideal settings, often university clinical settings,” says Farley. Out in the real world, many clinicians work in less structured settings, and the research used to validate the criteria does not necessarily reflect these conditions.

Furthermore, Farley expressed concern with the results of the field trials, which often demonstrated poor inter-judge reliability. This means that two different diagnosticians may come up with different conclusions for the same client when relying on DSM-5 criteria. Given the inconclusive support for some diagnoses in the field trials, Farley asks “If [clinicians] don’t have great agreement under those conditions, what does that mean for the sole professional doing diagnoses under not very structured or pristine conditions?”

The DSM-5 has also been critiqued for causing “diagnostic inflation,” or over pathologizing everyday problems and normative responses to stress. New labels have been developed for individuals demonstrating behavioral extremes, such as Disruptive Mood Dysregulation Disorder for children demonstrating severe temper tantrums. Farley calls this the “relentless coining of new terms” and claims that, “We are pathologizing extremes of behavior that are not sick.” Proponents of these changes point to the benefits of gaining additional labels when working with insurance companies. Opponents like Farley worry that these labels will lead to inappropriate uses of psychotropic medications.

In an effort to address some of the shortcomings of current classification systems, Farley has co-chaired the development of a Global Summit on Diagnostic Alternatives (see www.dxsummit.org). The Global Summit is an internet-based discussion group that was developed to form an open dialogue to discuss concerns with current diagnostic practices and to lead to alternative approaches.

This is not the only group that has publically criticized the DSM-5. Two weeks prior to the manual’s release, Thomas R. Insel, M.D., the Director of the National Institute for Mental Health (NIMH), reported that the agency would withdraw funding for projects relying on DSM-5 criteria. Although he later released a joint statement of support for the DSM-5 with the president of the American Psychiatric Association, the NIMH has begun working on an alternative classification system that focuses on behavioral and neurobiological markers, named the Research Domain Criteria Project (RDoC).

In addition to concerns surrounding the manual as a whole, discussions have been raised regarding specific diagnostic categories. Perhaps one of the most public controversies in this area, particularly among those working with school-age students, surrounds the new definition of Autism. In the previous version of the manual, the DSM-IV-TR, Autistic Disorder was considered to be one of five distinct disorders, including Asperger’s Disorder, which fell under the umbrella of Pervasive Developmental Disorders (PDD). Under the DSM-5, however, there is simply one diagnostic category that captures all of these behavioral variances. This reflects the increasing understanding that Autism Spectrum Disorder (ASD) encompasses a spectrum of disorders and severity levels.

Whereas a diagnosis of Autism previously required symptoms across three areas, the DSM-5 limits this to two broad areas. In order to be diagnosed with ASD, an individual must: 1) manifest deficits in social communication and social interaction, and 2) demonstrate restricted and repetitive patterns of behavior. Instead of just identifying whether symptoms are present, the severity of symptoms is rated along a three-point scale.

There is also now a list of specifiers that help to qualitatively define areas of impairment. These include specification of whether there is the accompaniment of intellectual impairment, language impairment, a known medical, genetic, or environmental condition, a neurodevelopmental, mental, or behavioral disorder, or catatonia. Therefore, while everyone now receives a diagnosis of ASD, there is additional information included with the diagnosis. Previously, one of the most significant differences between Autistic Disorder and Asperger’s Syndrome was that a language delay was present in children with Autistic Disorder. Now that these two disorders have been collapsed into one label, language delay is no longer a distinguishing symptom and is instead recognized through specifiers.

So what does this mean for students with Asperger’s? Whereas Asperger’s was considered a separate diagnostic category from Autism in the DSM-IV-TR, both syndromes are now categorized under ASD. According to the APA, “Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder” (APA, 2013, p.51). Because students who were previously diagnosed with Asperger’s now technically have Autism, there is reason to be concerned about how they are coping with these changes. Future posts will examine the impact these changes might have on college students as they replace their previous diagnosis with a more stigmatizing label.


Recommended readings:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brock, S. E. & Hart, S. R. (2013, October). Changes to ASD diagnosis. Communique,
42(7), 1, 34-35.

Frances, A. (2009). A warning sign on the road to DSM-V: Beware of its unintended
consequences. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/10168/1425378

Grant, R. & Nozyce, M. (2013). Proposed changes to the American Psychiatric
Association Diagnostic Criteria for Autism Spectrum Disorder: Implications for
young children and their families. Maternal and Child Health Journal, 17(4),
586-592.

Mahjouri, S. & Lord, C. E. (2012). What the DSM-5 portends for research, diagnosis, and
treatment of Autism Spectrum Disorders. Current Psychiatry Reports, 14(6), 739-
747.



Recommended websites:

American Psychiatric Association DSM-5: http://www.dsm5.org/Pages/Default.aspx

The Global Summit on Diagnostic Alternatives: http://dxsummit.org/

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