Not autistic under DSM 5!

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I feel like they are making new disorders, and discounting the old ones. I sincerely hope those who DX follow the old guidelines. It sounds like this whole social communication disorder is just another part of having an ASD.

and for that matter, are they still changing the name of Asperger's to Autism spectrum disorder/ incasing the whole of the spectrum under that title? Now that I understnd whats going on, I'm even more displeased.

Clinicians will have to follow the new guidelines. And yes, "Asperger's" will no longer exist as a diagnosis. But I expect the term will continue to be used for a long time, just like we still use the term "ADD" (which was removed in the DSM-IV.)

How did they decide to make these changes to begin with? What were the deciding factors?

Repetitive behaviors.

I've been wondering that myself... There are plenty of theories, but nobody really seems to know for sure.

So what criteria separates language imapired ASD from SCD? they seem awfully close??

A. Social Communication Disorder (SCD) is an impairment of pragmatics and is diagnosed based on difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social relationships and discourse comprehension and cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability.

B. The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement, or occupational performance, alone or in any combination.

C. Rule out Autism Spectrum Disorder (ASD). Autism Spectrum Disorder by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of the autism spectrum. Therefore, ASD needs to be ruled out for SCD to be diagnosed.

D. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,

2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning.

Asperger's Syndrome

(I) Qualitative impairment in social interaction, as manifested by at least two of the following:
(A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
(B) failure to develop peer relationships appropriate to developmental level
(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people)
(D) lack of social or emotional reciprocity

(II) Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:

(A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(B) apparently inflexible adherence to specific, nonfunctional routines or rituals
(C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
(D) persistent preoccupation with parts of objects


(III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.

(IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)

(V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.

(VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia

Is there any way they can be asked flat out?

New name for category, autism spectrum disorder, which includes autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.


•Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.
•Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.

Three domains become two:

1) Social/communication deficits

2) Fixated interests and repetitive behaviors

•Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities
•Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis
•Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity
•Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains
•Decision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases
Several social/communication criteria were merged and streamlined to clarify diagnostic requirements.

•In DSM-IV, multiple criteria assess same symptom and therefore carry excessive weight in making diagnosis
•Merging social and communication domains requires new approach to criteria
•Secondary data analyses were conducted on social/communication symptoms to determine most sensitive and specific clusters of symptoms and criteria descriptions for a range of ages and language levels
Requiring two symptom manifestations for repetitive behavior and fixated interests improves specificity of the criterion without significant decrements in sensitivity. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria.

The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.

Reorganization of subdomains increases clarity and continues to provide adequate sensitivity while improving specificity through provision of examples from different age ranges and language levels.

Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specfication of different behaviors that can be coded within this domain, with examples particularly relevant for younger children

Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.

In making the recommendation to delete Asperger’s disorder, the following questions were considered:

Q.1. Have the DSM-IV diagnostic criteria for Asperger Disorder worked?

The ‘Asperger’ label has proved popular, ‘acceptable’, and has widened recognition of autism spectrum disorder (ASD) in combination with good language and intelligence. In addition, the introduction of this diagnostic entity has achieved the intended aim of prompting research into possible differences between this and other subgroups of PDD, with more than 500 published articles on Asperger syndrome.


1.1. Do the DSM-IV criteria work in clinical practice?

A number of published papers have argued that the DSM-IV Asperger disorder criteria do not work in the clinic (e.g., Mayes et al., 2001; Miller & Ozonoff, 2000; Leekam, Libby, Wing, Gould & Gillberg, 2000). Specifically, key problems exist in applying the current criteria:

· Early language details are hard to establish in retrospect, especially for older children and adults; average age of first diagnosis is late (7 years according to Mandell et al. 2005; 11yrs, Howlin & Asgharian, 1999).

· The trumping rule means most/all Asperger cases should strictly be diagnosed as having ‘Autistic disorder’ (Miller & Ozonoff, 2000; Bennett et al, 2008; Williams et al, 2008), although clinicians prefer to give the more specific term (Mahoney, et al.,1998)

o Specifically, since language delay is not a necessary criterion for Autistic disorder, to meet criteria for Asperger disorder (without being trumped by Autistic disorder), a person would need to fail to meet Communication criteria for Autistic disorder. In practice, the Communication criterion (B.2.) of “marked impairment in the ability to initiate or sustain a conversation with others” is typically met by even very able individuals fitting the Asperger picture.

As a result, ‘Asperger syndrome’ is used loosely with little agreement: e.g. Williams et al (2008) survey of 466 professionals reporting on 348 relevant cases, showed 44% of children given Asperger, PDD-NOS, atypical autism, or ‘other ASD’ label actually fulfilled criteria for Autistic Disorder (overall agreement between clinician’s label and DSM-IV criteria; Kappa 0.31).



1.2. Do the DSM-IV criteria delineate a meaningful subgroup for research or practice?

In part because of the difficulty in applying the criteria (as outlined in section 1.1.), different research groups often uses different criteria, and quality of early language milestone information is variable (Eisenmajer et al., 1996; Klin et al., 2005; Woodbury-Smith, Klin, & Volkmar, 2005). Different criteria lead to different samples being identified (see Klin et al, 2005 comparison of 3 diagnostic approaches; also Kopra et al., 2008; Woodbury-Smith et al., 2005).



•Research suggests early language criteria do not demarcate a distinct subgroup with different:
◦Course/outcome: Children with autism who develop fluent language have very similar trajectories and later outcomes to children with Asperger disorder (Bennett et al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two conditions are indistinguishable by school-age (Macintosh & Dissanayake, 2004), adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998; Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003).
◦Cause/aetiology: Autism and Asperger syndrome co-occur in the same families (Bolton et al., 1994; Chakrabarti & Fombonne, 2001; Lauritsen et al., 2005; Ghaziuddin, 2005; Volkmar et al., 1998). No clear evidence to date of distinct aetiology.
◦Neuro-Cognitive profile: mixed evidence, for example some authors have reported worse motor functioning in Asperger than HFA (Klin et al., 1995; Rinehart et al, 2006), while others have not found significant group differences (Jansiewicz et al., 2006; Manjiviona & Prior, 1995; Miller & Ozonoff, 2000; Thede & Coolidge, 2007). Evidence is similarly mixed for differentiation of Asperger group by lower performance than verbal IQ profile (for, Klin et al, 1995; against, Barnhill et al., 2000; Gilchrist et al., 2001; Ozonoff, South & Miller, 2000; Spek et al., 2008), better theory of mind (for, Ozonoff et al, 2000 ; against, Dahlgren & Trillingsgaard, 1996; Spek et al, in press JADD; Barbaro & Dissanayake 2007) or executive function (for, Rinehart et al, 2006; reviewed by Klin, McPartland & Volkmar, 2005 ; against, Miller & Ozonoff, 2000; Thede & Coolidge, 2007; Verte et al., 2006) . Note the risk of circularity for group differences relating to verbal ability, since early language development (grouping criterion) is generally predictive of later language abilities (Paul & Cohen, 1984; Rutter, Greenfield & Lockyer, 1967; Rutter, Mawhood & Howlin, 1992).
◦Treatment needs/response: no empirical studies demonstrating the need for different treatments or different responses to the same treatment, and in clinical practice the same interventions are typically offered.
Q.2. Does the existing research literature allow us to suggest new criteria to diagnose Asperger Disorder, in contrast to Autistic Disorder/ASD?
The current clinical and research consensus appears to be that Asperger disorder is part of the autism spectrum, although with possible over-use of the term it is quite likely that other (non-ASD) types of individuals have received this label.

Research field currently reflects two views:

◦That Asperger disorder is not substantially different from other forms of ‘high functioning’ autism (HFA); i.e. Asperger’s is the part of the autism spectrum with good formal language skills and good (at least Verbal) IQ. Note that ‘HFA’ is itself a vague term, with underspecification of the area of ‘high functioning’ (performance IQ, verbal IQ, adaptation, or symptom severity).
◦That Asperger disorder is distinct from other subgroups within the autism spectrum (see Matson & Wilkins, 2008, review): e.g. Klin, et al. (2005) suggest the lack of differentiating findings reflects the need for a more stringent approach, with a more nuanced view of onset patterns and early language (e.g. one-sided verbosity, unusual circumscribed interests).2.1. What are the proposed differences? How strong is the evidence?

Several recent comprehensive reviews of the topic are available (Howlin, 2003; Macintosh & Dissanayake, 2004; Matson & Wilkins, 2008; Witwer & Lecavalier, 2008). Matson & Wilkins (2008) suggest current criteria could work if refined and supplemented. However, the research literature to date is not able to provide strong, replicated support for new or modified criteria likely to distinguish a meaningfully different group with Asperger disorder versus autism with good (current) language and IQ. Witwer and Lecavalier’s (2008) perhaps more comprehensive review concludes there is little evidence that Aspergers is distinct, and that current IQ is the main differentiating factor. Bennett et al’s (2008) follow-up study suggests that language impairment at 6-8years might have greater prognostic value than early language milestones, and Szatmari et al (2009) argue (on the basis of later developmental trajectory) for a distinction between ASD with (autism) versus without (Aspergers) structural language impairment at 6-8 years.

The draft criteria for ASD proposed by the Neurodevelopmental disorders workgroup would include dimensions of severity that include current language functioning and intellectual level/disability.




Q.3. If Asperger disorder does not appear in DSM-V as a separate diagnostic category, how will continuity and clarity be maintained for those with the diagnosis?
The aim of the draft criteria is that every person who has significant impairment in social-communication and RRBI should meet appropriate diagnostic criteria. Language impairment/delay is not a necessary criterion for diagnosis of ASD, and thus anyone who shows the Asperger type pattern of good language and IQ but significantly impaired social-communication and repetitive/restricted behavior and interests, who might previously have been given the Asperger disorder diagnosis, should now meet criteria for ASD, and be described dimensionally. The workgroup aims to provide detailed symptom examples suitable for all ages and language levels, so that ASD will not be missed by clinicians in adults of average or superior IQ who are experiencing clinical levels of difficulty.

There may be some individuals with subclinical features of Asperger/ASD who seek out a diagnosis of ‘Asperger Disorder’ in order to understand themselves better (perhaps following an autism diagnosis in a relative), rather than because of clinical-level impairment in everyday life. While such a use of the term may be close to Hans Asperger’s reference to a personality type, it is outside the scope of DSM, which explicitly concerns clinically-significant and impairing disorders. ‘Asperger-type’, like ‘Kanner-type’, may continue to be a useful shorthand for clinicians describing a constellation of features, or area of the multi-dimensional space defined by social/communication impairments, repetitive/restricted behaviour and interests, and IQ and language abilities.

Hope they get the help they need in time for DSM 6.

You say each "subtype" of developmental disorders under the PDD umbrella is different genetically but then contradict yourself by stating the it's "more due to the brains natural plasticity" than dramatic change in the gene function?
I am only saying this to you for your own education, avoid making categorical statements in your thesis dissertation that each (man made) discrete ASD category is "genetically" different.

What I meant is that I believe the subtypes differ, but that early intervention can make a great difference in severity. Because it's an environmental influence on the genes and brain structure. And I do not plan on doing a thesis on ASDs. They don't interest me enough to do so. While I am not an expert on genetics, I know a good bit, and I do not believe that I was contradictory.

Impairments in Social - emotional reciprocity are currently not a mandatory requirement under the DSMIV diagnosis of Aspergers, and they are also not a mandatory requirement in the DSMV diagnosis of Social Communication Disorder, however Impairments in Social - emotional reciprocity are mandatory in the revision of the DSMV autism spectrum disorder.

So, those that don't meet that mandatory social - emotional reciprocity criteria in the DSMV Autism Spectrum disorder for a re-assessment of those currently diagnosed with Aspergers, could potentially meet the SCD diagnostic criteria.

Also, those that currently meet the mandatory 1 criteria of RRB's in Aspergers, that may not meet the mandatory 2 criteria of RRB's in Autism Spectrum disorder, might be put in SCD as well.

A greater problem might be for those that don't currently meet the non-verbal communication criteria in Aspergers, as they also would not likely meet the criteria for SCD.

The similiar potential issue exists for those currently diagnosed with Autism Disorder, because social emotional reciprocity and non-verbal communication impairments are not a mandatory requirement in that disorder either, while they are a mandatory requirement in the new Autism Spectrum Disorder. Autism Disorder already has a mandatory requirement of 2 RRB's, so that likely won't be an issue.



http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=489



http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94

Autism Spectrum Disorder

Must meet criteria A, B, C, and D:




http://www.autreat.com/dsm4-aspergers.html

You did contradict yourself, the brain's natural plasticity (phenotypic) manifests from the same genetic makeup... Environment influence on genes is contraversial as there is no known environmental influence on genes related to autism.

Not to mention SCD and cognitive impairment!

Childhood bipolar diagnosis is just shameful. Granted, some diagnoses ARE legit, mostly in kids who have a strong family history of bipolar disorder. But a lot of the "bipolar" children nowadays are being given that label over explosive anger. While explosive rage is very much a common part of mania, there is SO much more to mania than that! I KNOW that, if I were a kid growing up today, I would have been falsely diagnosed with bipolar disorder. My psychiatrist actually suspected cyclothymia when I first started seeing him in college, but I had already become an expert on bipolar, so I correctly dismissed the claim. If I were bipolar, how could I have tried various SSRIs for OCD/anxiety all throughout my late teens and never become manic?! I did try Lamictal for my moodiness, and it didn't really do much. But I tried it because my moods ARE intense and disruptive, but they still aren't indicative of bipolar moods. It wasn't until I learned about AS that I figured out that my moodiness and sudden outbursts of anger are always, always, always connected to being interrupted during a special interest, being exposed to a sensory issue, and/or having to suddenly change my routine. When the triggers aren't there, I'm fine. Bipolar moods are present no matter WHAT happens. A manic patient will still be euphoric if they hear their grandmother died. Similarly, a depressed patient will still be depressed if they win the lottery. There is no mood connection to environmental triggers.

The problem is that anger and rage in children are being pegged as early-onset bipolar disorder when there aren't ANY other manic symptoms present. While it is true that real early-onset bipolar disorder often is given a "bipolar-NOS" label due to kids having more rapid cycling and not fitting the time requirements in the DSM-IV, it is NOT true that these children with atypical manifestations are only showing anger as a symptom. Yes, you don't usually see classic "euphoric" mania in children, as mixed states usually are the norm, but so few of these "bipolar" kids have any symptom other than irritability and moodiness. They don't sleep less, have pressured speech, have hypersexuality, have increased productivity/goal-setting, etc. Anger is a very non-specific symptom. It can be present in a slew of neuropsych disorders, and it really angers me that these children are being given the label of a very serious and severe condition because doctors don't want to take the time to tease out what's really going on.

I do think that, in the case of childhood bipolar disorder, overdiagnosis is being fueled by drug companies, and that really angers me. It helps keep people anti-medication, just because doctors are giving it out when not needed. And that hurts those of us who DO need psychiatric medication. But the reason I'm thinking this is a drug company thing is WHAT medications kids are being prescribed. The "gold standard" for mania still is and always will be lithium. How many kids do you see being given lithium first nowadays? Yes, some people don't respond to lithium, but the next step should be the anti-epileptic mood stabilizers (Depakote, Tegretol, Lamictal, etc.). The atypical anti-psychotics may work for a small subset as management and are needed during acute psychotic mania hospitalizations, but they are NOT mood stabilizers! And the atypicals are being handed out like candy nowadays. They are serious medications, and they should only be used for severe, treatment-resistant bipolar disorder, schizophrenia, schizoaffective disorder, and cases of depression or OCD that are highly treatment-resistant.

And as far as the bipolar spectrum getting out of control, there are some out there who propose making "bipolar II-1/2" and "bipolar 1/2" and all of these other ridiculous subsets that aren't even seen in the clinical population. Mood disorders as a BASIC spectrum works beautifully. But the "basic" spectrum is lengthy, already: bipolar-I (euphoric mania, irritable mania, or mixed episodes, with or without psychotic features that are mood congruent or mood incongruent), bipolar-II (hypomania only), cyclothymia (hypomania and dysphoria only), unipolar depression (with or without psychotic features that are mood congruent or incongruent), schizoaffective disorder (bipolar type, depressed type, or schizophrenic type), and atypical/NOS bipolar. And that's not even including early-onset, rapid cycling, people who have only been depressed but have the genes to become manic in the future or on antidepressants, and children who look like they have ADHD but are really bipolar and become manic on stimulants. Do we really need to make a spectrum category for all of these MANY stipulations and variations? The bipolar part of the spectrum should be kept simple for diagnostic purposes, with just bipolar-I (manic or mixed), bipolar-II, and cyclothymia. (We should examine the different subsets of symptom types in research but not clutter the diagnostic criteria with every possible manifestation.) Even the NOS category is ridiculous. If a kid is clearly manic for THREE days, not FOUR, he shouldn't be counted as being bipolar-I? And if a kid is moody but has no other bipolar symptoms, he should be called "atypical bipolar"?

Anyway, that's my rant for the day.