DSM-V Contradiction

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The problem here is that the meaning of the word "limit" in this context is not clear. What you just stated above is an assumption about what it might mean.

Also, if you can't complete a test on time, your scores are detrimentally impacted.



"hard to establish" doesn't mean "prohibitively difficult." also, they are specifically saying that early language details are hard to establish in retrospect. A history has somewhat more information than when you started speaking or how, and those other details may cover a time period much longer than any delay in speech development, and thus be easier to establish.

A "diagnosis" isn't a jury trial. They don't have to prove anything... just plausibly establish that the symptoms emerged in childhood, and didn't just spontaneously appear at some point during adulthood. The whole point is to draw a line between "people who've always exhibited the traits associated with ASD" and "people who haven't".

As for the number of individuals diagnosed with ASD, here's something to consider. Apparently, the entire category of Schizoid Personality Disorder is being eliminated as well, and anybody who falls into it will have to be reassigned to either ASD or Schizotypal Personality Disorder. AFAIK, the majority of individuals with Schizoid PD will end up as ASD, because they don't have "odd thinking" (the main thing that distinguishes schizotypal from schizoid).

My prediction: the DSM committee will end up compromising. It will declare that Autism is a single spectrum, with "Asperger Subtype" as its high end, and "Socioavoidant Personality Dynamic" as the subset of "Asperger Subtype" that exhibits little to no interest in social interaction or interpersonal relationships and has specific problems because of it.

From that point, it's a simple matter to add verbiage grandfathering in everyone with an existing DSM-IV diagnosis.

* AS, HFA, and PDD-NOS are automatically ASD, and specifically AS(-ASD) as long as they can effectively communicate by some means.

* DSM-IV Schizoid PD is automatically SPD(-AS-ASD) unless some other DSM-5 diagnosis ends up being more appropriate. If the patient is asocial, but isn't bothered by it or has no desire to change, the diagnosis changes to AS(-ASD).

Problem solved.

* Aspies get to keep our nickname & avoid getting indiscriminately lumped in with individuals who can't communicate normally via some means.

* SPD gets its stigma erased by severing its misleading association with schizophrenia & gets reclassified as a subset of AS.

* Both acronyms are preserved & refer to more or less the same people they do now, minimizing future confusion going forward.

* Nobody with a current diagnosis gets dumped on the curb, and if large numbers of individuals are identified who don't qualify for DSM-5 diagnosis, but are practically-indistinguishable from those grandfathered under DSM-IV diagnoses, the DSM-5 can be quickly amended to expand the new definition as necessary.

Epic win, and everyone gets to go home satisfied.

Last edited by dr01dguy on 26 Jan 2012, 12:50 am, edited 1 time in total.

I have thought of something. You know how schizophrenia and autism used to be the same thing and a spectrum, then in 1980, they made it separate. Then bam there were people who were no longer considered a schizophrenic. They were both separate. Now they just had autism. I think it's happening again. They have decided to re define it and they might make Asperger's it's own condition. Technically they have, it's called Social Communication Disorder. So what if they were to change the autism spectrum and bam lot of us don't have autism anymore and we now have SCD. What if they were to decide how SCD and autism have similar issues and similar characteristics? So that would mean nothing had really changed about us. Only the label has. Look at Schizophrenics and autistics, did anything change about them when they re defined autism in 1980? Did any of them lose the help they got or the treatment or the medicine? This change would just take us a while to get used to.

Last edited by League_Girl on 26 Jan 2012, 5:16 am, edited 2 times in total.

http://www.medscape.com/viewarticle/757515

This link above is a full version of a representative of the neurodevelopmental work group's response to the article about the research in the "New York Times":

The worst case scenario that he is talking about, but not specifying, is that since 2 measures of restrictive repetitive behaviors and interests (RRBI's) will now be required, this could eventually potentially change the diagnosis for those with PDD NOS, for those re-assessed in the future, that currently don't have any clinically significant problems with RRBI's.

Those individuals currently diagnosed without any clinically significant problems with RRBI's, do have significant problems with social interaction/communication, so they likely would be moved to the new Social Communication Disorder. It appears that he is suggesting they would still receive services under that new diagnosis and label.

Note, that he says: "field testing has not indicated that there will be any change in the number of patients receiving care for autism spectrum disorders in treatment centers — just more accurate diagnoses that can lead to more focused treatment"

He's dodging the issue carefully here, in suggesting there will not be any change in the number of patients receiving care for ASD's, but he has already suggested that a new label will emerge for some, and they would still be able to get the treatment they need.

It's really not likely that the folks with PDD NOS that currently have significant clinical impairments in social interaction/communication will lose access to treatment simply because they are moved over to a different diagnosis and label.

The patients needs won't change, just the diagnosis, however if it is clear they don't have problems with RRBI's, their treatment program can be tailored for the problems they do have, which is likely already the case.

I don't think there is any getting around the likelyhood though, that, some folks with PDD NOS, without RRBI's will eventually be moved over to the new Social Communication Disorder. That's a pretty cut and dry issue; RRBI's are a mandatory requirement in the current revision.

And, although they will likely never admit it, it is probably one of the main reasons they are adding "Social Communication Disorder", to the DSMV.

PDD NOS is the largest category, currently of Autism Spectrum disorders, and while Aspergers wasn't part of the data from 1993, in the research reported in the "New York Times", the criteria for PDD NOS was identical to the current criteria.

The New York Times article doesn't indicate that the 85 percent of folks with PDD NOS, that they suggest will lose that diagnosis, likely, largely because of a lack of clinical impairments with RRBI's, will likely be moved over to the new Social Communication Disorder, and may still receive services under that potential new diagnosis and label.

He addresses some other issues that have been raised in this thread regarding diagnoses for adults and adolescents. He actually suggests that the window is open for more diagnoses rather than less diagnoses in this area.



So it appears like neither the New York Times article or this report from Dr. King, are completely forthcoming, in including specific information, regarding the eventual potential move of many existing individuals with PDD NOS, lacking clinical impairments in RRBI's, over to the new Social Communication Disorder.

It appears that they haven't received too may complaints about it, up until now; this specific issue regarding PDD NOS and RRBI's, wasn't even brought up on this website until recently. There likely are many parents that have no idea that the criteria is even potentially changing.

Perhaps we will see some type of specific response to this on the official DSMV website, once this third round of public comments is completed.

I guess they have been in somewhat of a catch 22 situation up until this point, because they can't really suggest that those folks with PDD NOS, without RRBI's, are specifically going to be moved into the social communication disorder, when at this point it is only proposed as a new diagnosis and disorder.

It bothers me though the way that Dr. King talks about it like a worst case scenario, when he likely understands exactly what the issue is.

Being labeled as "low functioning" does not mean "unable to effectively communicate normally by some or any means."

One thing though, is for those individuals currently diagnosed with Aspergers, they already meet the RRBI requirement, whereas RRBI's aren't part of the new proposed Social Communication Disorder. For those individuals that are higher functioning that meet the requirements for Aspergers, other than RRBI's, they have already likely been placed in PDD NOS and will potentially, eventually move over to SCD.

The current criteria associated with Aspergers better matches the criteria for the new Autism Spectrum Disorder, than the current criteria associated with PDD NOS. I think the DSMV committee has pretty much decided that they are going to make RRBI's a mandatory requirement for anyone to meet the future criteria for Autism Spectrum Disorder.

Here is another article that references another member of the DSMV working group that has actually addressed the issue in a research paper. This individual addresses the specific issue in their research paper.

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Still waiting to see it on the DSMV website, however at least this member of the DSMV working group publically acknowledges the full issue and the potential resolution of it.

However, if one notes in the comments in the paper, a lawyer responds and suggests that these individuals may lose their insurance coverage, that currently cover ABA treatments for Autism Spectrum Disorders.

This is likely a potential huge issue for some, that would probably take legislation of some kind to require insurance companies that currently cover ABA treatments for ASD's to cover ABA for those individuals moved over to SCD. Not sure it will be as much of an issue in the school system, my best guess is that those currently receiving specialized education, will continue to receive it, if they are moved to SCD.

Going to probably be harder to get the insurance companies to comply though, since many others will likely fall under that category of SCD's, including those identified as having pragmatic learning impairments.

Marcia

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I would hope that your ophthalmologist/ optometrist (optician is someone who makes and dispenses eyeglasses) would test your vision both with and without corrective lenses. The purpose of the examination with glasses would be to confirm that the proper optics have been prescribed enabling your eyes to function in the normal ~20/~20 range. If your vision impairment is unable to be corrected, I would agree that it constitutes a limit.

Based upon your examples and discussion, I am struggling to understand how you are differentiate the term "impair" from "limit". What do you see as the difference?

@aghogday.long time no see,good to see you again.i was afraid maybe you were kidnapped by asan militants for defending autism speaks to much

Verdandi-

I have presented the complete dictionary definition of the term "limit" and "impair" earlier in the thread. As the committee as chosen to deliberately add the additional term "limit" it must have a discrete meaning from the word "impair". I welcome you to present an alternative definition, interpretation of the limit and how it contrasts with the term "impair"


If a "reasonable accommodation" is made which is required by law, and additional time is allowed, the score will not be impacted. Thus I argue not limited.



When using the phrase "hard to establish" was in a section that dealt with why the current diagnostic criteria does not work in clinical practice. In the following section the committee states

).

I interpreted this to mean, that collectively the difficulty in applying the criteria prohibited a uniform application of the diagnostic standard. The purpose of the DSM after all is "to provide a common language and standard criteria for the classification of mental disorders"



I respectfully disagree. The DSM-V Symptoms are



These are heavily nuanced and context dependent behaviors. My position is that is retroactively possible to establish behaviors however it is atleast as difficult as the prior criteria and more subject to confirmation bias

Last edited by antimuda on 26 Jan 2012, 9:55 am, edited 1 time in total.

One point regarding RRBIs and PDD-NOS -- the DSM-5 criteria require a minimum of 2, but it doesn't require that each & every criterion debilitatingly impair & limit the individual... only that the minimum number exists, and they collectively impair & limit the individual. Are there really that many PDD-NOS individuals who can't come up with at least two plausible excuses of RRBIs to list, even trivial ones that would not, on their own, be that big of a deal? Hell, most NTs could probably come up with two examples if they looked hard enough. The RRBIs would only have to themselves be debilitating if they were the main reason for seeking a diagnosis.

Remember, it's the whole bundle that ultimately weighs in. Plenty of things are individually-tolerable, but become a problem when you dump all of them on somebody at once.

Also, I'd argue that the specific word limit implies "when unmedicated" by common understanding within a psych. context. Otherwise, 95% of depressed individuals would officially cease to be depressed after 3 days on Wellbutrin.

dr01dguy-

As I have stated repeatedly I am not a clinician and therefore can not comment on how the standard will be applied in practice beyond what the committee itself has said. However in regard to making a diagnosis the DSM says the process, "consists of selecting those disorders from the classification that best reflect the signs and symptoms that are exhibited by the individual being evaluated." And the overall purpose of the DSM is "to provide a common language and standard criteria for the classification of mental disorders"

According to the APA "...more accurate diagnoses ... lead to more focused treatment." (from the Medscape article posted by aghogday)

It is therefore my conclusion that without accurate diagnostic criteria, there can not be an effective diagnosis and therefore patients will not receive the most efficient and effective treatment. In doing so an accurate diagnosis can only be made with accurate data. Though I agree there is a difference between the terms "prove", "plausibly establish" and "best reflect" it does not effect the fact that retroactively creating a data set detrimentally impacts the accuracy of the data.

It is not quite the same thing. If the individual with a prosthetic grew a new leg, he/she would no longer be described as an amputee. I think a more valid comparison might be for example, someone with a hearing impairment who had surgery to correct the problem and was then able to hear. That person would no longer be eligible for services, and quite rightly. To my way of thinking, if you do not have a difficulty, for whatever reason, you do not need support. I would far rather see the limited public purse be directed to support the people who really need it.

dr01dguy

You have further proven my point. The term limit does not appear in the DSM definition of depression. If it did you would be completely right.

All the criteria are considered significant clinical impairments; none of them are considered trivial from a clinical perspective, for good reason. One cannot suddenly make them up or find an excuse for them, and easily fool a psychiatrist, once they have already been diagnosed without them.

None of the impairments, by themselves, necessarily significantly limits and/or impairs one in everyday functioning. The requirement there, is that together the criteria, limit and impair one in everyday functioning.

Currently, individuals with PDD NOS not observed as having RRBI's, only needed one example to meet the requirement; in the future they will need two examples.

Even if they currently have sensory integration problems, they will still need to meet a criteria, that they have already been diagnosed not to possess.

Currently PDD NOS is measured at about two-thirds of all diagnosed cases of ASD's. Even if conservative estimates of twenty-five percent of those individuals don't have RRBI's, that's about 17 percent of ASD's, potentially re-assessed, as SCD, at some point in time in the future.

From the year 1994 to 2000, only one requirement of the current triad of impairments was needed to be met for PDD NOS, because of an editorial mistake in the DSMIV, corrected in 2000.

Technically an individual that had no impairments with social interaction or communication could have been diagnosed with PDD NOS, only with impairments in RRBI's, because of that mistake.

The DSM is far from an infallible organization, in the past they have shown an extreme lack of quality control, for an editorial mistake like that to be missed for six years.

@aghogday.i have a question.i do think it is true that all aspies and pdd_nos types have repetitive behaviors and the neurilogical condition does affect the function in life.its just that with some people its more severe than others.i mean many people with AS think it doesnt affect there life but it does,they just cant admitt it.so where do you draw a line in the sand.

Aspergers, DSMIV:

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

ASD, DSMV:

"Symptoms together limit and impair everyday functioning."

Comparing the two statements, the second is more of a general statement that is inclusive of the first.

A disturbance that causes Clinically significant impairments in social, occupational, or other important area of functioning, would reasonably be considered a disturbance that limits and impairs one in everyday functioning.

And even RRBI's by themselves could limit and impair one easily in everyday life, if it prevented one from fulfilling priorities of functioning for everyday living. Same with limits and impairments in social interaction and communication, from a daily functioning perspective.

That seems to me to be a more inclusive criteria rather than a more restrictive one.