With the Americans Reclassifying Asperger's......

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MirrorWars
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28 May 2013, 12:31 pm

Are there any other countries planning something similar?

Or is it just the U.S.?



Thelibrarian
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28 May 2013, 1:15 pm

First off, it's not the Americans who are attempting to abolish the standard taxonomy for AS; it is the American Psychiatric Association's doing. I'm an American and don't approve of the APA's actions at all.

Having said this, the reason the APA has so much influence is that they produce the DSM. My understanding is that the DSM is influential because it is used by insurance companies in the US, and by governments in countries where socialized medicine is the standard.

There is reason to take heart though. I have read that the APA is meeting with a lot of resistance over the new DSM V. Consequently, I wouldn't be surprised if the DSM V were rendered more acceptable.



redrobin62
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28 May 2013, 4:09 pm

There are currently two widely established systems for classifying mental disorders—Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders.

Some 25 countries use ICD-10 for reimbursement and resource allocation in their health system. ICD has been translated into 42 languages.

From ICD-10
F84.5 Asperger's syndrome
A disorder of uncertain nosological validity, characterized by the same kind of qualitative abnormalities of reciprocal social interaction that typify autism, together with a restricted, stereotyped, repetitive repertoire of interests and activities.

It would seem that only DSM-V is eliminating the Asperger's term. Internationally, the term remains.

It should be noted that there is a bill in the U.S. Senate to prevent the implementation of ICD-10 in the U.S.

http://www.icd10watch.com/blog/effort-s ... -us-senate



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28 May 2013, 4:51 pm

I really don't get why this is a big deal at all. It makes no sense to separate out AS from autism, there's piles of research showing there's no clear dividing line.

For someone who actually reads psychiatric literature, I see very little to complain about in the DSM-V, and quite a lot to be happy about. Including many of the things other people are freaking out about.

Seriously, if you're going to criticize the DSM, you should make sure you actually know what you're talking about. Psychology is a specialized field. There is a large body of research behind each and every one of the DSM's changes, as you can tell if you read their rationale for the changes.



Liane
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28 May 2013, 8:06 pm

We have all known for a long time that the Dsm should not be taken absolutely literally. No practitioner worth their salt does not read between the lines.



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28 May 2013, 8:22 pm

redrobin62 wrote:
It should be noted that there is a bill in the U.S. Senate to prevent the implementation of ICD-10 in the U.S.

http://www.icd10watch.com/blog/effort-s ... -us-senate


There is also a bill in New York State to reject using DSM-V as a standard in court or for insurance purporses. It has roughly the same (non-existant) chances as the US Senate bill referenced above.


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28 May 2013, 8:27 pm

The coming ICD-11 is a mess regarding Asperger's. I wouldn't want that. It doesn't even list the repetitive behaviors, which are just as important as the lack of social reciprocity.

If you're unhappy with the DSM-V, you could technically request Gillberg's Criteria for AS; it's close to Hans' paper for the most part, and experts do use it (Attwood does, for example).



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29 May 2013, 12:17 am

Ettina wrote:
I really don't get why this is a big deal at all. It makes no sense to separate out AS from autism, there's piles of research showing there's no clear dividing line...


Actually, they aren't separating Asperger's from autism. They're getting rid of the term "Asperger's Syndrome" and saying most cases are autism while some may be something else.

Right. All the signs of high functioning autism except for language delay/loss, and some aren't autistic.

Right.

Only a week or two ago wasn't there a defiant cry from the American medical community to abandon that whole DSM system anyway?


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29 May 2013, 3:51 am

http://www.apa.org/monitor/2009/10/icd-dsm.aspx

Quote:
What is the difference between the ICD and DSM?

The ICD is a core function of the World Health Organization, spelled out in its constitution and ratified by all 193 WHO member countries. The ICD has existed for more than a century, and became WHO's responsibility when it was founded in 1948 as an agency of the United Nations. Before 1980, psychiatric diagnostic systems reflected the dominant psychoanalytic ideas of the time, emphasizing the role of experience, downplaying biology.

"The American Psychiatric Association can really be credited with a revolution in psychiatric nosology with the publication of DSM-III by introducing a descriptive nosological system based on co-occurring clusters of symptoms," said WHO psychologist Geoffrey Reed, PhD.

There was very little international participation in the DSM-III, but at the time it may have been impossible to make such a big shift at the international level, he explained. As a result, DSM-III and ICD-8 (the version in effect at the time) were quite different from one another but as the descriptive phenomenological approach to diagnose mental disorders became dominant, the DSM and ICD have become very similar, partly because of collaborative agreements between the two organizations.

Still, there is widespread sentiment that it is not helpful to the field to have two separate classification systems for mental disorders. Many important distinctions between the two systems remain, Reed said:
The ICD is produced by a global health agency with a constitutional public health mission, while the DSM is produced by a single national professional association.
WHO's primary focus for the mental and behavioral disorders classification is to help countries to reduce the disease burden of mental disorders. ICD's development is global, multidisciplinary and multilingual; the primary constituency of the DSM is U.S. psychiatrists.

The ICD is approved by the World Health Assembly, composed of the health ministers of all 193 WHO member countries; the DSM is approved by the assembly of the American Psychiatric Association, a group much like APA's Council of Representatives.

The ICD is distributed as broadly as possible at a very low cost, with substantial discounts to low-income countries, and available free on the Internet; the DSM generates a very substantial portion of the American Psychiatric Association's revenue, not only from sales of the book itself, but also from related products and copyright permissions for books and scientific articles.

Will the DSM be superseded by the ICD? There is little justification for maintaining the DSM as a separate diagnostic system from the ICD in the long run, particularly given the U.S. government's substantial engagement with WHO in the area of classification systems. But, said Reed, "there would still be a role for the DSM, because it contains a lot of additional information that will never be part of the ICD. In the future, it may be viewed as an important textbook of psychiatric diagnosis rather than as the diagnostic 'Bible.'"


What the National Institute of Mental Health thinks of the DSM5 approach: http://www.nimh.nih.gov/about/director/ ... osis.shtml (for me it was like a breath of fresh air reading what they said).

For the UK:

http://www.autism.org.uk/About-autism/A ... teria.aspx

What does the NAS think of the DSM changes?

Quote:
The new diagnostic criteria
The NAS welcomes the overall proposed approach to streamline diagnostic criteria and make them simpler, to develop dimensional measures of severity and recognise the range of full health problems someone is experiencing, as well as any other factors that impact on their diagnosis.

Severity levels
However, we do believe that the proposed severity levels are not fit for purpose and potentially very unhelpful as they are currently drafted, for the following reasons:

There would need to be much more detail to make the severity levels appropriate and widely applicable.

The levels are not consistent with the diagnostic criteria. Diagnostic criterion D states that “Symptoms together limit and impair everyday functioning” – in other words the impairment is the result of all the different symptoms of autism interacting. Therefore it is not appropriate to break down severity levels into the two separate domains.

Key areas, including sensory aspects, are not mentioned within the severity levels.

The minimum criteria for level 1 severity “Needs support” are considerably higher than the minimum criteria for a diagnosis. This is particularly worrying as, in the UK, many people with autism struggle to have their needs recognised by services and get the support they need, particularly where their needs are less obvious.

The linking of a clinical diagnosis to recommendations of support may create expectations for people on the autism spectrum that services will be provided when this will not always be the case (at least in the UK), due to high eligibility thresholds or because decisions about such support may be taken by professionals who have no relation to the diagnostic process.

Creating a direct link between a clinical decision over diagnosis and a recommendation for support could affect clinical impartiality. In the UK we are aware of situations where clinical professionals have felt under pressure from their employers to under-assess needs in order to ration limited resources.

We believe that the complexity of the presentation of autism spectrum disorders requires that the severity of impairment can only be assessed on an individual basis. It must not be linked to such a simplistic recommendation for support.

How will this affect diagnosis in the UK?

DSM is an American publication. Most diagnoses in the UK are based on the International Classification of Diseases (ICD), published by the World Health organisation, or other criteria, such as those developed by Professor Christopher Gillberg.

The current ICD (ICD-10) is virtually the same as DSM. The next version of the International Classification of Diseases (ICD-11) is due to be published in 2015. They will consider the changes made to DSM-5, but their descriptions are often slightly different. For example, the diagnostic names in ICD-10 are different to those in DSM-4.

At present we are not aware of any plans to change the label of Asperger syndrome during the next revision. View the very early proposals for ICD-11.


Proposed ICD11 Draft: http://apps.who.int/classifications/icd ... f523143960


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29 May 2013, 4:04 am

MirrorWars wrote:
Are there any other countries planning something similar?

Or is it just the U.S.?


Professional opinion has reached a consensus - AS and autism, along with PDD-NOS and some other conditions have the same root causes and the distinctions between them are subjective and not clinically maintainable. There will be one diagnosis but it will be one that covers all the myriad presentations the spectrum throws up.

Consequently the DSM is only the first publication to drop the notion that AS is different from autism. The others will follow suit because it makes sense in clinical terms.

If you read the literature properly you will realise that actually we are not just losing AS but we are losing autism too - all conditions will be autism spectrum disorders, not AS or autism.

It is highly likely that clinicians will continue to distinguish between the presentations for some time - the DSM gives severity of impact levels but professionals will probably use an informal presentation type, so a diagnosis may be something like ASD (AS-type presentation) or ASD (autism-type presentation) but eventually those will be dropped too as professionals move away from the specific diagnosis of AS or autism and become more familiar with the ASD form of diagnosis. Professionals in the UK have been doing this for some time - when my son was diagnosed over 10 years ago he was given ASD - he fits the criteria for AS only because he could talk before he was 1 and the clinician wanted to give an autism diagnosis but couldn't. Then, this was almost unheard of - you usually got one or the other - but now many clinicians use the ASD term, and were doing so even before the DSM revisions were in the pipeline.



whirlingmind
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29 May 2013, 4:30 am

...but if you read this:

whirlingmind wrote:
What the National Institute of Mental Health thinks of the DSM5 approach: http://www.nimh.nih.gov/about/director/ ... osis.shtml (for me it was like a breath of fresh air reading what they said).


...you will see that this is a far more sensible way to go than mere subjective opinion. I applaud the NIMH as it's far closer to how things should be.


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29 May 2013, 4:36 am

whirlingmind wrote:
...but if you read this:

whirlingmind wrote:
What the National Institute of Mental Health thinks of the DSM5 approach: http://www.nimh.nih.gov/about/director/ ... osis.shtml (for me it was like a breath of fresh air reading what they said).


...you will see that this is a far more sensible way to go than mere subjective opinion. I applaud the NIMH as it's far closer to how things should be.


Don't read too much into it. They're not saying "Dump the DSM model right now." They're saying that they're supporting research that is not based on DSM categories and diagnoses. Any likely changes to clinical practice due to the possible shift in research are probably at least a few years away, if not longer.



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29 May 2013, 4:52 am

As I understand it, they are saying that a diagnosis should incorporate a cross-disciplinary process. Yes, the psychiatric/psychological evaluation plays a part, but so should (as science becomes more able) include genetic, medical and any other relevant area. That way the person can be treated more individually.


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zemanski
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29 May 2013, 8:12 am

As always there is a huge gap between what we know would be best practice and where we are right now.

Until we have a more reliable method of diagnosing ASCs - a blood test, a DNA screening... - then we have to make do with the clinical psychology methods. They may not be perfect but they are moving away from the subjective, qualitative approach into a more objective approach based on the findings of research over the last couple of decades.

It is even less likely that a medical screening test will differentiate between AS and autism - we already know that the same clusters of genes are involved in both presentations, we just haven't pinpointed the common factors for all people on the spectrum yet.

The DSM has taken one step but it is not the final one, NIMH is moving forward into finding the next step - let's hope it isn't another 20 years till it gets there.



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29 May 2013, 2:36 pm

Quote:
Actually, they aren't separating Asperger's from autism. They're getting rid of the term "Asperger's Syndrome" and saying most cases are autism while some may be something else.

Right. All the signs of high functioning autism except for language delay/loss, and some aren't autistic.

Right.


If you have all the signs of HFA except language delay, you will meet DSM-V criteria for autism. I mean, even I meet those criteria, and I wasn't severe enough for DSM-IV Asperger's Syndrome.



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29 May 2013, 3:03 pm

redrobin62 wrote:
Some 25 countries use ICD-10 for reimbursement and resource allocation in their health system. ICD has been translated into 42 languages.

From ICD-10
F84.5 Asperger's syndrome
A disorder of uncertain nosological validity, characterized by the same kind of qualitative abnormalities of reciprocal social interaction that typify autism, together with a restricted, stereotyped, repetitive repertoire of interests and activities.

It would seem that only DSM-V is eliminating the Asperger's term. Internationally, the term remains.


It seems AS will soon be eliminated in the ICD too. Right now, the ICD-11 is in development and its current draft turns Asperger's Syndrome into "social reciprocity disorder".

So far, it's description hints at that the "new" disorder is characterised by a purely social impairment (an impairment of social reciprocity) unlike the current diagnosis of Asperger's.


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