"Two Fatal Technical Flaws In The DSM5 Definition of Au

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TPE2
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30 May 2013, 11:59 am

Allen Frances:

http://www.psychologytoday.com/blog/sav ... ion-autism

Quote:
A poorly written DSM criteria set is useless. The essential prerequisite to an accurate diagnosis is that different clinicians can agree on whether it is present or absent in a given individual. If the definition lacks precision, different people will interpret it in their own different and idiosyncratic ways.

The DSM 5 definition of Autistic Spectrum Disorder has two fatal technical flaws that make it impossible to interpret and use reliably.

A truncated version of its Criterion A reads as follows:

"A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following....

1. Deficits in social-emotional reciprocity

2. Deficits in nonverbal communicative behaviors used for social interaction

3. Deficits in developing, maintaining, and understanding relationships."

The DSM 5 examples offered for each of these three items are vague enough to overlap into normality, but I wouldn't have made a big fuss about this.

The really fatal flaw here is that no instructions are given as to whether 1 item, 2 items, or all 3 items must be present to make the diagnosis of Autistic Spectrum Disorder. The diagnosis will vary dramatically from rater to rater, institution to institution, and place to place depending on which of these three different possible convention is chosen. It will be even more impossible than it is now to determine rates of autism and why they shift so much over time.

The second fatal flaw is comes in the following statement attached to the end of the criteria set for Autistic Spectrum Disorder:

"Note: 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. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social communication disorder. "

This throws wide open to raters the choice of using DSM IV criteria or DSM 5 criteria depending on their personal preferences.

DSM 5 has essentially made it clinician's choice how to define and diagnose Autistic Spectrum Disorder. Some will require 1 item from criterion A; others 2; yet others 3; and some will chuck DSM 5 altogether and use the very different definitions that are contained in DSM IV


I had the impression that the DSM-5 will require to have all the 3 social criteria for a diagnosis. Or that was changed from the final version?



redrobin62
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30 May 2013, 12:07 pm

Here is what I've been reading.

Proposed DSM-V criteria for autism spectrum disorders.

An individual must meet criteria A, B, C and D:

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



daydreamer84
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30 May 2013, 12:15 pm

redrobin62 wrote:
Here is what I've been reading.

Proposed DSM-V criteria for autism spectrum disorders.

An individual must meet criteria A, B, C and D:

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


That's what I've seen too. I haven't been able to find final DSM criteria by google though, only "Proposed Criteria".



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30 May 2013, 12:20 pm

The proposed criteria certainly made it clear that all three points in criteria A must be met, but perhaps the final version left this part out, probably an oversight/typo.



redrobin62
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30 May 2013, 12:30 pm

I've been on the internet looking for the actual printout from the DSM-5 regarding autism but haven't located it. The actual book sells for $185 and is 940 pages long so I guess it'll be a while before it shows up on the internet. Interestingly, the ICD-10 Bluebook is available as a free PDF.

The link I've created below is the closet to what I've seen will be on DSM-5 regarding Autism. It says:

This month, the American Psychiatric Association will publish the latest edition of its Diagnostic and Statistical Manual – the DSM-5. The manual contains significant changes to the diagnostic criteria for individuals with autism.

As you'll see, the criteria in the link is the same as the criteria we've all been reading.

http://www.ageofautism.com/2013/05/safe ... -2013.html



Ettina
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30 May 2013, 12:36 pm

Quote:
"Note: 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. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social communication disorder. "

This throws wide open to raters the choice of using DSM IV criteria or DSM 5 criteria depending on their personal preferences.


No, it doesn't. All it means is that everyone who was diagnosed before the DSM 5 retains their diagnosis. Once DSM 5 is out, it will no longer be accepted to issue new DSM-IV diagnoses.



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30 May 2013, 12:39 pm

Of all of the issues I've seen raised about DSM-5, these seem rather weak.

Of course, when the author is also the author of DSM-IV, it does make some sense. Perhaps he's suggesting that they really did'nt change it at all.


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30 May 2013, 12:59 pm

Here they are I found them on YouTube :$ yes it s a long video http://youtu.be/ILiX9gGd0Ik


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30 May 2013, 1:08 pm

Thanks for posting the video, ASdogGeek. Around the 16 minute mark you'll see that the criteria is just what is commonly known - all 3 of Criterion A must be met.



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30 May 2013, 2:18 pm

They are trying to define gold?



btbnnyr
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30 May 2013, 2:53 pm

The first flaw is dumdum, cuz criteria have said all 3 required, but maybe error that needs correction ASAP.

The second flaw indicates that the flaw pointer outer has reading comprehension problems.


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redrobin62
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30 May 2013, 3:07 pm

What is utterly surprising is the writer of the article is not only a doctor but the chair of the DSM-IV committee as well! Maybe he wasn't asked to consult with the DSM-5 crew so he's angry? Very strange.



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30 May 2013, 3:23 pm

redrobin62 wrote:
What is utterly surprising is the writer of the article is not only a doctor but the chair of the DSM-IV committee as well! Maybe he wasn't asked to consult with the DSM-5 crew so he's angry? Very strange.


He was one of the first to launch the public attacks on DSM-5, take that for what you will. That said, he has pointed out issues with the process, it's just that the two he mention above really arn't issues.


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30 May 2013, 7:09 pm

btbnnyr wrote:
The first flaw is dumdum, cuz criteria have said all 3 required, but maybe error that needs correction ASAP.

The second flaw indicates that the flaw pointer outer has reading comprehension problems.


:lol: true



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30 May 2013, 7:17 pm

Quote:
... across multiple contexts, as manifested by the following....


That means all of them.



btbnnyr
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31 May 2013, 3:47 am

I am wondering, does this Allen Frances have any awareness of how stupid his objections are, esp. #2? If he did, then I would think that he wouldn't publish them, but maybe he is blinded by anger caused by changes to his DSM-IV. See how much awesome ToM I applied in this post.


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