A panel recently convened to discuss proposed changes to the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to be released in May 2013. They confirmed the changes to the diagnosis of autism spectrum disorders (ASD), while dropping two diagnoses that they concluded were not supported by evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.
Under the current DSM, delays in the domains of socialization, communication and play must be observed prior to age 3. If delays are observed later in life, the diagnosis of autism does not apply. The new DSM would eliminate this age restriction, and state rather that the symptoms must have been observed in early childhood, the rationale being that such delays may not be noticed until later in life because of the relatively low social demands placed on young children.
Another change which has sparked its share of controversy is the streamlining of the diagnostic labels. As it currently stands, there are separate diagnoses of autism spectrum disorder, Asperger's syndrome, childhood integrative disorder and pervasive developmental disorder not otherwise specified, or PDD-NOS, each with their own specified diagnositc criteria. The new DSM will combine all of these diagnoses into one "autism spectrum disorder," with one set of diagnostic criteria, as well as severity ratings in the domains of socialization, restricted interests and stereotypy, or repetitive behaviors.
The rationale behind this change is evidenced in a study of the rate of diagnoses at 11 different clinics, where there was high variability in the rates of Asperger's and PDD-NOS diagnoses, while the diagnosis of autism spectrum disorder was more consistent. In addition, the symptoms of each of the four diagnoses are extremely similar, with variations in the severity and significance of each symptom. PDD-NOS predominantly refers to delays in socialization, and the "not otherwise specified" moniker is not altogether clinically significant.
While some parents and educators are worried that the new criteria would exclude some, the panel asserted that the DSM-V criteria are more sensitive than those in the DSM-IV, as they integrate gestures and verbal communication into the criteria. The domain of social behavior has also been altered from "failure to develop peer relationships and abnormal social play" in the DSM-IV to "difficulties adjusting behavior to suit different social contexts" in the DSM-V. The scientists noted that this change is specific to ASD and would filter out those who have a diagnosis of ADHD, who may also have some social deficits.
A study which sought to test the diagnostic rate with the new criteria found that out of approximately 300 children in the trial, the diagnostic rate of autism spectrum disorder did not change significantly. At one test site, it increased from 23% to 25% and at another it decreased from 26% to 20%.
The main purpose of these changes, as maintained by the panel, was to include all individuals with ASD but with specific criteria that would delineate those with a true disorder and those who are "self-diagnosed." The panel emphasized that people who currently receive services for diagnoses such as Asperger's syndrome would continue to be eligible for services.
While there was cause for alarm when news first came out at the possible exclusion of some who are currently diagnosed on the autism spectrum, the panel's clarifications of the changes that would take effect are encouraging, as they point to more inclusionary and transparent criteria, rather than exclusionary.
The public has the chance to comment on these changes until June 15th on the DSM-V website, before it is finalized in December for release next year.
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