DSM IV vs DSM 5 - A Diagnostic Comparison

Post Reply New Topic

This will be a very long, detailed and thorough post (2000+ words) and you may not have the time to read it all, but with an issue as important as this I think it is important to be thorough. I welcome any criticism, but I do ask that you don't merely skim read and criticise single sentences out of context. If you don’t have time to read it I would honestly prefer it if you didn’t reply.

There is a fair bit of controversy about the proposed changes to autism diagnoses in the upcoming DSM 5, with many people claiming that the consolidation of Autistic Disorder and Asperger's Disorder (and PDD-NOS) into a single diagnosis - Autistic Spectrum Disorder will result in people losing their diagnosis altogether and losing access to badly needed services, but by comparing the three diagnoses we can see that this is not necessarily the case.

First of all, let's compare the two existing diagnoses - Autistic Disorder (AUT) and Asperger's Disorder (ASP). Here is a site with each diagnosis listed.You may find it easier to print these pages out so you can look at them side by side, instead of scrolling up and down. Or you could copy them into some word documents and have them side by side on your monitor like I did, whichever you find easiest.

https://www.firstsigns.org/screening/DSM4.htm

Straight away we can see many similarities, much of the text is identical even. It can get confusing though, as each list uses different numbers/letters to refer to the same things. AUT has section (1) which corresponds word for word with section A. in ASP. Both diagnoses require 2 of the 4 subsections (a-d in AUT, 1-4 in ASP). Section (3) in AUT also corresponds word for word with Section B. in ASP. Both require only 1 of the 4 subsections.

Section (2) in AUT however does not have an exact match in ASP, and this is where the key difference lies. Section (2) in AUT describes language difficulties, whether it be a complete lack of language or an idiosyncratic use of it, and also includes impairment in conversational skills and social play. Only one of these subsections is needed. We can contrast this with section D. in ASP, which states that there is no language delay in ASP, but let's keep in mind that only one of the (2) (a)-(d) in AUT is needed. From the criteria here, it would be technically possible for a patient to have developed excellent language skills on time, but satisfy (2)(d) in AUT and qualify for a diagnosis of Autistic Disorder.

Although AUT requires 2 symptoms from section (1), one from (2) and one from (3) it also requires two additional symptoms from either sections. That makes a total of 6 symptoms, twice as many as the 3 symptoms required in ASP.

Now onto the last few sections. I see section C. in AUT and Section F. in ASP as roughly comparable: both are saying that a different diagnosis isn't a better fit. Section B. in AUT describes symptoms very similar to those already covered in section A., but with the addition of 'with onset prior to age 3 years'. Section E. in ASP describes NO clinically significant delay in various areas that are often seen in Autistic Disorder (self help skills etc.), but are not part of the official diagnosis; nowhere in AUT does it say that the patient MUST have a delay in one or more of these areas.

From this we can see the difference in the official DSM-IV diagnoses of AUT and ASP. The key difference is that AUT requires more symptoms, and includes many symptoms relating to language difficulty (although they are not necessary, if you have enough of the other symptoms you can bypass these) while ASP requires no delay in language development. This means that if your language developed on time you could conceivably fit AUT or ASP, but if it was delayed then you cannot fit ASP. Also, AUT requires difficulty in social interaction, language or imaginative play to have begun before the age of three, while ASP actually does not explicitly require ANY difficulties in childhood.

How accurate is this? Many people who identify as Aspies and are even diagnosed as such DID in fact have a language delay, and while it seems possible for someone with no delay in language skills to receive an Autistic Disorder diagnosis, in practice these people are usually given a diagnosis of Asperger's Disorder. Also, while ASP makes no mention of delays in childhood, in practice childhood difficulties are very important in making a diagnosis. It is easy to see that in borderline cases it may be difficult to decide whether a patient has ASP or AUT, or even what difference it would make to treatment. This is one of the reasons for the new spectrum diagnosis


Now for the good part, let's look at the proposed DSM 5 criteria for Autistic Spectrum Disorder (ASD):

http://www.dsm5.org/ProposedRevisions/P ... spx?rid=94

Many people seem concerned that some people with ASP diagnoses will not fit into the new ASD criteria. As we are now familiar with the differences between the ASP and AUT criteria, we can look at the ASD criteria and see for ourselves.

A.1. in ASD seems to cover the same ground as A.(3) and (4) in ASP. While ASP shows a lack of social/emotional reciprocity and a lack of sharing enjoyment/interests/achievements as separate criteria ASD describes a deficit (not a lack) in social/emotional reciprocity which shows as, among other things, reduced sharing of enjoyment etc. This seems to make sense, the lack of reciprocity is the underlying symptom which results in a lack of sharing. We should also note that the ASD criteria uses words like "deficit" and "reduced" while ASP/AUT uses the word "lack". Here at least, ASD seems to be MORE inclusive than ASP, not less.

A.2. in ASD corresponds with A.(1) in ASP, they both describe difficulties with nonverbal communication. The ASP/AUT criteria describe a "marked impairment" in the USE of nonverbal communication, while the ASD criteria describes a "deficit" in areas ranging from the use OR the understanding of nonverbal communication. The ASD criteria here may seem more specific, listing abnormalities in eye contact, a complete lack of facial expressions etc., but these are only possible manifestations of the core problem with nonverbal communication. It may be more detailed, but I don't see it as more specific. If anything, by listing a variety of possible manifestations it is at least as general and inclusive as the ASP/AUT criteria.

A.3. in ASD corresponds with A.(2) in ASP. Similarly to the above section, this is longer and more detailed, but all they are really doing is listing possible manifestations of the same underlying symptom - "deficits in developing and maintaining relationships". This seems to be equally inclusive in each criteria, although the choice of words; "deficits" in ASD as compared to "failure" in ASP suggests that ASD could, again, actually be more inclusive.

An important difference here is that ASD requires all three criteria to be satisfied, while ASP/AUT requires only two out of four. This certainly suggests that ASD could indeed be less inclusive.

B.1. in ASD is similar to B.(3) in ASP, but while the ASP criteria specifies that the mannerism must be physical (hand movements etc.) the ASD criteria accepts both physical and speech patterns, including things such as echolalia and idiosyncratic phrases. It also includes repetitive use of objects. This is far more inclusive in ASD than in ASP, which describes only those stereotypically autistic stims

B.2. in ASD seems to correspond to B.(2) in ASP, but it actually is far more general. While ASP here requires adherence to “specific, nonfunctional routines or rituals”, ASD allows adherence to verbal or non-verbal patterns of behaviour (they give the example of repetitive questioning, something very unlikely to be included in the ASP criteria), and even allow the very general “excessive resistance to change”, without the need for a specific routine. Many aspies like to carefully plan out their day in the morning or previous evening, and can get quite upset if circumstances disrupt their plan. This would satisfy the ASD criteria, but not the ASP criteria as the day’s plan could be very functional, and could be far from a routine (something repeated day after day). I see this criteria as being far more inclusive in ASD than in ASP

B.3. in ASD corresponds with B.(1) in ASP, and although they are worded differently they seem very similar in meaning. This is the 'special interest' criteria that is famous in many aspies. The ASD criteria does however mention that it could be a strong attachment to an unusual object rather than to a topic. While this is not explicitly ruled out in the ASP criteria, the implication is that they are referring to topics rather than objects. I see these two criteria as being roughly equally inclusive, with the ASD criteria perhaps being slightly more inclusive

B.4. in ASD does not have a similar criteria in ASP or AUT. This section refers to the sensory abnormalities that many people experience, whether it be hypersensitivity or hyposensitivity. While there is no similar criteria in ASP and it may therefore seem less inclusive than ASP, we should keep in mind that unlike the criteria in section A., this is not a necessary part of the diagnosis, and that some sensory abnormalities (whether or not they greatly impact day-to-day functioning) is a very commonly reported symptom and definitely warrants inclusion. In fact it begs the question as to why it wasn't included in the DSM-IV to begin with.

ASP/AUT also contains a curious additional criteria - B.(4) "persistent preoccupation with parts of objects". This isn't something that there is much literature on nowadays, and it seems that in the 18 years since the DSM IV was written this criteria has lost favour, hence it's removal from ASD

It is also very interesting to note that Section (2) in AUT which deals mostly with language difficulties is absent from ASD. This of course does not mean that if you have these language difficulties that you would not fit into ASD, it merely means that it is not a necessary feature. This not only makes ASD much more inclusive than AUT (as is to be expected), but means that, despite the fact that ASD is closer in name to AUT, the criteria is actually far closer to ASP.

An important difference here is that ASD requires two symptoms from Section B., while ASP requires only one from their similar but slightly different section B.

Section C. in ASD requires that symptoms be present in early childhood, but does mention that they may seem to get more serious and debilitating as "social demands exceed limited capacities". The symptoms must have been present in childhood, but need not have been serious enough to warrant attention, diagnosis and/or intervention. This is not something that is mentioned in the ASP criteria, and is therefore more exclusive, but I find it hard to believe that there are many people with ASP diagnoses out there that had zero symptoms in early childhood and would lose their diagnosis because of this. It is generally agreed, especially among aspies themselves, that ASP is a biological and neurological difference that is present from birth, and I haven't yet heard from an aspie claiming to have been a perfectly normal NT as a child.

Section D. in ASD is equivalent to Section C. in ASP. The choice of words - "limit and impair" in ASD and "clinically significant impairment" in ASP could suggest that ASD is more inclusive in this respect, as it does not explicitly say that the impairment need be “clinically significant”, although seeing as this is in a diagnostic criteria for mental illness that could be implied. So depending on your interpretation the ASD criteria here is either more inclusive or equally inclusive.

While each seperate criteria in ASD seems to be either equally or (more commonly) more inclusive than those in ASP, there is the undeniable fact that ASD requires more of these criteria to be satisfied than ASP. These can balance each other somewhat. ASD does not require that all 5 needed symptoms (3 from A. and 2 from B.) need be severe enough to cause daily impairment, or even any impairment, as long as when taken together they do. For example take B.4., dealing with sensory (in)sensitivities. It is easy to see that it is possible to have these sensitivities without it impacting your life that greatly. I, for example, have a very weak sense of smell, almost non-existent, but this does not affect my life much at all, certainly not to the level of “clinically significant impairment”. It is therefore my opinion that the vast majority of aspies would have little trouble fitting the diagnosis of ASD.

It's also good to keep in mind that removing the diagnosis Asperger's Disorder from the DSM 5 is not banning the term altogether. Aspies will certainly continue to use the term to describe themselves and professionals will also likely use the term to help differentiate people from different parts of the spectrum, even if it is only informally.