DSM IV - V (Another way to look at it)

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It's been debated before. It'll be debated again. Even after it's been adopted, whether the APA decides to adopt the proposed changes in DSM V, it'll be debated afterward no matter what they decide. There was a recent thread about this (again) that I commented on, and said that I had thought of a way to picture the changes with a logical model. I did, and was able to build a logic model with a program I have, that was really revealing, but I have no way of putting on a web page. Instead, I put together an image to graphically demonstrate it for anyone who is like me and has an easier time with images. The image itself doesn't really show you how it would all work in practice though. The model I built does, but since i can't share that, I tried to explain what I was seeing. It's not an easy explanation to follow if you just glance it over. I suggest reading each line, and referring to the image as a reference, and really thinking about it if you've never taken much time before looking at it.

I'm not coming down for or against this thing at this point. I see some problems with it, but I also see there may not be any problems with it. In the end, it seems to me the problem isn't with the DSM, but with how it may be interpreted and implemented. And that's already a problem.

The image below shows the correlation between criteria in DSM IV and V. (You may not agree with how I've mapped it, that's fine ~ that is where some of the debate lies ~ this is how I see it, not necessarily how it is.)

[img][800:646]http://www.safewebtrade.net/images/DSMIVandV_AS.jpg[/img]

A, in DSM IV has become 1 in V, but the phraseology has been changed to more closely match item C in DSM IV. Items A and C in DSM IV are basically the same as Item 1 in DSM V.

Sub items 1 – 4 in DSM IV have become items 1-3 in DSMV, with items 3 and 4 becoming a single item. I don't see a problem with that so much because items 3 and 4 in DSM IV are for all practical purposes, IMHO, the same thing. “Social reciprocity” pretty much encompasses both.

Sub items 1 and 4 in DSM IV are now encompassed by item 2C in DSM V. I don't see too much of a problem with that either.

DSM item C is now Item 1. DSM items D through F are now gone. I don't see that as a problem either, because they are all “negatives” or things that must be DISproven before DX can be made. Now, none of those things need to be proven or disproven, and thus can be ignored. This increases the chance of diagnosis.

Item 3 in DSM V has been ADDED. Now symptoms must be present from early childhood, whereas they did not have to be before. I don't see a problem with that because understanding that AS is present from birth has been pretty wide spread for a long time. Yes there are some who disagree with that, but I believe they are a small minority. I think it's a good idea for this to be there anyway, as it should eventually settle debate over whether AS or Autism can appear later in life.

It's when I start looking at how MANY of the criteria that must be met where the problems people have with it come to light.

DSM IV: Out of 12 possible criteria, three of which are said by the APA to be redundant, and three of which are now said to be unnecessary, 7 must be met.

DSM V: Out of 7 possible criteria, 6 must be met.

If you view that in strict mathematical terms, ignoring the redundancies and unnecessary items, it looks like DSM IV requires 58.3% positive for DX, and DSM V requires 85.7% positive.

But if three of the twelve in DSM really are unnecessary, and two are really the same, DSM IV can also be said to only require a total of 7 criteria, which would seem to being saying we need 100% positive (7 out of 7).

I realize that looking at it all mathematically is kind of a funky way to think about it, because there is a lot more to it than simple mathematics. A lot of what's done in DX requires quite a lot of mental analysis that has nothing to do with math.

Eliminating the bottom four criteria from IV means it doesn't matter whether you do or do not meet them, which increases everyone's chances of a DX. (Or so it may seem, if one only looks at it with strictly mathematical analysis, which is admittedly not entirely accurate.)

Combining two criteria from both A and B, doesn't really decrease or increase anyone's chances because they are essentially covered by a broader description anyway in V.

Requiring three out of three, and two out of three, instead of two out of four and one out of four though, definitely increases the number of criteria one must meet.

I do believe that increase will result in more negative results (people who would receive a diagnosis now, who won't if these changes are made). I think that change is far more significant than the criteria being dropped.

All the criteria being dropped are all negatives anyway, (you MUST NOT meet them). This won't affect anyone who would currently receive a diagnosis. Will it every result in false positives? I'm not sure, but the reason they must be dropped is because of where the criteria will be once the changes are made (Autism). They can't have those bottom criteria there anymore, otherwise a lot of people who are currently diagnosed with non-Aperger's Autism, would not be if they were included. So that's why they aren't there anymore.

I already know my analysis is full of holes, but the gist of the differences is there at least. There is no mathematically accurate way to determine what the effects will be. There is no 100% intellectually accurate way to analyze the real impact either.

At least from this I can now put a finger on what it was that bothered me in the first place when I looked at it. I can now understand not only what the problems are others have with it and why. I can also understand now why others have no problem at all with it.

In the end, I think whether there is a problem or not, is going to depend heavily on how professionals who make the actual diagnoses will interpret and apply it.

I can see some interpreting it extremely narrowly, and others extremely broadly.

Come to think of it, I believe that was the problem I had with the changes in the first place. Then again, perhaps the DSM V is no more prone to that problem than DSM IV anyway.

(Disclaimer: I'm not about to be very defensive of how I looked at this. I know it's full of room for debate. There may even be some mistakes in it. Go ahead and tear it to pieces if you wish. I'm only hoping this might help some who have been confused about the differences. But then, because I know I'm not always that great at explaining things, it might confuse some of you even more. If so, just ignore this, and you have my apologies.)

By the way, what can't be seen so easily in that post can be seen in the logic model I built based on correlating the symptoms the way I did in the above image.

Using the model, there does appear to be some diagnoses that would be positive with the current DSM, but negative with the proposed changes. There are also some instances where it could be negative currently, and positive with the changes, but that the latter seems to only work with certain combinations that might not be logical to begin with.

Wish there were a way to post the model on line.

Serious issue with the changes.
Primarily with the loss of
"c: significant impairment in social, occupational or other areas of functioning"
I cannot equate that with
"1. Significant persistent deficits in social communication and interactions"

Because right now i'm seeking some assistance with career training / advancement and placement which will be available for AS.
I believe it will be available in my region because of this line. I also prefer the term 'functioning' over 'deficits' as I believe it has amore stable and comprehensible measurement.

You don't think "social" encompasses "occupational?"

I would think it should, but then, as I said, it is going to depend heavily on interpretations of the pros that use it, so...

Yeah, I can see this and several other possible problems, most revolving around interpretation.

If you go in for a diagnosis, all of the mentioned criteria must be met, as well as many less important criteria (upwards of 80 symptoms) in order to be diagnosed with AS. I, for one, welcome the changes, as they most certainly will weed out the false-positives. This is why self-diagnosis is simply inadequate for AS. It can too easily lead to a wrong conclusion (i.e: false positive).

I see that potential too. There are several positives just based on the twelve main ones now that do result in negatives with the changes. Since two pairs of the current ones are actually so similar to two other pairs, it is probable, I think, that two are being given more weight now than they should. That could result in false positive under the current criteria, but shouldn't with the changes.

The "clinically significant..." part is just basically a way of saying you can't diagnose it without impairment in some important area of life. Similar statements are included in most DSM-IV diagnostic criteria.

I'm having a hard time reading that chart.

Hard time seeing it? Try:

Windows: Control +

Mac: Command +

If you're having a hard time making sense of it, sorry there's not much I can do about that. That's the way it's set up on the official DSM site. All I did was add arrows that show where the DSM IV symptoms would be going in DSM V. I know the way I did it is confusing for some. Trying to figure it out just by reading it though, is too confusing for me and a lot of other people. Visually, the way I did it up there, is less confusing for me. I thought it might be less confusing for at least a few other people too.

Everybody's got their own way of needing information organized. I didn't think this would work for everyone.

Yeah I can't see it. The font is very blurry and small. It's hurting my eyes.

Go to:

http://www.safewebtrade.net/images/DSMIVandV_AS.jpg

Good point. It is pretty squarshed here. That link will open the original not so screwed up.

*tries unsuccessfully to bite tongue yet again as self-diagnosed for 7 years, officially diagnosed for 2-3 months, I was right all along thank you very much*

My concern is that the new criteria are vague as hell. What, for example, *are* peer relationships "appropriate to developmental level"? Many AS girls, for example, don't alienate all the other kids in their class and may even have one friend now and then, but don't really connect with other people like NT kids do. Superficially, that might just look "shy" and a "labelphobic" clinician may be loath to dx a kid on the spectrum even if the kid doesn't have good eye contact, doesn't really socialize well, feels isolated, gets obsessed with special interests, is a geeky A student, etc. That same person might look at the AS criteria and see this kid as meeting them.

~Kate

There are some passages in the documents of DSM-5 that gives me the suspicion that they (the APA) suspect that AS is being over-diagnosed:

Autism and Other Pervasive Developmental Disorders Conference (February 3-5, 2008) (http://psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/ConferenceSummaries/AutismConference.aspx):



Asperger Disorder (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=97) - Rationale:





Autistic Disorder (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94) - Rationale:

As in one of Attwoods books, Gillberg's criteria allows for more to be diagnosed than the DSM-IV as of now. It states that these individuals( via Gillberg) fit the original description of Hans Asperger more so than the more restrictive "DSM."

Why is there confusion over this in the medical community? Is it a "philosophy" to re- hone this to current thinking, arbitralily, due to a current consensus of : "What I think it should entail?" Is it an effort to keep more folks off of disability? Is money part of this issue?

I think money is part of the issue, and not just in terms of keeping folks off disability. Many AS people, including myself, do work and contribute to taxes....and I for one have no problem with my all-too-high taxes helping out other Aspies who haven't been as fortunate as I have in the area of employment.

The other area where money is an issue is in education. Kids with AS require some accomodations and those cost money. If the schools can manage to force the square pegs into the NT round holes, even at the expense of the aspie kids, then they stand to save beaucoup bucks. This is one thing that concerns me greatly. It's one thing that I was disciplined over sensory issues rather than accomodated 35-40 years ago, when nobody knew SQUAT about AS, but quite another (inexcusable, in fact) in the 21st century. Education is an area where politicians have traditionally tried to scrimp, so it does concern me.

~Kate