DSM-V Contradiction

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Tuttle-
I did not over look them, I just did not respond to them. Which I will now do.

First DSM-IV criteria for Aspergers requires

But lets continue

DSM-V Proposed Definition


Lets look at criteria for Schizophrenia as it relates to Aspergers DSM-IV
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these should include 1-3
1. Delusions -no
2. Hallucinations- no
3. Disorganized speech - no
4. Grossly abnormal psychomotor behavior, such as catatonia - perhaps
5. Negative symptoms, i.e., restricted affect or avolition/asociality - yes
A symptom does not meet criteria 1-3 therefore a diagnosis is not possible.

B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). - perhaps Diagnosis possible

C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). - perhaps/ no Diagnosis possible

D- Diagnosis possible
E-Diagnosis possible
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder or other communication disorder of childhood onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month- yes since the question was about the situation where there is not a history. Diagnosis possible

Final verdict. A diagnosis is not possible. Aspergergers type behaviors are not characterized by delusions, hallucinations or disorganized speech.

Last edited by antimuda on 10 Feb 2012, 11:52 am, edited 1 time in total.

Tuttle-

Now on to ]Social Anxiety Disorder.

From the DSM-V

I will agree that there is an overlap with some of social communication and social interaction criteria from DSM- V ASD criteria A. However it does not address the impairments in communication and in forming relationships. There is a closer match with Social Communication Disorder which by definition captures the social aspects of ASD. In addition Social Anxiety disorder fails to address ASD Criteria B for the Restricted, repetitive patterns of behaviors

Childhood medical records are rarely accessible for adults. Psychiatrists don't normally call in relatives or caregivers for interviews, for functioning adults; they rely on self-reports of life history or medical reports (if available) from patients in determining this criteria.

In my case, throughout my life, my mother commented that, I could not put words together until after 4 years of age. Iniatially, at age 47, I was diagnosed with Aspergers. When I provided that information, later, to my psychiatrist, he moved me over into PDD NOS.

Both my sister and one of her acquaintences were diagnosed with aspergers at around age 50, and they were asked questions about their youth, which were relevant to their current behaviors that met the criteria.

Basically, the psychiatrists must determine that another disorder is not responsible for the behaviors, such as depression, schizophrenia, bi-polar, anxiety, borderline personality disorder, etc. A self-report of symptoms from childhood, helps in determining this.

It is far from an exact science, but it is already, currently, all the information that is available for many adults diagnosed with Aspergers and many other conditions.

The abscence of medical records or caregiver reports from youth, is not going to stop an adult from getting diagnosed with aspergers, when the DSMV comes out, anymore than it does now, and that aspect isn't likely going to be significant cause for a loss of diagnosis for any adult that is currently diagnosed with aspergers.

The way it was worded before the current revision was made might have, but the less restrictive wording in the current revision, was made in light of the reality that adults diagnosed, often do not have accessible childhood records.

One doesn't need a diagnosis of anykind to see a psychiatrist or a psychologist, so the course of treatment for behavioral difficulties and/or co-morbid psychological conditions would not likely be impacted for adults with Aspergers, in the unlikely circumstance that someone were to lose their diagnosis based on a revision in the DSMV

For children, in part, it depends on the law as it exists for eligibility for school programs, that has suggested might play a role for some children with PDD NOS changed over to SCD because of the lack of RRB's, but when all is said and done, I doubt many children that have the same behavioral and psychological issues are going to be dropped from school programs. SCD is basically a more specific diagnosis, but the problems don't change.

Other than that the treatment they receive from therapists and psychiatrists would likely remain the same as long as their specific behavioral and psychological issues did not significantly change. The significant issue could be in insurance coverage, and whether or not it would be modified to cover ABA for children in a new diagnostic classification.

There really doesn't appear to be any significant concerns for anyone that currently has an actual diagnosis of Aspergers to lose their diagnosis. The APA clearly states this in the current revision rationale. They have made adjustments to ensure that it is not an issue.

The APA is the organization that psychiatrists receive guidance from, in regard to revisions in the DSM. I doubt they are going to be looking to take anyone's Asperger's diagnosis away from them, given the current revisions and rationale for those revisions in the DSMV.

I respectfully disagree, that Criteria D is not an ambigous phrase on it's on, without reference to the inclusion of the severity levels, in regard to whether or not it matches the definition of ADA disability.

DSMIV
Criteria
"The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning"

DSMV
Criteria
D. Symptoms together limit and impair everyday functioning

ADA Statutory
"a physical or mental impairment that substantially limits one or more major life activities of such individual"

The DSMV Criteria D on it's own doesn't match the ADA statutory requirement because it doesn't qualify the limits or impairments in everyday functioning.

The severity levels in the DSMV qualifies the limits and impairments.

The ADA statutory definition qualifies the limit as substantial. If the DSM V criteria was taken on it's own, without the severity levels, or diagnostic features, it could mean anything from minor limitations and impairments to major limitations and impairments in everyday functioning, because there would be no qualification of degree or severity of the limit.

Considerable, Clinically significant, or substantial are all synonyms that basically mean the same thing, that the impairments and/or limitations are not insignificant, unsubstantial, or not considerable. Basically, impairments and/or limitations in everyday functioning that aren't just minor issues.

In other words, how much of a limit in everyday life functioning. A minor limit in everyday life functioning wouldn't meet the ADA definition for disability, and Criteria D on it's own, doesn't qualify whether or not the limit is a minor, substantial, or severe limitation in daily functioning.

Interestingly, the criteria in the DSMIV TR qualified the level of impairments as clinically significant, however there were no severity levels included to qualify the impairments in the DSMIV TR.

The diagnostic features section in the DSMIV TR, did though, clarify that the impairments were a source of considerable disability, not minor disability.

Without some type of qualification of degree or severity of impairment or disability, I think it is actually more of an ambiguous statement.

Given the addition of the word limit and the whole context of the criteria and diagnostic features in the DSMIV TR as opposed to the whole context of the criteria and severity levels in the DSMV, I don't see much of an overall diagnostic impact other than the severity levels.

The legal definition issue will be moot in the DSMV, because once Aspergers is subsumed it will be part of a disorder that is already defined in US legal code as one that is inherently disabling, because of the degree of limitation in brain functioning identified as an inherent part of the diagnosis of Autism.

Assessment for ADA disability is always required, but once it is known that there is a record of a diagnosis of autism, it is going to be very hard for any employer to legally contest the disability, under the umbrella of autism, considering that Autism is listed in the US Code.

aghogday-

From the Introduction of the DSM-IV-TR

To that extent the purpose of the DSM is to "provide a common language and standard criteria for the classification of mental disorders". If criteria are be ignored or unable to be verified (due to administrative burden, non existence of records etc) this DSM is failing in its stated purpose. As your personal example shows, criteria ASD DSM-V C is riddled with difficulty when the diagnosis is made in adults


I agree completely. My point is that if the criteria is not adding any additional value and is introducing more subjectivity. Some clinical practitioners will apply the standard directly as written others will not. Therefore DSM will fail to provide a common language.




The DSM frequently uses exclusion criteria that are necessary to establish boundaries between disorders and to clarify differential diagnoses ie "not better accounted for by . . ." This language does not appear in the DSM-V diagnostic criteria for ASD



I again agree. We can have another lengthy discussion about SCD which deals with pragmatics, the field in linguistic where context contributes to meaning.


Every field has a standards setting body the APA is the de facto standard for mental disorders. The application of the any standard will never be uniform across a population yet it is the job the standards organization to attempt to provide a framework that can be objectively applied. Again each individual patient and clinician are different and treatment will progress regardless of the existence of the standard. However part of the stated objectives for the DSM is to provide a clear nomenclature so accurate statistics can be maintained and research performed. If a uniform standard is not being applied this objective can not be met.

aghogday-

The ADA criteria is for a major life activity which is defined as "functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

The DSM criteria is for daily functioning. By reviewing the literature daily functioning is defined as the ability to complete the Activities of Daily Living (ADL).

The Basic ADLs are



Instrumental ADLs



Based upon this definition of daily functioning, I still fail to see how any of the defined activities do not meet the ADA standard of a "major life event".



The commentary for Aspergers added in the DSM-IV-TR includes the clarification stating the symptoms are disabling, for ASD it did not. Your point regarding the severity levels is still quite valid (as it was several pages ago However for Severity Level 1


The word limit does not appear. If the word limit is included it becomes severity level 2. Based upon the very language of the severity levels we can conclude the DSM is defining a limit as having greater severity then an impairment. This would suggest (to me at least) that a severity level 1 diagnosis would not be possible since it is not limiting and as a result would fail criteria D.

The other issue is whether a ADA "major life activity" is the same as "daily functioning". I believe they are based upon the discussion in the prior posting.




The DSM-IV-TR criteria for ASD does not contain the language regarding a disability. It describes an impairment and uses the word 16 times. The terms limit and disability do no appear. As it relates to ASD this is an entirely new concept.



This actually would be a very interesting and novel legal argument. It could be argued that in Taylor v Food World, Aspergers as defined by DSM-IV, was a disability. Going forward it may be possible to use that as prescendance for an individual that meets Aspergers DSM-IV criteria but for some reason fails to meet ASD DSM-V

I see only two choices. Remove criteria C, and leave no criteria indicating that ASD is a neurodevelopmental disorder.

Or, leave it in to acknowledge the disorder as a neurodevelopmental disorder with early childhood symptoms that may not become fully manifest until social demands exceed limited capacities.

Do you see any other choice?

The statement as is, is going to lead to subjective evidence that cannot be validated by medical sources, potentially, for anyone over the age of early childhood.

However, subjective evidence from a self report, is better than no childhood information at all, from choice one.

I suspect that further guidance will be provided for the clinician, in the diagnostic features, once the revision is finalized. Otherwise, as is, if someone states they can't remember if they had symptoms in early childhood, and there is no one else to ask that remembers, they wouldn't qualify for a diagnosis. I don't think that scenario is likely, but it is possible.

I don't see the every functioning part of it as an issue, I think the list you provide meets that requirement. Just that on it's own, criteria D doesn't qualify the degree of impairment and limits in whatever the function may be, whereas the ADA definition of disability does through the use of the word "substantially limit"

However, that's just a matter of semantics; again, once Aspergers is subsumed as Autism Spectrum Disorder it is identified by US code as a disorder that inherently limits Brain Function, which meets the ADA definition of disability, as described in that specific section of US Code.

This should not change as long as the disorder remains a neurodevelopmental disorder; it may be part of the reason that the childhood symptom requirement will remain. That appears to be part of the rationale as described in the revision for criteria D.

I've been missing your point on the DSMIV for disability. There is no criteria for ASD in the DSMIV, so I've been assuming you were referring to Aspergers. I see now that you were talking about Autism Disorder when you were speaking about disability not being in the clinical features section for ASD.

I don't see it as a necessary statement in the clinical features in the DSMIV for Autism Disorder, because developmental delays are included in that criteria that indicate inherent disability; the US Code already specifies the Brain dysfunction as the disability for Autism Disorder.

There is no doubt that severity level one would meet requirement D, regardless of whether or not the word limit is in there. Otherwise there would be no reason for severity level 1 to exist.

I don't see why they would have to preface the paragraph with impairments and limitations, if they describe a limitation within the paragraph.

Clear examples of unsuccessful attempts to respond to social overtures can be defined as a limitation in communication, regardless of whether or not they preface it as such. It would be clearer if impairments and limitations were used to preface the paragraph, but it appears they decided it is clear enough as stated to meet requirement D.