DSM-V Contradiction

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the real question is the subjectivity that different doctors will interperit there criteria.so where will the line be drawn

They might have been officially diagnosed with one in the past, but all that really means is that their specific doctor identified one specific RRBI. There could easily be more of them that aren't as obvious, especially with an adult who's gotten to be so good at covering them up & avoiding their triggers, he's not even consciously aware of them anymore.

Case in point: if a doctor assessed me 2 months ago for AS, he'd have likely concluded that I had no sensory issues, because I couldn't think of any of real importance. The truth is, I had them so well buried & was so good at avoiding them, I rarely get them triggered anymore. One involves coconut (hate the taste, but I'll literally melt down if I end up with actual chewy coconut in my mouth & can't spit it out), and two more involve sex & won't be mentioned here.

I'd forgotten all about my "coconut problem" (which goes back "forever") until I accidentally bit into a chocolate over Christmas that I *thought* contained nuts, and ended up with about a cubic centimeter of coconut in my mouth... while driving, with nowhere obvious to spit. Oh, god. It was awful.

I later rembered that raisins do the same thing to me. And dates. Or any dried chewy fruit, for that matter. If anything, my "raisin" reaction is even worse than coconut, because I can't even "not chew" and "zone out" enough to keep from retching on the spot. I have plenty of other taste issues (banana, peach, grapefruit, strawberries, and plenty more), but coconut & raisins are the two that nail me every few years because they can be concealed & catch me totally by surprise.

Anyway, the point of the example is that this is just one example of something that can literally send me over the edge, but would have never even have come up had I enthusiastically run to a dr. the week after discovering AS, instead of spending 2 months playing Aspie Archaeologist dredging up & documenting 37 years of executive dysfunction, stims, & sensory issues that have been aggressively avoided for decades and go *way* beyond mere ADD & nerdiness.

If they don't admit it, that is fine. They don't see the need for dx. Too often I feel that other people want the dx for adults when that is the concern of the adult only unless there is legal involvement. Everything else can be managed as individual characteristics.

aghogday-

First thank you for posting the very interesting medscape article.
However I respectfully disagree with

As I have argued many times in this thread, the author has chosen to include both terms, "limit" and "impair" and as a result the terms must have discrete meanings. In your usage it appears that you are using the terms as synonyms. How do you differentiate the two terms?



I believe the new criteria is in fact more "limiting" as it requires not only an impairment but also a limit.

Point of information: English has a long, well-established tradition of "doubling up" pairs of words with French and Saxon roots that are effectively synonyms. For example, 'Cease and Desist'. I don't have time to look up the etymology of 'impair' and 'limit' (I'm in line at Target on my phone), but it's one possibility to consider.

Remember, the sentence was written by somebody who's overwhelmingly likely to be NT, not Aspie, and there's a good chance that somebody involved with the DSM will eventually read this thread, do a facepalm, and sigh, 'Aspie literalism'.

dr01dguy-
Words have meaning. Based upon your implication Bill Clinton would be an Aspie

I will save you the etymological search
Limit
Origin:
1325–75; Middle English lymyt < Latin līmit- (stem of līmes ) boundary, path between fields

Impair
Origin:
1250–1300; Middle English empairen, empeiren to make worse < Middle French empeirer, equivalent to em- im-1 + peirer to make worse < Late Latin pējōrāre, equivalent to Latin pējōr-, stem of pējor worse + -ā- thematic vowel + -re infinitive suffix; compare pejorative

Dictionary definitions can be foundational, but are often not useful in discussions as usage tends to cast a broader net based on context than dictionaries have space to allow for. Further, terminology used in documents like the DSM tends to have other meanings relevant to psychiatric and medical practice that are often not listed in dictionary definitions. In other words: You can't base an argument on a dictionary definition.



You're making no sense. If most people can complete a test in an hour and achieve a score that accurately reflects their abilities and knowledge and you cannot then you are limited. Giving you 90 minutes to allow you to achieve an accurate score does not mean you are not limited, you need that extra 30 minutes. That's a limitation.



But you're taking two different - related, but different - things and making them the same thing. There's a difference between establishing whether you spoke complete sentences at two years old or four years old and establishing that you had social difficulties throughout grade school. One of these is much easier to self-report on than the other. The meaning of "speaking on time" is also ambiguous in the AS criteria because the examples use actually describe a speech delay, while stating that speech delays preclude a diagnosis.



Then your disagreement is wrong. A childhood history has more information than when you started to speak or how. That is a factual statement: It includes your performance in school, your relationships with other children, your relationships with your family, your behavior over time. It also covers a longer period of time than speech development. You are entitled to your own opinion on this, but you are not entitled to your own facts.



Your position is factually wrong.

As far as being vulnerable to confirmation bias, all self-reporting is vulnerable to confirmation bias. That's something that psychiatrists and therapists have to deal with whether they're dealing with someone who is depressed, autistic, schizophrenic, bipolar, and every other diagnosis in the DSM. It is my understanding that it is something they are trained to look for and probe.

You're welcome.

In further review of the criteria in consideration of the severity levels:

I think one would first need to define everyday functioning and how it applies to each disorder in context of the new criteria and severity levels.

Social Interaction and verbal/non verbal communication are clearly a part of everyday life functioning, as well as occupational/school functioning, self care functioning, taking care of dependents, house chores, all of which could be limited by impairments in social interaction/communication/RRBI's.

The severity levels describe the impairments and limitations that affect everyday life functioning from level one to level three. The limitations provided are discrete and can be measured by empirical means.

Severity level one, quoted below indicates the minimum required impairments and limits in everyday functioning that are part of the disorder in both social communication and RRB's.

I think the reason they use the wording limit and impair, is because they have added a measure of the limits and impairments in the severity levels. If one doesn't meet the minimum requirements of severity level one, they won't likely be diagnosed.

Since the disorder by default impairs and limits one in everyday life functioning to some degree in the area of social functioning, without the severity levels that requirement could be met by meeting that one impairment and limitation, depending on how a clinician interpreted the statement. Same, currently, with the statement used in the DSMIV.

The severity levels specify and require impairments and limitations in everyday life functioning in RRB's as well, so some clarity is provided there.

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94#



The first sentence of each paragraph describes the impairment in everyday life functioning. And, the second sentence, bolded in each paragraph describes a specific limitation in everyday life functioning.

I doubt that many, initially, properly diagnosed with an ASD did not have these specific minimum limitations in everyday life functioning, except those diagnosed without RRB's, currently diagnosed with PDD NOS.

That statement in regard to those currently diagnosed with Autism Disorder, Aspergers and severity levels, doesn't seem to be reasonably more limiting than what was in place before, if a proper diagnosis was provided. The severity levels present limits in functioning in everyday life that were not presented in the DSM IV, so overall, it is a more limiting criteria, given the severity levels.

The statement in regard to PDD NOS and severity levels is definitely more limiting. There is no question about that, because of the RRB issue.

Good question. Hopefully my last post will help to answer that question.

The severity levels, presented in the DSMV provide a line in the sand.

Regarding the RRB's, some folks with PDD NOS don't have clinically significant ones, that meet the level one requirements of the severity levels in the DSMV, so they would likely be moved over to Social Communication Disorder, if re-assessed as such.

Verdandi-

I am not denying the right of the APA to act as its own lexicography. I can not find an alternative definition issued from the APA or a scholarly work in the field that could be used to reasonably establish an alternative definition. If you could find such a reference please post it.

In the absence of an alternative definition, the dictionary definition must serve. The purpose for the DSM is to "provide a common language and standard criteria for the classification of mental disorders". In such that it uses ambiguous terms which open to different interpretations it has failed its purpose.


To this I will in fact agree to the extent that I am 5'7 and am limited in my ability to dunk a basketball. However this limit does not effect my ability to play the sport.
As it relates to a more practical example the purpose of the SAT is to determine how well students are prepared for college level academics. The additional time does not limit the function of the test in its determination. Thus the impairment and the accommodation to adapt to the impairment does not limit the student.


Speaking represents a discrete measurable event the new criteria does not. For instance if we look at

For the purposes of brevity lets look at the starting range, "difficulties adjusting behavior to suit different social contexts". Part of the growing up process and one a common challenge to parents is teaching the proper behavior to children. It is unfortunately a common sight when one eats at a restaurant, attends a religious service or sits in a Starbucks cafe to observe children behaving inappropriately(running around, screaming etc) and their poor parents trying to do everything in their power to make them behave. These behaviors would be proper in other situations. This is a common behavior to all children and not necessarily of ASD. What differentiates the two are the context, details and frequency of the behaviors. Retroactively these nuanced differences would be difficult to establish and would be prone to memory errors particularly as they relate to the exceptional. (If you are curious on the topic I can provide several interesting books and papers on the topic of memory errors.)


At no point have I presented my own facts. I have when ever possible cited the actual documents and included links. I may interpret the documents differently than others. Throughout this rather lengthy thread there has been a respectful discourse about different interpretations of the meaning and applications of DSM-IV and DSM-V however the documents are in all cases the facts and all of commentaries are opinions.

Objective reporting of early language development is fraught with difficulty. People confronted with echolalia, for example, often mistake very sophisticated sentences for advanced language, not realizing that the child may be merely substituting approximations for meaning and not formulating his or her own responses. There are difficulties with parental expectations, so a highly educated parent might have very high expectations of what constitutes average development, while another may not know what constitutes meaningful speech. For example, I have seen a 6 month old baby babbling mm mmm mmm but the parent insisted that she was saying "mum". Similarly, a child may speak in sentences, but not use language for social purposes or may have present with a very ideosyncratic syntax or use of vocab. Caregivers may attribute this to "cute" behaviour, not realizing that the child actually has a difficulty.

There are also less well known difficulties such as overly rapid speech, or cluttering, in which the child speaks fluently, if a little fast, but inserts a stream of non essential information. There is also the variation between expressive and receptive language. They can differ widely. Some children speak rarely, but when they do, speak well. Voice quality - pitch and volume also need to be considered. It is all very complex and far more difficult to report on that motor development etc.

Verandi-
Confirmation bias resulting from self reporting is a clinical problem

( http://schizophreniabulletin.oxfordjour ... l.pdf+html )

aghogday-

I agree with that as a starting point. I assumed, perhaps incorrectly that in the jargon of the APA this was a well defined term. According to Patterson, Goldman, McKibbin et al (http://schizophreniabulletin.oxfordjournals.org/content/27/2/235.full.pdf+html)

The paper actually presents a numerical approach, UCSD Performance-Based Skills Assessment (UPSA) and goes through a lengthy discussion of the potential failures of each of the 5 approaches. The paper is an interesting read and presents a structured numerical test method which has been adopted in several other papers.


Yet I fail to agree with you as to the inclusion of the new term limit. In your excerpt the emphasis does not appear in the DSM nor is there supporting commentary. Furthermore the severity guide would still be applicable regardless of the term 'limit'. Furthermore there is nothing in the severity level 1 that would constitute a limit and that is where I believe the contradiction is derived. You will also notice that the term limited appears in the definitions of level 2 and level 3
Level 3

Level 2



I again agree that the controversy regarding the new standard is best attributed to level 1. I personally do not like the severity level distinctions as it attempts to draw bright lines on behaviors where no such boundaries exist.

Finally in regard to several comments regarding losing a diagnosis, that still remains the sole responsibility of doctors. They are the ones who are charged with interpreting the facts of the case and applying an accurate standard. Coincidentally from a legal perspective any discussion of the DSM is academic as of January 16, 2009 (mandatory adoption date January 1, 2012) and the adoption of HIPAA, the ICD-10 standard is used in the United States for medical insurance and with the social security administration. (https://www.cms.gov/TransactionCodeSetsStands/02_TransactionsandCodeSetsRegulations.asp)

My point in the creation of this thread was that I believe that the role of a standards board is to provide clear guidelines. The APA has failed to do so because it has elected to in including vague language and require a retrospective behavioral history prone to error and interpretation.

The APA really had no choice but to allow for a retrospective behavioral history, other wise it would prohibit the ability to diagnose adults with the disorder, as currently is done, with respect to historical accounts of behavior.

Diagnoses obviously have been missed, because Aspergers has only been available as a diagnosis for about 18 years. This revision was recently added as a result of research, and advisement that many would be excluded from diagnosis, if the change was not made. How else could adults be diagnosed? Would it be fair to exclude them, because the diagnosis wasn't available when they were children?

That was just my opinion as to why they might have added the verb limit as well as impair in describing everyday life functioning, otherwise I don't see why they didn't just leave the statement as is, other than to generalize it. Only the DSMV organization would be able to fully clarify that point. Although, I'm not seeing quite the problem that it appears that you are seeing.

The verbs limit and impair in describing other disabling conditions and their impact on life functioning are commonly used, interchangeably. For simple example: the symptoms of a broken leg creates an impairment in walking and limits one's ability to walk in everyday life functioning. An example of a limit/limitation would be one could only walk to and from the store with a crutch, but it would be almost impossible to provide a precise limit, even with a physical limitation that is more easily measured than a psychological/behavioral one.

An impairment in social interaction or an impairment from RRB's is analagous as well as the limitations that result from these impairments. The specific difficulty in iniating social interaction described in level 1 is a mild limitation in everyday life functioning, per social functioning, that results from the impairing symptoms of the disorder.

As you quote they describe this everyday life function as limited in level 2 and very limited in level three. This is basically what they are saying in their statement: that the symptoms work together to limit everyday life functioning.

Limit is used as a verb to describe the impact of the symptoms on everyday life functioning.

Used as noun one might refer to limit as a height or weight limit, whereas used as a verb one might refer to symptoms of endocrine dysfunction working together to limit and impair growth in an individual. Obviously. it would be impossible to provide a precise height limit or weight limit. The same applies to the limits in functional behavior required in everyday living.

One couldn't provide an exact limit on the number of times an individual would have problems iniating social interaction. It can only be described to degrees like difficulties in, limited in, and very limited in.

Per example above if there were severity levels in endocrine dysfunction, growth could be slightly limited, to limited, to very limited, with some type of range per growth norms. It's harder to provide a precise range with human social interaction.



The DSMV organization appears to be a good reflection on just how disorganized human behavior is in it's effect on real life, even when one would think that a norm of quality and efficiency should apply.

The editorial mistake in the DSMIV on PDD NOS, and the ICD10 fiasco described below in the links, along with what seems like obvious mistakes from the get go in the DSMV revisions, are evidence of it. But, on the other hand, human behavior is extremely complex, and it is worth attempting to get it right, which at most will be approximated in regard to analysis of human behavior. Clarity has been attempted, and there is an approximation of it.



Regarding HIPPA regulations, before January of this year the ICD9 was used to code medical transactions, because of requirement from international treaty.

A move to the ICD10 better coordinated with the DSMV, has been planned for some time now, however the DSMV organization has lagged behind, for smooth coordination of this change.

The links below provide details, that as is the case now, the DSMV will still be used for diagnosis with the ICD10, just as the DSMIV was used in conjunction with the ICD9, per January 1, 2012.

They will have to contort the codes to match the ICD10, as has already been done with the ICD9, in meeting the transactional requirements.


http://www.psych.org/MainMenu/Research/DSMIV/FAQs/SinceDSMIVTRhasnotbeenofficiallyadoptedasaHIPAACodeSetcanIstillusetheDSMIVTR.aspx

http://www.psychologytoday.com/blog/dsm5-in-distress/201104/dsm-5-keeps-missing-its-deadlines?page=2

https://www.cms.gov/TransactionCodeSetsStands/02_TransactionsandCodeSetsRegulations.asp



.

I know what you're talking about. That is what I was talking about. It's a possible problem no matter what, which is what I said further up. Pointing out that it's a real problem when I agreed it's a problem is confusing.