APA Clarifies Diagnostic Requirements for DSM5 ASD

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It appears that the Chair of the DSM5 neurodevelopmental work group, Susan Swedo, identifies in the linked video from the APA website below that RRB's can be diagnosed from the history of the patient, in the finalized DSM5 Diagnostic requirements for ASD.

In the video she suggests that the social-communication criterion are lifelong serious impairments, but RRB criterion impairments can be adapted to through time where they are no longer clinically significant impairments.

Catherine Lord, from the work group, was quoted in an article a little over a month ago, stating that "essentially everyone get's in" per the final revision of the DSM5 and the addition of consideration of the history of the patient in the diagnostic text, for those currently diagnosed.

I suppose this video may clarify what it is she meant by that statement that was not worded clearly in that article.

But, the DSM5 concern voiced by several advocacy organizations was not the RRB's, it was the greater mandatory requirements of the Social-Communication Criterion, for those currently diagnosed with Asperger's syndrome.

This change may actually be more beneficial to some of those currently meeting a diagnosis of PDD-NOS, that may have experienced clinically significant difficulties in RRB's earlier in life, per history of symptoms, that currently meet requirements of a diagnosis of PDD NOS without clinically significant impairments in RRB's.

So, in short, it appears they are suggesting that a person on the spectrum cannot "outgrow" their Social-Communication impairments but "adaptations" are possible for RRB's, where they no longer present as clinically significant impairments.

http://www.psychiatry.org/practice/dsm/ ... m-disorder

She probably means the early childhood ones such as rocking a lot and other motor mannerisms, fixated with parts of objects (like only playing with the wheel of a car on a toy), and a [very] marked distress to change and routine and imposing that on others.

These are generally seen as things that people with HFA [and AS] lack compared to when they were children, and those with more severe forms probably show some form of improvement as well (not as much though). I doubt she means things other than this.

I agree that the social deficits are fairly stable and lifelong, other than perhaps utilizing rote memory for appropriate replies later on in life (but that's still not socializing naturally).

My take on the video was that she suggests a person can be diagnosing presenting no clinically significant impairments in RRB's, as long as they were present in the history of the individual, which would definitely include the RRB's you describe, but as I read her statement all the other potential RRB's listed in that new DSM5 ASD criterion, would be included as well. Even hypo and hypersensitivity to environmental stimuli.

I suppose when the actual DSM5 is released in May, it will be quoted somewhere in writing directly from the text. But until then, we continue to get snippets of information from work group members. I rely on the opinion of Susan Swedo, more than Catherine Lord, if for no other reason than she is chair of the workgroup. And, I suppose in someways their determination supports the limited effectiveness reported in research for ABA and associated therapies.

Interestingly, their findings reflect the opinion of Gillberg and Lord that deficits in social imagination are the origin of RRB's. If so one would expect them to potentially be reduced over the course of a lifetime through adaptation. But, as I remember Gillberg and Wing's recommendation was a social imagination criterion in place of the RRB titled criterion, which I guess could have included some of those RRB elements. It doesn't look like they got that change but this still in a way reflects it, I think.

That's also one that's supposedly not really clinically evident in many of those with AS and HFA (though it can be). The narrow interest tends to be the end-stage for the higher functioning folk regarding the repetitive behaviors, and I can see how that might not be clinically impairing in all cases (say they have a marketable interest and they fit into society with it regarding work, but since they have all of the social deficits still there, then ASD).

(I haven't listened to it, so I of course can be wrong in regards to what they intend.)

So they are saying we can't improve our social skills and get better or we don't have an ASD if we do?

My understanding from the video is that they are saying that the clinically measured impairments in social-communication are life long after onset, and must be present to meet requirements for a diagnosis. What is or what is not a clinically measured impairment though, is left up, in part, to the clinical judgement of the qualified professional doing the diagnosing.

I don't think that improving social skills necessarily means that the impairments will not still be visible to a qualified professional with sufficient clinical experience, but there is always the potential for misdiagnosis, particularly among females, as they are understand to be better at mimicking social communication skills, in general. Unfortunately this does not appear to be addressed by the DSM5. Perhaps in another version in the future, when more research is done in that area.

My spouse took the AQ test tonight for the first time and scored a 32. My spouse has absolutely no problems with non-verbal communication, or reading the non-verbal communication of others, no problems with social-emotional reciprocity, and can still play along with children and share childlike social imagination.

But, the OCD is through the roof, the social anxiety is uncomfortable, and my spouse has had difficulty in developing and maintaining peer appropriate relationships. But, the most ironic thing is my spouse is one of the most selfless and empathic persons I have ever met in my life. It would not be possible to stay married to someone like me, if that were not the case:).

I suspect that the core issue of difficulties my spouse has is too much affective empathy and social imagination. It seems that RRB's may be the solution as a defense mechanism for a deficit in social imagination and OCD may be a defense mechanism for too much social imagination. At least in our cases.

My point is, and it is a side track in this topic per my experience with my spouse who finally took the test out of curiosity tonight, is that the AQ test measures social anxiety and OCD as well as it measures ASD and does not easily exclude the potential of measuring an extremely empathic person at the "very high" systemizing score level. My spouse is an extreme organizer and planner, that comes with the OCD. I have a hard time finding my way out of a paper bag, so that part works out okay, for me at least..

Perhaps more ironic, is there may be some social contagion of ASD traits from me that has influenced my spouse over two decades. My spouse remarked several times that the answers given would have been significantly different at a younger age.

My score would have been extremely high as a child, lower as an adult, and as high as it has ever been in my life today, all as a result of different environmental exposures and adaptations. My personal opinion is that a person could potentially drift in and out of a diagnosis in a lifetime depending on environment and adaptation and what methods are used to diagnose an individual. Some clinicians use the DSM only, and others use extensive testing as well. I'm pretty sure in real life, most experienced clinicians will take these "common sense" things in consideration, before actually excluding anyone from a diagnosis.

Yeah, I agree with that. It's entirely possible to suppress a behavior or replace it with something less offensive.

It's very difficult to learn to process something your brain is not wired for-- and, although I think it is possible, the cost in terms of stress, exhaustion, and lost quality of life isn't worth it. That was my decision about decoding the finer points of social interaction-- too much pain for too little payoff.

The only people actually benefitting were the NTs.

And that's what bothers me. I really don't see my social cluelessness as a serious impairment. Granted it's been 11 years since I tried to hold a paying job, but-- I raise my kids, I talk to my relatives, I keep my house, I do our business, I socialize with the neighbors. I go to parent teacher conferences, and I'm more plugged-in to what's going on with these kids and more able to deal with it than their wonderful NT father.

Seriously impaired?? Really?? The only thing I'm impaired by, if you ask me, is the occasional jerkwad who thinks my awkwardness necessarily means I'm BAD, or assumes upon disclosure that my "condition" means I'm totally disabled and/or a psychopath.

I don't argue with the statements in the DSM5. I argue with the goddamn value judgments that those statements carry with them. I am *sick* and *tired* of the "culture of can't" that surrounds ASD.

I know that, for me personally, I've adapted much more to social situations over the years (through "scripts" and learning "rules") than I have to change/being without a routine. The DSM-5 criteria is backing themselves in a hole even more by adding this stipulation, if you ask me.

To be accurate, Swedo says that "the social-communicative deficits are impairing and lifelong persistent". She doesn't say out loud that adaptation is not at all possible, and though the following statement about adaptation to RRBs sort of implies that to be the case, I think that that may be reading too much into it.

In my own case I've clearly had a 'developmental delay' in many aspects of social interaction and communication, but I've learned to adapt to some extent over the years. This is in part thanks to intensive psychotherapy including CBT and art therapy during my twenties (at a time in my life when Asperger's didn't exist as a possible diagnosis). Nevertheless, while therapy definitely improved my quality of life, it didn't make me any more able to 'fit in' than before - it just made me make peace with my differentness. So in the sense of me being impaired with regards to being a 'contributing (money-earning) member of society', that is very much still the case.

The problem with the term 'impairment' is that it depends on the viewpoint. From society's point of view my most important impairments are those that keep me from getting an education and having a job, i.e. social-communicative impairments. From my own point of view my most important impairments are the ones that are with me 24/7, whether or not I'm with other people, such as sensory issues, clumsiness, sleep problems and executive dysfunction. The way I see it, if I didn't need to spend most of my mental energy dealing with the latter issues, I would probably have had more to spare to deal with the former. It does seem rather obvious to me, that since sensory issues and clumsiness were the most immediate sources of suffering for me as a child, that that was the areas I concentrated on being able to cope with first. I simply didn't rate being social as important enough to deal with as a first priority, or the second or third even. So it follows that as I am now, I am better adapted with regards to RRBs than to social interaction.

One thing that doesn't seem logical to me is why "Hyper-or hypo-reactivity to sensory input" is placed under the RRB criterion. A sensory issue not in itself a behavior, interest or an activity, though it may be the root cause of either of those. According to Gillberg 'perceptual abnormality' is "the most stable of all the signs or all the symptoms in our follow-up study, even more stable - although at about the same level - as the social-communicative deficits". This goes directly against the claims of Swedo, at least as long as you bundle sensory issues with RRBs. In my opinion they should make sensory issues a separate criterion (and maybe an optional, not an obligatory one). The Gillberg quote is from this video: http://www.youtube.com/watch?feature=en ... e-iik&NR=1 He talks about perceptual abnormality between 15:05 and 15:58.

I wasn't suggesting that Swedo stated social communication impairments could not be adapted to, but she did specifically state that RRBI's could be met by history alone, which implies that adaptation to the point of the absence of significant clinical impairment is possible for RRBI's. I think what she is suggesting with the Social Communication impairments are they are severe enough were they cannot be masked as non-observable clinical impairments. That does not necessarily mean that some adaptation can occur to lessen the severity of the symptoms, as long as they are observed as clinically significant impairments. But, as stated before there is still a subjective analysis by the diagnosing professional as to what they determine is clinically significant impairments in social-communication.

The DSM5 categorizes the behavior associated with hypo-hyper sensitivity per restriction of behavior to the environment in defense of stimuli, or repetitive behavior in seeking stimulus from the environment. Everything in the DSM5 criteria for ASD is described in terms of observable behavior, apparently except for this new potential fulfillment of requirements for RRBI's met by history of the individual undergoing a diagnosis. I think that is an oversimplification of the type of sensory difficulties that some experience, but it appears that is how the classification in RRBI's is justified.

I don't think the DSM5 ASD definition is necessarily suggesting that the sensory impairments can easily be adapted to, because it appears to acknowledge that not everyone on the spectrum experiences them as they are not listed as a mandatory criterion element in RRBI's, and technically a person could still meet one current RRBI criterion element and meet another element from history and still meet requirements for a diagnosis per Swedo's general description of meeting RRBI's by history alone in the video.

I think the cultural environment can have a big impact on what might be observed or not observed as an ASD, whether that focus might be on issues associated with clumsiness and sensory perception, or for those diagnosed on the spectrum without those impairments, as they are not mandatory ones, a focus on anything else that might take the place and priority away from human social interaction and the learning process associated with those skills. And for others inherent issues may make any adaptation extremely difficult, no matter what they are exposed to in the environment. It seems the bottom line for diagnosing professionals is that the DSM5 appears to be largely designed as a "what you see is what you got" manual for ASD, except for RRBI's, in terms of current observed behavior.

Yes, I can see how it's possible to deduce this from the criteria. I do still think that the actual wording in the DSM-V is not very good.

Anyway, thank you for taking the time to clarify.

And - I agree that the term 'clinically significant' and the emphasis on observed behavior are both problematic, as they make it possible for a great deal of subjectivity to be involved in the process. This wouldn't be a problem in a perfect world, where all the professionals were very enlightened beings; but that is very far from the reality of things, I'm afraid.

Sometimes you have to live in the world we have.

This is the best we have. It's not perfect, but it does seem to catch a lot of people who do need to be caught and thus helped. Nothing wrong with criticizing it for its flaws, but I think that it's possible to overstate those flaws and make things out to be much worse than they really are.

Subjectivity is an issue throughout medicine. Not just in psychiatry. Every time I visited my PCP in 2010-2011, I told her I was in moderate-severe pain and she recorded my statements as if I had said I was in mild pain, apparently because I did not look like I was actually in pain to her.

As time has gone on I have become very impressed with Christopher Gillberg, Lorna Wing, and others in autism research associated with them. I suppose the cultural differences in the US impact the way disorders are viewed differently here by some professionals in the US.

There seems to be a more holistic approach by Gillberg and Wing. I like that. But, I do acknowledge that I find comfort in rigid rules. All the criteria combinations available for a diagnosis for five disorders in the DSMIV seemed chaotic to me.

The new criteria, is neat and tidy looking on paper, at least.

I think eventually it will change the face of research on Autism Spectrum Disorder, as the largest piece of the funding for the research pie is in the US. The last criteria was so loose that depending on the diagnosing professional someone with a restrictive repetitive behavioral addiction, that interfered with a major area of life functioning technically could be diagnosed as long as they had a significant impairment in developing and maintaining peer appropriate relationships and in reciprocal communication with another individual that could have been a lack of interest in initiating conversations with others, which can be par for the course for some with behavioral addictions, and obviously a potential problem in developing and maintaining peer appropriate relationships.

The DSM5 still does not consider behavioral addictions as a DSM5 disorder, so that source of RRBI like behavior may have resulted in more than a few diagnoses later in the teenage years and beyond. The disease of addiction and ADHD are correlated. Replace the substance abuse with a severe behavioral addiction interfering with a major life activity along with the ADHD, without motor clumsiness or sensory difficulties, and I think the resulting potential for misdiagnosis has been real for at least the last two decades.

The motor clumsiness and sensory difficulties do seem to indicate an inherent neurodevelopmental and neurological impairment. And I'm not sure that the lack of muscle tone that often goes along with some of this is not in part responsible for what is perceived as non-verbal language impairments, as fine motor control extends out into the facial muscles, along with general motor control and odd posturing in non-verbal communication.

As an example the first three criterion for the Gillberg criteria for Asperger's disorder could technically potentially be inclusive of the minimum requirements for the DSMIV definition of Asperger's syndrome described above. And a severe behavioral addiction on it's own could lead to the other factors being met in criterion 1 through 3 that is bolded below.

But, a behavioral addiction is not likely going to lead to the verbal language impairments or the motor clumsiness, and not likely the non-verbal impairments either. The last three Gillberg criterion seem to be criterion that can be pinpointed to neuro-developmental issues, but I'm not sure that the first three criterion inclusive of current DSMIV minimum requirements could not result from a behavioral addiction alone.

The strongest element now a mandatory requirement in the DSM5 as a potential innate neuro-developmental issue is non-verbal language impairments. And, the addition of sensory impairments actually improves on the Gillberg Criteria, as it is one area that was described by Hans Asperger's not included in the Gillberg Criteria.

However, the DSM5 basic criteria is still lacking per what was described as motor clumsiness and verbal language impairments by both Kanner and Hans Aspergers, although I'm sure it will be included in the associated features text of the DSM5. The mandatory requirement of all three social communication criterion elements in the DSM5, will likely reduce the potential of a misdiagnosis associated with behavioral addiction later in life.

I still think, overall, the Gillberg Criteria is still more likely to capture an actual neurodevelopmental disorder than the DSM5, because there is almost no way that the environment alone can cause 3 out 5 of the Gillberg verbal language impairments listed, or the requirement for motor clumsiness as a neurodevelopmental impairment.

But, if the DSM5 had adopted the Gillberg Criteria, significant numbers of people would definitely lose their diagnoses if re-assessed with Gillberg Criteria, as there are quite a few people reporting diagnosed playing football and other team sports, with no significant issues of motor clumsiness, verbal language impairments, or non-verbal language impairments. They more often report they are impacted by issues associated with ADHD, that also often include sensory integration problems.

Passivity according to Gillberg is higher associated with motor-clumsiness and aggressive behavior is higher associated without the motor-clumsiness along with the ADHD like symptoms. The studies done on children on the spectrum for those more likely to engage in bullying behavior after being bullied by others is reflective of what Gillberg has noted. He refers to a much broader spectrum of "Autisms" that do not exclude psychopathic behavior or any other co-morbid condition, with the underlying element being a neurological impairment of social instinct/social imagination, per the video linked again here that you linked above.

http://www.youtube.com/watch?feature=en ... e-iik&NR=1




http://www.bbbautism.com/asp_gillberg.htm

Overall it seems that Gillberg still better captures what Kanner and Hans Asperger described than what the DSM5 has come up with, but there are still some people receiving treatments that would likely lose out on them in the US, through insurance restrictions, if the US had adapted these greater requirements that the Gillberg criteria lists to meet a diagnoses. It is kind of interesting though, that the Gillberg criteria for Asperger's now sets the highest bar for diagnosis of any autism spectrum disorder, as compared to the new described DSM5 requirements.

Pretty good summary linked below for Asperger's 1944 paper on "Autistic Psychopathy". It is apparent that Gilberg did an excellent job of capturing what Hans Asperger described. But, it appears that the DSMIV cut and pasted fewer requirements out of autistic disorder to describe Aspergers in the DSMIV, with fuller consideration of Asperger's description in the associated features section of the text in the DSMIV, but much less consideration in the basic criteria in the DSMIV for Asperger's syndrome. Per basic criteria it was essentially 'Autism Disorder Light', instead of a fuller description of what Hans Asperger's described.

And now, except for the addition of the sensory difficulties, the two disorders have been synthesized to create a midline of the same basic criteria requirements from the DSMIV. I think the biggest mistake was to remove the verbal communication criterion that would have been almost perfect to describe the full spectrum with how Gillberg describes it as a range from verbal delays to odd prosody of language.

But, at least non-verbal language impairments are a mandatory requirement in the DSM5, because neither verbal or non-verbal language impairments were a mandatory requirement for ICD9, 10, or DSMIV Asperger's Syndrome. Asperger would have rolled over in his grave, I think, if that was possible for him to be aware of that limitation of description with his name used. Gillberg stood firm in describing what was described by Asperger, in his modern era criteria.

http://www.paulcooijmans.com/asperger/a ... rized.html

^^^
why are they using the term aspergers disorder when i thought that aspergers is now a dead term.isnt now( level 1 autism spectrum disorder)

The Gillberg Criteria is separate from the DSMIV or 5 and ICD10 criteria. While the Asperger's diagnostic label is dropped in the DSM5, it continues to be a valid disorder and label under the ICD10 and Gillberg Criteria.

Gillberg lives in Sweden. I suspect that the disorder and label of Asperger's has a long life ahead of it in Sweden, and in some other countries, using the Gillberg Criteria to diagnose Asperger's Disorder.

But, my understanding is that in the future under the ICD11 Asperger's will be changed to Social Emotional Reciprocity Disorder. So, at that point in time there will likely be some people in the world with symptoms of the same disorder some classified with Autism Spectrum Disorder, some with Social Emotional Reciprocity Disorder, and still yet others with Asperger's Disorder. It doesn't seem to be getting any less confusing on a global scale, particularly considering that Autism research is done on a global scale.

How would that explain nonverbal autistic people who later learn to talk, type, or sign as a means of communication? This seems poorly thought out.