The New Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
and Implications for Autism Spectrum Disorder
The American Psychiatric Association released its long-awaited DSM-5 on May 22, 2013. There has been considerable discussion over the new definition of Autism Spectrum Disorder (ASD) and how it might affect diagnosis and services for people and their families. To assist families and professionals, the Autism Society of North Carolina offers this summary description adapted from a presentation by Pamela L. Compart of the Autism Research Institute, which compares the previous (DSM-IV) definition with the new DSM-5 definition. Related issues are introduced at the end of this summary.
DSM-IV Criteria and Requirements for a Diagnosis of ASD
Diagnosis required meeting at least six items across three categories:
A. Qualitative impairment in social interaction meeting at least two of the following:
- Marked impairment in use of multiple nonverbal behaviors (e.g., eye contact, postures, facial expressions)
- Failure to develop developmental-level peer relationships
- Lack of spontaneous seeking to share enjoyment, interests, or achievements
- Lack of social or emotional reciprocity
B. Qualitative impairment in communication meeting at least one of the following:
- Delay or total lack of development of spoken language
- Marked impairment in conversation
- Stereotyped and repetitive use of language or idiosyncratic language
- Lack of spontaneous, varied make-believe play or social imitative play
C. Restricted, repetitive and stereotyped patterns of behavior, interests, and activities meeting at least one of the following:
- Encompassing preoccupation with one or more stereotyped and restricted patterns of interest; abnormal in either intensity or focus
- Apparently inflexible adherence to specific non-functional routines or rituals
- Stereotyped or repetitive motor mannerisms
- Persistent preoccupation with parts of objects
Age of delays or abnormal functioning:
Before age 3 years in one of:
- Social interaction
- Language as used in social communication
- Symbolic or imaginative play
Diagnosis now requires meeting criteria across four categories:
A. Persistent deficits in social communication and social interaction across contexts meeting all of the following:
- Social-emotional reciprocity (e.g., conversation, joint attention)
- Nonverbal communicative behaviors (e.g., eye contact, body language, facial expressions, gestures)
- Developing and maintaining relationships (e.g., imaginative play, making friends)
B. Restricted, repetitive patterns of behavior, interests, and activities meeting at least two of the following:
- Stereotyped/repetitive speech, motor movements, or use of objects
- Excessive adherence to routines/rituals or excessive resistance to change
- Highly restricted fixated interests, abnormal in intensity or focus
- Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment
C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
D. Symptoms together limit and impair everyday functioning
Also, three levels of severity:
- Requiring support (Mild)
- Requiring substantial support (Moderate)
- Requiring very substantial support (High)
A new, additional diagnostic category (not under ASD) was also added to the DSM-5: Social Communication Disorder.
So, what’s the expressed rationale for these changes? Why do it, what is the potential benefit? What are the potential concerns?
The American Psychiatric Association indicated that in the DSM-IV criteria, the same symptomology could be scored in multiple categories, perhaps resulting in excessive weight in diagnosis and possible over-diagnosing. They further noted that deficits in social and communication categories were inseparable, and that delays in language are not unique or universal. It was felt that the consolidation of labels to “Autism Spectrum Disorder,” eliminating PDD-NOS and Asperger’s Syndrome, was more functional.
The potential benefits of the DSM-5 criteria are increased accuracy in diagnosis, combining overlapping symptoms into one category, loosening the 3-year-old age requirement such that for children with milder symptoms their symptoms would be allowed to become evident later in childhood, and the inclusion of a severity range (mild to high).
The potential concerns about the DSM-5 criteria can be summarized as:
- It no longer allows a separate Asperger’s diagnosis – it is subsumed under ASD.
- Its criteria are more restrictive, requiring all three symptoms in Section A to be present,
- And therefore may result in loss of diagnosis and subsequently loss of services or insurance benefits
- Children with milder symptoms could lose their diagnosis, especially those with Asperger’s Syndrome
- Most field testing has been primarily done by psychiatrists and other mental health professionals and in care centers that mostly treat children with severe symptoms; this testing may not generalize to more community-based settings.
Perhaps in response to concerns raised over an earlier draft of the DSM-5 diagnostic criteria, there is an additional notation in the criteria, specifying that “individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the new diagnosis of autism spectrum disorder.” This may alleviate some concerns about people losing their diagnosis and services.
Additional potentially confounding news: As if this change to the new DSM-5 diagnostic criteria wasn’t enough, a new wrinkle was added upon the release of the DSM-5 on May 22. Shortly thereafter, the National Institute of Mental Health (NIMH) announced that it was no longer going to fund research based on DSM symptom clusters. What effect this will have on the use of this new DSM categorization for ASD is unknown at this time. As the DSM has served historically as the diagnostic resource for all of mental health, it will probably continue to carry considerable weight. But NIMH distancing itself from the DSM is surprising. Stay tuned for further developments as we hear of them.
Update: Early Impressions on How This Affects Those with ASD
The big questions in all of our minds after the DSM-5 changes were released:
- How does this affect services for people with ASD?
- Will people be underdiagnosed?
- Will services be lost?
- Will it be more functional and aid diagnosis, or will it have a detrimental effect?
The data seem to be coming in gradually on this. So far, verbal reports and early data are promising. A study reported by Tamara Dawkins, Allison T. Meyer, and Mary E. Van Bourgondien with Division TEACCH at the University of North Carolina suggested that the majority of people (children and adults) with Pervasive Developmental Disorder (PDD) are not likely to be affected by the changes in DSM-5.
Perhaps as importantly, I have yet to hear any horror stories about people losing services. More information must be gathered before we all relax, though. In particular, it will be interesting to learn what is happening to people who in the past would have received an Asperger’s Syndrome diagnosis. Will they continue to find services? It was a wise move to “grandfather in” those people who carried that diagnosis under the DSM-IV, but what is happening to other people now with the same characteristics? We need to keep a close watch. I’m optimistic, but cautious.
By Alexander M. Myers, Ph.D., LP, HSP; Clinical Director, ASNC