DSM-5 and Proposed Changes to ASD

Jack Dikian

January 2012

It has been 17 years since the last significant overhaul of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The planned fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is due for publication in May 2013.

And whilst the proposed changes to DSM-IV diagnoses are many and include Asperger syndrome, Attention Deficit Hyperactivity Disorder, Bipolar disorder, Depression, Dissociative identity disorder, Hypersexual disorder, etc, the proposed changes to the diagnostic criteria for Autism has received much concern by many.

The proposed change includes consolidating autism spectrum disorder and eliminating Asperger syndrome and Pervasive Developmental Disorder-Not Otherwise Specified (PDD.-NOS). The new criteria would also require a person to exhibit three social interaction and communication deficits and a minimum of two repetitive behaviors. In contrast, the current requirement is exhibiting 6 or more of 12 behaviors to be diagnosed as autistic.

Concerns are numerous and aired by families of autistic children and adults, practitioners, and researchers. Families are worried that if the proposed changes are accepted, their access to support services might diminish. Others are concerned, understandably, that with these changes will impair the ability of health officials and researchers to compare future rates of autism spectrum disorders to past rates.

For example, a recent Yale University study found that out of a group of patients diagnosed with autism participating in a 1994 field trial, roughly half wouldn’t be considered autistic anymore under new guidelines proposed by the American Psychiatric Association (APA).

The following link takes you the APA’s DSM-5 development site.

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

Psychiatric classifications over the years

Jack Dikian

November 2011

Not long ago I came by a 1968 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II). The first thing that struck me, although I wasn’t too surprised, was its size. It’s 134 pages in total and lists 182 disorders. Compare this to what is on my desk - DSM-IV (1994) 886 pages and 297 disorders. The next version of the DSM, DSM-5 will be due for publication in May 2013.

Over the years the DSM has attracted controversy and criticism as well as praise. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. I for one am interested in how those involved in reaching consensus and publishing the DSM over the years have had to react to, and be informed by evolving social norms, public perceptions, labels, and of course field trials, diagnoses reliability checking and other influences.

I wanted to put together a time-line reflecting key milestones or versions of the DSM, its size, estimate of the number of classifications as well as key historic backdrops. This is in no way comprehensive, however may be useful nevertheless.

Version	Year	Pages	No of Diagnoses	Remarks
	1840		1	The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census which used a single category, "idiocy/insanity".
Guide	1917		22	A new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane",
DSM-I	1952	130	106	World War II saw a large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers – thus shifting the focus away from mental institutions and traditional clinical perspectives. At the same time an APA Committee undertook to standardize the diverse and confused usage of different documents.
DSM-II	1968	134	182	The DSM-II as in earlier versions reflected the predominant psychodynamic psychiatry. Symptoms mostly seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis.
DSM-II Seventh Printing	1974			The seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder and the diagnosis was replaced with the category of "sexual orientation disturbance".
DSM-III	1980	494	265	A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy. “Neurosis” was reinserted in parentheses after the word “disorder” in some cases. Also, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
DSM-III-R	1987	567	292	Controversial diagnoses such as pre-menstrual dysphoric disorder and masochistic personality disorder were considered and discarded. Also, “Sexual orientation disturbance" was also removed and was largely subsumed under "sexual disorder not otherwise specified".
DSM-IV	1994	886	297	A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
DSM-IV-TR	2000			The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD.

DSM-5

It will be interesting to see the final product, its size, and more importantly the handling of a large number of revision areas. I look forward to, for example, the treatment of Neurodevelopmental Disorders, previously under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and Anxiety Disorders.

The American Psychiatric Association provides an official DSM-5 Development Website at: http://www.dsm5.org/pages/default.aspx