Under the new DSM-5 definition, the age at onset criterion for the diagnosis of ASD has been relaxed to state that symptoms must be present in early childhood. This change is intended to improve the specificity of the diagnosis. Under the new criteria, 2 or more restrictive, repetitive behavior symptoms must be present, instead of a single symptom as required under the DSM-IV definition. This new criterion describes hypersensitivity or hyposensitivity to sensory input or an unusual interest in sensory cues. The category of restrictive, repetitive behaviors has been expanded to include sensory symptoms, which have long been observed in individuals with autism but were not part of the diagnostic criteria under DSM-IV. The shift from 3 to 2 symptom domains in the definition of ASD was proposed because, as stated by the APA, “Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities.” 6 It was felt that under the DSM-IV definition, a single symptom could meet criteria in both of the distinct domains of social impairment and communication impairment, giving undue weight to that symptom. Social and communication impairments have been merged into a single symptom domain, while restricted, repetitive behaviors have remained distinct. 4, 5 On their Web site describing the revisions, the APA states, “A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation previously, the criteria were equivalent to trying to ‘ cleave meatloaf at the joints.’ “ 6Ī second major shift in the DSM-5 criteria is in moving from the 3 major symptom domains in DSM-IV, namely social impairments, communication impairments, and restricted, repetitive behaviors, to 2 domains. The merging of diagnoses under the single category of ASD has been introduced in response to concerns about the diagnostic reliability of DSM-IV subtypes, which has been shown to be weak, 1-3 particularly with regard to the distinction between Asperger’s disorder and “high-functioning” autism. The DSM-IV diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and PDD-NOS have been brought together under the single diagnostic heading of ASD, effectively eliminating the Asperger’s disorder, childhood disintegrative disorder, and PDD-NOS diagnoses. With regard to the diagnosis of pervasive developmental disorders (PDDs) (the categorical title used for the “autism spectrum disorders” in DSM-IV), DSM-5 has introduced several major changes, which include (1) converging the diagnostic groups previously subsumed under the category of PDDs into a single diagnosis of ASD (2) merging the social and communication impairment symptom domains required for the diagnosis of autism into a single domain, thus reducing the symptom domains involved in diagnosis from 3 to 2 (3) expanding the “restricted, repetitive behaviors” symptom domain to include abnormalities in sensory processing and (4) relaxing the age at onset criterion.įor autism and related conditions, the most significant and controversial revision in DSM-5 is the merging of 4 disorders that were distinct under DSM-IV criteria into a single diagnostic category. Furthermore, the applicability of items and concepts taken out of context and without formal training in the assessment processes from which the items are derived may create some significant issues. This approach, while both cost efficient and research focused, comes at the potential price of some loss of “ecological validity.” In other words, in real-world settings, clinicians do not have the time to take weeks of training on a panoply of research instruments. The use of such instruments for research is well known, and often, as in autism, these have been explicitly “keyed” to categorical diagnostic criteria. A second shift in the DSM-5 has been the focus on the use of relevant dimensional and other assessment instruments. Historically, DSM has been used for both research and clinical purposes this differs from the current ICD-10 approach, which has separate manuals for research and clinical work. This decision, understandable particularly from the point of view of more specific and research-based criteria sets, also poses some practical challenges for DSM-5. One is the elimination of “subthreshold” categories, such as pervasive developmental disorder not otherwise specified (PDD-NOS), throughout the manual. Before discussing the specific changes, it is important to note 2 overarching conceptual shifts in DSM-5.
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