Embracing the autism spectrum
Often called a neurodevelopmental disorder, autism is characterized by impaired social interaction and communication—such as delayed language development, avoiding prolonged eye-contact and sometimes difficulty making friends—as well as restricted and repetitive behavior, such as repeated vocal quirks or gestures. In the DSM-IV, autistic disorder, Asperger's and childhood disintegrative disorders, along with pervasive developmental disorders not otherwise specified (PDD-NOS), are distinct diagnoses listed in the same chapter. The DSM-5 combines them all into a single new diagnosis named autism spectrum disorder (ASD). The APA argues that the symptoms of these disorders are so similar that they belong to the same continuum, rather than constituting separate entities. Some people in the Asperger's community maintain that Asperger's is different enough from autistic disorder to merit its own category, worrying that they will lose an important part of their identity; others in the community applaud the change, embracing the idea of a continuum. Some parents have pointed out that the change may in fact help children who have been denied after-school programs or assistance from insurance companies because Asperger's was considered too mild to warrant such support.
The APA has also made it more difficult for someone to get a diagnosis of autism. As Scientific American has previously reported, the DSM-IV offered 2,027 different ways to be diagnosed with autism; the DSM-5 provides just 11. That reduction might sound drastic but, overall, many psychiatrists agree that this is a helpful change. They argue that past criteria were too loose: Some people who received a diagnosis probably did not have autism, and this misdiagnosis has surely contributed to skyrocketing rates of autism diagnoses worldwide since the 1980s. The U.S. Centers for Disease Control and Prevention estimates that one in 88 children in the nation is diagnosed with an autism spectrum disorder.
By early 2012, however, several studies had tested the new DSM-5 autism criteria and concluded that they were too strict, excluding some high-functioning people on the milder end of the spectrum. In October 2012 a larger and more comprehensive analysis of data from more than 5,000 children concluded that the DSM-5 autism criteria identified 91 percent of children who received a diagnosis of autism or a related developmental disorder under DSM-IV. A few tweaks suggested by the smaller studies published in early 2012 might have made the DSM-5 criteria even more inclusive and helped to identify the 9 percent of children neglected in the October 2012 study. Yet when it came time to finalize the DSM-5 at the end of 2012, the APA decided to stick with the stricter criteria, as confirmed by Catherine Lord of Weill Cornell Medical College, one of the work group members who helped revise the definitions.
Attenuated psychosis syndrome was too weak to make the cut
The APA originally proposed adding a new disorder to the DSM-5 called attenuated psychosis risk syndrome, which was intended to identify children with warning signs that precede full-blown psychosis—signs such as hallucinated voices or images. Critics pointed to research showing that two thirds of children who would meet the proposed criteria never develop serious psychosis (see “At Risk for Psychosis?” by Carrie Arnold; Scientific American MIND, September/October 2011). Related research suggests that 11 percent of the general population sometimes hears voices or engages in moments of intense magical thinking without any distress or interference in work and social life. Allen Frances, chair of the DSM-IV Task Force and the most vociferous critic of the new manual, called attenuated psychosis syndrome the "single worst DSM-5 proposal." As with disruptive mood dysregulation disorder, the fear was that children who did not need medication would be given powerful antipsychotics with potentially harmful side effects such as trembling, suppressed immunity and weight gain. The APA acknowledged the criticism and, after disappointing tests of the proposed criteria, moved attenuated psychosis risk syndrome out of the DSM-5's main section into section 3, reserved for conditions that require further research before they are considered formal disorders.