DSM-5 - Commonwealth Autism Service

Changes in DSM-5:
Autism Spectrum Disorder and
Social (Pragmatic)
Communication Disorder
Donald Oswald, PhD
Commonwealth Autism Service
The Goal of DSM-5
• APA DSM-5 workgroups formed in 2007 with the
goals of:
– Creating a more “dimensional” classification system
– Separating constructs of impairment and disorder (e.g.,
with the use of severity scales)
– Reducing “-NOS” diagnoses in favor of broad categories
with dimensional specifiers
– Representing greater reflection of (and easier
incorporation of) neurobiological findings
» Gotham, K. (July 11, 2013). Autism Spectrum Disorder in DSM-5: Overview of
Updates to the Diagnostic and Statistical Manual and to the Autism Diagnostic
Observation Schedule (ADOS-2). Webinar hosted by the New Hampshire Autism
Council Screening & Diagnosis workgroup
Global Changes in DSM-5
• DSM-5 combines the first three DSM-IV-TR axes into one list
that contains all mental disorders, including personality
disorders and intellectual disability, as well as other medical
diagnoses.
• Contributing psychosocial and environmental factors or other
reasons for visits are now represented through an expanded
selected set of ICD-9-CM V-codes . . .
• The DSM-5 includes separate measures of symptom severity
and disability for individual disorders, rather than the Global
Assessment of Functioning (GAF) scale.
» APA. (2013). Insurance Implications of DSM-5
Autism Spectrum Disorder
• Autistic Disorder, Asperger’s Disorder, and Pervasive
Developmental Disorder NOS all subsumed under the
diagnostic label Autism Spectrum Disorder;
• CDD eliminated: “not being used” “age of onset specifier
added” [actually just a more flexible age of onset criterion]
» (http://www.psychiatry.org/practice/dsm/dsm5/dsm5-video-series-changes-to-autism-spectrum-disorder)
• Rett syndrome, if associated with ASD, is now specified as
“known genetic condition”
[Brief ICD-10 Digression]
Pervasive developmental disorders
– F84.0 - Autistic disorder
– F84.2 - Rett's syndrome
– F84.3 - Other childhood disintegrative disorder
– F84.5 - Asperger's syndrome
– F84.8 - Other pervasive developmental disorders
– F84.9 - Pervasive developmental disorder,
unspecified
» Source: ICD-10-CM TABULAR LIST of DISEASES and
INJURIES - 2014
Symptom clusters
“(A) qualitative impairment
in social interaction” and
“(B) qualitative impairments
in communication”
(from DSM-IV)
The restricted repetitive
behavior cluster is
retained.
becomes
“A. Persistent deficits in
social communication
and social interaction”
(in DSM-5)
Social-Communication Factor
(Mandy et al., 2012)
• In a sample of verbal children with social communication
difficulties . . .
• “The [two-factor] DSM-5 model [Social Communication
(SC) and Restricted, Repetitive Behavior (RRB) ] was
superior to the three-factor DSM-IV-TR model.”
• “[At least] Among higher-functioning individuals, ASD is
a dyad, not a triad, with distinct social communication
and repetitive behavior dimensions.”
• Pretty good empirical support for two-factor model.
Autism Spectrum Disorder
A. Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by the following currently or by history
(examples are illustrative, not exhaustive):
1. Deficits in social-emotional reciprocity, ranging, for
example, from abnormal social approach and failure of
normal back and forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or
respond to social interactions.
Autism Spectrum Disorder (DSM-5)
2. Deficits in nonverbal communicative behaviors used
for social interaction, ranging, for example, from
poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and
body-language or deficits in understanding and use of
gestures; to a total lack of facial expression and
nonverbal communication.
3. Deficits in developing, maintaining and understanding
relationships, ranging, for example, from difficulties
adjusting behavior to suit various social contexts; to
difficulties in sharing imaginative play or in making
friends; to absence of interest in peers.
Digression Re: Criterion A
• “The really fatal flaw here is that no
instructions are given as to whether one item,
two items, or all three items must be present
to make the diagnosis of Autism Spectrum
Disorder. “
» Allen Frances, chairman of the DSM-IV task force. (Blog,
May 25, 2013)
Autism Spectrum Disorder (DSM-5)
B. Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history
(examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of
objects, or speech (e.g., simple motor stereotypies,
lining up toys or flipping objects, echolalia, idiosyncratic
phrases).
2. Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
behavior (e.g., extreme distress at small changes,
difficulty with transitions, rigid thinking patterns,
greeting rituals, need to take same route or eat same
food everyday).
Autism Spectrum Disorder (DSM-5)
3. Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively
circumscribed or perseverative interests).
4. Hyper-or hypo-reactivity to sensory input or unusual
interest in sensory aspects of environment (e.g., apparent
indifference to pain/temperature, adverse response to
specific sounds or textures, excessive smelling or touching
of objects, visual fascination with lights movement).
Autism Spectrum Disorder (DSM-5)
C. Symptoms must be present in the early developmental period
(but may not become fully manifest until social demands
exceed limited capacities, or may be masked by learned
strategies in later life).
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual
disability (intellectual developmental disorder) or global
developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid
diagnoses of autism spectrum disorder and intellectual
disability, social communication should be below that
expected for general developmental level.
Specify if:
• With or without accompanying intellectual
impairment
• With or without accompanying language impairment
• Associated with a known medical or genetic
condition or environmental factor
• Associated with another neurodevelopmental,
mental, or behavioral disorder
• With catatonia
RE: Catatonia
Specify if:
• With or without accompanying intellectual
impairment
• With or without accompanying language
impairment
• Associated with another neurodevelopmental,
mental, or behavioral disorder
• With catatonia
Severity levels for Autism Spectrum
Disorder
• Level 1: "Requiring Support"
• Level 2: "Requiring Substantial Support"
• Level 3: "Requiring Very Substantial Support
A Comment on Discrepant Conceptualizations of
Severity in ASD (Weitlauf et al., 2013)
• it is not clear how individuals with mixed levels of
impairment across cognitive, adaptive, and autismspecific symptom domains would be classified in
terms of DSM-5 ‘‘Level of Support’’
• [Should Level of Support . . .?]
– be influenced by co-occurring symptoms and
impairments that, although related to ASD, are not
part of its core symptom profile [or]
– indicate ‘‘level of support’’ for ASD symptoms alone
(i.e., should not overlap with functional impairment)
Issues with respect to Level of Support
• What are the psychometric properties of this
scale?
• How will this characterization of individuals be
used?
Autism Spectrum Disorder in DSM-5
• The DSM-5 allows dual diagnosis of ASD and
AD/HD
Autism Spectrum Disorder in DSM-5
• "Note: 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 diagnosis
of autism spectrum disorder. Individuals who
have marked deficits in social communication,
but whose symptoms do not otherwise meet
criteria for autism spectrum disorder, should be
evaluated for social (pragmatic) communication
disorder."
Impact of DSM-5
(Frazier et al., 2012)
• “DSM-5 criteria had superior specificity relative to
DSM-IV-TR criteria (0.97 versus 0.86); however
sensitivity was lower (0.81 versus 0.95). Relaxing
DSM-5 criteria by requiring one less symptom
criterion increased sensitivity (0.93 versus 0.81),
with minimal reduction in specificity (0.95 versus
0.97).”
• Retrospective, using existing assessment data
Impact of DSM-5
• McPartland et al. (2012), Matson, Belva et al. (2012),
Matson, Kozlowski et al. (2012), and Worley and Matson
(2012) . . . All of these studies show that according to the
proposed algorithm, 30–45 % of children, adolescents,
and adults classified with ASDs according to DSM-IV-TR
criteria will not meet DSM-5 criteria for ASD.
• Matson, Hattier, & Wiliams, 2012
• Utilizing combined ADOS/ADI-R data, 93 % of participants
met DSM-5 criteria, which suggests likely continuity
between DSM-IV and DSM-5 research samples
characterized with these instruments in combination.
• Mazefsky et al., 2013
• All retrospective, using existing assessment data
DSM-5 Field trial
• At Stanford . . . there were a total of 41 children who
qualified for an autism spectrum disorder diagnosis
under DSM-IV versus 36 with DSM-5 [88%]. But there
were an additional 10 children who received a
diagnosis of a newly proposed condition dubbed
"social communication disorder" in the DSM-5 draft,
which had no counterpart in DSM-IV.
• Among the total of 46 who received diagnoses of
autism spectrum or social communication disorders
under DSM-5 were six who could not be diagnosed
with anything under DSM-IV.
• Reported response by Susan Swedo, MD, of the National Institute
of Mental Health, head of the American Psychiatric Association
committee rewriting the diagnostic criteria for autism spectrum
disorders
DSM-5 Field trial
• . . .when the clinicians applied DSM-IV and DSM-5
criteria to the nearly 300 children included in the
trial [across both sites], the autism spectrum
prevalence was not changed much.
• At Baystate Medical Center in Springfield, Mass., it
increased a bit, to 25% with DSM-5 versus 23%
with DSM-IV. At Stanford University in Palo Alto,
Calif., it dropped to 20% from 26%.
• Reported response by Susan Swedo, MD, of the National
Institute of Mental Health, head of the American
Psychiatric Association committee rewriting the diagnostic
criteria for autism spectrum disorders
Impact of DSM-5
Barton et al. (2013)
• In a sample of toddlers (n=422; Mean age = 25.76
months), the best algorithm required meeting only two
(rather than three) of the DSM-5 social communication
criteria and one (rather than two) of the repetitive
behavior criteria.
• In addition, the algorithm adopted a relaxed threshold
for meeting the repetitive behavior criteria, meaning that
a child’s repetitive behaviors could be less marked or less
prototypical and still meet a criterion.
• Conclusion: the DSM-5 symptom criteria for ASD, as
currently conceptualized, are too restrictive to be
acceptable for use with young children.
• Retrospective study using existing assessment data
Impact of DSM-5
Gibbs et al., 2013
• Prospective study
• 132 children and adolescents referred to a tertiary-level
autism speciﬁc assessment service for an initial diagnostic
assessment for autism
• DSM-IV-TR and DSM-5 diagnostic decisions were based on
clinical judgment, informed by scores from the ADOS and ADIR, information gathered from background reports and
teachers or other professionals, results of previous cognitive
assessments, information regarding academic functioning
• Twenty-six of the 111 children (23.4 %) who received a
diagnosis under DSM-IV-TR did not meet criteria when
considered under the proposed DSM-5 criteria.
Impact of DSM-5
Gibbs et al., 2013
• Comparing those who did retain an autism diagnosis with
those who did not, no significant difference regarding age or
gender.
• “ . . . compared to those diagnosed with Asperger’s Disorder
or Autistic Disorder [under DSM-IV-TR], a higher proportion
[50%] of children with PDD-NOS under DSM-IV-TR [failed] to
meet criteria under DSM-5”
• “It is possible that many of the children who would no longer
meet ASD criteria under DSM-5 would instead meet criteria
for a diagnosis of the proposed DSM-5 Social Communication
Disorder (SCD).” [SCD not assessed in this study.]
Impact of DSM-5
Gibbs et al., 2013
• “. . . of the 26 children who did not retain their DSM-IV-TR
diagnosis under DSM-5, 14 failed to meet criteria under DSM5 due to insufﬁcient evidence of impairment in RRBs . . . 12
cases were sub-threshold in terms of the DSM-5 social
communication domain, with the majority of this group (eight
children) displaying largely intact use of nonverbal behaviors,
both currently and according to historical record.”
• “. . . without any further changes, DSM-5 is likely to reduce
the number of children who will be diagnosed with an ASD in
the future due to the more stringent requirements. . .”
Impact of DSM-5
Young & Rodi 2013
• Of the 210 participants in the present study who met DSMIVTR criteria for a PDD [i.e., autistic disorder, Asperger’s
disorder and pervasive developmental disorder-not otherwise
specified (PDD-NOS)], only 57.1 % met DSM-5 criteria
(specificity = 1.0) for autism spectrum disorder when criteria
were applied concurrently during diagnostic assessment.
• High-functioning individuals (i.e., Asperger’s disorder and
PDD-NOS) were less likely to meet DSM-5 criteria than those
with autistic disorder.
• failure to satisfy all three criteria in the social-communication
domain was the most common reason for exclusion (39 %).
Some Questions
• What will be the impact of the “by history”
qualifier?
• How will the DSM-5 criteria be applied in
community settings?
Impact of DSM-5
• “One might ask what . . . the actual impact of
DSM-5 will be. The simple response is that we
do not know.”
– Volkmar & Reichow, 2013
Autism Spectrum Disorder in DSM-5
• "Note: 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 diagnosis
of autism spectrum disorder. Individuals who
have marked deficits in social communication,
but whose symptoms do not otherwise meet
criteria for autism spectrum disorder, should be
evaluated for social (pragmatic) communication
disorder."
Social (Pragmatic) Communication
Disorder
A. Persistent difficulties in the social use of verbal and nonverbal
communication as manifested by all of the following:
1.
2.
Deficits in using communication for social purposes, such as
greeting and sharing information, in a manner that is
appropriate for the social context.
Impairment of the ability to change communication to match
context or the needs of the listener, such as speaking
differently in a classroom than on a playground, talking
differently to a child than to an adult, and avoiding use of
overly formal language.
Social (Pragmatic) Communication
Disorder
A.
(cont):
3.
4.
Difficulties following rules for conversation and storytelling,
such as taking turns in conversation, rephrasing when
misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.
Difficulties understanding what is not explicitly stated (e.g.,
making inferences) and nonliteral or ambiguous meanings of
language (e.g., idioms, humor, metaphors, multiple meanings
that depend on the context for interpretation.
Social (Pragmatic) Communication
Disorder
B. The deficits result in functional limitations in effective
communication, social participation, social relationships,
academic achievement, or occupational performance,
individually or in combination.
C. The onset of the symptoms is in the early developmental
period (but deficits may not become fully manifest until social
communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or
neurological condition or to low abilities in the domains of
words structure and grammar, and are not better explained by
autism spectrum disorder, intellectual disability (intellectual
developmental disorder), global developmental delay, or
another mental disorder.
Social (Pragmatic) Communication
Disorder
• ASD is characterized by 1) deficits in social
communication and social interaction and 2)
restricted repetitive behaviors, interests, and
activities (RRBs). Because both components
are required for diagnosis of ASD, social
communication disorder is diagnosed if no
RRBs are present.
– APA (2013).Highlights of Changes from DSM-IV-TR to DSM-5.
ASD and S(P)CD
• ASD Social
Communication criteria
– Deficits in socialemotional reciprocity
– Deficits in nonverbal
communicative behaviors
used for social interaction
– Deficits in developing,
maintaining and
understanding
relationships
• S(P)CD criteria
― Deficits in using
communication for social
purposes
— Impairment of the ability to
change communication to
match context or the needs of
the listener
— Difficulties following rules for
conversation and storytelling
— Difficulties understanding
what is not explicitly stated
(e.g., making inferences) and
nonliteral or ambiguous
meanings of language
S(P)CD Critique
Norbury, 2013
• Diagnosis of SPCD is currently challenged by a lack of
culturally valid assessment tools and a paucity of research
evidence that the diagnostic criteria identify a coherent and
persistent clinical condition.
• The existing evidence suggests that social communication and
pragmatic language impairments are best conceived of as
symptoms, rather than a diagnostic entity.
• In addition, social communication and pragmatic language
impairments do not necessarily go together and therefore the
requirement that both are present for diagnosis is untenable.
Some Questions about S(P)CD
• Do these specific communication differences
cluster together in nature?
• Does this combination exist in a ‘pure’ form,
justifying a distinct diagnostic category, or
only as difficulties that are invariably a part
of some other condition?
• How will the education system handle the
Social Communication Disorder diagnosis?
Contact Information
Donald Oswald, PhD
Commonwealth Autism Service
[email protected]