Autism And The DSM-5: Doorstop Or Diagnostic Tool?

“I use it as a doorstop.” That was the response I got from a psychiatrist when I gestured at his copy of the DSM (Diagnostic and Statistical Manual of Mental Disorders)-TR-IV and asked what he thought about it. If you read news stories about this book and its update, the DSM-5 (they’ve abandoned the Roman numerals), you might think that a clinician keeps at hand a much-used, heavily notated, dogeared version of this tome, the so-called “bible” of psychiatry. But from what I can see, the general inclination regarding this particular bible is apostasy.

And for good reason. By the time the DSM version du decade appears, its assumptions and conclusions are often passé, and if they haven’t been ground into dust by biological and medical sciences by publication, give it a few years. Anyone remember when this “bible,” like another book with that name, said that homosexuality was abnormal?

Even in the absence of debunking from basic science, the DSM can tilt the earth under its own characterizations of disorders. Possibly no other example of this ever-shifting diagnostic ground has led to more controversy than the upcoming version’s treatment of autism. As the parent of an autistic child and as a scientist who’s been writing about autism for almost exactly 8 years, I’ve watched these controversies closely. My top take-home message is quite similar to the one the psychiatrist I quote above sent. In fact, I currently do use my copy of the DSM-IV-TR as … a doorstop.

In spite of my inclination to dismissiveness, however, the DSM also carries weight because it’s one benchmark people use, diagnostically and in research, to identify and characterize autism. The just-mothballed version (IV) split autism diagnoses into categories of autistic disorder, Asperger’s, and the ever-muddled PDD-NOS (Pervasive Developmental Disorder-Not Otherwise Specified). The new version, the DSM-5, groups all autism into one category but sort of grandfathers in the previous categories. With the new version, for evaluating autism as a diagnosis, clinicians are expected to consider two domains of behavior— (1) social communication/interaction difficulties and (2) restricted/repetitive behaviors and interests—and rank them on severity scales. The idea is to create a snapshot of a person’s place on an autism spectrum and thus that individual’s level of “severity” and need for support.

Also for this new version of the DSM is a category of “social communication disorder.” Note above that “social communication/interaction difficulties” constitutes one of the behavioral domains for an autism diagnosis. Presumably, if a person presents with problems in this domain but without manifesting symptoms in the restricted behaviors domain, the intention is for that individual to be shunted into the social communication disorder category. Problem is, it’s one that no entity currently providing services—or paying for them—recognizes.

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