Two Fatal Technical Flaws in the DSM-5 Definition of Autism
by Allen Frances
05/25/2013The DSM-5 definition of Autistic Spectrum Disorder has two fatal technical flaws that make it impossible to interpret and use reliably. A truncated version of its Criterion A reads as follows:
"A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following…1. Deficits in social-emotional reciprocity;2. Deficits in nonverbal communicative behaviors used for social interaction;3. Deficits in developing, maintaining, and understanding relationships."The DSM 5 examples offered for each of these three items are vague enough to overlap into normality, but I wouldn’t have made a big fuss about this. 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. The diagnosis will vary dramatically from rater to rater, institution to institution, and place to place depending on which of these three different possible convention is chosen. It will be even more impossible than it is now to determine rates of autism and why they shift so much over time.
The second fatal flaw comes in the following statement attached to the end of the criteria set for Autism Spectrum Disorder:
"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 communication disorder."This throws wide open to raters the choice of using DSM-IV criteria or DSM-5 criteria depending on their personal preferences. DSM-5 has essentially made it clinician’s choice how to define and diagnose Autism Spectrum Disorder. Some will require one item from criterion A; others two; yet others three; and some will chuck DSM-5 altogether and use the very different definitions that are contained in DSM-IV.
The diagnosis of Autism is already badly muddled. There has been a forty-fold increase in rates in just 20 years. Some of this is due to the introduction of Asperger’s in DSM-IV, some to improved case finding and reduced stigma, but a significant portion comes from loose and inaccurate diagnosis. DSM-5 turns the current confusion into a complete Babel. The impossibly vague and confusing DSM-5 definition of Autism Spectrum Disorder is essentially useless for clinical or research purposes and is not a trustworthy guide for determining school services…
To my way of thinking, these bloopers are emblematic of a more fundamental problem with the manual. It’s not the manual the DSM-5 Task Force wanted to write. They set out to write a biomedical psychiatry manual and failed. So all the peculiar add-ons, the other idiosyncratic changes, the failed field trials, and screw-ups like the ones mentioned here are just reflections of a get-it-done mind set without the kind of dedication it takes to produce a really useful document.