Posts Tagged ‘ DSM 5 ’

2013 and … Autism

Wednesday, December 18th, 2013

Two themes stand out when I reflect on autism research in 2013.

First, there was substantial debate about how we diagnose autism, primarily spurred by changes introduced in DSM-5 (which was published in May). The reformulation of the diagnostic criteria – which led to a discontinuation of the category of Asperger Syndrome in favor of a broad-based category of Autism Spectrum Disorder (ASD) – spurred concerns that many youth would no longer qualify for a diagnosis and hence have their intervention options limited. Others suggested that more precise diagnostic criteria are needed to ensure that ASD does not get overdiagnosed. While we await empirical resolution via publication of well-designed studies, it’s clear that the DSM-5 debate will stand out as an important time in which we wrestled (again) with the best way to be inclusive in diagnosis without expanding diagnostic criteria too broadly.

Second, we are seeing more research on the early diagnosis of ASD, or at least detection of early warning signs, using methods like tracking eye movements of babies when looking at a human face. While this line of work will need to continue to refine the validity and feasibility of the approach – particularly when studying infants – it is an intriguing approach that may eventually have important implications for delivering interventions in the first year of life. Given the proven utility of early intervention, the hope is that the earliest interventions may hold the most promise for promoting development.

Wherever these research directions take us, we know for sure that early detection and intervention is essential. That’s one message that has not changed in 2013.

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Early Signs of Autism
Early Signs of Autism
Early Signs of Autism

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Red-Hot Parenting Recap May 2013: DSM-5

Friday, May 31st, 2013

The big theme this month was DSM-5. It’s here, we’re reacting – and parents will be dealing with the implications of this diagnostic system for quite some time.

So …. here’s a recap of what was covered this month:

General Issues: Changes Made, Controversies Raised, And What To Expect

An Overview For Parents

The “Saving Normal” Debate

Specific Disorders: What You Need To Know

Autism Spectrum Disorder

ADHD

Conduct Disorder

Disruptive Mood Dysregulation Disorder

 

 

 

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“Saving Normal”: Has DSM-5 Gone Too Far?

Thursday, May 30th, 2013

While DSM-5 should be reflecting consensus, it has certainly spurred many reactions – from inside the ranks. 

Consider that the National Institute of Mental Health – the primary funding agency for mental health research in the US – will essentially ignore the DSM-5 in favor of its own research-based criteria. In other words – the DSM-5 is not especially informative for those who do research on mental health.

Consider the serious critique of the process offered by Allen Frances, M.D., in his book Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Dr. Frances was chair of the DSM-IV Task Force, and as such has an insider’s viewpoint on the whole process. The bottom line for him is that the DSM-5 not only does not improve on what we had before, it makes matters worse, primarily by introducing new disorders and making decisions about diagnostic criteria without sufficient evidence or grounding. The bigger point is that the diagnostic approach is losing the ability to discriminate behaviors that are part of the normal spectrum (and reflective of normative variation) and those that are truly problematic for individuals and deserving of diagnosis as a way of guiding treatment.

So what do we make of all this? I have two reactions.

I’m not all that concerned about the NIMH part of this. The reality is that researchers frequently look at “psychiatric disorders” in a number of ways – and not by following whatever clinical system is in place. That’s the point of research – to come up with something better. The problem, though, is that while there has been a lot of research that impacts our understanding of the various disorders, it has not yielded a radically different way of defining them clinically. It’s the goal, but it’s far from the reality.

That’s where “Saving Normal” comes into play. It’s hard to see that substantial progress was made at the research end to justify a whole new system. The choices made in DSM-5 are bringing more uncertainty to an already uncertain process. Let’s look at kids briefly. What’s especially troubling is that some kids who need treatment may no longer meet criteria for a disorder (like the estimated 10% reduction rate in diagnosing Autism Spectrum Disorder) – whereas others who exhibit potentially age-appropriate typical behaviors (like tantrum tantrums) may be diagnosed with the rather shaky Disruptive Mood Dysregulation Disorder.

So where are we at? Diagnoses need to be made. Kids (and adults of course) need treatment. A diagnostic system for psychiatric disorders is going to be very fuzzy at best. Wouldn’t the best approach be to introduce changes for a given disorder when the evidence suggests it is the time to do so – rather than arbitrarily replace one system with another at a designated time in the future? In this day and age, wouldn’t that be feasible?

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Should Disruptive Mood Dysregulation Disorder Be In DSM-5?

Wednesday, May 29th, 2013

The biggest controversies that arise in diagnostic systems – like DSM-5 – come about when a previous diagnosis category is eliminated (as is the case with Asperger’s Disorder) or a new one is introduced. Such is the case with the new disorder Disruptive Mood Dysregulation Disorder (DMDD). Part of the rationale for including it was to prevent inappropriate use of a diagnosis of pediatric bipolar disorder. But that’s not a strong enough rationale to introduce a whole new diagnosis. So … should it be in the DSM-5? 

The answer is no. Here’s why.

The idea of the DSM is to represent not just current clinical thinking but sufficient evidence to support a diagnostic category. This process is already murky because DSM-5 operates by defining a disorder as a collection of symptoms. While this is necessary when known causes – and gold standard methods for identifying a disorder – are not available, we typically rely on a number of carefully designed studies that support diagnostic criteria. Simply put, that is what is lacking right now with respect to DMDD.

We are just starting see research studies that evaluate the utility of the diagnosis of DMDD. At best, they highlight the complexities involved in sorting through whether or not DMDD offers unique insight into the developmental profile of a specific subset of children who could profit from intervention.

And that’s the point. This research is important and will continue. But until it yields more clear guidelines – which will take some time – it’s just not time to include it in DSM-5. There is concern that kids with extreme temperamental traits – like those who are prone to tantrums – will get inappropriately labeled. It may be that many kids who will get the DMDD diagnosis can be better captured by other disorders with similar symptom profiles (like oppositional defiant disorder). Until we have better trials to evaluate these issues DMDD should not be in the manual. That’s how clinical science is supposed to work.

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Why Callous-Unemotional Traits Matter In DSM-5

Wednesday, May 29th, 2013

DSM-5 has raised lots of controversies by making changes to the way some psychiatric disorders are defined. But less controversial is flagging the importance of callous-unemotional traits in childhood as part of the diagnostic approach to Conduct Disorder. 

Conduct Disorder refers to a pattern of behavior that consistently violates the rights of others. As kids reach later childhood and their early teens, the types of behaviors include what we would think about as things that would get kids in trouble: destroying property, breaking and entering, fighting, lying, stealing. While some kids may do some of these things now and then, what’s important clinically is when a lot of these behaviors cluster together and occur with some frequency.

There can be many reasons why kids behave this way. It’s clear that kids exhibiting signs of Conduct Disorder require some type of intervention. It’s a pattern of behavior which can be associated with a lot of bad outcomes – dropping out of school, eventual substance abuse, and even jail.

So why are callous-emotional traits relevant, and flagged in DSM-5? The risk for these outcomes may be especially high if a child is showing callous-unemotional traits – such as a lack of empathy, a lack of remorse, and shallow emotions. When tracked over time, youth with these traits are especially likely to show a stable pattern of antisocial behavior over time – from childhood through adulthood. Their actions may be (or become) especially aggressive and violent.

Treating kids with callous-unemotional traits is complicated. A number of behavioral strategies may be considered, as well as some forms of drug treatment (especially if they have symptoms of other disorders, such as ADHD or depression).

DSM-5 has certainly be criticized. There are many hot-button topics raised in the revision. But the inclusion of callous-unemotional traits is an example of how research findings can lead to diagnostic changes that are simply there to signal which kids may be at especially high risk for a number of bad long-term outcomes and hence require some immediate form of intervention. That’s solid information for a clinician to weigh during the evaluation process.

Doctor with checklist via Shutterstock.com 

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