Thursday, November 12, 2009
Asperger's, Autism, and the DSM: A New Autistic Spectrum without Asperger's Syndrome
Not according to an expert panel charged with revising the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of mental health workers in addition to health insurance companies. The panel wants to get rid of Asperger's and Pervasive Developmental Disorder (ususally reserved for younger children, often with more mild symptoms). In essence, the new DSM would replace the separate autistic disorders with an autism diagnosis characterized by severity of symptoms. So, children who would have fit the Asperger's category would most likely be labeled with mild autism.
Why all this fuss?
There's a growing trend to treat related disorders as a single disorder ranging in degree from mild to severe.
And then there's the hard scientific evidence. Or lack thereof.
Research has yet to find enough biological markers (okay, genes) to clearly delineate the autistic sub-groups - though psychologists and the like can and do distinguish people (and thus sub-groups) by their behavioral traits.
The lack of physical proof really hits mental health professionals where it hurts. We've got the chip on our collective soft-science shoulders. Psychologists and psychiatrists would love some solid evidence that we're not just making things up.
You see there's a history of playing loosey-goosey with the DSM categories. What we consider abnormal and thus in need of fixing has been fascinating and at times, cringe-worthy. Only as of 1986 was homosexuality totally removed from the DSM. Yes, what we've done to people who are different from the rest of us. Or most of us. Pathologizing them is the least of it. You can read more about the history of Asperger's and related issues in an excellent article in the New York Times A Powerful Identity, A Vanishing Diagnosis.
Of course there's plenty of folks unhappy with the proposed changes. Like people with the Asperger's label who've become attached to their label and their rather large and vocal peer group. Not to mention notice in Hollywood films of late. Or the clinicians who treat them and worry parents may be reluctant to have their children diagnosed as "austistic." And then there's the hassle of what to do with people who've been given the Asperger's diagnosis. Do we re-classify them? Then there're the scientists looking for those pesky genes, like Dr. Simon Baron-Cohen, one of the biggie autism researchers who said his piece in a New York Times op-ed, The Short Life of a Diagnosis - he'd like more time to find that hard evidence before we toss out the spectrum as we know it.
Me, I see both sides. I really like the idea of recognizing disordered behavior as part of a spectrum. In some sense it de-stigmatizes what we perceive as problematic behavior. If we say social skills, for instance, varies among people, an impairment of social skills is not something solely dogging kids we send to the school psychologist. At some point, an impairment becomes problematic but it's not evidence of some strange, mysterious disease afflicting only the unlucky. It's easy to spot tendencies of what we label abnormal behavior in people who aren't classified, whose symptomatology never meets the criteria for a DSM diagnosis. Plenty of bad behavior out there. Like the distinguished-looking man flipping me the bird this morning when I stopped (as NJ law dictates) for the children waiting at the pedestrian walk.
If you think sorting out the autistic spectrum is messy, take a look at the far-flung symptomatology attached to Sensory Perception Disorder (a.ka. Sensory Integration Disorder, Sensory Processing Disorder). The checklist covers everything from diarrhea, mood swings, fear of loud noises, brushing teeth, heights, and honestly, it's on the list - licking stamps and stickers. The American Psychiatric Association has a real challenge here - it's gotta decide whether to officially recognize the name-challenged slew of symptoms before it turns out the new DSM.
But before you bemoan the state of clinical psychology (and psychiatry), remember we have come a long way. We have plenty of therapies that do work despite their critics and the field's own sordid background.