The problem I have with DSM-5-TR's diagnostic criteria for ASD

[Oz67]

Does the Broad Autism Phenotype blur the differences between people with ASD and normal persons with autistic traits? To what extent does the Broad Autism Phenotype manifest into ASD and should get diagnosed as a young or older adult?


The problem I have with the DSM-5-TR diagnostic criteria for ASD is this “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).”

 

[marc_101]

The DSM is written in something resembling legal writing mixed with the worst medical writing.

My understanding of what C. means is something like:

We think ASD is a neurological disorder. People are born with it. But it changes over time and it may not be noticeable until it is noticeable. For some, the symptoms will be obvious at early ages. For others, it will only become clear (i.e., it will "manifest") later --say, when a kid starts having problems socializing after going to school. For others, it could be as late as teen years, college, or even after many failed relationships or work-related problems.

Every person has autistic traits to some degree and at some point. The diagnosis is fitting the cluster of traits over a long time even if problems arrived later.

 

[Oz67]

The DSM is written in something resembling legal writing mixed with the worst medical writing.

My understanding of what C. means is something like:

We think ASD is a neurological disorder. People are born with it. But it changes over time and it may not be noticeable until it is noticeable. For some, the symptoms will be obvious at early ages. For others, it will only become clear (i.e., it will "manifest") later --say, when a kid starts having problems socializing after going to school. For others, it could be as late as teen years, college, or even after many failed relationships or work-related problems.

Every person has autistic traits to some degree and at some point. The diagnosis is fitting the cluster of traits over a long time even if problems arrived later.

What it means is that your symptoms of ASD always caused problems but it didn't bother you much until much later and you need help at some point.

 

[Neonatal RRT]

Does the Broad Autism Phenotype blur the differences between people with ASD and normal persons with autistic traits? To what extent does the Broad Autism Phenotype manifest into ASD and should get diagnosed as a young or older adult?


The problem I have with the DSM-5-TR diagnostic criteria for ASD is this “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).”

Hmmm. Probably a better question for a trained psychologist, but, let's pick this apart a bit. "...the DSM-5-TR diagnostic criteria for ASD is this “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).” If we can possibly isolate for ASD (difficult to do), but regardless, this statement should hold true.

Now, given "the spectrum", as we say, things can get a bit nebulous/fuzzy/blurry at times. Normal persons with autistic traits? Normal persons can certainly exhibit intermittent behaviors that persons with an ASD experience more consistently, but they are considered "normal". However, as you pointed out, this is the difficult part. At what point does intermittent become more of a chronic or consistent behavior trait that is part of a neurodevelopmental condition from the perspective of the psychologist? I suspect this is subject to the cognitive biases of the psychologist.

You've identified the primary problem with trying to diagnose a prenatal, genetic, neurodevelopmental condition (autism) via signs and symptoms, rather than genetics, neuroimaging, and neurodiagnostic testing. I suspect we will eventually get there some day, but it is not this day.

 

[Oz67]

Hmmm. Probably a better question for a trained psychologist, but, let's pick this apart a bit. "...the DSM-5-TR diagnostic criteria for ASD is this “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).” If we can possibly isolate for ASD (difficult to do), but regardless, this statement should hold true.

Now, given "the spectrum", as we say, things can get a bit nebulous/fuzzy/blurry at times. Normal persons with autistic traits? Normal persons can certainly exhibit intermittent behaviors that persons with an ASD experience more consistently, but they are considered "normal". However, as you pointed out, this is the difficult part. At what point does intermittent become more of a chronic or consistent behavior trait that is part of a neurodevelopmental condition from the perspective of the psychologist? I suspect this is subject to the cognitive biases of the psychologist.

You've identified the primary problem with trying to diagnose a prenatal, genetic, neurodevelopmental condition (autism) via signs and symptoms, rather than genetics, neuroimaging, and neurodiagnostic testing. I suspect we will eventually get there some day, but it is not this day.

I even told my parents at some point that our family tree could have ASD, because it can be genetic and run in families, even my brother who is in the army could have ASD traits as well.

My parents agree with that possibility, but they asked why they need a diagnosis if they function so well in the world.

Even my mom said to me that everyone shows symptoms of ASD sometimes. Still, she explained to me that if it becomes chronic and intense, that is when it becomes a problem and you might need a diagnosis, and if it is not ASD, seek an alternative diagnosis.

 

[marc_101]

I think that's more or less correct. If it is not a problem, then what is the problem?

For some, ASD is not a problem for a long time until it becomes a problem.

The neurodiverse movement, which I like, by the way, added some more fuzziness. We're all different, unique, and it's all part of the natural diversity in nature. But then how do you define a disorder? There has to be a line somewhere even if that line changes person by person. And then there are people who get offended even with the word disorder.

But for me the key is distress, problem. A diagnosis is part of finding a solution for a problem.

Then again, there are psychopaths who seldom seek help because according to them they are awesome. They can be a serious problem for others...

 

[Oz67]

I think that's more or less correct. If it is not a problem, then what is the problem?

For some, ASD is not a problem for a long time until it becomes a problem.

The neurodiverse movement, which I like, by the way, added some more fuzziness. We're all different, unique, and it's all part of the natural diversity in nature. But then how do you define a disorder? There has to be a line somewhere even if that line changes person by person. And then there are people who get offended even with the word disorder.

But for me the key is distress, problem. A diagnosis is part of finding a solution for a problem.

Then again, there are psychopaths who seldom seek help because according to them they are awesome. They can be a serious problem for others...

That is a good point to consider, but I am different, I have ASPD+P traits, but with empathy and want to change. I go to psych therapy and take meds for some of my antisocial thoughts or sometimes antisocial delusions that I tend to hide.

 

[Oz67]

I have a diagnosis of Autistic Disorder according to recent medical records, it used to be Pervasive Developmental Disorder Not Otherwise Specified, and when I was in mental institution for command hallucinations and homicidal ideation, I got diagnosed with Autism Spectrum. The psychiatrist there decided to leave the word "Disorder" out of the picture to avoid further stigma.

 

[Outdated]

You've identified the primary problem with trying to diagnose a prenatal, genetic, neurodevelopmental condition (autism) via signs and symptoms, rather than genetics, neuroimaging, and neurodiagnostic testing. I suspect we will eventually get there some day, but it is not this day.

I find it strange that we don't have this technology already available. I can have a genetic assay done from a cheek swab that will tell me if I'm likely to have a bad reaction to SSRIs, a class of drug that typically only autistic people have bad reactions to. Sooner or later someone will put two and two together and a test for autism will be simple, quick, and concise.

 

[Oz67]

I find it strange that we don't have this technology already available. I can have a genetic assay done from a cheek swab that will tell me if I'm likely to have a bad reaction to SSRIs, a class of drug that typically only autistic people have bad reactions to. Sooner or later someone will put two and two together and a test for autism will be simple, quick, and concise.

That is exactly my point

Thanks

 

[Au Naturel]

Does the Broad Autism Phenotype blur the differences between people with ASD and normal persons with autistic traits? To what extent does the Broad Autism Phenotype manifest into ASD and should get diagnosed as a young or older adult?


The problem I have with the DSM-5-TR diagnostic criteria for ASD is this “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).”

Genes and some epigenetic factors set you up for autism. Then, the environment you grow up in might move you a little in one way or another. By the time you are two, there are some simple tests to perform that have a high degree of accuracy in predicting your future experience.

ASD-1 might not experience problems until they go to school and must integrate with their teachers and peers. Many go a lifetime without anyone thinking to test for autism. But, if you can get an objective glance at their early childhood, it was there. Nobody becomes autistic with age.

Autism isn't just a lone spectrum, separate from the rest of life. It is part of a greater spectrum. (At the other end of the spectrum might be "anti-autism" but I have no idea what that would be.) In the middle of a great Bell curve are the neurotypical. Since it is a spectrum, NT blends imperceptibly into autistic. The line is arbitrary, and there's a blending zone where the differentiation is subjective. A person near the line might well be diagnosed by one professional but not by another.

"NTs with autistic traits" experience many of the same issues we do, just a toned-down version.

It is like asking where red ends and orange begins. It is obvious there's a difference but where the line is drawn is completely arbitrary.

All human traits that are governed by multiple genes exhibit a Bell curve. A trait that is governed by a single gene but then modified by epigenetics or post-natal environment is also exhibited as a Bell curve.

 

[Au Naturel]

I find it strange that we don't have this technology already available. I can have a genetic assay done from a cheek swab that will tell me if I'm likely to have a bad reaction to SSRIs, a class of drug that typically only autistic people have bad reactions to. Sooner or later someone will put two and two together and a test for autism will be simple, quick, and concise.

It seems very difficult to pin down a specific test for most autism genes. I'm not sure how high the priority is for finding them.

There are a couple of genes that can be tested for. We know that having one of those genes 100% will make you autistic. Most autistic people don't have one of those genes, yet the evidence for genetic factors in autism is overwhelming. Some say as high as 80% of autistic traits are genetic.

If you look at the development of a section of the brain, it might be governed by many genes plus the genes for the development of adjacent areas can have an impact. Last I heard there were a hundred+ candidate genes. I had a complete DNS sequencing done just out of curiosity, and I have one of them.

Epigenetics also injects noise into the signal we are looking for, especially when you are looking at ASD-1 vs. NTs with autistic traits. Since autism diagnosis is based on phenotype and not genotype, your home and school environment might shift a person between those two categories. That's even more noise.

It is amazing what we can learn by studying reproduction via egg donation, sperm donation, surrogacy, and so on.

 

[jsilver256]

To make it more difficult, there are identical twin cases where one twin is not intellectually disabled and ASD1 and another twin is severely intellectually disabled and ASD3. Here's one article.

 

[Au Naturel]

To make it more difficult, there are identical twin cases where one twin is not intellectually disabled and ASD1 and another twin is severely intellectually disabled and ASD3. Here's one article.

That is an incredible article. Same genes but a surgery and an infection at a critical point may have made a huge difference. Or maybe it was a point mutation in one sibling during gestation.

 

[Oz67]

Genes and some epigenetic factors set you up for autism. Then, the environment you grow up in might move you a little in one way or another. By the time you are two, there are some simple tests to perform that have a high degree of accuracy in predicting your future experience.

ASD-1 might not experience problems until they go to school and must integrate with their teachers and peers. Many go a lifetime without anyone thinking to test for autism. But, if you can get an objective glance at their early childhood, it was there. Nobody becomes autistic with age.

Autism isn't just a lone spectrum, separate from the rest of life. It is part of a greater spectrum. (At the other end of the spectrum might be "anti-autism" but I have no idea what that would be.) In the middle of a great Bell curve are the neurotypical. Since it is a spectrum, NT blends imperceptibly into autistic. The line is arbitrary, and there's a blending zone where the differentiation is subjective. A person near the line might well be diagnosed by one professional but not by another.

"NTs with autistic traits" experience many of the same issues we do, just a toned-down version.

It is like asking where red ends and orange begins. It is obvious there's a difference but where the line is drawn is completely arbitrary.

All human traits that are governed by multiple genes exhibit a Bell curve. A trait that is governed by a single gene but then modified by epigenetics or post-natal environment is also exhibited as a Bell curve.

Thank you for education, it's a good point to consider.

 

[Oz67]

That is an incredible article. Same genes but a surgery and an infection at a critical point may have made a huge difference. Or maybe it was a point mutation in one sibling during gestation.

That is an interesting article.

 

[Oz67]

It seems very difficult to pin down a specific test for most autism genes. I'm not sure how high the priority is for finding them.

There are a couple of genes that can be tested for. We know that having one of those genes 100% will make you autistic. Most autistic people don't have one of those genes, yet the evidence for genetic factors in autism is overwhelming. Some say as high as 80% of autistic traits are genetic.

If you look at the development of a section of the brain, it might be governed by many genes plus the genes for the development of adjacent areas can have an impact. Last I heard there were a hundred+ candidate genes. I had a complete DNS sequencing done just out of curiosity, and I have one of them.

Epigenetics also injects noise into the signal we are looking for, especially when you are looking at ASD-1 vs. NTs with autistic traits. Since autism diagnosis is based on phenotype and not genotype, your home and school environment might shift a person between those two categories. That's even more noise.

It is amazing what we can learn by studying reproduction via egg donation, sperm donation, surrogacy, and so on.

That makes sense.

 

[Shamar]

Does the Broad Autism Phenotype blur the differences between people with ASD and normal persons with autistic traits? To what extent does the Broad Autism Phenotype manifest into ASD and should get diagnosed as a young or older adult?


The problem I have with the DSM-5-TR diagnostic criteria for ASD is this “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).”

Don't pay any attention to DSM-5. In my opinion, it was politically corrected, woked, de-offensivized, and overly simplified to the point of near uselessness. I suspect they anticipated the quality of graduates that will be coming out in the next few years, and wrote accordingly.

 

[Seladon]

It seems very difficult to pin down a specific test for most autism genes. I'm not sure how high the priority is for finding them.

To examine demography and how it is socially-engineered I think is a critical point. Because:

1. Autistic people are not, even in this slowly destigmatising age, a sociopolitically welcome nor desirable demographic, at least not to those in power;
2. The birth rate and also the productivity rate in the West is dropping off a cliff, and governments are anxious to dissuade people from declining the governmentally-approved NT-friendly mortgage-and-two-kids lifestyle, and;
3. If everyday people could find out in vitro or at birth whether or not their child has autism, they may be motivated to abort or disown said child to prevent strain on their lives.

So for there to be a cheap, easy and convenient, quick and painless and relatively accurate genetic test isn’t in the business interests of anyone who has the means to provide it, I.e. politicians, big pharma and private healthcare providers, insurance providers, other corporations. The only powerful entity who could stand to benefit is a national not-for-profit social welfare, care or health service, who would be put under less strain to handle ASD people in their system.

 

[Seladon]

Something that’s bothered me about the DSM-V is how the differences between ASD in males and females are not taken into account, and how separate healthcare needs for each are not specifically recommended, thereby lumping all autistic patients together in healthcare settings.

E.g. I’ve known of unwell ASD1 women being placed onto wards with ASD2 & 3 men or ASD3 children, and emerging with little to no treatment and more traumatised than they were to start with. This kind of thing shouldn’t be happening.