Hear Voices? You’re No Longer Schizophrenic in DSM-V

In DSM-IV, if you hear voices, you can be diagnosed with schizophrenia even if this is the only “psychotic” symptom. This has been controversial for a while, because many people hear voices without being actually psychotic. Not only other conditions – such as dissociative identity disorder – are characterized by voice-hearing, but voice-hearing may be a normal symptom related to stress.

Thankfully, the DSM-V workgroup is recommending that someone must have two or more characteristic symptoms of schizophrenia for a substantial period of time in order to be diagnosed. These two symptoms must include at least one core symptom, which are determined to be delusions, hallucinations and disorganized speech. In addition, people must display a significant deterioration in their social or occupational functioning. This criterion was considered for elimination, but the workgroup thankfully decided against this. Again, this protects functioning voice-hearers from a false diagnosis.

Of course, there is the newly considered diagnosis of attenuated psychosis syndrome, which includes symptoms suggesting a person is at risk of a psychotic disorder. This diagnosis may cause voice-hearers to be pathologized after all, which is a very sad thing.

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Factitious Disorder

I have been told a few times that I fake being dissociative. Faking is often assumed to be a behavior problem, sometimes even an offense, rather than a mental illness. In fact, factitious disorder, popularly known as Münchhausen Syndrome, is a real mental health condition.

In DSM-IV, factitious disorder is characterized by intentional feigning or creating of symptoms or signs of illness, which is present even without obvious external reward, and which is not due to another mental disorder (eg. delusional disorder). Furthermore, the person must present themself to others as ill or impaired.

In the current proposal for DSM-V, slight modifications have been made to the wording. The part about intent has been replaced with wording about a pattern of falsification of signs or symptoms. It is added that the faking of symptoms or signs must be associated with deception. This change of wording was made in order to clarify that intent or motivation must be objectified, rather than inferred.

The DSM-V workgroup is still uncertain as to how to classify severity. It is proposed that level one is diagnosed when a person only reports faked symptoms, level two when lab tests were modified, level three when a person makes themself sick, and level four when one’s faking leads to life-threatening illness. Of course, here, it seems there is an overemphasis on physical symptoms, because psychological symptoms do not present themselves on lab tests or the like. I do not know how the faking of psychological symptoms would be graded.

Obviously, of course, I do not have factitious disorder. Imagining of symptoms – even assuming my DID symptoms are indeed not real, which I do not believe – is not the same as intentionally falsifying them. There is, however, no category in the DSM for people who unintentionally imagine a (psychological) disease.

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Post-Traumatic Stress Disorder: DSM-IV and DSM-V

I have very recently been labeled with PTSD. I am not sure that I agree with this sort-of diagnosis – I’m not sure whether it’s an official diagnosis or not. I checked the DSM-IV criteria and unfortunately do seem to meet them. I was particularly reluctant to believe I avoid stimuli associated with the trauma, since most triggering things are also particularly fascinating to me. However, in DSM-IV, avoidance and numbing of emotions are categorized together into one criterion, and I do meet that criterion, because I have enough symptoms of detachment, expecting to have a limited future, etc.

In DSM-V, however, avoidance is its own criterion. One must either avoid internal or external stimuli associated with the trauma. I’m not sure I do that. Further, negative alterations in cognition and mood are collected in their own criterion. I do definitely meet that criterion even in DSM-V, where a higher threshold for a diagnosis is required than in DSM-IV. This is still under consideration though. The other two symptom criteria – reliving the trauma and hightened arousal – are pretty much retained as in DSM-IV.

The definition of trauma, most notably, has been made much more strict in the proposal for DSM-V than it currently is. First of all, threat to physical integrity (DSM-IV) had been renamed actual or threatened sexual violation. Whether this is significant remains to be seen. Secondly, however, witnessing violence through electronic media is explicitly excluded from the definition of trauma, unless it is work-related (such as for police officers). I can sort of see where the DSM-V workgroup is coming from there, but I’m not sure I agree. Lastly, death of a relative must be violent or accidental in order to meet the definition of trauma, except in children, where it is considered that death of an attachment figure can count. Again, I can see where the workgroup is coming from, but I’m not sure I agree.

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Usefulness of DSM-IV-TR Criteria in Diagnosing Autism in Children with Intellectual Disabilities

Harold L. Doherty recently posted a link on Twitter to a study on the usefulness of the diagnostic criteria for autism in children with intellectual disabilities. The study was published in the June, 2010 issue of Focus on Autism and Other Developmental Disabilities.

The study tested 89 children with intellectual disabilities on a variety of tests, including for intelligence, adaptive behavior, and language ability. Then, children were assessed for autism using the ADOS-G, an observation scale for autistic behaviors. A consensus was reached over whether they had ASD (31 children) or not (58 children). Then, a parent of each of the children was given a semi-structured interview based on DSM-IV-TR criteria for autism. The resutls of these interviews were than analyzed to determine which criteria each child met. This information was used to determine the sensitivity (how likely this criterion was to correctly identify children with ASD) and specificity (how well this criterion correctly identified children without ASD as such) for each criterion. Differences in which criteria were met, could not be explained by differences in IQ, adaptive behavior, or any other independent variable, since there were no significant differences between groups on these measures. That is interesitng in itself, but not the focus here.

It was found that all four criteria of the social interaction domain (poor non-verbal communication, lack of appropriate peer relationships, lack of spontaneous sharing, and lack of social and emotional reciprocity), two of the criteria of the communication domain (stereotyped language and lack of appropriate make-believe play), and one of the criteria of the stereotypic behavior domain (stereotyped or restricted interests) were useful in distinguishing children with intellectual disability and ASD from those with only an intellectual disability. Within the domain of social interaction, an impairment in non-verbal communication was the most useful criterion, with both pretty good sensitivity and specificity. Interestingly, only impairment in non-verbal communication and stereotyped language have both sensitivity and specificity greater than 70%. The reason for the lack of usefulness of the other criteria was mostly the fact that a significant number (over forty percent, often) of the children with only intellectual disability and no ASD, also met these criteria. Interestingly, only 33% of the children who had ASD, met the criterion of preoccupation with parts of objects. This makes me wonder how useful this criterion is in the diagnosis of autism in general. It is not being proposed as a criterion in DSM-V anymore.

As I said, DSM-IV-TR interviews were used in this study. The authors stress the importance of using an observational method for diagnosing ASD in children with intellectual disabilities. They also advise that further research be done into specific methods of diagnosing autism in individuals with intellectual disability. Besides the fact that, apparently, only half the DSM-IV-TR criteria are useful in diagnosing ASD in people with intellectual disabilities, the reasoning goes that it is possible that, on the other criteria, there may be qualitative and quantitative differences between people with intellectual disabiliteis with and without ASD. These qualitative or quantitative differences are not properly identified by an all-or-nothing algorithm such as the DSM.

Lastly, research is needed on the usefulness of autism diagnostic criteria for people without intellectual disabilities versus those who do have intellectual disabilities. After all, the authors say, it is possible that autism presentation varies depending on level of intellectual ability. I would say that such research could also help us further figure out the complex interrelatedness between cognitive, social, behavioral, and communicative impairments that is seen in both autism and intellectual disability, and in the combination of these.

Reference

Hartley SL, Sikora DM (2010), Detecting Autism Spectrum Disorder in Children With Intellectual Disability: Which DSM-IV-TR Criteria Are Most Useful? Focus on Autism and Other Developmentqal Disabilities, 25(2):85-97. DOI: 10.1177/1088357609356094.

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