Autistisch persoon
8 augustus 2016
Bleuler (Eugen)
10 augustus 2016

Wat staat er over autisme in de DSM?

Vraag

 
Wanneer het gaat over de diagnose 'autisme' wordt vaak gesproken over de DSM. Dit is het handboek dat psychiaters en klinisch psychologen gebruiken bij het vaststellen van diagnoses. Sinds 1952 zijn er vijf edities van de DSM verschenen. Wat wordt daarin precies over autisme geschreven? Hier vindt je de oorspronkelijke teksten.

Welke edities en relevante classificaties zijn er?

DSM-5 (2013-heden): Autism Spectrum Disorder

Diagnostic criteria

A. Deficits in social communication and social interaction

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

A1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

A2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

A3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests or activities

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

B1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

B3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

B4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

C. Sympoms are present in the early developmental period
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).
D. Symptoms cause significant impairment in current functioning
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. Disturbances are not better explained by other disorders

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

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 (pragmatic) communication disorder.

Severity levels

Level 1: Requiring support

Social communication. Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.

Restricted, repetitive behaviors.Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning.

Level 2: Requiring substantial support

Social communication. Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and how has markedly odd nonverbal communication.

Restricted, repetitive behaviors. Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.

Level 3: Requiring very substantial support

Social communication. Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.

Restricted, repetitive behaviors. Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.

Comorbidity
Specify if: * With or without accompanying intellectual impairment * With or without accompanying language impairment * Associated with a known medical condition * Associated with a known genetic condition * Associated with another neurodevelopmental disorder * Associated with another mental disorder * Associated with another behavioral disorder

DSM-4 (1994-2013): Pervasive Development Disorder

Diagnostic criteria for Autistic Disorder

Introduction
The central features of Autistic Disorder are the presence of markedly abnormal or impaired development in social interaction and communication, and a markedly restricted repertoire of activity and interest. The manifestations of this disorder vary greatly depending on the developmental level and chronological age of the individual. Autistic Disorder is sometimes referred to as Early Infantile Autism, Childhood Autism, or Kanner’s Autism.
A1. Qualitative impairment in social interaction
Manifested by at least two of the following: * Marked impairment in the use of multiple nonverbal behaviors such as eye to-eye gaze, facial expression, body postures, and gestures to regulate social interaction * Failure to develop peer relationships appropriate to developmental level * A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) * Lack of social or emotional reciprocity.
A2. Qualitative impairments in communication
Manifested by at least one of the following: Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime) * In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others * Stereotyped and repetitive use of language or idiosyncratic language * Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.
A3. Restricted, repetitive patterns of behavior, interests and activities
Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: * Encompassing preoccupation with one or more stereotyped patterns of interest that is abnormal either in intensity or focus * Apparently inflexible adherence to specific, nonfunctional routines or rituals * Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) * Persistent preoccupation with parts of object.
B. Delays occur with onset prior to age 3
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by other disorders
C. The disturbance is not better accounted for by Rett's disorder or childhood disintegrative disorder.

GAF-score

Introduction
The Global Assessment of Functioning (GAF) is a numeric scale (1 through 100). The scale is presented and described in the DSM-IV-TR on page 34. The score is often given as a range.
GAF 61-100: No, transcient or mild symptoms

91 - 100 No symptoms. Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities.

81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.

71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

GAF 31-60: Moderate to serious symptomps

51 - 60 Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work).

31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

GAF 1-30: severe symptoms

21 - 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends).

11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute).

1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.

Diagnostic criteria for Asperger's Disorder

Introduction
The essential features of Asperger’s Disorder are severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interest, and activity. The disturbance must clinically show significant impairment in social, occupational, and other important areas of functioning. In contrast to Autistic Disorder, there are no clinically significant delays in language. In addition there are no clinically significant delays in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior, and curiosity about the environment in childhood.
A. Qualitative impairment in social interaction
As manifested by at least two of the following: * Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction * Failure to develop peer relationships appropriate to developmental level * A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) * Lack of social or emotional reciprocity
B. Restricted, repetitive patterns of behavior, interests, and activities
Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: * Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus * Apparently inflexible adherence to specific, non-functional routines or rituals * Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) * Persistent preoccupation with parts of objects
C. The disturbance causes significant impairment in functioning
The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D-E. No delay in language, cognition, adaptation and curiosity

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.<.p>

F. Criteria are not met for another disorder
Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

Diagnostic criteria PDD-NOS

Introduction
The essential features of Pervaisve Development Disorder-Not Otherwise Specified (PDD-NOS) are severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills; and stereotyped behaviors, interests, and activities. The criteria for Autistic Disorder are not met because of late age onset; atypical and/or sub- threshold symptomotology are present.
A. Criteria are not met for another Pervasive Developmental Disorder
This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypical Personality Disorder, or Avoidant Personality Disorder. For example, this category includes “atypical autism”– presentations that do not meet the criteria for Autistic Disorder because of late age of onset, atypical symptomatology, or sub-threshold symptomatology, or all of these.

DSM-3 (1980-1994): Infantile Autism / Autistic Disorder

Diagnostic criteria Infantile Autism

A. Onset before 30 months of age
[No comments]
B. Pervasive lack of responsiveness to other people (autism)
[No comments]
C-D. Gross deficits in language development or peculiar speech patterns

C. Gross deficits in language development

D. If speech is present, peculiar speech patterns such as immediate and delayed echolalia, metaphorical language, pronominal reversal.

E. Bizarre responses to various aspects of the environment
E. Bizarre responses to various aspects of the environment, e.g., resistance to change, peculiar interest in or attachments to animate or inanimate objects.
F. Absence of schizophrenic symptoms
F. Absence of delusions, hallucinations, loosening of associations, and incoherence as in Schizophrenia.

Diagnostic criteria for Autistic [Child] Disorder

A. Qualitative impairment in reciprocal social interaction
A. Qualitative impairment in reciprocal social interaction as manifested by the following (examples are arranged so that those first listed are more likely to apply to younger or more disabled, and the later ones, to older or less disabled): A1. Marked lack of awareness of the existence or feelings of others (for example, treats a person as if that person were a piece of furniture; does not notice another person's distress; apparently has no concept of the need of others for privacy); A2. No or abnormal seeking of comfort at times of distress (does not come for comfort even when ill, hurt, or tired; seeks comfort in a stereotyped way, for example, says "cheese, cheese, cheese" whenever hurt); A3. No or impaired imitation (does not wave bye-bye; does not copy parent's domestic activities; mechanical imitation of others' actions out of context); A4. No or abnormal social play (for example, does not actively participate in simple games; refers solitary play activities; involves other children in play only as mechanical aids); and A5. Gross impairment in ability to make peer friendships (no interest in making peer friendships despite interest in making fiends, demonstrates lack of understanding of conventions of social interaction, for example, reads phone book to uninterested peer).
B. Qualitative impairment in verbal and nonverbal communication
B. Qualitative impairment in verbal and nonverbal communication and in imaginative activity, (the numbered items are arranged so that those first listed are more likely to apply to younger or more disabled, and the later ones, to older or less disabled) as manifested by the following: B1. No mode of communication, such as: communicative babbling, facial expression, gesture, mime, or spoken language; B2. Markedly abnormal nonverbal communication, as in the use of eye-to-eye gaze, facial expression, body posture, or gestures to initiate or modulate social interaction (for example, does not anticipate being held, stiffens when held, does not look at the person or smile when making a social approach, does not greet parents or visitors, has a fixed stare in social situations); B3. Absence of imaginative activity, such as play-acting of adult roles, fantasy character or animals; lack of interest in stories about imaginary events; B4. Marked abnormalities in the production of speech, including volume, pitch, stress, rate, rhythm, and intonation (monotonous tone, question-like melody, or high pitch); B5. Marked abnormalities in the form or content of speech, including stereotyped and repetitive use of speech (immediate echolalia or mechanical repetition of a television commercial); use of "you" when "I" is meant (for example, using "You want cookie?" to mean "I want a cookie"); idiosyncratic use of words or phrases ("Go on green riding" to mean "I want to go on the swing"); or frequent irrelevant remarks (for example, starts talking about train schedules during a conversation about ports); and B6. Marked impairment in the ability to initiate or sustain a conversation with others, despite adequate speech (indulging in lengthy monologues on one subject regardless of interjections from others);
C. Markedly restricted repertoire of activities and interests
Manifested by the following: C1. Stereotyped body movements (for example, hand flicking or twisting, spinning, head-banging, complex whole-body movements); C2. Persistent preoccupation with parts of objects (for example, sniffing or smelling objects, repetitive feeling of texture of materials, spinning wheels of toy cars) or attachment to unusual objects (for example, insists on carrying around a piece of string); C3. Marked distress over changes in trivial aspects of environment (for example, when a vase is moved from usual position); 4. Unreasonable insistence on following routines in precise detail (for example, insisting that exactly the same route always be followed when shopping); C5. Markedly restricted range of interests and a preoccupation with one narrow interest, e.g., interested only in lining up objects, in amassing facts about meteorology, or in pretending to be a fantasy character.
D. Onset during infancy or early childhood
Specify if childhood onset (after 36 months of age)

DSM-1 en DSM 2 (1952-1980): Childhood Schizophrenia

Description in DSM-1 (1952)

Schizophrenic reaction, childhood type

Here will be classified those schizophrenic reactions occurring before puberty. The clinical picture may differ from schizophrenic reactions occurring in other age periods because of the immaturity and plasticity of the patient at the time of onset of the reaction. Psychotic reactions in children, manifesting primarily autism, will be classified here.

Description in DSM-2 (1968)

Schizophrenia, childhood type
This category is for cases in which schizophrenic symptoms appear before puberty. The condition may be manifested by autistic, atypical and withdrawn behavior; failure to develop identity separate from the mother's; and general unevenness, gross immaturity and inadequacy of development. These developmental defects may result in mental retardation, which should also be diagnosed.

Conclusie

 
Omdat de grondleggers van het autisme-onderzoek kinderpsychiaters waren, werd autisme in het begin vooral als kinderstoornis gedefinieerd. En omdat het werk van Hans Asperger in het Duits geschreven was, bleef dit lange tijd onbekend bij de Amerikaanse psychiaters. Zodoende werden vooral de criteria van Leo Kanner gebruikt. Vanaf de jaren '90 zijn de criteria meer geformuleerd met insluiting van volwassenen en in de meeste recente editie zijn ook sensorische afwijkingen opgenomen als criterium.
 

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