DR. JOANNE GERENSER: OK. So let's now talk about the DSM-5. The DSM-5 was launched in 2013 after many, many years of work on it. The reason that we needed to move to the DSM-5 was that researchers found that the diagnostic criteria were not being applied consistently across the country, or for that matter, across other countries that also use the DSM.

In some cases, a child might get four different diagnoses from four different clinicians. And so they felt that they really needed to clean this up, because we were not being very consistent and it was having a major impact on things like access to treatment or doing research.

So there are two basic fundamental changes, I mean, there are many, many changes, but two fundamental ones. The first is that it collapsed all of the five diagnostic criteria into one. And so it now has just one diagnostic criteria called autism spectrum disorders.

And the second thing that it did was it took the three domains-- so if you remember in the DSM-IV, there was social, communication, and repetitive behavior-- and it collapsed it into two. So it took the social and communication and turned it into one category called social communication disorder. And then it maintained the repetitive behavior.

The thinking was that in reality, the language disorder in and of itself wasn't really reflective of autism. It was the way that individuals used their language in a non-social way, or in a stereotypical way, that was more consistent with an autism spectrum diagnosis.

And so the diagnostic criteria again, did maintain a certain set of rules that diagnosticians would use. So there were persistent deficits in social communication that couldn't be accounted for by simple developmental delays. And so again. I'm not going to go through each of these individual categories, but what you can do is, you'll look and see that there's an A and a B. The A is the social communication disorders, and the B is the repetitive behavior criteria.

And you'll look and see that there's a list of symptoms that the diagnosticians would look for, reduced sharing of affect, poor social imitation, failure for back and forth conversations. You're going to take a look and you're going to see that they're somewhat collapsed and they're far more detailed. I mean, the idea is that the more detail you can give a diagnostician, hopefully the more accurate they can be in their diagnoses.

So in addition to the social piece, there is the non-verbal communication. But again, four social interactions. So problems with prosody in pitch, which we'll talk again later in the lecture, difficulty understanding gestures or body postures, failure to have social relationships, lack of theory of mind, lack of perspective-taking. And again, if you compare the DSM-IV-R to the DSM-5, you're going to see that it's far more specific, that they get into much more detail about what these symptoms should look like.

In the B, which is the repetitive behavior, you need to have at least two of the symptoms. And again, you'll see that it's B1 all the way through B4, and you need to have two of these. So again it's repetitive speech, it could be repetitive use of objects, it could be adherence to rules to the point that it interferes, restrictive food repertoires, fixated interests. You'll see, without being too repetitive, that it gets far more specific. It gets into the hyper or hypo-sensitive responses to sensory stimulation. Fixations on lights, this is where you're going to see a little bit more of the stereotypical repetitive behaviors that we would often refer to as stemming.

Again, the symptoms have to be present in early childhood, but they may not actually demonstrate themselves until later. You might not actually identify them until later. And D is really important, it's that they must together impair everyday functioning without supports. So if the individual doesn't have supports, is this individual having impairments in their ability to function every day?

Now the other addition to the DSM-5 is this addition of specifiers. So you will specify whether or not the individual has intellectual impairment or not, whether they have language impairment or not, and whether they have medical or genetic impairment or not. As you can see, particularly for those of you who read the literature or do research, this is the kind of information that's going to be very important so that we can start to understand well, who are we really looking at. How are we clustering these individuals on the spectrum? Because some individuals with autism have mental retardation, some don't. Some have significant language deficits, some don't. Some have known genetic disorder, some don't. So we're starting to develop a system that will allow us to create these subgroups.

So now we've got the two symptoms rather three, we've got the addition of the specifiers. And the last thing that we've added to this new DSM-5 are severity levels. So here we get into how impaired is the individual. Because remember, we've taken Aspergers disorder and lumped it together with autism. So we now have only one diagnostic category called autism spectrum disorders. And in that, you're going to have somebody with profound mental retardation and autism and somebody with an IQ of 150 and autism.

So somehow we have to identify those individuals. So we do that by using the specifiers and the severity levels. So for example, severity Level 3 is somebody who's significantly involved, somebody who requires significant-- and they define it as very substantial support-- and again, they go through this with giving you very clear examples. So it may be severe deficits in verbal and non-verbal communication. It may be somebody who's completely non-verbal. And they give you examples if you're the diagnostician.

They also talk about the repetitive behaviors. And again, requiring very substantial support. Somebody who has a meltdown or severe tantrum if their environment is changed. Somebody who engages in high rates of self-stimulatory behavior. So they give you these examples.

Level 2 is somebody who requires substantial support. Again, I suspect that the levels is where you're going to start having some blurring. You know, what is the difference between very substantial support and substantial support? So I think this is going to take some work for diagnosticians to get fluent at being able to discriminate somebody from Level 2 to Level 3, but they try and give you examples so that you can discriminate these.

Again, they talk about it both in the areas of social communication and the behaviors. And then there's Level 1. These are individuals who require support. But it could be minimal support. But without the support, they'll demonstrate problems. And so they go through examples of this. This is where you're going to see the individuals who previously were diagnosed as high-functioning autism or Aspergers disorder.

And remember, in the DSM-IV-R, there was no such thing as high-functioning autism. So this level differentiation provides us with the ability to be able to discriminate between somebody with Aspergers disorder, who will now be a Level 1 autism spectrum disorder. And it goes through the symptomatology.

Now what's challenging is the DSM-5 has added a new diagnostic category called social communication disorder. Some refer to it as social pragmatic communication disorder. And this is going to be, I think, something that will evolve over time. What this category is, is for individuals who have social communication disorders but do not have restrictive repetitive behaviors, do not have restricted interests.

So I have a young man for example, who works with me, who has a lot of anxiety, has some social communication disorders, but really doesn't have fixed interest. He doesn't obsess on topics. He doesn't perseverate. And he probably today, would fall under the social communication disorder. Previously he was diagnosed as Aspergers disorder.

There are some who don't believe that there's sufficient differentiation to actually have this diagnostic category. Some believe that this will become the new pervasive developmental disorder. So we're going to have to just see how this plays out.

So you should take the quiz that's at the bottom of this video and it'll sort of test how well you understood the information that was presented in this video.