The new DSM-5: changes in the diagnosis of autism and intellectual disability

By Martin J. Lubetsky, M.D.

What are the primary changes made by the American Psychiatric Association (APA) in May 2013 in the new DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria for Autism Spectrum Disorder and Intellectual Disability?

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder, characterized by severe and pervasive impairments in reciprocal social communication and social interaction (verbal and nonverbal), and by restricted, repetitive patterns of behavior, interests, and activities. The current DSM-IV-TR describes Pervasive Developmental Disorder (PDD) as the diagnostic umbrella, with five subtypes.

• The first change is that there is a single category of Autism Spectrum Disorder instead of five subtypes.
• The second change is that the three domains are combined into two: (1) deficits in social communication and social interaction, and (2) restricted, repetitive patterns of behavior, interests, or activities.
• The third change is that there must be five out of seven criteria to make the diagnosis of Autism Spectrum Disorder.
• The fourth change is that “restricted, repetitive patterns of behavior, interests, or activities” expanded to include “abnormalities in sensory processing”.
• The fifth change is the broadened age of onset criteria – “symptoms must be present in the early developmental period”.
• The sixth change is the addition of “specifiers” to describe features such as “with or without intellectual impairment”, “with or without language impairment”, “associated with known medical or genetic condition”, and “with catatonia”.
• The seventh change is the addition of “level 1, 2 or 3 as severity specifiers requiring supports”.

In addition, the APA DSM-5 Committee response to concern of loss of services is that “all individuals with current diagnosis should not lose diagnosis or services or school placement.”

Also, the APA DSM-5 added a new diagnosis of Social (Pragmatic) Communication Disorder to describe individuals who have “difficulties in the social use of verbal and nonverbal communication” but do not have “restricted, repetitive, and stereotyped behavior, interests, and activities”, as a way to distinguish from ASD.

In addition, intellectual disability (ID) is the new diagnosis in the DSM-5 to revise mental retardation. The diagnosis of ID emphasizes the focus on deficits in adaptive functioning in three domains: conceptual, social, and practical. The diagnosis of ID is then confirmed by deficits in intellectual functions through standardized intelligence testing. Also, there are now level specifiers of deficit severity in adaptive functioning and intellectual functions defined as mild, moderate, severe, and profound.

Martin J. Lubetsky, M.D. is Associate Professor of Psychiatry at the University of Pittsburgh School of Medicine, and the Chief of Child and Adolescent Psychiatry Services and Center for Autism and Developmental Disorders at Western Psychiatric Institute and Clinic of UPMC, and Chief of Behavioral Health at Children’s Hospital of Pittsburgh of UPMC. Dr. Lubetsky is a past recipient of the Grandin Award from the Advisory Board On Autism and Related Disorders (ABOARD). He is co-editor and co-author of Autism Spectrum Disorder.

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