To the Editor: Dr. Hoffman emphasizes a very important point regarding the limitations of a purely categorical diagnostic approach with respect to pervasive developmental or autism spectrum disorders.
In clinics throughout the world, the adage that “if you have seen one child with autism, you have seen one child with autism” is probably repeated daily. Perhaps more so than any other diagnostic category, pervasive developmental disorders underscore our inability to capture individual difference within a categorical diagnostic framework. Approximately 50% or more of persons with a diagnosis on the autism spectrum are given the “not otherwise specified” or “atypical autism” diagnosis. How can it be that the dominant diagnosis within a category is one for which the distinguishing feature is that the classic picture does not quite fit?
Although it is likely that clinicians use the not otherwise specified diagnosis for a variety of reasons, including hedging their bets or, perhaps, wanting to soften the blow of diagnosis, our experience has been similar to that expressed by Dr. Hoffman in that the vocabulary to adequately capture individual differences within the simple categorical diagnosis does not exist and clinicians default to not otherwise specified in order to highlight a given patient’s particular strengths or differences. A child who makes good eye contact, appears to be interested in others despite profound social skills deficits, is very bright, or has interests that are not too dissimilar from those of children in the mainstream may be given this more ambiguous diagnosis. Similarly, a child who once met all criteria for autism but who has demonstrated remarkable improvement over the years might move from one category to another to reflect this change (1).
In DSM-V, there is an opportunity to address the concerns expressed by Dr. Hoffman and other clinicians regarding new ways of combining categorical and dimensional approaches (2). Incorporating specific descriptors, for example, relating to intellectual ability, sensory sensitivities, language development, and the like may provide additional tools with which clinicians can more specifically capture areas of particular consequence for a given patient, without the need to append the not otherwise specified label. That said, no diagnosis, regardless of the wealth of descriptors, will ever substitute for a detailed, individualized understanding of a given patient. There is no such thing as an “autistic” or “schizophrenic” or “depressive” but rather an individual whose life is affected by autism or schizophrenia or depression. The ultimate goal of any diagnostic schema is not to capture an individual as a diagnosis but to recognize the presence of a disease or disorder that will inform our treatment and prevention efforts.
Kelley E, Paul JJ, Fein D, Naigles LR: Residual language deficits in optimal outcome children with a history of autism. J Autism Dev Disord 2006, 36:807–8282.
Regier DA: Dimensional approaches to psychiatric classification, in Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Edited by Helzer JE, Kraemer HC, Krueger RF, Wittchen HU, Sirovatka PJ, Regier DA. Arlington, Va, American Psychiatric Publishing, 2008, pp xvii–xxiii
The authors’ disclosures accompany the original article.
This letter (doi: 10.1176/appi.ajp.2008.08091455r) was accepted for publication in November 2008.