When I started working in psychiatry 50 years ago, Asperger's disorder was a recognized diagnosis. During that period, the diagnosis drifted into my consciousness through conferences, articles, and discussions with colleagues.
Sometimes, I was asked to evaluate an adult who had difficulty socializing and learning all of his life, and someone had labeled the man with Asperger's disorder. It has become part of the psychiatrist's nomenclature and diagnostic system for a group of patients who otherwise would have been dumped into many other places. The label has provided us with an ability to split and share concepts in a helpful way.
I became very conscious of the illness when we realized that a neighbor's son at 55 years of age had the disorder. He was friendly in a very superficial way; he was peculiar in his looks and manner; and he was the kind of person one might tend to avoid.
He had no friends, no social life, and no seemingly useful activities. We were convinced that he had Asperger's.
He died while in his early 60s, and no one on our street expressed one word of regret that this odd man was no longer on the road. I think that it would have been difficult to call him autistic, so the plan to take Asperger's out and make it part of the autism spectrum disorders will take a great deal of learning on the part of 40,000 psychiatrists and several thousand patients after the DSM-5 is published.
For me, what is most interesting about this is how the diagnosis arrived and might leave in the course of my career. I, like many people in the field, do not understand the rationale of the task force in proposing this change.
Controversy Is Nothing New
I commend the task force members and their efforts, however, in refining this important document. After all, this volume plays a major role in the care and treatment of patients as well as with insurers with regard to getting paid for the work we do.
Each of the previous DSM editions caused much controversy, as this version is doing. Many praise it, and many will be highly critical of the efforts. Preparing a diagnostic and statistical manual takes a great deal of effort, time, and money, and it is one of the most important activities of the American Psychiatric Association. The manual becomes a trusted instrument used by almost everyone after it has been approved and published.
This year, the task force has done something that has never been done before and put a draft outline on the Internet. The APA has invited comments, reactions, and criticism. After the viewing period is over, the final work of editing will begin, and the DSM-5 will be published in 2013.
Psychiatric diagnosis is extremely controversial. I think it is important to say that both Dr. David J. Kupfer nd Dr. Darrel A. Regier are very sincere in their desire to produce a useful volume that will serve both the research and clinical communities well.
Everything I've read leads me to believe that the DSM-5 will be the easiest of all for clinicians to use.
The previous two DSMs were seen as being written for researchers, which made it a little more difficult for the clinician to fit his patient neatly into one of the descriptive groups. Some of the inventions of DSM-III and DSM-IV were thought to be useless by a large number of us who see patients.
And the precision of some of the categories was foolish–at least for me. I saw no value in schizotypal, for example, but I know that younger clinicians found the category very useful.
Calls for Transparency
Both of the previous task force chairs, Dr. Robert Spitzer and Dr. Allen J. Frances, have decried the secrecy of the work of the hundreds of people involved in creating the DSM-5. They kept calling for transparency in a way that brought some discredit on them. Now this entire volume is available for all to see and comment upon.
Transparency might be important to people who played an important role in writing previous DSMs but not to most of us in the field.
Our concerns have been more about how the new DSM will change what we do each day, and how will the manual affect the treatment of people who are very sick, and need correct diagnoses and treatment in order to re-enter life.
We don't want big changes that will have us running to the DSM-5 on a daily basis to be sure that we know what the experts are thinking about a term we've been using for 40 or 50 years.