The dominant diagnostic instrument used to identify autism in New Zealand, is the DSM-IV-TR (Diagnostic and Statistical Manual, Fourth Edition, Text Revision). The DSM-IV was published in 1994, and the text revision in 2000. (Those revisions did include some changes to the autism spectrum disorders.) The DSM originates in the USA, from the American Psychiatric Association (APA). In New Zealand we also use and recognise the ICD-10 (International Classification of Diseases, tenth revision, 1993), which comes from and has a comparatively more international focus than the DSM. The ICD is published by the World Health Organisation (WHO).
I’ve become somewhat familiar with the DSM and its proposed update – the DSM-5 – specifically because I’ve been trying to get my head around the changes to autism and the rationale behind those changes. I’ve largely neglected an understanding though of the ICD, and how it differs from the DSM. In my research to better understand the ICD, I’ve gathered together enough information that I wanted to record it all in one place for personal future reference; so what better way than a post, whereby you readers can further refine my amateur understanding.
It’s not just the DSM-IV that is currently under review. The ICD-1o is due to be updated with the ICD-11, in 2015 (initial due date was apparently 2014). The due date for DSM-5 has also shifted back, from 2012 to 2013 (and some are speculating that it could – and should – shift even further back).
Though there are differences between the DSM and ICD, these differences are not seen as necessarily undesirable. There are some ways in which having differing versions of various conditions are seen as a positive, for example it highlights that these are groupings of symptoms rather than definitive single-truth versions of disorders, and it allows researchers to choose which version best suits their purposes. As a general rule though, the distinctions between the two manuals are not seen as a good thing. There is professional recognition of the importance of the two manuals coinciding; there is a body set up with the aim of encouraging this co-ordination, the “DSM–ICD Harmonization Coordinating Group.” This group includes people involved in the up-coming changes to both publications.
One of the key factors standing in the way of the possible co-ordination of the two manuals, is the that the ICD works from conceptual definitions as a primary starting point, whereas the DSM starts from a researching point of view. Both defending and supporting their preferred focal starting point.
Is there much difference between the ICD-10 and DSM-IV-TR’s version of autism spectrum disorder? The short answer is: No, not substantially. The lengthier answer is, yes, there are differences in terminology, and in the groupings of people under the spectrum. But generally these differences are not seeing as significantly impacting on research findings. However, the proposed changes to the DSM will be a far more significant shift from the current closeness of the DSM-IV-TR to the ICD-10, so those interested in maintaining some coherency and closeness between the ICD and the DSM are understandably concerned about this shake-up and what those working on the ICD-11 will do in response.
At this point it appears that the ICD team intends to hold on to the various divisions under the autism spectrum (including Aspergers), obviously this doesn’t sit harmoniously alongside the combined autism spectrum proposed in the DSM-5. The ICD currently has eight categories under autism, whereas the DSM-IV-TR has the five most people are currently familiar with, but they align close enough to be meaningful for most purposes (as I understand it). The current publicly available version of the proposed ICD-11 has nine categories under autism, the new one being “social reciprocity disorder,” which sounds (purely by the name and placement of it) like it’s referencing the “social communication disorder” due to be introduced in the DSM-5. I’ve had trouble finding anything else out about this new ninth category at this point.
Obviously, with the DSM revision being due out sooner, there is more information currently available about the DSM-5 than the ICD-11. It is also clear that what the ICD-11 proposes for autism will take into account what the DSM-5 does (and how successfully it does it, one presumes). It is possible that the ICD-11 – despite hope for harmonisation – will ultimately not follow the lead of the DSM-5 in regards to autism, and it’s conceivable that this could impact on the popularity and wide use of the DSM (Allen Frances for one, has shared concerns that the DSM may – and perhaps should – drop in popular use, in the face of ongoing issues with how it’s currently constructed).
Though I did find out a lot in my research into this topic, there was a lot I couldn’t quite isolate or get enough information on either. I was restricted to online research (and we all know how reliable that can be) but I tried to use official and reputable sources to counteract the limitation. To those with more personal and practical knowledge of the two manuals and their relationship, I would love to hear from you, so I can learn more about these very important, influential and often life-changing publications.
Selective list of useful resources:
- Harmonisation of ICD-11 and DSM-V: Opportunities and Challenges. (2009, BJPsych)
- Towards ICD-11 and DSM-V: issues beyond ‘harmonisation.’ (2009, BJPsych)
- Interview to Professor Sir Michael Rutter, Chair of the Child and Adolescent Psychiatry working party for ICD-11.
- Autism Spectrum Disorders in DSM-IV and ICD-10 (Autism Aspergers Advocacy Australia)
- ICD, WHO website
- ICD11 Beta – Autism Spectrum Disorders
- DSM-5 proposed autism criteria (official DSM-5 website)
- New Zealand Autism Spectrum Disorder Guideline