Good-Bye Asperger’s, Hello TDD?

02 Feb

To say I am dumbfounded is a bit of an understatement. I’ve been reviewing the proposed changes to the upcoming DSM-V with regard to ASD. It is well-documented that the manual is likely to remove Asperger’s Disorder (299.80). Opinions are mixed on this omission. Some argue that the spectrum is the spectrum; that Asperger’s is like autism and that a diagnostic label doesn’t matter. Others argue, myself included, that leaving out AS is a mistake. Today, I stumbled across the DSM-V’s latest brilliant idea:

Temper Dysregulation Disorder with Dysphoria

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3.  The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, three or more times per week.

C. Mood between temper outbursts:

1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

2.  The negative mood is observable by others (e.g., parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.

F.  Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX).  Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I.  The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

Am I the only one who is worried about this? This is not to say that TDD is replacing AS. In fact, it appears that the presence of a PDD (AS, PDD-NOS, autism) is a possible rule-out (explanation) for TDD. My concern about this diagnosis relates to rationale. The DSM creators supposedly are removing AS because the diagnosis overgeneralizes. Well, if TDD isn’t overgeneralizing, what is it?

Posted by on February 2, 2011 in ASD in the Grand Scheme


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21 responses to “Good-Bye Asperger’s, Hello TDD?

  1. Cazzie!!!

    February 2, 2011 at 11:30 PM

    I do not think these people (who ever the people are) have lived one milli second in the life of a family affected by any or all of the above mentioned states… have they? Hrumph!

  2. C. S. Wyatt

    February 2, 2011 at 11:40 PM

    The researchers with whom I’ve worked are wondering if students now considered AS will be migrated to ADHD/ADD, where many were before their AS/PDD-NOS diagnoses. At the same time, the ADHD criteria are likely to be refined, so I’m wondering if some will be removed from any DSM-V categories. A few will undoubtedly be migrated to various other DSM diagnostic categories.

    When I meet students at support groups, many were or are officially everything from ADHD to OCD. About half at some support groups (definitely not all such groups) have either self-diagnosed or parent-diagnosed with Asperger’s Syndrome. The DSM-V is going to further confuse parents and individuals trying to understand themselves.

    My own diagnosis could change, as it has every decade… the one constant being change.

    • jholverstott

      February 2, 2011 at 11:42 PM

      I find it immensely ironic that “the one constant being change” is the antithesis of what people on the spectrum need.

      • C. S. Wyatt

        February 3, 2011 at 2:38 AM

        I can’t claim the best experiences with diagnoses over a lifetime, admittedly. From “mentally retarded” to “brain trauma” to “ADD/ADHD” and then off to “autism” (I’m sure there are several others my wife recalls that I have forgotten). The drugs along the way were counter-productive, too, causing very negative and dangerous reactions. Thankfully, no meds in years, now.

        Ironic that I could not have completed my doctorate on all the medications directly related to bad diagnostic practices, so my dissertation included a chapter on diagnostic instruments.

        Honestly, not one good experience with the mental health professionals. In the end, finally saying “I’m done” was best for me. That’s definitely *not* the best answer for the students I meet, but I find myself hoping they get quality support and not being sure they will.

        I want to stress, to parents and individuals, I know there are quality professionals out there, but the 1970s and 80s were still the dark ages for special education and mental health supports. I worry we might be going backwards.

  3. Tam

    February 2, 2011 at 11:41 PM

    Aren’t Pervasive Developmental Disorder and Oppositional Defiant Disorder two of the things that are going away with the new DSM? But they used them in the definition of a new one? uhmmm

    And doesn’t this pretty much describe anyone with a bad attitude and a short temper (as long as they’re not bipolar)?

  4. Madmother

    February 2, 2011 at 11:45 PM

    Truly truly ignorant people. Do they even begin to consider the damage this will cause? No.

    After all the years we have fought educating and informing and some idiots band together and do this?

    I hope the backlash drowns them in shame.

    • jholverstott

      February 2, 2011 at 11:48 PM

      As a clinician, I see a kernel of value, what they were trying to isolate diagnostically, but the key manifestations are subsumed and better explained by other DSM diagnoses.

  5. Jemikaan

    February 3, 2011 at 12:50 AM

    That does not even cone close to describing my sons aspirers and qhat us the point in fixing something that’s not broke? Aspergers is finally a name which is known by people, dudplayed in the media and the understanding of it is building within the wider community, so why in he’ll would you now do this? And I completely agree with a previous commenter in saying that the people this change will affect the most are the ones who need stability and routine to have a grounding in this world. Tell them they no longer have Aspergers but instead have…. And you may as well set the hard work we’re doing back to the beginning! Do you have any idea what the loss of identity could do to these kids?

  6. Aimee Yermish

    February 3, 2011 at 1:30 AM

    Well, I have to say that I like “temper dysregulation with dysphoria” (which is often related to parenting, systemic concerns, stress, adjustment issues, etc) better than “bipolar” (which is a serious lifelong medically-based illness treated with big-guns medications). Yet as another clinician, I also have to say that I strongly disagree with the trend to say, “Kid gets grouchy, sometimes tantrums, must have bipolar, TDD, wild child syndrome, or whatever we’re calling it today, better get the prescription pad.” We have to accept that kids are very often the weak link where the dysfunction of an entire system manifests — most of the kids I’ve treated who walked in carrying bipolar diagnoses were actually suffering from PTSD (another disorder where the new version is just as much of a hash as the old version), complicated by parents who themselves were survivors of type II trauma and had never really learned how to regulate themselves, much less how to help their kids learn to self-regulate.

    As far as Asperger’s, I work with a lot of high-IQ autism-spectrum clients, and virtually none of them meet criteria for autism under the old or the new guideliness, but they are nevertheless suffering clinically significant impairment. The old criteria for AS basically describe an average-IQ boy with AS (probably around age 10). The new criteria leave out so many folks who really do benefit from an explanation. I don’t think they should get dumped back in the alphabet soup of ADHD, OCD, GAD, ODD, DCD, SPD, etc that they typically were in before their AS diagnoses.

  7. Petri

    February 3, 2011 at 7:09 AM

    I’m utterly confused by this new diagnostic entity. Sure, I can see the phenomenological value, but is this going to be an addition or a replacmenet? If yes on either/both, then, what becomes of things like borderline personality disorder, bipolar disorder (where some doctors suggesting there are many “finer-grained” versions other than BP I/II, like, up to IV-V), AS?

    And when considering those by nosology inherently different diagnoses, will this new entity mash these up so that any and all can be treated by any and all methods applicable to each one of the diagnoses, either making people get complementary or inappropriate therapy, or possibly even get no help at all because there’s just too many labels to work with?

    Seems like opening up a million cans of worms at once to me. Then again, I’m not a pro. 😉 Though I did have a nice bunch of personality-related diagnoses before my AS/ADHD issues were thought of. It’s just that nobody understood what to do because all these “bits of this, parts of that”-type of labels essentially amounted to just a huge mass of words, so diverse that it in the end lacked any practically applicable meaning. Especially for me.

    • jholverstott

      February 4, 2011 at 2:18 AM

      TDD sounds like another “bits of this, parts of that” type label, if you ask me.

      • Petri

        February 4, 2011 at 5:35 AM

        Yes, I guess it is. Also, another point I didn’t think of when typing my first reply, is whether there is any”end” criterion for TDD, i.e., does it “go away”? Can it only be applied to kids, or is it something that will be in-your-face for the rest of one’s life? I’m not sure the DSM is entirely to blame if the latter is true, but I can’t help but to notice that it seems like an “eternal” condition, and also a potential thoughtstopper – “oh, s/he’s just having TDD again/still”. It seems to be patterned like a personality diagnosis, that somewhat could be conceived of as a “part” of oneself, no?

  8. Laura

    February 3, 2011 at 11:11 AM

    I was under the impression that there was little difference between AS/PDD/mild autism (meaning the child learns to speak by preschool or before) in the DSM-IV. I was also led to believe that the DSM-V would have 3 categories of severity for ASD diagnoses. The disorder mentioned in this post seems like it would become a new diagnosis specifically for those who have meltdowns (if ASD) or tantrums (if NT) significantly more than would be expected. It may not even apply to those with ASDs/PDDs at all.

    Even so, this is still not final, since the DSM-V isn’t supposed to come out for another couple years.

    • jholverstott

      February 3, 2011 at 2:08 PM

      I agree, Laura, that the introduction of TDD isn’t necessarily an “replacement” for AS. What is interesting is that the presence of a PDD is a possible rule-out for TDD.

    • jholverstott

      February 4, 2011 at 2:14 AM

      In the current DSM (IV), AS does not have an age of onset, neither does PDD-NOS. But, the criteria for those two diagnoses are highly different. Interestingly, I think there are less differences between the AS and autism criteria. That is, the big differences are age of onset (36 months) and no language delay in AS. Clinically, I have noticed language delays in AS.

  9. Jess Kahele

    February 3, 2011 at 12:42 PM

    I’m not an expert on diagnostic criteria, but I do have a MAJOR problem when a disorder is characterized by outward/emotive reaction as opposed to the actual cause/action of the behavior. Another example is describing autism as a social disorder, when it is a brain disorder that affects social behavior. It leaves me asking where is the scientific approach as opposed to this dangerous social/normative approach?

    • jholverstott

      February 4, 2011 at 2:10 AM

      It is troubling when we don’t identify antecedents. I think that the DSM is guilty of this short-sightedness in many capacities.

  10. B

    February 3, 2011 at 5:04 PM

    All I can say, as someone who actually has AS, is if this is what they think having AS looks like from the inside, they should all be fired. Because none of them know what they’re doing.

  11. throckles

    February 10, 2011 at 9:30 AM

    I saw a show on childhood bipolar in the last year that suggested that this category is being added instead of childhood bipolar. I had never heard it suggested as a replacement for AS. On the other hand, I can see easily where at the age of 4 or so that my daughter (AS) would get this TDD diagnosis if no one considered why she has those outbursts.

    • jholverstott

      February 10, 2011 at 12:07 PM

      It is not a replacement for AS, I agree. But, I find it interesting that the writers of the DSM would remove a helpful diagnosis like AS but introduce something like TDD. I do see the possibility of how TDD could be related to childhood BP. But, as your comment suggests, TDD introduces yet another way to misdiagnose ASD.

  12. pookiepookison

    February 19, 2011 at 12:55 PM

    Are you kidding me? This is insanity!


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