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Purposed Updates for the DSM-6 and ICD-11

The purposed changes for the DSM-6 and ICD-11:

  • To begin, the DSM-6 should do rid with the diagnosis Gender Dysphoria (formerly called Gender Identity Disorder) since it is really a sexual orientation—not a mental disorder.
  • In the context of this article, empathy refers to affective (emotional) empathy—as that is how the DSM defines it, while social cognition describes cognitive empathy (also known as Theory of Mind, perspective taking, or mentalization).

Neurodevelopmental Disorders

Auditory Processing Disorder (APD)

  • The DSM-6 should add the disorder for funding purposes, and the ICD-11 is purposing to call it Other Specified Disorders with Hearing Impairment in the Disorders with Hearing Impairment of The Diseases of Ear and Mastoid Process category, but both manuals should classify it as APD in the Neurodevelopmental Disorders category since the research considers it to be a neurodevelopmental disorder.
  • Figurative Language Disorder, Speech Sound (Phonological) Disorder, and Spoken (Oral) Language Disorder Specifier

Physical Coordination Disorder (PCD)

  • A disorder of physical discoordination, or dyspraxia which affects the development of the individual's physical motor coordination across their lifespan.
  • The ICD-11 calls it Developmental Motor Coordination Disorder while the DSM-5 refers to it as Developmental Coordination Disorder, but coordination doesn’t always mean physical, and motor can include vocalizations as well (i.e., verbal apraxia, phonic tics, etc.), so the DSM-5 should've called it physical coordination disorder with the ICD-11 classifying it as developmental physical coordination disorder.
  • Sensory Integration Disorder Specifier
  • There should be a number severity scale of 1, 2, and 3.

Sensory Integration Disorder (SID)

  • ASD should be ruled out before diagnosing SID.
  • SID was considered to be included in the DSM-5, but not added because there has yet to be enough research to distinguish it from only being a comorbidity to ADHDs, ASD, PCD, and SMD despite many mental health practitioners noting it to be a distinct disorder that needs a diagnostic label for funding purposes.
  • Speech Sound Disorder and Spoken Language Disorder Specifiers

Other Specified Neurodevelopmental Disorder (ND-OS)

Unspecified Neurodevelopmental Disorder (ND-US)

Attention Deficit-Hyperactivity Disorders (ADHDs):

  • Inattentiveness, hyperactivity/impulsivity, or combined are classified as different subtypes of ADHD—not separate sub-disorders—in the DSM-5 and ICD-11 because inattention and hyperactivity physiologically function on the same receptors and most with the condition have the combined type. However, they should be classified as separate sub-disorders (as some are inattentive without exhibiting hyperactivity and vice versa, and they often—but not always—require different medical treatments as well).
  • The DSM-5 uses a severity specifier of mild, moderate, and severe, but the ADHDs should just have a severity number scale of 1, 2, and 3 instead, so it does not conflict with the severity scale of Autism Spectrum Disorder (ASD) since a diagnosis of an ADHD—regardless of severity—does not necessarily impact spoken language, intellectual, or adaptive functioning.

Attention Deficit Disorder (ADD)

  • Figurative Language Disorder, Insomnia, and Spoken Language Disorder Specifiers

Hyperactivity Disorder (HD)

  • Childhood Emotional Dysregulation Disorder, Bipolar Affective Disorder, Conduct Disorder, Insomnia, and Sensory Integration Disorder Specifiers

Mixed Attention Deficit Hyperactivity Disorder (ADHD-MX)

  • Childhood Emotional Dysregulation Disorder, Bipolar Affective Disorder, Conduct Disorder, Figurative Language Disorder, Insomnia, Sensory Integration Disorder, and Spoken Language Disorder Specifiers

Unspecified Attention Deficit-Hyperactivity Disorder (ADHD-US)

  • The “unspecified” disorder should only be used when a client (parent or legal guardian if the client is a minor) or general medical doctor (i.e., pediatrician, internist) suspects the individual has an ADHD but would need to refer them to a speciality medical doctor (i.e., psychiatrist, neurologist), as everyone is inattentive (and children are often hyper and disruptive in school) to an extent but do not need to be prescribed stimulant medication unless they actually have an ADHD (as well as narcolepsy), especially since they are often overprescribed by physicians who don’t even specialize in mental health.
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Communication Disorders:

Autism Spectrum Disorder (ASD)

  • A disorder of deficits in the pragmatics of social communication, or more specifically, difficulties in social interaction—ranging from lack of engaging and "responding to the interaction" (American Psychiatric Association, 2013) of others, as well as "reduced sharing of interests, [imaginative play], and affect" (American Psychiatric Association, 2013), to inappropriate social approaches (i.e., trembling, proximity), which leads to failure in forming and maintaining friendships with their peers—as well as in identifying the aspects of figurative language (i.e., nonliteral humor, sarcasm, etc.); nonverbal (social cues)—including establishing eye contact, greeting others (i.e., waving), and understanding gestures (such as facial expressions or body language) and social cognition (cognitively (or mentally) processing emotions and others' differing perspective)—and verbal communication (varying from initiating, maintaining, or properly finishing a conversation; to "taking turns [when conversing with others] and rephrasing if misunderstood" (American Psychiatric Association, 2013); to "sharing information [or speaking in a volume that is] appropriate for the social context [or setting]" (American Psychiatric Association, 2013); to discussing a favorite topic, interest, or hobby in an overly formal, lengthy, narrow-sided exchange; to echolalia and minimal or lack of spoken language). There is typically also repetitive behaviors, including stereotypic body movements, self-injury, or restricted, maladaptive patterns of activity with toys and objects (i.e., twirling or compulsively lining them up) that are usually caused by hypo- or hyper- sensory integration dysfunction; as well as perseverative questioning or worrying; "rigid routines (i.e., taking same route, eating same food every day, [etc.])" (American Psychiatric Association, 2013); and distress over minor changes to schedule.
  • Common co-morbidities include irritability and deficits in attention; for those who have receptive language delays, the inattention is more profound than those who have ADD alone and it typically leads to other significant developmental impairments, such as gazing their eyes to the ceiling or floor and not responding to their name being called. Severely afflicted individuals usually also have profound intellectual impairments and remain uncommunicative over the course of their lifespan, while those who are moderate may show these developmental delays during early childhood or up until aged 10 (and become more high-functioning). Even when the child initially looses their diagnosis (especially as they become more verbal and begin to interact with others), some lingering social communication traits tend to persist. It is quite rare to fully overcome the social communication deficits associated with the condition, as well as to no longer require anymore specialized services, but has sometimes been reported in those who were more moderate or mild earlier on in their lives. However, there is no cure on the physiological level.
  • Attention Deficit-Hyperactivity Disorders (ADHDs), Catatonia, Intellectual Developmental Disorder, Irritability, Insomnia, Speech Sound Disorder, and Spoken Language Impairment (Expressive or Receptive) Specifiers
  • For those who have social communication impairments without the restricted interests/repetitive behaviors, the DSM-5 added the new controversial disorder, Social (Pragmatic) Communication Disorder (SPCD), yet it is really a milder form of ASD. Therefore, SPCD should be removed, as it "led to families to be defunded services" (Tager-Flusberg, 2018), mental health practitioners "do not even find the diagnosis necessary or useful" (Tager-Flusberg, 2018), and it was too premature in the research literature to be augmented (studies have since not been able to conclude that it is a distinct disorder); in other words, restricted/repetitive behaviors are often part of but should not necessarily be required for a diagnosis of ASD. The ICD-11 will be calling it ASD, Unspecified (if without a spoken language deficit) and Other Specified ASD (if there is absence in spoken language), which is technically more accurate and the insurance won't deny coverage since it's in the ICD. However, the updated manual will not be available in the United States until 2027.
  • They should also rephrase Criterion A to "Persistent deficits in the pragmatics of social communication, including social interaction and verbal and nonverbal communication"; incorporate an additional sub-domain for the difficulties in understanding figurative language; include "to minimal or the lack of spoken language" after discussing the failure of the typical back-and-forth conversation in that same broader domain; and mention the range of nonreciprocal conversational exchanges mentioned above in the social (pragmatic) communication domain of the mild form of the ASD severity table scale.
  • The DSM should even rewrite in Criterion E that it is an ADHD which frequently co-occurs with ASD and clarify that a co-morbidity of Intellectual Disability is more common in severe cases of ASD, but can co-occur in moderate and mild forms as well. Further, they should add a "Spoken Language (Expressive or Receptive) Impairment Specifier" to indicate which form of early applied behavior analysis (ABA) intervention the child requires, as well as an "Irritability Specifier" to determine whether the individual needs an antipsychotic (i.e., risperidone (Risperdal), aripiprazole (Abilify), etc.) augmented to an SSRI antidepressant (i.e., sertraline (Zoloft), fluoxetine (Prozac), etc.) and an "Inattention Specifier."
  • The ICD-11 is purposing to classify it solely in the broader Neurodevelopmental Disorders category, but it should further be subcategorized in the developmental speech or language disorders section.
  • In the DSM-5, ASD has a severity number scale of 1, 2, and 3, but it should use the terms mild, moderate, and severe instead since severity is based predominantly on spoken language, adaptive, and often intellectual functioning as well.

Figurative Language Disorder (FLD)

  • A pragmatic language impairment of "understanding nonliteral or ambiguous meanings of language (i.e., idioms, humor, [sarcasm], metaphors" (American Psychiatric Association, 2013), etc.).
  • ASD must be ruled out before diagnosing FLD.
  • The ICD-11 is purposing to call it Developmental Language Disorder with Impairment of Mainly Pragmatic Language, but they should classify it as Figurative Language Disorder instead since pragmatics is also a broader term for social forms of language as well, and they should list it in the broader developmental speech or language disorders section.

Speech Fluency Disorder (SFD)

  • A disorder of speech disfluency—also called stuttering (or dysphemia).
  • The DSM-5 refers to it as Childhood-Onset Fluency Disorder, while the ICD-11 will be calling it Developmental Speech Fluency Disorder, but they should be titled Speech Fluency Disorder.

Speech Sound (Phonological) Disorder (SSPD)

  • A disorder of deficits in pronouncing oral speech sounds (phonetics), such as acoustic (transmission), articulation (production), and auditory (perception). The broad diagnosis includes the following disorders: verbal apraxia (motor planning), dysarthria (slurred speech), and sensory impairments (blind or deafness).
  • Blind, Deaf, Dysarthria, Spoken Language Disorder, and Verbal Apraxia Specifiers
  • The DSM-5 classifies it as Speech Sound Disorder, but the ICD-11 is purposing to title it Developmental Speech Sound Disorder.