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1/22

demystifying the DSM-V

what on earth does it all mean?!

What’s a DSM?
It stands for Diagnostic and Statistical Manual of Mental Disorders (edition five).
The DSM-V is a big book of all the different mental health diagnosis. It contains the diagnostic criteria for each disorder, so that doctors have a standardised set of characteristics of each disorder from which to diagnose people.

England actually uses the ICD-10 to diagnose, and the DSM-V for research, but as my background is research, I’ll explain this one first!

2/22

Who wrote it?

The mental health disorders included in the DSM-V were identified, written, and categorised by researchers and clinicians*. It has been revised five times over 69 years.
*Thus, it was written via external observation, not via lived experience.

Is autism a mental disorder?

No, not in the sense of being a mental illness. The book contains many conditions with relation to the brain and central nervous system. For example, sleep apnoea isn’t a mental health condition, but it is a condition controlled by the brain. 

3/22

So why is autism listed in the mental disorders book?

It’s been written through the lens of the “medical model”, so differences are identified through “deficits”. We’ll talk more about what this means later on.

What does it say about autism?
Let’s break it down! 

4/22

DSM-V Criterion A

DSM-V autism diagnostic criterion a

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history…

“Multiple contexts” – Many autistic people mask in some or all contexts. This means to cover up their differences, and act in ways that they have observed allistic people act in, even if they don’t understand why.

For example, masking at work by engaging in scripted small talk at the coffee machine, and coming home exhausted from hiding yourself, or a child masking all day at school by forcing themselves to make eye contact and not to stim, and then getting home and having a meltdown. 

5/22

DSM-V autism diagnostic criterion a

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

Autistic people communicate differently to allistic people, for example by relying more heavily on the literal content of words than figurative meanings. They can come across as blunt to allistic people, while allistic people come across as confusing to autistic people. For example, many autistic people are unable to engage in small talk due to the purpose of this exercise being unclear.

In fact, autistic people are as good at information exchange and rapport with other autistic people as allistic people are with other allistic people. Autistic people communicate differently to, but not worse than, allistic people. 

6/22

DSM-V autism diagnostic criterion a

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

Allistic people use a lot of layers of tacit nonverbal behaviours in their communication, and these do not seem to translate to autistic communication. It feels like allistic people were given a handbook or a class on extra layers of silent information that we did not get; often we try really hard to learn about different parts of this silent language, and often we miss cues altogether. But again, when communicating with other autistic people, autists are as efficient communicators as allistic people are. We just communicate differently. 

7/22

DSM-V autism diagnostic criterion a

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

Difficulties with expressing and interpreting facial expressions have recently been shown to be related to a condition called alexithymia rather than to autism.

Many autistic people (~98%) have Sensory Sensitivities, which means that we feel sensory stimuli more intensely, or more muted, than allistic people tend to. This can include proprioception, which can impact ones ability to sense their body in space. This can make it difficult to incorporate nonverbal gesture & facial expression into communication. 

8/22

DSM-V autism diagnostic criterion a

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

Many autistic people find that eye contact is intimate, intense, information-heavy, or otherwise uncomfortable, and prefer not to engage in eye contact. This is not in itself abnormal as casual eye contact is a culturally bound social construct. Not all cultures use eye contact in the ways we do, and thus not wishing to maintain eye contact is not intrinsically a deficit, but is a social difference.

Eye contact is not required for autistic people to listen or to pay attention; in fact, being forced to keep eye contact actually hinders our ability to concentrate. 

9/22

DSM-V autism diagnostic criterion a

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Autistic people are as able to have meaningful and intimate connections as allistic people are.
Most autistic people do want to have friends and social lives, but have found themselves repeatedly ostracised for making accidental social faux pas. This can lead to a withdrawal from attempting to initiate or engage in social contact as a protection mechanism. Social isolation and loneliness are common causes of depression for autistic adults.

Most of the difficulties that autistic people experience with social relationships comes from misunderstandings of communications and of needs between autistic and allistic individuals. 

10/22

DSM-V autism diagnostic criterion a

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Much of the difficulty in changing behaviour according to social contexts comes from a difficulty in interpreting ambiguity. The social rules of different contexts are subjective and ambiguous.

E.g. if an invite says “dress code: black tie”, this doesn’t just mean clothing (even though that’s what it says!), it also dictates the social etiquette. And to work this out, you need to know that is what it is saying, and also know what the social etiquette is for a formal event in this culture and time – it is rarely actually explained, it is assumed to be tacit knowledge. 

11/22

DSM-V autism diagnostic criterion b

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

This can be related to a couple of things;

A) self-stimulatory behaviours, or stimming, are an important part of autistic body language. Stimming is an repetitive act which provides predictable sensory stimulation and helps to regulate the self against sensory or emotional overwhelm.
E.g. rocking back and forth, tapping, flapping the hands, echolalia, vocalising 

12/22

DSM-V autism diagnostic criterion b

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

This can be related to a couple of things;

B. autistic people often like to engage in the same activities over and over, for example watching the same movie over and over. While allistic people tend to experience less joy each time they experience something, autistic people often experience similar levels of joy to the first time they experienced something, or even more due to the fact that it is no longer an ambiguous situation. 

13/22

DSM-V autism diagnostic criterion b

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

This can be related to a couple of things;

C) autistic people might engage in behaviours such as lining things up, or spending a lot of time ensuring that a picture or shelf is perfectly straight. There is emerging evidence that autistic people have higher visual acuity, that is, they can see smaller angles than allistic people can. So when something is not aligned correctly, it can bother us! 

14/22

DSM-V autism diagnostic criterion b

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

Autistic people are frequently stressed by ambiguous situations. Adherence to a routine means that an individual knows what is going to happen and when; it removes the stress of ambiguity. 

15/22

DSM-V autism diagnostic criterion b

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

Autistic people often find one or more topics which brings them comfort and pleasure to focus on. This can be anything, and some of these are seen as socially acceptable hobbies, for example, football, and some are seen as socially “abnormal”, such as hand driers. “Special interest” is sometimes seen as a bit infantilising, because autistic people often become an expert in these topics. 

16/22

DSM-V autism diagnostic criterion b

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Most autistic people experience hyper- or hypo-sensitivity. It is common to be hyper-sensitive to noise, and to struggle with “complex noise”, for example in a cafe with lots of different conversations going off. It is common to be hypersensitive to touch, with light touches feeling sharp or uncomfortable, and being irritated by clothes labels. It is common to be hypersensitive visually, and to become overwhelmed by fluorescent lighting, for example. It is also common to be both hypo- and hyper- within the same sense, and this can fluctuate day to day. 

17/22

DSM-V Criterion C

DSM-V autism diagnostic criterion c

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).

Many autistic people who are identified in adulthood are discovered to have autism after they have experienced an autistic burnout, often interpreted as, or alongside a mental health crisis.
“‘Autistic burnout’ is the intense physical, mental or emotional exhaustion, often accompanied by a loss of skills, that some adults with autism experience. Many autistic people say it results mainly from the cumulative effect of having to navigate a world that is designed for neurotypical people.” – Sarah Deweerdt, Spectrum News 

18/22

DSM-V Criterion D & E

DSM-V autism diagnostic criterion d & e

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

This diagnostic criteria, by definition of criterion D, cannot identify non-distressed autistic people. 

19/22

Medical Model

The DSM-V is written by and for practitioners, and researchers. They analyse things using a medical model, which means they see differences as a physiological problem with an individual which can and should be solved and cured.

The diagnostic criteria for autism is a model of deficits. In fact, the word “deficit” is mentioned 11 times. Other negative language, such as “abnormal” is also used repeatedly, but the many strengths associated with being autistic are not mentioned. Many autistic people do consider themselves to be disabled, however, having a positive image of autism and a positive self-image are protective against depression. 

20/22

Medical Model

This means that autistic people are not identified by this criteria until they are struggling and distressed. It also means that the an individuals understanding of autism, based on this criteria, will be overwhelmingly negative. This has come through into the mainstream media, with caricaturesque portrayals of “walking DSM” characters like Sheldon Cooper from The Big Bang Theory, and more recently Music in Music by Sia.

It also frames autism as something that is a problem to be solved, which it is not. 

21/22

Autism as a neurotype

Neurodiversity refers to the natural variation in human neurology. There are different ways of experiencing your body and the world.
Neurotypical is a neurotype which refers to people who are neurologically average. They aren’t autistic, and they have no other neurodivergence.
Neurodivergent is an umbrella term which refers to people who are not neurologically average. There is still debate as to who exactly this includes, but the term was borne of the autistic community (see: Judy Singer). 

22/22

Autism as a neurotype

Autism is a neurotype, a specific type of neurological processing, characterised by differences in sensory processing, in the use of verbal and non-verbal language for socio-emotional purposes, and in the tolerance of ambiguity.

Autistic people engage in stimming with a self-regulatory purpose to prevent sensory or emotional overwhelm, and often engage with deep focus in a topic of passion.