Schizophrenia Research 158 (2014) 264–265

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Letter to the Editor Problems with autism, catatonia and schizophrenia in DSM-5

Dear Editors There is a problem with the relationship between autism spectrum disorder, catatonia and schizophrenia in DSM-5 (American Psychiatric Association, 2013). A case of autism spectrum disorder with an onset between 12 and 24 months of age is easy to differentiate from a positive symptom-predominant case of schizophrenia with onset at 25 years and good premorbid function. The DSM-5 criteria can clearly differentiate two such cases (Tandon and Carpenter, 2012; Tandon et al., 2013a,b), because schizophrenia requires the presence of one of delusions, hallucinations or disorganized speech, which are not included in the criteria for autism. However, it is difficult, based on the DSM-5 criteria, to differentiate autism spectrum disorder from a childhood-onset, negative symptomcatatonia case of schizophrenia that has not yet developed delusions, hallucinations or disorganized speech. This is because the two disorders can share all their symptoms, in some cases, except for the one additional symptom required in the criteria for schizophrenia. DSM-5 schizophrenia can be diagnosed with only two symptoms; these can be catatonia or negative symptoms plus one of: delusions, hallucinations, and disorganized speech. The other criteria for schizophrenia include: duration of 6 months; deterioration in level of functioning; and several exclusion criteria. Criterion F for schizophrenia states that if there has been a prior diagnosis of autism spectrum disorder, then prominent delusions or hallucinations plus the other symptoms of schizophrenia are required for a change of diagnosis. This solves the differential diagnostic problem once delusions or hallucinations have appeared, but does not do so for the period of schizophrenia prodrome during which there has been a false-positive diagnosis of autism. Autism spectrum disorder requires the presence of two Criterion A symptoms: deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors; and deficits in relationships. It also requires two Criterion B symptoms: stereotyped or repetitive movements; insistence on sameness; highly restricted, fixated interests; and hyper or hyporeactivity to sensory input or arousal. Most if not all children with a negative symptom-catatonia form of schizophrenia, but who have not yet developed hallucinations, delusions or disorganized thinking, will meet criteria for autism spectrum disorder. In such cases, a diagnosis of other specified psychotic disorder (attenuated psychosis syndrome) (Tsuang et al., 2013) with predominant negative and catatonic symptoms could be made, but there is no way to differentiate this diagnosis from autism. This DSM-5 category (298.8.2) does not specify that one of delusions, hallucinations or disorganized speech is required (p. 122). This problem could persist for many years if there is a long schizophrenia prodrome. Alternatively, one could consider a diagnosis of catatonia, which is included in the Schizophrenia Spectrum and Other Psychotic Disorders section of DSM-5 (Heckers et al., 2010; Tandon et al., 2013c). The criteria

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for catatonia require three out of twelve symptoms. If the symptoms in a case of catatonia were mutism and negativism (which are similar to two of the autism Criterion A symptoms) and stereotypy and stupor, (which are similar to two of the autism Criterion B symptoms) it would be difficult to differentiate such a case from autism. The autism spectrum disorder specifier of “with catatonia” (p. 51) does not solve this problem because the Criterion A and B symptoms are sufficient to diagnose autism, and resemble catatonia quite closely. This diagnostic problem could potentially result in two errors: falsepositive diagnoses of autism, and false negative diagnoses of catatonia. The situation becomes even more difficult if we consider a childhoodonset depression with predominant psychomotor retardation. According to DSM-5 (p. 163), psychomotor retardation can include muteness, and slowed body movements and thinking; negative symptoms of schizophrenia can include diminished emotional expression, a decrease in motivated self-initiated purposeful activities, and “the individual may sit for long periods of time.” (p. 88). In the Introduction to DSM-5, the fact that the symptoms and risk factors for different disorders overlap extensively is acknowledged: “The results of numerous studies of comorbidity and disease transmission in families, including twin studies and molecular genetic studies, make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder “categories” are more fluid over the life course than DSM-IV recognized, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders.” (p. 5). It seems possible that many cases of autism, catatonia and a subset of schizophrenia cases (negative symptom-catatonia cases that haven't yet developed delusions, hallucinations or disorganized speech) are actually the same disorder, or part of the same spectrum of disorders. The two diagnostic categories are placed in neighboring sections of DSM-5 because they are considered to be closely related. The relationship may be so close that a subset of cases of autism, catatonia and psychosis are indistinguishable, especially in childhood cases in which delusions, hallucinations or disorganized speech have not yet appeared. This problem should be addressed in future research and in future editions of the DSM manual. Contributors This is a single author letter with no other contributors and no funding source. Conflict of interest The author of this letter has no conflict of interest. Acknowledgments There was no funding for this letter and no one else contributed to its preparation.

References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Author, Washington, DC. Heckers, S., Tandon, R., Bustillo, J., 2010. Catatonia in the DSM—shall we move or not? Schizophr. Bull. 36 (2), 205–207.

Letter to the Editor Tandon, R., Carpenter, W.T., 2012. DSM-5 status of psychotic disorders: 1 year prepublication. Schizophr. Bull. 38 (3), 369–370. Tandon, R., Bruijnzeel, D., Rankupalli, B., 2013a. Does change in definition of psychotic symptoms in diagnosis of schizophrenia in DSM-5 affect caseness? Asian J. Psychiatry 6 (4), 330–332. Tandon, R., Gaebel, W., Barch, D.M., Bustillo, J., Gur, R.E., Heckers, S., Malaspina, D., Owen, M.J., Schultz, S., Tsuang, M., Jim Van Os, J., William Carpenter, W., 2013b. Definition and description of schizophrenia in DSM-5. Schizophr. Res. 150 (1), 3–10. Tandon, R., Heckers, S., Bustillo, J., Barch, D.M., Gaebel, W., Gur, R.E., Malaspina, D., Owen, M.J., Schultz, S., Tsuang, M., van Os, J., Carpenter, W., 2013c. Catatonia in DSM-5. Schizophr. Res. 150 (1), 26–30. Tsuang, M.T., Van Os, J., Tandon, R., Barch, D.M., Bustillo, J., Gaebel, W., Gur, R.E., Heckers, S., Malaspina, D., Owen, M.J., Schultz, S., William Carpenter, W., 2013. Attenuated psychosis syndrome in DSM-5. Schizophr. Res. 150 (1), 31–35.

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Colin A. Ross The Colin A. Ross Institute for Psychological Trauma, 1701 Gateway, #349, Richardson, TX 75080, United States Tel.: +1 19729189588; fax: +1 19729189069. E-mail address: [email protected]. 7 June 2014

Problems with autism, catatonia and schizophrenia in DSM-5.

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