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Abstract

The DSM-5 has introduced the Social (Pragmatic) Communication Disorder (SPCD) as a new mental disorder. It is characterized by deficits in pragmatic abilities and serves to address individuals with communication difficulties that do not fall under Specific Language Impairments (SLI). The introduction of SPCD into the psychiatry nosography has sparked debates regarding its relationship with Autism Spectrum Disorder (ASD), particularly concerning symptom overlap and diagnostic independence.

Introduction

• SPCD is included in the macro-category of Communication Disorders (CDs) within the DSM-5.

• The disorder is defined by difficulties in using communication socially, adapting language to context, and following conversational rules.

• This revision was partially motivated by the need to identify individuals who do not meet the criteria for typical SLI but still exhibit significant communication impairments.

• The shift from DSM-IV to DSM-5 also included the merging of several disorders under ASD, complicating the diagnostic landscape.

Nosological Revisions from DSM-IV to DSM-5

Transition to ASD and its Impact on SPCD

• The introduction of ASD replaced several previous categories such as Asperger’s Disorder and Childhood Disintegrative Disorder.

• Individuals with pragmatic deficits but without restricted and repetitive behaviors (RRB) may fall under SPCD, leading to diagnostic confusion.

• Critics argue that the DSM-5 has narrowed the category of autism, reducing diagnostic flexibility, and consequently affecting the number of ASD diagnoses.

Diagnostic Inconsistencies

• The overlap in symptoms between SPCD and ASD raises questions regarding diagnostic criteria and treatment eligibility.

• Epidemiological data suggests that a substantial number of individuals previously diagnosed with ASD may not meet the criteria for SPCD, highlighting potential diagnostic inconsistencies.

Validity and Reliability of SPCD

Scientific Validators

• There are concerns regarding the validity of SPCD as a distinct category. Potential validators include etiology, response to treatment, and measurability.

1. Etiology

   • Studies have shown overlapping genetic and neurobiological factors between ASD and SPCD.

   • Current evidence does not support SPCD as having a unique etiology.

2. Response to Treatment

   • Treatments for ASD and SLI may not be effective for individuals with SPCD, who may require specific interventions tailored to their unique profiles.

   • Available evidence on differential treatment responses is inconclusive, complicating the classification of SPCD.

3. Measurability

   • There are challenges in quantitatively measuring social communication skills due to cultural differences and context dependence.

   • Tools like the Children’s Communication Checklist-2 show overlapping features of SPCD with other disorders, raising questions about its specificity.

Reliability and Nosological Inconsistencies

The Grandfather Clause

• The DSM-5 includes a grandfather clause that allows those previously diagnosed under DSM-IV to retain an ASD diagnosis, even if current symptomatology suggests otherwise.

• This leads to discrepancies where individuals with similar needs receive different diagnoses, impacting access to treatments and resources.

Concept of Spectrum

• The classification of ASD as a spectrum complicates the categorization of SPCD.

• Symptoms of DSC (deficits in social communication) could overlap significantly with those defined under SPCD, suggesting redundancy in diagnostic categories.

Thresholds of Diagnosis

• The DSM-5’s clinical thresholds create grey areas in diagnostics, where individuals may fall in between categories or even lead to no diagnosis at all.

• The absence of clearly defined thresholds for SPCD raises risks of overdiagnosis and unnecessary medicalization.

Conclusion

• The introduction of SPCD into the DSM-5 has raised significant questions about its independence from ASD and the guidelines governing psychiatric nosology.

• Given the existing overlaps and inconsistencies, it may be more prudent to consider SPCD as a subtype of a broader disorder, a cluster of symptoms, or a research entity rather than a stand-alone diagnosis.

• Considerations should include both evidential and non-evidential factors to facilitate clear and effective clinical practices.