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Am J Psychiatry 166:2, February 2009 235

LETTERS TO THE EDITOR

ajp.psychiatryonline.org

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RUTH SHIM, M.D., M.P.H.

Atlanta, Ga.

The author reports no competing interests.

This letter (doi: 10.1176/appi.ajp.2008.08111617) was accepted

for publication in November 2008.

Aspergers Syndrome and Autistic Disorder:

Clearly Differentiating the Diagnostic Criteria

TOTHEEDITOR: In their excellent, comprehensive Treatment

in Psychiatry article on Aspergers syndrome, published in the

August 2008 issue of theJournal, Karen Toth, Ph.D. and Bryan

H. King, M.D. (1) implicitly pointed to the inherent problems,

particularly in evaluating young children, of a categorical no-

menclature such as DSM. For example, the authors stated

that diagnosing Aspergers syndrome can be tricky, as the di-

agnostic criteria are not clearly differentiated from those

defining autistic disorder (1, p. 962). A more dimensional di-

agnostic approach can be found in the Psychodynamic Diag-

nostic Manual (2).

In the assessment of children, rather than focus on the ex-

act categorization of any particular child, the clinician should

evaluate the nature of the childs social interactions with par-ents, siblings, relatives, and other children and significant

adults as well as how others interact with the child. One needs

to understand the nature of the childs responses (appropri-

ate, under-reactive, over-reactive) to sensory stimuli as well as

the nature of his or her fine and gross motor development,

language development, memory, fund of knowledge, and

ability to understand social situations. A central clinical ques-

tion is regarding whether the childs development has pro-

ceeded smoothly or unevenly.

In addition, it is necessary for the clinician to evaluate the

degree to which the childs feelings (mainly depression or

anxiety) affect his or her ability to function as well as his or

her sense of self, without focusing too much on the concept

of comorbidity. The clinician must determine the degree to

which the childs problems are externalizing, internaliz-

ing, or a combination of both. Finally, it is important to eval-

uate the degree to which the child feels internal conflict in

contrast to conflict with other people as well as the degree to

which he or she can differentiate his or her fantasy li fe from

real experiences.

Drs. Toth and King presented such a paradigm and dis-

cussed a treatment plan whereby one can maximize the

strength of the child and address the childs developmental

delays and deviationswhether they are linguistic, aca-

demic, or socialand various other symptoms. Such an ap-

proach, of course, might require an integrated interdiscipli-

nary model.

Since the capacity to relate in general can be defined on a

spectrum (from no ability to relate at one end to well-related

at the other), one can observe clinically many situations in

which a psychodynamic approach could address the poten-

tial conflicted origins of certain social aversion, even in a

child who is diagnosed with Aspergers syndrome. Such anaversion may be the childs defensive retreat from an anxiety-

filled state when attempting social interactions.

References

1. Toth K, King BH: Aspergers syndrome: diagnosis and treat-

ment. Am J Psychiatry 2008; 165:958963

2. The PDM Task Force: Psychodynamic Diagnostic Manual. Silver

Spring, Md, Alliance of Psychoanalytic Organizations, 2006

LEON HOFFMAN, M.D.

New York, N.Y.

The author reports no competing interests.

This letter (doi: 10.1176/appi.ajp.2008.08091455) was accepted

for publication in November 2008.

Drs. Toth and King Reply

TOTHEEDITOR: Dr. Hoffman emphasizes a very important

point regarding the limitations of a purely categorical diag-

nostic approach with respect to pervasive developmental or

autism spectrum disorders.

In clinics throughout the world, the adage that if you have

seen one child with autism, you have seen one child with au-

tism is probably repeated daily. Perhaps more so than any

other diagnostic category, pervasive developmental disorders

underscore our inability to capture individual difference

within a categorical diag nostic framework. Approximately

50% or more of persons with a diagnosis on the autism spec-trum are given the not otherwise specified or atypical au-

tism diagnosis. How can it be that the dominant diagnosis

within a category is one for which the distinguishing feature is

that the classic picture does not quite fit?

Although it is likely t hat clinic ians use the not otherwise

specified diagnosis for a variety of reasons, including hedging

their bets or, perhaps, wanting to soften the blow of diagnosis,

our experience has been similar to that expressed by Dr. Hoff-

man in that the vocabulary to adequately capture individual

differences within the simple categorical diagnosis does not

exist and clinicians default to not otherwise specified in order

to highlight a given patients particular strengths or differ-

ences. A child who makes good eye contact, appears to be in-

terested in others despite profound social skills deficits, is

very bright, or has interests that are not too dissimilar from

those of children in the mainstream may be given this more

ambiguous diagnosis. Similarly, a child who once met all cri-

teria for autism but who has demonstrated remarkable im-

provement over the years might move from one category to

another to reflect this change (1).

In DSM-V, there is an opportunity to address the concerns

expressed by Dr. Hoffman and other clinicians regarding new

ways of combining categorical and dimensional approaches

(2). Incorporating specific descriptors, for example, relating