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LETTERS TO THE EDITOR

References
1. OHara A: Housing for people with mental illness: update of a
report to the Presidents New Freedom Commission. Psychiatr
Serv 2007; 58:907913
2. Tanzman B: An overview of surveys of mental health consumers preferences for housing and support services. Hosp Community Psychiatry 1993; 44:450455
3. Newman S: Housing attributes and serious mental illness: implication for research and practice. Psychiatr Serv 2001; 52:
13091317
4. Clark C, Rich A: Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatr Serv 2003; 54:7883

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


Atlanta, Ga.

The author reports no competing interests.

demic, or socialand various other symptoms. Such an approach, of course, might require an integrated interdisciplinary 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 potential conflicted origins of certain social aversion, even in a
child who is diagnosed with Aspergers syndrome. Such an
aversion may be the childs defensive retreat from an anxietyfilled state when attempting social interactions.
References
1. Toth K, King BH: Aspergers syndrome: diagnosis and treatment. 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.

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


for publication in November 2008.

The author reports no competing interests.

Aspergers Syndrome and Autistic Disorder:


Clearly Differentiating the Diagnostic Criteria
TO THE EDITOR: In their excellent, comprehensive Treatment
in Psychiatry article on Aspergers syndrome, published in the
August 2008 issue of the Journal, 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 nomenclature such as DSM. For example, the authors stated
that diagnosing Aspergers syndrome can be tricky, as the diagnostic criteria are not clearly differentiated from those
defining autistic disorder (1, p. 962). A more dimensional diagnostic approach can be found in the Psychodynamic Diagnostic Manual (2).
In the assessment of children, rather than focus on the exact categorization of any particular child, the clinician should
evaluate the nature of the childs social interactions with parents, 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 (appropriate, 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 question is regarding whether the childs development has proceeded 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, internalizing, or a combination of both. Finally, it is important to evaluate 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 life from
real experiences.
Drs. Toth and King presented such a paradigm and discussed a treatment plan whereby one can maximize the
strength of the child and address the childs developmental
delays and deviationswhether they are linguistic, acaAm J Psychiatry 166:2, February 2009

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


for publication in November 2008.

Drs. Toth and King Reply


TO THE EDITOR: Dr. Hoffman emphasizes a very important
point regarding the limitations of a purely categorical diagnostic 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 autism 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 diagnostic framework. Approximately
50% or more of persons with a diagnosis on the autism spectrum are given the not otherwise specified or atypical autism 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 that clinicians 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. Hoffman 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 differences. A child who makes good eye contact, appears to be interested 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 criteria for autism but who has demonstrated remarkable improvement 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
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