El autismo en el DSM.

Con el fin de homogeneizar la conceptualización de los trastornos mentales y unificar los criterios diagnósticos entre los profesionales se elaboraron los manuales diagnósticos, la OMS el International Classification of Diseases (ICD) y la American Psychiatric Association el Diagnostics and Statistics Manual of Mental Disorders (DSM).

La primera versión, el DSM-I (41) apareció en el año 1952. Aunque el autismo ya había sido identificado como una entidad específica nueve años antes no fue incluido en esta versión. Los niños de características descritas en el autismo eran diagnosticados como “reacción esquizofrénica de tipo infantil”.

El DSM-II (42), aparecido en 1968, tampoco contemplaba el autismo como un diagnóstico específico, sino como una característica propia de la esquizofrenia infantil.

Se puntualizaba: “La condición puede manifestarse por conducta autista, atípica y aislamiento”; y se mencionaba además, la existencia de un fracaso para desarrollar una identidad independiente de la madre.

También hacía referencia a la posible asociación con retraso mental, como una característica adicional.

No fue hasta 1980, con la publicación del DSM-III (43), cuando se incorporó el autismo como categoría diagnóstica específica. Se contemplaba como una entidad única, denominada “autismo infantil”.

Para su diagnóstico se requerían seis condiciones, todas las cuales debían estar presentes. La tabla II, muestra los criterios del DSM III, para el autismo infantil.

El DSM III-R (44), aparecido en 1987, supuso una modificación radical, no solo de los criterios sino también de la denominación. Se sustituyó autismo infantil por trastorno autista.

Con ello el autismo quedaba incorporado a la condición de “trastorno” (disorder), término que se usa en los manuales para definir genéricamente los problemas mentales, marcando una distancia conceptual con la terminología propia de los problemas médicos de etiología y fisiopatología conocida total o parcialmente.

Si bien el término “trastorno” es útil para marcar la singularidad de los problemas mentales tal como los contempla el DSM, adolece de una falta de significado conceptual. En el DSM IV-TR (45) se menciona la falta de concreción de “trastorno”, por lo cual queda pendiente consensuar una definición coherente con el paradigma hacia donde se van a orientar las nuevas revisiones del DSM (46) (47).

El DSM III-R amplió la versión anterior al delimitar los criterios diagnósticos, cada uno de los cuales era descrito minuciosamente y con gran detalle. Además, se incorporaban al texto ejemplos concretos que aclaraban cuando un criterio se debía considerar positivo.

El DSM III-R contemplaba el autismo como una categoría única, si bien admitía el diagnóstico de autismo atípico, para aquellos casos que aunando características claras de autismo no cumplían todos los criterios.

En los años 1994 y 2000 aparecieron respectivamente el DSM-IV (48) y el DSM IV-TR (Tabla IV), que aunque no planteaban modificaciones sustanciales entre ellos, representaron un nuevo cambio radical.

Por una parte se definieron 5 categorías de autismo: trastorno autista, trastorno de Asperger, trastorno de Rett, trastorno desintegrativo infantil y trastorno generalizado del desarrollo no especificado.

Además, se incorporó el término trastornos generalizados del desarrollo (pervasive developmental disorders), como denominación genérica para englobar los subtipos de autismo.

fuente: http://scielo.isciii.es

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