We could solve this issue if we focused on making context-specific theories about shared factors and personality traits of each of these rather than treating them as separate entities with separate etiologies and interventions and one single, APA/FDA-approved theory for each.
When people find the label that resonates and internalize it, then any change whatsoever in their life, personality system, or "symptom" set will threatens their very identity. Thus: a new DSM diagnosis with each new medical field interaction fuels identity crises. What is instead happening are extreme personality traits that have not been suitably actualized in a reliably appropriate manner, and so, manifest various DSM categories across life chapters.
Thus, rather than looking at broad categories like Schizoid PD, Borderline PD, ASD, and such and such, I believe it's more useful to look at many combinations (Forms) of underlying constructs like hyper-systemizing, alexithymia, high sensory sensitivity, extreme error detection (eg, inconsistency detection), elevated conscientiousness or openness, and so on. From these alone, it is not difficult to create a process model that spits out a different DSM category each time. If so, it shows we should focus on said traits as causal "unto themselves" rather than (weakly) emergent DSM categories that are unreliable from the start by virtue of their ever-changing natures. That is, Big 5 traits tend to be extremely stable across 5 year durations but schizophrenia does not have this same reliability.
You mentioned OCPD, which is strongly correlated with abnormally high conscientiousness and abnormally low openness to experience: hence, generalized behavioral rigidity. But rather than trying to "treat OCPD", I'm saying people should focus on increasing trait openness to experience in this one (literally n=1) example, which would necessarily lead to cognitive plasticity at the expense of over-control and over-inhibition. There are now dozens of long-term (multi-year) longitudinal studies showing that psilocybin increases trait Openness in dozens of DSM categories without meaningful safety effects.
Notice, however, I did NOT say "We should indiscriminately treat OCPD with ANY psychedelic". It is not even implied. Instead, I said people should focus on influencing the underlying personality traits unique to each individual rather than their diagnosis (hence, n=1), that just so happen to manifest many kinds of DSM categories every few months or years when aggregated in a sample. Modifying one's personality traits to change oneself is not a controversial idea.
An excellent source of theories about how such combinations of traits in the DSM manifest is Evolutionary Psychopathology by Del Giudice (2018). Unfortunately, people misinterpret the book as arguing DSM categories are themselves "evolutionary adaptations" or moral prescriptions. But he rejects this. Instead, the UNDERLYING personality traits (which have a biological basis) are possible adaptations-to-context (NOT society at large nor the entire gene pool), such that, when the context abruptly changes afterwards, become maladaptive and therefore manifest a new DSM category on each occasion. This suggests contexts, not individuals, are what become broken. Yet if persons and contexts are always changing then so will DSM categories. Therefore, we should focus on the suspiciously unchanging (highly reliable) contexts and personality traits correlated to suffering and breakdown, rather than ever-changing DSM categories diagnosed post-hoc that are apparently unmeasurable.
Thinking in terms of traits is just too sensible, no one is interested anymore.
I don't see how we can do much more than think I'm terms of traits unto themselves and I don't understand why people no longer find this idea more relaxed and less anxiety provoking.
It seems people today enjoy the self-consciousness and social anxiety that come with pigeon-holing their entire personality.
This is a great, very compassionate while still being skeptical. The word I hear most often is "neurodiverse". I have had similar experiences encountering people who self-diagnose in a way that might risk shutting down alternate possibilities. Referencing neurodiversity as a stand-in for the autism spectrum seems to have the appeal of being somewhat nonclinical while still authoritative, and also, perhaps, references a soft etiological claim, suggesting that the cause is rooted in determined neuroscience, possibly immutable. This has real implications for how people see themselves and their possibilities for change.
Aside from the consideration of different classification categories, for example, we could consider different contributing factors. Eg attachment issues (and not even necessarily formal trauma) can contribute to rigidity, repetitive soothing behaviors, certainly social awkwardness. But that is something that can be addressed! Whereas a "Neuro" label (sometimes, not always!) runs the risk of a sort of determined fatalism.
Great article Awais, you gave a crystal clear definition of what autism really is and thank you for that because a lot of "neurodivergent" people seem to struggle to understand what autism really is. Just a few comments regarding the differentials: from my clinical experience a lot of people who were given diagnoses of Schizoid Personality, Obsessive-Compulsive Personality and even Schizophrenia years ago had been misdiagnosed and actually had autism (and I have a high threshold for diagnosing autism). Here in the UK unfortunately our colleagues who work in mainstream mental health services i.e. not in specialist neurodevelopmental services (I am a neurodevelopmental psychiatrist working in a specialist service) still struggle to recognise autism in patients. What we see often is people with Borderline Personality pursuing an autism diagnosis aggressively as they do not like the Borderline Personality label. Furthermore, what is common here in the UK is that a lot of people who don't get a formal autism diagnosis don't have any of the differential diagnoses you listed above but rather have some autism traits but do not reach the diagnostic threshold. So we need to be more confident and brave to say to the patient "you have autism traits/features but you don't reach the threshold for diagnosis" (even though here in the UK a patient might make a complaint if they don't get the autism diagnosis they want) rather than be forced to give one of the differential diagnoses incorrectly.
I encounter this and find that arriving at an accurate diagnosis opens up meaningful conversations with patients about what that diagnosis means to them — how it shapes treatment, illuminates day-to-day patterns, and clarifies their agency to change their quality of life. Bipolar disorder is (to me) another example of a condition that draws a high degree of self-diagnosis and, at times, misattribution by clinicians. My sense is that people are trying to make sense of their experience, which is entirely understandable. Certain diagnoses trend through the public consciousness and, much like in medical school when we believed we had every condition we studied, my sense is that people naturally wonder as well.
A patient’s relationship to a diagnosis becomes something to thoughtfully navigate; optimally it becomes a tool for understanding rather than a limiting label. For me, the work lies in combining diagnostic clarity with a broader conceptualization — psychodynamic, trauma-informed, or otherwise — which can make ALL the difference in tone and trajectory. In summary: how do we help people learn themselves, deeply?
Really though there is nothing great about being diagnosed as “schizoid,” “obsessive compulsive,” “cluster B,” “social anxiety,” “generalized anxiety,” “trauma,” “socially awkward”, trauma sends you down an endless therapy black hole where you end up worse.....the various "anxiety" diagnoses lead to endless antidepressant merrygoround till you get fat and die. Ditto OCD, cluster B is just a way of insulting people and who on earth would want a label of schizoid? takes you nowhere but a house full of urine stained newspaper. None of them are actually treatable, they just serve to keep us psychiatrists in jobs and out of trouble. I think that perhaps we are moving towards ASD spectrum being a bigger and dimensional way of understanding a type of person, and these people can find each other online and find meaning and a way of being in the world. Obviously they tend to be very sensitive to medication and often avoid, they self identify, so not much of a pharmaceutical or psychiatric market, but infinitely better for the patient. And a lot closer to getting ADHD medication which actually helps ......
So, I can see your point. At the same time, autism being less stigmatized than these others didn't come out of nowhere. It's largely an effect of autistic advocacy, right?
Sam Fellowes, in the paper that Awais cites above, also talks about how no one advocates on behalf of schizoids etc when everyone decides to identify as autistic. So, we might have a self-enforcing circle here:
more autistics->less stigma for autism than for other diagnoses
less stigma for autism-> more people want to identify as autistic rather than some of the others
and this would always be a better choice for them right, SZ is basically untreatable and by definition anyone who hasn't managed the leap from that to ASD (widely considered similar) is not going to be supporting anyone .....
I'm so glad you made this post. I see this so much and it can be so discouraging to see ASD diagnoses applied indiscriminately, particularly because the ASD interventions aren't helpful if the individual's symptoms are much better explained by another more appropriate diagnosis. A big red flag is the criterion B - many people just don't meet that despite being given the diagnosis.
Okay, you got me. This is the post that earned my subscription!
As a parent of an autistic teen, this was so helpful to me to read through possible differential diagnoses and to realize that, yes, he has the right diagnosis.
Now I'm gonna talk about myself again, as I always do. ;-)
Once upon a time, in the distant 1990s, my mum suggested (after having read some magazine article about it), that perhaps I was autistic.
Now, I was already in treatment for recurring psychotic symptoms, and "autism only" was never on the diagnostic table for me. But I guess it could have been an additional diagnosis? However, my psychiatrist was certain I DIDN'T have it; certain that all social difficulties I had had as a kid (BIG ones) and any social difficulties I still had (more moderate as an adult, but still noticeable at the time) was a side effect of having had my first big psychotic break at the tender age of ten and then recurring psychosis issues.
This seemed plausible to me and seems plausible still, but IDK. MAYBE I would fit the criteria for ASD too, if I was investigated for it.
However, in the end, I've never been precisely diagnosed beyond "psychotic issues, probably on the schizo-spectrum".
Once upon a time, this bothered me. I wanted one or more firm diagnoses, like everyone else seemed to have. But now, I think it's been overall good for me. I've changed a lot over time. I can change again in the future. But if I had had one or more firm diagnoses, I suspect that would have influenced my self-understanding, and prevented me from changing and evolving as much as I have.
Decades ago, I had a note in my medical records about abnormal mood swings. I think this was a correct description at the time. But I really don't have that issue anymore. Perhaps, if I had been diagnosed as schizo-affective, I would still have those swings? And perhaps, if I had been diagnosed as autistic in addition, I would have retained more social difficulties over time.
This is such a helpful post in describing the possible differentials, really appreciated being able to read and reflect.
I'm unsure exactly how this fits into the existing clinical literature, but I've been learning and implementing Gutstein's Relationship Development Intervention (RDI) therapy recently. Without getting too far into the weeds or explain what you probably already know, RDI attempts to address what autism "is" in the brain (not just what it looks like in terms of DSM criteria, or how it feels). I am massively simplifying, but according to Gutstein autism is overreliance on static thinking/processing and severe challenges with dynamic thinking/processing. One may be exceptional at applying knowledge in predictable, unchanging situations but unable to cope with situations where there is no clear "answer" and problem-solving is required. https://www.rdiconnect.com/static-thinking-vs-dynamic-thinking/
I am not able to diagnose officially at this level, though I can make preliminary diagnoses and refer on for confirmation. I have found this understanding of what autism "is" useful in differential diagnosis work, though I'm not sure how well-accepted RDI is within the greater psychiatric field.
In the exhausting Woozle hunt we find ourselves in, perhaps the most exasperating past time is the public’s fascination with autism. I was in primary school here in Australia when that knucklehead Attwood was promoting the idea that bookishness or a fondness for Pokémon were practically pathognomonic of Asperger’s. And before anyone jumps in with “that’s not exactly what he said,” please don’t. That dunce should have been frog marched out of the profession. I still chuckle once a week when I think about his absurd claim of diagnosing his own 37 year old son with Asperger’s based on an old VHS tape, something he had apparently never noticed before. What a pretentious dingbat. It was a wild time; half my class had an ADHD diagnosis.
Fast forward to today and the situation is even less tolerable. My wife and I endure a steady stream of colleagues whispering that some new client “should be assessed” or is “on the spectrum,” which has become code for any form of distress that is not explicitly depression. They must be neo-Kraepelinians, dividing humanity into two giant buckets, “MDI” and “autism”. The most outrageous part is that the clients in question are often strikingly charismatic, if somewhat highly strung. I find that people living with neurotic personality traits usually have stronger emotional feeling, more sensitivity in the old fashioned sense. They feel awkward not because they are socially blind but because they are socially acute, the diametric opposite of what I associate with autism.
The latest fixation is to hunt for it in women. It is astonishing how often the woman in question is an emotionally troubled femme fatale. In my own social circle, many of my most glamorous and socially magnetic female friends either have a diagnosis or are eager to get assessed, preferably without paying for it. Their romantic catastrophes, highly charged emotional lives and occasional hypochondria are held up as proof of some deep seated social deficit. It is a remarkable feat of conceptual stretching.
Now, I do not believe in most personality disorders, with the exception of anankastic personality which I view more as a type than a disorder, in the same spirit as a hyperthymic temperament. I have my own ideas about what schizoid personality is and what BPD is, but setting all that aside, I do think autism has genuinely pathognomonic features, and they are not an enthusiasm for anime or the Harry Potter franchise. There is something in the restriction of behaviour and here my thinking goes back to the old French psychiatric link between autism and hebephrenia.
For a start, there are social deficits that are neuropsychologically measurable. You can present faces and find a marked impairment in recognising expressions. Eye contact, on the other hand, is mostly useless; hardly any of us make much and anxiety can either increase or decrease it. It is entirely contextual. Far more telling is the consistent missing of small non verbal cues, gesturing towards an open door and receiving a blank look, waving and getting no response. Yes, people can learn to compensate and many do. But when you are around genuine autism, you notice these lapses.
Then we come to the idea of special interests which I have always found amusing as a diagnostic marker. Anyone without deep interests is, in my opinion, a beige dullard. What is distinctive in autism is not having interests, it is the stereotyped restriction of interest, almost a monomania. This is where that very well known old textbook example from the 80s and 90s of “collecting bus timetables” actually earned its keep. It captures the obscure, narrow and stereotyped quality of autistic interests in a way that ordinary enthusiasm simply does not.
I recall one example from when I was training at a centre that supported people with autism into employment. One young woman I was assigned to had a special interest, she was interested in cruise ship rewards program point systems. Let me be very clear, she was not interested in travel, or cruises, or ships, or the rewards themselves, or rewards programs generally. Her interest was in the points mechanisms of the reward schemes used by cruise ship companies and she was utterly dispassionate about the whole thing. An extreme example, yes, but do you see the difference.
By contrast, I had a hyperthymic friend who had a great passion for a certain BMW model. He could talk about it in exquisite detail, gather a crowd, make it sound fascinating and adjust the level of detail to suit whomever he was speaking to. That is not monomania, that is charisma attached to a hobby.
Now, masking. Everyone masks sometimes; it is part of civilised life. The idea is especially fashionable in discussions of autism in women. The number of anxious, sensitive women I know who sincerely believe their natural sociability is masking is astonishing. They will cite their breakups and difficulties in relationships as evidence of autism. Everything is masking, being charming is masking, being shy is masking, being expressive is masking. One friend told me she only seemed outgoing because she was covering her social deficits, another said that her tendency to over explain herself was a form of masking. None of it bothers me. I just feel sad that so many of them believe society requires them to have a diagnosis.
Don't get me started on neurodivergence, how someone as intelligent as Simon Baron-Cohen could get caught up in "internal phrenology" is a matter for future historians to grapple.
Constantly online I see the troubling catchphrase that "we see more autism today for the same reason we saw more stars after telescopes were invented". I know I complain a lot about simple heuristics being repurposed as thought terminating clichés, but this telescope analogy might be the most pernicious. It is perfectly crafted to be liked straight to the top of the comments. It is a near perfect meme. Coupled with the concept of masking, which can be used to wave away any inconvenient evidence, we now have the ingredients for a formidable social contagion, if you believe in that sort of thing.
You would like Personality Shaping by Dabrowski (1967, but i recommend the 2015 edition). Actually, most of what you said mirrors Misdiagnosis by Webb et al (2016)., too, but is ultimately based on Dabrowski.
My cousins son is 40, still living at home, no job. I recommended he get assessed when he was a kid, but both parents refused as they did not want him “labeled.” Anyway, my cousins husband died in January and she is showing signs of dementia. We are trying to get her into an assisted living, but that leaves her son with no support. Is it possible to get a 40-year-old man diagnosed with autism so that he can get services? I truly believe that would be the diagnosis.
A diagnosis is possible at any age after a suitable diagnostic evaluation. Access to services and supports varies, though. Many counties and states have boards of developmental disabilities that can help with things like group homes with suitable supports. Case managers at community mental health services can also be helpful in arranging group homes and assisted living.
We could solve this issue if we focused on making context-specific theories about shared factors and personality traits of each of these rather than treating them as separate entities with separate etiologies and interventions and one single, APA/FDA-approved theory for each.
When people find the label that resonates and internalize it, then any change whatsoever in their life, personality system, or "symptom" set will threatens their very identity. Thus: a new DSM diagnosis with each new medical field interaction fuels identity crises. What is instead happening are extreme personality traits that have not been suitably actualized in a reliably appropriate manner, and so, manifest various DSM categories across life chapters.
Thus, rather than looking at broad categories like Schizoid PD, Borderline PD, ASD, and such and such, I believe it's more useful to look at many combinations (Forms) of underlying constructs like hyper-systemizing, alexithymia, high sensory sensitivity, extreme error detection (eg, inconsistency detection), elevated conscientiousness or openness, and so on. From these alone, it is not difficult to create a process model that spits out a different DSM category each time. If so, it shows we should focus on said traits as causal "unto themselves" rather than (weakly) emergent DSM categories that are unreliable from the start by virtue of their ever-changing natures. That is, Big 5 traits tend to be extremely stable across 5 year durations but schizophrenia does not have this same reliability.
You mentioned OCPD, which is strongly correlated with abnormally high conscientiousness and abnormally low openness to experience: hence, generalized behavioral rigidity. But rather than trying to "treat OCPD", I'm saying people should focus on increasing trait openness to experience in this one (literally n=1) example, which would necessarily lead to cognitive plasticity at the expense of over-control and over-inhibition. There are now dozens of long-term (multi-year) longitudinal studies showing that psilocybin increases trait Openness in dozens of DSM categories without meaningful safety effects.
Notice, however, I did NOT say "We should indiscriminately treat OCPD with ANY psychedelic". It is not even implied. Instead, I said people should focus on influencing the underlying personality traits unique to each individual rather than their diagnosis (hence, n=1), that just so happen to manifest many kinds of DSM categories every few months or years when aggregated in a sample. Modifying one's personality traits to change oneself is not a controversial idea.
An excellent source of theories about how such combinations of traits in the DSM manifest is Evolutionary Psychopathology by Del Giudice (2018). Unfortunately, people misinterpret the book as arguing DSM categories are themselves "evolutionary adaptations" or moral prescriptions. But he rejects this. Instead, the UNDERLYING personality traits (which have a biological basis) are possible adaptations-to-context (NOT society at large nor the entire gene pool), such that, when the context abruptly changes afterwards, become maladaptive and therefore manifest a new DSM category on each occasion. This suggests contexts, not individuals, are what become broken. Yet if persons and contexts are always changing then so will DSM categories. Therefore, we should focus on the suspiciously unchanging (highly reliable) contexts and personality traits correlated to suffering and breakdown, rather than ever-changing DSM categories diagnosed post-hoc that are apparently unmeasurable.
(Edited to reduce word count)
Thank you, agree with a lot of what you are saying!
Thinking in terms of traits is just too sensible, no one is interested anymore.
I don't see how we can do much more than think I'm terms of traits unto themselves and I don't understand why people no longer find this idea more relaxed and less anxiety provoking.
It seems people today enjoy the self-consciousness and social anxiety that come with pigeon-holing their entire personality.
Then you would appreciate The Mind-body Politic by Maiese & Hanna (eg https://link.springer.com/book/10.1007/978-3-030-19546-5). It is heresy in academia-land, get it while you can.
This is a great, very compassionate while still being skeptical. The word I hear most often is "neurodiverse". I have had similar experiences encountering people who self-diagnose in a way that might risk shutting down alternate possibilities. Referencing neurodiversity as a stand-in for the autism spectrum seems to have the appeal of being somewhat nonclinical while still authoritative, and also, perhaps, references a soft etiological claim, suggesting that the cause is rooted in determined neuroscience, possibly immutable. This has real implications for how people see themselves and their possibilities for change.
Aside from the consideration of different classification categories, for example, we could consider different contributing factors. Eg attachment issues (and not even necessarily formal trauma) can contribute to rigidity, repetitive soothing behaviors, certainly social awkwardness. But that is something that can be addressed! Whereas a "Neuro" label (sometimes, not always!) runs the risk of a sort of determined fatalism.
Great article Awais, you gave a crystal clear definition of what autism really is and thank you for that because a lot of "neurodivergent" people seem to struggle to understand what autism really is. Just a few comments regarding the differentials: from my clinical experience a lot of people who were given diagnoses of Schizoid Personality, Obsessive-Compulsive Personality and even Schizophrenia years ago had been misdiagnosed and actually had autism (and I have a high threshold for diagnosing autism). Here in the UK unfortunately our colleagues who work in mainstream mental health services i.e. not in specialist neurodevelopmental services (I am a neurodevelopmental psychiatrist working in a specialist service) still struggle to recognise autism in patients. What we see often is people with Borderline Personality pursuing an autism diagnosis aggressively as they do not like the Borderline Personality label. Furthermore, what is common here in the UK is that a lot of people who don't get a formal autism diagnosis don't have any of the differential diagnoses you listed above but rather have some autism traits but do not reach the diagnostic threshold. So we need to be more confident and brave to say to the patient "you have autism traits/features but you don't reach the threshold for diagnosis" (even though here in the UK a patient might make a complaint if they don't get the autism diagnosis they want) rather than be forced to give one of the differential diagnoses incorrectly.
I encounter this and find that arriving at an accurate diagnosis opens up meaningful conversations with patients about what that diagnosis means to them — how it shapes treatment, illuminates day-to-day patterns, and clarifies their agency to change their quality of life. Bipolar disorder is (to me) another example of a condition that draws a high degree of self-diagnosis and, at times, misattribution by clinicians. My sense is that people are trying to make sense of their experience, which is entirely understandable. Certain diagnoses trend through the public consciousness and, much like in medical school when we believed we had every condition we studied, my sense is that people naturally wonder as well.
A patient’s relationship to a diagnosis becomes something to thoughtfully navigate; optimally it becomes a tool for understanding rather than a limiting label. For me, the work lies in combining diagnostic clarity with a broader conceptualization — psychodynamic, trauma-informed, or otherwise — which can make ALL the difference in tone and trajectory. In summary: how do we help people learn themselves, deeply?
Really though there is nothing great about being diagnosed as “schizoid,” “obsessive compulsive,” “cluster B,” “social anxiety,” “generalized anxiety,” “trauma,” “socially awkward”, trauma sends you down an endless therapy black hole where you end up worse.....the various "anxiety" diagnoses lead to endless antidepressant merrygoround till you get fat and die. Ditto OCD, cluster B is just a way of insulting people and who on earth would want a label of schizoid? takes you nowhere but a house full of urine stained newspaper. None of them are actually treatable, they just serve to keep us psychiatrists in jobs and out of trouble. I think that perhaps we are moving towards ASD spectrum being a bigger and dimensional way of understanding a type of person, and these people can find each other online and find meaning and a way of being in the world. Obviously they tend to be very sensitive to medication and often avoid, they self identify, so not much of a pharmaceutical or psychiatric market, but infinitely better for the patient. And a lot closer to getting ADHD medication which actually helps ......
So, I can see your point. At the same time, autism being less stigmatized than these others didn't come out of nowhere. It's largely an effect of autistic advocacy, right?
Sam Fellowes, in the paper that Awais cites above, also talks about how no one advocates on behalf of schizoids etc when everyone decides to identify as autistic. So, we might have a self-enforcing circle here:
more autistics->less stigma for autism than for other diagnoses
less stigma for autism-> more people want to identify as autistic rather than some of the others
and this would always be a better choice for them right, SZ is basically untreatable and by definition anyone who hasn't managed the leap from that to ASD (widely considered similar) is not going to be supporting anyone .....
I'm so glad you made this post. I see this so much and it can be so discouraging to see ASD diagnoses applied indiscriminately, particularly because the ASD interventions aren't helpful if the individual's symptoms are much better explained by another more appropriate diagnosis. A big red flag is the criterion B - many people just don't meet that despite being given the diagnosis.
Okay, you got me. This is the post that earned my subscription!
As a parent of an autistic teen, this was so helpful to me to read through possible differential diagnoses and to realize that, yes, he has the right diagnosis.
Now I'm gonna talk about myself again, as I always do. ;-)
Once upon a time, in the distant 1990s, my mum suggested (after having read some magazine article about it), that perhaps I was autistic.
Now, I was already in treatment for recurring psychotic symptoms, and "autism only" was never on the diagnostic table for me. But I guess it could have been an additional diagnosis? However, my psychiatrist was certain I DIDN'T have it; certain that all social difficulties I had had as a kid (BIG ones) and any social difficulties I still had (more moderate as an adult, but still noticeable at the time) was a side effect of having had my first big psychotic break at the tender age of ten and then recurring psychosis issues.
This seemed plausible to me and seems plausible still, but IDK. MAYBE I would fit the criteria for ASD too, if I was investigated for it.
However, in the end, I've never been precisely diagnosed beyond "psychotic issues, probably on the schizo-spectrum".
Once upon a time, this bothered me. I wanted one or more firm diagnoses, like everyone else seemed to have. But now, I think it's been overall good for me. I've changed a lot over time. I can change again in the future. But if I had had one or more firm diagnoses, I suspect that would have influenced my self-understanding, and prevented me from changing and evolving as much as I have.
Decades ago, I had a note in my medical records about abnormal mood swings. I think this was a correct description at the time. But I really don't have that issue anymore. Perhaps, if I had been diagnosed as schizo-affective, I would still have those swings? And perhaps, if I had been diagnosed as autistic in addition, I would have retained more social difficulties over time.
This is such a helpful post in describing the possible differentials, really appreciated being able to read and reflect.
I'm unsure exactly how this fits into the existing clinical literature, but I've been learning and implementing Gutstein's Relationship Development Intervention (RDI) therapy recently. Without getting too far into the weeds or explain what you probably already know, RDI attempts to address what autism "is" in the brain (not just what it looks like in terms of DSM criteria, or how it feels). I am massively simplifying, but according to Gutstein autism is overreliance on static thinking/processing and severe challenges with dynamic thinking/processing. One may be exceptional at applying knowledge in predictable, unchanging situations but unable to cope with situations where there is no clear "answer" and problem-solving is required. https://www.rdiconnect.com/static-thinking-vs-dynamic-thinking/
I am not able to diagnose officially at this level, though I can make preliminary diagnoses and refer on for confirmation. I have found this understanding of what autism "is" useful in differential diagnosis work, though I'm not sure how well-accepted RDI is within the greater psychiatric field.
In the exhausting Woozle hunt we find ourselves in, perhaps the most exasperating past time is the public’s fascination with autism. I was in primary school here in Australia when that knucklehead Attwood was promoting the idea that bookishness or a fondness for Pokémon were practically pathognomonic of Asperger’s. And before anyone jumps in with “that’s not exactly what he said,” please don’t. That dunce should have been frog marched out of the profession. I still chuckle once a week when I think about his absurd claim of diagnosing his own 37 year old son with Asperger’s based on an old VHS tape, something he had apparently never noticed before. What a pretentious dingbat. It was a wild time; half my class had an ADHD diagnosis.
Fast forward to today and the situation is even less tolerable. My wife and I endure a steady stream of colleagues whispering that some new client “should be assessed” or is “on the spectrum,” which has become code for any form of distress that is not explicitly depression. They must be neo-Kraepelinians, dividing humanity into two giant buckets, “MDI” and “autism”. The most outrageous part is that the clients in question are often strikingly charismatic, if somewhat highly strung. I find that people living with neurotic personality traits usually have stronger emotional feeling, more sensitivity in the old fashioned sense. They feel awkward not because they are socially blind but because they are socially acute, the diametric opposite of what I associate with autism.
The latest fixation is to hunt for it in women. It is astonishing how often the woman in question is an emotionally troubled femme fatale. In my own social circle, many of my most glamorous and socially magnetic female friends either have a diagnosis or are eager to get assessed, preferably without paying for it. Their romantic catastrophes, highly charged emotional lives and occasional hypochondria are held up as proof of some deep seated social deficit. It is a remarkable feat of conceptual stretching.
Now, I do not believe in most personality disorders, with the exception of anankastic personality which I view more as a type than a disorder, in the same spirit as a hyperthymic temperament. I have my own ideas about what schizoid personality is and what BPD is, but setting all that aside, I do think autism has genuinely pathognomonic features, and they are not an enthusiasm for anime or the Harry Potter franchise. There is something in the restriction of behaviour and here my thinking goes back to the old French psychiatric link between autism and hebephrenia.
For a start, there are social deficits that are neuropsychologically measurable. You can present faces and find a marked impairment in recognising expressions. Eye contact, on the other hand, is mostly useless; hardly any of us make much and anxiety can either increase or decrease it. It is entirely contextual. Far more telling is the consistent missing of small non verbal cues, gesturing towards an open door and receiving a blank look, waving and getting no response. Yes, people can learn to compensate and many do. But when you are around genuine autism, you notice these lapses.
Then we come to the idea of special interests which I have always found amusing as a diagnostic marker. Anyone without deep interests is, in my opinion, a beige dullard. What is distinctive in autism is not having interests, it is the stereotyped restriction of interest, almost a monomania. This is where that very well known old textbook example from the 80s and 90s of “collecting bus timetables” actually earned its keep. It captures the obscure, narrow and stereotyped quality of autistic interests in a way that ordinary enthusiasm simply does not.
I recall one example from when I was training at a centre that supported people with autism into employment. One young woman I was assigned to had a special interest, she was interested in cruise ship rewards program point systems. Let me be very clear, she was not interested in travel, or cruises, or ships, or the rewards themselves, or rewards programs generally. Her interest was in the points mechanisms of the reward schemes used by cruise ship companies and she was utterly dispassionate about the whole thing. An extreme example, yes, but do you see the difference.
By contrast, I had a hyperthymic friend who had a great passion for a certain BMW model. He could talk about it in exquisite detail, gather a crowd, make it sound fascinating and adjust the level of detail to suit whomever he was speaking to. That is not monomania, that is charisma attached to a hobby.
Now, masking. Everyone masks sometimes; it is part of civilised life. The idea is especially fashionable in discussions of autism in women. The number of anxious, sensitive women I know who sincerely believe their natural sociability is masking is astonishing. They will cite their breakups and difficulties in relationships as evidence of autism. Everything is masking, being charming is masking, being shy is masking, being expressive is masking. One friend told me she only seemed outgoing because she was covering her social deficits, another said that her tendency to over explain herself was a form of masking. None of it bothers me. I just feel sad that so many of them believe society requires them to have a diagnosis.
Don't get me started on neurodivergence, how someone as intelligent as Simon Baron-Cohen could get caught up in "internal phrenology" is a matter for future historians to grapple.
Constantly online I see the troubling catchphrase that "we see more autism today for the same reason we saw more stars after telescopes were invented". I know I complain a lot about simple heuristics being repurposed as thought terminating clichés, but this telescope analogy might be the most pernicious. It is perfectly crafted to be liked straight to the top of the comments. It is a near perfect meme. Coupled with the concept of masking, which can be used to wave away any inconvenient evidence, we now have the ingredients for a formidable social contagion, if you believe in that sort of thing.
You would like Personality Shaping by Dabrowski (1967, but i recommend the 2015 edition). Actually, most of what you said mirrors Misdiagnosis by Webb et al (2016)., too, but is ultimately based on Dabrowski.
My cousins son is 40, still living at home, no job. I recommended he get assessed when he was a kid, but both parents refused as they did not want him “labeled.” Anyway, my cousins husband died in January and she is showing signs of dementia. We are trying to get her into an assisted living, but that leaves her son with no support. Is it possible to get a 40-year-old man diagnosed with autism so that he can get services? I truly believe that would be the diagnosis.
A diagnosis is possible at any age after a suitable diagnostic evaluation. Access to services and supports varies, though. Many counties and states have boards of developmental disabilities that can help with things like group homes with suitable supports. Case managers at community mental health services can also be helpful in arranging group homes and assisted living.
Thank you so much.