Some interesting (not indicating agreement!) comments from LinkedIn worth sharing here:
1) Steven Reidbord
Psychiatrist, psychotherapist
"This is probably true, that people are drawn to intricate mechanistic explanations to explain mysterious personal phenomena. That’s one reason psychoanalysis and neurobiological accounts have been popular in their turns, and why autism is now.
Unfortunately, intricacy itself says nothing of validity. A once popular model explained how the sun (and the rest of the heavens) revolved around the earth. Actual physical models, made of metal gears and wheels-within-wheels, showed how it operated. It was no doubt comforting to “understand” the world this way, even though it was completely wrong.
Other diagnoses can’t “learn” anything from the success of autism, unless the message is to make up compelling stories with no basis in reality. Science only advances as fast as it does, and pretending that we know more than we do has repeatedly misled and embarrassed us."
2) Rachael Winstanley
Child & Adolescent Psychotherapist in private practice
"I think this is an excellent piece, thank you to the author and you Awais Aftab for posting it. The description of the construct of autism being 'profoundly phenomenologically organizing' really powerfully captures my experience.
I spent a long time in psychodynamic psychotherapy because I believed that my difficulties were emotional, psychological, unconscious. I even trained in the field. Although I still find the Kleinian framework I trained in helpful, I didn't get 'better' because my 'issues' were not primarily emotional, they were differences in cognitive-perceptual processing, as described.
I am well aware, as are so many autistic people, that these models are approximations, and that these descriptions generated collectively by autistic people themselves may change, according to cultures, time and place etc. just like all our models of human understanding.
But many of us need explanatory or mechanistic models that organise our subjective experience to feel well. This is a profound and essential need, not a 'comfort' (how infantalising). Suggestions from 'experts' that we don't really understand what we're doing when we describe ourselves as autistic, that we've got it wrong yet again, really miss the mark."
3) Sindhu Ashim
Psychiatrist
"I think this article mistakes a consequence of cultural acceptance as a cause for it.
Autism’s theories feel compelling and widespread because the label is now culturally acceptable (neurodiversity is celebrated). By contrast, BPD already has detailed mechanistic accounts— Gunderson’s interpersonal hypersensitivity model (core rejection sensitivity→frantic efforts to avoid abandonment) and Linehan’s biosocial theory of emotional dysregulation (invalidating environments + biological vulnerability → extreme emotional cascades)—yet BPD as a construct is rarely experienced as patient-empowering. Similarly, schizophrenia’s neural, chemical & predictive-coding models of psychosis are "mechanistic" but evoke fear rather than appeal.
Edward Shorter’s insight (symptom pool effect) is that cultural legitimacy comes first and each generation has its epidemic!"
I upgraded my subscription for the sole purpose of expressing my appreciation to the author for writing this post and to Dr Aftab for posting it.
I read the original post, which was explicitly "not for me" because, in fact, I don't really care about the clinical diagnostic criteria for autism. Given the historical biases of autism diagnosis (with regard to gender, intelligence, arbitrarily specific behavioral markers, etc), it takes a lot of hubris to assume that the DSM-5 has finally nailed it. But when I saw Riva Stoudt's response post, I was heartened that someone would take on the challenge of explaining why we shouldn't let the internet "popularity" of autism (and its attendant trivialization and trend-ification) distract us from the fundamentally different orientation that the current, evolving framework of autism offers us in terms of reducing human suffering. It gives us not only some language for describing subjective experience that has previously been poorly served by vague words like "weird" and "intense" and "anxious," but also a more convincing unifying theory of why some people to have that hard-to-describe experience.
Full disclosure: I am not a psychiatrist or a clinician, so this comment might not be for you.
Where am I coming from? A lifelong effort to understand my own psychological suffering and that of the people around me, i.e. the so-called "human condition." Instead of trying to engage with what I consider to be the bad-faith arguments of the previous commenters (what does being an "attractive young woman" have to do with diagnostic validity? why would anyone claim "authority" on subjective experience?), I will describe why this post resonated so strongly with me.
About a year ago I read this article by Michael Edward Johnson )https://opentheory.net/2023/05/autism-as-a-disorder-of-dimensionality/) that posits a specific "mechanistic substrate" (neuronal network dimensionality) for autism and elegantly shows how DSM-5 personality disorder clusters can be characterized as strategies for finding stability in a highly dynamic nervous system. In other words, coping strategies. He describes such a nervous system as "maladaptive," in that it produces the "autistic bundle of symptoms," but also discusses how nervous systems of high network dimensionality can also have unique advantages ("winning lottery tickets"): creativity, sensitivity, outlier intelligence, etc. Ah! A concrete explanation for what philosophers and theologians and psychologists and therapists are always struggling to convince us of: that our vulnerabilities are inextricably intertwined with our strengths. It's an opening to *experience* non-duality.
Understanding one's neurosis not as a disease, but as a way of tolerating a highly dynamic internal experience makes it possible to develop a healthier relationship with that internal experience, and thereby weaken the neurosis. Why? Because it gives a *semantically neutral* framework for understanding what is happening and why it's happening. It's a MUCH more satisfying explanation for one's suffering than "I have a chemical imbalance" or "I'm still mad at my mom after all these years."
I believe the diagnosis and discussion of autism currently confuses the underlying condition with the strategies for coping with it. This is one of the reasons why adopting autism as an "identity" supported by internet content gets so messy. When people are considering how this framework applies to them as adolescents or adults, it can be a harrowing spiritual jungle to traverse. Some people grow up in contexts that support and/or accept their outlier behaviors; many don't and have to learn how to mask and/or suppress their experience (see: women, attractive and otherwise). But the autism framework can provide effective tools for confronting the fear, shame, and rigidity that are the natural consequences of living in families and societies that don't understand or recognize or even have language for the autistic experience.
Many people (I dare not speak for everyone) are seeking not just a practical "solutions" for their suffering (which, if they succeed, are almost always temporary), but the kind of relief that comes with a proximity to some kind of truth. For some people, the autism framework feels like truth. And that's hard to beat as a place to grow from.
Thank you, Madonna, for the eloquently stated reminder that the stakes of diagnosis are, first and foremost, about addressing human suffering. Too often, it seems that people become overly concerned with whether other people are being taxonomized correctly and less concerned than they ought to be about whether and how the taxonomies created to explain and address that suffering are doing the job. Given the devastatingly strong association between autistic traits and suicide, in particular, I find it troubling that so many people seem to be more interested in catching people they think are posers than exploring the strong possibility that this diagnosis could be a crucial tool in suicide prevention, among other things.
This explanation seems to me a little overwrought and out of date. Maybe a decade ago the people seeking diagnosis were the sorts of people you describe, but my recent observation is that the diagnosis has become increasingly popular among strikingly charismatic young people, and I don’t just mean on TikTok. The cultural centre of gravity is shifting.
The key to seeing what is going on memetically is realising that the meme is not just popular among those seeking an autism diagnosis. It is overwhelmingly more popular among people not seeking a diagnosis. For every person wanting to be assessed, there are ten who love to say, “I think so-and-so is on the spectrum.” The fact that the meme is even more popular with people who are not experiencing the subjective inner experience is the giveaway: it has become a byword for “unconventional,” something overwhelmingly imposed by others, rather than experienced.
Once you recognise that, you can map it straight onto earlier cultural trends. Whatever is “weird” to one generation of youth becomes “cool” to their younger siblings, and by the next generation it is being manufactured by Hot Topic. We have watched this happen over and over. The genuinely odd outsider artists of the 1970s turn into the cool underground musicians of the 1980s, who turn into the mall goths of the 2000s, who turn into the e-girls of the 2010s. Nerd culture follows the same trajectory: trainspotting anoraks to “geek is chic” to Marvel going mainstream to conventionally attractive people doing cosplay. It is the same memetic conveyor belt every time.
Autism, in its pop-cultural version, is following the same trajectory. Traits once interpreted as awkward or eccentric get rebranded as quirky, intense, interesting, cool. Once that happens, the meme stops mapping onto autism and starts mapping onto whatever the culture currently finds appealingly unconventional.
The other historical precedent is neurasthenia, which may have started life as a descriptor for real neuropathic disease but quickly became a wastepaper basket diagnosis, applied loosely and in its later years often to women seen as difficult by their male doctors.
To my mind, the effect of modern diagnosis often acts in a way similar to fortune telling, to the extraordinary debasement of psychiatry, which apparently cannot remember anything beyond what it had for breakfast this morning.
Here is another point. Just as true melancholics never used to complain of depression, so too, once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety. For the most part, they were oblivious and at best distressed out of confusion. They lacked insight into their social deficits and, while lonely, had little real idea of what the issue was. Today, we are seeing something completely different: emotionally intelligent people, frequently with above average social skills, mistaking the commensurate anxiety that often accompanies self-awareness for deficit. They notice people sometimes treat them as weird, first because their charisma makes them a target for bullying, and second because most people of average social abilities coast through life almost as blindly as autistic people.
The neurotic and neurasthenic, on the other hand, “has a keen insight into his condition, and tends to exaggerate his symptoms, but the paretic has little or no insight, or, if present, he rather minimizes than exaggerates his symptoms.”
“Just as true melancholics never used to complain of depression, so too, once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety.” Exactly this.
Peter, your original comment struck me as a bad faith critique, so I wasn’t planning to respond as I have a general policy of not engaging with bad faith critiques of my work. However, based on your second comment (downthread), I’ve decided to reconsider.
First, I’d encourage you to examine your heavy reliance on misogynistic tropes. Referencing women’s “attractiveness” to impugn their seriousness and diminish them as credible reporters is a long and storied - and still very much alive - tradition in psychiatry specifically and in medicine generally. The same pattern underpinned earlier labels like neurasthenia and hysteria, and your rhetoric recreates it almost perfectly. It is no coincidence that the popular dismissal of autism is converging with the time that many more women are being diagnosed. Your first comment indicates that uninterrogated (I hope) misogyny is playing an influential role in your stance on this issue. If you’re invested in your own credibility, I’d urge you to reflect on that.
Now, to address the substance of your argument:
“…once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety. For the most part, they were oblivious and at best distressed out of confusion. They lacked insight into their social deficits and, while lonely, had little real idea of what the issue was.”
This is straightforwardly false. This perspective calls back to a decades-outdated, dehumanizing view of autistic people as intrinsically non-self-reflective. In the intervening decades - well before the recent cultural visibility of autism - a massive body of research was produced documenting high levels of social self-awareness, self-monitoring, and social anxiety among communicative autistic adults. Much of the core conceptual work in autism studies (including the models I mentioned in the piece: monotropism, context insensitivity, “intense world,” and atypical predictive processing) emerged directly from autistic people articulating their own phenomenology. These models would be impossible without the very insight you claim autistic people do not have.
Your proposal that a diagnosis “is more convincing” if its recipient is surprised presupposes the premise that the purpose of a diagnosis is to identify something essential and material about the subject of that diagnosis. But that isn’t what a diagnosis does, and that is not its purpose. Psychiatric diagnoses are constructs, and Dr. Aftab has written extensively here about the clinical problems created by the misconception that these constructs map onto individual biological realities.
Even at its most hierarchical, psychiatric diagnosis has always been a collaborative project (if sometimes a contentious one) between the diagnostic subject, the diagnostician, the arbiters of diagnostic frameworks, and the wider culture. The tension between these stakeholders is a feature of the diagnostic process, not a bug, and cannot be so easily resolved by asserting the diagnostic authority of diagnosticians like myself and diminishing the value of the self-authorship of the person who is the subject of diagnosis. At their best, psychiatric diagnoses provide frameworks through which an individual and their supporters can substantively mitigate their suffering. Incuriosity, dismissal, and misogyny serve that purpose poorly.
You’re quite right. My original comment was thoughtless and crude. I will remove the offensive sections. I am very sorry to anyone who experienced distress or felt belittled by reading it.
What I had in mind was that intellegent, attractive (by way of their minds) and clever women do not need to resort to neurodevelopmental diseases because society cannot deal with them burning so brightly. I admit I went about this like a bull in a china shop. Also, it goes without saying that autism is a real neurodevelopmental disorder from which women suffer and are somewhat harder to pick out then men, I have no issues with that line of thinking, just to where it has led us.
I believe that people are the best experts on their own experiences, both inner and outer. Only by listening to people, and I mean really listening to what they are actually saying, do we have any hope of working together with them to understand what the problem is.
Freud originally understood that sexual abuse played a central role in hysteria, although he too quickly moved away from this view. Subsequent psychoanalysts did retain a general understanding that hysteria was often linked to abuse in childhood. It seems an extraordinary thing that, seventy years later, mainstream psychiatry still struggles to take this idea seriously.
Neurasthenia likely has as its substrate real neuropathic and nervous diseases, problems that women, overwhelmingly, and men still suffer from today but which remain largely unacknowledged and are frequently dismissed.
It seems to me that the problem is one of selective hearing. Psychiatry does not want to listen to a woman describing her experiences in any real detail. Instead, the task is to assign a label, and all the better if the woman has already done this job herself. People are experts on their own experiences. Doctors are experts on disease, physiology, and, once upon a time, psychology. The aim should be to get both experts in a room, listen very carefully to each other, and reach a conclusion about the most likely cause. To me, it is sad indeed that many women feel a neurodevelopmental disorder is the only acceptable explanation for their experiences. In many cases, such an explanation is simply implausible, and one is left wondering about the judgement of the other expert in the room.
Of course people living with autism have insights, I would never suggest otherwise.
As for the rest of what you have said, I am really not sure what to make of it, other than to say that people believe all sorts of incompatible things. The idea that someone can have a neurodevelopmental disorder which, twenty years ago, led people with the same disorder to describe having great difficulty understanding what was going on socially, and yet now allows vivid accounts of social experience, is not compatible with believing people’s experiences in a fair minded manner. You have to disbelieve the former to believe the latter. This simply cannot be so, and no amount of nomothetic research can undo this.
I do not agree with your description of diagnosis. Diagnosis is a case-wise, empirical and idiographic process in which two experts reach a consensus on either a disease or a functional syndrome. I will not be too pedantic about the last part. Arguing about diseases, syndromes and constructs is as silly as arguing about the difference between a donkey and a horse, you know one when you see one. The first part is the more important part.
It seems to me that psychiatry has been on something of a Woozle hunt for many decades. The field has a terrible memory for past discoveries, especially those that involved listening to patients, now days known as "anecdotes". It cannot be that a field of medicine can have diseases appear, vanish, and then return again so many times and still be taken seriously.
I am not quite sure why this comes to mind, but I suppose some of my thinking is expressed in Roland Kuhn’s words.
Roland Kuhn:
“When I make a psychiatric examination, I ask the family to be around and if the patient says, ‘I am always good in the morning’, I ask the wife or the husband about the patient. Sometimes you find that the patient is horrible in the morning and good only in the evening. If you do not ask, and psychiatrists often do not ask, you are unable to ask the most simple questions. The questions can be put and answered in a few minutes. This is no good, but psychodynamic and theoretical constructions sometimes are not good as well. All this is the consequence of an absolute inability to learn. Everything is in the books by Kraepelin and Bleuler, but who reads them today? Nobody in psychiatry actually reads, because the majority of psychiatrists are unable to read. They are unable to read a scientific text and for this reason my counsel is to read classic psychiatric texts with one’s pupils. In one hour you will maybe read one page, but you cannot make reference to the seventh chapter of Freud in one hour”.
“Today the psychiatrist who researches reads literature of the previous five years. Because of this we get discoveries today which have been known much better, and described much more beautifully a hundred years ago. And everybody thinks it highly interesting what Mr X has discovered, when all along in the old literature it had been wonderfully illustrated – much nicer much better.”
Of course, Kuhn’s ideal is very lofty, and I apologise for being a wanker. Suffice it to say, I get quite upset by the idea of diagnostic expansion in the case of women and neurodevelopmental disorders. Call me old fashioned, but I think some women are simply very smart and clever individuals who society cannot resist cutting down.
Well, what I say is that I like and respect Riva, so I'm glad you decided to apologize for being rude! I don't think you are hallucinating.
I do have issues with the essay tho. My biggest one is this: I'm not sure that there's such a wide gap between autism being "profoundly phenomenologically organizing" as a diagnostic construct and autism being a cool and quirky way to relate to/ talk about yourself. Those experiences are, to me, not categorically different. If you'll have me, I want to talk about how I came to that understanding: my own life.
Once upon a time, I was diagnosed with a million DSM things that didn't feel quite right or very useful. I long suspected I was autistic, and I eventually found a therapist who shared my conviction, and she got me a neuropsych eval, and the eval found me autistic. I experienced the consequent relief, the "there it is" kinda feeling that so many describe. You could have called it profoundly organizing. The relief, in my case, was directly proportional to autism's utility in the the social sphere. It helped me explain to myself and others why I was [insert social/cognitive/perceptual difference here], and when people (myself included) understood that whatever I was doing "wrong" was not my fault (this is the "mechanistic substrate" mentioned in the essay), they (myself included) treated me a lot better. So that was good incentive for me to make it very clear that I was autistic, to be loud but playful about it. I was being the quirky autistic girl, because the diagnosis' utility was contingent on my being the quirky autistic girl!
The relief I experienced as a result of my autism diagnosis was actually pretty short-lived, on the order of a few years. I continued to have a lot of struggles that had no clear relationship to autism and its mechanisms. I focused less on autism as a hermeneutic tool, and in so doing, without knowing what I was doing, I became a lot less Autistic, in the Tik-Tok sense, and I eventually became very dissatisfied with autism as a hermeneutic tool. Notably, the therapist who had me assessed for autism never knew this, because by the time I was like "hey wait, why did I want this diagnosis in the first place??", I had moved across the country and hadn't spoken to her in five years. It's no wonder that clinicians who favor autism as the ur-diagnosis because of the relief it brings patients are never challenged.
At the end of the essay, Riva says that the utility of a given construct is based on its usefulness in describing reality, and how it allows us to better interact with that aspect of reality. My personal experience with autism really makes me really want to interrogate what we mean by "interacting well with reality" in regard to the construct of autism (setting aside the question of "what is 'reality' in this sense?"). Do we mean sense-making? Do we mean psychologically organizing? Shame-reducing? Something else? All of the above? The essay makes nods to each of these. Autism afforded me all those things. And it afforded me all those things by encouraging me to relate to myself in a specific way. I no longer find the construct or mode of relating to myself remotely useful. I find it a lot more useful to regard myself as kind of eccentric, kind of awkward, very cerebral, and not for everyone. That is ultimately a lot more phenomenologically organizing for me than trying to map my experience onto existing frameworks of extra special and strange subjective experience.
This is just one patient's story, and it's not a direct quibble with the premise that autism is popular because it offers patients as deep self-understanding with well-mapped mechanics. But it is a quibble with the premise that mechanics are the be-all end-all of psychiatric diagnosis as it relates to patients' self-understanding.
This is a great comment. Thank you for sharing it.
I was provisionally diagnosed with autism as a child. I too felt that sense of relief, that “this is why I’m different and the other kids think I’m weird” moment, although in my case the cracks were so large that the relief barely lasted a week. I was nervous in primary school and at times would be observed doing things that might be considered stimming. I thought I had trouble fitting in, although in retrospect and objectively there is no evidence of this, and it is fairly clear to me now that I was a bit of a git and that my classmates liked me well enough. It was me who treated them badly. I grew up in a country town and I didn’t like townies.
The whole thing fell apart pretty quickly. About a year after the initial evaluation the paediatrician decided to send me to the Royal Children’s Hospital in Westmead along with my sister for further evaluation. I’m lucky enough to live in a country where we are still pretty good at diagnosis, and so I met kids my age with high-functioning autism, and it was painfully obvious that I was nothing like them. The psychiatrists at the children’s hospital gave my sister a primary diagnosis of schizotypal personality disorder, and after interviewing me they felt that I was at high risk of developing psychosis. They did not think I had autism. As time would prove, they weren’t too far off the mark, although I managed to evade schizophrenia.
Throughout my teens I was generally popular, and later on I had no difficulty at all with dating. In my adult life I have always picked jobs that rely on my social skills, as they are my strongest suit, my obnoxiousness online notwithstanding. And so it seems there was never anything to the autism diagnosis. I never had a father; maybe that is why I was anxious in school. For a few years in my early teens, though, the diagnosis really messed with my self-confidence. The self-consciousness of puberty collided with the diagnosis in a way that caused great suffering. I got over it as experience gradually reconfirmed the absurdity of the idea.
The thing is, those kids I met at Westmead, and the many other lovely people living with autism that I have worked with since, didn’t have something that in my view was particularly hard to diagnose. In fact, it struck me then, and still strikes me today, as among the most eminently easy diagnoses to make. The entire reason for this is that it is an incredibly tight phenotype. In my opinion it has very sharp edges. I also think the old criteria were pretty good, if you could exercise some self-control and stick to them objectively. Unfortunately too many had their imaginations captured by geek archetypes, anoraks, trainspotters.
For some time now psychiatry has been on a bandwagon on the subject of spectrums. The field became obsessed with fuzzy edges and went cross-eyed from staring at them. Of course, in this instance it is clear that psychologists hold the greater share of the blame. In 1990, in the book The Suspended Revolution, David Healy suggested that neuropsychology would usher in the triumphant return of psychopathology and pharmacopsychology. Wundt and Kraepelin would be reunited once more to banish the bean counters of statistical phrenology and restore both professions to their former glory. Well, some of this came to pass. Neuropsychology has shed a little bit of awkward light on our treatments, but for the most part it has just introduced a new form of phrenology in the form of the fMRI.
Now, I love fMRI research, and calling it phrenology is hyperbole, but as a field it is a mixed bag. Along with the good it has given rise to a great deal of brain mythology and a new kind of neurobabble, measuring differences between people’s brains. Out of all this has emerged an idea that a few decades ago would have been very strange indeed. We now sort everyone on the planet into two categories: neurotypical and neurodivergent. If this sounds prima facie like a bad idea to you, I’m sorry to tell you that most people seem to think it is splendid. One spectrum to rule them all. One spectrum so vast that the word “spectrum” alone could not suffice. It is the neurodivergence spectrum that gives autism its Mirror of Erised quality. Old-school autism was something very narrow, very distinctive. I also think it is no coincidence that this framework is so popular in societies that value individualism.
Phrenology and neurodivergence share a similar coastline problem: how granular do you make the measurements? To what sensitivity do you set the fMRI algorithm?
Our bodies are tied to our identity, and throughout human history this has led to a great many treatments crossing the line between the physical and the metaphysical, often mixing medicine with spirituality. Bloodletting, trepanning, exorcisms. For people who want this sort of treatment, there are many practitioners, but in my view medical doctors need to stay in their lane.
Psychiatry needs to restrain itself from these kinds of metaphysical debates. It is an irresponsible and dangerous preoccupation for any physician. If they wish to engage in such activities, they can do it in their private time.
Describing reality is a lofty goal, and while it is often supposed to be the domain of science, in reality is more often the domain of religion. I'm not a post modernist and I think we can investigate reality but thinking we've crossed the threshold into actually describing it in a gestalt sense, that's when I think we're running a dangerous line. Psychiatry has a far simply job, diagnosing diseases and clinical syndromes, treating them and then trying to figure out the cause. It has not been tasked with diagnosing all of the worlds ills.
I think an additional facet in regards to autism's 'popularity' (for want of a better term) is that increasingly it is being framed so positively. I use this word deliberately to go a step further than 'destigmatisation' - to have an autism diagnosis in certain social media circles is not only to have an explanation, it is to be a superior brand of human. You are "evolution's next step" you care about justice and are more moral, you are more interesting and empathic than the normies, you see through bullshit while the other plebs play along with dumb games, etc. Certainly I agree the psychodynamic personality styles/disorders have a branding problem (having just written about this today and seen the response), there's so much focus on negativity and deficits and I think a more "morally neutral" approach might be helpful. But neutral is the operative term (or at least, a focus on the unique strengths of each kind) as opposed to superiority.
I would have been interested to see your comparison re diagnostics applied to one of the personality constructs mentioned rather than social anxiety. For example, I have some schizoid tendencies (a differential mentioned in Awais' original article) but wondered for some time if I might be mildly autistic. Certainly I relate to plenty of the listicle reels. However, having learned more about ASD, I'm pretty clear that I don't favour static over dynamic processing (to use RDI terminology). That's not something that tends to be well-explained in 12-second video form.
A big reason I eventually left autism behind as an understanding for what's going on with me is that it has become so idealized. Where borderline is shaming/devaluing, autism is, at this cultural moment, idealized. When will this damned field stop splitting?
Actually, in spite of BPD's enduring stigma (BPD has always been the "bad object" relative to other common diagnoses, including other heavily stigmatized ones like bipolar disorder), of the personality disorders, BPD remains the most popular as a self-diagnosis/phenomenological organizer/identity framework, and I believe it's for the very reason that of the personality disorders, BPD has the most accessible and robust set of mechanistic explanations analogous to what I described in the piece (not Linehan's model, which is causative, not robustly mechanistic), though at least in popular discourse, it lacks the cognitive/perceptual layer. (This layer is present in the research on BPD and has very interesting implications.) I will write a lot more about this eventually but not today.
Also gets me thinking about how both borderline and autistic traits present across a spectrum but the 'image' of both exists as something fixed. Borderline as its most catastrophic form, shameful and "manipulative" and "toxic", autism as idealised quirkiness. Not much said about the high-functioning borderline character (who no longer meets the criteria for BPD or perhaps never did, and who has plenty of strengths) or about severe autism.
I think it is very clearly not the case that not much is said about severe autism, but *is* very much the case that the spectrum of borderline traits/borderline organization/the reality that most people who meet criteria for BPD remit with time and without BPD-specific interventions is very rarely mentioned. My suspicion is that the dichotomy you are highlighting has very much to do with the fact that BPD is strongly associated with women (crazy women!) and autism with men (awkward but brilliant men!)
I would agree if the discussion is limited to clinical literature and research, but the dominant media discourse skews very heavily towards Level 1 ASD. Presentations that would once have been labelled Aspergers (or "weird nerds"). There is the odd mention of severe cases, but look at (for example) the enraged pushback and talk of "genocide" any time there is mention of researching treatment or causative factors for ASD. In any case ... severe cases DO get a mention, which is very much not the case for healthy/neurotic levels of borderline personality organisation. So you do have a point there.
You might well be onto something re the female association with BPD, psychiatry's history of weaponisation against female nonconformity has a long and ugly tail. I do remember a brief period where more negative associations with male autism were quite dominant but less so now. If one describes the autistic 'sense of injustice' incel type often people will respond that is not 'real autism'. Because in the discourse an autistic 'sense of injustice' is always pro-social.
I think this is a really great point, and I think it illustrates one of the down-sides (or perhaps a perversion of) the strengths-based lens, of which there can be many upsides.
Just subscribed (long overdue!) so I can reply to this post. I will try to be as concise as possible and raise three counter-points, which I would love to hear the author’s (and others’) perspectives on.
My first counter-point is historical: Even if one were to grant the claim that autism currently has greater phenomenological or explanatory potency than alternative diagnoses (which is itself questionable if one looks closely at the available empirical data), it’s important to recognize that this appeal does not come from nowhere. Instead, it comes almost entirely from the very traditions the author critiques: namely, psychoanalysis and early personality theories. Indeed, until relatively recently, there was no such thing as “high-functioning autism” as a distinct diagnostic category because what clinicians historically described were schizoid personality (or relational) dynamics: namely, social withdrawal, hypersensitivity, diminished reciprocity, and an unusual way of relating to others. Indeed, Bleuler’s use of the term ‘autism’ was explicitly tied to such schizoid dynamics and even Asperger’s original accounts were also embedded in this same personality-theoretical language. To suggest, therefore, that autism uniquely supplies phenomenological depth or explanatory power is to overlook the fact that these resources were already there, just articulated in a different manner (see also footnote 1).
Which leads me to my second point: If autism is just a re-articulation of schizoid dynamics, then does it add anything (justifying its existence as a separate and idealized diagnostic category) or does it simply re-invent the wheel? Here, I would say that it does add something, but not in the way this post suggests. The main thing the autism construct seems to offer is not a superior explanation, but a different moral framework. Historically, strange terms like “personality pathology” (and “character pathology” before it) were used to describe ego-syntonic difficulties: that is, maladaptive ways of relating that a person experiences as part of themselves and does not necessarily wish to correct. This framing, however, carries an implicit sense of responsibility, and often blame. The autism, and broader neurodiversity, frameworks largely remove this blame by instead saying: “you have these relational difficulties, but they are not your fault; they simply reflect how your mind (or brain) works rather than a problem with who you are as a person”. This shift is clearly meaningful and often *feels* more scientific or objective because the alternative is either a subjective moral inference (“you are relating in these and these ways because you have a horrible character or personality”) or a descriptive statement (“you suffer because you relate to others in a maladaptive manner”). Yet what I would argue is that autism’s moral reframing should not be confused with greater explanatory clarity or stronger evidence base. Instead, what I would argue is that autism gains explanatory appeal (but not explanatory depth) because it (a) removes responsibility for one’s suffering and (b) repaints chronic relational difficulties in a brain-based language that feels objective but is still only moderately supported empirically (and, importantly, no more so than many other diagnostic categories; please see footnote 1).
This leads me to my final counter-argument which is clinical: namely, having said all that, what’s the take-home message for clinicians and patients alike? I think the take-home message is this: many clinical diagnoses entail strikingly similar relational difficulties (from depression to social anxiety to ‘personality’ or ‘relational’ disorder, and autism) and the task is not to favour one diagnosis over another because it is more socially appropriate or personally appealing, but rather to offer a diagnosis as a tentative explanation for the patient’s relational suffering and then explore (with the patient, of course!) whether that explanation matches reality (not each other’s fantasies). In some cases, when these patterns are present from very early in life (like infancy), a neurodevelopmental explanation such as autism may be appropriate. In other cases, the same (or similar) relational difficulties may be framed as outcomes of severe traumatic experiences: a person who has been repeatedly violated (physically and even sexually) may relate to others in disorganised or intense ways and the clinical priority is to frame these relational difficulties in a trauma-based way (enter, complex PTSD) in order to properly address them clinically. Finally, and I would argue more subtly and rarely if at all understood by anyone today, similar relational difficulties may be best explained neither by neurodiversity nor by a history of severe trauma; instead, they may be best explained by temperament and personality development: not in the impoverished way the DSM implies or the sexist, racist, and largely unscientific way that many past theorists paint, but in the philosophically and clinically rich way that *some* early analysts outlined and that my team and I are now trying to clarify (and rectify). The basic idea here is simple: a person is brought into the world with some relatively automatic ways of relating (think withdrawn versus active temperament styles); these ways of relating are then either dismantled with ‘good enough’ social relationships (Winnicott style) or amplified with ‘bad enough’ social relationships (Zavlis style), leading to what we can call, for the sake of the current illustration, ‘personality quirks’). These quirks are part of the person (just like any other trait is) and can be a major source of suffering, but, importantly, that suffering is not intentional or agentic, that is, it is not something that the person is “doing on purpose” (which is what many personality-based historical accounts get wrong).
In any case, the reason I am mentioning all of this (apologies for this mini essay) is to highlight the following: there are many different kinds of mechanisms that can explain (autism-like) relational difficulties, and the fundamental clinical task is not to endorse any one of these mechanisms preferentially or idealistically (as some people in the comments have also implied), but rather to hold them tentatively, revise them in light of new clinical evidence, and, most importantly, formulate them collaboratively with the patient (while still being willing to respectfully disagree when a particular explanation feels more like a comforting narrative than an accurate account of what is actually generating suffering).
Footnote 1: This comment (or, better put, mini essay) is already too long for me to provide a complete review of why autism is not any more “evidence based” than other mental disorders. Perhaps I should write a paper about this, but briefly, the main points are the following: we have as much neurobiological evidence for autism as we do for most other psychiatric categories (i.e., largely heterogeneous findings, modest effects, and limited diagnostic specificity); we have as many computational accounts of autism as we do for other disorders (indeed, predictive-processing and related computational models have arguably been more successful for psychosis, anxiety, depression, and even ‘personality disorder’, aka ‘relational disorder’, than for autism); and we have no unique “mechanistic” mapping from proposed cognitive-perceptual differences to heterogenous autistic experiences that would justify treating autism as a special diagnostic category. Taken together, all this implies that any preference for the autism construct does not actually come from superior “cognitive-perceptual mechanistic explanations,” as the author assumes, but rather, as I have argued above, from its moral and cultural affordances: namely, its reframing of chronic relational suffering in a way that feels more neutral, less blame-laden, and therefore more acceptable to patients, clinicians, and the wider culture (without necessarily guaranteeing, as I have argued previously, that this is the true diagnosis).
Orestis, you’re in luck! Not only do I have a strong intrinsic drive to correct people’s erroneous interpretations of what I say, I also grew up on message boards in the 90s (there’s your trait-environment interaction right there.)
Actually, about that: I’d like to address your final (pre-footnote) point first. Trait-environment interaction (or to use your relatively narrower lens, temperament-relationship, if you prefer) is not only not a unique standpoint, nor a counterargument to me - or anyone but the most die-hard genetic determinists or old-school tabula rasa devotees. Trait-environment interaction is consensus among anyone remotely serious about understanding the emergence of behavioral phenotypes. It is not an alternative to autism, trauma, personality pathology, or any other model for describing particular phenotypic expressions; it is the developmental substrate on which all of them already rest, and one that the vast majority of us agree upon. Any site of reasonable debate on these issues takes place on the basis of that shared premise.
Second, to your footnote: whether autism is more evidence-based than any other diagnostic frameworks, and even whether the mechanistic theories underpinning it are correct, is irrelevant to the argument I make in the piece.
Third, regarding whether autism is nothing more than a recapitulation of schizoid personality disorder: the constructs actually aren’t that similar. The social criteria for SPD and autism are quite different; SPD also contains intrapersonal qualities that are out of autism’s scope, and has no relationship to anything contained in autism’s criterion B. Many diagnoses have shared historical underpinnings, and have undergone increased differentiation and reformulation for good reasons. I do think, though, that the SPD criteria represent an archetype of an autistic person that many people hold, are attached to, and would like the autism construct to continue to represent. Many psychoanalytically inclined clinicians and theorists are interested in staking turf that they see as belonging to personality disorders that autism has “taken” (I count myself among the psychoanalytically inclined, but am disinterested in conceptual turf wars.)
Fourth, and relevant not just to your comment but to a pattern I’m seeing in quite a few of the “counterarguments” made in the comments section here: you’re responding to this piece as though I was making a monocausal argument. I wasn’t, and I wouldn’t. To some degree, this misread is understandable given that monocausal arguments are unfortunately common in contemporary discourse. Is your moral exculpation idea also a contributing factor to autism’s current status? It’s certainly possible. One of my premises, always, is that complex social phenomena are multifactorial. That could be one of the factors. It’s not a counterargument, though.
To restate my thesis, for clarity’s sake:
Autism currently offers a particularly tight and usable mapping between lived phenomenology and explanatory models, relative to other diagnoses as they are currently formulated and culturally operationalized, and this is a contributing factor to its contemporary popularity.
It’s a relatively modest claim, and I think it’s interesting that so many people are so resistant to entertaining it.
Thanks a lot for replying – I am really interested to understand how you think! I will thus try to reply to each of your points (hopefully, more concisely this time):
1. I’m not making a generic claim about trait–environment interaction, nor disputing that temperament plays some role across many forms of psychopathology. My claim is much more specific: autism, as it is currently conceptualized, is best understood as a temperamental or personality-based condition––that is, a congenital way of being that is present from birth onward and remains relatively stable across the lifespan. This is not how most other mental disorders are conceptualized. While temperament may confer vulnerability to anxiety, mood, or other mental disorders, those are fundamentally ‘mental-state’ disorders rather than ‘temperamental or trait-based’ disorders. I appreciate that this claim of mine is rather controversial (I am, after all, suggesting that autism is a form of ‘personality trait pathology’) but if you’re more interested in this view of mine, have a look at the following: https://osf.io/preprints/psyarxiv/gswz3_v1, https://doi.org/10.1192/bjp.2024.80, https://substack.com/home/post/p-180892583.
2. I am surprised to hear that whether autism is more evidence-based is irrelevant to your argument. As I read the piece, one of its central claims is that other diagnoses can and should learn from autism precisely because it is said to offer clearer, more specific cognitive-perceptual mechanistic explanations than they do. That is an empirical claim. It seems that with this admission of yours (‘evidence base is irrelevant’), the main claim of your essay (at least as I read it) shifts from “autism offering genuinely superior mechanistic explanations” to “autism is *being experienced* as providing such superior explanations but that may very well be an illusion”. I must say that the latter is perfectly consistent with my view which suggests that the sole reason autism is more appealing has little to do with mechanistic explanations but rather the moral framing around the autism diagnostic framework.
3. I never stated that autism is a recapitulation of schizoid *personality disorder*; I only stated that it is partly a recapitulation of schizoid *personality dynamics* as discussed by traditional theorists like Bleuler and later psychoanalytic writers. This distinction matters, because modern-day schizoid personality disorder and classical schizoid theory have relatively little in common, and both have only a partial and non-isomorphic overlap with the contemporary autism construct.
4. Regarding mono-causality: to be honest, I did read your piece as, at least implicitly, mono-casual, and, having read some of the comments herein, I believe that at least a few others may have also read it this way. So, at this point, I think it’s worth exploring (together, if you'd like) why this piece may have been perceived in this way. In my eyes, the issue is not that you explicitly deny multi-factorial causation in principle; instead, the issue may be that your essay overwhelmingly promotes the advantages of the autism construct itself (e.g., mechanistic clarity, phenomenological fit, and explanatory power) while not acknowledging, not even passingly, that alternative mechanisms can generate very similar relational phenotypes. When a framework is presented almost exclusively in terms of its advantages, and others primarily in terms of their disadvantages, it’s understandable that readers would infer some form of idealization of the former framework and a denigration of the latter frameworks.
That’s why I found your restated thesis here genuinely more nuanced than how the entire piece came across. Read on its own, your restated thesis sounds modest. Read alongside the essay, however, it feels different, because the essay consistently highlights what autism supposedly does better (mechanistically, phenomenologically, explanatorily) compared to other diagnostic concepts. But, in any case, my concern here is less about intent than about effect: idealizing one diagnostic framework while sidelining others that are equally evidence-based, and often more prevalent in everyday clinical life, risks narrowing rather than expanding our explanatory and diagnostic imagination. I suspect that it is this tension (particularly in relation to Awais’ original autism post) that explains much of the pushback you’re noticing.
I won't be engaging further with the substance here, not because I lack a response, but because the terms of engagement have shifted.
The customary response to an author’s clarification of their position is to engage with the substance of that clarification, not to offer a retrospective analysis of why the piece may have “come across” a certain way. Out-of-bounds evaluative commentary is not how I conduct public intellectual exchange. I'll leave it here.
Fair enough. Just to close the thread: I did engage with the substance of your clarification, and I only raised my ''retrospective analysis'' in an exploratory and reflective spirit. For me, part of writing publicly (especially about sensitive clinical topics) is being willing to reflect not only on what one intended to say, but also on how what they said landed on thoughtful and careful readers. In any case, I appreciate the exchange!
I’m a parent of an autistic son (level 1), and I’ve followed this extended conversation with interest (it’s also the conversation that got me to subscribe!). I’m not a clinician, so I’ll have to read through these pieces several times to fully understand. But my initial impression is that all three of these pieces (Awais’s Riva’s, and yours) don’t say much about level 3 autists. A lot of the focus is on the individual’s self-conception and what framework makes the most sense for them phenomenologically. But of course, not all autistic people are capable of having those conversations with their clinicians. What changes in your framework when considering the experiences of the most severely affected individuals?
I also wonder about the emphasis on schizoid personality constructs when so much of the autistic experience (at all levels) is related to sensory challenges. Perhaps this is an unfounded worry on my part, but when, historically, autism was more closely associated with schizoid personality traits, stimming was sometimes mislabeled as hallucinating or psychosis. I’m sure I’m getting much of this wrong and am happy to be corrected.
Thank you for sharing -- these are very fair questions, and I’m glad you raised them.
On your first point: you’re absolutely right that most of this discussion (mine included) is implicitly focused on verbal, reflective, often late-diagnosed individuals -- typically those labelled “level 1”. My framework is not intended to generalize to individuals with profound autism (defined by comorbid intellectual disability) and high support needs. I see these presentations as qualitatively distinct and I would straightforwardly label them as disabilities. My core idea then (which is that autism can sometimes be better framed as a temperamental or personality difference) would apply only to the subset of cases where the core difficulty is chronic ways of thinking, perceiving, and relating that are causing suffering in a particular context (and can thus be ameliorated either by subtly shifting them or by changing one’s environment). For individuals who cannot meaningfully participate in phenomenological or explanatory dialogue, the clinical task is necessarily different, and my argument simply does not apply there.
On your second point about sensory features: I agree this is super important and I should have perhaps mentioned that at some point in my earlier reply. The way I view this is that (a) there are people out there who experience relational difficulties (this is usually the first observation clinicians make) and (b) there are different explanations for these difficulties (including that it might be trauma, it might be a specific personality quirk that has nothing to do with neuro-development, it might be autism, or it might in fact be all of these). In the case where it’s only or predominantly autism, I would agree with major theorists that what might explain, or generate, autistic relational difficulties is a sensory-processing difficulties (in the sense that atypical sensory integration, prediction, or filtering can make ordinary social environments overwhelming, unstable, or hard to navigate, thereby secondarily shaping relational strategies like withdrawal, rigidity, or stimming). Now, whether sensory-processing differences are sufficient on their own, whether they specific to autism, and whether they can empirically differentiate autism other relational maladies remains an open empirical query -- but they are plausibly one of the key mechanisms that is involved in autistic difficulties.
To summarize, I agree that I should have drawn a distinction between high-functioning vs. low-functioning autism, clarified that my personality and relational proposal applies predominantly to the former (which is best understood as a personality difference that may or may not be impairing depending context) over the latter (which is best viewed as a disability and, in my opinion at least, belongs to the domain of neurology), and talked more about sensory mechanisms and how they are possibly the best candidate mechanism for explaining the generation of autism-like (relational) difficulties.
Interesting to read, and a nice expansion to Awais’ original piece, which I think was great and informative, but also offered only part of the picture. I think the theories behind autism (ie why do differences in brain development lead to these specific deficits) do offer insight to the patient when those theories resonate.
There are major differences between neurodevelopmental disorders (ASD, ADHD) and other psychological or psychiatric disorders found in the DSM, in how they are diagnosed and treated. I’ll offer some other points as to how these diagnoses can provide more relief than other ones:
Neurodevelopmental disorders are diagnosed after comprehensive neuropsych testing, which give the patient insight into their specific strengths and weaknesses, particularly when it comes to school and work settings. Oftentimes co-occurring learning disabilities are also discovered in this process.
Neurodevelopmental disorders are early onset, and require management, not treatment. Understanding this is insightful for patients and relatives of patients who have been fixated on finding a cure for the problems they or their child faces.
Autism in particular can be associated with not just cognitive developmental delays, but physical ones. Dyspraxia, and other problems in proprioception and coordination can affect many aspects of one’s school/home/work life. Physical and occupational therapy can provide much needed support.
Autism, in particular, is associated with a number of health issues, including some rare genetic diseases. Sometimes a diagnosis of autism leads to genetic testing and a proper diagnosis for the patient’s physical health struggles.
In this sense I’d argue that autism is a more systemic mind/body diagnosis - associated not just with psychological or psychiatric interventions; but also potential interventions for learning, gross and fine movement, and physical disease. What I think other diagnoses could learn from autism in addition to mechanistic theory (which I agree is helpful) is a holistic approach to treatment/management.
Tone is a tricky thing to get right in brief written comments but, for me, this whole thread is richer than anything I’ve heard in the last 2 decades in any psychiatry meeting. Thanks to everyone who has contributed here.
I appreciate this explanation but feel it falls a little bit short. Rather than focusing on the memetic virality of the autism diagnosis (which is useful), I wonder if it would serve us more broadly to consider the memetic virality of any diagnosis, and how a diagnosis sits in dialogue with an individual's phenomenology. If we look at the history of psychotherapy and mental health diagnosis, memetic virality and satisfaction with how it aligns with the phenomenology of an individual is a relatively newer construct.
In a certain way, the "democratization" of mental health diagnosis via the firehose of information on the internet (and firehouse of misinformation) can correct some of the issues with the DSM (if we're optimistic). In another way, we risk losing the thread on why an authority on these things (whether it's the DSM or just an "expert") is important in the first place.
To put it even more simply, the role of a clinician can often be seen as helping folks both "feel better" AND "get better," and I wonder what happens when we lean towards one of those two directions, even in our use of diagnosis and diagnostic processes.
Once more, I'll reference the book that no one on this blog is reading, because it alone can address almost every post here. It contains >1000 empirical references.
The autism/neurodivergence label has become an identity of sorts in America. This is uncontroversial outside of psychotherapy-land. Go speak to a non psy-professional under the age of 40 in a coffee shop to see for yourself.
As a consequentialist, it would appear that the asd/neurodivergence "identity" is being used by certain groups as a status-symbol or "credential" of sorts. But to understand this premise, I must first point out that increasingly the neurodivergence/asd crowd has become quite vocal and acknowledged as being legitimate human beings (as opposed to the sub-humans we were portrayed as by mainstream media growing up, along with the Autism-Industrial-Complex, see here https://www.madinamerica.com/2021/02/disability-studies-scholars-critique-autism-industrial-complex/ ).
Because of this so-called "neurodiversity movement" the last decade, those with the ASD label have gained some epistemic credibility or "sympathy" from the neuro-typical (non-ASD) population. And most unfortunately, BECAUSE of the last premise, now all the sudden, various status-seeking neuro-typical individuals are now noticing the tinniest of "quirks" about themselves, and then, in the name of status-seeking alone, are attaching themselves to the ASD/neurodiversity label, purely to reap the social benefits of the asd/neurodivergence label that instead belongs to the latter.
The most ironic part of this state of affairs is that decades of empirical research shows those truly on the ASD spectrum, along with their sub-traits, tend to AVOID status-seeking across the lifespan. That is, people with ASD category membership seldom appeal to titles, credentials, or other labels for instrumental gain. They purposefully turn down job opportunities that result in upgrading their credentials, and purposefully choose to avoid situations that would result in them gaining more social approval, even when there are little costs. In fact, this partially explains why those who belong to the ASD category membership tend to get diagnosed with cluster C and cluster A PD's, but rarely cluster B. This is not my opinion, it is an established cross-cultural fact per the book I shall cite at the end here.
Instead, it is (non-ASD) neurotypicals who do this sort of thing (malingering an ASD category in the name of status-seeking). Therefore, re-stated: the genuine ASD crowd is being victimized by neurotypicals who, themselves, are trying to identify as ASD, but did not earn it per their psychometrics (e., Baron-Cohen's Empathising-Systemising scale), and only in the name of gaining "sympathy" from other neurotypicals and neurodivergents of sorts.
This is not an idiosyncratic hypothesis. Actually, the same conclusion can be reached indirectly in this book: Evolutionary Psychopathology by Del Giudice, 2018. Compare chapters 4, 6, then 10 in particular.
For according to this book, it is neurotypical (non-ASD) "fast spectrum" populations who are status seeking in the first place. But the "slow spectrum" population described in this book, which includes the ASD crowd, seldom promote their identities in the name of social approval. That is, people with ASD are not malingerers, it is actually people with functionally opposite traits (such as hyper-mentalizing).
A similar social phenomenon happened with PTSD in the 1980s and 90s. A bunch of semi-traumatized individuals (who lack "Big T" trauma), in the name of status seeking, decided to self-identify with PTSD in place of their personality disorder diagnosis, because PTSD was then seen as "more virtuous" than making a set of extreme traits ego-dystonic (as in Borderline PD). But ironically, to identify with PTSD in place of Borderline PD is logically identical a personality-disordered individual making their extreme traits ego-syntonic. Then, once the Iraq war kicked off, PTSD all the sudden became re-stigmatized (and for obvious reasons). The cycle continues!
(My epistemic credibility can be found in my blog)
I’m not going to address the broader claims offered under the auspices of the evolutionary typology framework here, as that is outside the scope of this piece and would require a lengthy interrogation of our respective premises. However, I do want to correct a couple of specific points that fall within my area of expertise.
First, hypermentalization is not an “opposite trait” to autism, nor can it be reasonably framed as the opposite of hypomentalization. Hypermentalization and hypomentalization are both mentalizing errors; a high prevalence of either or both in a given individual indicates atypical mentalizing, and both occur transdiagnostically. Importantly, hypermentalization is well documented in the literature among autistic populations -particularly in the form of hostile attribution bias, excessive rule-based social inference, over-interpretation of social contingencies, and compensatory, deliberative social reasoning. It is simply not referred to using that exact terminology. Given this, framing hypermentalization as functionally antithetical to autism is not only a category mistake, but also reinforces a flat, outdated view of autism that the broader body of research on autism and mentalization does not support.
Second, appeals to instruments like Baron-Cohen’s Systemizing–Empathizing scale as arbiters of who has or has not “earned” an autism diagnosis reflect an outdated understanding of both autism research and clinical practice in 2025. While the systemizing theory of autism is historically influential and represents a meaningful theoretical contribution, this measure is widely recognized as limited and overly binaristic, and I doubt Baron-Cohen himself would claim it as diagnostically definitive at this point.
The question of whether autism has become an identity-organizing construct is not in dispute - indeed, it is one of the premises of this piece. My argument concerns the mechanistic and phenomenological explanatory power of autism as a construct relative to other psychiatric diagnoses, not the moral valence of diagnosis-as-identity. Conflating these domains obscures rather than clarifies the clinical and theoretical issues at stake.
If you read chapter 10 of the book i cite, it spoon-feeds you the very "mechanistic" explanations you seek. It is well within the scope of your post. Specifically, see page 249.
I don't think you have the guts to read it. I will bet $1000, publicly, you wont do it.
Consistent with my blog, it is unclear if you are an AI chat bot or an embodied soul.
For example, your appeal to "mechanistic and phenomenological" explanations of ASD is a contradiction unto itself. That is like saying you want to be both hot and cold simultaneously. For the phenomenological tradition is based in the Continentalist tradition, and mechnaistic descriptions are based in the Analytic (American) tradition. The two paradigms are so at odds with eachother that it fully explains why the humanities department is separate from the science department at every university in the english speaking world.
I should say that my comment is a bit flippant, and in trying to push the pendulum in the other direction I've ridden rough shod over the nuances. I realise that people might find aspects of what I've said distressing or offensive. I am aware that many people living with autism do indeed experience social anxiety to varying degrees and that they are distressed by it. It is just that there is typically, in my view, a strong confusional element. I has to be said that degrees of insight surely serve some proxy in distinguishing the endogenous from the hypochondriacal, and it's a bit more convincing when the consumer is at least a little bit supprised by the diagnosis.
Yes absolutely why have a rubbish diagnosis and access to treatment that will make you worse when you can have one that opens up your understanding of yourself and enables you to access your tribe, help, support and understanding. Thanks for posting this is spot on
Some interesting (not indicating agreement!) comments from LinkedIn worth sharing here:
1) Steven Reidbord
Psychiatrist, psychotherapist
"This is probably true, that people are drawn to intricate mechanistic explanations to explain mysterious personal phenomena. That’s one reason psychoanalysis and neurobiological accounts have been popular in their turns, and why autism is now.
Unfortunately, intricacy itself says nothing of validity. A once popular model explained how the sun (and the rest of the heavens) revolved around the earth. Actual physical models, made of metal gears and wheels-within-wheels, showed how it operated. It was no doubt comforting to “understand” the world this way, even though it was completely wrong.
Other diagnoses can’t “learn” anything from the success of autism, unless the message is to make up compelling stories with no basis in reality. Science only advances as fast as it does, and pretending that we know more than we do has repeatedly misled and embarrassed us."
2) Rachael Winstanley
Child & Adolescent Psychotherapist in private practice
"I think this is an excellent piece, thank you to the author and you Awais Aftab for posting it. The description of the construct of autism being 'profoundly phenomenologically organizing' really powerfully captures my experience.
I spent a long time in psychodynamic psychotherapy because I believed that my difficulties were emotional, psychological, unconscious. I even trained in the field. Although I still find the Kleinian framework I trained in helpful, I didn't get 'better' because my 'issues' were not primarily emotional, they were differences in cognitive-perceptual processing, as described.
I am well aware, as are so many autistic people, that these models are approximations, and that these descriptions generated collectively by autistic people themselves may change, according to cultures, time and place etc. just like all our models of human understanding.
But many of us need explanatory or mechanistic models that organise our subjective experience to feel well. This is a profound and essential need, not a 'comfort' (how infantalising). Suggestions from 'experts' that we don't really understand what we're doing when we describe ourselves as autistic, that we've got it wrong yet again, really miss the mark."
3) Sindhu Ashim
Psychiatrist
"I think this article mistakes a consequence of cultural acceptance as a cause for it.
Autism’s theories feel compelling and widespread because the label is now culturally acceptable (neurodiversity is celebrated). By contrast, BPD already has detailed mechanistic accounts— Gunderson’s interpersonal hypersensitivity model (core rejection sensitivity→frantic efforts to avoid abandonment) and Linehan’s biosocial theory of emotional dysregulation (invalidating environments + biological vulnerability → extreme emotional cascades)—yet BPD as a construct is rarely experienced as patient-empowering. Similarly, schizophrenia’s neural, chemical & predictive-coding models of psychosis are "mechanistic" but evoke fear rather than appeal.
Edward Shorter’s insight (symptom pool effect) is that cultural legitimacy comes first and each generation has its epidemic!"
I upgraded my subscription for the sole purpose of expressing my appreciation to the author for writing this post and to Dr Aftab for posting it.
I read the original post, which was explicitly "not for me" because, in fact, I don't really care about the clinical diagnostic criteria for autism. Given the historical biases of autism diagnosis (with regard to gender, intelligence, arbitrarily specific behavioral markers, etc), it takes a lot of hubris to assume that the DSM-5 has finally nailed it. But when I saw Riva Stoudt's response post, I was heartened that someone would take on the challenge of explaining why we shouldn't let the internet "popularity" of autism (and its attendant trivialization and trend-ification) distract us from the fundamentally different orientation that the current, evolving framework of autism offers us in terms of reducing human suffering. It gives us not only some language for describing subjective experience that has previously been poorly served by vague words like "weird" and "intense" and "anxious," but also a more convincing unifying theory of why some people to have that hard-to-describe experience.
Full disclosure: I am not a psychiatrist or a clinician, so this comment might not be for you.
Where am I coming from? A lifelong effort to understand my own psychological suffering and that of the people around me, i.e. the so-called "human condition." Instead of trying to engage with what I consider to be the bad-faith arguments of the previous commenters (what does being an "attractive young woman" have to do with diagnostic validity? why would anyone claim "authority" on subjective experience?), I will describe why this post resonated so strongly with me.
About a year ago I read this article by Michael Edward Johnson )https://opentheory.net/2023/05/autism-as-a-disorder-of-dimensionality/) that posits a specific "mechanistic substrate" (neuronal network dimensionality) for autism and elegantly shows how DSM-5 personality disorder clusters can be characterized as strategies for finding stability in a highly dynamic nervous system. In other words, coping strategies. He describes such a nervous system as "maladaptive," in that it produces the "autistic bundle of symptoms," but also discusses how nervous systems of high network dimensionality can also have unique advantages ("winning lottery tickets"): creativity, sensitivity, outlier intelligence, etc. Ah! A concrete explanation for what philosophers and theologians and psychologists and therapists are always struggling to convince us of: that our vulnerabilities are inextricably intertwined with our strengths. It's an opening to *experience* non-duality.
Understanding one's neurosis not as a disease, but as a way of tolerating a highly dynamic internal experience makes it possible to develop a healthier relationship with that internal experience, and thereby weaken the neurosis. Why? Because it gives a *semantically neutral* framework for understanding what is happening and why it's happening. It's a MUCH more satisfying explanation for one's suffering than "I have a chemical imbalance" or "I'm still mad at my mom after all these years."
I believe the diagnosis and discussion of autism currently confuses the underlying condition with the strategies for coping with it. This is one of the reasons why adopting autism as an "identity" supported by internet content gets so messy. When people are considering how this framework applies to them as adolescents or adults, it can be a harrowing spiritual jungle to traverse. Some people grow up in contexts that support and/or accept their outlier behaviors; many don't and have to learn how to mask and/or suppress their experience (see: women, attractive and otherwise). But the autism framework can provide effective tools for confronting the fear, shame, and rigidity that are the natural consequences of living in families and societies that don't understand or recognize or even have language for the autistic experience.
Many people (I dare not speak for everyone) are seeking not just a practical "solutions" for their suffering (which, if they succeed, are almost always temporary), but the kind of relief that comes with a proximity to some kind of truth. For some people, the autism framework feels like truth. And that's hard to beat as a place to grow from.
Thank you, Madonna, for the eloquently stated reminder that the stakes of diagnosis are, first and foremost, about addressing human suffering. Too often, it seems that people become overly concerned with whether other people are being taxonomized correctly and less concerned than they ought to be about whether and how the taxonomies created to explain and address that suffering are doing the job. Given the devastatingly strong association between autistic traits and suicide, in particular, I find it troubling that so many people seem to be more interested in catching people they think are posers than exploring the strong possibility that this diagnosis could be a crucial tool in suicide prevention, among other things.
This explanation seems to me a little overwrought and out of date. Maybe a decade ago the people seeking diagnosis were the sorts of people you describe, but my recent observation is that the diagnosis has become increasingly popular among strikingly charismatic young people, and I don’t just mean on TikTok. The cultural centre of gravity is shifting.
The key to seeing what is going on memetically is realising that the meme is not just popular among those seeking an autism diagnosis. It is overwhelmingly more popular among people not seeking a diagnosis. For every person wanting to be assessed, there are ten who love to say, “I think so-and-so is on the spectrum.” The fact that the meme is even more popular with people who are not experiencing the subjective inner experience is the giveaway: it has become a byword for “unconventional,” something overwhelmingly imposed by others, rather than experienced.
Once you recognise that, you can map it straight onto earlier cultural trends. Whatever is “weird” to one generation of youth becomes “cool” to their younger siblings, and by the next generation it is being manufactured by Hot Topic. We have watched this happen over and over. The genuinely odd outsider artists of the 1970s turn into the cool underground musicians of the 1980s, who turn into the mall goths of the 2000s, who turn into the e-girls of the 2010s. Nerd culture follows the same trajectory: trainspotting anoraks to “geek is chic” to Marvel going mainstream to conventionally attractive people doing cosplay. It is the same memetic conveyor belt every time.
Autism, in its pop-cultural version, is following the same trajectory. Traits once interpreted as awkward or eccentric get rebranded as quirky, intense, interesting, cool. Once that happens, the meme stops mapping onto autism and starts mapping onto whatever the culture currently finds appealingly unconventional.
The other historical precedent is neurasthenia, which may have started life as a descriptor for real neuropathic disease but quickly became a wastepaper basket diagnosis, applied loosely and in its later years often to women seen as difficult by their male doctors.
To my mind, the effect of modern diagnosis often acts in a way similar to fortune telling, to the extraordinary debasement of psychiatry, which apparently cannot remember anything beyond what it had for breakfast this morning.
Here is another point. Just as true melancholics never used to complain of depression, so too, once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety. For the most part, they were oblivious and at best distressed out of confusion. They lacked insight into their social deficits and, while lonely, had little real idea of what the issue was. Today, we are seeing something completely different: emotionally intelligent people, frequently with above average social skills, mistaking the commensurate anxiety that often accompanies self-awareness for deficit. They notice people sometimes treat them as weird, first because their charisma makes them a target for bullying, and second because most people of average social abilities coast through life almost as blindly as autistic people.
The neurotic and neurasthenic, on the other hand, “has a keen insight into his condition, and tends to exaggerate his symptoms, but the paretic has little or no insight, or, if present, he rather minimizes than exaggerates his symptoms.”
“Just as true melancholics never used to complain of depression, so too, once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety.” Exactly this.
What say you Sorbie? I wrote this off the cuff and no doubt it is highly insensitive but do you think I am entirely hallucinating?
Peter, your original comment struck me as a bad faith critique, so I wasn’t planning to respond as I have a general policy of not engaging with bad faith critiques of my work. However, based on your second comment (downthread), I’ve decided to reconsider.
First, I’d encourage you to examine your heavy reliance on misogynistic tropes. Referencing women’s “attractiveness” to impugn their seriousness and diminish them as credible reporters is a long and storied - and still very much alive - tradition in psychiatry specifically and in medicine generally. The same pattern underpinned earlier labels like neurasthenia and hysteria, and your rhetoric recreates it almost perfectly. It is no coincidence that the popular dismissal of autism is converging with the time that many more women are being diagnosed. Your first comment indicates that uninterrogated (I hope) misogyny is playing an influential role in your stance on this issue. If you’re invested in your own credibility, I’d urge you to reflect on that.
Now, to address the substance of your argument:
“…once upon a time, it was rare to hear high-functioning people living with autism complain, at least not with great accuracy, about social anxiety. For the most part, they were oblivious and at best distressed out of confusion. They lacked insight into their social deficits and, while lonely, had little real idea of what the issue was.”
This is straightforwardly false. This perspective calls back to a decades-outdated, dehumanizing view of autistic people as intrinsically non-self-reflective. In the intervening decades - well before the recent cultural visibility of autism - a massive body of research was produced documenting high levels of social self-awareness, self-monitoring, and social anxiety among communicative autistic adults. Much of the core conceptual work in autism studies (including the models I mentioned in the piece: monotropism, context insensitivity, “intense world,” and atypical predictive processing) emerged directly from autistic people articulating their own phenomenology. These models would be impossible without the very insight you claim autistic people do not have.
Your proposal that a diagnosis “is more convincing” if its recipient is surprised presupposes the premise that the purpose of a diagnosis is to identify something essential and material about the subject of that diagnosis. But that isn’t what a diagnosis does, and that is not its purpose. Psychiatric diagnoses are constructs, and Dr. Aftab has written extensively here about the clinical problems created by the misconception that these constructs map onto individual biological realities.
Even at its most hierarchical, psychiatric diagnosis has always been a collaborative project (if sometimes a contentious one) between the diagnostic subject, the diagnostician, the arbiters of diagnostic frameworks, and the wider culture. The tension between these stakeholders is a feature of the diagnostic process, not a bug, and cannot be so easily resolved by asserting the diagnostic authority of diagnosticians like myself and diminishing the value of the self-authorship of the person who is the subject of diagnosis. At their best, psychiatric diagnoses provide frameworks through which an individual and their supporters can substantively mitigate their suffering. Incuriosity, dismissal, and misogyny serve that purpose poorly.
You’re quite right. My original comment was thoughtless and crude. I will remove the offensive sections. I am very sorry to anyone who experienced distress or felt belittled by reading it.
What I had in mind was that intellegent, attractive (by way of their minds) and clever women do not need to resort to neurodevelopmental diseases because society cannot deal with them burning so brightly. I admit I went about this like a bull in a china shop. Also, it goes without saying that autism is a real neurodevelopmental disorder from which women suffer and are somewhat harder to pick out then men, I have no issues with that line of thinking, just to where it has led us.
I believe that people are the best experts on their own experiences, both inner and outer. Only by listening to people, and I mean really listening to what they are actually saying, do we have any hope of working together with them to understand what the problem is.
Freud originally understood that sexual abuse played a central role in hysteria, although he too quickly moved away from this view. Subsequent psychoanalysts did retain a general understanding that hysteria was often linked to abuse in childhood. It seems an extraordinary thing that, seventy years later, mainstream psychiatry still struggles to take this idea seriously.
Neurasthenia likely has as its substrate real neuropathic and nervous diseases, problems that women, overwhelmingly, and men still suffer from today but which remain largely unacknowledged and are frequently dismissed.
It seems to me that the problem is one of selective hearing. Psychiatry does not want to listen to a woman describing her experiences in any real detail. Instead, the task is to assign a label, and all the better if the woman has already done this job herself. People are experts on their own experiences. Doctors are experts on disease, physiology, and, once upon a time, psychology. The aim should be to get both experts in a room, listen very carefully to each other, and reach a conclusion about the most likely cause. To me, it is sad indeed that many women feel a neurodevelopmental disorder is the only acceptable explanation for their experiences. In many cases, such an explanation is simply implausible, and one is left wondering about the judgement of the other expert in the room.
Of course people living with autism have insights, I would never suggest otherwise.
As for the rest of what you have said, I am really not sure what to make of it, other than to say that people believe all sorts of incompatible things. The idea that someone can have a neurodevelopmental disorder which, twenty years ago, led people with the same disorder to describe having great difficulty understanding what was going on socially, and yet now allows vivid accounts of social experience, is not compatible with believing people’s experiences in a fair minded manner. You have to disbelieve the former to believe the latter. This simply cannot be so, and no amount of nomothetic research can undo this.
I do not agree with your description of diagnosis. Diagnosis is a case-wise, empirical and idiographic process in which two experts reach a consensus on either a disease or a functional syndrome. I will not be too pedantic about the last part. Arguing about diseases, syndromes and constructs is as silly as arguing about the difference between a donkey and a horse, you know one when you see one. The first part is the more important part.
It seems to me that psychiatry has been on something of a Woozle hunt for many decades. The field has a terrible memory for past discoveries, especially those that involved listening to patients, now days known as "anecdotes". It cannot be that a field of medicine can have diseases appear, vanish, and then return again so many times and still be taken seriously.
I am not quite sure why this comes to mind, but I suppose some of my thinking is expressed in Roland Kuhn’s words.
Roland Kuhn:
“When I make a psychiatric examination, I ask the family to be around and if the patient says, ‘I am always good in the morning’, I ask the wife or the husband about the patient. Sometimes you find that the patient is horrible in the morning and good only in the evening. If you do not ask, and psychiatrists often do not ask, you are unable to ask the most simple questions. The questions can be put and answered in a few minutes. This is no good, but psychodynamic and theoretical constructions sometimes are not good as well. All this is the consequence of an absolute inability to learn. Everything is in the books by Kraepelin and Bleuler, but who reads them today? Nobody in psychiatry actually reads, because the majority of psychiatrists are unable to read. They are unable to read a scientific text and for this reason my counsel is to read classic psychiatric texts with one’s pupils. In one hour you will maybe read one page, but you cannot make reference to the seventh chapter of Freud in one hour”.
“Today the psychiatrist who researches reads literature of the previous five years. Because of this we get discoveries today which have been known much better, and described much more beautifully a hundred years ago. And everybody thinks it highly interesting what Mr X has discovered, when all along in the old literature it had been wonderfully illustrated – much nicer much better.”
Of course, Kuhn’s ideal is very lofty, and I apologise for being a wanker. Suffice it to say, I get quite upset by the idea of diagnostic expansion in the case of women and neurodevelopmental disorders. Call me old fashioned, but I think some women are simply very smart and clever individuals who society cannot resist cutting down.
Well, what I say is that I like and respect Riva, so I'm glad you decided to apologize for being rude! I don't think you are hallucinating.
I do have issues with the essay tho. My biggest one is this: I'm not sure that there's such a wide gap between autism being "profoundly phenomenologically organizing" as a diagnostic construct and autism being a cool and quirky way to relate to/ talk about yourself. Those experiences are, to me, not categorically different. If you'll have me, I want to talk about how I came to that understanding: my own life.
Once upon a time, I was diagnosed with a million DSM things that didn't feel quite right or very useful. I long suspected I was autistic, and I eventually found a therapist who shared my conviction, and she got me a neuropsych eval, and the eval found me autistic. I experienced the consequent relief, the "there it is" kinda feeling that so many describe. You could have called it profoundly organizing. The relief, in my case, was directly proportional to autism's utility in the the social sphere. It helped me explain to myself and others why I was [insert social/cognitive/perceptual difference here], and when people (myself included) understood that whatever I was doing "wrong" was not my fault (this is the "mechanistic substrate" mentioned in the essay), they (myself included) treated me a lot better. So that was good incentive for me to make it very clear that I was autistic, to be loud but playful about it. I was being the quirky autistic girl, because the diagnosis' utility was contingent on my being the quirky autistic girl!
The relief I experienced as a result of my autism diagnosis was actually pretty short-lived, on the order of a few years. I continued to have a lot of struggles that had no clear relationship to autism and its mechanisms. I focused less on autism as a hermeneutic tool, and in so doing, without knowing what I was doing, I became a lot less Autistic, in the Tik-Tok sense, and I eventually became very dissatisfied with autism as a hermeneutic tool. Notably, the therapist who had me assessed for autism never knew this, because by the time I was like "hey wait, why did I want this diagnosis in the first place??", I had moved across the country and hadn't spoken to her in five years. It's no wonder that clinicians who favor autism as the ur-diagnosis because of the relief it brings patients are never challenged.
At the end of the essay, Riva says that the utility of a given construct is based on its usefulness in describing reality, and how it allows us to better interact with that aspect of reality. My personal experience with autism really makes me really want to interrogate what we mean by "interacting well with reality" in regard to the construct of autism (setting aside the question of "what is 'reality' in this sense?"). Do we mean sense-making? Do we mean psychologically organizing? Shame-reducing? Something else? All of the above? The essay makes nods to each of these. Autism afforded me all those things. And it afforded me all those things by encouraging me to relate to myself in a specific way. I no longer find the construct or mode of relating to myself remotely useful. I find it a lot more useful to regard myself as kind of eccentric, kind of awkward, very cerebral, and not for everyone. That is ultimately a lot more phenomenologically organizing for me than trying to map my experience onto existing frameworks of extra special and strange subjective experience.
This is just one patient's story, and it's not a direct quibble with the premise that autism is popular because it offers patients as deep self-understanding with well-mapped mechanics. But it is a quibble with the premise that mechanics are the be-all end-all of psychiatric diagnosis as it relates to patients' self-understanding.
This is a great comment. Thank you for sharing it.
I was provisionally diagnosed with autism as a child. I too felt that sense of relief, that “this is why I’m different and the other kids think I’m weird” moment, although in my case the cracks were so large that the relief barely lasted a week. I was nervous in primary school and at times would be observed doing things that might be considered stimming. I thought I had trouble fitting in, although in retrospect and objectively there is no evidence of this, and it is fairly clear to me now that I was a bit of a git and that my classmates liked me well enough. It was me who treated them badly. I grew up in a country town and I didn’t like townies.
The whole thing fell apart pretty quickly. About a year after the initial evaluation the paediatrician decided to send me to the Royal Children’s Hospital in Westmead along with my sister for further evaluation. I’m lucky enough to live in a country where we are still pretty good at diagnosis, and so I met kids my age with high-functioning autism, and it was painfully obvious that I was nothing like them. The psychiatrists at the children’s hospital gave my sister a primary diagnosis of schizotypal personality disorder, and after interviewing me they felt that I was at high risk of developing psychosis. They did not think I had autism. As time would prove, they weren’t too far off the mark, although I managed to evade schizophrenia.
Throughout my teens I was generally popular, and later on I had no difficulty at all with dating. In my adult life I have always picked jobs that rely on my social skills, as they are my strongest suit, my obnoxiousness online notwithstanding. And so it seems there was never anything to the autism diagnosis. I never had a father; maybe that is why I was anxious in school. For a few years in my early teens, though, the diagnosis really messed with my self-confidence. The self-consciousness of puberty collided with the diagnosis in a way that caused great suffering. I got over it as experience gradually reconfirmed the absurdity of the idea.
The thing is, those kids I met at Westmead, and the many other lovely people living with autism that I have worked with since, didn’t have something that in my view was particularly hard to diagnose. In fact, it struck me then, and still strikes me today, as among the most eminently easy diagnoses to make. The entire reason for this is that it is an incredibly tight phenotype. In my opinion it has very sharp edges. I also think the old criteria were pretty good, if you could exercise some self-control and stick to them objectively. Unfortunately too many had their imaginations captured by geek archetypes, anoraks, trainspotters.
For some time now psychiatry has been on a bandwagon on the subject of spectrums. The field became obsessed with fuzzy edges and went cross-eyed from staring at them. Of course, in this instance it is clear that psychologists hold the greater share of the blame. In 1990, in the book The Suspended Revolution, David Healy suggested that neuropsychology would usher in the triumphant return of psychopathology and pharmacopsychology. Wundt and Kraepelin would be reunited once more to banish the bean counters of statistical phrenology and restore both professions to their former glory. Well, some of this came to pass. Neuropsychology has shed a little bit of awkward light on our treatments, but for the most part it has just introduced a new form of phrenology in the form of the fMRI.
Now, I love fMRI research, and calling it phrenology is hyperbole, but as a field it is a mixed bag. Along with the good it has given rise to a great deal of brain mythology and a new kind of neurobabble, measuring differences between people’s brains. Out of all this has emerged an idea that a few decades ago would have been very strange indeed. We now sort everyone on the planet into two categories: neurotypical and neurodivergent. If this sounds prima facie like a bad idea to you, I’m sorry to tell you that most people seem to think it is splendid. One spectrum to rule them all. One spectrum so vast that the word “spectrum” alone could not suffice. It is the neurodivergence spectrum that gives autism its Mirror of Erised quality. Old-school autism was something very narrow, very distinctive. I also think it is no coincidence that this framework is so popular in societies that value individualism.
Phrenology and neurodivergence share a similar coastline problem: how granular do you make the measurements? To what sensitivity do you set the fMRI algorithm?
Our bodies are tied to our identity, and throughout human history this has led to a great many treatments crossing the line between the physical and the metaphysical, often mixing medicine with spirituality. Bloodletting, trepanning, exorcisms. For people who want this sort of treatment, there are many practitioners, but in my view medical doctors need to stay in their lane.
Psychiatry needs to restrain itself from these kinds of metaphysical debates. It is an irresponsible and dangerous preoccupation for any physician. If they wish to engage in such activities, they can do it in their private time.
Describing reality is a lofty goal, and while it is often supposed to be the domain of science, in reality is more often the domain of religion. I'm not a post modernist and I think we can investigate reality but thinking we've crossed the threshold into actually describing it in a gestalt sense, that's when I think we're running a dangerous line. Psychiatry has a far simply job, diagnosing diseases and clinical syndromes, treating them and then trying to figure out the cause. It has not been tasked with diagnosing all of the worlds ills.
I think an additional facet in regards to autism's 'popularity' (for want of a better term) is that increasingly it is being framed so positively. I use this word deliberately to go a step further than 'destigmatisation' - to have an autism diagnosis in certain social media circles is not only to have an explanation, it is to be a superior brand of human. You are "evolution's next step" you care about justice and are more moral, you are more interesting and empathic than the normies, you see through bullshit while the other plebs play along with dumb games, etc. Certainly I agree the psychodynamic personality styles/disorders have a branding problem (having just written about this today and seen the response), there's so much focus on negativity and deficits and I think a more "morally neutral" approach might be helpful. But neutral is the operative term (or at least, a focus on the unique strengths of each kind) as opposed to superiority.
I would have been interested to see your comparison re diagnostics applied to one of the personality constructs mentioned rather than social anxiety. For example, I have some schizoid tendencies (a differential mentioned in Awais' original article) but wondered for some time if I might be mildly autistic. Certainly I relate to plenty of the listicle reels. However, having learned more about ASD, I'm pretty clear that I don't favour static over dynamic processing (to use RDI terminology). That's not something that tends to be well-explained in 12-second video form.
A big reason I eventually left autism behind as an understanding for what's going on with me is that it has become so idealized. Where borderline is shaming/devaluing, autism is, at this cultural moment, idealized. When will this damned field stop splitting?
Actually, in spite of BPD's enduring stigma (BPD has always been the "bad object" relative to other common diagnoses, including other heavily stigmatized ones like bipolar disorder), of the personality disorders, BPD remains the most popular as a self-diagnosis/phenomenological organizer/identity framework, and I believe it's for the very reason that of the personality disorders, BPD has the most accessible and robust set of mechanistic explanations analogous to what I described in the piece (not Linehan's model, which is causative, not robustly mechanistic), though at least in popular discourse, it lacks the cognitive/perceptual layer. (This layer is present in the research on BPD and has very interesting implications.) I will write a lot more about this eventually but not today.
That's such a useful way of framing it!
Also gets me thinking about how both borderline and autistic traits present across a spectrum but the 'image' of both exists as something fixed. Borderline as its most catastrophic form, shameful and "manipulative" and "toxic", autism as idealised quirkiness. Not much said about the high-functioning borderline character (who no longer meets the criteria for BPD or perhaps never did, and who has plenty of strengths) or about severe autism.
I think it is very clearly not the case that not much is said about severe autism, but *is* very much the case that the spectrum of borderline traits/borderline organization/the reality that most people who meet criteria for BPD remit with time and without BPD-specific interventions is very rarely mentioned. My suspicion is that the dichotomy you are highlighting has very much to do with the fact that BPD is strongly associated with women (crazy women!) and autism with men (awkward but brilliant men!)
I would agree if the discussion is limited to clinical literature and research, but the dominant media discourse skews very heavily towards Level 1 ASD. Presentations that would once have been labelled Aspergers (or "weird nerds"). There is the odd mention of severe cases, but look at (for example) the enraged pushback and talk of "genocide" any time there is mention of researching treatment or causative factors for ASD. In any case ... severe cases DO get a mention, which is very much not the case for healthy/neurotic levels of borderline personality organisation. So you do have a point there.
You might well be onto something re the female association with BPD, psychiatry's history of weaponisation against female nonconformity has a long and ugly tail. I do remember a brief period where more negative associations with male autism were quite dominant but less so now. If one describes the autistic 'sense of injustice' incel type often people will respond that is not 'real autism'. Because in the discourse an autistic 'sense of injustice' is always pro-social.
I think this is a really great point, and I think it illustrates one of the down-sides (or perhaps a perversion of) the strengths-based lens, of which there can be many upsides.
Just subscribed (long overdue!) so I can reply to this post. I will try to be as concise as possible and raise three counter-points, which I would love to hear the author’s (and others’) perspectives on.
My first counter-point is historical: Even if one were to grant the claim that autism currently has greater phenomenological or explanatory potency than alternative diagnoses (which is itself questionable if one looks closely at the available empirical data), it’s important to recognize that this appeal does not come from nowhere. Instead, it comes almost entirely from the very traditions the author critiques: namely, psychoanalysis and early personality theories. Indeed, until relatively recently, there was no such thing as “high-functioning autism” as a distinct diagnostic category because what clinicians historically described were schizoid personality (or relational) dynamics: namely, social withdrawal, hypersensitivity, diminished reciprocity, and an unusual way of relating to others. Indeed, Bleuler’s use of the term ‘autism’ was explicitly tied to such schizoid dynamics and even Asperger’s original accounts were also embedded in this same personality-theoretical language. To suggest, therefore, that autism uniquely supplies phenomenological depth or explanatory power is to overlook the fact that these resources were already there, just articulated in a different manner (see also footnote 1).
Which leads me to my second point: If autism is just a re-articulation of schizoid dynamics, then does it add anything (justifying its existence as a separate and idealized diagnostic category) or does it simply re-invent the wheel? Here, I would say that it does add something, but not in the way this post suggests. The main thing the autism construct seems to offer is not a superior explanation, but a different moral framework. Historically, strange terms like “personality pathology” (and “character pathology” before it) were used to describe ego-syntonic difficulties: that is, maladaptive ways of relating that a person experiences as part of themselves and does not necessarily wish to correct. This framing, however, carries an implicit sense of responsibility, and often blame. The autism, and broader neurodiversity, frameworks largely remove this blame by instead saying: “you have these relational difficulties, but they are not your fault; they simply reflect how your mind (or brain) works rather than a problem with who you are as a person”. This shift is clearly meaningful and often *feels* more scientific or objective because the alternative is either a subjective moral inference (“you are relating in these and these ways because you have a horrible character or personality”) or a descriptive statement (“you suffer because you relate to others in a maladaptive manner”). Yet what I would argue is that autism’s moral reframing should not be confused with greater explanatory clarity or stronger evidence base. Instead, what I would argue is that autism gains explanatory appeal (but not explanatory depth) because it (a) removes responsibility for one’s suffering and (b) repaints chronic relational difficulties in a brain-based language that feels objective but is still only moderately supported empirically (and, importantly, no more so than many other diagnostic categories; please see footnote 1).
This leads me to my final counter-argument which is clinical: namely, having said all that, what’s the take-home message for clinicians and patients alike? I think the take-home message is this: many clinical diagnoses entail strikingly similar relational difficulties (from depression to social anxiety to ‘personality’ or ‘relational’ disorder, and autism) and the task is not to favour one diagnosis over another because it is more socially appropriate or personally appealing, but rather to offer a diagnosis as a tentative explanation for the patient’s relational suffering and then explore (with the patient, of course!) whether that explanation matches reality (not each other’s fantasies). In some cases, when these patterns are present from very early in life (like infancy), a neurodevelopmental explanation such as autism may be appropriate. In other cases, the same (or similar) relational difficulties may be framed as outcomes of severe traumatic experiences: a person who has been repeatedly violated (physically and even sexually) may relate to others in disorganised or intense ways and the clinical priority is to frame these relational difficulties in a trauma-based way (enter, complex PTSD) in order to properly address them clinically. Finally, and I would argue more subtly and rarely if at all understood by anyone today, similar relational difficulties may be best explained neither by neurodiversity nor by a history of severe trauma; instead, they may be best explained by temperament and personality development: not in the impoverished way the DSM implies or the sexist, racist, and largely unscientific way that many past theorists paint, but in the philosophically and clinically rich way that *some* early analysts outlined and that my team and I are now trying to clarify (and rectify). The basic idea here is simple: a person is brought into the world with some relatively automatic ways of relating (think withdrawn versus active temperament styles); these ways of relating are then either dismantled with ‘good enough’ social relationships (Winnicott style) or amplified with ‘bad enough’ social relationships (Zavlis style), leading to what we can call, for the sake of the current illustration, ‘personality quirks’). These quirks are part of the person (just like any other trait is) and can be a major source of suffering, but, importantly, that suffering is not intentional or agentic, that is, it is not something that the person is “doing on purpose” (which is what many personality-based historical accounts get wrong).
In any case, the reason I am mentioning all of this (apologies for this mini essay) is to highlight the following: there are many different kinds of mechanisms that can explain (autism-like) relational difficulties, and the fundamental clinical task is not to endorse any one of these mechanisms preferentially or idealistically (as some people in the comments have also implied), but rather to hold them tentatively, revise them in light of new clinical evidence, and, most importantly, formulate them collaboratively with the patient (while still being willing to respectfully disagree when a particular explanation feels more like a comforting narrative than an accurate account of what is actually generating suffering).
Footnote 1: This comment (or, better put, mini essay) is already too long for me to provide a complete review of why autism is not any more “evidence based” than other mental disorders. Perhaps I should write a paper about this, but briefly, the main points are the following: we have as much neurobiological evidence for autism as we do for most other psychiatric categories (i.e., largely heterogeneous findings, modest effects, and limited diagnostic specificity); we have as many computational accounts of autism as we do for other disorders (indeed, predictive-processing and related computational models have arguably been more successful for psychosis, anxiety, depression, and even ‘personality disorder’, aka ‘relational disorder’, than for autism); and we have no unique “mechanistic” mapping from proposed cognitive-perceptual differences to heterogenous autistic experiences that would justify treating autism as a special diagnostic category. Taken together, all this implies that any preference for the autism construct does not actually come from superior “cognitive-perceptual mechanistic explanations,” as the author assumes, but rather, as I have argued above, from its moral and cultural affordances: namely, its reframing of chronic relational suffering in a way that feels more neutral, less blame-laden, and therefore more acceptable to patients, clinicians, and the wider culture (without necessarily guaranteeing, as I have argued previously, that this is the true diagnosis).
Orestis, you’re in luck! Not only do I have a strong intrinsic drive to correct people’s erroneous interpretations of what I say, I also grew up on message boards in the 90s (there’s your trait-environment interaction right there.)
Actually, about that: I’d like to address your final (pre-footnote) point first. Trait-environment interaction (or to use your relatively narrower lens, temperament-relationship, if you prefer) is not only not a unique standpoint, nor a counterargument to me - or anyone but the most die-hard genetic determinists or old-school tabula rasa devotees. Trait-environment interaction is consensus among anyone remotely serious about understanding the emergence of behavioral phenotypes. It is not an alternative to autism, trauma, personality pathology, or any other model for describing particular phenotypic expressions; it is the developmental substrate on which all of them already rest, and one that the vast majority of us agree upon. Any site of reasonable debate on these issues takes place on the basis of that shared premise.
Second, to your footnote: whether autism is more evidence-based than any other diagnostic frameworks, and even whether the mechanistic theories underpinning it are correct, is irrelevant to the argument I make in the piece.
Third, regarding whether autism is nothing more than a recapitulation of schizoid personality disorder: the constructs actually aren’t that similar. The social criteria for SPD and autism are quite different; SPD also contains intrapersonal qualities that are out of autism’s scope, and has no relationship to anything contained in autism’s criterion B. Many diagnoses have shared historical underpinnings, and have undergone increased differentiation and reformulation for good reasons. I do think, though, that the SPD criteria represent an archetype of an autistic person that many people hold, are attached to, and would like the autism construct to continue to represent. Many psychoanalytically inclined clinicians and theorists are interested in staking turf that they see as belonging to personality disorders that autism has “taken” (I count myself among the psychoanalytically inclined, but am disinterested in conceptual turf wars.)
Fourth, and relevant not just to your comment but to a pattern I’m seeing in quite a few of the “counterarguments” made in the comments section here: you’re responding to this piece as though I was making a monocausal argument. I wasn’t, and I wouldn’t. To some degree, this misread is understandable given that monocausal arguments are unfortunately common in contemporary discourse. Is your moral exculpation idea also a contributing factor to autism’s current status? It’s certainly possible. One of my premises, always, is that complex social phenomena are multifactorial. That could be one of the factors. It’s not a counterargument, though.
To restate my thesis, for clarity’s sake:
Autism currently offers a particularly tight and usable mapping between lived phenomenology and explanatory models, relative to other diagnoses as they are currently formulated and culturally operationalized, and this is a contributing factor to its contemporary popularity.
It’s a relatively modest claim, and I think it’s interesting that so many people are so resistant to entertaining it.
Thanks a lot for replying – I am really interested to understand how you think! I will thus try to reply to each of your points (hopefully, more concisely this time):
1. I’m not making a generic claim about trait–environment interaction, nor disputing that temperament plays some role across many forms of psychopathology. My claim is much more specific: autism, as it is currently conceptualized, is best understood as a temperamental or personality-based condition––that is, a congenital way of being that is present from birth onward and remains relatively stable across the lifespan. This is not how most other mental disorders are conceptualized. While temperament may confer vulnerability to anxiety, mood, or other mental disorders, those are fundamentally ‘mental-state’ disorders rather than ‘temperamental or trait-based’ disorders. I appreciate that this claim of mine is rather controversial (I am, after all, suggesting that autism is a form of ‘personality trait pathology’) but if you’re more interested in this view of mine, have a look at the following: https://osf.io/preprints/psyarxiv/gswz3_v1, https://doi.org/10.1192/bjp.2024.80, https://substack.com/home/post/p-180892583.
2. I am surprised to hear that whether autism is more evidence-based is irrelevant to your argument. As I read the piece, one of its central claims is that other diagnoses can and should learn from autism precisely because it is said to offer clearer, more specific cognitive-perceptual mechanistic explanations than they do. That is an empirical claim. It seems that with this admission of yours (‘evidence base is irrelevant’), the main claim of your essay (at least as I read it) shifts from “autism offering genuinely superior mechanistic explanations” to “autism is *being experienced* as providing such superior explanations but that may very well be an illusion”. I must say that the latter is perfectly consistent with my view which suggests that the sole reason autism is more appealing has little to do with mechanistic explanations but rather the moral framing around the autism diagnostic framework.
3. I never stated that autism is a recapitulation of schizoid *personality disorder*; I only stated that it is partly a recapitulation of schizoid *personality dynamics* as discussed by traditional theorists like Bleuler and later psychoanalytic writers. This distinction matters, because modern-day schizoid personality disorder and classical schizoid theory have relatively little in common, and both have only a partial and non-isomorphic overlap with the contemporary autism construct.
4. Regarding mono-causality: to be honest, I did read your piece as, at least implicitly, mono-casual, and, having read some of the comments herein, I believe that at least a few others may have also read it this way. So, at this point, I think it’s worth exploring (together, if you'd like) why this piece may have been perceived in this way. In my eyes, the issue is not that you explicitly deny multi-factorial causation in principle; instead, the issue may be that your essay overwhelmingly promotes the advantages of the autism construct itself (e.g., mechanistic clarity, phenomenological fit, and explanatory power) while not acknowledging, not even passingly, that alternative mechanisms can generate very similar relational phenotypes. When a framework is presented almost exclusively in terms of its advantages, and others primarily in terms of their disadvantages, it’s understandable that readers would infer some form of idealization of the former framework and a denigration of the latter frameworks.
That’s why I found your restated thesis here genuinely more nuanced than how the entire piece came across. Read on its own, your restated thesis sounds modest. Read alongside the essay, however, it feels different, because the essay consistently highlights what autism supposedly does better (mechanistically, phenomenologically, explanatorily) compared to other diagnostic concepts. But, in any case, my concern here is less about intent than about effect: idealizing one diagnostic framework while sidelining others that are equally evidence-based, and often more prevalent in everyday clinical life, risks narrowing rather than expanding our explanatory and diagnostic imagination. I suspect that it is this tension (particularly in relation to Awais’ original autism post) that explains much of the pushback you’re noticing.
I won't be engaging further with the substance here, not because I lack a response, but because the terms of engagement have shifted.
The customary response to an author’s clarification of their position is to engage with the substance of that clarification, not to offer a retrospective analysis of why the piece may have “come across” a certain way. Out-of-bounds evaluative commentary is not how I conduct public intellectual exchange. I'll leave it here.
Fair enough. Just to close the thread: I did engage with the substance of your clarification, and I only raised my ''retrospective analysis'' in an exploratory and reflective spirit. For me, part of writing publicly (especially about sensitive clinical topics) is being willing to reflect not only on what one intended to say, but also on how what they said landed on thoughtful and careful readers. In any case, I appreciate the exchange!
Really good Orestis! Compelling response. Love it!
Excellent! Thank you for the comprehensive reply.
I’m a parent of an autistic son (level 1), and I’ve followed this extended conversation with interest (it’s also the conversation that got me to subscribe!). I’m not a clinician, so I’ll have to read through these pieces several times to fully understand. But my initial impression is that all three of these pieces (Awais’s Riva’s, and yours) don’t say much about level 3 autists. A lot of the focus is on the individual’s self-conception and what framework makes the most sense for them phenomenologically. But of course, not all autistic people are capable of having those conversations with their clinicians. What changes in your framework when considering the experiences of the most severely affected individuals?
I also wonder about the emphasis on schizoid personality constructs when so much of the autistic experience (at all levels) is related to sensory challenges. Perhaps this is an unfounded worry on my part, but when, historically, autism was more closely associated with schizoid personality traits, stimming was sometimes mislabeled as hallucinating or psychosis. I’m sure I’m getting much of this wrong and am happy to be corrected.
Thank you for sharing -- these are very fair questions, and I’m glad you raised them.
On your first point: you’re absolutely right that most of this discussion (mine included) is implicitly focused on verbal, reflective, often late-diagnosed individuals -- typically those labelled “level 1”. My framework is not intended to generalize to individuals with profound autism (defined by comorbid intellectual disability) and high support needs. I see these presentations as qualitatively distinct and I would straightforwardly label them as disabilities. My core idea then (which is that autism can sometimes be better framed as a temperamental or personality difference) would apply only to the subset of cases where the core difficulty is chronic ways of thinking, perceiving, and relating that are causing suffering in a particular context (and can thus be ameliorated either by subtly shifting them or by changing one’s environment). For individuals who cannot meaningfully participate in phenomenological or explanatory dialogue, the clinical task is necessarily different, and my argument simply does not apply there.
On your second point about sensory features: I agree this is super important and I should have perhaps mentioned that at some point in my earlier reply. The way I view this is that (a) there are people out there who experience relational difficulties (this is usually the first observation clinicians make) and (b) there are different explanations for these difficulties (including that it might be trauma, it might be a specific personality quirk that has nothing to do with neuro-development, it might be autism, or it might in fact be all of these). In the case where it’s only or predominantly autism, I would agree with major theorists that what might explain, or generate, autistic relational difficulties is a sensory-processing difficulties (in the sense that atypical sensory integration, prediction, or filtering can make ordinary social environments overwhelming, unstable, or hard to navigate, thereby secondarily shaping relational strategies like withdrawal, rigidity, or stimming). Now, whether sensory-processing differences are sufficient on their own, whether they specific to autism, and whether they can empirically differentiate autism other relational maladies remains an open empirical query -- but they are plausibly one of the key mechanisms that is involved in autistic difficulties.
To summarize, I agree that I should have drawn a distinction between high-functioning vs. low-functioning autism, clarified that my personality and relational proposal applies predominantly to the former (which is best understood as a personality difference that may or may not be impairing depending context) over the latter (which is best viewed as a disability and, in my opinion at least, belongs to the domain of neurology), and talked more about sensory mechanisms and how they are possibly the best candidate mechanism for explaining the generation of autism-like (relational) difficulties.
Interesting to read, and a nice expansion to Awais’ original piece, which I think was great and informative, but also offered only part of the picture. I think the theories behind autism (ie why do differences in brain development lead to these specific deficits) do offer insight to the patient when those theories resonate.
There are major differences between neurodevelopmental disorders (ASD, ADHD) and other psychological or psychiatric disorders found in the DSM, in how they are diagnosed and treated. I’ll offer some other points as to how these diagnoses can provide more relief than other ones:
Neurodevelopmental disorders are diagnosed after comprehensive neuropsych testing, which give the patient insight into their specific strengths and weaknesses, particularly when it comes to school and work settings. Oftentimes co-occurring learning disabilities are also discovered in this process.
Neurodevelopmental disorders are early onset, and require management, not treatment. Understanding this is insightful for patients and relatives of patients who have been fixated on finding a cure for the problems they or their child faces.
Autism in particular can be associated with not just cognitive developmental delays, but physical ones. Dyspraxia, and other problems in proprioception and coordination can affect many aspects of one’s school/home/work life. Physical and occupational therapy can provide much needed support.
Autism, in particular, is associated with a number of health issues, including some rare genetic diseases. Sometimes a diagnosis of autism leads to genetic testing and a proper diagnosis for the patient’s physical health struggles.
In this sense I’d argue that autism is a more systemic mind/body diagnosis - associated not just with psychological or psychiatric interventions; but also potential interventions for learning, gross and fine movement, and physical disease. What I think other diagnoses could learn from autism in addition to mechanistic theory (which I agree is helpful) is a holistic approach to treatment/management.
Tone is a tricky thing to get right in brief written comments but, for me, this whole thread is richer than anything I’ve heard in the last 2 decades in any psychiatry meeting. Thanks to everyone who has contributed here.
I appreciate this explanation but feel it falls a little bit short. Rather than focusing on the memetic virality of the autism diagnosis (which is useful), I wonder if it would serve us more broadly to consider the memetic virality of any diagnosis, and how a diagnosis sits in dialogue with an individual's phenomenology. If we look at the history of psychotherapy and mental health diagnosis, memetic virality and satisfaction with how it aligns with the phenomenology of an individual is a relatively newer construct.
In a certain way, the "democratization" of mental health diagnosis via the firehose of information on the internet (and firehouse of misinformation) can correct some of the issues with the DSM (if we're optimistic). In another way, we risk losing the thread on why an authority on these things (whether it's the DSM or just an "expert") is important in the first place.
To put it even more simply, the role of a clinician can often be seen as helping folks both "feel better" AND "get better," and I wonder what happens when we lean towards one of those two directions, even in our use of diagnosis and diagnostic processes.
Once more, I'll reference the book that no one on this blog is reading, because it alone can address almost every post here. It contains >1000 empirical references.
The autism/neurodivergence label has become an identity of sorts in America. This is uncontroversial outside of psychotherapy-land. Go speak to a non psy-professional under the age of 40 in a coffee shop to see for yourself.
As a consequentialist, it would appear that the asd/neurodivergence "identity" is being used by certain groups as a status-symbol or "credential" of sorts. But to understand this premise, I must first point out that increasingly the neurodivergence/asd crowd has become quite vocal and acknowledged as being legitimate human beings (as opposed to the sub-humans we were portrayed as by mainstream media growing up, along with the Autism-Industrial-Complex, see here https://www.madinamerica.com/2021/02/disability-studies-scholars-critique-autism-industrial-complex/ ).
Because of this so-called "neurodiversity movement" the last decade, those with the ASD label have gained some epistemic credibility or "sympathy" from the neuro-typical (non-ASD) population. And most unfortunately, BECAUSE of the last premise, now all the sudden, various status-seeking neuro-typical individuals are now noticing the tinniest of "quirks" about themselves, and then, in the name of status-seeking alone, are attaching themselves to the ASD/neurodiversity label, purely to reap the social benefits of the asd/neurodivergence label that instead belongs to the latter.
The most ironic part of this state of affairs is that decades of empirical research shows those truly on the ASD spectrum, along with their sub-traits, tend to AVOID status-seeking across the lifespan. That is, people with ASD category membership seldom appeal to titles, credentials, or other labels for instrumental gain. They purposefully turn down job opportunities that result in upgrading their credentials, and purposefully choose to avoid situations that would result in them gaining more social approval, even when there are little costs. In fact, this partially explains why those who belong to the ASD category membership tend to get diagnosed with cluster C and cluster A PD's, but rarely cluster B. This is not my opinion, it is an established cross-cultural fact per the book I shall cite at the end here.
Instead, it is (non-ASD) neurotypicals who do this sort of thing (malingering an ASD category in the name of status-seeking). Therefore, re-stated: the genuine ASD crowd is being victimized by neurotypicals who, themselves, are trying to identify as ASD, but did not earn it per their psychometrics (e., Baron-Cohen's Empathising-Systemising scale), and only in the name of gaining "sympathy" from other neurotypicals and neurodivergents of sorts.
This is not an idiosyncratic hypothesis. Actually, the same conclusion can be reached indirectly in this book: Evolutionary Psychopathology by Del Giudice, 2018. Compare chapters 4, 6, then 10 in particular.
For according to this book, it is neurotypical (non-ASD) "fast spectrum" populations who are status seeking in the first place. But the "slow spectrum" population described in this book, which includes the ASD crowd, seldom promote their identities in the name of social approval. That is, people with ASD are not malingerers, it is actually people with functionally opposite traits (such as hyper-mentalizing).
A similar social phenomenon happened with PTSD in the 1980s and 90s. A bunch of semi-traumatized individuals (who lack "Big T" trauma), in the name of status seeking, decided to self-identify with PTSD in place of their personality disorder diagnosis, because PTSD was then seen as "more virtuous" than making a set of extreme traits ego-dystonic (as in Borderline PD). But ironically, to identify with PTSD in place of Borderline PD is logically identical a personality-disordered individual making their extreme traits ego-syntonic. Then, once the Iraq war kicked off, PTSD all the sudden became re-stigmatized (and for obvious reasons). The cycle continues!
(My epistemic credibility can be found in my blog)
I’m not going to address the broader claims offered under the auspices of the evolutionary typology framework here, as that is outside the scope of this piece and would require a lengthy interrogation of our respective premises. However, I do want to correct a couple of specific points that fall within my area of expertise.
First, hypermentalization is not an “opposite trait” to autism, nor can it be reasonably framed as the opposite of hypomentalization. Hypermentalization and hypomentalization are both mentalizing errors; a high prevalence of either or both in a given individual indicates atypical mentalizing, and both occur transdiagnostically. Importantly, hypermentalization is well documented in the literature among autistic populations -particularly in the form of hostile attribution bias, excessive rule-based social inference, over-interpretation of social contingencies, and compensatory, deliberative social reasoning. It is simply not referred to using that exact terminology. Given this, framing hypermentalization as functionally antithetical to autism is not only a category mistake, but also reinforces a flat, outdated view of autism that the broader body of research on autism and mentalization does not support.
Second, appeals to instruments like Baron-Cohen’s Systemizing–Empathizing scale as arbiters of who has or has not “earned” an autism diagnosis reflect an outdated understanding of both autism research and clinical practice in 2025. While the systemizing theory of autism is historically influential and represents a meaningful theoretical contribution, this measure is widely recognized as limited and overly binaristic, and I doubt Baron-Cohen himself would claim it as diagnostically definitive at this point.
The question of whether autism has become an identity-organizing construct is not in dispute - indeed, it is one of the premises of this piece. My argument concerns the mechanistic and phenomenological explanatory power of autism as a construct relative to other psychiatric diagnoses, not the moral valence of diagnosis-as-identity. Conflating these domains obscures rather than clarifies the clinical and theoretical issues at stake.
If you read chapter 10 of the book i cite, it spoon-feeds you the very "mechanistic" explanations you seek. It is well within the scope of your post. Specifically, see page 249.
I don't think you have the guts to read it. I will bet $1000, publicly, you wont do it.
Consistent with my blog, it is unclear if you are an AI chat bot or an embodied soul.
For example, your appeal to "mechanistic and phenomenological" explanations of ASD is a contradiction unto itself. That is like saying you want to be both hot and cold simultaneously. For the phenomenological tradition is based in the Continentalist tradition, and mechnaistic descriptions are based in the Analytic (American) tradition. The two paradigms are so at odds with eachother that it fully explains why the humanities department is separate from the science department at every university in the english speaking world.
I should say that my comment is a bit flippant, and in trying to push the pendulum in the other direction I've ridden rough shod over the nuances. I realise that people might find aspects of what I've said distressing or offensive. I am aware that many people living with autism do indeed experience social anxiety to varying degrees and that they are distressed by it. It is just that there is typically, in my view, a strong confusional element. I has to be said that degrees of insight surely serve some proxy in distinguishing the endogenous from the hypochondriacal, and it's a bit more convincing when the consumer is at least a little bit supprised by the diagnosis.
Yes absolutely why have a rubbish diagnosis and access to treatment that will make you worse when you can have one that opens up your understanding of yourself and enables you to access your tribe, help, support and understanding. Thanks for posting this is spot on