What Other Diagnoses Could Learn From Autism’s Diagnostic Appeal
The role of cognitive-perceptual mechanistic explanations
Riva Stoudt, MA, LPC, is a psychotherapist, educator, writer, and lifelong resident of Portland, Oregon. She maintains an active client practice with a focus on targeted methods of trauma processing. On her podcast, “A Therapist Can’t Say That,” she explores taboo topics within the therapy field with an eye towards nuance, complexity, and productive discomfort. Learn more at The Kiln.
This is a response by Riva Stoudt to the post, “Autism’s Confusing Cousins: A differential diagnosis for the weird and the awkward.”
While as a fellow clinician I’m sympathetic to the increasingly prevalent dilemma of handling clients’ attachment to diagnoses we’re skeptical they truly meet criteria for, I think this misses the mark when it comes to identifying the reasons behind autism’s memetic power and current popularity as an interpretive construct, and that there is something much more meaningful and important happening with autism than the framing “colloquial term for weird person” vs. “traditional clinical differential diagnosis as represented by contrasting DSM checklists” can capture.
In the first place, in my clinical experience, most adults seeking to explore an autism diagnosis have already accrued a number of DSM diagnoses—and nearly universally a diagnosis of your first-line differential, an anxiety disorder—and found those diagnoses not only to have inadequate explanatory power but also to lack satisfactory applied utility when it comes to addressing the suffering that they were seeking a diagnosis to address in the first place. In sharp contrast, I rarely hear this complaint about the autism diagnosis. Autism is more often experienced as the diagnosis that “explains everything,” “fills in the blanks,” is a “skeleton key,” etc. Why is this? While many adults diagnosed with autism do articulate that it provides a lens for understanding why they have always felt weird, different from others, and so forth, I think to reduce autism’s virality as a construct to this one domain is reductive, and runs the risk of coming across as patronizing to the large number of people who find that the construct of autism is profoundly phenomenologically organizing to them in a way that other psychiatric diagnoses rarely are. Since, as diagnosticians, we have disproportionate influence over how people organize their subjective experiences through the lens of diagnosis, we have the responsibility to investigate the phenomenological power of diagnosis in informal settings without flattening it into its most simplistic folk psychological forms, and to reconcile what we find there (or at least attempt to) with our clinical/medical diagnostic lens without reifying deeply flawed DSM checklist constructs. Without a richer representation of the reasons behind autism’s current cultural power to balance out the still-dominant DSM model, the framing in this piece skates pretty close to that reification.
So to pose the question again: why is autism so memetically potent, and why does it have such unusual explanatory power to those who adopt the diagnosis? I believe it’s because the construct of autism gestures at a mechanistic substrate to phenomenological experience in a way that almost no other diagnosis does, and TikTok soundbites notwithstanding, the theoretical frameworks that comprise our emerging collective understanding of that mechanistic substrate are widely available and heavily disseminated throughout the community that identifies with the diagnosis of autism. (The mechanistic substrate, of course, is not referenced in the DSM criteria themselves, which is one of many reasons why focusing too tightly on DSM criteria provides limited insight both into the broader construct of the diagnosis and how it operates in the broader social context.) With few exceptions, other DSM diagnoses included as part of the differential you described are constructed as psychological. Setting aside the question of their empirical validity, personality disorders in particular are dripping with psychodynamic residue that, while I believe it has utility especially in the long-term therapeutic treatment context, provides an unsatisfyingly incomplete phenomenological picture because it lacks the cognitive-perceptual mechanistic layer that the construct of autism provides. Why do so many people with personality disorder diagnoses who go on to be diagnosed with autism report that the personality disorder diagnosis was of limited utility and the autism diagnosis was helpful? It would be easy to write this off as simple preference due to reduced stigma of autism compared to personality disorders, or to reify the constructs by saying the person “really” had autism and not a personality disorder. But this ignores the phenomenology that autism explains via its associated cognitive-perceptual mechanistic explanations, which personality disorders largely, and problematically, lack.
To credibly advocate for a return to increased diagnostic granularity in the population of people now being diagnosed with autism, or who adopt a self-diagnosis because they find the construct of autism appealing, the diagnostic constructs proposed as alternatives are going to have to do a lot more mechanistic and phenomenological heavy lifting than they currently are.
In contrast to the implications of psychodynamic etiology that associate with personality disorders, and the relatively superficial etiological models that associate with anxiety disorders, many of the proposed theoretical models for the cognitive substrate of the autistic behavioral phenotype—atypical (perceptual and allostatic) predictive processing, context insensitivity, monotropism, “intense world”—provide clear, specific, logical, comprehensive mechanistic descriptions of subjective experiences and external behaviors associated with autism. Often people who strongly identify with an autism diagnosis find these models to relate concretely and directly to their perceptual, cognitive, sensory, relational, and emotional experiences—even if they are not fully versed in the totality of the theoretical frameworks themselves—and thus the autism construct accumulates immense and compelling explanatory power.
By way of illustration, imagine a person whose presenting concerns in seeking a diagnosis are social difficulties, and particularly anxiety related to social situations, as anxiety is often the most obviously aversive and thus the most emotionally salient experience a person with various social difficulties might seek an explanation and relief for. Say this person receives a diagnosis of social anxiety disorder—a disorder for which, for the purposes of this thought experiment, they actually do meet criteria for, or in common parlance, “have.” The diagnosis of social anxiety disorder doesn’t contain any new information—it’s a DSM label for a symptom they already had enough self-awareness to come in complaining of. If this person then wants to use the diagnosis as a lens to understand more about themselves and about the phenomenological domain it describes, and sought out more information about the conceptual framework of social anxiety disorder, they’d be likely to find references to concepts like intolerance of uncertainty, maladaptive fear learning, and perhaps something like evolutionarily advantageous anxiety run amok. While these might be interesting, supported by evidence, and perhaps even factually accurate, they are mechanistically thin explanations. They serve a purpose as proposed causes, but they lack a complex mechanism, meaning they do not describe a sequence relating to a causal chain between the proposed cause and the manifestation of these social-anxiety-related experiences and behaviors. What is happening in the person’s subjective experience at the point where maladaptive fear learning, the intolerance of uncertainty, or out-of-balance trait anxiety turns into social anxiety? These frameworks provide little-to-no accounting for that, and so social anxiety disorder is lacking in utility when it comes to providing a description and explanation of that phenomenological domain.
Contrast this to autism. Imagine that instead of social anxiety disorder, this person receives a diagnosis of autism, or goes on to receive a diagnosis of autism subsequently, which is, of course, increasingly common. Immediately, criterion A of the autism spectrum disorder diagnosis accounts for a broader band of social experiences—not just social anxiety, but other aspects of the phenomenology of feeling “weird,” of feeling like something is notably different about their means of participation in the social world. At this point, if the person again seeks out something beyond the criteria in the diagnosis that explains why that is, what they are likely to encounter is not just causative, but mechanistic theories: models that provide sequential, process-focused, relatively detailed explanations for the surface-level phenotype. For example, if part of this person’s experience is that “more than others seem to, I experience anxiety particularly in novel social situations, because I find it confusing to understand how to act in social environments I haven’t been in before,” via the diagnosis of autism, they could pretty easily find the mechanistic explanation of context insensitivity to apply to this experience. They would now have access to the concept that a contributing factor to their anxiety is difficulty inferring the social meaning of contextual clues that other people use as signals to understand how it is appropriate to behave. Because people often have a direct subjective experience of this perceptual difference, the mechanism of context insensitivity fills in a gap in their phenomenology of social difference that a diagnosis like social anxiety disorder leaves empty. The other aforementioned models of autism (monotropism, “intense world,” atypical predictive processing, and others) also provide mechanistic descriptions that many who are diagnosed with autism, or who find the diagnosis compelling, find to map on to specific identifiable aspects of their subjective experiences.
Does that mean that all of these mechanistic theories are necessarily correct? No, it doesn’t. People can be wrong about the attributions they make about their subjective experiences. But they are a significant strength of what autism is currently delivering that, for the most part, other diagnoses simply aren’t keeping up with. I always say that the utility of a construct is based on two things: how well it reflects reality and how well it enables us to interact with the aspect of reality it was designed to reflect. The virality of autism is showing us that phenomenologically speaking, in those regards, it’s blowing other adjacent constructs out of the water. Instead of writing it off as having to do with name recognition or a descriptive label for “weirdness,” case closed, I think we would do well to heed the deeper message and seek to understand more about the aspects of the construct that make it so potent. To credibly advocate for a return to increased diagnostic granularity in the population of people now being diagnosed with autism, or who adopt a self-diagnosis because they find the construct of autism appealing, the diagnostic constructs proposed as alternatives are going to have to do a lot more mechanistic and phenomenological heavy lifting than they currently are.
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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 and, in many cases, very attractive young women, 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 very 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 for attractive socialites with a neurotic personality and a love of spa treatments.
It is also no coincidence to me that these are the same types of people who often like fortune telling and star signs. To my mind the effect of modern diagnosis often acts like the former, 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 neuroasthenic on otherhand "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.".
I think the real issue is that a lot of clinicians just aren't cool enough to see what is going on.