Welcome to the Psychofarm Podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality.
Good morning, Dr. Malthberg.
Good morning, Dr. Fu. How are we doing?
Oh, well, do you like Spider-Man?
Uh... I think I saw the first movie and I haven't really followed it since then. Why do you ask?
You don't have an encyclopedic knowledge of Spider-Man? All the issues, all the movies, the different actors?
No, really just that first movie. Probably had a Spider-Man action figure I played with for a little bit.
You disappoint me. I was hoping for a more systematic knowledge of Spider-Man so I could then assess how you like to think and organize your favorite subjects. That brings us, I think, to our topic today, which is autism spectrum disorders. You know, we've had some requests for autism as a topic of an episode. And initially I thought to myself, who am I to talk about autism? You know, do I really know anything about it?
I'm not a child psychiatrist. But then I kind of thought about it and I realized, just like the line from the first Tobey Maguire Spider-Man movie, perhaps I am something of an autism expert myself. And what do I mean by that? I'm not saying that I would say that in the court of law. I'm not saying that I've had any formal supervision or training in this, but my patient population is probably way more overrepresented I mean, what percent the patient panel do you think most psychiatrists would see autism spectrum disorder?
Incredibly tiny. It's a very, very small percentage out here. Yeah, I polled a lot of my outpatient, inpatient colleagues. I think I do see more than average. I think it has to be minimum 5-10% of the population that I'm seeing has autism with or without comorbidities. So I actually see quite a lot and I have been for many years. So I guess based on that, I might be able to say something about it.
And, you know, take what I say with a grain of salt, I suppose. That's what I'm saying before we get into this.
So, Dr. Fu, I have to admit something. We talked before, you mentioned your opener was going to have to do something with that, you know, I'm something of a scientist myself. I thought you were alluding to the fact that you actually have autistic traits. And you were saying, you know, I'm something of autism spectrum myself.
Well, that may have been your wish, Dr. Malzberg, may have been your wish or perhaps your projection, but I don't know if I'd agree with that assessment. I say that jokingly sometimes.
I wouldn't say you were or weren't. I'm just saying that that's, I thought you said that we're going to open with the meme of, you know, I'm something of that myself. And I didn't know you meant autistic expert.
Right. Well, I think that says something about your formulation of me, which may or may not be accurate. But I think at the end of this episode, we'll be able to say whether or not Dr. Malzberg's idea of me does or does not have accuracy. And I can't say because I'd be biased, of course, with looking at myself. OK, let's jump right in.
So let's just go right into the DSM criteria, DSM-5 TR, and then we'll add some color to it. Sounds good. Two major criteria, and I'll go into more specifics, but I think it's always helpful to kind of quickly summarize. I think of it as there's two major criteria. There's criteria A, which has to do with social communication and social interaction, and criteria B, which is restrictive repetitive patterns of behavior, interests, or activities.
Let me go a little bit slower. A is persistent deficits in social communication and social interaction across multiple contexts. And then it gives three different subcategories of that.
Yeah, which are non-exhaustive, by the way. It's simply listing examples and there can be more.
And one thing, not to add too much, We really see that this is a gigantic bucket of patients because it talks about the range and the range that it talks about for each symptom is so enormous as to be unhelpful, I think in some sense, but it's a huge range. So let me go through the three social communication things. First is deficits in social emotional reciprocity, ranging from abnormal social approach and The second one is deficits in nonverbal communicative behaviors used for social interaction.
To me, that's such an enormous range, but let me continue. The third social communication and social interaction thing is deficits in developing, maintaining, and understanding relationships ranging from difficulties adjusting behavior to suit particular contexts to difficulties in sharing imaginative play or making friends to a complete absence or interest in peers.
You know, that's a lot of jargon. It's important to have that jargon in the DSM, right? And it's important that we understand it. But I think we should summarize. How do we summarize this? The first arm that you need for a DSM-defined autism spectrum disorder That is about social back and forth in interactions. That is about how one communicates, both verbally and non-verbally. And it's about whether or not the relationships are there.
And I think there are good reasons why these are the criteria. There can be a lot of argument about this. But I think they're good criteria. It's important to note that having these issues does not mean that you have autism. This is only one arm of the ASD definition and there's a lot more to it. And like almost every other disorder in the DSM, there are multiple possible things that can explain the same deficits, right?
The differential diagnosis process is key in diagnosis. But let's go down to the second arm now. Awesome.
pharm. All right, back to the show. Criterion B, the second arm, is restricted repetitive patterns of behavior, interests, or activities, manifested by two of the followings. It lists four things. The first is stereotyped or repetitive motor movements, use of objects, or speech. Some examples, hand flapping, lining up toys, echolalia, when you repeat back something you hear. The second one is insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior.
Here we're thinking about extreme distress at small changes, difficulties with transitions, rigid thinking patterns, need to take the same route every day or eat the same food every day. The third is highly restricted fixated interests that are abnormal in intensity or focus. For example, strong attachments to unusual objects or excessively circumscribed interests. The fourth and last is hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment.
Right. And to summarize in more plain language, this is basically repetition and restriction of attention, almost a love or a drive to repetition or restriction of attention and activity, right? Manifesting in a lot of different ways. I think this one is a little less intuitive for a lot of people. It's easier to see a deficit in something that most people have, which is normal social communication and back and forth in relationships, versus something that you would really mostly see in a smaller subset of the human population, which is the B criterion, the second R.
Now, the key here, I think, is that this is a neurodevelopmental disorder. Both of these issues can happen because of other conditions as listed and described in the DSM. But for it to be autism spectrum disorder, they must be present in the early developmental period. And it's part of the neurodevelopment. That's the cause, okay? The DSM claims to be ideology neutral, but let's be honest. We know that it's irrational to be totally ideology neutral, especially when we're talking about neurodevelopmental disorders.
Ian, when I'm reading the DSM, even though the criteria gives you the bare bones of the criteria, I also think it's important to read the whole chapter, the whole The whole thing to understand what it is that they're talking about. And when you read the rest, I think in the development section, it mentions that this is typically recognized within the second year of life. And if someone has a regression after two years, it's not saying that it's not autism spectrum disorder, but you need to have a closer eye to looking at other things.
So if you just read this criteria, which there's a few more, you might say like, oh, some of those things describe me, but... As you mentioned, the neurodevelopmental piece is really important.
Yeah, there are some disturbing trends that I've seen, at least in my area, about people, even PhD psychologists, not really applying DSM rules in a way that makes sense rationally. I have seen numerous cases now of Autism Spectrum Disorder being diagnosed in adults after the onset of schizophrenia. I'm not kidding. I am not kidding. The first testing and evaluation for autism is taking place after the clear onset of schizophrenia.
And then they say this person also has Autism Spectrum Disorder. Now there could be a Charity-based or kindness-based reason they're doing that because it qualifies them for certain entitlements and services. And in some cases, I can agree because there is enough evidence of autism spectrum disorder prior to the onset of the psychotic disorder, but not in every case. It's a fuzzy area, right? Autism spectrum disorder is supposed to have disorder.
That's the problem with the neurodevelopmental disorders. They are actually present to some degree in the general population. And there's no bright line about when that becomes a disorder or not, right? We don't have a objective way to measure that. It's totally clinical judgment call. And I think because of that, that's why today we are seeing a lot of people self-diagnosing with autism spectrum disorder and ADHD and also being in some cases or even many cases irresponsibly diagnosed with that by clinicians because there is no bright line.
It's a big blurry boundary. And again, you need all these things together. They need to be neurodevelopmental and it needs to actually be a disorder. Otherwise, we should properly be calling it autistic traits or ADHD traits. And in the cases I'm talking about, I do suspect a lot of the time those people did have what looked like autistic traits, but it could have been early onset psychosis, prodromal, right?
It really depends. We don't have a perfect crystal ball to look into the past, but things get very complicated is my point.
There's social reasons for what you're describing. The autism rights movement, there's a big push for a neurodiversity framework, which pushes autistic traits as healthy variation of the human condition rather than a disease and a disorder. And in some sense, rather than de-pathologizing autism, we've pathologized normal traits. We'll get there. Let's finish with the rest of the criteria. I mentioned A and B. I didn't explicitly say criteria C is it's got to be present in the early developmental period, but it's possible to mask and it might not show until later.
D is symptoms must cause clinically significant impairment in social, occupational, or other important areas. And then E is just not better explained by intellectual disability or some global developmental delay.
I do have a problem with the DSM-5 version of this diagnosis and your criterion E. I don't think they are aggressive enough about the not better acceptable aspect. Yeah, the differential diagnosis. And I think it's probably because autism researchers and the framers of the definition of this diagnosis probably mostly work with children. And let's face it. In young children, where in a perfect world, most of the autism diagnosis and assessment should be happening between the ages of like three and eight, let's say, you would not really see any evidence of bipolar disorders, psychotic disorders, personality disorders in any clear way.
So then it becomes unnecessary to consider those as exclusions or other ways to explain the criterion A and B phenomena.
Yeah, and we see this all the time. Patients who do genuinely have some of the deficits in the things that we mentioned, but they're not best understood by autism. I see a lot of patients with personality disorders who feel the neurodevelopmental label fits them better. For a clinician to be able to easily tell that it's not a neurodevelopmental issue, there's personality pathology kind of going on.
Yeah, I think that's a big issue. I feel that there is a large mutual blind spot between both clinicians and researchers who are interested in and recognize personality disorders on one hand and neurodevelopmental disorders like autism spectrum on the other hand. There's not enough coordination between these groups in research or clinical settings. And I believe that as a result, what we see is that Patients can choose a sort of preferred explanation for their condition by going to the type of doctor who recognizes or treats one version of it.
And I know there's a strong argument that a lot of what looks like personality disorder can be entirely explained by neurodevelopmental issues like autism. At the same time, I have to Comment that if you see a lot of people with autism spectrum disorders, there's a very clear difference between people who only have autism and people who have both traits of autism and of some kind of a personality problem, whether that's borderline or narcissistic or even antisocial.
There's no rule saying that you can't have both. Is it probably more rare to have both? I'm not actually sure that may be the case. There could be some shared vulnerability. I think that if you grow up with neurodevelopmental problems, you're more likely to have an adverse childhood environment and have traumas and develop these kinds of interpersonal problems. Yet it's really obvious to me there are plenty, plenty, plenty of people with neuro atypicality Neurodevelopmental disorders with basically no personality problems at all.
Ian, I worry, similar to a lot of other areas in psychiatry, there's a false dichotomy that either you think it's overdiagnosed and all these people think they have autism when they don't, or you think it's underdiagnosed and there's people suffering who have a diagnosis that's underdiagnosed. And the much more obvious route is that both are true. I see all the time patients who were diagnosed late, who had it missed, who suffered as a result of the fact that it wasn't caught and it wasn't treated and it wasn't taken serious.
And I also see the other side of patients coming in saying, I think I have autism, me providing the reasons why I don't quite see it and them feeling invalidated, even though It's not the best descriptor as to what's there going on. But both are true. It's not either or.
Yeah. There's one more thing about the DSM... Disorder definition that I really want to point out. It's the catatonia specifier. I don't know if most people know that they specifically included a catatonia specifier with catatonic features for autism spectrum disorder. I think most people think of the psychotic disorders when it comes to catatonia, even though they're more frequent in bipolar disorder. Sorry, catatonia is more frequently found in bipolar disorder and mood disorder.
And I don't know if people realize that you can have catatonia as a outcome of a primary diagnosis of autism spectrum disorder, even without apparent psychosis. So that's an important thing to consider when you see that very rare presentation, but it is possible.
Yeah, I should probably very quickly go through all the specifiers because they are helpful. You can specify based on impairment. So requiring very substantial report, substantial support, or just support. You can specify with or without accompanying intellectual impairment, with or without language impairment. You can specify associated with a known genetic or medical condition or environmental factor. And you can also specify associated with a neurodevelopmental, mental or behavioral problem.
Now, what's interesting about that little specifier is the... Sometimes it sounds like the specifier explains why that person has autism. That's not necessarily the case. You can have autism with Crohn's disease. Now, the Crohn's disease is not the reason why that person has autism, but it is a part of their autism as a result of the complexities between an autistic individual having Crohn's disease and all the stresses that go with it.
And then the last specifier, as you mentioned, is with catatonia.
Yeah. Speaking of the levels of support, this is what people mean when we talk about levels of autism. It's kind of funny. I didn't really notice people using levels of autism, saying level one, two, and three until maybe in the last few years. Yeah, same. It seems to have picked up now that we have had the DSM-5 out for a while. We should probably mention it. Level one is requiring support, okay?
So that should tell you something, I think. The idea is that if you have a DSM-defined autism spectrum disorder, you need some kind of support. That's probably the bar that they are drawing there for whether or not it's disorder. Because Asperger's has disappeared, right? They don't believe in Asperger's anymore. DSM definition of the spectrum, autism spectrum disorder, and it's either that or you don't really have the illness, you just have traits.
There's level two, which is requiring substantial support. And level three is, of course, requiring very substantial support. And I think a lot of people don't realize that anywhere from maybe half to even the majority of people Yeah, and I think...
The fact, I always use the word bucket. And when I say bucket, what I'm saying is that these diagnoses aren't saying that it's not identifying what's going on underneath. So something like autism is a gigantic bucket capturing patients with totally different pathologies, even if there's some convergence with regards to the social communication and repetitive behaviors. And a lot of problems arise socially as a result of the fact that this bucket so huge because you have, as we said, patients who used to be diagnosed with Asperger's using the same label as caregivers of patients who are completely unfunctional.
We saw the autism movement was trying to spread awareness and understanding by saying that these are normal traits, which is a good thing. But then you have caregivers of saying you're really minimizing the suffering of the child that I'm taking care of that can't speak, that needs full care. And the complications is the fact that we don't have different words for these patients. And we're using the same label for these people who have very little overlap.
Yeah, it's a big problem, and it's nothing that any one person or committee can solve, unfortunately. There are so many social, ethical, humanistic, financial, educational concerns intersecting on this one issue that I don't think we're going to make much headway. I think all we can do is really, as a group of humanity, better understand exactly what we're talking about when we're doing this thing. And to illustrate your point, I'll say, you know, The problem with modern ASD definition is that under those rules, in some sense, both my friend who is a top tier programmer at fang companies and makes like half a million dollars a year, but also will forget things and needs prompting for appointments.
Has the same diagnosis as the former patient I had who basically had two major activities besides ADLs spinning around and hitting people. That's all he did, right? So... Those are both people with autism spectrum disorder. That's how big that spectrum is. And you should know then that it's not exactly a helpful category and that you need to explain much more about people than simply identifying whether or not there's an autistic traits or disorder.
Yeah, it makes me think, what makes it hard to learn about these things is, you know, my brain to understand it wants to see like, oh, what's going on underneath? So when we say autism, what's the cause of autism? What's the reason for autism? What's the, if there's a problem in the person's brain, what's wrong in their brain? And those two people you said, there's almost no, like obviously whatever the problem is, that doesn't have a shared common mechanism.
But I still want to learn it. Well, I don't know about that.
I don't know about that. I think there could be. There could be. But the fact that there's so much distance means that we need more fidelity and more accuracy in what we're calling disorder or not. And we need to, as probably we've emphasized too much at this point, introduce and consider the concept of traits rather than disorder. Now, before we get to theories around the core pathology and the cause and whether it even is pathology in some cases, let's revisit some other things from the DSM that I think are important to know if we're really going to have a good general clinician's grasp of ASD.
First, what we just talked about in terms of diagnostic criteria is, again, a non-exhaustive description of this syndrome. It's simply sort of Really clear markers that help you make or confirm a diagnosis. But we should know what are the other common symptoms that you see in ASD because they are of clinical interest and cause impairments. Executive dysfunction, I think, is a big one. In fact, back in the day, they wouldn't even diagnose ADHD if you could justify a diagnosis of autism spectrum disorder because executive dysfunction was considered a part of autism spectrum disorder.
That is still something that is under some debate, even if the DSM has decided that you should simply diagnose both. And to that end, by the way, I would say that you should not assume that stimulants will always work for the executive dysfunction We have to also point out that patients can have incredibly high IQs.
The defining thing that you typically see in those patients is an uneven profile of abilities. They'll be incredibly intelligent in one area. And then in particular areas, there's a mismatch.
We also commonly see problems with theory of mind or mentalization. And the source of this, we probably should consider as separate and different than the ones that we see in the personality disorders.
I think theory of mind, what you're saying there is seeing the world from another person's perspective.
Yes. Yes. The ability to understand with reasonable accuracy what another person is thinking, feeling, or being motivated to do or think and feel. There's some tendency, especially in the classical research in autism, for focusing on details rather than the broader picture. Missing the forest for the trees, for example. We'll talk more about that later. You can You can also see things like physical symptoms. There's neurological motor symptoms, clumsiness.
You can see GI problems. You can see sleep-wake cycle problems, circadian rhythm problems. There's also some tendency for self-injury, especially in the context of distress. And there is naturally emotional dysregulation and irritability.
And these things are challenging because you mentioned the theory of mind deficits. That's also a core deficit in personality disorders. And the way that it manifests is very differently. In autism, there's one test that it's... There's two kids on the end of a box and one kid's touching the box and the other kid's looking at the box. And the test question is which person can see what's inside the box?
And autistic individuals tend to not perform as well as regular controls. The theory of mind than what the personality disorders struggle with. And what makes this confusing is mentalization-based therapy is now emerging as one of the most evidence-based therapies for personality disorders. It's overlapping but slightly different from the theory of mind.
Yeah, it gets confusing so we won't get too much into the details. I'd like to talk, before we move to theories, more just about diagnostic consideration. And I think the biggest mimics that we can see for especially adult patients today are the schizophrenias and the personality disorders. And the DSM does go into this and give you a little wisdom. So let's boil it down. When you consider schizophrenia, especially of childhood onset, you will have some period of normal or near normal development before the onset of the prodrome.
And in the prodromal psychotic state, you can definitely see atypical interests, beliefs, social impairment, and that can look like the social deficits and fixated interests seen in autism spectrum. At the same time, when you evaluate someone with autism spectrum disorder, their way of answering questions may seem odd or unusual or even look like thought disorganization because they may be overly concrete, literal, or misinterpret social cues or language.
For example, in the DSM, they say, when you ask, do you hear voices when no one is there? Someone with autism may say yes, but what they mean is that they hear them on the radio. Autism and schizophrenia can also co-occur, and actually there's probably a shared gene risk pool here, so it gets very, very confusing, and I've treated numerous individuals with both, and it can get so confusing about which one you're dealing with at a particular time.
Longitudinal assessment and looking at how they actually respond on these core markers to medication treatments can really show you what's what. And then for personality, the DSM actually specifically notes that behaviors associated with autism spectrum disorder can be perceived as symptoms of narcissistic, schizotypal, or schizoid personality. And that schizoid, sorry, schizotypal personality I'm going to say that's absolutely true, and the opposite is true too. Symptoms of narcissistic, borderline, schizotypal, schizoid, and even antisocial personality can be misinterpreted as or seem like symptoms of autism spectrum disorder.
More difficult area to determine than I think people give it credit for. What they do say is this, and I agree with this, the early developmental course of autism spectrum disorders with lack of imaginative play, restrictive and repetitive behavior, and sensory sensitivities is most helpful in differentiating it from personality disorders. But here's the problem. When we're doing retrospective, memory is incredibly fallible. People make up memories without knowing it all the time.
And if you're asking a patient or family to recall the past, we can't really be sure what happened back there. So it's always a blurry area diagnostically, if you ask me.
Yeah, and it says in the criteria, diagnoses are most valid and reliable when based on multiple sources of information, including clinicians, observations, caregiver history, and self-report. And I think that's helpful to know in that if you walk into a clinician's office, answer five questions, and they say you definitely have autism, they're not giving credence to the fact that the diagnosis is very rarely made in a 45-minute conversation without a full understanding.
If you've gone 30 years without it being identified, chances are a clinician doesn't have a magical superpower to know what other people aren't seeing in those 45 minutes and just by hearing reports. Now, as you said earlier, oftentimes patients with a lot of psychopathology have families with a lot of psychopathology and self-report, it's not their fault that they can't provide an accurate report. I've called patients of schizophrenic Oh boy.
Okay.
Well, I don't know. I think it's offensive to people of a certain ideology. But when you look at stories like that, I think popular article in the magazine or newspaper in the last 10 years about a woman who finally had her autism diagnosed. I think when you read something like that, if someone can go in a modern Western society for 30 years without an autism spectrum diagnosis, and then they begin to have new difficulties, I think you're doing a disservice if you don't consider all the other things that could be interacting with a baseline of autistic traits to produce now a global psychological or psychiatric disorder.
I think in those cases with apparent late onset worsening, what you are seeing is not autism spectrum disorder. It may be a very strong baseline of autistic traits, and it is always interacting with something else, whether that's substance use, social stressors, the development and worsening of the personality disorder, a depressive anxiety or bipolar disorder, or even OCD. There's always, in my opinion, something interacting with that baseline of autistic traits to produce the new problems.
Even if there were difficulties, everybody has some level of difficulties in life. It is not necessarily a psychiatric disorder.
I agree, but I'm also terrified of agreeing. So let's move on.
Okay. For the rest of the episode, I think I'd just like to talk about the theories behind the psychopathology or development of autism. And for those that come to this channel for direct clinical care recommendations, I know you might be bored. We will cover that in another episode. I hope to anyway. But this is important. You have to understand fundamentally what you're kind of looking at and working with in order to identify it and then treat it.
The features of autism are diverse, kind of as we said. There's tons of different behavioral features, and there have been tons of theories in the past to help describe what is going on with autism. Now, whenever, it's funny, because I think sometimes people who don't consume this kind of research think like, which theory's right? Which one's the one that's the most right? Which one is actually like, oh, that theory's old, it's not right.
It's actually not helpful to read the literature that way. It's helpful to view it as like each theory is a different, they're trying to get more and more aspects of it, but sometimes an older theory will better capture a patient and sometimes one of the newer theories will better capture a patient. So something like the extreme male brain is something that I've heard people say like, oh, that theory was disproven.
Well, it's still helpful. And there's still a lot of juice you can squeeze from it.
And also, I don't think it's disproven. And we can't get into that. But we can argue about the literature and the findings. I don't think it's disproven either.
Yeah. So a lot of the theories build on each other. They add more elements. Sometimes they're more inclusive. But that doesn't mean that the old ones are wrong and we throw them out.
Yeah, I think the best way to understand theories around any mental state or autism spectrum disorder is that it is basically impossible to explain anything as complicated as the brain's functioning with one theory or even a A few sets of theories. Each theory is some inaccurate and imperfect way of using human language to capture this complex system in a little snapshot. So yeah, I think having some familiarity with all the theories, regardless of modern opinions on them that may change in five years or not, you'll understand the general syndrome a lot better.
Let's start with a social motivation hypothesis. This one is basically the idea. It's sort of a psychological idea that children or people with autism, they find social stimuli inputs less rewarding. We see that they attend less. They pay less attention to faces and gaze. They have reduced social learning opportunities because of that then. That's the theory. And then that itself blunts their social skill development. Okay, so it's kind of like a drive theory in a way.
It's that, oh, people of autism have less fundamental human drive to pay attention to social stuff, and therefore they don't develop it. I mean, is that true? Well, you can argue about whether or not it's true. But I think that it does point to something important today in that a deficit can worsen its own deficit, right? A lot of people are anti-masking today, but the fact is masking, regardless of its personal toll, will continue.
Confer upon the subject some level of adaptability and higher function in broader neurotypical social settings. So there's utility to masking, okay? And if that process of learning to mask isn't an automatic one for a person, you basically don't become socialized and then the deficits become worse.
Dr. Fu doesn't think autism, lady at 40 is autistic and is pathologizing the stress that comes with masking. Oh boy. You're killing me.
It's not popular, but you know, I believe we're in 2026. I'm removing the nuance. I've heard that Woke is Dead. Maybe we should edit that out. But anyway. Okay. So what is the problem with social motivation hypothesis? Okay. The social motivation hypothesis. Well, it assumes that all social reactivity, everyone's capacity to do social things is simply a matter of learning. And I don't believe in that personally.
I do think it's something more fundamental, something within the neurodevelopmental, the biology of the brain functioning.
And it doesn't capture the Major second criteria, the unusually narrow interests and repetitive behavior. Obviously, you can stretch it if you want to and that develops, but that underlying thing really only captures criterion A and not criterion B.
Yeah. The next theory is something we mentioned previously. It's the focus on details versus a broader context. And there was some research evidence to show that people with autism are much more likely to focus on details rather than a broader context, missing the forest for the trees. With the benefit, of course, of being able to notice the trees in explicit and very high detail. This was used to also explain some of the executive dysfunction that you might see in autism, saying that it's the hyper-focus on details that then also produces the apparent executive dysfunction.
This is called the weak central coherence theory. Right, right. That's the official term. There was also then another hypothesis about deficits in theory of mind. Deficits in theory of mind. We already talked about that a little bit. The mind blindness theory. Yes, mind blindness theory, I think the official term. But the one I like the most, and again, not exactly a politically correct hypothesis to like the most for autism, but I think the most compelling one is the systematizing versus empathizing versus autistic traits breakdown of the general population.
Yeah, and to me, this one captures, is one of the only ones that Captures both the criterion, A and B, and that you can deduce those problems just from the theory itself. So why don't you tell us a little bit about what this theory is?
Essentially, Baron Cohen, and yes, this is a classic autism researcher who is, I believe, the cousin of Sacha Baron Cohen, the comedian who plays Bora and Ali G. Oh, I didn't know they were related. Oh, you didn't know that? No. It's one of my favorite little trivias about autism theory and research. Yeah, they're related. So the idea is that the general population just has distribution along certain lines about capacity to...
Empathize or Systematize. You can measure people who are even split for their systematizing tendency and their empathizing tendency. Some people are much more systematizing and much less empathizing. Some people are much less systematizing and some people are low on both. It's a matter of the differences. And what has been found, subject to some dispute, depending on the type of research you're reading.
I'll let you finish, but I think we should define systematizing before you go into what you're about to say. That's a very good point. Go ahead. So systemizing. It's systemizing. It's not systematizing. Whatever. Systemizing. Systematizing. It's systematizing, isn't it? I think it's systemizing. Oh, God. Is this going to be a tiny thing again? There's another one that I did. Carbamazepine.
It's systemizing.
This is a T&E thing again. Oh, man. Systematizing. Well, boy is my face red. Systemizing. Systemizing. Leave it in. Don't edit it.
Show the people my failure.
So systemizing is the drive to analyze or construct systems. So- What defines a system is that it follows rules. So when we systemize, we're trying to identify the rules that govern the system so that we can predict how that system will behave. So you systemize by picking up on the regularities and the rules.
Empathizing, on the other hand, it's the capacity differently distributed across the general population to have a drive towards feeling and understanding what somebody else is feeling and understanding within themselves, their motivations and their affects. There's a very useful split we can make in empathizing, one being cognitive empathy and And one being affective empathy. We might be able to intellectually understand what someone else is feeling or wanting.
That's cognitive empathy. That's learnable. You see this, for example, with psychopaths, not the same condition as autism, okay, where they can have very good cognitive empathy if they're very intelligent, but they have no affective empathy. And then affective empathy is really having that mirroring or congruent internal emotional feeling in response to seeing someone else going through some kind of emotional state. Okay, so that's empathizing. Some people are stronger on empathizing.
Some people are stronger on systematizing, which I think is a real word, but systemizing. And some people are, there's just different distributions for these.
So, yeah, talk to us about how these differences show up and what research has shown.
Yeah, so... Again, there's other research, but I'm just going to say what's interesting. In some research, you will see that if you take a random male-female pair and you compare them, the female has a higher empathizing score two-thirds of the time and the male has a higher systemizing score two-thirds of the time. Also, you will see in the clinically identifiable autism spectrum disorder population, Those patients will have more systemizing than even the general population male, whether or not they are male or female themselves.
What else should we know? Generally speaking, systematizing can be seen with high capacity for it without autism or autism spectrum traits. And for that population, you probably see that overrepresented in higher education, people in graduate school and especially people in the sciences. And where does most of the practical dysfunction come from? In autism spectrum disorders, it's probably from low empathizing. Now, there's an important caveat here. Since the introduction of the systemizing versus empathizing framework, they have done further research to show that there could be a double empathy problem.
And I will just say, before I say more on this, life is very cruel. And there's not much we can change about that, in my opinion. I'm very cynical. But I think that the research does reasonably show that part of the dysfunction that you see for people with autism is that not only do they have struggles in empathizing, detecting, doing theory of mind for neurotypical people, neurotypical people also fail to empathize for those with autism.
Okay? It's a double empathy failure. And I remember I was reading this review article on whether or not we should differentiate ADHD from autism. And there was just one piece of research that I thought was just so tragic. They did a research on kids and they showed kids, I think it was video There's an eclipse of other kids and children would conclude they did not want to socialize with someone with autism only after three seconds of watching them act.
Oh, that's so sad. That we don't like certain things or we don't like things are not like us. And unfortunately, autism spectrum is something that is relatively rare within the general population. It's a minority group. And so I think there's natural discrimination. And so there is truth to that double empathy failure.
Yeah, and I'm glad. I actually think the culture is moving in the right direction with developing more of that empathy. I remember growing up as a kid, there were autistic kids in our class and the experiences they would have were awful with regards to socializing. And one of my friends is a teacher and he told a story that there was an autistic kid in his class and he had an emotional outburst.
And he said he was blown away at how the other kids responded. And they all were like, He's having an episode. Let's give him a break. Let's give him some time. It was a story that made me feel so good. When we were kids, that kid would get crushed. He would get bullied. He would get made fun of. And kids these days actually have so much more understanding.
It's clear that there's been a shift in terms of how we understand those things.
That is a nice story to hear. It gives me a little bit more hope on top of my general high cynicism. I think it can result, these social changes can result in interesting things. I briefly looked into this. I think it's kind of funny. There have been attempts in some workplaces to institute management styles, rule sets, and also environments that are more conducive to people with autistic traits.
However, it should not surprise you to learn that two major companies that have done this include Microsoft and Ernest & Young. Okay, accounting and software IT. Should not surprise you that systemizing is probably overrepresented in the talent pool for these companies. Is that happening? Will that reasonably happen in retail spaces or sales departments? I highly doubt it. Quick note. Before I looked into this stuff more, I was curious about whether neurodevelopment could explain what we today consider borderline conditions, BPD, even antisocial or narcissistic.
What if it's a failure of empathy? Well, not a well-supported hypothesis. They've looked at empathizing. Systems in people diagnosable with borderline personality disorder. And they actually had the same level of empathizing as the general population, unlike the autism spectrum group. Now, you could say That's a problem of self-insight because a lot of the empathizing measure that they do for research is self-report based or other report based.
And maybe people of BPD are not able to understand that they have deficits in empathizing. But I think that's still compelling evidence. And then it's interesting to look at psychopaths, too. If you look at psychopaths, they actually have the opposite profile to autism spectrum disorder. They have really good cognitive empathy. They're strong in cognitive empathy, unlike autism spectrum disorder. They have bad affective empathy. And I think there's actually research to show that autistic individuals actually have some internal affective reaction to other people.
It's a matter of not being able to To express or interact in the way that the general population does. And finally, the genetic studies, supposedly, I haven't looked into this closely, do not show shared risk genes between the personality disorders and autism. So I think we need to maintain these as separate conditions.
Yeah, I remember, I think it was in Cleckley's book, I think he hypothesizes some neurological deficit that makes that disconnect. And I remember being like, oh, whoa, that's interesting. I never thought of that as a neurological deficit. Now, one thing that's interesting in the empathizing systemizing paper we were talking about, they talk about the different profile. If you think of just the empathy dimension and the systemizing dimension, there's people who have really high empathizing and low systemizing.
They have people who are equal. There's people who are high in one and medium and other in a mismatch. Autism here is defined as systemizing is severely swamping their empathizing. When we think of the opposite profile, the empathizing being very high and the systemizing being very low, we do see... People come, you know, I'm an empath, which probably I might get in trouble here. You're going to see a lot of borderline personality disorder in that category.
I don't know whether we can make that claim. I think we need more research, but I think you're right. I need to get in trouble. You've got enough trouble today. No, no, no. I don't think that's a troublesome thing because I think we actually have a reason to believe that people with borderline personality disorder are actually better at certain types of empathizing. I think they're better at empathizing negative reactions.
They're better at detecting interpersonal threat. Okay. And disapproval. But because they're so good at that, that also it ruins their ability to detect accurately other mind states. But that's for a different episode. Yeah. Anyway, I think we're reaching time. The conclusion, at least of part one for me, is that me personally, I do favor the systemizing, empathizing framework. I think that the autism spectrum and the autism disorder Disorder is where you have high systematizing, systemizing, low empathy, and probably a collection of other associated issues and symptoms that come together with the neurodevelopmental Downstream to genetics and neurobiology, repetition tendency, emotional regulation problems, some learning problems.
When you get all those things together and they're at enough of a level, that's when you get autism spectrum disorder instead of traits. And yes, I still believe that you can have traits without disorder. We all have different struggles in life. We don't need to identify everything as a diagnosis. Now, I wonder how people like this episode. There may not be enough treatment recommendations. We do plan for treatment recommendations and also recommendations around diagnosis in a future episode.
I'd like to hear from people about whether they felt we didn't cover anything or if there are any All right. See you later. All right. Until next time.