What we’ve said about Autism

“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”

“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”

“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”

“A is persistent deficits in social communication and social interaction across multiple contexts. And then it gives three different subcategories of that”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“We definitely see in more severe autistic conditions, aggressive outbursts, and that's usually due to poor emotional regulation, right? Often triggered by things like changes in routine, unexpected outcomes, or simply mood problems that are secondary to the autism”

“the concrete use of language in autism should actually do the opposite. In general, people who have autistic disorders and use language in a very concrete way tend to be particularly detailed about their use of language”

“people who tend to have very specific And constrained interests, people who struggle with social communication and understanding social cues, people who like to organize their understanding of the world into a very predictable system, people who are sensitive to certain types of stimuli, who like routines, who don't do well with change”

“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”

“one moment like that alone, again, only tells us about traits, right? It doesn't tell us anything about disorder, and it particularly does not allow us to come to much in terms of conclusions about why someone did what they did in terms of a criminal charge”

“I would not say that those things are outside the realm of normal variation. So I wouldn't attribute that to anything in particular”

“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”

“If you create an identity entirely around having this set of traits and having a disorder, you might create an entirely different life for yourself and the people around you”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“is that personality or is it simply that they lack conscious understanding or have a lot of difficulty understanding the emotions of others? Right. Is it inability or lack of interest? That's the dividing line. We want that dividing line between autism and personality disorders”

“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”

“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”

“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”

“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”

“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”

“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”

“while autism and general personality oddness is a mimic for true psychosis, we should also note that those conditions are risk factors for true psychosis as well”

“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”

“I think, again, we are touching upon our inability as a field to correctly capture the crossover genetic risk between psychotic disorders, bipolar disorders, OCD and autism. I would just do a careful eval on those”

“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”

“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”

“diagnoses are most valid and reliable when based on multiple sources of information, including clinicians, observations, caregiver history, and self-report”

“it's almost as if asking the question begets an interview that's guaranteed to get that diagnosis when you do the structured interviews that are for those specific diagnoses”

“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”

“If this single diagnosis accurately describes both these people, then that makes that diagnosis kind of useless, right, as a category. If you make your diagnostic category super broad, then it doesn't tell us anything at all”

“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”

“that is not for the treatment of quasi-psychotic symptoms, and it is not for general functional improvement so much as it is for the control of quote-unquote unwanted or disruptive behaviors. You should not Give those to high-functioning people who don't have severe disruptive behaviors”

“do not be afraid also to use mood stabilizers. We don't understand these categories as much as we think. And I think the reality is that there's probably a lot of genetic and pathophysiological crossover between the bipolar disorders and the schizophrenia and sometimes OCD, ADHD, autism”

“someone who seems to have neurodevelopmental but not adhd uh like autistic traits uh often you see dysregulation the sleep-wake cycle i'm going to give something not habit forming”

“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”