The Broader Autism Pphenotype
Journal of eISSN: 2373-6445JPCPY
Psychology & Clinical Psychiatry
Volume 9 Issue 3
The broader autism phenotype: expanding the clinical gestalt of autism and broadening DSM V criteria of autism spectrum disorder
Department of Psychiatry, Trinity College Dublin, Ireland
Received: January 15, 2018 | Published: June 15, 2018
Correspondence: Michael Fitzgerald, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland, Tel 00353-868597547, Email
Citation: Fitzgerald M. The broader autism phenotype: expanding the clinical gestalt of autism and broadening DSM V criteria of autism spectrum disorder. J Psychol Clin Psychiatry. 2018;9(3):316‒324. DOI: 10.15406/jpcpy.2018.09.00542
The clinical gestalts of autism are very broad and much more heterogeneous than professionals realise. The diagnostic and statistical manual of the American Psychiatric Association DSM V,1 gives a more narrow and condensed description of what autism is in the twentieth century. DSM1 focuses on problems with socioemotional reciprocity, non-verbal communication and difficult interpersonal relationships, restricted, repetitive patterns of behaviour, early onset and functional impairment. First, it’s necessary to flesh out the autism spectrum disorder gestalts as it presents to experienced clinical practitioners. It is the opposite of the, “tick box”, approach to diagnosis, so common today. It focuses on the phenomena, the clinical gestalt as they would have been focused on in the late nineteenth and early twentieth century, an approach that has faded into the background in the late twentieth and early twenty first century.2 It is critical at this point of the twenty first century that we re-engage with phenomenology and with the clinical gestalt of psychiatric conditions neurodevelopment disorders, which show a great deal of overlap with much mixed phenomenology.3
Broader autism phenotype: diagnosis
There has been very considerable evolution of the concept of autism since the Kanner 1943 paper. The move has been from a very narrow concept of autism with Kanner, to a much broader concept of autism today, which was foreshadowed by Hans Asperger in 1938 and 1944. This paper will describe the characteristics of the broader autism phenotype as the author has observed them over forty years of clinical experience having diagnosed over four thousand persons with autism. Andreason,2 has warned us of the negative effect of the declining interest in phenomenology. Indeed, “the death of phenomenology”. Which is what she called her paper? In terms of psychopathology, what was thought about in the nineteenth century and early twentieth century was the concept of clinical gestalts. Unfortunately, later in the twentieth century we had the rise of the, “menu”, type criteria and, “tick box”, psychiatry and psychology, that we have today. Nevertheless, the most experienced clinicians retain and develop the concept of the clinical gestalt today over the course of very long careers. This is the, “gold standard”, of diagnosis even today. Nevertheless, outside of these very experienced practitioners there is generally a reliance on, “tick box”, style of diagnosis. What we have in psychiatry are broad spectrums of psychopathology for example, autism rather than narrow categories for example, Kanner’s autism of 1943. Unfortunately, many clinicians are still very attracted to this narrow categorical approach to diagnosis when it has long since outlived its usefulness and indeed never gave a proper characterisation of the clinical gestalt of autism, in the general population or most other psychiatric conditions.3
As Cooke,4 put it, the clinical gestalt is a pattern of, “recognition”, which is a, “heuristic approach to decision-making”, and is a, “top-down”, activity. It is hardly surprising then that this clinical gestalt, “gold standard diagnosis”, is made by a very experienced clinician. The National Institute for Clinical Excellence,5 warns about this, “tick box”, approach and against the reliance on any autism instruments as primary diagnosis for autism. It sees these instruments correctly as adjuncts to autism diagnosis. Unfortunately, many clinicians, particularly inexperienced clinicians use these instruments as primary diagnosis of autism in clinical practice.6 These instruments have legitimacy in research where you want populations being studied to fit agreed criteria which are really points on the autism spectrum. Nevertheless, these points are legitimate when researchers want to communicate with other researches throughout the world. Unfortunately, this is entirely different to the situation in clinical practice, where the clinician wants to give their patient the best diagnosis which will lead to the best treatment for their condition. There is a question whether this should be a disconnect between research and clinical practice where the goals are very different.
Fitzgerald,3 pointed out that, “the concept of autism spectrum disorder is now almost universally accepted”. This paper outlines the broader autism phenotype. Unfortunately, it is widely believed that there is one, “gold standard”, instrument for the diagnosis of autism and this leads to many children on the spectrum being excluded from autism and from the autistic diagnosis, with great distress to children themselves, their families and the schools they attend. These instruments exclude them from autism services and unfortunately this happens in many parts of the world. The great array of autism instruments can be useful for information gathering, particularly for new mental health professionals in the field. They do not give you a, DSM diagnosis as outlined by the National Institute for Clinical Excellence Guidelines. One of the instruments which are widely used in clinical practice, which is quite appropriate for use in research is the ADI-R.7 This has been widely criticised, for example, by the most experienced and distinguished professionals. An example is Professor Dorothy Bishop, Professor of Developmental Neuropsychology, and University of Cambridge. Professor Dorothy Bishop,8 states that, “the main problem with the, “ADI-R is not just the financial cost, (although that is certainly prohibitive for many), but also the cost in time; time for training, time for administration and time for scoring and consensus coding”, and, “if it could be shown that there were real benefits in accuracy of diagnosis from adopting this lengthy procedure, then I would be happy to say: “okay, this is the best way forward and we just have to find a way to do it”, but the originators of the instrument have never demonstrated that you actually need such a long process – it is really more an article of faith with them”, and that, “part of the problem is that the criteria for autism keep changing, and cut-offs are entirely arbitrary. I personally think that we’d be better off with a dimensional, rather than a categorical, conceptualisation of autism – that is, one with a measure that gave a quantitative index of level of Autism symptoms on different dimensions”,. Professor Bishop8 points out that there are, “plenty of children who come out as meeting criteria on one instrument only, and there seems no sensible guidelines as to how you then proceed, other than to seek expert clinical opinion”. The bottom line, as she told Adam Feinstein8 was that those devising the diagnostic instruments for autism, “should be doing studies to see what is the minimum set of items you have to get reasonable diagnostic accuracy”. I doubt that we need a three-hour interview for each case. The International Meeting for Autism Research was held in London in May 2008,9 “where many of the most experienced and distinguished autism researchers in the world lambasted the tool for missing many cases of autism”. This creates a public health concern, the missing of these persons with autism. This is especially so in countries that put excessive emphasis on the inappropriate clinical use of the ADI-R, (Lord & Rutter 1994) for the diagnosis and particularly where the prevalence of autism, as we know is much higher than in the past, the Centres for Diseases Control,9 put the prevalence of autism at 1 in 68, in school-age children. From a clinical perspective, the most serious problem facing autism, is missing the diagnosis in many situations. Lorna Wing,10 used the concept of autism spectrum disorder or the broader autism phenotype which is accepted by clinicians in most parts of the world today and forms the basis of autism and DSM V, and also in the proposed criteria for ICD X to be published by the WHO in the future. This paper will expand the clinical gestalt out of DSM V1 while using DSM V as core features. It will expand the gestalt and looking at a much broader gestalt, will allow clinicians to make a much more sophisticated nuanced and broadly-based diagnosis for the benefit of their patients. Many of these features, which won’t be described in the core DSM V criteria will be, “red flags”, for autism for the experienced clinician. It is critical that these are made more widely available. Many of these features could benefit from formal empirical research at a later period so as to give a more comprehensive understanding of the autism gestalt. It is acknowledged now that autism is one of the neurodevelopment disorders and that there is much overlaps between all these neurodevelopment disorders.3 These neurodevelopment disorders will include autism, schizophrenia, bipolar disorder, intellectual disability and ADHD. The core autism gestalt will also have overlaps with other neurodevelopment disorders.11 There are overlaps between them to a greater to lesser extent. This is basically our new understanding of developmental psychopathology.12 Autism is possibly one of the most complex spectrums in terms of variability that one can find in psychology and psychiatry. It is both a spectrum and also a continuum. All the clinical features present in a variety of spectrums and differences with endless variability but also on a continuum of severity. There is no, “tick box” instrument or questionnaire that can cover this variability. Indeed, all the instruments tend to simplify and reduce autism to a very narrow, unreal clinical diagnosis, very different from autism in the general population.3,13
A new expanded gestalt of the autism spectrum disorder
In relation to autism spectrum disorder DSM V,1 problems with social and emotional reciprocity are particularly highlighted. In expanding features of this central construct we observe; clinging to one parent and when a stranger enters the room this clinging to one parent intensifies; when the child with autism is asked a question, they will run behind and hide behind a parent; they will commonly not answer a question or answer all questions with the phrase, “I don’t know”; they will most often, give minimal information to questions; and will answer, yes and no, when asked a question like, are they happy?. When asked if they are a good mixer, they will describe themselves as both a loner and a good mixer; they have great difficulty coming down on one or other side and generally don’t know.
At eighteen months, they will tend not to have proto-imperative pointing, proto-declarative pointing or pretend play.14 They are often highly sensitive to criticism and will collapse into tears with temper tantrums and hitting and kicking when a parent or anybody else mildly criticises them or indeed, appropriately supervises them. They can show mild, moderate or severe aggression to peers, biting and kicking in the preschool or at home, is extremely common and certainly a, “red flag”, for autism. Interpersonal aggression is very common, even before preschool and biting and kicking will be very common and should always be enquired about. They will often show the most severe tantrums or what mother and father call, “meltdowns”, that can go on for an hour or more, associated with the most plaintive, sad and distraught cry that you can imagine. These might be called, “autistic cries”, to those who are familiar with them. Once heard, they are never forgotten.
Primary school & early secondary school
Another paradoxical and somewhat contradictory feature of autism is excessive and inappropriate sharing of thoughts and feelings in school and elsewhere. This can cause major social interactional skills difficulties and upset to parents as personal family matters are disclosed in appropriately. Some children with autism will simply shout out random thoughts in a school room situation or insist on answering all questions that the teacher asks the class or challenge a teacher in a very severe way if they think a teacher has made a mistake. Another strategy that they seem to enjoy is being the, “class clown”, being a role that gives them particular pleasure and gives them the attention that they crave. Some children with very high IQ can camouflage their autism and find alternative to the neurotypical strategies used by persons without autism to deal with the school situation and of course, many teachers like highly intelligent children and therefore give them more latitude. What is puzzling to parents, teachers and professionals, is that a child can expend a massive amount of energy keeping things together in the classroom and then, “explode”, with aggression on the way home from school and for the rest of the evening. This is not surprising.
On the other hand, for many, social interactional difficulties are much less evident in the home as compared to school or work. Home is their comfort zone with people whom they’ve known all their life. Indeed, professionals who are not aware of this could do a home visit and see the child behaving well and conclude, based on this observation, that the child did not have autism. The opposite is more common where the child with autism, “freezes”, and becomes emotionally rigid in school in a state of hidden terror, which then causes no behavioural difficulty in school. Professionals will visit school and observe these children and see no behavioural difficulty in school and will then believe that they don’t have autism. Many professionals believe falsely that if a child doesn’t show psychological problems in school, then they have no psychological problems. This is a myth as there can be specificity to psychological difficulties which are evident in one location but not another. Other children with autism can be very dangerous to siblings, particularly younger ones in the home, so much so, that baby sitters will refuse to look after them and parents are terrified of leaving their autistic child with a neurotypical sibling. They may engage in severely dangerous behaviour like choking without realising the full implications of what they are doing. As the children get older, they will be very suspicious and feel everybody is against them and out to get them. They will have a paranoid attitude. Selective mutism in school can also be a feature and in this clinical situation, the underlying autism is often missed. They will often say that everybody in a class of twenty are their friends which basically means that they don’t understand the concept of personal friendship. In school, children with autism will show this behaviour. They will often be described as, “little professors”,15,16 but this phrase will only be used for their relatively small group of talented children on the spectrum, children with autistic savantism. Lesser talents of course are quite common. They will tend to discuss with a teacher or adult on an adult level using inappropriate adult language, topics such as black holes, the solar system etc. They can have extremely advanced mathematical or scientific interests.3 They often criticise teachers inappropriately if they make a mistake. They make and define their own, “social rules”, which basically means that other people have to do exactly what they want for them to do including sharing everything they want with them, with no sense of any need to reciprocate. They insist on being the leader and the one who gives the orders and are very controlling and dominating and get very upset if they don’t win. They are very poor, “losers”, and have severe temper tantrums if they lose. If something is said to them that they disapprove of, this will either cause a temper tantrum or have them hit out and kick adults. They can be a danger to others and to themselves. Mostly they show no remorse but this is not an, “all or nothing issue”, because some will later show remorse but then do the very same thing the next day. The contradictory presentation of the spectrum are what cause so much diagnostic difficulty and puzzlement.
Parents and marriage
Parents, when they are asked about whether they are loners or not, will describe these contradictory features in themselves and by that I mean, being loners and good mixers, while the observer will see that they are clearly, “loners”. This will be complicated by the fact that sometimes in the professional situation, they can function satisfactorily, but once they get out of this narrow structure of work, they have huge difficulties in social relations and withdraw. They will often say that they love their private time and are very happy alone, but they will also describe themselves as sociable in the context I have just described. Ambivalence and an incapacity to make up their minds on emotional matters are extremely common, which often then gives contradictory findings to the inexperienced observer. The social and emotional is their area of difficulty.
These men with autism will very commonly have interpersonal difficulties at work, be unable to relate to their colleagues appropriately, often have a sense, correctly, that they are being bullied and because of all these problems, they will often retreat to the home and will be very happy to become house-husbands or indeed unemployed. Unemployment is in a way a default position for a person with autism. This may in a way, suit the marriage in one sense, in that his wife is able to go out and work and to get many of her interpersonal needs met in the work situation. Employee/employer disputes are very common. A further complication is that the person with autism will misconstrue ongoing supervision by an employer as, “bullying”. The employee with autism and the employer can often be close to despair and completely misinterpret each other without a diagnosis of autism.
Unfortunately, it’s not uncommon for husbands with autism to marry highly emotional women with massive expressions of emotion which makes the man with autism become terrified, freeze and withdraw, and this makes their spouse even angrier. The husband finds himself, “drowning”, in this, “river of emotion”, from his wife and he has to separate or flee to preserve his, “life”, or, “self”. His wife feels he is not expressing emotional deliberately and the, “scales”, only falls from her eyes when she discovers he has autism. In one way, this changes everything for her and at the same time of course, he is still the same person which means that nothing has changed, but the new understanding is critical and makes the possibility of specialised work on empathy, mind reading etc to be done by the couple which can salvage the marriage. Many of these marriages will have had inappropriate marital therapy which only aggravates the situation for many years or may have had long term psychoanalysis without any realisation that the person had autism. Unfortunately, in psychoanalysis, Freud would have described these failures in persons with autism as being due to a negative therapeutic reaction.17 This of course is completely inaccurate but autism undiagnosed is a very common cause of failure of psychoanalysis and psychological treatment for over one hundred years. Indeed, psychoanalysis leads to these patients becoming more confused and to deteriorate mentally because the treatment is inappropriate and has no meaning for them and only confuses them. They need therapy focusing on mind reading skills.18
Fear, anxiety, depression, suicidal behaviour in autism
Another common contradiction in the social area is that many persons with autism are extremely anxious with and hide from people they don’t know, for example, going behind mother or clinging to her for, “dear life”, while another group of persons with autism are fearless and have no stranger anxiety. In children with autism, forms of anxiety disorder, separation anxiety as well as generalised anxiety can be present over the life span. Indeed, it’s not uncommon to see adults with autism housebound or flat bound with no contact with anyone and being completely unwilling to leave for example, a bedroom in their parents’ house. If a decision is made to give them home tuition in the long term, this must be used very cautiously and short term, as it can just simply feed in to school non-attendance and housebound behaviour later. Indeed, sometimes the separation anxiety can be so severe that the underlying autism is missed. Clearly, these two conditions often go together and there is often a great deal of overlap. The clinginess to a parent in a child with autism is a manifestation of this separation anxiety. Living in an autistic mental world will tend to have a huge amount of anxiety associated. Of course, another contradiction is that one will see people with autism who have no sense of anxiety or depression. Indeed, these words mean nothing to them and they will ask the interviewer what is depression; what do you mean by depression. They are often hypersensitive to expressed emotion which leads to them developing anxiety, depression, and suicidal thoughts or even completed suicide.3 Meeting the criteria for depressive disorder,1 is extremely common. Persons with autism are also very fearful of the future, of dying, anxiety about their parents dying and have massive amounts of death anxiety which can be a constant preoccupation. They are often very fearful of what will happen later on in the day and ask their parents constantly what’s going to happen next.
Behaviour of the person with autism in the mental health professional’s office
When a parent with a child with autism enters a doctor’s office, they will take up what is normally regarded as mother’s chair and sit on it, which is closest to the doctor. Usually in this situation the mother will direct them to a chair a little further away which would be the appropriate chair for a neurotypical child. In the older age group, adolescents and adults in my experience will sit in the chair furthest away from the doctor in the room, often at a very inappropriate long distance from the doctor when there is nobody else in the room. These are the kind of subtleties that will only be recognised by an experienced clinician. The first statement a verbal child with autism may come out with on entering the mental health professionals office will be something like, “you have a sensational tie”. At other times, they will often hold mother’s face roughly to get her to look straight at them. In communication, they will often look past the mental health professional and have reduced eye contact in consultation or in other social settings.3 Others will paradoxically immediately invade the mental health professional’s personal space without realising it. They will tend to climb all over the place and be hyperactive. Going under chairs will be extremely common and be very typical of the autistic child.
Oppositional defiance and autism
Another extremely common feature of persons with autism is oppositional defiance or oppositional defiant disorder.1 It is the most common co-morbidity in children with autism. I would hypothesise that the empathy deficits and theory of mind deficits are playing a role here. They are oppositional and defiant because they misinterpret or do not understand people’s social behaviour or what is being said to them and this leads to massive frustration and anxiety leading to huge temper tantrums and oppositional defiance which becomes also a default position for these children with autism. Indeed, oppositional defiance can be the major problem that initially parents bring their children to professionals with, or indeed can often be the major problem that children who have autism have. Sometimes, a diagnosis of oppositional defiant disorder is made correctly, but the autism associated is missed. One feature of Oppositional Defiance which is very characteristic of persons with autism is spitefulness and vindictiveness and when this feature is present at an initial consultation, this should be a, “red flag”, and raise the possibility of ruling out autism. Parents will often comment about children with autism, that they often lose their temper, often argue with adults, often actively defy, often deliberately annoy people, often blame others for their mistakes, often touchy and easily annoyed by others, often angry and resentful, often spiteful and vindictive. The phrase, “spiteful and vindictive”, is extremely common in persons with autism and for me, this is a, “red flag”. Most parents, when you ask them about oppositional defiance, when the child doesn’t have autism, the parents will reply that the child was not spiteful or vindictive.
Sports and autism
Persons with autism have huge difficulties understanding the unwritten rules of group sports and will get very angry and walk off the field with the ball if the rules are not followed precisely. The key to understanding group sports as played which is to push the rules or break the rules until the referee intervenes. Persons with autism cannot understand this double standard. Persons with autism will follow the sporting rules to the, “letter of the law”, and this will cause major conflict with other neurotypical players. They will give up or refuse to play in the school yard because other children are not obeying the rules of the games, or because they cannot understand the informal rules of the games played in an ordinary school yard. They will often hit and kick other children. They will have great difficulty sharing the ball or passing the ball. They will be dismissed from the team, or more often, they will withdraw from sports completely. Occasionally they can function as goalkeepers. It is the exception in terms of autism, Aspergers syndrome that would play group sports.
Bullying and autism
It’s hardly surprising that bullying of children with autism is almost universal, both in school and in group situations. This can be just one step on the road to the school non-attendance. School for them means going into a situation where they are viciously bullied. Indeed, when you ask many of these children with autism describe who is bullying them, they will often describe and name a person who mother will immediately say is their friend. Most commonly the bully and the friend are embodied by the same name and the same person. Many professionals new to this area will find this situation most perplexing, paradoxical and confusing. This unfortunately is central to the autism gestalt, which, to the neophyte will appear highly contradictory. In relation to every activity of persons with autism, there is a very wide spectrum from mild to moderate to severe. The autism spectrum is extremely wide. They will very often be bullied and of course, this will increase their suspiciousness and their paranoid attitude. The effect of this is of course sometimes to increase the bullying. Suicide is not rare.3 They therefore find themselves in a vicious circle. This can lead to them developing school non-attendance and becoming housebound in later life and an inability to go out to work.
Copying and imitation in autism
Another strategy that is particularly used by females and to a lesser extent by males, is copying other people’s personal behaviour, one second after it is performed and in that situation, they can be very easily mistaken for engaging in normal social behaviour. This delays the diagnosis of autism. This is particularly evident in adolescent girls with autism. Another manifestation of this is the picking up of foreign accents from television etc, by persons with autism. Of course, we must remember that, imitation is not an exact copy, Hopper,19 states that when a child imitates they develop, “traditions, ultimately our culture. It allows for the transfer of information, (behaviour, customs), between individuals and down generations without the need of genetic inheritance”. I would argue that the problem in autism is not copying but that their problem is imitation leading to a capacity to absorb the culture they live in which a person who is neurotypical is capable of. What great comedians with autism engage in is copying but not imitation.20,21 They copy absolutely precisely which is why they can be the best comedians in the world. In their huge hyperdeveloped capacity to copy, they are massively observant of surface communication and language and accent of other people, but at the same time they have massive problems in recognising the emotional or intentional feelings behind this superficial copying or mimicking. Winnicott,22misinterpreted this as a false self (copying another self) with pathological parent/child interactions causing it. In actual fact, this problem is to a major extent genetic in autism. Persons with autism develop what Deutsch,23 called, “as if”, personality or chameleon-like personality because of this copying behaviour. Again, Deutsch did not understand autism and felt the problem was the mother’s style of parenting. Indeed, Hans Asperger’s first description came out in 1938 and Leo Kanner’s in 1943.
Identity diffusion: diffuse sexual identity
Persons with autism have a confused sense of gender or a fluid sense of gender, in addition to other problems with aspects of personal identity. They can be misdiagnosed as having so-called multiple personality disorder, when autism would be the correct diagnosis. Autism shows many contradictory aspects of self at different times and in different places. This is simply a manifestation of their identity diffusion and lack of a clear sense of personal self. It can be confused with dissociated states and borderline personality disorder.24 This identity diffusion is greatly exacerbated by interpersonal stress which can lead to further decompensation into depression or indeed, paranoid states even including psychosis. It is hardly surprising that it leads to drop out from universities or employment. These persons with autism have a poor sense of themselves and similarly a poor understanding of other people. Indeed from childhood onwards, they begin to perceive other people as persecutory because of their difficulty in understanding them. Autism is commonly associated with identity diffusion in a general sense and also sexual identity diffusion. They can be androgynous and only want to play with the opposite sex and have contempt for the same sex. Others and this is another contradiction, will have absolutely nothing to do with the opposite sex.
It is very common, when meeting a person with autism for the first time in making a mistake about whether that person is male or female. This may be due to their dress, their hair style etc. They have an incredibly wide spectrum of identity and therefore, gender identity is particularly confused and particularly variable and can include transsexualism etc. Indeed, some of the terms applied nowadays can range from, “agender”, to, “bigender”, “transgender”, or, “gender fluid”, which fits well with identity diffusion in persons with autism. It is much too restricting to limit the phrase, “identity diffusion to adolescents”, in persons with autism. Males can have very soft feminine features and females can have rough, male facies in autism. The paradox is that females with autism can be totally contemptuous of neurotypical females. It is not surprising that they feel unreal and feel that the social world around them is unreal. Persons with autism, who describe themselves as, “agender”, are not to be taken literally as I have observed some of these who later were engaging in very perverse and serious dangerous sexual activities. Autism has a major impact on sexual identity and sexual behaviour. The brain connectivity issues affect this as well.25 Persons with autism describe themselves in a very contradictory way and experience themselves in very contradictory ways. No wonder they have severe identity diffusion. They have much ambivalence and confusion about emotional matters.
Sensory issues are part of DSM V ASD.1 It was a good decision to put sensory issues into the criteria for DSM V autism. They are almost always present but not 100%. There are a very tiny number of persons with autism where it can be impossible at the time of diagnosis, to find some sensory issues but it does happen that they had them in early childhood and have now lost them. Taste issues and selective eating are extremely common in autism and these do, in my view, have a sensory basis to them. The sensory issues in the classroom are commonly huge issues and necessitate sensory breaks from the classroom. Severe oppositionality and temper tantrums in the classroom can often be caused by sensory overload. Another paradox is that children can be hypersensitive to noise made by other people but can tolerate without any problem, the same noise created by themselves. This requires further research and has never been explained, but it is one of the very common contradictions and paradoxes that one finds in the clinical gestalt of autism. The most common sensory problems are noise of, for example, hoovers, hairdryers, crowds etc. Nevertheless, I have come across one child who paradoxically adored the sound of the hoover and wanted to listen to it all day. Tactile sensory problems are not uncommon, for example, clothes tags on skin, hair cuts etc. Another contradictory and paradoxical finding is that many children are sensory-seeking at the same time, chewing on clothes or plastics, putting everything into their mouth, eating unusual objects including their faeces. It’s not possible to understand the clinical gestalt in autism unless one understands the wide variety of variations of sensory issues from hyper to hypo. Another group will overeat and have no concept of satiety. This needs further research but my hypothesis would be that there are sensory abnormalities in the stomach which does not transmit to the brain, the sensation of satiety. Alternatively, a central problem in the brain. Autism is also made much more difficult because there are abnormalities in a wide variety of systems in the body. Another contradiction is that many persons with autism are very upset by lights which gives them sensory overload while another group adore looking at lights and are sensory-seeking in relation to light. Others are absolutely fascinated by watching washing machines spinning or other objects spinning. They love the repetition, preservation of sameness, here and they will also lay on the ground watching these objects spinning through the corner of their eyes. Others will run along window sills looking at them through the corner of their eyes. This looking at things through the corner of their eyes seems to be either pleasurable or else reduces sensory input and makes this activity more tolerable. They can be hypersensitive or hyposensitive to pain, another contradiction.
Narrow interests are a striking part of children and adults with autism. Younger children are often fascinated by dinosaurs, LEGO, trains, lining them up in straight lines, etc. They are very fascinated by iPhones and computers from a very early age and indeed, will show skill in this from a very early age, and will play the same video game endlessly and repetitively. They may watch the same TV., programme endlessly and watch the same video endlessly. They often love turning pages of books earlier on and look at the pictures and when the learn to read they become obsessed with books who in many ways become their, “friends”. They are fascinated by books they read, for example, Harry Potter. They are often fascinated by nature, by the outdoors, by the garden and by dogs, cats, bugs, bees, sharps, dinosaurs, World War Two history etc. Unusual topics are palaeontology, Egyptology, mathematics, science, science fiction, history, encyclopaedias, books of facts which they want to tell everybody about repeatedly. Other fascinations can be horror movies, serial killers, death, guns, war and homicide. A small group of people with autism will have a condition described by Fitzgerald,26 as criminal autistic psychopathy and will engage in very serious crimes. Music and mathematics are related and it’s not rare to find persons with autism having special interests in these.16 Some persons with autism are obsessed by time as was Albert Einstein.26 Their interest is sometimes based on their ability to hyperfocus on detail. Imaginative play is delayed, and they are often, as children, more interested in household objects than toys. Nevertheless, they can have massive scientific or mathematical imagination etc. It is their social, interpersonal imagination that is the problem.
Comfort blankets: autistic objects
Comfort blankets, comfort teddy bears are very common with autistic children or with children with autism and indeed, also adolescents with autism. Donald Winnicott,27developed an extremely elaborate theory around comfort blankets which he called, “transitional objects”, as being of critical importance in child development. For Winnicott,27 transitional space was, “an intermediate developmental space between the psychic and external reality …. Subjective omnipotence”. Winnicott’s fanciful imaginative theory is without scientific basis. There have never been any limits to the psychoanalytic imagination. The theorising as in the psychoanalytic theory of transitional objects was random and based on Winnicott’s free association of ideas, a technique suitable for literature but not psychological science. The autistic object also involved an object that was unchanging, what in autism is called preservation of sameness, and there was also a very strong sensory component. It was part of the sensory seeking that is common in persons with autism. Another paradox or contradiction in the profile of persons with autism is that some can be easily overwhelmed by sensory issues, for example, noise, while being sensory seeking in relation to the, “autistic blanket”. Autistic objects have a true, simple role as described above and this has not to be confused with the convoluted, confused story of Donald Winnicott. The blankets etc, are simply comfort objects that remain the same, have the major characteristic of autism that is, preservation of sameness, and also have a reassuring sensory presence. They are not symbolic. They defend against anxiety in the totally unpredictable world of the child with autism. The level of despair that a child with autism experiences in temper tantrums, (meltdowns), gives one of the most severe cries that one can imagine, if they are separated from these autistic objects.
Winnicott was a paediatrician with no formal training in psychiatry and little interest in psychiatric diagnosis. Winnicott confused neurotypical children with autistic children.
Speech and language
Speech and language development in autism is in my view, always abnormal, even if this is only a slight pragmatic difficulty in very high functioning autism, which can occur in the context of the most perfect spoken language of the, “Oxbridge”, type or other similar type. They can use language in a very novel way, as seen in the writings of Ludwig Wittgenstein,26 and this is part of autistic novelty seeking,28 a feature of highly creative persons with autism. They are often extremely slow in processing questions most likely due to brain connectivity problems in autism.25 Another cause of delay in answering questions is wanting to give a very precise or perfect answer to a question, as one sees in Wittgenstein’s answer to oral questions he wrote a lot about. Persons with autism engaged in a great deal of copying of accents and phrases which they repeat over and over again. Some of the most high functioning persons with autism produce expressive verbal humour as described by Lyons & Fitzgerald.21
Parents will often describe the voices of their child as being, “babyish”, and, “immature”, even in adolescence. Problems in prosody are very common and they will involve problems in intonation, tone, stress and rhythm. Parents will often describe the child as having a high-pitched tone of voice or a monotonous tone of voice or a very loud voice. I have paradoxically also observed children with autism having extremely low, almost inaudible tone of voice or indeed speaking with an adult tone of voice. They often engage in almost subvocal talking or singing. Persons with autism are fascinated by all aspects of language. They see language as very problematic for them for all the reasons described above. They will often engage in repetitive questioning trying to get understanding, want an answer to be given in the exactly the same way every time. This is part of the wish to have preservation of sameness, which greatly reduces their anxiety and their fear of change in the world. They tend to engage in a great deal of self-talk as children and adults. Since they live in an autistic personal world, this is just one more feature of their autism where they are trying cognitively and linguistically to sort out their confusing personal and interpersonal autistic world. In trying to manage this confusing linguistic world, they will pronounce every word with enormous precision.
Another area where the autistic condition shows itself is in the autistic narrative, described by Fitzgerald,18 which is a narrative of facts without context. The autobiographies of persons with autism often consist of a list of facts but no sense of themselves. They view their lives as a list of facts or concrete list of journeys or events that have happened to them during the course of their lives. It’s history or autobiography without the real person of the autobiography being present. There is a whole genre or, “cottage industry”, of autobiographies by persons with autism now. They can be full of statistics and lists. They can be very, “wordy”, without saying anything about themselves. There can be sentences that are very difficult to elucidate the meaning. There is therefore an autistic style of autobiography and biography. Loss of language in the first two years is not rare and occurs in at least 15%.29 I always ask as well, about a loss of babble. The regression in language in my experience can occur up to three years or more while regression most commonly occurs between sixteen and twenty months.30 It does occur before and after these dates.
Persons with autism often confuse fact and fiction which works brilliantly in fiction and literary works and particularly science fiction works but is very dangerous in real life and in science. At the same time, very commonly they are, “brutally”, honest and will talk for example about some listener’s nose or other physical aspect that will cause massive hurt and offence. Again, we have another paradox or contradiction, the clinical profile or gestalt of autism is full of contradictions, which confuses the neophyte working with persons with autism. They will make up fantastic stories and some of these have developed a career of this with science fiction writing but the other more serious aspect they will tell fantastic stories about parents or teachers having committed crimes, which have no basis in reality, which they will report to the police or other competent authorities who would have no skill in assessing these allegations in people with these neurodevelopment problems. The mishandling of these allegations can lead to imprisonment of innocent individuals, similar for what happened in false memory syndrome. There is no simple understanding of autism, a condition which requires decades of experience to develop a high degree of competence in. Indeed, persons beginning to work in this area will often require up to ten years of close supervision before they become expert in the area. Often, persons with autism conversations may not seem very coherent and if they are met by an adult psychologist or psychiatrist who only works with people with schizophrenia, they can be easily confused with persons with thought disorder and an inaccurate diagnosis of schizophrenia made and treatment initiated. In childhood and later, they can often make up their own language and mother will tell you, “he has his own language”, with neologisms which can also lead to a false diagnosis of schizophrenia. It was mistakenly believed that autism and schizophrenia did not occur together.31,32 This was a huge error and of course, they can and do often occur together, particularly in later life. Fitzgerald,11 Of course, autism and schizophrenia are both neurodevelopmental disorders.33,34 They can have huge difficulties with the meaning of the word, “depression”, and will ask what does that mean, even though they have very good cognitive processing otherwise.
It was an error in DSM V, ASD,1 to downplay motor difficulties in their criteria, to simply put them as associated features when they are so common in autism. Indeed, motor features are often the first feature seen in the development of autism. Parents mostly ignore them or just see them as amusing and don’t attach much significance to them, while parents normally put the major focus on language delay and this is usually what propels the parent to look for a diagnosis. The language that parents use is very descriptive and highly relevant in relation to motor issues when heard by an experienced professional. The phrases used will include; Tippy-toe walking; bum-shuffling; combat crawl; crabby crawl; walking on knees; one leg out and one leg underneath him; crawling on abdomen; stiff gait; hand rigidly by his side and rigid, stiff body, awkward walk; clumsy; walking sideways through a door; frog-like crawling; walking like a “monkey”; crawling backwards; legs crossed and jumping up and down or the child never crawled, but just stood up and walked; In terms of the clinical gestalt, this parents’ language is very powerful and significant in relation to motor issues. These parents’ phrases are so powerful, and the experienced clinician hears them over and over again and they are much more powerful in making a diagnosis than strict technical language. Another feature is asymmetrical body movement. Parents will say the child with autism, “is an extremely careful walker”.
Reduced non-verbal behaviour is extremely common as well as so-called flattened affect which could be confused with schizophrenia by an inexperienced clinician or clinician who usually diagnoses schizophrenia. Persons with autism can be very good at slapstick comedy, Lyons & Fitzgerald,21 and be brilliant at copying the behaviour and speech of other people. This has always in the past, been called mimicking. Mimicking and copying are basically the same. Other features can include head-banging, chewing inanimate objects, rocking, inappropriate grabbing of mother’s face and holding the mother’s face rigid to look at them, staring at another person for a very long time. Persons with autism commonly take up the exact same body posture of the people that they are communicating with. This is copying or mimicking. Their dress can often be the kind of dress that would be more appropriate for the opposite sex to wear because of their identity diffusion. They will often wear the same clothes every day and refuse to have their clothes washed or changed. Mother has sometimes to do this late at night and hope that they won’t recognise that their clothes have been cleaned. They will often dress in immature outfits like a, “rabbit type”, outfit which might be appropriate for a much younger child. They show clear emotional behavioural immaturity. Nowadays children with autism will very often be using headphones to keep out sensory overload. Of course, these are often used by neurotypical as well but never so persistently and for different reasons. They always like to look at things from different angles, for example, lying on the ground as they look at some object on their sides. This can lead to creativity. Fitzgerald,18 Contradictory non-verbal facial behaviour is also not uncommon with different emotions or different parts of the face, including a mixture of laughing and crying at the same time. This kind of contradictoriness is central to autism. One often sees the child with autism jumping up and down, flapping their hands, spinning their body, running up and down in straight lines, running around in circles, moving their fingers in front of their eyes. Often, they can be unusually tall and can be mistaken for Marfan’s Syndrome. Another contradiction of paradox is that while most children with autism have reduced eye contact, a small group do precisely the opposite and stare excessively, possibly trying to understand or read the faces.
This is very important for the diagnosis of autism and is seen in many of the features of autism, already described in this paper. They love to switch on and off lights. They love to put objects in and out of boxes. They love calculating and this would relate obviously more too autistic savantism. They ask repetitive questioning and there’s a lot of memorising of dates and facts.
Others will react with dangerous internal aggression and indeed, may save up slights for many years and then react with a savage outburst of aggression, which can be dangerous. They may persist dealing with these slights and this behaviour can lead to them presenting to the public in a very eccentric fashion with placards outside of public buildings which can go on for decades. They have what used to be called, “idee fixe”, and of course, obsessions and compulsions are common in persons with Autism. They are often androgynous. They will very often engage in rough play which appears to give sensory pleasure and also gives them a sense of control and power which is extremely important to them. They will also lack awareness of the consequences of what they are doing because of their empathy and theory of mind deficits. On the extremely rare occurrence when they engage in serial killing,35 after being caught they will confess every detail and take the police to the site of each crime.
It is categorically stated that you can differentiate autism spectrum disorder from psychopathy by the presence of Theory of Mind skills in psychopathy with huge difficulties in this area in autism. This is not so in clinical practice and what is found in the real clinical world is different from what is found in the laboratory or within a small group of research subjects who do not represent all persons with this condition in the world. The same problem occurred in Theory of Mind research which now shows that persons with autism can pass these Theory of Mind tests. (Blair et al 2005)
Autism and schizophrenia
It is not rare in adult life for persons with autism to develop co-morbidity, paranoid psychosis in particular, or less commonly to co-morbid schizophrenia.11 Indeed Bleuler,36defined autism in schizophrenia as the, “poor ability to enter into contact with others, withdrawal and/or inaccessibility, negativistic tendencies, rigid attitudes and behaviours, a private hierarchy of values and goals, inappropriate expression of behaviour, idiosyncratic thinking”, in relation to schizophrenia. Of course, all these features are also commonly seen in autism spectrum disorders.1 They are extremely sensitive to high expressed emotion, in my experience, even more than persons with schizophrenia.
Preservation of sameness
Rigidity and wanting to keep things the same are very characteristic. They want the day to follow rigid patterns. If a plan is made it has to be followed exactly, as promised. Journeys to school or other places have to go the exact same route every day. They are extremely controlling, dominating and change comes with a great deal of anxiety and often challenging behaviour. They will insist on the same food every day and wearing the same clothes.
The clinical autistic gestalt can be very confusing and contradictory to the neophyte. This is why the rush to the so-called, “tick box”, instruments. These instruments are not recommended by the NICE5 Guidelines as primary diagnostic tools. The diagnosis is made by an experienced clinician who is comfortable with all the contradictions in the autism spectrum which they will be so familiar with.37−46
Conflict of interest
The author declares that there is no conflict of interest.
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