Skip to main content Accessibility help
×
Home
Hostname: page-component-55597f9d44-2qt69 Total loading time: 0.501 Render date: 2022-08-10T23:27:37.201Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Adult autism spectrum as a transnosographic dimension

Published online by Cambridge University Press:  09 September 2015

Liliana Dell’Osso*
Affiliation:
Department of Clinical and Experimental Medicine, Psychiatry Sector, University of Pisa, Pisa, Italy
Riccardo Dalle Luche
Affiliation:
Department of Clinical and Experimental Medicine, Psychiatry Sector, University of Pisa, Pisa, Italy
Mario Maj
Affiliation:
Department of Psychiatry, University of Naples SUN, Naples, Italy
*
*Address for correspondence: Liliana Dell'Osso, University of Pisa - Department of Clinical and Experimental Medicine, Psychiatry Unit, via Roma 67, 56100 Pisa, Italy. (Email: liliana.dellosso@med.unipi.it)
Rights & Permissions[Opens in a new window]

Abstract

Type
Editorial
Copyright
© Cambridge University Press 2015 

Autism is usually diagnosed in childhood on the basis of early impairment in reciprocal communication and social interaction, stereotypic behaviors, late or poor language development, or intellectual retardation. However, subjects with mild forms of autism, with normal or above-average intelligence, may reach high levels of functioning, developing in some cases excellent abilities in restricted areas, and may be undiagnosed until adulthood or misdiagnosed as having other mental disorders. Growing interest has been devoted in the last several years to the adult courses of these conditions, previously labelled as Asperger’s disorder (AD) and recently merged into the autism spectrum disorder (ASD) in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), along with growing literature indicating that they are associated with high rates of comorbidity with anxiety, mood, psychotic, and trauma- and stress-related disorders and with suicidal behaviors.Reference Kato, Mikami and Akama1Reference Vannucchi, Masi, Toni, Dell’Osso, Marazziti and Perugi3

While DSM-5 made the attempt to fill the gaps between diagnostic categories by applying a spectrum approach to neurodevelopmental disorders, ASD diagnostic criteria may still be not sensitive enough to detect some adult forms with no intellectual or language disability and characterized by mild impairment in interpersonal and empathic functions, such as attuning and socialization, leading to isolation and social phobias. Individuals with such forms, lying at the boundaries of ASD, might be easily misdiagnosed as having a wide range of personality disorders (eg, schizoid, schizotypal, avoidant, dependent, borderline) or unspecified schizophrenia spectrum disorders and other psychotic disorders.

Looking back at Asperger’s original descriptions, he focused on some stable autistic traits, often associated with special abilities, referring to Eugen Bleuler’s concept of autism as a fundamental symptom of schizophrenia and somehow recalling Jung’s “introvert” psychological type and Kretschmer’s “schizoid psychopathy.” Since entering the DSM in 1994, AD has lost the distinctiveness of Asperger’s first observations. Moreover, diagnostic criteria have mostly referred to the childhood course rather than to the adult clinical phenotype. From this perspective, there is no blame for dropping AD as a separate category in DSM-5. However, Asperger’s work should be revised within a coherent adult autism spectrum model that is currently supported by both clinical and neurobiological data.

Consistent with Asperger’s intuition, it has been proposed that a neurodevelopmental deviation may represent the common vulnerability factor for most mental disorders (eg, schizophrenia, bipolar disorder, attention deficit hyperactivity disorder), as suggested by their clinical overlap, familial co-aggregation, and shared genetic risk factors with ASD. Along with this hypothesis, genetic and environmental factors would act together to cause a neurodevelopmental deviation, the timing, severity, and anatomical location of which determine a gradient of neuroatypicality underlying different mental conditions.Reference Doherty and Owen4 Somehow consistent with this hypothesis, it has been proposed that mental disorders should be reformulated as pathologies of the whole-brain organization, or “globalopathies,” rather than disturbances of a discrete neural network.Reference Peled and Geva5, Reference Peled6 If a global, brain-based physiopathology must be hypothesized for psychiatric conditions,Reference White, Rickards and Zeman7 this might involve neurodevelopmental processes and the extent to which the brain is neuroatypic. This idea is also in line with some new and intriguing perspectives derived from neurobiological studies that have raised the hypothesis that schizophrenia could be considered a late-onset neurodevelopmental disorder,8 or the late stage of one,Reference Insel9 rather than an early-onset neurodegenerative disease, as initially suggested by the Kraepelinian definition of dementia praecox.

Interestingly, growing bodies of data indicate that ASD often remains unrecognized until adulthood, coming to clinical attention only when other mental disorders arise, often prompted by a breakdown of relations, such as a parent’s death or other life events and changes, leading to challenging diagnostic procedures.Reference Kamio, Moriwaki and Takei10 This is likely the case of ASD patients with comorbid complex posttraumatic stress disorder (PTSD) who may be diagnosed as borderline personality disorder, while the ASD goes unrecognized.Reference King11 The same idea applies to those ASD adults with comorbid mood disorders who are often diagnosed as schizophrenics because of the atypical mood episodes and inter-episodic behavioral patterns related to ASD.Reference Skeppar and Adolfsson12 Moreover, ASD seems to contribute to impulsive suicidal behaviors in the context of many different comorbid mental disorders.Reference Storch, Sulkowski and Nadeau2, Reference Simoncini, Miniati and Vanelli13, Reference Takara and Kondo14

We suggest an adult autism spectrum (AdAS) model that would encompass not only threshold-level symptoms but also mild and atypical manifestations, behavioral traits, and personality features associated with the DSM-5 ASD diagnostic category. These may, or may not, interfere with overall functioning and quality of life,Reference Kamio, Moriwaki and Takei10 ending in the continuum of normality and even including positive aspects of neuroatypicality and some hyper-adaptive features such as originality, creativity, divergent thinking,Reference Baron-Cohen, Richler, Bisarya, Gurunathan and Wheelwright15, Reference Tantam and Girgis16 thus overcoming the distinction between symptom and trait.

From a clinical standpoint, we hypothesize that the use of the AdAS model will help both to detect high-risk subjects before they develop other mental disorders, and to identify ASD-colored clinical presentations in the context of these latter,Reference King11 when a mild/subthreshold autism spectrum is present. More speculatively, the AdAS will also help to investigate whether, besides its role as a vulnerability factor for other mental disorders, neuroatypicality may also increase patients’ resilience to certain kinds of life events.

From the point of view of research, the AdAS approach will help to investigate the genetic basis of autism. The DSM-5, in fact, still draws a line between what is autism and what is not,Reference Happé17 disregarding more subtle phenomena such as the broad autism phenotype or the subthreshold autism spectrum,Reference Nemeroff, Weinberger and Rutter18 spanning across the general population who do not fully meet criteria for ASDReference Scheeren and Stauder19 but who share, however, genetic underpinnings with the clinical population.Reference Le Couteur, Bailey and Goode20Reference Ronald and Hoekstra23 While a reliable threshold for the diagnosis is essential in clinical practice, our search for neurobiological mechanisms may need some intermediate entities between the presence and the absence of a mental disorder.Reference Maj24 From this perspective, the AdAS approach will allow us to investigate more comprehensively the genetic underpinnings of autism, providing researchers with a broader range of autistic endophenotypes to be tested in their studies.Reference Gottesman II25, Reference Sucksmith, Roth and Hoekstra26

Further, such a spectrum approach has the potential to overcome the descriptive artifice of comorbidity.Reference Maj27 According to Krueger and Markon,Reference Krueger and Markon28 who proposed a “liability spectrum model” of comorbidity, mental disorders are the manifestation of latent liability factors that explain comorbidity by virtue of their impact on multiple disorders.Reference Dell’Osso and Pini29 According to such a model of comorbidity, the AdAS could help to assess individual deviations along a number of autistic dimensions, which may predispose patients to several mental disorders, that would explain the high rates of comorbidity between ASD and other psychiatric conditions. Just as a panic attack is conceptualized not only in the context of a specific disorder, but also as a transnosographic specifier for different disorders in the DSM-5, in the same way the assessment of AdAS could help clinicians to better define the physiopathology, course, vulnerability/resilience factors, and specificity in pharmacological and psychological treatment response of most mental disorders. From this perspective, some dimensions underlying autistic symptomatology (eg, social phobias, social withdrawal, proneness to rumination, obsessive perfectionism, rigidity, clumsiness, disturbance of empathy, anhedonia) could represent a sort of common autistic core of several mental conditions.Reference Chanachev and Berney30Reference Del-Monte, Capdevielle and Gély-Nargeot32

Ruminative thoughts, for example, have been shown to be associated with PTSDReference Ben-Sasson, Cermak, Orsmond, Tager-Flusberg, Kadlec and Carter33Reference Foley Nicpon, Doobay and Assouline35 and the literature indicates a high incidence of multiple traumas in individuals with ASD, such that a few authors have speculated that ASD constitutes a vulnerability factor to PTSD after trauma exposure.Reference King11 Taken together, these data may suggest the intriguing hypothesis that subjects with ASD might be at higher risk of developing trauma- and stress-related disorders due to their proneness to rumination. We think that the revision and reconceptualization of Asperger’s work within the framework of such an AdAS model will allow the detection of symptoms that clinicians usually overlook, but which interfere with the vulnerability and the clinical presentation of most mental disorders. Eventually, we argue the AdAS model as a transnosographic dimension based on a neurodevelopmental physiopathology of mental disorders.

Disclosures

The authors do not have an affiliation with or financial interest in any organization that might pose a conflict of interest.

References

1.Kato, K, Mikami, K, Akama, F, et al. Clinical features of suicide attempts in adults with autism spectrum disorders. Gen Hosp Psychiatry. 2013; 35(1): 5053.CrossRefGoogle ScholarPubMed
2.Storch, EA, Sulkowski, ML, Nadeau, J, et al. The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders. J Autism Dev Disord. 2013; 43(10): 24502459.CrossRefGoogle ScholarPubMed
3.Vannucchi, G, Masi, G, Toni, C, Dell’Osso, L, Marazziti, D, Perugi, G. Clinical features, developmental course, and psychiatric comorbidity of adult autism spectrum disorders. CNS Spectr. 2014; 19(2): 157164.CrossRefGoogle ScholarPubMed
4.Doherty, JL, Owen, MJ. Genomic insights into the overlap between psychiatric disorders: implications for research and clinical practice. Genome Med. 2014; 6(4): 29.CrossRefGoogle ScholarPubMed
5.Peled, A, Geva, AB. “Clinical brain profiling”: a neuroscientific diagnostic approach for mental disorders. Med Hypotheses. 2014; 83(4): 450464.CrossRefGoogle ScholarPubMed
6.Peled, A. Brain “globalopathies” cause mental disorders. Med Hypotheses. 2013; 81(6): 10461055.CrossRefGoogle ScholarPubMed
7.White, PD, Rickards, H, Zeman, AZ. Time to end the distinction between mental and neurological illnesses. BMJ. 2012; 344: e3454.CrossRefGoogle ScholarPubMed
8.Paus T, Keshavan M, Giedd JN. Why do many psychiatric disorders emerge during adolescence? Nat Rev Neurosci. 2008; 9(12): 947957.Google ScholarPubMed
9.Insel, TR. Rethinking schizophrenia. Nature. 2010; 468(7321): 187193.CrossRefGoogle ScholarPubMed
10.Kamio, Y, Moriwaki, A, Takei, R, et al. [Psychiatric issues of children and adults with autism spectrum disorders who remain undiagnosed]. Seishin Shinkeigaku Zasshi. 2013; 115(6): 601606.Google Scholar
11.King, R. Complex post-traumatic stress disorder: implications for individuals with autism spectrum disorders—part 1. Journal on Developmental Disabilities. 2010; 16(3): 91100.Google Scholar
12.Skeppar, P, Adolfsson, R. Bipolar II and the bipolar spectrum. Nord J Psychiatry. 2006; 60(1): 726.CrossRefGoogle ScholarPubMed
13.Simoncini, M, Miniati, M, Vanelli, F, et al. Lifetime autism spectrum features in a patient with a psychotic mixed episode who attempted suicide. Case Rep Psychiatry. 2014; 2014: 459524.Google Scholar
14.Takara, K, Kondo, T. Comorbid atypical autistic traits as a potential risk factor for suicide attempts among adult depressed patients: a case-control study. Ann Gen Psychiatry. 2014; 13(1): 33.CrossRefGoogle ScholarPubMed
15.Baron-Cohen, S, Richler, J, Bisarya, D, Gurunathan, N, Wheelwright, S. The systemizing quotient: an investigation of adults with Asperger syndrome or high-functioning autism, and normal sex differences. Philos Trans R Soc Lond B Biol Sci. 2003; 358(1430): 361374.CrossRefGoogle ScholarPubMed
16.Tantam, D, Girgis, S. Recognition and treatment of Asperger syndrome in the community. Br Med Bull. 2009; 89(1): 4162.CrossRefGoogle Scholar
17.Happé, F. Criteria, categories, and continua: autism and related disorders in DSM-5. J Am Acad Child Adolesc Psychiatry. 2011; 50(6): 540542.CrossRefGoogle ScholarPubMed
18.Nemeroff, CB, Weinberger, D, Rutter, M, et al. DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions. BMC Med. 2013; 11: 202.CrossRefGoogle ScholarPubMed
19.Scheeren, AM, Stauder, JE. Broader autism phenotype in parents of autistic children: reality or myth? J Autism Dev Disord. 2008; 38(2): 276287.CrossRefGoogle ScholarPubMed
20.Le Couteur, A, Bailey, A, Goode, S, et al. A broader phenotype of autism: the clinical spectrum in twins. J Child Psychol Psychiatry. 1996; 37(7): 785801.CrossRefGoogle ScholarPubMed
21.Smith, CJ, Lang, CM, Kryzak, L, Reichenberg, A, Hollander, E, Silverman, JM. Familial associations of intense preoccupations, an empirical factor of the restricted, repetitive behaviors and interests domain of autism. J Child Psychol Psychiatry. 2009; 50(8): 982990.CrossRefGoogle ScholarPubMed
22.Constantino, JN, Zhang, Y, Frazier, T, Abbacchi, AM, Law, P. Sibling recurrence and the genetic epidemiology of autism. Am J Psychiatry. 2010; 167(11): 13491356.CrossRefGoogle ScholarPubMed
23.Ronald, A, Hoekstra, RA. Autism spectrum disorders and autistic traits: a decade of new twin studies. Am J Med Genet B Neuropsychiatr Genet. 2011; 156B(3): 255274.CrossRefGoogle ScholarPubMed
24.Maj, M. DSM-5, ICD-11 and ‘pathologization of normal conditions’. Aust N Z J Psychiatry. 2014; 48(2): 193194.CrossRefGoogle ScholarPubMed
25.Gottesman II, Gould TD. The endophenotype concept in psychiatry: etymology and strategic intentions. Am J Psychiatry. 2003; 160(4): 636645.CrossRefGoogle ScholarPubMed
26.Sucksmith, E, Roth, I, Hoekstra, RA. Autistic traits below the clinical threshold: re-examining the broader autism phenotype in the 21st century. Neuropsychol Rev. 2011; 21(4): 360389.CrossRefGoogle ScholarPubMed
27.Maj, M. “Psychiatric comorbidity”: an artefact of current diagnostic systems? Br J Psychiatry. 2005; 186(3): 182184.CrossRefGoogle ScholarPubMed
28.Krueger, RF, Markon, KE. Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology. Annu Rev Clin Psychol. 2006; 2: 111133.CrossRefGoogle ScholarPubMed
29.Dell’Osso, L, Pini, S. What did we learn from research on comorbidity in psychiatry? Advantages and limitations in the forthcoming DSM-V era. Clin Pract Epidemiol Ment Health. 2012; 8: 180184.CrossRefGoogle ScholarPubMed
30.Chanachev, A, Berney, A. Apathy, a transnosographic symptom: diagnosis and treatment. Rev Med Suisse. 2010; 6(236): 326329.Google ScholarPubMed
31.Chevallier, C, Grèzes, J, Molesworth, C, Berthoz, S, Happé, F. Brief report: Selective social anhedonia in high functioning autism. J Autism Dev Disord. 2012; 42(7): 15041509.CrossRefGoogle ScholarPubMed
32.Del-Monte, J, Capdevielle, D, Gély-Nargeot, MC, et al. [Evolution of the concept of apathy: the need for a multifactorial approach in schizophrenia]. Encephale. 2013; 39(Suppl 1): S57S63.CrossRefGoogle Scholar
33.Ben-Sasson, A, Cermak, SA, Orsmond, GI, Tager-Flusberg, H, Kadlec, MB, Carter, AS. Sensory clusters of toddlers with autism spectrum disorders: differences in affective symptoms. J Child Psychol Psychiatry. 2008; 49(8): 817825.CrossRefGoogle ScholarPubMed
34.Lecavalier, L, Gadow, KD, Devincent, CJ, Houts, CR, Edwards, MC. Validity of DSM-IV syndromes in preschoolers with autism spectrum disorders. Autism. 2011; 15(5): 527543.CrossRefGoogle ScholarPubMed
35.Foley Nicpon, M, Doobay, AF, Assouline, SG. Parent, teacher, and self perceptions of psychosocial functioning in intellectually gifted children and adolescents with autism spectrum disorder. J Autism Dev Disord. 2010; 40(8): 10281038.CrossRefGoogle ScholarPubMed
You have Access
30
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Adult autism spectrum as a transnosographic dimension
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Adult autism spectrum as a transnosographic dimension
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Adult autism spectrum as a transnosographic dimension
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *