The concept of autism
Bleuler (1919) regarded autism as one of the fundamental features of schizophrenia. He described it as an active withdrawal from contact with reality in order to live in an inner world of fantasy. Gruhle (1929) pointed out that it was just as likely to be forced on the patient by the cognitive disorder. Kanner (1943) recognized, in a flash of genius, a syndrome worth separating from the then amorphous mass of ‘subnormality’ and ‘psychosis’ in children. His observations were precise and brilliant, but at the same time he adopted the much less exact term ‘autism’ to describe it, thus linking it to Bleuler’s concept.
Within a year, Asperger (1944/1991) independently described a behaviour pattern he called ‘autistic psychopathy’, now referred to as Asperger’s syndrome. Both Kanner’s and Asperger’s syndromes had in common a range of disorders of development present from birth or early childhood (Wing 1981, 2000; Tantam 1988; Frith & Frith 1991; Gillberg 2002). The results of an epidemiological study in south-east London (Wing & Gould 1979) showed typical examples of each syndrome, but identified many more children who shared features of both, or who met some but not all the diagnostic criteria for either. The authors developed the hypothesis of an autistic spectrum, characterized by a triad of impairments affecting the development of social interaction, communication and imagination, associated with a narrow repetitive pattern of activities.
The chief feature of the triad was social impairment, which could be manifested in several ways. Three groups were particularly evident.
1 Aloofness and indifference to others, e.g. avoiding social contact except for simple needs or to obtain pleasure from physical stimulation such as tickling. Those in this group tended to be the most disabled because of intellectual, behavioural and language impairments.
2 Passive acceptance of approaches from others but little or no spontaneous social interaction.
3 Initiating contacts in an odd one-sided way, unaffected by the reaction of the person approached. Those in this group tended to have less global impairment but behaviour was markedly abnormal.
The borders between groups are not neatly differentiated and can change over time; for example, some children change from aloofness to passivity, or to active but odd participation, as they grow up. Psychological examination has suggested that affected children and adults have an inborn difficulty that limits their understanding of other people’s thoughts and feelings (Frith 1989). This lack is one part of a more general and fundamental problem shared by all those with the spectrum, which limits the attribution of meaning to experiences (Wing 1982; Frith 1989; Frith & Happe 1994). This hypothesis comes closer to Gruhle’s view that autism is a consequence of cognitive disorder rather than of an ‘active withdrawal’ as suggested by Bleuler, and is in striking contrast to Jasper’s description of the intrusion of abnormal meaning in the primary delusions of schizophrenia.
The diagnosis of autistic spectrum disorders in adults depends on characteristics of early development that are rarely considered by psychiatrists when taking histories from adult patients. For some diagnostic categories used in adult psychiatry, the ICD-10 criteria overlap with those in the autistic spectrum. For example, the criteria for schizoid and schizotypal personality disorders are closely similar to those for Asperger’s syndrome as defined in ICD-10 and DSM-IV. Sula Wolff (1995) followed up children with ‘schizoid personality disorder’ and came to consider that they were better placed in the autistic spectrum, representing the most able individuals who fit Asperger’s descriptions.
Many of the features of catatonia, as recently described by Joseph (1992), Bush et al. (1996) and by Rogers (1992), are identical to those found in autistic spectrum disorders, especially in younger and more severely disabled children. Follow-up into adult life has shown that a small proportion of those with autistic disorders, at any level of ability, have marked exacerbation of catatonic features in adolescence or early adult life. Some become severely incapacitated as a result (Wing & Shah 2000).
The narrow repetitive range of activities characteristic of autistic spectrum disorders can be mistaken for obsessive–compulsive disorder but the more common misdiagnosis is that of schizophrenia, although the diagnostic criteria for the latter are substantially different from those of autism. Such mistakes tend to be based on a misinterpretation of the social aloofness and passivity, or the odd speech and ideas that are found in people with active but odd social interaction. There is no evidence that medications, whether ‘typical’ or ‘atypical’, have a useful effect on the core symptoms of autism, although their tranquillizing effects are sometimes useful. The ‘management’ of autistic spectrum disorders depends on the provision of an appropriately structured environment, with well-programmed activities that encourage the use of any potential skills.
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