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.
J.K. Wing and N. Agrawal
Steven R. Hirsch
MD FRCP FRCPsych
Professor of Psychiatry Emeritus, Division of Neuroscience and Psychological Medicine Imperial College Faculty of Medicine and Director of Teaching Governance, West London Mental Health NHS Trust
Daniel R. Weinberger MD
Chief, Clinical Brain Disorders Branch
Intramural Research Program
National Institute of Mental Health
MD 20982, USA
- American Psychiatric Association (1993) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. APA, Washington, DC.
- Andreasen, N.C. & Carpenter, W.T. (1993) Diagnosis and classification of schizophrenia. Schizophrenia Bulletin 19, 199 - 211.
- Asperger, H. (1944/1991) Autistic psychopathy in childhood. In: Autism and Asperger Syndrome. Cambridge University Press, Cambridge. Translated and annotated by U. Frith, from: Die 'Autistischen Psychopathen' im Kindesalter. Archiv fur Psychiatrie und Nervenkrankheiten 117, 76 - 136.
- Bentall, R.P., Jackson, H.F. & Pilgrim, D. (1988) Abandoning the concept of schizophrenia. British Journal of Psychology 27, 303 - 324.
- Berrios, G.E. & Hauser, R. (1988) The early development of Kraepelin's ideas on classification: a conceptual history. Psychological Medicine 18, 813 - 821.
- Berze, J. (1914/1987) Primary insufficiency of mental activity. In: The Clinical Roots of the Schizophrenia Concept (eds J. Cutting & M. Shepherd), pp. 51 - 58. Translated from Chapter 4 of Die primare Insuffizienz der psychischen Aktivitat. Deuticke, Leipzig.
- Bleuler, E. (1911/1950) Dementia praecox or the group of schizophrenias. New York: International Universities Press. Translated by J.Zinkin from Dementia Praecox oder der Gruppe der Schizophrenien. In: Handbuch der Geisteskrankheiten (ed. G. Aschaffenburg). Deuticke, Leipzig.
- Bleuler, E. (1919) Das Autistisch-Indisziplinierte Denken in der Medizin und Seine Uberwindung. Springer, Berlin.
- Bush, G., Fink, M., Petrides, G. et al. (1996) Catatonia. I. Rating scale and standardised examination. Acta Psychiatrica Scandinavica 93, 129 - 136.
- Cohen, H. (1961) The evolution of the concept of disease. In: Concepts of Medicine (ed. B. Lush), pp. 159 - 169. Pergamon, Oxford.
- Creer, C. & Wing, J.K. (1974) Schizophrenia at Home. National Schizophrenia Fellowship, London. [Reprinted with a new preface, 1988.]
- Crow, T.J. (1985) The two syndrome concept: origns and current status. Schizophrenia Bulletin 11, 471 - 486.
- Crow, T.J. (1998) Nuclear schizophrenic symptoms as a window on the relationship between thought and speech. Schizophrenia Research 28, 127 - 141.
- Diem, O. (1903/1987) The simple dementing form of dementia praecox. In: The Clinical Roots of the Schizophrenia Concept (eds J. Cutting & M. Shepherd), pp. 25 - 34. Translated from Die einfach demente Form der Dementia Praecox. Archiv fur Psychiatrie und Nervenkrankheiten 37, 81 - 87.
- Endicott, J. & Spitzer, R.L. (1978) A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry 35, 837 - 844.
- Falret, J. (1854) Lecons Cliniques de Medicine Mentale. Bailliere, Paris.
- Fish, F.J. (1958) Leonhard's classification of schizophrenia. Journal of Mental Science 104, 103.
- Fisher, C.M. (1983) Abulia minor versus agitated behavior. Clinical Neurosurgery 31, 9 - 31.
- Flaum, M. & Andreason, N.C. (1991) Diagnostic criteria for schizophrenia and related disorders: options for DSM-IV. Schizophrenia Bulletin 17, 143 - 156.
- Foucault, M. (1967) Madness and Civilisation. Tavistock, London.
- Foulds, G.A. (1965) Personality and Personal Illness. Tavistock, London.
- Frith, C.D. & Frith, U. (1991) Elective affinities in schizophrenia and childhood autism. In: Social Psychiatry. Theory, Methodology and Practice (ed. P.E. Bebbington), pp. 65 - 88. Transaction, New Brunswick.
- Frith, U. (1989) Autism: Explaining the Enigma. Blackwell, Oxford.
- Frith, U. & Happe, F. (1994) Autism: beyond theory of mind. Cognition 50, 115 - 132.
- Gillberg, C. (2002) A Guide to Asperger Syndrome. Cambridge University Press, Cambridge.
- Goffman, E. (1961) Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. Penguin, Harmonsworth.
- Griesinger, W. (1861) Die Pathologie und Therapie der Psychischen Krankheiten. Krabbe, Stuttgart.
- Gruhle, H.W. (1929) Psychologie der Schizophrenie. In: Psychologie der Schizophrenie (eds J. Berze & H.W. Gruhle). Springer, Berlin.
- Jackson, J.H. (1869/1932) Certain points in the study and classification of diseases of the nervous system. Reprinted in: Selected Writings of
- John Hughlings Jackson, Vol. 2. (ed. J. Taylor). Hodder and Stoughton, London.
- Janzarik, W. (1984) Jaspers, Kurt Schneider und die Heidelberger Psychopathologie. Nervenarzt 55, 18 - 24.
- Janzarik, W. (1987) The concept of schizophrenia: history and problems. In: Search for the Causes of Schizophrenia (eds H. Hafner, W.F. Gattaz & W. Janzarik). Springer-Verlag, Heidelberg.
- Jaspers, K. (1946/1963) General Psychopathology. Manchester University Press, Manchester. Translated by J. Hoenig & M. Hamilton from Allgemeine Psychopathologie. Springer Verlag, Heidelberg.
- Joseph, A.B. (1992) Catatonia. In: Movement Disorders in Neurology and Neuropsychiatry (eds A.B. Joseph & R.R. Young), pp. 335 - 342. Blackwell Scientific, Boston.
- Kahlbaum, K. (1874/1973) Catatonia. Johns Hopkins University Press, Baltimore. Translated by Y. Levij & T. Priden from Die Katatonie oder das Spannungs-Irresein. Hirschwald, Berlin.
- Kanner, L. (1943) Autistic disturbances of affective contact. Nervous Child 2, 217 - 250.
- Kendell, R.E. (1987) Diagnosis and classification of functional psychoses. British Medical Bulletin 43, 499 - 513.
- Kendell, R.E. (1989) Clinical validity. Psychological Medicine 19, 45 - 55.
- Kendell, R.E. & Brockington, I.F. (1980) The identification of disease entities and the relationship between schizophrenic and affective psychoses. British Journal of Psychiatry 137, 324 - 331.
- Kendell, R.E., Cooper, J.E., Gourlay, A.J. et al. (1971) Diagnostic criteria of American and British psychiatrists. Archives of General Psychiatry 25 (2), 123 - 130.
- Kendler, K.S. (1985) Diagnostic approaches to schizotypal personality disorder: a historical perspective. Schizophrenia Bulletin 11, 538 - 553.
- Kleist, K. (1960) Schizophrenic symptoms and cerebral pathology.Journal of Mental Science 106, 246 - 255.
- Kraepelin, E. (1896/1987) Dementia praecox. In: The Clinical Roots of the Schizophrenia Syndrome (eds J. Cutting & M. Shepherd), pp. 15 - 24. Cambridge University Press, Cambridge. Translated from Lehrbuch der Psychiatrie, 5th edn, pp. 426 - 441. Barth, Leipzig.
- Kraepelin, E. (1920) Die Erscheinungsformen des Irreseins. Zeitschrift fur Neurologie und Psychiatrie 62, 1 - 29.
- Kretschmer, E. (1966/1974) The sensitive delusion of reference. In: Themes and Variations in European Psychiatry (eds S.R. Hirsch & M.Shepherd). Wright, Bristol. Translated from Der sensitiver Beziehungswahn. Springer, Heidelberg.
- Laing, R.D. & Esterson, A. (1964) Sanity: Madness and the Family. Tavistock, London.
- Leekam, S.R., Libby, S.J., Wing, L. et al. (2002) The diagnostic interview for social and communication disorders. Algorithms for ICD 10 childhood autism and autistic spectrum disorders. Journal of Child Psychology and Psychiatry 43, 325 - 327.
- Leonhard, K. (1957) Aufteilung der Endogenen Psychosen. Akademie Verlag, Berlin.
- Locke, J. (1959) Essay Concerning Human Understanding, Vol. 1, 2nd edn (ed. A.C. Fraser ). Dover, New York.
- Lorr, M. (1966) Explorations in Typing Psychotics. Pergamon, London.
- McKenna, P.J., Lund, C.E., Mortimer, A.M. & Biggins, C.A. (1991)
- Motor, volitional and behavioural disorders in schizophrenia. II. The 'conflict of paradigms' hypothesis. British Journal of Psychiatry 158, 328 - 336.
- Magnan, V. (1893) Lecons Cliniques Sur les Maladies Mentales. Battaille, Paris.
- Robins, L.N., Wing, J., Wittchen, H.U. et al. (1988) The Composite International Diagnostic Interview: an epidemiological instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 1069 - 1077.
- Rogers, D. (1992) Motor Disorder in Psychiatry: Towards a Neurological Psychiatry. Wiley, New York.
- Scheff, T.J. (1966) Being Mentally Ill. Aldine, Chicago.
- Schneider, K. (1959) Clinical Psychopathology. Translated by M.W.Hamilton. Grune & Stratton, New York.
- Schneider, K. (1976) Klinische Psychopathologie, 11th edn. Thieme, Stuttgart.
- Spitzer, R.L., Endicott, J. & Robins, E. (1975) Research Diagnostic Criteria: Rationale and Reliability. Hodder and Stoughton, London.
- Sturt, E. (1981) Hierarchical patterns in the distribution of psychiatric symptoms. Psychological Medicine 11, 783 - 794.
- Szasz, T. (1971) The Manufacture of Madness. Routledge, London. Tantam, D. (1988) Asperger's syndrome. Journal of Child Psychology and Psychiatry 29, 245 - 255.
- Wing, J.K. (1961) A simple and reliable subclassification of chronic schizophrenia. Journal of Mental Science 107, 862 - 875.
- Wing, J.K., ed. (1975) Schizophrenia from Within. National Schizophrenia Fellowship, London.
- Wing, J.K. (1978) Reasoning About Madness. Oxford University Press, London.
- Wing, J.K. (1991) Social psychiatry. In: Social Psychiatry: Theory, Methodology and Practice (ed. P.E. Bebbington), pp. 3 - 22. Transaction, New Brunswick.
- Wing, J.K. & Brown, G.W. (1961) Social treatment of chronic schizophrenia: a comparative survey of three mental hospitals. Journal of Mental Science 107, 847 - 861.
- Wing, J.K. & Brown, G.W. (1970). Institutionalism and Schizophrenia.Cambridge University Press, London.
- Wing, J.K., Cooper, J.E. & Sartorius, N. (1974) The Description and Classification of Psychiatric Symptoms: an Instruction Manual for the PSE and CATEGO System. Cambridge University Press, London.
- Wing, J.K., Sartorius, N. & Ustun, T.B. (1998) Diagnosis and Clinical Measurement in Psychiatry: the SCAN System. Cambridge University Press, Cambridge.
- Wing, L. (1981) Asperger's syndrome. Psychological Medicine 11, 115 - 129.
- Wing, L. (1982) Development of concepts, classification and relationship to mental retardation. In: Psychoses of Uncertain Aetiology (eds
- J.K. Wing & L.G. Wing), pp. 185 - 190. Cambridge University Press, Cambridge.
- Wing, L. (2000) Past and future research on Asperger Syndrome. In: Asperger Syndrome (eds A. Klin, F. Volkmar & S. Sparrow). Guildford Press, New York.
- Wing, L. & Gould, J. (1979) Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorder 9, 11 - 29.
- Wing, L. & Shah, A. (2000) Catatonia in autistic spectrum disorders. British Journal of Psychiatry 176, 357 - 362.
- Wing, L., Leekam, S.R., Libby, S.J. et al. (2002) The diagnostic interview for social and communication disorders. Journal of Child Psychology and Psychiatry 43, 307 - 325.
- Wolff, S. (1995) Loners: The Life Path of Unusual Children. Routledge, London.
- World Health Organization (1973) The International Pilot Study of Schizophrenia. WHO, Geneva.
- World Health Organization (1993) The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO, Geneva.
- World Health Organization (1999) Schedules for Clinical Assessment in Neuropsychiatry. World Health Organization, Geneva.
Provided by ArmMed Media