Diagnostic Criteria

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Autism is a neurological condition, present from early childhood, characterized by great difficulty in communicating and forming relationships with other people and in using language and abstract concepts.

Since the 2013 change in diagnoses, classical autism and Aspergers now share the same diagnostic criteria, with severity tables indicating “low” or “high” functioning ability.

The shift in diagnostic criteria has caused some disruption in the autistic population, with fears of greater stigma… but I think it’s actually given those with “high” functioning autism a chance to access better services.

As you may know, the condition of autism is a spectrum, so abilities of a person who is considered “high functioning” may not pertain to a complete comfort or “normality” in all areas of their life. As such, the new criteria has allowed all autistics a chance to be seen for their difficulties and their strengths.  And in terms of stigma/ discrimination, I fathom this is more a challenge at a social level.  Our diagnostic criteria ought not impact this…

Anyway. Without further ado…

The formal diagnostic criteria for Autism Spectrum Disorder, per the new Diagnostic Statistical Manual for Mental Health (299.00, American Psychiatric Association, 2013) is as follows:

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A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history :

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

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B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or  perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to  specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

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C. Symptoms must be present in the early developmental period

(Symptoms may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

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D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

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E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

Intellectual disability and autism spectrum disorder frequently co-occur; to make co-morbid/ dual diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

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Specify if:

  • With or without accompanying intellectual impairment
  • With or without accompanying language impairment
  • Associated with a known medical or genetic condition or environmental factor
  • With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition)

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Specify current severity:

  • Severity is based on social communication impairments and restricted,
    repetitive patterns of behavior–

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Level 1 – Requiring Support – Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

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Level 2 – Requiring Substantial Support – Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others.  Inflexibility of behavior, difficulty coping with change, or other restricted / repetitive behaviors appear frequently enough to be obvious to the casual observer
and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.

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Level 3 – Requiring Very Substantial Support – Severe deficits in verbal and non-verbal social communication skills cause severe impairments in functioning, very limited  initiation of social interactions, and minimal response to social overtures from others. Inflexibility of behavior, extreme difficulty coping with change, or other restricted / repetitive behaviors markedly interfere with functioning in all spheres. Great distress / difficulty changing focus or action.

 


 

Please be mindful that diagnoses MUST be undertaken by a trained professional, commonly a clinical psychologist or psychiatrist.  While you may self-identify, you cannot access services readily without a formal diagnosis.

Bipolar vs. Autism

Research shows that autism shares signatures with schizophrenia and bipolar disorder. But is this a case of co-occurrence, or just that of misdiagnosis?

 

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For those who are not familiar with bipolar disorder, this is a condition which affects MOOD. Individuals slide from feelings of intensely elevated (mania) to intensely low (depression) in a pattern of repeating episodes. Some people cycle rapidly through these moods, others follow more slow set patterns.  Bipolar individuals get “stuck” in moods, and often experience extreme negative intrusive thoughts which can lead to relationship difficulties and suicidal ideation.

In autism, individuals also experience relationship issues and mood disturbances. We too get “stuck” in emotional states and experience periods of mania and long-standing depression.  We hyper-focus, suffer irritability, intrusive thoughts and suicidal ideation.

So what’s up? Are all autistics bipolar, or all bipolars autistic?

 

Can bipolar and autism co-occur?

Many researchers and therapists say NO. They say that autistics are often misdiagnosed as bipolar, because of the periods of mania that many of us experience. I have to agree.  I have met many autistics who have been misdiagnosed and given medications for bipolar due to their presentations of mania, depression, anger, sadness and general confusion about the world.  In women, most often the misdiagnoses are disassociation or borderline personality disorder; in men, bipolar or schizophrenia.

An old study (which is too often quoted as the prevailing thought) showed that 27 % of autistics also have symptoms of bipolar disorder, and I reckon that’s where it stops: SYMPTOMS.  Just because you have some symptoms of the bubonic plague doesn’t necessarily mean you’re about to die from the plague.  You could just as easily have the flu, or an infection from an untreated blister.  My point is that while there are overlaps,  I think bipolar is mistakenly over-diagnosed in those with autism.

I think there’s something to be said about how autistics and bipolar individuals relate.  I can sort of see both sides, because I have bipolar friends… I think bipolar is distinctly different because there’s a much stronger lean towards negativity, and to the idea that the Self is not true, or not clear.

Christopher Baddock explains this well. He says—

“Autism involves difficulties reading others; it is an inter-psychic disorder. Bipolar, however, is …intra-psychic mentalism: in other words, [difficulty] reading of your own mind. Normally, we read our own mental states by way of sensing our moods, thoughts and feelings in relation to something, and report these to others with phrases like I feel like Y; I’m in the mood for X; or, I’m happy with Z. In bipolar disorder, these internal mind-readings become pathologically exaggerated into crippling swings… often combined with delusional ideas about the self, messianically megalomanic or suicidally self-critical as the case may be”

So, with autism, we can get to understand ourselves and learn what our authentic feelings are.  We may have intrusive thoughts (OCD), but the grounding is still us to ourselves in clarity of feeling.  When we look externally, THAT is where we struggle.  In bipolar, they look within and struggle.

 

What are the differences and similarities between bipolar and autism?

The symptoms of bipolar disorder fall into two overarching categories: mania and depression.  Most untreated bipolars flip between the two and rarely find any periods of “normal” or “balanced” self. A “normal” state for a bipolar individual varies, but what I know from friends with bipolar, they say it’s a place where they have control over their emotions and feel stable to get things done without feeling pulled towards a pole. So, without further ado, here’s the bipolar symptoms, based on the mood extremes–

Symptoms of a manic episode include:

  • excessive happiness, upbeat and wired
  • suddenly changing from joy to irritability to angry to hostile
  • increased energy and agitation
  • restlessness
  • exaggerated sense of self and inflated self-esteem
  • sleep disturbances
  • poor judgment and impulsive behaviour
  • being easily distracted, forgetting stuff
  • drug and alcohol abuse, excessive sex-drive or promiscuity
  • mania leading to difficulties maintaining relationships

 

Symptoms of a depressive episode include:

  • acting or feeling down or depressed, sad, or hopeless or worthless or VICTIM-like
  • difficulty making decisions
  • loss of interest in normal activities
  • sudden and dramatic changes in appetite
  • unexpected weight loss or weight gain
  • fatigue, loss of energy, and sleeping lots
  • inability to focus or concentrate
  • suicidal thoughts or attempts
  • disconnecting from relationships, people, things

 

Autism is a unique and complex disorder where symptoms vary from person to person, along with the severity of those symptoms.  In general, autism presents with:

  • challenges with social interaction and communication
  • difficulties creating and maintaining relationships
  • a tendency to prefer routine and structure
  • focus on repetitive behaviours (often undertaken leading to self-soothing)
  • displaying very specific preferences for item placement or activities

If there’s auditory processing disorder alongside autism (a common dual disability), the autistic can also present with difficulties concentrating, remembering information, and an agitated state.

 

As you read the two groups of symptoms– the mania/ depression from bipolar and those of autism, you’ll see they are remarkably different.  I think the overlap is seen as times where the autistic person is emotional.

 

Anyway, I guess it’s possible you’re reading this and you’re that one person who is legitimately bipolar AND autistic! I guess it’s possible to have both, but if you have got a bipolar diagnosis and you feel as though it doesn’t quite fit…. maybe you actually have autism?

Just a thought.

Hey Girl: You Don’t Look Autistic!

Why autistic women don’t fit the DSM-5 criteria

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Autism is a spectrum, so regardless of what you know, you’ll rarely see someone who exhibits exactly what you know. Perhaps you are unaware, but the main diagnostic criteria that is present in the DSM-5 pertains to the MALE characteristics. Much like most of medicine, a woman’s experience has been reduced to the idea that we are simply “little men”. See this article for more on that!

In females, autism presents differently.

*enter shocked face here*

A female’s gender role (i.e. how we are forced into social situations from a young age… aka gender stereotyping) leads to this ability to apply our attention to detail and observation skills to very good use. What do female autistics do from childhood? We copy. We mimic social cues and social interactions which makes us go ‘unseen’. We can read you and copy you, so our behaviour often does not reflect what you *think* you know about autism.

Now, I am sure someone wants to say, “but that’s just mirroring; every child does it”. Indeed. That is true for non-autistics. We, however, are aware that we do not fit in, even though we look like you; we know we’re copying you. It’s a cognitive thing. It’s NOT automatic. It’s thought-out, planned copying. And the interesting thing about female autism is that our level of copying you is actually often better than how you do it.

Growing up, females on the spectrum learn to fit in. We realize it’s a survival mechanism, so we survive. We hide our autistic traits, we “pretend” to be normal, for YOUR benefit. It is extremely taxing on our well-being, and many women on the spectrum (including me) experience anxiety and depression at times, trying to produce this “perfect social expression” so that you will accept us. We do it do be accepted, even though it hurts us.

Other than the mimicking, females on the spectrum struggle because our special interests are most commonly things that are strangely considered “normal” for our gender. Where a boy may fixate on trains (which is often stereotyped as inherently male), the appearance of such an interest is included as an example in the DSM. However, a girl with a passion for teddy bears, flowers, or sewing — this is considered ‘acceptable’…. even if her whole room is covered with those things, or if she seems obsessed with those things, it’s still okay. Somehow, being female means “it’s normal”. And, furthermore, when a female autistic child fixates on 1 person, making that person their special interest, no-one bats an eyelid — everyone just says, “aww she has a best friend”. If she is shy, that’s also acceptable. If she is overly energetic, that is “fun”; babylike, that is “cute”; a bookworm, that is “studious”… we constantly overlook the female experience with gendered thoughts!

Do I look autistic? Probably not. But then again, you are looking for male characteristics.

And one more thing — when ANY autistic person is completely involved in something they love, be that a hobby or a job, they will (like any human) excel. We, when doing what we are skilled at, qualified for, and enjoy; we will shine. We may seem unusually extrovert, fun, loud, engaging and/ or inspired. We may seem “without trouble”, and really — is that not a true reflection of any human in such a similar situation?

I excel in teaching and leading groups; reaching, inspiring, mentoring and supporting others. I shine where I am designing new products, being innovative, developing something, solving a problem, applying research, or simply “doing good”.

If you want to help autistics shine, let us demonstrate our talent and ability, and stop saying to us “you don’t look autistic”; better be humble and note your destructive bias. Better be kind and see our ‘humanness’ first.