The Key to Diagnosing Autism Spectrum Disorder in Adults: Theory of Mind

Introduction

• Autism spectrum disorder (ASD) is a neurodevelopmental disorder. It poses life altering challenges, both for those who live on the spectrum((I never say somebody “has autism” or is “autistic.” Instead, I talk about “living on the spectrum” or “living with autism.”)) and for those who care about them.
• If you provide psychotherapy to adults, you will discover patients who live on spectrum.
• Often patients who do not live on the spectrum((Sometimes people not on the spectrum are referred to as “neurotypical.”)) have spouses, children, parents, friends, work supervisors and others on the spectrum.
• It is important that all providers of psychotherapy for adults be competent in diagnosing ASD in adults for two reasons:
  • Your patients who live on the spectrum can learn about their assets, growth edges, and limitations so as to better manage their social relationships, social communications, and their emotional reactions.
  • Patients not on the spectrum can exercise empathic concern for those people on the spectrum.((Of course, ethical psychotherapists do not diagnose people who are not their patients and, therefore, have not given informed consent to be diagnosed. A delicate line exists between helping our patients understand others’ situations and not enabling our patients to wield a diagnosis of autism like a light saber.))
• Diagnosing ASD in adults is straightforward((Please note that this post is about adults. Please leave the diagnosing ASD in children and younger adolescents to specialists in psychology (e.g. child psychologists, school psychologists, or some neuropsychologists), pediatricians, or child neurologists.)) for any licensed psychotherapists who has learned the basics about ASD.
• Because this post is not a comprehensive overview of ASD, please pay close attention to the ASD diagnostic criteria and the accompanying discussion in the DSM-5­™ (American Psychiatric Association, 2013).

The problem

• As useful as the DSM-5 overview of ASD is, it does not explicitly acknowledge theory of mind (ToM) deficit.
• Theory of mind, or more accurately the lack of theory of mind, is implicit in ASD; the disorder cannot exist except in the absence of theory of mind.

Theory of Mind

ToM has two equal parts:

1. 1. The awareness of the mental states of others, specifically, what other people believe (cognitions), what other people feel (emotions), and what other people want (intentions).
   2. The awareness that the mental states of others can be different from one’s own mental states.

Examples of theory of mind deficits

1. Deeply held belief in the accuracy of one’s own assessments of others’ mental states. Profound resistance to altering one’s own beliefs in spite of contrary objective evidence.
2. Personal identity firmly tied to one’s own beliefs no matter how illogical in the larger context.
3. Unconsciously ascribing one’s own mental states, especially negative ones, to others. Often quick to see hostility in others where none exists.
4. Narrow framework of subjective reality divorced from logic and science.

Diagnostic criteria

If you are having difficulty in assessing an adult for ASD, here are my suggested changes to the DSM-5 criteria for ASD. I have divided criterion “A” into two parts. The quoted passages below are directly from the DSM-5. I have much respect for the authors of the DSM-5. Their scholarship and clinical experience are obvious, and the DSM-5 remains the single best description of ASD. My justification for adding ToM as a criterion is that ToM demystifies diagnosing  ASD in adults.

1. Persistent deficits in theory of mind that go back to age four to six years and continue to the present. Note that in normal development ToM skills first appear from four to six years of age.
2. “Persistent deficits in social communication….”
3. “Persistent deficits in social interaction….”
4. “Restricted, repetitive patterns of behavior, interests, and activities….”
5. Some evidence that the symptoms go back to early developmental history.
6. “Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.”

Differential diagnosis of autism  spectrum disorder

• Unresolved complex trauma sometimes appears as ASD. (Note that children with ASD often become targets for childhood maltreatment, but that is another part of the ASD narrative.)
• ToM deficits can be present in other disorders, especially schizophrenia.
• Attention-deficit/hyperactivity disorder (ADHD) appears similar to ASD, but closer analysis of patients displaying only ADHD soon reveals a functioning ToM and, therefore, no ASD.
• The DSM-5 lists the following for consideration of differential diagnosis: Rett syndrome, selective mutism, language and communication disorders, intellectual disability, stereotypic movement disorder, attention-deficit/hyperactivity disorder, and schizophrenia.

Associated Signs and Symptoms

The following list can make clinicians aware of the possibility of ASD in an adult. These items are only suggestive, the proverbial “where there is smoke, there may be fire.” A conclusive diagnosis of ASD for an adult must rely on the DSM-5 criteria.

1. Rigid, naïve expectations of others, especially authority figures, sales people, professionals, tradespeople, and family members, even children.
2. Frequent aversion to everyday visual, tactile, auditory, olfactory, and gustatory stimuli.
3. Intense dislike of novel stimuli: Even a change of the packaging in a breakfast cereal.
4. Preoccupational interests: Those that are either highly unusual in themselves or unusual in the resources devoted to the interests.
5. Employment difficulties: Successful employment is more about getting along with others  than the core knowledge, skills, and abilities of a job. The modern workplace is about teams – the lone craftsperson is largely a thing of the past.
6. Not waiting to be invited into activities in new settings, e.g. school recess or new workplace.
7. Obsessive-compulsive issues: Valuing routine and sameness.
8. Savant abilities.
9. Substituting numerical values for human values. Often “funny about money.”
10. Troubled intimate relationships.
11. Transactional style in all relationships.
12. One sibling singled out for maltreatment by parents.
13. Children singled out by adults or peers for maltreatment in K-12.
14. Conflict with authority (Please see #1 on this list).

Please note that I did not include eye contact on this list. Some patients without ASD never give me sustained eye contact, and some patients with ASD stare at my eyes for entire therapy sessions. The lack of eye contact is relevant in infants and children, but not adults.

The Utility or Inutility of Diagnosis

• ASD especially in men is common for unhappily married couples.
• Some adults find the diagnosis of ASD comforting as ways of explaining their social difficulties and illuminating their growth edges.

Evolutionary Psychology and Autism

Hypothesis: People with ASD have been necessary for the survival of their communities because (1) different world views and (2) conflicts with authority provide communities with alternatives to groupthink.

Internet diagnosis

• Lay people often believe that the internet gives them the ability to diagnose ASD.
• But, lay people are often more interested in weaponizing the diagnosis,
• Or they neglect the DSM-5 language: “(C)linically significant impairment in social, occupational, or other important areas of current functioning.”
• Accurate or not, diagnosis must be left to professionals who have obtained informed consent of individuals being evaluated.

Levels of Severity

• The deficits in social communication and the deficits resulting from repetitive behaviors vary from
  • Requiring support
  • Requiring substantial support
  • Requiring very substantial support
• Usually if ASD is not diagnosed until adulthood, the severity level is most often “requiring support.” The more serious levels of severity would have been noticed before adulthood.
• Often adults who live on the spectrum manage to have careers which range from decent to spectacular, but their personal lives are problematic.
• Some adults meet some but not all of the ASD criteria. Although they do not live  on the spectrum, they are socially marginalized and, hence, lonely.

Selected bibliography

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC: Author.
• American Psychological Association (2017). Diagnosing and Managing Autism Spectrum Disorder.  https://www.apa.org/topics/autism-spectrum-disorder/diagnosing
• Badcock, C. (2009). The Imprinted Brain. Philadelphia PA: Jessica Kingsley.
• Doherty, M.J. (2009). Theory of Mind. New York NY: Psychology Press.
• Finch D. C. (2012). The Journal of Best Practices: A Memoir of Marriage, Asperger Syndrome, and One Man’s Quest to Be a Better Husband. New York NY: Scribner.
• Wilkinson, L. A. (Ed.). (2014). Autism Spectrum Disorder in Children and Adolescents. Washington DC: American Psychological Association.

Endnotes

• For the past 10 years I had been mulling over the question: What is the quintessential symptom of autism spectrum disorder?
• I had repeatedly turned to ToM deficit, but that answer never was satisfactory.
• Then I realized that ToM deficit is not the quintessential symptom but rather a necessary but not sufficient condition.
• I hope that by  making ToM deficit explicit, clinicians will be less cowed by the volume of material about diagnosing ASD in adults.
• And, perhaps more importantly helping people on the spectrum acknowledge their growth edges and to find workarounds to reach higher levels of social functioning.

Thank you,

Dr. Michael DeCaria

(The featured photo was taken by the author in Salt Lake City on 2 February 2021, Groundhog Day in the USA and Canada.)