Blurry lines between autism and it’s comorbidities

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In my other post that talked about the social model of disability, there was a brief discussion about the deficits caused by ASD alone and the ones caused by the common comorbidities that accompany ASD.

Given that a neurodiverse brain is essentially different from the control (a neurotypical brain), and the different wiring alone may land itself to present the common comorbidities, how do we draw the line between what’s “purely” ASD and what is comorbidity?

I was listening to a neuroscience presentation where they were talking about ASD as being a multifaceted condition, where its presentation is essentially unique in each individual. Yes, there is a social deficit component that may have varying degrees, and a multitude of repetitive behaviors and sensory processing deficits. Each of these categories can have an infinite number of combinations and degrees of intensities.

But where do you draw the line between ASD and the comorbidities when the exact definition of ASD changes from person to person? Who is to say that the comorbidities are independent from the ASD?

ASD is not only a social “disorder” of the brain. It is more than that. It affects the patterns of how thought is organized. It affects the brain’s neuroanatomy and levels of neurotransmitters.

Until someone presents a stronger explanation, I will believe that each autistic person has their own recipe for their autism, and in that recipe, they will have some level of social-communication issues, some level of repetitive behaviors, and some level of other deficits and conditions such as facial blindness, dyslexia, dyspraxia, executive dysfunction, working memory deficits, attention disorder, alexithymia, etc. Infinite possibilities and combinations.

The answer is we don’t know very well what is an autism trait or a co morbid condition. Until we do have a better idea the seemingly never ending debate between autism is a disease in need of a cure vs autism as a different way of being will go on.

There are conditions that many Autistic people experience that are their own separate diagnoses that other people also have without having Autism. I think that that kind of plays a part in what is considered a comorbid and what is not and I think what is also considered is how many Autistic people have the certain condition and with what severity. For example, I am not sure of my figures, so please correct me if I am wrong, but I read somewhere, can't remember specifically where, that 26% of Autistic people have Cerebral Palsy. So I would safely say that Cerebral Palsy is a comorbid and not actually part of the Autism. And many people have Cerebral Palsy without having Autism. On the flip side, most Autistics that I have spoken to have some form of hypertonia. I only say most because I have not asked this question to all of the Autistics that I have ever spoken to. But all of the Autistics or parents of Autistics that I have asked, say that they have this. I have it very severely. Doctors that I have spoken to have told me that every single one of their Autistic patients has some degree of hypertonia, whether it be very mild or very severe like mine. So I believe that that is actually part of the Autism.

Ok. This is an interesting discussion. So perhaps we need to separate the comorbidities in two different groups: pathologies and conditions.

Even though both pathologies and conditions can appear in non-ASD people, the non-pathological conditions could be thought of as what “flavors” someone’s autism. Those would be like someone’s dyspraxia, alexithymia, prosapagnosia, etc.

The pathological comorbidities would include things such as Down syndrome, fragile x syndrome, mitochondria disease, GI dysfunction, etc.

This could be a way to better delineate what belongs to someone’s individualized autism recipe. But it is still hard to say that those pathologies would not be present if that person had not been born on the spectrum.

We could also classify them in terms of mental health/neurological vs internal organ related. Or perhaps hormonal vs energy related; or even something else I didn’t think of.

The overlap is so great, since the brain is the control center of the body, that any dysfunction happening elsewhere in the body (or in the brain itself) makes you think how all the comorbidities interconnect.

Achieving the fine balance to get an autistic person healthy is the enigma. When it comes to the neurotransmitter levels, vitamin levels, blood work levels, etc, who is to say that what is within normal limits for NTs will also be true for autistics?

I like how you are breaking this up. I think it is very important to study this subject and see where the differences lie and what is Autism related and what is not.

In my own case, well, my whole case is not very clear.
I could wake up highly qualified on all possible comorbids out there, only to wake up on days or weeks or months after or so disqualified from all it.

So whatever comorbid I got, that causes comorbids to 'happen', is mainly biological.

There's just something within my body's system that causes these changes and giving me a rather wide ranges of confusing functioning levels and several comorbid 'happenings' within varying timespans.

No amount of restrictions, maintenances and routines seem to 'correct' it.
In fact, there are times I went super negligent -- junk foods, high on screen exposures, less hours of sleep, yet woke up super functioning for weeks.
Or wake up with weeks and months of healthy maintenances, yet still waking up with pathetic levels of functioning.
Same true with other way around.
It seems to ignore reproductive cycles, seasonal changes and situational circumstances. Even moods, levels of awareness and states of consciousness -- as I found, independent from the practical functioning levels.

Than merely some 'bad day' or 'good day' moment that everyone can have -- short term with explainable patterns and logical reason for it...
Mine doesn't seem to have that -- except waking up that way.
I only have so many memories of varying functioning experiences, that I cannot base my past abilities and achievements for my own present and future.

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Lose more time here - Updates at least once a week.

In general, I think that there is little point in trying for exact definitions of various conditions, because there are always at least minor combinations of strangeness to affect progress, and because the infinite combinations with two or more major factors are somewhat like whole new conditions themselves.
I think that AS gave me some high aptitudes, and some low aptitudes, but that by now, more of my troubles are caused by the traumas of trying to live with them. My AS mother gave me a major attachment disorder early on, and later experiences with irrational people gave me PTSD that pretty much rules my life now.

The problem is people look at autism in the same way as a disease where theres a pure form of it i.e theres a pure form of Tuberculosis for example.

Theres huge irony in this as many critise those who treat autism as a disease,but those who critise still think like this even if its unconsciously.

Autism is a malformation / deformaty of the brain that can range from hardly detectable to severe. All co morbid conditions stem from whats impacted and how bad.

As the functions of the brain are so vast and varried these black hole deficits can arise anywhere, as the old saying goes you've seen a child with autism you've seen just one presentaion of the condition.

In My Humble Opinion (IMHO) many of the relationships between autism and comorbidities are a function of stress. Most Aspies experience significantly more stress than the average neurotypical. It should almost be our middle name.

From my perception:

Stress Based Aspie Traits
* hypersensitivity to senses...............................................................................∆
------ sight
------ smell
------ hearing
------ taste
------ touch
* sensory overload and shutdowns........................................................................€
* weakening of the autoimmune system..................................................................O
* gastrointestinal problems related to prolonged stress................................................O
* mental health problems/psychological disorders......................................................€
------ depression
------ self-harm
------ suicidal
------ eating disorders (anorexia, bulimia)
------ bipolar disorder (BD), maniac depressive disorder (MAD) - obsessive-compulsive disorder (OCD)
------ attention-deficit/hyperactivity disorder (ADHD) - generalized anxiety disorder (GAD)
------ post-traumatic stress disorder (PTSD)
------ agoraphobia
------ intermittent explosive disorder (IED)
------ childhood onset schizophrenia (COS) disorder
* ret*d growth..............................................................................................O
* suppressed reproduction (inability in courtship, gender identity disorder, premenstrual dysphoric disorder (PMDD))........................................................................,........€
* exhibits self-stimulatory behavior (stimming), Tourette syndrome (TS)............................∆
* picky eater....................................................................................................∆

Legend
∆ – Stress at the Core (Preverbal)
O – Biological Resource Deprivation
€ – Stress Energy Storage Overload

The relationship between stress and these conditions are primarily derived from the study of animals. Stress is a part of life and is not inherently bad. All life forms have evolved mechanisms to cope with the stresses in their lives. Animals experiencing severe stress can succumb to disease or fail to reproduce or develop properly. Stress is the biological response elicited when an individual perceives a threat to its homeostasis. The threat is the ‘stressor’. When the stress response truly threatens the animal’s well-being, then the animal experiences ‘distress’.


Jimmy M., thank you for this chart--it's pretty comprehensive & describes the "autism experience" in a way I couldn't dream of getting right.

I placed the following on my blog back in 2008. Lorna Wing made this interesting contribution to autism & its co-morbids ...

I entitled it "What's In a Label?"

The NAS Autism Helpline is frequently contacted by parents who are puzzled by the diagnostic label their child has been given. Confusion is also expressed on many online forums and in support groups, both on and offline the world over, by both those on the spectrum and their families. Most parents are now familiar with the terms ‘autism’ and ‘autistic spectrum disorder’, but problems arise with a range of other diagnoses where the relationship to the autistic spectrum is not clear. In the following article, Lorna Wing helps provide clarity.

The use and misuse of diagnostic labels

Clarification is important because, whatever other condition may also be present, when a child or adult has an autistic spectrum disorder, this has a major effect in determining the needs of the person concerned. Providing the right kind of help and services is essential for the person’s future progress and quality of life. The right diagnosis and the right help also makes life much easier for the person’s family.

1. Terms used for autistic disorders


Autistic spectrum disorders

Commonly used to cover the whole range of conditions that have in common the triad of impairment of social interaction, social communication and social imagination. This triad is associated with a repetitive pattern of behaviour. The social interaction impairment is the most important part of the triad so people who have this on its own can be included in the spectrum. This is particularly relevant for people coming for a diagnosis later in childhood or adult life. They may have learned to compensate for their disabilities in communication and imagination, but the social interaction impairment is still evident even though it may be shown in subtle ways.


Pervasive developmental disorders

Used in the International Classification of Diseases, 10th edition (ICD-10) and the American Diagnostic and Statistical Manual, 4th edition (DSM-IV) to cover more or less the same range as autistic spectrum disorders.


Childhood autism (ICD-10)

Used when the person’s behaviour fits the full picture of typical autism.


Autistic disorder (DSM-IV)

This is the same as childhood autism.


Atypical autism (ICD-10)

Used when the person’s behaviour pattern fits most but not all the criteria for typical autism.


Pervasive developmental disorder not otherwise specified (PDD-NOS)

This is more or less the same as atypical autism.


Asperger’s syndrome (ICD-10)/Asperger disorder (DSM-IV)

Briefly, this is used for more able people who have good grammatical language but use it mainly to talk about their special interests.

2. Labels sometimes used for particular patterns of disabilities and/or behaviour that can be found among people with autistic spectrum disorders


Some professionals in the field have picked out particular patterns of disabilities and/or behaviour that can be seen in some people with autistic spectrum disorders, and have named them as separate syndromes.


There is disagreement as to whether these so-called syndromes can ever occur on their own without the social, communication and imagination impairments that are diagnostic of an autistic spectrum disorder.


My own view, shared by many colleagues, is that they are part of the autistic spectrum, as is shown when a detailed developmental history is taken.


Non-verbal learning disorder(NVLD)

Study of the criteria for this condition shows that it covers people with the social behaviour pattern of Asperger syndrome, who also have problems with the non-verbal skills of arithmetic and some visuo-spatial skills. Asperger included such people in his descriptions but also included people with social problems who were very good with numbers and visuo-spatial skills.


Right hemisphere learning disorder

The same as non-verbal learning disorder. The non-verbal learning problems mentioned above are mainly located in the right hemisphere.


Semantic-pragmatic disorder

Good grammatical language but lack of ability to use language in a socially appropriate manner. This pattern is characteristic of the people Asperger described.


Pathological demand avoidance (PDA)

Briefly, avoidance of everyday tasks and manipulative, socially inappropriate, in some cases aggressive, behaviour.

3. Developmental disorders that are not in the autistic spectrum but often occur together with an autistic spectrum disorder


These developmental disorders can occur on their own – that is, the child or adult concerned does not have the triad of impairments. However, the disorders listed below very often occur as part of the picture of an autistic spectrum disorder.


One of the most common mistakes made by clinicians lacking experience with autistic disorders is to observe the person’s clumsiness, or reading difficulty, or poor attention span and to diagnose that as the main problem.


They miss the fact that underlying the obvious difficulties seen on the surface is an autistic spectrum disorder with the characteristic social impairments.


It is of the greatest importance that the autistic spectrum disorder is recognised and the appropriate help and services provided.


Attention deficit/hyperactive disorder (ADHD)

Poor attention span together with marked overactivity.


Hyperkinetic disorder

Marked overactivity without poor attention span.


Attention deficit disorder(ADD)

Poor attention span without marked overactivity.


Tourette’s syndrome

A condition in which the person has many sudden involuntary jerky movements and vocal noises they cannot control.


Dyslexia

Specific difficulty with reading.


Dyspraxia

Specific difficulty with co-ordinating movements.


Developmental co-ordination disorder

Same as dyspraxia


Disorder of attention, motor co-ordination and perception (DAMP)

Used when the person has a combination of these problems; the perceptual problem may, for example, be dyslexia.

4. Physical conditions affecting the brain that can be associated with autistic spectrum disorders

There are a number of conditions of this kind that can be associated with autistic spectrum disorders. Just a few examples are:


Tuberous sclerosis

Fragile X

Rett’s syndrome

Brain damage following encephalitis


If a child or adult has one of these conditions together with an autistic spectrum disorder, the physical condition should have appropriate treatment.


The autistic spectrum disorder requires the type of treatment, education and other services as for any autistic spectrum disorder occurring on its own.

5. Terms used in the International Classification System that are applied to difficult behaviour


Conduct disorder

Oppositional defiant disorder


These labels are most unhelpful. They simply name the behaviour without any indication of the underlying cause.


It is possible for a child or adult with an autistic spectrum disorder to be given one of these diagnoses if a proper history is not taken and the proper psychological investigations are not carried out.


If this happens, the needs of the child or adult concerned and their family are likely to be misjudged, with disastrous results.


Advice for parents


If parents are given one or more of the labels listed under 2. – 5. above, but feel that their son or daughter has features of an autistic spectrum disorder, the first step is to discuss this with the professional who has made the diagnosis.


If this professional insists that autism, in any of its forms, is not present, the parents should ask to be referred to someone who specialises in the field of autistic spectrum disorders.



Subtypes of Aspergers(Lorna Wing et al)

Aloof

Most frequent subtype among the lower functioning. Most high-functioning in this group are a mixture of aloof and passive. Limited language use. Copes with life using autistic routines. Most are recognised in childhood. Independence is difficult to achieve. There may be loneliness and sadness beneath the aloofness. Rain Man is an excellent example of this subgroup.

Passive

Often amiable, gentle, and easily led. Those passive rather than aloof from infancy may fit AS. More likely than the aloof to have had a mainstream education, and their psych skill profiles are less uneven. Social approaches passively accepted (little response or show of feelings). Characteristic autistic egocentricity less obvious in this group than in others. Activities are limited and repetitive, but less so than other autistics. Can react with unexpected anger or distress. Recognition of their autism depends more on observing the absence of the social and creative aspects of normal development than the presence of positive abnormalities. The general amenability is an advantage in work, and they are reliable, but sometimes their passivity and naivete can cause great problems. If undiagnosed, parents and teachers may be disappointed they cannot keep a job at the level predicted from their schoolwork.

Active-but-odd

Can fall in any of the other groups in early childhood. Some show early developmental course of Kanner’s, some show AS. Some have the characteristic picture of higher visuospatial abilities, others have better verbal scores (mainly due to wide vocabulary and memory for facts). May be specific learning disorders (e.g., numerical). School placement often difficult. They show social naivete, odd, persistent approaches to others, and are uncooperative in uninteresting tasks. Diagnosis often missed. Tend to look at people too long and hard. Circumscribed interests in subjects are common.

Stilted

Few, if any clues to the underlying subtle handicap upon first meeting. The features of AS are particularly frequent. Early histories vary. Normal range of ability with some peaks of performance. Polite and conventional. Manage well at work. Sometimes pompous and long-winded style of speech. Problems arise in family relationships, where spontaneity and empathy are required. Poor judgement as to the relative importance of different demands on their time. Characteristically pursue interests to the exclusion of everything and everyone else. May have temper tantrums or aggression if routine broken at home, but are polite at work. Diagnosis very often missed. Most attend mainstream schools. Independence achieved in most cases. This group shades into the eccentric end of normality.

Source: http://www.aspie-editorial.com/whats-in-a-label/

Jimmy M and Juliette, excellent points! I really appreciate your comments!

Juliette, I can totally see myself in the Stilted subtype.

Comorbidities by themselves can be very well defined and understood in the medical field. But one thing we need to consider is that when they happen on a person with autism, things can change a bit simply because the starting point can be vet different from the standard neurotypical person.

For example, my son has stomach pains due to gastritis. Now we know he has anxiety, and we just learned he is autistic. Before we knew he was on the spectrum, I was left wondering why a 6 year old kid would have gastritis. And the pediatric GI doctor had no explanation for me other than some kids do, we don’t know why. Now, with the ASD baseline in place, I am seeing his gastritis in a totally different light. I’m considering stress and anxiety, which aren’t necessarily present because of any major event happening in his life. A lot of the internal stresses that we deal with by ourselves can do a number on our GI system. May not even be a parent to anyone else.

I think sometimes the medical community fail to see the person as a whole, and only see the part of the person that corresponds with their specialty. And so, we miss headaches that may be caused by stomach issues, because the neurologist is not considering “stomach” or “GI structures”, he is considering only “brain structures”.

There may be doctors who understand complex conditions, but I'm sure that there are far more who are just guessing when they prescribe antidepressants. It isn't unusual for types and dosages to be changed monthly for a year. I have been physically attacked by two people during their experimental phase, and by no others.