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Is Autism a Mental Illness?

The strange battle over what's psychiatric versus neurological.

There was an interesting exchange this past Tuesday on CNN’s Anderson Cooper show about whether autism is a mental illness versus some other kind of developmental or neurological state. The two guests were Dr. Wendy Walsh, a psychologist and regular speaker on CNN, and Liza Long, an author, fellow PT blogger, and mental health advocate. The guests were discussing the new revelations that the gunman in the Roseburg, Oregon shootings may have been diagnosed with Asperger’s at one time. For most of the interview, the two guests were in complete agreement and said many things that should be said, such as reminding viewers that people on the autism spectrum are far more likely to be victims of violence than perpetrators of it. But then Dr. Walsh veered in a different direction and made the comment that, by the way, Asperger’s was not a mental illness but rather a description of people who are not “neurotypical.” Dr. Walsh also implied, incorrectly, that the reason Asperger’s was removed from the official catalogue of psychiatric disorders in the DSM-5 manual was in recognition of this recategorization. Liza politely objected to the idea that autism should be carved out this way and argued that such boundaries were artificial and potentially harmful.

This debate has surfaced many times before and in many venues. It is a difficult one to resolve because there really is no scientific basis on which to separate a psychiatric disorder from a neurological or developmental one. Certainly, there are some things that feel different when considering autism, especially in its more severe forms, relative to things like depression or anxiety. The development of autism seems less dependent on environmental factors than something like PTSD, for example. It also is generally present at a very early age. For many, autism just seems more intrinsically “biological” than many other conditions. With closer scrutiny, however, it is easy to find holes in these distinctions. As science progresses, the neurobiological basis, or at least substrate, of many other psychiatric conditions is increasingly appreciated. And even though there seems something quite medical about autism, we still have been unsuccessful in identifying the specific processes in the brain that underlie the condition, similar to more classic psychiatric disorders.

Unlike diagnoses such as bipolar disorder and schizophrenia, the physicians who specialize in assessing and treating autism are more wide-ranging and include behavioral pediatricians, neurologists, and psychiatrists with no single specialty “claiming” this particular condition. This, of course, is in addition to the many non-physicians (psychologists, speech pathologists, occupational therapists, special education teachers, etc.) that often provide the bulk of care. Autism treatment definitely works best as a team approach. At the same time, it is probably true that the largest number of patient visits with a specialist physician for autism come from psychiatrists. Furthermore, the only medications with FDA approval in autism are psychiatric medications, although these are used to address irritability and aggression and not the core autistic features.

Yet despite these facts and the lack of any solid basis on which to divide various diagnoses into tidy categories, many autism advocates have worked hard to frame it as a developmental or neurological disorder rather than a psychiatric one. In a classic “be careful what you wish for” moment, they were successful enough to convince some insurance companies not to cover patient visits with psychiatrists that were related solely to autism, leaving some families scrambling to get the care they need.

Autism Speaks currently seems to be trying to avoid this quagmire by now calling autism “a group of complex disorders of brain development.” Such a description is true enough, but the statement seems just as valid for a variety of other diagnoses such as ADHD or even bipolar disorder.

The motivation behind the push to label autism as something other than a psychiatric disorder, in my view, comes much more from fears of stigma than any scientific principle. Unfortunately, however, one unintended consequence of the push to move certain conditions out of the mental illness category is increased stigmatization for those that remain there. “We are not you,” is the not so subtle message being sent.

I guess my main point here is that if someone wants to label more extreme and less typical behavior as psychological or neurological or developmental (or as no disorder at all) then that's their interpretation. However, what is neither scientifically supported nor constructive is to parse out us versus them or you’re ill and I’m not groups that promote further division and stigma. We need to appreciate fully how words like psychiatric, neurological, and developmental are really our own arbitrary creations that the human brain doesn’t recognize or respect. From there, I wonder if it might be best just to leave terms like “mental illness” behind for everyone in favor of more encompassing labels that don’t carry the same history or baggage. Maybe something like “complex brain disorders” would work? That way, we can move beyond this weary debate and work to speak in a unified voice for adequate resources and rights for all people who struggle with cognitive-emotional-behavioral challenges, whatever we decide to call them.

For more reading on a related topic, please see my earlier post, What If We All Got Mentally Sometimes?

@copyright by David Rettew, M.D.

I am the author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine. Follow me at @PediPsych and like PediPsych on Facebook.