Autism in the Psychodynamic Diagnostic Manual

I recently started an accelerated MS program in Psychology. While exploring psychodynamics for my course, I inadvertently stumbled upon the Psychodynamic Diagnostic Manual (PDM). What is that? Does it have any advantages over other diagnostic manuals? And how does it describe autism? Those are the questions I will be answering today.

NB: If you are only interested in how the PDM describes autism, feel free to skip right to the section entitled The Psychodynamic Diagnostic Manual.

Diagnostic manuals & subjectivity

In many parts of the world, autism is formally diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD).

Both these manuals outline observable symptoms associated with mental health conditions. And that’s very useful, because diagnosis based on observable symptoms is the quickest and easiest way to diagnose many conditions. But there is one significant issue with this approach, which is that the objective “symptoms” take precedence over the subjective experiences of the conditions it describes.

In 1921, a certain M.D. called Tom A. Williams warned us about this, arguing that “subjective sensations of patients have a validity not inferior to the facts which are denominated objective in contradistinction.”^[1]Subjective signs in diagnosis (Williams, 1921) That may not be such an issue when it comes to diseases, but it becomes problematic when describing innate neurotypes such as autism. Why? Because our experiences don’t necessarily align with how others perceive our external behaviors. I quite like this abstract from Williams’ 1921 paper:^[2]Subjective signs in diagnosis (Williams, 1921)

It is customary to deride what is called subjective, i. e., what we learn by the revelations of the patient about himself even when elicited by examination. By ignoring these data failure is courted,
of which scores of examples could be adduced.

The reason of this derision of the subjective is largely a confusion on the part of the examiner between the actual subjective feelings of the patient and a very different phenomenon, viz., the interpretation the patient places on these feelings, which is very often extremely erroneous, as all of us know.

But patients are not the only sinners in this respect,
for the history of medicine is crammed with fallacious interpretations of objective signs […]

By negating the subjective experience, it also becomes far too easy to pathologize certain conditions, and to describe them only in terms of (perceived) negative effects.

And to be fair, it’s not a bad initial approach to describe conditions in terms of objective signs—particularly ones that have a negative effect on the person and their environment, because that is what drives the patient to seek help in the first place—either in the form of therapy, treatment, or simply getting a diagnosis. But it’s an incomplete approach, and it inadvertently gives even many medical professionals the idea that neurotypes such as autism and ADHD are exclusively characterized by deficits and impairments. It also troubles the binary between normality and abnormality, and between optimization and essentialization.^[3]Contesting normal: The DSM-5 and psychiatric subjectivation (Sweet & Decoteau, 2017)

Besides, why wouldn’t you take a more holistic approach to diagnosis, where you assess a person based on both the challenges and advantages that are characterized by the condition, and where you consider the subjective experience just as much as—if not more than—what it externally looks like? I think this will give a much more comprehensive view of what autism entails and how it can manifest, which should benefit autistic people and medical professionals alike.

Psychodynamics

This brings me to psychodynamics. Based on Sigmund Freud’s psychoanalytical theories, psychodynamics is the study of the different parts of the mind (which Freud conceived of as Id, Ego, and Superego) and personality, and how they relate to feelings, emotions, and early experiences. It posits that past experiences—especially in early childhood—shape how a person feels and behaves throughout life.

The unconscious mind and the impact it has on our behavior—informed by childhood experiences and trauma—plays a large role in this. So psychodynamics focuses heavily on subjective experience, and how unconscious drives and past experiences inform our behaviors and our personality.

While gathering information on the seminal researchers and theorists, emphasis on nature or nurture, key tenets, strengths and weaknesses, and contemporary applications and fields of research of psychodynamics, I got a little sidetracked and stumbled upon the Psychodynamic Diagnostic Manual. I had never heard of it before, so I was immediately intrigued. Considering the PDM is based on how our past experiences inform who we are and how we act today, will it show any advantages over the other diagnostic manuals that are in common use?

The Psychodynamic Diagnostic Manual

The PDM is a diagnostic manual grounded in psychodynamic clinical models and theories, explicitly oriented toward case formulation and treatment planning. What excited me about the PDM is that it describes the subjective experiences of various conditions, including autism!^[4]Psychodynamic Therapy (2009) | GoodTherapy

So I acquired a copy of the PDM-2 (2017)—the 2nd edition of the PDM—and looked up autism. Before I give my impression of it, have a look at the table below to see how many pages the PDM-2 (2017), the DSM-5 (2013), and the ICD-10 (1994) dedicate to autism and associated conditions and features.

As you can see, the PDM-2 appears to be quite comprehensive, and seems to feature more information on autism than the DSM-5 and ICD-10. And indeed, the PDM-2 goes into various subjective aspects of autism, including affective states, cognitive states, somatic states, and relationship patterns. And to my surprise, it even describes several aspects of autism and related features that are not described in the DSM-5 and ICD-10!

Autism & gender incongruence

For instance, the PDM-2 dedicates 3 pages to gender incongruence, which is wonderful given that it’s so strongly associated with autism. Based on its description, it seems the PDM-2 defines gender incongruence as broader than gender dysphoria, and attempts to depathologize the concept.^[5]The S Axis in PDM-2. Symptom patterns: The subjective experience (Mundo, Persano, & Moore, 2018) The PDM-2 distinguishes between two subtypes of gender incongruence:

• Desisters — People who grow up to be gay, bisexual, and cisgender (non-transgender) adults.
• Persisters — People with gender dysphoria continues into adulthood.

The DSM-5 spends a lot of time drawing gender distinctions in autism, but unlike the PDM-2, it completely fails to mention either the high prevalence of transgenderism among autistic people, or the greater amount of gender variance.^[6]Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder (Strang et al., 2014)

I think the PDM-2 deserves some praise for dedicating several pages to this issue, while the DSM-5 really seems to be showing its age here.

Autism & depression

The PDM-2 also highlights how common depression is in autism, which is good, because we know how common depression and suicidality are in the autistic population—and not just in autistic adolescents.^[7]Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: a clinical cohort study (Cassidy, 2014)^[8]What Do We Know About Suicidality in Autism Spectrum Disorders? A Systematic Review (Segers & Rawana, 2014)^[9]Systematic Review of Suicide in Autism Spectrum Disorder: Current Trends and Implications (Hedley & Mirko Uljarević, 2018)^[10]A 20-year study of suicide death in a statewide autism population (Kirby et al., 2019)

Depression is also common among adolescents diagnosed with ASD. Studies of parent reports of depressed mood show a rate as high as 50% (Schall & McDonough, 2010). Emerging research finds an increased risk for suicidal thoughts and tendencies among teens with diagnosed ASD.

The PDM-2 also warns about how depression may be difficult to detect in autistic adolescents, which I think is helpful as well:

As with anxiety, recognizing depression in autistic adolescents can be challenging, as some characteristics of ASD (e.g., decreased interactions with peers and reduced emotional expression) resemble signs of depression.

Depression may appear as increased moodiness (including anger, irritability, and sadness), reduction of interest in prior favorite activities, and changes in eating and sleep habits.

Read the post below for more statistics on suicide and depression among autistics.

Autism & suicidality

Autism in the PDM

I also appreciate how the PDM-2 talks about the ways in which the social environment impacts autistic people, rather than describing our “failures” in engaging with that environment. Here is a quote on entering adolescence as an autistic person that I found helpful, and true to my experience:^[11]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

Children with ASD are confronted with
difficult challenges as they enter adolescence.

Separation from the family, construction of a personal identity, opening to social relationships, and access to sexuality are particularly challenging to them.

And although I don’t approve of the term ‘deficits’, I do think the following quote is significant:

Relationships between social skill deficits and social anxiety can be reciprocal: Adolescents with poor social skills are likely to experience negative peer interactions, which may then lead to fear and distress about subsequent social interactions, resulting in avoidance and withdrawal. This behavior then limits opportunities to acquire social skills through exposure to social situations, thereby leading to social skill deficits.

But the more of the PDM-2 I read, the more my initial excitement diminishes. I mean, the tone already becomes immediately clear when you read PDM-2’s description of autism:

ASD is a complex neurodevelopmental disorder characterized
by qualitative impairment in social interaction, language, and communication, and by restricted interests and repetitive stereotyped behaviors.

These symptoms are present from early childhood and cause severe limitation in several key areas of functioning.^[12]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

In fact, the PDM-2 describes autism almost exclusively in terms of deficits and impairments.

Deficits in social relationships and a circumscribed range of interests are hallmark features of this diagnostic group. Repetitive behavior in a circumscribed interest area is common.

This category incorporates the full range of what was previously categorized as pervasive developmental disorders, including what DSM-5 refers to as autism spectrum disorder.^[13]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

And to my surprise, it even describes our sensory functioning in exclusively negative terms. Have a look at this quote:

Sensory and motor functioning is significantly compromised, and many of these children have language delays (or regressions) and sensorimotor integration difficulties, including tactile and other sensory sensitivities.^[14]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

And it’s not that we don’t experience any sensory-motor challenges, because there is a myriad of studies that indicates we do.^[15]Sensory-motor problems in Autism (Whyatt & Craig, 2013)^[16]Sensory Processing in Children with Autism Spectrum Disorders and Impact on Functioning (Suarez, 2012) But are they also saying that our sensory functioning is significantly compromised? Because research shows autistic people have a myriad of advanced sensory abilities,^[17]Enhanced Perceptual Functioning (Mukerji, Mottron, & McPartland, 2013)^[18]Enhanced Perceptual Functioning in Autism: An Update, and Eight Principles of Autistic Perception (Mottron, Dawson, & Soulières et al., 2006)^[19]Enhanced perceptual functioning in the development of autism (Mottron & Burrack, 2001) and more of our brain resources are associated with visual detection and identification.^[20]Enhanced visual functioning in autism: An ALE meta-analysis (Samson, Mottron, Soulières, & Zeffiro, 2011)^[21]New research explains autistic’s exceptional visual abilities (2011) | EurekaAlert!

DSM-5 supplement

All things considered, the PDM-2 mostly feels like a supplementary manual to the DSM. And indeed, that is how the PDM-2 is described on the publisher’s website:

Explicitly oriented toward case formulation and treatment planning, PDM-2 offers practitioners an empirically based, clinically useful alternative or supplement to DSM and ICD categorical diagnoses.^[22]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

I am quite surprised by this, because I was expecting that subjective accounts of autism would necessarily include our subjective experiences in a broader sense; meaning not just our subjectivity with respect to our challenges, but incorporating our positive experiences as well.

I guess I shouldn’t forget, the diagnostic manual has a basis in psychodynamics, which, as far as I understand it, doesn’t really celebrate our abilities, but focuses on how our childhood experiences and innate drives have a deterministic grip on our personality and mental health, and how we may liberate ourselves by becoming more aware, and addressing our challenges in therapy.

That last bit does seem to be a fairly important point of distinction with the DSM though. Because where the DSM may recommend psychiatric treatments, the PDM highlights the influence of trauma, and believes we can make progress through advancing our awareness.

Autism vs. Asperger’s syndrome

Even though the PDM-2 mostly seems to complement the DSM and ICD, it does go against the DSM-5 on one important point: the autism classification. The DSM-5 removed Asperger’s syndrome as a diagnostic category in 2013,^[23]The DSM-5: Classification and criteria changes (Regier, Kuhl, Kupfer, 2013) and the ICD-11, which will become operational in 2022, removed it as well, although Asperger’s syndrome does still exist as a diagnostic category in the ICD-10. But the PDM-2 takes this revision into question:

DSM-5 has eliminated Asperger’s disorder as a separate diagnostic entity. However, both before and since its publication, considerable research—including extensive meta-analyses^[24]How will DSM-5 affect autism diagnosis? A systematic literature review and meta-analysis (Kulage, Smaldone, & Cohn, 2014)^[25]Asperger’s Disorder will be Back (Tsai, 2013)^[26]DSM-5 ASD Moves Forward into the Past (Tsai & Ghaziuddin, 2014)—has suggested that the distinction between Asperger’s disorder/Asperger syndrome and high-functioning autism (HFA) is real, measurable, and valid.^[27]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

The PDM-2 cites the following factors on which they claim (high-functioning) autism and Asperger’s syndrome can be distinguished, and further state that this is a non-exhaustive list:^[28]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

• Many have cited the lack of early language delay in Asperger syndrome, which is present and significant in HFA.
• Noterdaeme, Wriedt, and Höhne (2010) and others have noted the higher verbal IQ in Asperger syndrome.
• Woodbury-Smith and Volkmar (2009) highlighted the consistent pattern of superior verbal IQ compared with performance IQ in Asperger syndrome, a pattern that seems reversed in HFA. Instead, the relationship between verbal and performance IQ in Asperger syndrome is very similar to the one observed in nonverbal learning difficulties.
• Executive functioning has been studied with the Behavior Rating Inventory of Executive Function (BRIEF) to distinguish between the two diagnoses (Blijd-Hoogewys, Bezemer, & van Geert, 2014).
• Some research highlights greater social-seeking behavior in Asperger’s syndrome, in contrast with social isolation in autism. Children with Asperger’s syndrome may be socially clumsy, but they tend to be much more interested in social relations than autistic children; in fact, some have characterized Asperger’s syndrome as socially motivated autism.
• Conversational patterns have been studied, including variables such as topic management, gaze management, intonation, and reciprocity. This apparently meaningfully distinguishes between the two neurotypes as well.

The authors of the PDM-2 conclude the following:^[29]Psychodynamic Diagnostic Manual (Second Edition) | Guilford Press

Although the current research is not unequivocal, it seems to us premature to eliminate the Asperger diagnosis. It continues to have considerable face validity. Existing research has been hampered by inconsistent starting definitions and diagnostic procedures, small sample sizes, and circular logic. At this juncture, it makes sense to treat Asperger syndrome as a valid diagnostic entity whose varied dimensions merit further study and delineation.

I find it interesting that the PDM-2 feels it may be premature to remove Asperger’s syndrome. I felt the same back in 2013, although I am less certain of it now. Language delay was long cited as an important differentiator between autism and Asperger’s syndrome, but I personally question whether there is such a clear division between the two. Because, although I fit most of the classical descriptions of Asperger’s syndrome, I DID experience language delay. So I think on this factor, a trait-based perspective of autism better accounts for that variance than two discrete diagnoses.

The PDM-2 lists a few differentiators based on IQ. However, I am not convinced that intelligence is a meaningful construct to differentiate between two neurotypes. Admittedly, certain neurotypes are associated with low IQs, and I’m sure that within an autism sample you can identify certain patterns in their IQs which allow you to create different subgroups. But again, do those subgroups point to discrete conditions, or is this another example of variance in traits between members of the same neurotype?

Another challenge I have is that in the research literature, I have often seen Asperger’s syndrome being defined as autism without intellectual disability, or as autism with an IQ above 72. And is it actually surprising to find differences in IQ if you define one condition as having an IQ above a certain threshold? I can similarly claim that Baron-Cohen syndrome is neurotypicality without intellectual disability; then, I can conduct a research study where I investigate the IQs of a sample of people that qualify as having Baron-Cohen syndrome, and a sample of lower-IQ neurotypicals, thus showing that there are two distinct groups based on IQ. But is this not an entirely arbitrary definition and division? I don’t see how this shows that Baron-Cohen syndrome is a valid construct; I’ve really just shown that I can arbitrarily divide people into two groups based on their IQs.

The PDM-2 talks about social motivation being a significant factor that differentiates the two conditions. I question this as well, because in my understanding, alexithymia contributes significantly to the lack of social motivation, and I have not seen any research on how Asperger’s syndrome and autism can be differentiated based on alexithymia. So at the very least, I think the research is incomplete. But I worry that Asperger’s syndrome isn’t even a consistent construct between different papers.

And finally, I just want to mention that for at least 3 of the claims the PDM-2 makes about the distinction between Asperger’s syndrome and autism, it failed to cite research to substantiate the claim. Here I want to invoke Hitchen’s razor: What can be asserted without evidence, can also be dismissed without evidence.

My skepticism aside, let me quote here the two clinical illustrations the PDM-2 presents of autism and Asperger’s syndrome. Even if they aren’t meaningfully distinct conditions, perhaps it serves as a nice illustration of how diverse the manifestations and representations of autism can be.

In the end, I think the PDM-2 adds very relevant information on related features to autism, and while it’s shocking that the DSM-5 and ICD-10 do not cover this appropriately, fortunately, the PDM-2 does. Bravo! When it comes to the descriptions of autism itself though, I think the PDM-2 is only marginally more nuanced than the DSM-5, and largely echoes it. What a missed opportunity!

Perhaps it was naive of me to think that this PDM-2 would do significantly better than the DSM-5. But as lacking as diagnostic manuals may be about autism, I’m glad that there is some progress. It’s just that the updates on these manuals are so painfully slow, and that has significant consequences for many that seek diagnosis or other clinical help. And it’s sobering that some of the necessary updates are to be found in an obscure manual from the field of psychodynamics, rather than any of the diagnostic manuals in common use.

Based on this, I realize that *someone* ought to write a less biased and more comprehensive diagnostic manual for autism. Who can be our savior?

What do you think of the ways the PDM-2 describes autism?