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Autism and Developmental Disorders
2023. Vol. 21, no. 4, 34–42
doi:10.17759/autdd.2023210404
ISSN: 1994-1617 / 2413-4317 (online)

Diagnosis or Metaphor: Metamorphosis of the Infantile Autism Concept in a Psychiatry and Clinical Psychology. Overview

132

A.N. Kornev

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Abstract

Оbjectives. A paradigm shift in modern Western psychiatry has changed some well-known ideas about childhood autism elaborated in the 20th century. Mostly, it was a consequence of revisions of the thesaurus and guidelines for classifying the given disease. This causes obvious difficulties in professional interdisciplinary communication between psychiatrists and clinical psychologists. This review compares the terms used in our national psychiatry (which were related to childhood autism during the nosological era of the 20th century) to those built in the 21st century in the USA and the European Union countries to describe antinosological andparametric approaches. The move to parametric, quantitative approaches in psychiatric diagnosis has expanded the boundaries of childhood autism while simultaneously increasing epidemiological rates.

Characteristics of sources used. The review encompasses publications that representing Western scientific trends, as well as scholars of our national psychiatry of the 20th century. Although some of them may be unfamiliar to contemporary readers, they still possess significant worth in the realms of science and practical application.

Conclusions. Modifying the thesaurus and taxonomic principles does not necessarily result in the acquisition of fresh scientific knowledge. It is important to emphasise the necessity of taking into account professional boundaries of competence when incorporating psychiatric terminology from related fields. The review discusses some psycholinguistic aspects of the coining and use of psychiatric terms in interand intradisciplinary sciences. This information may be valuable for specialists engaged in the training, retraining and advanced training of clinical and correctional psychologists, as well as defectologists.

General Information

Keywords: infantile autism; autism spectrum disorder; schizophrenia; psychiatry; terminology; classification; clinical psychology

Journal rubric: Research of ASD

Article type: scientific article

DOI: https://doi.org/10.17759/autdd.2023210404

Funding. The reported study was funded by Russian Foundation for Basic Research (RFBR), project number 19-29-14078

Received: 30.12.2022

Accepted:

For citation: Kornev A.N. Diagnosis or Metaphor: Metamorphosis of the Infantile Autism Concept in a Psychiatry and Clinical Psychology. Overview. Autizm i narusheniya razvitiya = Autism and Developmental Disorders, 2023. Vol. 21, no. 4, pp. 34–42. DOI: 10.17759/autdd.2023210404. (In Russ., аbstr. in Engl.)

Full text

Introduction

Sectoral Differences in the Acquisition and Application of Professional Terminology in Psychiatric and Pathopsychological Diagnosis

Professional terminology, particularly when it comes to mental health, plays a very important role in the health professions. Using some medical diagnoses is seen as a traumatizing and frightening factor for the general public. As the Italian researcher M. Zapella [9] notes: “The impressive, continuous growth of new diagnoses of ‘autism’ has a dramatic social aspect, since this diagnosis […] in most cases has serious consequences for the whole family: maternal depression, family breakdown and the development of severe stress in the parents, and the child’s stigmatization” [9, p. 72]. As an alternative, less precise, descriptive labels are offered. For example, such diagnostic terms as “oligophrenia”, “debility”, “imbecility”, etc. have long since been practically abandoned. More importantly, clinical terminology must be used correctly and accurately. In essence, the professional language, the thesaurus, enables professionals to translate knowledge and share experiences among themselves. This applies to both oral and written discourse (e.g. in scientific publications). It should be borne in mind that human mental health is the concern of several professions: psychiatry, clinical and correctional psychology and correctional pedagogy. Yet these applied disciplines are not equally developed in their semiotic and terminological apparatuses. For example, in psychiatry this issue is under close attention and control of the professional community. In clinical (and especially in correctional) psychology, the professional thesaurus is much less developed. There are few attempts to unify it. In correctional pedagogy there has been virtually no discussion of this issue and no control by the professional community. As a result, medical terminology is quite widely used in the above non-medical fields, but for obvious reasons this is not always done correctly.
Diagnosis in medicine is known as a categorical decision about the presence/absence of a disease or pathological condition in a subject. Such a categorical decision is associated with identifying the main defining features of a pathological condition and is expressed in certain concepts that are used by a specialist. These concepts and their verbal labels constitute a professional thesaurus. The first descriptions often began by using descriptive and metaphorical epithets, some of which later became accepted terms. For example, the term “autism” was first used by E. Bleuler as a metaphor (from the Greek αὐτός – “oneself”) to describe a way of thinking immersed in one’s inner world with a disconnection from reality [4], and later became a term denoting one of the negative symptoms of schizophrenia. In psycholinguistics, the role of metaphors in creating new categorical concepts or transforming the meanings of existing words into metaphorical ones has been studied quite thoroughly (e.g. [17]). However, as opposed to metaphors, the usual rules for using professional terms are explicitly controlled by terminological dictionaries and guidelines.
Taking into account the Sepir-Whorf hypothesis of linguistic determinism, we should note the dual nature of the relationship between the practical experience of diagnosis and the thesaurus [16]. On the one hand, clarifying the meaning of a new concept depends on its factual and conceptual basis and the existing consensus on how to interpret it. On the other hand, a particular specialist's practice of using a term may influence the assessment of psychopathological states or individual characteristics. Given that professional knowledge tends to be transmitted orally or in writing, the consistency and accuracy of terminology used affects the quality of diagnosis.
For example, psychiatry attaches great importance to terminological accuracy [14]. A special section of the discipline, called “general psychopathology”, is devoted to this issue [13]. Accuracy and uniformity of terminology are achieved in professional training in two complementary ways. The first is to read specialist literature which defines basic concepts. The second is participation in medical consultations devoted to analyzing individual cases, where the young specialist clarifies basic professional concepts by correlating observed psychopathological features in a particular patient with their diagnostic descriptions by experienced colleagues. Using written texts alone is not enough, because many words are polysemous and the meaning of what is read depends on the context. In oral discourse, paralinguistic and metalinguistic means: prosody (intonation, logical accentuation), facial expressions and gestures, convey a significant layer (up to 50%) of information [41]. These communicative means make it possible to express so-called connotations, i.e. emotional and evaluative shades of the statement.
The problem of the taxonomy of mental disorders has been discussed particularly actively in the last 30-40 years in connection with the next revisions of the International Classification of Diseases (ICD 9th, 10th and 11th revisions) and the American Diagnostic and Statistical Manual of Mental Disorders (DSM). Since ICD-10, the Western psychiatric community has gradually moved away from the nosological positions in diagnosis that have dominated psychiatry for a hundred years following E. Kraepelin's classic works [15]. This is certainly reflected in the terminology used, which changes more or less with each revised ICD.
 
Diversity of Autism Manifestations
The term "autism" has two psychiatric meanings: 1) to describe certain personality traits found in schizophrenia and sometimes in healthy people (e.g. schizoid personality accentuation), and 2) to describe the dysontogenetic syndrome of early childhood autism (ECA) [1; 3; 11; 12; 18]. The psychopathological concept of autism was first introduced by Swiss psychiatrist E. Bleuler to describe peculiar thinking with weak links to external and social influences: "One of the main symptoms of schizophrenia is the preponderance of the internal life, combined with an active withdrawal from the external world. The most severe cases are completely reduced to dreams in which the patient's whole life seems to pass by" [4, p. 8]. The term "autism" has created an entire lexical family, entering various languages and enriching everyday vocabulary [7].
Autistic personality changes observed in schizophrenia in adults and children are well described in the psychiatric literature [3; 5; 6]. It can manifest itself in various forms of the patient's detachment from the surrounding human world, emotional coldness, immersion in his or her own unusual world of bizarre images and ideas, little understood by most healthy people. In most cases this is accompanied by increasing alienation, reduced empathic ability, emotional resonance [4]. Numerous studies have described clinical variants of early schizophrenia in children, in which the characteristic symptoms were increasing symptoms of emotional impairment, emotional coldness, loss of emotional bonds with loved ones, i.e. procedural autism [3; 30]. The Soviet psychiatrists G.E. Sukhareva (1925) [31] and T. Simson (1929) [27] first described peculiar forms of non-processual autism in children and called them "schizoform psychopathy". Later, similar conditions were described by the Austrian physician G. Asperger as "autistic psychopathy" and became clinically used as "Asperger syndrome". In 1943, L. Kanner described a specific state of disharmony in mental development in children, resembling procedural autism in early childhood schizophrenia by some psychopathological features; this state was called early childhood autism [37]. The main difference from schizophrenic procedural autism was the lack of progression in psychopathological symptomatology. After L. Kanner, many authors described similar conditions, which are very rare in children (according to V.E. Kagan, approximately 2-5 cases per 10,000 children [11]).
The polymorphism and clinical diversity of manifestations of the dysontogenetic syndromes in ECA have been noted in early descriptions. Two syndromes are central to this group:
1) Kanner syndrome with predominance of cognitive, speech and affective disorders: avoidance of social contact and direct communication, stereotyped behavior, peculiar underdevelopment of language with deficit of pragmatic skills and echolalia, retarded intellectual development, fears and high anxiety [6; 11; 26; 37];
2) Asperger syndrome with a predominant emotional personality disorder, low social/emotional intelligence and high academic intelligence, or autistic/schizoid psychopathy [31; 32; 38].
In the USSR, clinical research on early infantile autism (EIA) took place in two scientific lines:
  1. Studying childhood schizophrenia [3; 6; 30]. Within the framework of this trend, EIA was considered in several aspects: a) as a variant of dysontogenia, b) as a pre-morbid condition in children with a later manifestation of the schizophrenic process, and c) as a result (deficiency) of a supposedly premature (at the age of 1-2 years or earlier) onset of schizophrenia. In general, this fits into the concept of an "evolutionary process disorder", which is proposed to be distinguished from procedural autism, i.e. childhood schizophrenia [3; 26]. A similar but more cautious view of the relationship between childhood autism and early schizophrenia persisted in studies by British and American scientists from the first half of the 20th century until the early 1980s [38; 40].
  2. Studying residual organic dysontogenias [11; 12; 23]. S.S. Mnukhin and his colleagues, within the framework of clinical and physiological classification of residual organic dysontogenias, described the atonic form of residual organic psychopath-like states, in which children had a picture of schizoform disorders, manifested as "[t]he carelessness, resonance, complacency, spontaneity, tendency to mental chewing, then peculiar "schizoform" pictures with pallor of emotions, strange and sometimes ridiculous actions, insufficient or formal contact with the environment [...] tendency to useless 'reasoning' and fantasies" [23, p. 9]. According to the authors, some of these children show a clinical picture similar to Asperger syndrome, and it is legitimate to consider them as psychopath-like schizophrenic conditions of organic genesis or as "organic autism" [11]. Among children with mental retardation, S.S. Mnukhin [23] and D.N. Isaev [10] studied in detail the atonic form of oligophrenia, the peculiarity of which was a gross disturbance of mental tone, aspontaneity, field behavior and the presence of various stereotypes (hand patting, jumping, running in circles). Differential diagnosis of dysontogenia with Kanner syndrome can be difficult [11; 12]. Broadly similar clinical descriptions can be found in Western publications under the name "pervasive developmental disorders" [38; 40].
Similar views are expressed in clinical-psychological studies of childhood autism by a group of scientists led by V.V. Lebedinsky. On the basis of G.E. Sukhareva's ideas about the types of dysontogenesis and L. Kanner's positions, a psychological typology of dysontogenesis was developed, in which early childhood autism was considered as a dysontogenesis of the distorted development type [20], in which the asynchrony of development is a characteristic feature. Distinct manifestations of disharmony of different affective levels of behavior regulation were revealed in the study of affective regulation of behavior in children with EIA based on the level model [18; 25]. The authors divide the conditions of childhood autism into 4 types, which differ in the degree and quality of disorders of communicative-speech behavior. Based on this model, a programme of differentiated correction of autism has been developed. It includes methods of play therapy [19; 29]. According to the authors' multilevel model of autism and the authors' psychological typology, different correction approaches are proposed.
Analysis of old and new Russian and foreign clinical publications on early childhood autism shows that over half a century there has been little clarity about the nature and clinical features of autism. What appears to be new in the texts turns out to be changed terminology, not new information. Moreover, many papers have been published in which socially oriented tendencies blur ideas about the clinical nature of childhood autism by shifting from nosological positions typical of the classical scientific school to everyday descriptive characteristics and epithets [9].
Classifications, Terminology and Paradigm Shifts
 
The above brief review of autism research illustrates the long-standing dissatisfaction of clinicians with the lack of reliability of differential diagnostic criteria to distinguish between the different clinical forms of non-processual and processual autism in children. Many definitions are highly ambiguous. It is known that in diagnosing childhood autism (as well as other psychiatric diagnoses), the clinical intuition of the specialist plays an important role, in addition to recording the observed psychopathological symptoms and qualifying them formally. It is only through clinical experience of observing similar cases that many nuances in the behavior and communication of children with ECA can be identified. This naturally leads to a large variation in diagnostic decisions made by different clinicians.
Different approaches to diagnosis and classification have been discussed in publications in preparation for new revisions of the ICD and DSM [24; 35]. Over the past 30 years, the Western psychiatric community has undergone a paradigm shift in classification, from nosological approaches to diagnosis to parametric, dimensional approaches to mental disorder taxonomy [8; 35; 38; 40]. In the nosological, categorical approach, diagnostic decisions are made on an alternative basis, relying on the identified pathognomonic syndrome. The parametric, dimensional approach considers clinical signs of mental illness as a continuum of symptoms of varying severity. The old, nosological, psychopathological syndrome is replaced by a set of traits reflecting components that may be fully or incompletely present. The decision about the required number of identified key features is made on the basis of a given critical threshold criterion. Autistic syndromes that are similar in appearance and difficult to distinguish based on formal characteristics have been grouped into a common continuum called the "autistic spectrum". The term "spectrum" in relation to autistic disorders in children was first used in the work of J. Golt, R.K. Kana [34] and meant a continuum of syndromes resembling G. Kanner's reference description to varying degrees. It should be noted, however, that using the term "autistic spectrum disorders" without taking into account the nosological affiliation "led to even greater terminological confusion and to a significant scattering of data regarding their prevalence according to age, diagnostic criteria, country and region" [8, p. 8].
ICD-11 defines ASD diagnostic criteria as the mandatory presence of two deficits:
  1. Persistent impairments in initiating and maintaining social communication and reciprocal social interactions [33; 36; 39].
  2. Sustained limited, repetitive and inflexible patterns of behavior, interests or activities [36].
Each of these areas has a specification of impairments in the form of 7 categories of abilities and skills that are detectable at the time of diagnosis of ASD in early infancy, but which can become fully manifest later, when social demands begin to outweigh the impairment [38].
Analyzing the given formulations of the conditions for diagnosing ASD, it becomes clear that these are not symptoms and syndromes, but rather manifestations of functional weakness, deficiencies in the specified areas. This means that the diagnostic criteria are functional, psychological and not syndromological. There are no criteria for the degree of expression (severity) of these areas of deficit, which can be a source of considerable variation in the conclusions of different experts [14]. A formal, parametric approach based on identifying a list of specific behaviors (echolalia, communication difficulties, unusual fears, rituals, etc.) significantly reduces the reliability of the diagnosis and may become a source of overdiagnosis, leading to a significant expansion of the range of such children.
Changing the diagnostic paradigm poses considerable difficulties even for psychiatrists, let alone clinical psychologists. New, unfamiliar terminology is introduced. It is relegated to the category of new metaphors, poorly tested in the mind. Rather than interpreting the terms accurately, a series of associations are made, sometimes far removed from the original meaning [22]. For example, autism screening questionnaires that are completed by parents or educators (e.g. CARS) cannot be used to diagnose autism [2]. It is a tool for the early, presumptive identification of children who may be at risk for further, more in-depth assessment by a psychiatrist.
As stated earlier, specialists from other branches of science and practice are poorly acquainted with medical terminology, but they often use this terminology, resulting in several negative effects. The most important of them is creating information noise, disturbing professional communication, both oral and written, in scientific, popular, methodological and practical publications.
Analysis of the epidemiology of childhood autism has shown that the epidemiological indicators of this diagnosis in our country and abroad have not changed much, remaining in the range of 0.02-0.04%, during 50 years of using the diagnosis of "childhood autism" and "early childhood autism" (ECA) with a clinical nosological approach [11]. During 30 years of transition to the concept of ASD and parametric, dimensional diagnosis, the frequency of making this diagnosis has increased tenfold [9; 19; 21; 27; 32]. A similar trend has been observed in Russia. It is known from population genetics that the prevalence of dysontogenia in a population is relatively stable and cannot change significantly without extreme external causes. This leads us to believe that such a sharp increase in the frequency of diagnosing ASD can be explained by broadening or migrating the diagnosis of some disorders, which used to fall into another diagnostic category, to ASD. In Russian practice, this happens with children who have severe forms of total speech underdevelopment (motor or sensory alalia), atypical forms of mental retardation, and some forms of mental retardation. The usefulness of such confusion is questionable.

Conclusion

Medicine and pathopsychology have different principles of developing and using professional terminology. They are related to professional peculiarities. If for a doctor in diagnostics the reliability of recognizing the disease picture is important for the correct choice of treatment tactics (i.e. minimizing individual variability and reliable codification of diagnostic information), then for a pathopsychologist, on the contrary, the individual features of symptomatology, psychological, psychodynamic and neuropsychological mechanisms are of greater importance and interest for selecting individualized tactics of psychological help. Therefore, using metaphorical psychological descriptions to express the elusive variety of individual manifestations of adapting and maladapting can be considered quite justified. This seems a lesser 'evil' than borrowing medical terminology. With such understandable differences in professional language, it is important to be clear about the boundaries of responsibility and competence and not to manipulate medical terminology where only a doctor is competent [28].

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Information About the Authors

Alexander N. Kornev, Doctor of Psychology, PhD in Medicine, Professor, Head of the Department of Logopathology, Head of the Laboratory of Neurocognitive Technologies, Saint Petersburg State Academy of Pediatric Medicine, Teacher at the Institute of Practical Psychology "Imaton", St.Petersburg, Russia, ORCID: https://orcid.org/0000-0002-6406-1238, e-mail: k1949@yandex.ru

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