Rediscovering Autism As a Feature of Schizophrenia

Autism and schizophrenia are now viewed as two distinct mental health disorders, and autism is not included in the description of schizophrenia in the fifth edition of “Diagnostic and Statistical Manual of Mental Illnesses,” the American Psychiatric Association’s professional reference book on mental health and brain-related conditions. But the authors of a lengthy opinion piece in The Lancet Psychiatry argue it is important to “rediscover what autism in schizophrenia is,” partly because people with schizophrenia who exhibit autistic features can be misdiagnosed as having autistic spectrum disorder and, therefore, receive inadequate treatment.

Mads Gram Henriksen, M.A., D.M.Sc.

“Patients with schizophrenia spectrum disorder have not ceased to exhibit autistic features just because the concept of autism fell out of the schizophrenia vocabulary,” wrote Mads Gram Henriksen, M.A., D.M.Sc., an associate professor at the University of Copenhagen in Denmark, and his co-authors.

Henriksen and his colleagues review the history of the seminal studies and writings about autism starting with Eugen Bleuler, a Swiss psychiatrist who coined the concept of schizophrenia and saw autism as “a diagnostically specific, fundamental symptom of schizophrenia.” Bleuler’s reputation has been colored by his eugenic opinions and the forced sterilization at the clinic he ran.

The well-referenced essay by Henriksen and his colleagues also sums up the writings and occasionally recondite theories — even the helpful explanations by Henriksen et al.— of Eugene Minkowski, Ludwig Binswanger and Wolfgang Blankenburg. Henriksen and his co-authors conclude their nine-page (inclusive of 74 references) opinion piece with what they describe as four “key observations” that can be synthesized from their reading of these writings.

First, they wrote, autistic features are common in schizophrenia and that autistic features exhibited by a patient should not, by default, lead to a diagnosis of autistic spectrum disorder.

Next, autistic features in schizophrenia can manifest themselves as experiences and behaviors. They give as examples patient experiences such as “profound existential solitude,” not feeling truly human, frequent questioning of what others consider matters of fact, and social withdrawal or acting in ways that can appear eccentric or inappropriate to wider society. “The fact that such autistic features cut across the experience-behavior divide is one of the reasons it has been so difficult to define autism in schizophrenia,” wrote Henriksen and his co-authors.

Their third observation gleaned from Bleuler, Minkowski, Binswanger and Blankenburg is that autism in schizophrenia “designates a frail constitution of and indwelling in the life world.” They cite Edmund Husserl to explain that the lifeworld is “the world in which we are already always living,” and the frail constitution and indwelling in the lifeworld signify “a basic intersubjective displacement” that manifests as a “pervasive inability to take for granted what others consider obvious (e.g., that I exist, that my thoughts are mine, that others are real, and how to navigate everyday life and make decisions).” They also noted that autism in schizophrenia is dynamic, shaped by a person’s adaptions, compensations and reactions.

Their fourth point is that autism in schizophrenia is caused by a “core disturbance,” which they go on to say was framed differently by the authors they reviewed. For Bleuler, it was the splitting of psychic functions; for Minkowski, it was loss of contact with reality. Regardless of the differences, Henriksen and his colleagues say that the core disturbance of schizophrenia affects “the very constituting level of experience” and that empirical research over the last several decades has corroborated the idea of self-disorder, or what is sometimes referred to as “anomalous self-experiences.” They added, though, that the concept of autism in schizophrenia cannot be simply reduced to the contemporary notions of self-disorders and that it occurs as both experiences and behaviors.

“Autism, namely the frail constitution of and indwelling in the lifeworld, can be what gives a specific schizophrenic coloring to some symptoms (e.g., social anxiety) or to a patient’s reactions to them (e.g., social withdrawal), which can otherwise be perceived as nonspecific or transdiagnostic,” wrote Henriksen and his co-authors.