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Concept, Diagnostic Criteria and Classification of Autistic Disorders: A Proposed New Model

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Concepts of autism and autistic spectrum can be difficult to understand to the public as well as untrained professionals. This is reflected in difficulties in diagnosing mild autism; first recognised in adulthood, compared with severe autism; first recognised in childhood. This paper provides a new model of autistic spectrum disorders that is simple and easier to use. It is more in line with established literature about autism, clinical evidence and recent developments in neurosciences. The model has used the Triune Brain Theory to establish the neuropsychological basis for the Object Related, Emotional and Social intelligences. The model suggests that autism is a form of “Socio-Emotional Learning Disability”. Diagnostic criteria include; “core symptoms” that do exist in both severest as well as mildest forms of autism. Other symptoms are included under “associated symptoms”, “compensatory symptoms” and “complications related symptoms”. Autistic spectrum has been classified into Central and Peripheral autism disorders as well as Non-autistic socio-emotional conditions. The difference between Central and Peripheral autism depends on severity of symptoms according to a particular cognitive-clinical scale based on Lezak’s stages of intelligence. In this model Narcissistic Personality Disorder, is part of the autistic spectrum. Evidence from the literature has been summarised and discussed.
Concept, Diagnostic Criteria and
Classification of Autistic Disorders:
A Proposed New Model
Dr Khalid A Mansour
.    
Concepts of autism and autistic spectrum can be difficult to understand to the public as
well as untrained professionals. This is reflected in difficulties in diagnosing mild autism;
first recognised in adulthood, compared with severe autism; first recognised in
childhood. This paper provides a new model of autistic spectrum disorders that is simple
and easier to use. It is more in line with established literature about autism, clinical
evidence and recent developments in neurosciences. The model has used the Triune
Brain Theory to establish the neuropsychological basis for the Object Related,
Emotional and Social intelligences. The model suggests that autism is a form of “Socio-
Emotional Learning Disability”. Diagnostic criteria include; “core symptoms” that do exist
in both severest as well as mildest forms of autism. Other symptoms are included under
associated symptoms”, “compensatory symptoms” and “complications related
symptoms”. Autistic spectrum has been classified into Central and Peripheral autism
disorders as well as Non-autistic socio-emotional conditions. The difference between
Central and Peripheral autism depends on severity of symptoms according to a
particular cognitive-clinical scale based on Lezak’s stages of intelligence. In this model
Narcissistic Personality Disorder, is part of the autistic spectrum. Evidence from the
literature has been summarised and discussed.
Keywords: autism, autistic spectrum, asperser syndrome, high functioning autism,
narcissistic personality disorder, Triune Brain Theory.
Declaration of interest: None
Concept, Diagnostic Criteria and Classification of Autistic Disorders:
A Proposed New Approach
The concepts of autism and autistic spectrum disorders (ASD) can difficult to
comprehend especially for people who don’t have first-hand knowledge of autistic
people. It is well known for clinicians who work in the field of developmental
disorders that even experts can disagree about diagnosis of autism, especially the
milder forms of it (1-4). Part of the problem is that the current concepts of autism
and autistic spectrum are not clear enough. They seem to need further
development and clarity (4-5). Another part of the problems is that most of the
literature refer to severe autism in children as the prototype of autistic disorders.
This makes it difficult to apply such literature on milder forms of autism especially
the ones that are first diagnosed in adulthood.
This paper represents the author’s effort to reformulate the concepts of both autism
and autistic spectrum, provide clearer diagnostic criteria and “easier to use”
classification of autism. The model proposed in this paper will expand further on the
main features of the autistic spectrum. This new model would try to explain autism
and autistic spectrum in a more consistent and meaningful way in reference to both
clinical and public use. It would also aim to produce a generic model which is fit to
deal with both mild and severe autism as well as autism-like conditions.
Although this model presents new formulations of autism, it is based on the
literature and clinical observations. This includes both well-established theories of
autism that have been widely accepted by professionals as well as the recent
advances in neuropsychological studies especially Triune Brain Theory of Paul
MacLean (6).
Historically established data about autistic spectrum disorders:
There have been a number of research data and theories that have been better
received and accepted by clinicians all over the world for a reasonable length of
time. These concepts are used here as landmarks for understanding ASD. These
include Kanner’s concept of Infantile Autism (7), the distinction between autism and
learning disabilities (7), the distinction between autism and childhood
schizophrenia (8-9), the data about milder forms of autism including high
Functioning Autism (HFA) (10), Asperger’s Syndrome (AS) (11-12), Broader Autism
Phenotype (13), Semantic Pragmatic Syndrome (Pragmatic Language Impairment )
(14), autistic spectrum disorder (15), “Theory of Mind” or “empathy” in autism (16),
“Mirror Neurons” (17-18), the work about co-morbidity in autism especially with
Learning Disability, Attention Deficit Hyperactivity Disorder (ADHD) and epilepsy
(19-21), the studies about forensic aspects of autistic spectrum disorders (22-23),
the work about cognitive aspects of autism including the “savant” phenomenon
(10,24), the genetic aspects of autism (25-27), its association with abnormalities in
the brain (10-28), and the different types of social inadequacy in autism (15).
Perhaps the diagnostic criteria of autistic disorders in the “Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition” (DSM-IV) (29) and “International
Statistical Classification of Diseases and Related Health Problems, 10th Revision”
(ICD-10) (30) are the most recognised embodiment of the concept of autism.
However there have been many difficulties which yet have to be dealt within those
two systems (31).
1) The DSM-IV and ICD-10 diagnostic classification of autistic disorders are
categorical rather than dimensional classifications under the heading of
Pervasive Developmental Disorders. The categories of Pervasive
Developmental Disorders include syndromes like Rett’s Syndrome and
Childhood Disintegrative Disorders. These disorders are of doubtful
significance from classification point of view. The use of such strict diagnostic
criteria has lead to inevitable over use of the category “Pervasive
Developmental Disorder Not Otherwise Specified” (32). However this is
expected to be corrected in DSM-V and ICD-11 (33).
2) The diagnostic criteria of autism are still focused on childhood severe autism
with less emphasis on milder forms of autism (34) that could be diagnosed for
the first time in adulthood.
3) The classifications do not include important concepts like “High Functioning
Autism” (HFA). This is probably partially due to the ambiguity of the difference
between HFA and Asperger’s Syndrome (AS) (35).
4) The diagnostic criteria are heavily influenced by the usual “diagnostic triads”
like the one developed by Lorna Wing (15) at the expense of other features of
autism like the “lack of empathy” and “lack of theory of mind” (36-37).
The Triune Brain Theory:
The Triune Brain is a model of brain functional structures based on evolutional
analysis of comparative neuroanatomy of vertebrates. The model has been
proposed by the American neuroscientist Paul D. MacLean in his book “The Triune
Brain in Evolution. Role in Paleocerebral Functions” (6). According to Maclean, the
human brain is made of three integrated but specialised brains;
1) The Reptilian Complex: (brain stem, cerebellum and basal ganglia), which is
the main brain structure in reptiles and fish. This part of the brain is
responsible for instinctual behaviours involved in exploration, feeding,
dominance, aggression, territoriality, procreation and behavioural motor
routines; aiming at achieving self-preservation and procreation.
2) The Limbic System: composed mainly of the septum, amygdala,
diencephalon, hippocampus complex and cingulate cortex. When the Limbic
System is added to the Reptilian Complex (as in the brains of lower mammals
like rats, cats and dogs), it starts to produce functions like; bonding, nursing,
parental care, separation anxiety, audio-vocal communication and
playfulness; aiming at maintaining mother–offspring contact.
3) The Neocortex: a structure found uniquely in higher mammals like apes and
humans, when its functions are added to the Limbic System and the Reptilian
Complex, this produces new skills like social languages, abstraction, planning,
and perception; aiming at preservation of ideas and transmission of culture
from generation to generation.
This theory is indirectly supported by the clinically established observations about
the human brain development. It is known that, phylogenetically, older brain areas
mature earlier in humans than newer ones. This means that reptilian brain in
humans matures earlier than the limbic lobe and then the Neocortex. This is
consistent with MacLean’s theory (38). The developmental milestones in humans
indicate that the functions of the Reptilian Complex, Limbic System and Neocortical
functions follow different lines of maturity. Babies in the first year to two rely mainly
on their Reptilian structures to produce their main functions like homeostasis and
identifying objects and producing primary sensori-motor development. In the years
3-5 children seem to develop emotional functions when the Limbic System starts to
be more functional. Later social skills start to develop further in school stages and
after that in a way consistence with what we know about neocortical maturity in the
human brain (39).
It is also possible to view regression in major mental illness to be consistent with
Maclean’s theory too. In major brain disease like dementia, schizophrenia or
demyelinating diseases, skills attributed to neocortex, are more likely to be lost
before those of the limbic lobe and then those of the reptilian complex in some
form of succession indicative of uniqueness and independence of these brain
Table 1: Socio-emotional line of brain development and regression:
Severe brain
e.g. Dementia
Severe Schizophrenia
5 y and above
Facilitated mainly by
neocortex (frontal lobe)
2 – 5 y
Facilitated mainly by
Limbic system
0 - 2 y
Facilitated mainly by
Reptilian Complex
Tri-dimensional Intelligence:
Based on Maclean theory, it is possible to think of the human brain functioning as
is the final product of integration of three subsystems. One brain subsystem is
more specialised in processing object related data. Another subsystem is more
specialised in processing emotional data. The third subsystem is more specialised
in processing social data. Subsequently, it is possible to subdivide human
intelligence into three different components; Object Related Intelligence, Emotional
Intelligence and Social Intelligence.
In this model, intelligence is defined as in the main stream psychology (e.g. the one
by the “Mainstream Science on Intelligence”) (40). It is also consistent with
Spearman’s G factor or general intelligence (41). This means that it is a stable skill
hardly affected by age, education or training. However, it is separated into three
main domains; the object, the person and the group.
The idea that there could be Emotional and Social Intelligences separate from the
object related intelligences (usually represented by IQ), is not a new idea in
neurosciences or psychiatry. It is widely accepted among clinicians and neuro-
researchers that that emotional intelligence (42-44) and social intelligence (45-46)
could exist independently from general intelligence.
Functions of the three intelligences:
The main function of intelligence is survival or effective management of the
environment. While this is relatively clear regarding materialistic or Objects Related
Intelligence, it needs further analysis with Emotional and Social Intelligences.
Social Intelligence is meant to be the skills necessary to function in a group to
achieve a shared goal even if there is no emotional attachment with members of
the group. Here the group is the primary functioning unit and not the individual and
the goal is larger than what could be achieved by each individual separately. It is
the intelligence necessary for creating societies and civilisations. Social intelligence
is usually practiced in the wider society like in the streets, public transport, new
work places, etc. In this regard, the above stages of social intelligence materialises
itself in the form of social appropriateness, social cooperation and promoting group
Emotional intelligence is simply the ability to understand and manage emotional
data to achieve better survival. There could be central psychological mechanisms
that explain how it works.
1) “Theory of Mind” seems to be central to emotional intelligence.
2) Theory of Mind in turn leads to “Empathy”, when applied to others (10),
and to “Insight”, when applied to one self (47).
3) Empathy then leads to the ability to “Individualise” people i.e. perceiving
each individual as unique and not just a member of a group. Then an
emotional charge is attached to the individual. If this emotional charge is
positive, the individual becomes intimate person too like; siblings, partners,
friends, relations, etc.
4) Insight can also lead to self awareness, self criticism, remorse after
making mistakes and joy after doing well.
5) Empathy and insight then allow the development of mutually convenient
and mutually beneficial relationship with other individuals. This in turn
achieves the ultimate goal of acquiring the “intimate, supportive
relationships” most crucial for survival in humans.
6) Other components in the limbic system functioning constitute the
machinery that serve the above system. They include abilities like “face
recognition”, mirror neurones, amygdala labelling systems, hippocampus
emotional memory functions, etc.
The possession of such intelligences can dramatically enhance survival skills and
levels of functioning in humans. Object Related Intelligence is the simpler form of
intelligence and is shared (in one level or another) with most animals. Adding the
emotional brain dimension improves the Object Related Intelligence and allows
new abilities to emerge like “partnerships” and “establishing families” which is a
major advance above the previous level. The Social Intelligences allows
enhancement of Object related and Emotional Intelligences but also adds
enormous new functions including building societies and civilisations. This would
be the peak of human performance that is not shared with any other animals.
Diagram 1: Relationship between functioning and levels of integration:
Clinical components of intelligences:
In this model, the clinical concept of intelligence is further subdivided into neuro-
behavioural components consistent with Lezak four classes of intelligence/cognition
(48); “receptive functions”, “memory and learning”, “thinking” and “expressive
functions”. However they have been modified to suit clinical usage as explained in
table 2.
Table 2: clinical stages of intelligence or skills compared to “Lezak’s classes of
Lezak’s classes Clinical equivalent
Receptive Functions 1- Monitoring the data (Object related,
emotional or social),
Thinking 2- Understanding/analysing the data
Expressive Functions - I 3- Formulating an increasingly appropriate
response to the data
Memory and Learning 4- Memorising the data and learning new ways
to improve responses by learning from one’s
own mistakes or by observing others
Expressive Functions - II 5- Generalising the new skills and applying
them in new/unfamiliar situations by the use
of imagination (episodic future thinking /
episodic prospection)
6- Mastering the new skills via training so that
they can be used in stressful situations
without pathological coping mechanisms like
“hostile dependence”, somatisation or
Usefulness of tri-dimensional intelligence to explain other clinical
Building on the idea that the triune brain could possess tri-dimensional intelligence,
it is possible to see the link between this model and personality disorders as
explain in the following illustrations.
Table 3: An average person should possess functional “Object Related
Intelligence” (IQ), “Emotional Intelligence” and “Social Intelligences”:
Object Related
Emotional Intelligence Social Intelligence
Table 4: A person with low “Object Related Intelligence” but normal “Emotional
Intelligence” and normal “Social Intelligence” would be identified as some one with
learning difficulties but with good coping abilities due to his other intelligences are
still normal:
Object Related
Emotional Intelligence Social Intelligence
Table 5: A person with normal “Object Related Intelligence” and normal “Social
Intelligence” but low “Emotional Intelligence” could suffering from antisocial
Antisocial Personality
Object Related
Emotional Intelligence Social
Table 6: A person with normal “Object Related Intelligence” and normal “Emotional
Intelligence” but low “Social Intelligence” could be having schizoid personality (high
self-satisfaction) or avoidant personality (low self-satisfaction):
Schizoid /
Object Related
Table 7: A person with low “Object Related Intelligence” and low “Social
Intelligence” but normal “Emotional Intelligence” could be seen as someone with
both learning disability and social awkwardness but still able to bond with carers:
awkwardness but
emotionally warm
(Dependent LD)
Object Related
Table 8: A person with low “Object Related Intelligence” and low “Emotional
Intelligence” but functional “Social Intelligence” could be seen as someone with
both learning disability problems due to difficulties in bonding with carers:
Learning Disability with
Callous Personality
(Learning Disability with
Challenging Behaviour)
Object Related
Diagnostic Criteria of Autism and
Tri-dimensional Intelligence
Autism as a socio-emotional Learning Disability:
This model adopts the view that autism is primarily a “socio-emotional learning
disability” and that the social and emotional dimensions are equally central for
diagnosis of autism. This model suggests that autism is better seen as a
biologically determined impairment in both emotional and social intelligences with
subsequent; “pervasive”, “regressive” and “developmental (since childhood)” socio-
emotional functioning.
Table 9: A person with autism essentially has low “Emotional Intelligence” and low
“Social Intelligence” (with functional “Object Related Intelligence” in this table):
Autistic Spectrum Disorder
Object Related
Table 10: A person with low “Object Related Intelligence”, low “Emotional
Intelligence” and low “Social Intelligences”. This would be autism with learning
Learning Disability with
Autistic Spectrum Disorder
Object Related
Core symptoms of autism and the emotional dimension:
In this model, core symptoms of autism are those symptoms that are shared
between both most severe and most mild autism. This would then exclude low IQ,
severe communication disorder, marked stereotyped behaviour, avoiding eye to
eye contact, pica, rocking, regressive obsessive compulsive disorder, etc. Such
model is not in total agreement with the DSM-IV and ICD-10, criteria of core
autistic features. In DSM-IV and ICD-10 core features of autism do not identify the
emotional dimension as an independent or major dimension separate from the
social impairment.
The emotional dimension in Autism has been mentioned implicitly inside the
“qualitative impairment in social interaction” section in DSM-IV and ICD-10 (29-30).
Then two vaguely worded emotional features were mentioned among four criteria;
“lack of social or emotional reciprocity” and “failure to develop peer relationships”.
Even then they are not crucial to make the diagnosis.
This model suggests that “qualitative impairment in emotional interactions” is as
important and as influential as the “qualitative impairment in social interactions” in
diagnosis of autism. The evidences in favour of a more elaborate emotional
dimension are numerous (49).
1) There is now significant level of agreement that emotional processing
problems like; lack of empathy, poor self-awareness, self-centredness, poor
reciprocation of emotion, poor ability to maintain emotional relationships,
anxiety and anger outbursts are more or less central features of autism (10,
2) Social and emotional skills are largely independent neurobiological functions
of the brain. While Social Intelligence is mainly centred in the neocortex
especially the frontal lobe, emotional skills are mainly related to the limbic
3) There are plenty of research data indicative of a high association between
autism and abnormalities in limbic system (52-54) as well as the studies about
the mirror neurones (18).
4) Neuropsychological research testing of emotional functioning (e.g. theory of
mind, empathy, facial recognition, etc) also suggests that impairment in
emotional functioning is central feature in autism (10,55).
5) Emotional development seems to be primary to social development (49).
Emotional functioning starts earlier in human development to social
functioning both developmentally and from evolutionary point of view. To be
able to deal with social groups and maintain reasonable social functioning we
need a minimum degree of self-awareness and empathy.
Other features of autism:
In this model, other features in autism have been divided into three groups of
symptoms; “compensatory behavioural symptoms”, “associated symptoms” and
1) Compensatory behavioural symptoms: like dependence on others, restricted
life style, having islets of interest, rigid routines, etc.
2) Associated symptoms: these seem to be associated disorders probably
caused by the same pathology causing autism. they include learning
disability, attention deficit hyperactivity disorder (ADHD), epilepsy, involuntary
movement disorders, pica, rocking, obsessional symptoms, ritualistic
symptoms, sensory processing disorder, etc. All these features can exist
independently of autism. Any single associated symptoms, alone, does not
justify a diagnosis of autism but can increase the likelihood of the diagnosis
once the core symptoms are first identified.
3) Complications: like “Habit Disorders” that can be seen as learnt pathological
behaviour related to coping with stress e.g. fire setting, misuse of
psychoactive substances, regressive aggression towards carers,
dysfunctional sexual habits, etc.
In this model communication disorder is paramount but it is divided into social and
emotional communication problems. They are included into the social and
emotional impairment sections.
In this model, “repetitive and stereotyped behaviours” (RSB), is not put separately
as it does not exist in all forms of autism (56). RSB was put as a possible feature in
“pervasive developmental disorder not otherwise specified” in the DSM-IV (29). In
this paper’s model, part of the stereotyped behaviour would be a compensatory
coping strategy e.g. keeping rigid routine to avoid losing control on the
environment. Another part of it is obsessional, ritualistic or involuntary motor
movement and this would be included under associated symptoms (57).
Differential diagnosis: Emotional and social skills can be seriously dysfunctional
in many psychiatric disorders and not all autistic or even biological in nature.
Acquired socio-emotional deterioration e.g. in chronic schizophrenia and
dementia. Premorbid functioning is usually relatively high if not normal compared to
developmental disorders.
Socio-emotional problems since childhood in individuals who are
developmentally normal in terms of social and emotional brain centres:
1) This could include complicated cases of; Learning Disability, Attention Deficit
Hyperactivity Disorder (ADHD), Post Traumatic Stress Disorder (PTSD),
physical disability with poor coping, severe neglect, severe isolation, severe
deprivation, complicated immature personalities or complicated personality
disorders etc. Complicating matters here include mental or physical traumas,
mental or physical illnesses, ADHD, misuse of psychoactive substances, etc.
2) In such cases it usually possible to see some quantitative and qualitative
differences in symptoms. The socio-emotional difficulties do not exist in all
areas of functioning of the affected individual e.g. symptoms are prominent at
home but not in school.
Diagnostic Criteria of Autistic Spectrum Disorders:
(I), (II) and (III) need to apply on the patient’s presentation:
(I) A diagnosis of autistic spectrum disorder must include features of both A,B,C and
possible features of D and E. The more symptoms, the severer the condition on the
a. Impairment of the development of Emotional Intelligence with impaired
emotional functioning that is pervasive, regressive and since childhood :
i. Cross-sectional (from interview and/or observation).
1. Emotional Inattention: poor monitoring of emotional data
2. Emotional Agnosia (alexithymia): poor understanding of
emotional data.
3. Emotional Inadequacy / awkwardness: poor ability to formulate
appropriate emotional responses.
4. Emotional dysmimia: poor ability to learn appropriate emotional
responses from others.
5. Emotional Concreteness: poor ability to apply previously learnt
emotional skills in new or unfamiliar situations.
6. Emotional Vulnerability: poor ability to apply newly learnt
emotional skills in stressful situations. Instead exhibits emotions like
the following:
a. Hostile dependence: hostility used as a mean to facilitate
dependence in safe relationships e.g. parents or carers
b. Anger outbursts: e.g. “catastrophic reactions” to stress
c. Quick superficial despair
d. Somatisation / hypochondriasis
ii. Longitudinal (from history):
1. Self-centeredness; inappropriate to developmental level and
cultural expectations
2. Poor self-awareness, poor ability to develop remorse or learn from
3. Poor empathy or appreciation of others feelings
4. Poor ability to reciprocate emotions.
5. Hostile dependency on safe relations.
6. Failure to develop emotional relationships appropriate to
developmental level and social norms
7. Treating people as objects or preferring objects over them
iii. Impairment of Emotional Communication.
1. Lack of emotional communication (e.g. poor appreciation of
emotional communication by others and poor ability to emotionalise
his/her communication in response).
2. Immature/childish emotional communication (e.g.
communication highly reflective of self-centeredness, childish
hostility, arrogance, stubbornness or childish expressions).
3. Abnormal emotional communication: e.g. paranoid alienation
during unexpected social interaction.
iv. Developmental or existential anxiety (not stress related); increases
when the person is unoccupied.
b. Impairment of the development of Social Intelligence with impaired social
functioning that is pervasive, regressive and since childhood :
i. Cross-sectional (from interview and/or observation).
1. Social Inattention: Poor monitoring of social data.
2. Social Agnosia: poor understanding and analysing social data.
3. Social Inadequacy/ Awkwardness: poor ability to formulate
appropriate social responses.
4. Social dysmimia: poor ability to learn appropriate social responses
from others.
5. Social Concreteness: poor ability to apply newly learnt social skills
in new situations.
6. Social Vulnerability: poor ability to apply newly learnt social skills
under stressful situations. Instead exhibits social behaviour like the
a. Hostile dependence especially on safe relationships e.g.
parents or carers
b. Manipulation or exploitation of more vulnerable others
c. Avoidance of social situations
d. Use of psychoactive substances to be able to socialise.
e. Proneness to exploitation
f. Poor problem solving skills and extremely poor coping
ii. Longitudinal (from history):
1. Limited social life in quantity (e.g. aloofness) or quality
(preoccupation with less-functional activities (e.g. hoarding unusual
material, taking photos of lamp posts, etc)
2. High dependency on others
3. Failure to develop peer relationships appropriate to age group
4. Poor appreciation of risks or danger
5. Lack of social activities appropriate to age group or social norms,
and if having activities they are usually dominated by:
a. Marked social awkwardness or bizarreness.
b. Marked social passivity.
c. The need to use external aid to allow it e.g. Alcohol or drugs
d. Over-formality and stiltedness
iii. Impairment of Social Communication.
1. Lack of social communication: e.g. lack of conversation skills
and/or use of unidirectional conversation rather than “social
2. Immature/childish social communication: attributing vague or
exaggerated meanings to social concepts e.g. he is against me
because he is right-handed and I am left-handed.
3. Abnormal social communication: e.g. self-hitting or destructive
behaviour in response to an argument.
c. Compensatory behaviour to cope with above impairments:
i. Restricting environment and relations
ii. Adherence to routines
iii. Fear of losing control
iv. Narrowing interests with or without overdoing them
d. Associated features:
i. Speech disorder
ii. Avoidance of eye to eye contact
iii. Rocking
iv. Involuntary movement disorder
v. Epilepsy
vi. Obsessional Compulsive Disorder (OCD) like symptoms
vii. Preoccupation with body fluids
viii. Hoarding behaviour
ix. ADHD
x. “Savant” phenomenon
xi. Sensory Processing Disorder
xii. Pica
xiii. Self-hitting or self-biting
e. Common complications:
a. Routine disorder: exaggerated use of functional routines to the
extents of disturbing general functioning e.g. rigidity in routines,
repetitiveness, catastrophic reaction in response to changes.
b. Habit disorder. (exaggerated use of non-functional routines which
usually aid some kind of pathological satisfaction e.g.
i. Drug and alcohol misuse
ii. Aggression towards carers
iii. Sexually inappropriate behaviour
iv. Stalking behaviour
v. Fascination with fire
vi. Cruelty to animals
II- All symptoms need to be taking place in the context of development since
III- Symptoms are not due to immature personality or acquired social-emotional
disorders, like schizophrenia, dementia or brain injury.
Autistic Spectrum
Nature and limits of the autistic spectrum:
This model adopts the view that the spectrum starts from normality to severe
autism (11,58). As autism is a socio-emotional disorder, the normality end of the
spectrum would be followed by conditions that are socio-emotionally abnormal but
still not severe enough to warrant a diagnosis of an autistic disorder and then
followed by autistic socio-emotional disorders.
Diagram 2: autistic and non-autistic parts of the socio-emotional spectrum
between normality and severe autism
None autistic socio-emotional disorders (NASED) are conditions in which the
individual is born with normal abilities but fail to put them into use due to adverse
biological or environmental factors in childhood like child abuse, severe isolation,
serious physical illness (e.g. ADHD, epilepsy, Cerebral palsy, etc) or mental
disorders (e.g. Obsessive Compulsive Disorder (OCD)). In this group, the affected
individual presents with significant problems in his or her socio-emotional
functioning despite of having normal socio-emotional basic brain structures.
In the meantime, non-autistic social-emotional problems are still clinically different
from autistic socio-emotional disorders.
1) The functioning is usually less pervasive, less regressive and more stress
2) They have better insight and better empathy than true autism.
3) Removal of stress, support and training can have better effect than what is
usually seen in autistic disorders.
Diagram 3: autistic parts of the socio-emotional spectrum between normality and
severe autism divided into central and peripheral autistic disorders
Central and Peripheral Autistic Disorders:
In this model, autistic spectrum disorders can classified based on the
neurobiological components of intelligence, explained in table 2 and table 11, into
two groups; Peripheral Autism and Central Autism.
Table 11: applying clinical stages of intelligence (consistent with “Lezak’s classes
of intelligence”) on autistic spectrum disorders:
Stages of skill /
Monitoring socio-
emotional data X +Partially Yes ++Partially
Understand /
analyse data X +Partially Yes ++Partially
responses from
Developing an
initial appropriate
Mastering the skill
in unfamiliar
Mastering the skill
under stress without
hostile dependence or
Conditions with “central” autism are those where the main impairment is in abilities
to monitor, understand, respond to, or learn from others; how to respond socio-
emotional data (Low and High functioning Autism).
The “peripheral” autistic disorders are those where central functions can be
partially done but the main focus of impairment is in the ability to use the central
skills in “unfamiliar settings” or in “stressful settings” (Asperger’s Syndrome (AS)
and Narcissistic Personality Disorder (NPD)).
Diagram 4: subdivisions of central and peripheral autistic disorders:
“Low Functioning Autism (LFA)” (infantile autism / severe autism), is usually
associated with lower IQ. The “central autistic” features are fully manifested in the
form of impairment of attention, monitoring or understanding of social and
emotional data. In High Functioning Autism (HFA) such problems are partially
mitigated due to the fact that people with HFA have higher IQ and can compensate
to some extent for their deficiencies. For example a person with HFA can
appreciate the significance of a relation (e.g. a mother) but in an emotionally cold
or mechanical way (e.g. mum is the provider of necessities like food and money).
However, people with HFA continue to have two other central autistic features i.e.
impairment of their abilities to formulate their own socio-emotional responses or
learning appropriate responses from others.
People with Asperger’s Syndrome (AS), they can better monitor the data, better
understand them, partially produce appropriate responses and partially learn from
others how to develop appropriate responses. However they still exhibit peripheral
autistic feature i.e. not being able to generalise what they learn from one setting
(familiar) to another (unfamiliar). This is probably due to impairment of imagination
(episodic future thinking / episodic prospection). Here, imagination means the
mental ability that equip the individual to envisage future scenario that are
unfamiliar and/or stressful and then be prepared to function well using past and
present skills (59-62). Such brain faculty also help knowing one’s own potential and
serve purpose of ventilation and self-assurance where the scenarios are self-
fulfilling. Despite of the fact that people with Asperger’s syndrome have more skills
than LFA and HFA, their “lack of imagination” (foresight or future thinking) is still
rendering them disabled (63).
Narcissistic Personality Disorder (NPD):
There is much disagreement about the various aspects of NPD including its validity
as a clinical diagnosis. The ICD-10 classification has not included NPD in the
classification of personality disorders (30). However NPD as a clinical concept,
seem to be widely accepted by clinicians and researchers as a valid and useful
diagnostic subtype of personality disorders.
Part of the problems is that many do not realise that there are two types of NPD;
“Grandiose” and “Vulnerable”. While systems like the DSM (29) highlights the
grandiose type, most of the NPD cases seen clinical settings are of the vulnerable
type. This is simply due to the fact that people with the grandiose type are more
functional and successful in life than the vulnerable type (64).
In clinical setting it is noticeable that people with NPD, do not show major degree
of functioning problems in stress free environment or when they are supported
(except that they are perceived as “not pleasant characters” to deal with). However
under stress and without support they can become quite dysfunctional in a way not
far from what we usually see in Asperger’s syndrome.
People with NPD have marked problems with self-esteem, sensitivity to stress (65)
and “paying undue attention to sources of praise and criticism” (66). This situation
manifest itself usually in the form of “Hostile Dependence” (or tendency to exploit
others) (29,67) and “Somatisation and/or Hypochondriasis” (68).
Such observations suggest that NPD could possibly be part of the autistic
spectrum, probably on the milder side of Asperger’s syndrome. NPD seems to
share with autistic disorders some key features (29) e.g.:
1) Inadequate emotional skills (self-centredness, Lacks empathy, arrogant
attitude, often envious of others, etc)
2) Inadequate social skills (grandiose sense of entitlement, rarely acknowledge
mistakes, requires excessive admiration, interpersonally exploitative, etc).
3) It usually starts in childhood like other personality disorders (ICD-10) (30).
Applying the above neuropsychological model, people with NPD seem to do
better in the functions lacking in both LFA, HFA and AS. However they still
exhibit one peripheral autistic feature i.e. not being able to generalise what they
learn from one setting (stress-less) to another (stressful). In this regard people
with NPD seem to be more sensitive to stress and less prone to benefit from
training or repeated exposure than average people. This is probably due to their
marked insecurity that makes them regress quickly under stressful conditions to
more primitive forms of coping.
Central Clear Area of Functioning” (CCAF):
“Central Clear Area of Functioning” (CCAF) is the part’s of the life of people on the
spectrum when they function well with no or few socio-emotional problems. Even
severe autism sufferers have CCAF, though quite narrow one. This would probably
be when they are with more objects not people e.g. playing with inanimate objects.
Following the autistic spectrum, the CCAF will increase in width while moving from
severe autism to mild autism to Non-autistic Socio-emotional Conditions.
Diagram 5: Central Clear Area of Functioning in different disorders on autistic
Relative Severity of Autistic Conditions on the Spectrum:
The general roles of severity as explained above can be altered due to the
complications and/or level of support associated with each part of the spectrum.
This means that a complicated Asperger’s Syndrome with poor support can be
worse than less complicated and well supported HFA.
Complication here mean conditions like low IQ, communication impairment,
neurological disorder (e.g. cerebral palsy, epilepsy, involuntary movement
disorder), OCD, routine disorder, habit disorder (e.g. paedophilia, pyromania,
hoarding behaviour), ADHD, Pseudologia Fantastica, learnt aggression, child
abuse, severe isolation, neglect, etc.
Diagram 6: Relative Severity of Autistic Conditions on the Spectrum. (C=
complicated, N/C. not-complicated).
Classification of disorders on the autistic spectrum:
1. The spectrum expands from normality to sever (central) autism.
2. Spectrum is divided into non-autistic socio-emotional disorders (NASED) and
Autistic socio-emotional disorders.
a. NASED sufferers are born with normal socio-emotional brain centres but
were subjected to biological and/or environmental adverse factors, in
their childhood, that have disturbed their socio-emotional functioning.
b. These adverse factors might include conditions like “severe neglect,
isolation, major physical illness (e.g. ADHD, epilepsy, Cerebral palsy,
etc) or mental disorders (e.g. OCD).
c. Functioning in NASED is usually less pervasive, less regressive and
more stress related.
d. People with NASED have better insight and better empathy than true
e. They usually have relatively wider “Central Clear Area of Functioning”
(CCAF) than in true autism.
3. The Autistic Socio-Emotional Disorders are divided into Central Autistic
Disorders (CAD) and Peripheral Autistic Disorders (PAD).
a. In people with CAD, they are unable to monitor or analyse socio-
emotional data and/or they are unable to appropriately respond to these
b. In people with PAD, they can partially monitor and analyse these data
and produce initial responses. They can also learn from others how to
initiate or improve responses. However they cannot generalise their
socio-emotional skills or intelligences to unfamiliar and/or stressful
4. Central autistic disorders are divided into Low functioning Autism (LFA) and
High Functioning Autism (HFA):
a. Both conditions are severe forms of autism but unlike LFA, people with
HFA have relatively high general intelligence which allows them to bridge
some gaps in their abilities, though in cold and /or mechanical way.
5. Peripheral Autistic Disorders are divided into Asperger’s Syndrome (AS) and
Narcissistic Personality Disorder (NPD):
a. People with AS lack of imagination (episodic future thinking / episodic
prospection) impair their ability to generalise their skills to unfamiliar or
stressful settings.
b. People with NPD have major problems with self-security. This impairs
their ability to generalise their skills in stressful situations
6. Complication and level of support can make level of severity relative different
on the scale:
a. E.g. complicated milder condition on the spectrum with poor support can
be clinically more challenging than the next severer condition if it is not
complicated and well supported.
Diagnostic criteria and classification of autistic spectrum disorders in DSM-5:
The Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5)
interim report on autism spectrum disorder was published in 2010 and invited
comments that are going to be taken into account before publishing the final draft in
May 2013 ( The proposed changed include eliminating the
categorical classificatory system including the concept of “pervasive developmental
disorder” and replace it by the dimensional classificatory system under the heading
of “autism spectrum disorder.” Also the various subtypes that were previously
described, including Asperger’s disorder, were eliminated. The diagnostic criteria
have also change from the old triad of impairment (impairment in social interaction,
impairments in communication and stereotyped patterns of behaviour) into dual
impairment by adding the social impairment together with the communication
impairment in one part.
The published draft of DSM-5 has attracted a lot of criticism. While adopting
dimensional diagnosis has met expected approval, the DSM-5 seems to fail again to
catch up with other recent developments as well as wide clinical agreement in both
diagnosis and classification of autistic spectrum disorders. The most disappointing
observation has been the elimination of Asperger syndrome (33,69).
Here there could be a strategic mistake in the APA thinking, either in autism or in
other diagnostic groups. DSM-5 is still Kraepelinian in approach (70) perhaps
because it relies heavily on behavioural patterns for making a diagnosis and
classifying psychiatric disorders. In the meantime, new advances in neuro-
psychological sciences seem to push hard for diagnosis based on both patterns of
behaviour as well as known neurophysiological data. We can afford this at this stage
of development of science. This would be the next step forward since Kraepelin time.
The following step forward will be to create diagnostic criteria and classification
criteria based on behavioural patterns, neurophysiology and neuropathology.
Conclusion and Clinical Implications:
The model used in this paper, portrays autism as a Socio-Emotional Learning
Disability. The model is based on the well-established data about autism in the
literature, recent developments in neurosciences, clinical observations and particular
neuropsychological theories like the Triune Brain Theory of Paul MacLean (6). The
Triune Brain Theory has been used to explain a possible neuropsychological basis of
“tri-dimensional intelligence”; Object Related, Emotional and Social. The model uses
“core symptoms” that is applicable to both “very severe” and “very mild” forms of
autism. The other symptoms known to be related to autism have been included
under Compensatory Behaviour, Associated Features and Complications. The
spectrum is then divided into central (LFA and HFA) and peripheral (AS and NPD)
forms of autism following the Lezak’s “4 stages of intelligence” (48). In this model,
the inclusion of NPD in the spectrum is advocated as a “milder than AS” form of
autism. The model also incorporate socio-emotional conditions that is clinically
significant but still not autistic in nature to fill in the gap between mild autism and
normality on the spectrum.
It is hoped that this model can be tested empirically in future research to establish its
clinical validity. It is a simpler concept close to Learning Disability one. It should be
easier to use by clinicians and public. It gives potential for developing new
psychometric tools to serve cover the three intelligences that would be clinically
more informative that the traditional IQ. the model expand the horizon of autistic
spectrum to allow better identification of milder autism like NPD and Non-autistic
Socio-emotional Conditions. The Lezak’s based classification of intelligence stages
can help better assessment as well as differentiation of levels of intellectual
functioning. It is hoped that this model can help better recognition of the different
autistic disorders and subsequently better services.
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I would like to thank Ms Melissa Fourie, Architectural Designer, for providing the art
work. I would like to express thank Dr Husni Al-Robb and Dr Alaa Haweel for
valuable comments, input and editorial assistance.
Dr Khalid A Mansour
Locum Consultant Psychiatrist in Learning Disabilities
Keresforth Centre,
South West Yorkshire Partnership NHS Foundation Trust
Barnsley, South Yorkshire, UK
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>,  YV #C Z5C = %! = [&C = !3 .:; [7   &' C  !C \+ 'C .X- 'C (*; "71)+ ,+ -%, ] ."^ &'C '1 <7 ' .X- (*1 (9 (* 4'  ) 0 ' T! l(23- -(-+ ( \3 M' " "U-A3 _A . (* A9 #$ O1)+   , 9 UX, < :;  .&' C 63C I  4&` #$3 < K5 (3  F" .F!
... The classifications of brain systems in this model are inspired primarily by Paul MacLean's triune brain theory [51]. However, many clinicians and neurobiology researchers have proposed the idea of 'multiple intelligence' [52][53][54][55][56][57][58]. ...
This study explored a new scientific approach for analysing mental disorders, as a possible way to modernise Kraepelinian psychiatry, using neurobehavioral principles to develop a model of personality (and personality disorders), as an example. The model uses a two-dimensional approach (behavioural and pathophysiological) to define personality disorders, instead of the prevailing one-dimensional (behavioural) approach used in Kraepelinian psychiatry. The model is also biological, socio-neurodevelopmental, and dimensional (non-categorical) and aims to integrate with clinical principles to the extent possible. The model begins from a platform of three origins of personality and personality disorders: basic skills (visceral, physical, and emotional and social intelligence), maturity, and environment. The model incorporates modern discoveries of neurosciences and makes them more amenable to clinical practice.
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