In 2013, when the American Psychiatric Association released its updated diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), the category known as pervasive developmental disorders that included disorders such as autism, Asperger’s disorder, and similar disorders was dropped from the manual.
All of the disorders in this category are currently classified under the new category of autism spectrum disorder (ASD), such that all of the former disorders classified as pervasive developmental disorders are now classified as one disorder, ASD, which share a specific symptom profile.
The reasoning behind this change was that quite a bit of the current research did not support these separate diagnoses as separate, standalone diagnostic entities, and there was quite a bit of confusion and discontinuity with clinicians using these diagnostic schemes. The singular category was designed to eliminate these issues and to be more consistent with current research findings. Thus, it is no longer clinically appropriate to describe a disorder as autism or Asperger’s disorder but instead to describe it as an autistic spectrum disorder.
The ASD category is a complicated category with a number of symptoms that will be discussed in this article. In addition, the potential for the development of a substance use disorder in an individual with a diagnosis of ASD will also be discussed.
Autism Spectrum Disorder (ASD) Criteria
The autism spectrum disorder is diagnosed when the following criteria are met according to the DSM-5:
Deficits in social communication and social interaction: The person displays deficits in social interaction and social communication in multiple situations. For example:
- Deficits in nonverbal communication that are typically used in social interaction, such as eye contact, gestures, facial expressions, and so forth
- Deficits in social reciprocity that occur in multiple contexts, such as failing to initiate social interactions, displaying a normal approach to individuals in social situations, failure to reciprocate emotions, etc.
- Deficits in the ability to understand, develop, or even maintain social relationships in multiple contexts
Repetitive and restrictive patterns of behavior, activities, or interests: The person displays these patterns in various situations. For example:
- Highly restricted or fixed interests that are abnormal in their focus and or intensity, such as preoccupation with unusual objects or very circumscribed interests
- An insistence on sameness or routine or ritualized patterns of behavior in multiple contexts, such as having meals at certain times of the day, needing to take the same route to a place every day, rigid thinking patterns, difficulties with transitions, rigid greeting rituals, etc.
- Repetitive or stereotyped uses of speech, motor movements, or objects
- Over or under reactivity to sensory input or an unusual interest in the sensory aspects of an environment, such as the temperature, time, smell, etc.
- Qualifiers: The symptoms must be present early in the development of the individual; cause significant impairment in their social, occupational, or other areas of functioning; and cannot be better explained by some type of an intellectual disability (even though many individuals with ASD have intellectual disabilities). These behaviors may also not be better explained by some other medical condition or psychiatric/psychological disorder in order for the individual to receive a diagnosis of an ASD.
- Severity: The severity of the symptoms and ASD are rated on a three-level continuum, ranging from the need to have support in order to function, to the need to have substantial support, to the most severe level where the individual requires very substantial support. Thus, ASD is a disorder that is rated on a continuum of severity that ranges from relatively high-functioning individuals in spite of their symptoms (note the term relatively) to extreme severe impairment that results in the individual needing significant support in nearly all aspects of their behavior.
The symptoms occurring in ASD must occur over a variety of different contexts and situations and, as explained above, result in significant impairment in the individual’s ability to function. Even individuals who are diagnosed with ASD and who are considered to be relatively high functioning still require some level of assistance to function in many aspects of their daily lives.
The term comorbidity is a clinical term used to describe a situation where an individual has two or more diagnoses at the same time. When a disorder is described as being comorbid with another disorder, this means that these disorders occur together even though they are different and mutually exclusive disorders or conditions. According to the American Psychiatric Association, there are a number of comorbid conditions associated with ASD, including intellectual impairment, language disorders, attention deficit hyperactivity disorder, and a number of other psychological/psychiatric disorders.
When an individual has a psychological/psychiatric disorder that is comorbid with a substance use disorder, these are often referred to as co-occurring disorders. The DSM-5 often lists the most common comorbid disorders with a particular diagnostic category; however, there is no mention in the DSM-5 of ASD having any significant comorbidity with substance use disorders.
ASD and Substance Abuse
There is little research describing significant comorbidities between autism, ASD, or even the former pervasive developmental disorders and substance use disorders. The majority of psychiatric diagnostic materials and descriptive materials that discuss these diagnostic categories do not even mention prevalence rates of co-occurring substance use disorders and ASD. This indicates that these co-occurring conditions are not commonly observed.
The reason for this is that individuals with ASD are fixated on other aspects of the environment, their interests, or themselves, and are not prone to seeking the type of psychoactive effects that are commonly associated with substances of abuse. These individuals would not use substances in a social matter because they are not social, often do not have the motivation to go out and procure these substances illegally because they need significant support in most of their daily activities, and are more fixated on internal aspects of their world than in seeking external aids for stimulation.
The individuals who are at the high-functioning level of ASD would be the ones who would be most likely to develop substance use disorders; however, as already discussed, there is no significant mention of comorbidities between ASD and substance use disorders in the clinical literature. This is not to be taken to mean that individuals with ASD never abuse substances, because this most likely does happen in isolated cases; however, the rates of these co-occurring disorders are so low that they are not commonly the focus of research and mention in clinical material, as are disorders that often have strong comorbidities with substance use or abuse, such as depression, anxiety, personality disorders, etc.
It is important to note that a recent study in the Journal of Studies on Alcohol and Drugs did find an association between individuals who display certain symptoms of autism and substance abuse. The study found that individuals with elevated scores on measures of autistic traits were more likely to use tobacco and cannabis, and were at an elevated risk for the use of alcohol. However, normal individuals displaying certain behaviors that resemble the behaviors that occur in ASD are not diagnosed with ASD. Instead, these are normal individuals that share certain restricted types of traits that are seen in individuals with severe psychiatric disorders, even though these individuals do not meet the criteria for those disorders. Thus, it would be a mistake to conclude that these findings suggest that individuals who are formally diagnosed with ASD are at a risk to develop substance use disorders based on this type of data.
In addition, as mentioned above the formal clinical research and diagnostic manuals for these disorders do not describe significant associations between ASD and substance use disorders. Thus, while individuals diagnosed with ASD may occasionally develop co-occurring disorders, this is not a common occurrence that represents a significant problem for the majority of these individuals.
ASD And a Co-occurring Substance Use Disorder Treatment
Because individuals with an ASD diagnosis have a number of functional deficits, the treatment of an individual who has ASD and a co-occurring substance use disorder would have to be personalized according to their abilities, the level of the individual’s understanding, and the intellectual capacity of the person. Certainly, any individual with an ASD and a co-occurring substance use disorder who developed physical dependence on a substance would need to go through a withdrawal management program. However, the counseling, social support, and other aspects of substance use recovery would be tailored to the individual’s capacity.
Because individuals with ASD often have significant deficits in their ability to interact with others, the treatment would most likely be most beneficial if it were delivered in some form of individual therapy. This would require a great deal of care, empathy, and understanding on the part of the individual’s treatment provider and most likely the use of a number of techniques from the behavioral school of psychotherapy that do not require significant insight and introspection.