On the Spectrum: High-Functioning Autism and Its Contemporary Relevance

With publication of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) in 2013, autism's prevalence in the United States nearly doubled to more than 2% of the population. In reconceptualizing the condition, DSM-5 collapsed 4 diagnoses into 1 diagnosis: autism spectrum disorder. What the 4 had in common were deficits in 2 broad areas: restricted, repetitive behaviors or interests; and deficits in social communication. Three of the 4 were severe forms easily recognized in childhood. The fourth, constituting most of the increase in prevalence, was Asperger disorder, or high-functioning autism, frequently going undiagnosed until adulthood. These patients typically have fluent language, intact intellect, and highly developed compensatory strategies including social "masking." The adult diagnosis is manifested in struggles to maintain employment or friendships both platonic and intimate. Nonpsychiatric providers are likely to encounter patients with autism spectrum disorder seeking care for myriad comorbid psychiatric and physical problems. Complicating matters is that many adult psychiatrists are unfamiliar with what was until recently the purview of child psychiatrists. Autism has neither cure nor specific pharmacologic treatments, but addressing comorbidities, with psychiatric and medical referrals where indicated, mitigates suffering. Services targeting employment and educational support, occupational therapy focused on activities of daily living, and skill-based psychotherapies that aim to improve social interactions can reduce stress and anxiety while enhancing function, reducing isolation, and encouraging satisfying relationships.