10 ms·

Lynn Waterhouse, Eric London and Christopher Gillberg have a similar opinion of autism/ASD: see their 2017 letter to the editors of Autism Research, “The ASD di

Lynn Waterhouse, Eric London and Christopher Gillberg have a similar opinion of autism/ASD: see their 2017 letter to the editors of Autism Research, “The ASD diagnosis has blocked the discovery of valid biological variation in neurodevelopmental social impairment” Some quotes from their letter: > Taken together, the preponderance of evidence argues that using the diagnosis of ASD in research is fruitless because the diagnosis is an arbitrary unscientific “convenient fiction” that has blocked the discovery of replicable neurobiological variation among individuals with serious neurodevelopmental social impairment. > More than seventy years of research studying the arbitrary diagnosis of autism has not resulted in any targeted medical treatments. Now is the time to abandon the ASD diagnosis in research. https://doi.org/10.1002/aur.1832 https://doi.org/10.1002/aur.1832

ncmncm 4y ago
You could say much the same about depression. As it is, we know there are lots of different conditions all labeled depression, distinguishable mainly by which medication they respond to, if any. (This, despite that symptoms vary widely; e.g. many suicidal, others just lacking affect and motivation.) At least treatments exist, somehow grandfathered in. The wastebasket diagnosis means that no new medication can be found to have any useful effect, because it only treats a small fraction of patients in a trial, and worsens others. And, somebody always pops up self-righteously insisting Gold Standard Randomized Controlled Trials prove that none of the medications that millions of people need daily to be able function at all have any effect.
- R0b0t1 4y ago
  I agree mostly, but w.r.t. medication, it's not that they have no effect, it's that they seem to function by accident with the most plausible explanation (chemical deficiency?) being suspect under closer consideration.
  - ncmncm 4y ago
    No. It is that the med under test could perfectly treat the small number diagnosed who actually have the illness it addresses, and have nil or negative effect on everybody else given the same diagnosis who have an actually different illness. According to the RCT, it just failed. Validity of RCT results is limited absolutely by validity of diagnosis. Bad diagnostics, bad results. That doesn't stop people from running invalid RCTs, so it should stop people from citing invalid RCTs. But it doesn't.
- skissane 4y ago
  I agree with you about depression also being a biologically dubious category. Lynn Waterhouse's publications focus on criticising ASD (and its predecessor diagnoses) in particular, but I very much doubt she thinks the rest of the DSM-5 is all fine–it is simply that autism/ASD is one of her core areas of professional/academic specialisation, in which she's spent much of her career, so that's where she focuses her criticisms. Discontent with the DSM is very widespread, in significant subsections of both research and clinical communities – however, attempts to dethrone it in practice are met with opposition from that other current of professional opinion ("it obviously is far from perfect but we need something and nobody's convinced us there is anything better"), and that other current seems to thus far be winning in the money/power/mindshare stakes. > The wastebasket diagnosis means that no new medication can be found to have any useful effect, because it only treats a small fraction of patients in a trial, and worsens others. New pharmacotherapies for depressive disorders do get approved – in 2019, the FDA approved brexanolone for post-partum depression and esketamine for treatment-resistant depression; before that, the FDA approved vortioxetine in 2013. Agometaline was approved in the EU in 2009 and and Australia in 2010, although its manufacturer gave up trying to get it approved by the FDA. And there are further new drugs in various stages of the approval pipeline. Brexanolone is particularly interesting as a drug to treat a rather specific form of depression rather than just "vanilla depression". No denying it could be better, but depression is a much better situation than autism/ASD – although risperidone and aripiprazole are both approved to treat behavioural issues (irritability and aggression) in children with ASD, neither has any impact on core autistic traits (social cognition, obsessiveness, etc). At least for depressive disorders, we have approved pharmacotherapies to treat their core symptoms, even if they only work for some patients some of the time.
  - ncmncm 4y ago
    Yes, ASD is in much worse shape than depression. And, risperidone is a terrible choice of treatment. Anxiolytics can be very effective.
sterlind 4y ago
there was a trend in neuropsychiatry to study "neuroendophenotypes" - the smallest behavioral changes linked to gene expression - rather than treat macro-level diagnoses like autism as monoliths. autism probably covers hundreds of discrete genetic disorders that share similar pathology. for instance, Rett syndrome is sometimes considered part of ASD, but only explains a small number of ASD diagnoses. I don't think that precludes ASD from being a useful diagnostic category, though. behavioral therapists don't need to know your genotype to help you cope with sensory overload. schizophrenia probably works the same way, but you still prescribe antipsychotics regardless.
- skissane 4y ago
  > I don't think that precludes ASD from being a useful diagnostic category, though. behavioral therapists don't need to know your genotype to help you cope with sensory overload. It is possible to have "sensory overload" – even severe problems with it – yet not have enough of the other symptoms of ASD to meet its diagnostic criteria. How do behavioural therapists treat sensory overload in a person without ASD? Pretty much in the same way that they treat sensory overload in people with ASD! Conversely, it is possible to meet the ASD diagnostic criteria, and yet have no sensory issues needing treatment – such people exist too. That's the thing – received wisdom justifies the clinical use of diagnoses as useful in treatment planning - but if you subject that received wisdom to scrutiny (too rarely done), it doesn't hold up very well. Almost all treatments in psychology/psychiatry/etc are (at best) symptom-specific not diagnosis-specific – almost all symptoms occur in multiple diagnoses, and many diagnoses have no one essential symptom. If person A has diagnosis B with symptom C – their treatment for symptom C will often be very similar, even identical, to the treatment of that same symptom in some other person who has completely different diagnoses instead. > schizophrenia probably works the same way, but you still prescribe antipsychotics regardless The same point applies to medications – medications don't really treat disorders, they treat symptoms. Antipsychotics are used to treat psychosis – which is a symptom which occurs not only in schizophrenia spectrum disorders, but very commonly seen in mood disorders as well (bipolar disorder with psychotic features, depressive psychosis), and (less commonly) can occur as a symptom of many more. Yet, whatever their diagnosis may be, a person with psychotic symptoms is highly likely to be prescribed an antipsychotic. Added to that, you can also be prescribed an antipsychotic without having any psychotic symptoms, since various antipsychotics are FDA-approved for treating non-psychotic conditions, including anxiety, behavioural issues in children with autism/ASD, bipolar disorder, depression and Tourette's syndrome, along with various non-specific symptoms such as "agitation", "behavioural problems" (ADHD, ODD, DMDD, conduct disorder, personality disorders), and "hyperactivity" [0] – to say nothing of their very widespread off-label use. [0] https://www.ncbi.nlm.nih.gov/books/NBK84656/ https://www.ncbi.nlm.nih.gov/books/NBK84656/

ncmncm 4y ago

You could say much the same about depression. As it is, we know there are lots of different conditions all labeled depression, distinguishable mainly by which medication they respond to, if any. (This, despite that symptoms vary widely; e.g. many suicidal, others just lacking affect and motivation.) At least treatments exist, somehow grandfathered in. The wastebasket diagnosis means that no new medication can be found to have any useful effect, because it only treats a small fraction of patients in a trial, and worsens others. And, somebody always pops up self-righteously insisting Gold Standard Randomized Controlled Trials prove that none of the medications that millions of people need daily to be able function at all have any effect.

R0b0t1 4y ago
I agree mostly, but w.r.t. medication, it's not that they have no effect, it's that they seem to function by accident with the most plausible explanation (chemical deficiency?) being suspect under closer consideration.
- ncmncm 4y ago
  No. It is that the med under test could perfectly treat the small number diagnosed who actually have the illness it addresses, and have nil or negative effect on everybody else given the same diagnosis who have an actually different illness. According to the RCT, it just failed. Validity of RCT results is limited absolutely by validity of diagnosis. Bad diagnostics, bad results. That doesn't stop people from running invalid RCTs, so it should stop people from citing invalid RCTs. But it doesn't.
skissane 4y ago
I agree with you about depression also being a biologically dubious category. Lynn Waterhouse's publications focus on criticising ASD (and its predecessor diagnoses) in particular, but I very much doubt she thinks the rest of the DSM-5 is all fine–it is simply that autism/ASD is one of her core areas of professional/academic specialisation, in which she's spent much of her career, so that's where she focuses her criticisms. Discontent with the DSM is very widespread, in significant subsections of both research and clinical communities – however, attempts to dethrone it in practice are met with opposition from that other current of professional opinion ("it obviously is far from perfect but we need something and nobody's convinced us there is anything better"), and that other current seems to thus far be winning in the money/power/mindshare stakes. > The wastebasket diagnosis means that no new medication can be found to have any useful effect, because it only treats a small fraction of patients in a trial, and worsens others. New pharmacotherapies for depressive disorders do get approved – in 2019, the FDA approved brexanolone for post-partum depression and esketamine for treatment-resistant depression; before that, the FDA approved vortioxetine in 2013. Agometaline was approved in the EU in 2009 and and Australia in 2010, although its manufacturer gave up trying to get it approved by the FDA. And there are further new drugs in various stages of the approval pipeline. Brexanolone is particularly interesting as a drug to treat a rather specific form of depression rather than just "vanilla depression". No denying it could be better, but depression is a much better situation than autism/ASD – although risperidone and aripiprazole are both approved to treat behavioural issues (irritability and aggression) in children with ASD, neither has any impact on core autistic traits (social cognition, obsessiveness, etc). At least for depressive disorders, we have approved pharmacotherapies to treat their core symptoms, even if they only work for some patients some of the time.
- ncmncm 4y ago
  Yes, ASD is in much worse shape than depression. And, risperidone is a terrible choice of treatment. Anxiolytics can be very effective.

sterlind 4y ago

there was a trend in neuropsychiatry to study "neuroendophenotypes" - the smallest behavioral changes linked to gene expression - rather than treat macro-level diagnoses like autism as monoliths. autism probably covers hundreds of discrete genetic disorders that share similar pathology. for instance, Rett syndrome is sometimes considered part of ASD, but only explains a small number of ASD diagnoses. I don't think that precludes ASD from being a useful diagnostic category, though. behavioral therapists don't need to know your genotype to help you cope with sensory overload. schizophrenia probably works the same way, but you still prescribe antipsychotics regardless.

skissane 4y ago
> I don't think that precludes ASD from being a useful diagnostic category, though. behavioral therapists don't need to know your genotype to help you cope with sensory overload. It is possible to have "sensory overload" – even severe problems with it – yet not have enough of the other symptoms of ASD to meet its diagnostic criteria. How do behavioural therapists treat sensory overload in a person without ASD? Pretty much in the same way that they treat sensory overload in people with ASD! Conversely, it is possible to meet the ASD diagnostic criteria, and yet have no sensory issues needing treatment – such people exist too. That's the thing – received wisdom justifies the clinical use of diagnoses as useful in treatment planning - but if you subject that received wisdom to scrutiny (too rarely done), it doesn't hold up very well. Almost all treatments in psychology/psychiatry/etc are (at best) symptom-specific not diagnosis-specific – almost all symptoms occur in multiple diagnoses, and many diagnoses have no one essential symptom. If person A has diagnosis B with symptom C – their treatment for symptom C will often be very similar, even identical, to the treatment of that same symptom in some other person who has completely different diagnoses instead. > schizophrenia probably works the same way, but you still prescribe antipsychotics regardless The same point applies to medications – medications don't really treat disorders, they treat symptoms. Antipsychotics are used to treat psychosis – which is a symptom which occurs not only in schizophrenia spectrum disorders, but very commonly seen in mood disorders as well (bipolar disorder with psychotic features, depressive psychosis), and (less commonly) can occur as a symptom of many more. Yet, whatever their diagnosis may be, a person with psychotic symptoms is highly likely to be prescribed an antipsychotic. Added to that, you can also be prescribed an antipsychotic without having any psychotic symptoms, since various antipsychotics are FDA-approved for treating non-psychotic conditions, including anxiety, behavioural issues in children with autism/ASD, bipolar disorder, depression and Tourette's syndrome, along with various non-specific symptoms such as "agitation", "behavioural problems" (ADHD, ODD, DMDD, conduct disorder, personality disorders), and "hyperactivity" [0] – to say nothing of their very widespread off-label use. [0] https://www.ncbi.nlm.nih.gov/books/NBK84656/ https://www.ncbi.nlm.nih.gov/books/NBK84656/