Autism in Females: Are we missing something?

Let's talk about autism in females. This is a topic I have had a lot of questions from followers about as there is a lot of new research and narratives forming around the subject. In this blog, I want to review what autism is and how we diagnose it. Then discuss how females tend to present differently than males. And finally, examine the prevalence of the higher rates diagnosed in males vs. females. This is where the controversy comes in, and emotions tend to run high, so go easy on me.

  Autism was first documented back around 1910 by a clinician describing unusual symptoms in a psychiatric patient, initially thought schizophrenic. The root of the Latin word autism is "autos," which means the self. He observed that this patient was withdrawn from the outside world and looked inward. 

       Fast forward to the 1940s. Two groups of researchers began to study the condition more intensively, one in the US. and the other in Germany. The name of the German researcher may sound familiar, Hans Asperger. This is significant because the higher functioning form of autism was referred to as Asperger's disorder after observing patients with higher functioning, often accompanied by intellectual or creative gifts. This label persevered until about eight years ago with the publishing of the DSM-5, categorizing autism as a spectrum rather than two distinct disorders.

Nevertheless, many still prefer to use this term to differentiate the presentations to the consternation of many. The Asperger's label continues to be highly controversial, and I will likely create a video/blog on this at some point (against my better judgment). Still, I'd prefer to stick with one controversy at a time. I can only handle so much heat all at once.

The two broad categories of autism symptoms are social and communication difficulties like being withdrawn from others, verbal and non-verbal deficits, a seeming lack of interest in relationships, and difficulty understanding social cues. The other category consists of repetitive movements and fixed interests. For example, folks with autism often may shake their hands, rock back and forth, or display other self-soothing behaviors. It's also common to have sensitivity to sensory stimuli like loud noises or certain textures. As far as fixations go, often, folks with autism have narrow and deep hobbies and interests that may even border on obsession. This could include comic books, WWF wrestling, anime, art, etc. 

It's important to note that the autism spectrum is quite broad. On the more severe end, individuals can present with significant intellectual impairment to the point of being non-verbal and needing round-the-clock caregiving. On the other end, some individuals may not get diagnosed until adulthood with full ability to function independently and often excelling in various areas. These would be the folks formerly diagnosed with Asperger's.

Now let's look at some of the nuanced differences of male and female presentation. We use the same criteria for both sexes. Like most mental health disorders, diagnosis is based on observation, so there's more room for bias. One of the most extensive studies on sex differences concluded some fascinating findings. Autistic females diagnosed with lower functioning and intellectual impairment tended to have more severe symptoms than their male counterparts. These included increased difficulties in social relationships, emotional regulation (another common symptom of autism), and overall difficulties in day-to-day functioning. However, on the less severe end of the spectrum, women's symptoms often go unnoticed, potentially due to their ability to mask. 

The term masking or camouflaging refers to one's attempt to fit in socially that does not come naturally. You are essentially acting or mimicking based on what you observe in others. This may be due to socialization, as women are expected to be more relational and pressured to socially conform. It's thought that females' fixed interests tend to be more culturally appropriate, like fashion, music, or animals, that would not appear too far out of the ordinary. 

Perhaps you've seen the reality show "Love on the Spectrum" on Netflix, which I highly recommend. One of the autistic individuals they followed was about my age, in his 30s or so, and was obsessed with dinosaurs. As cool as dinosaurs are, this tends to stick out a bit more. Another interesting finding was that many women with autism, despite the conventional belief, have a strong desire to form close relationships and bonds. Yet, despite this, they often struggle to maintain these relationships long-term and navigate conflicts. 

Now let's talk about prevalence rates. For decades, it has been believed that the number one protective factor against developing autism is being female, known as "the female protective effect." There are theories and research studies on various explanations that provide evidence of this phenomenon. These theories include testosterone levels in utero, prevalence among siblings, and resilience to genetic mutations, among others. However, these theories are still disputed among researchers. Frankly, these topics are too far above my paygrade to have an opinion one way or the other. 

There exist many prevalence studies comparing sex differences in autism diagnoses. Most articles I found aggregating the data put the prevalence rates of males vs. females somewhere around 4:1 or 5:1. That's a pretty big difference even compared to its neurodevelopmental disorder cousin, ADHD, at about a 2:1 or 3:1 ratio. These kinds of sex differences often make people upset. They question the validity of the findings, some of which may come from emotion and a desire for equality. Nevertheless, the latest research largely backs the narrative that bias exists and females with autism are underdiagnosed. 

According to that extensive study on sex difference referenced above, when you look at the prevalence of women with severe autism, the rate drops closer to 2:1. However, on the other end of the spectrum, of the higher functioning autism, it can be as high as 8:1. Because of the masking behaviors, women often do not get diagnosed until later in life. Perhaps due to a clinician bias, women must present more severe to get noticed and diagnosed. Hence, the findings above that women tend to have more pronounced symptoms on the lower functioning end of the spectrum. 

What is apparent in the research is that due to decades of bias, women do not get diagnosed at the rate they should. This is seldomly disputed. But is it possible that the rates are even among the sexes, and the female protective factor is a myth? For the other neurodivergents with ADHD, where women are also underdiagnosed, I think there is more possibility that the rates are even at the 3:1 ratio. Yet, with autism, at its approximate 5:1 ratio, that's a lot of ground to cover. 

With severe autism, it can be hard to miss, but it's much easier to overlook those who are higher functioning. My hunch that there remains a female protective effect is merely an educated guess. Researchers indicate a strong need for more studies to fully reverse the conventional view. 

Either way, I feel that we should make an attempt to take the emotion out of it. Let's see where the research leads instead of forming fixed narratives prematurely. If there are prevalence disparities between the sexes within disorders, I believe that's okay. For example, you see the opposite phenomenon with borderline personality disorder, diagnosed far more in women and overlooked in men.
Nevertheless, I'd like to see us be more objective and find out why there are discrepancies if they exist. We need to help those whose autism is overlooked and not divert bias in the other direction. At the end of the day, we certainly need to get better at identifying autism in women so they can get the services they need to live their best lives. 

        I hope you enjoyed this blog. Please like, subscribe, and share, and I look forward to seeing your comments, even if they are critical. 

-ETC

Resource list:

Spectrum News: The Female Protective Factor Explained - Resources for females with Autism - The Female Autism Phenotype and Camouflaging: a Narrative Review - Behavioral and Cognitive Characteristics of Females and Males With Autism  - A Qualitative Exploration of the Female Experience of Autism Spectrum Disorder (ASD)

Do I have bipolar I or II? What are the differences?

Okay, so what in the hell is the difference between bipolar I and II? As a therapist, I get this question all the time, and it's pretty damn confusing even for most therapists, myself included. So for this post, I went back through the DSM-V and looked through some of the literature to try to find a clear and concise way for clients and clinicians to understand the differences.

The DSM-V describes bipolar I as replacing what was known for many years as manic-depressive disorder. This phenomenon of individuals exhibiting extreme mood states has been observed throughout history. Though we can't say for sure, it's thought that historical figures including Sir Isaac Newton, VanGough, Hemmingway Hendrix, and potentially Winston Churchill had manic-depressive symptoms. Individuals with bipolar disorder tend to be vastly creative and often ingenious, though not all individuals can successfully manage their condition and achieve professional success.

So let's take a look at our modern understanding of bipolar disorder and how we diagnose it. Right off the bat, the DSM states that for bipolar I, you do not need to have a depressive episode though most will. However, for bipolar II, you have to experience at least one depressive episode. This was a bit of a shocker to me as I always thought there needed to be at least one depressive episode hence bipolar. Yet, the DMS has always maintained that the manic feature of the disorder is what makes it unique.

The most significant difference between the two is that bipolar I has manic episodes vs. bipolar II having hypomanic episodes. Both are elevated mood states with racing thoughts, irritability, impulsiveness, reckless behavior, excess energy, lack of sleep, and partaking in goal-directed behaviors. It's like drinking coffee on steroids that last days-weeks or even longer.

So what the hell is the difference between hypomanic and manic? When you pick apart the wording in the DSM, there are a couple of key differences. First, the DSM states a hypomanic episode lasts at least four days and a manic at least seven. Okay, not the most helpful. So, what else?

Here is where I differentiate the manic and hypomanic when diagnosing. Manic episodes cause enough impairment to have a significant impact on your ability to function in your day-to-day life. This includes work and personal responsibilities, to the point where you cannot fulfill them. Your functioning is clearly different from the norm with hypomanic, but you can still mainly function without severe consequences.

A manic episode is more severe than a hypomanic episode. If a client is having psychosis or requiring hospitalization, it is automatically manic and therefore labeled as Bipolar I. That's what most look for.

In reviewing the DSM, I found it interesting that they note Bipolar II as not necessarily a less severe disorder. The greater prevalence of depressive episodes can impair functioning just as badly. This makes sense, as depressive episodes can lead to a severe loss of functioning and even psychosis. Yes, there is depressive psychosis that is similar to that manic episodes. Sometimes the delusions are wrapped in guilt. Also, catatonia is often present, which is essentially a slowing of motor functioning and affect.

So there you have it, that is the best way I make sense of the differences. But, in the end, I think the best way to summarize the contrast is through the significant disruption of functioning, often present through psychosis or leading to hospitalization.

You likely have a better grasp than most mental health professionals if you read this, so congratulations!

-Evan the Counselor

Does my Therapist Hate Me?

Do you ever think your therapist hates you or judging you? It's common! I know it makes you want to run, but it can be beneficial! Heres how…

When you are in therapy, you are often at your most vulnerable by letting another human being see the parts of you that bring shame. Therefore you have a tendency to project your own insecurities onto your therapist.

I did an exercise where I told my client to say whatever they felt about me and our relationship and be as blunt and emotionally open as possible. He told me he feels that I think that he's a "bad person," a fraud, and a bad father. But he thought I was just being nice to him because I had to be.

This was far from the truth. I felt none of those things and the client. So right then and there, he realized that's how he thought about himself, and we knew precisely what needed to be worked on.

If you have a good therapist, they will recognize this opportunity as well. The therapy room is a place where you can practice having the difficult conversations you will benefit from in the real world. It is also a place to have "corrective emotional experiences." These experiences in therapy help challenge your previously held beliefs through a safer form of human connection through your therapist.

An example of a corrective experience was when I had a client afraid of "straight" men. He was mercilessly bullied growing up. After having corrective experience of a safe and positive relationship with me, a heterosexual man, he was able to challenge his deep fears from the past and slowly develop new relationships with others.

Therefore when you think your therapist is judging you, this is valuable information, so pay attention. Don't be afraid to bring it up in therapy. You may just have a breakthrough!

Borderline Personality Disorder vs. C-PTSD

C-PTSD vs. BPD.

Are Borderline Personality Disorder and Complex C-PTSD the same thing? I have gotten this question quite a bit so let’s clear the air. 

BPD is a specific pattern of behavior and way of coping with trauma and severe stress. Almost all of the symptoms overlap with PTSD, including emotional reactivity, substance use, other risky behavior, and trouble in relationships. 

However, complex PTSD has a longer list of symptoms, including flashbacks, nightmares, and dissociation. I use the term C-PTSD to refer to complex PTSD. C-PTSD is not an official diagnosis in the DSM but a common categorization for someone whose PTSD comes from a multitude of traumas throughout their life. Particularly during childhood.

Yet, not everyone with PTSD has the same coping pattern as someone with BPD. For example, one of the signature features of BPD is chronic self-harm and suicidal ideation. 

Many people with BPD meet the criteria for PTSD as well. Someone’s temperament can play a role in people being susceptible to BPD, such as naturally higher levels of impulsivity and emotional reactivity. 

If you have PTSD or BPD, you are likely to have one or the other, but they are not the same. At least not how we categorize these disorders today. 

-ETC