New Autism Theory: "The boy whose brain could unlock autism"

The article "The boy whose brain could unlock autism" from https://medium.com/ is beautiful. It is beautifully written. It is hosted on a beautifully designed site. And most importantly, the non-judgmental theory of autism presented is beautiful.  This theory is also pretty brilliant.

The article presents a theory that reconceptualizes autism as an "intense world syndrome."  This theory suggests that autism is not best thought of as a disorder characterized by a lack of empathy or intelligence, but by the existence of an overload of emotion plus a great capacity to learn.  Further, intense world syndrome suggests that people with autism experience sensations differently.  What an awe-inspiring idea.

There are so many different issues to discuss now!

Let's start with empathy.  Just because it may appear that people with autism lack empathy, doesn't mean this interpretation is correct.  It could be that a person's mind with autism is so overloaded that focusing on someone else is next to impossible.  Over time, this could result in lacking empathy for others.  Further, if people with autism are constantly bombarded with not only intense emotions (e.g. anxiety), but aversive sensory experiences as well (e.g. the act of brushing your teeth produces the internal sensations that nails on a chalkboard would typically evoke), certain consequences can be expected.  We know that spikes in anxiety result in increased calcium release and the encoding of memories.  This process could result in really rigid thinking.  Not to mention, one's focus is really narrowed in those moments.  So if there is constant anxiety, the brain is in a state of rapid-fire learning...on one hand.  On the other hand, it may be difficult to focus on anything but a particular target.  This combination of increased anxiety and rapid fire learning may carve out some pretty "strange" observable behavior patterns over time.  For instance, perhaps a hyper focus on learning calendar dates could result.  Also, the manner of brain processing could leave very little left over for attention on others, hence our current/previous perception of lack of empathy in people on the spectrum.

Speaking of the "spectrum," as a field we are very comfortable examining autism on this spectrum.  But it seems to me that there is still the perception of a dichotomous cutoff whereby some people have autism and others don't.  Right now, once a diagnosis of autism is made, then you are examined on the spectrum as compared to others with this diagnosis.  But what if we viewed every single person as representing a different degree of autism on a full spectrum?  What if the spectrum was thought to encompass all humans?  Well, I think that'd do us a huge service when conceptualizing cases.

Eating disorders, OCD, and self-injury are all jumping into my mind as relevant to this new theory of autism.

Let's take eating disorders for starters.  I'm too invested in writing this blog post right now to look it up, but I remember learning at this year's International Conference on Eating Disorders in Montreal that autism and eating disorders are related.  This was an internal hypothesis of mine for ages.  When I saw the data, I literally scribbled "I knew it!!!" in my notes.  [P.S. Even though I'm not going to look up the exact presentation I saw, here's a Medical News Today article on the relationship between eating disorders and autism from August 2013.]

Similar to what this new theory of autism posits, people with eating disorders are also in a state of anxiety, which results in rigid thoughts (e.g. "fat is bad"), compulsive behaviors (e.g. calorie counting), and a self-centered focus.  There's also usually an increased level of intelligence in people with eating disorders... or perhaps it's better conceptualized as "fast learners."   Sounds a bit like high-functioning autism, huh?  

Unlike autism though, many times people with eating disorders report desperately wanting the approval of others.  So, even if the behavior is seemingly self-centered (e.g. wanting to look good), I maintain that the function of the behavior is not completely egocentric.  But reconciling this seemingly self-centered focus and a desire to please others is usually not easy for family members of people with eating disorders.  The idea is difficult to grasp that intense anxiety about other's approval ironically results in a "self-centered" disorder. In short, I think it could be really useful to use intense world syndrome concepts in fostering understanding about eating disorders. 

Here are a few last notes before I move on with my Sunday: I think eating disorders relate to autism in the same way OCD is related to autism.  In fact, I conceptualize eating disorders as a specific subtype of OCD.  It appears to me that the process is the same in both disorders, but the content of the worry differs.  And as such, slightly different treatments are needed... but not too different.  I'll publish more on what I've written about this in the future.

And lastly, there is the example of how self-injury may relate to autism.  I've blogged here before about my hypothesis on self-injury's relation to sensory integration issues.  To read, click this link.  The idea that intense emotions can create perceptual disturbances (auditory hallucinations such as hearing voices) is not new in psychology.  But the idea that intense emotions can also lead to sensory disturbances remains an area where we need work.  Taking that a step further, exploring exactly how emotions are moderated with sensory acts like self-injury (or even doing things like soothing oneself with lavender hand lotion) is worth researching.

We need to know the following: is there a dose response relationship between intense anxiety/emotion and 1) sensory disturbances, 2) learning, 3) rigid thinking, 4) compulsive/repetitive behaviors, and 5) a self-centered focus?  If not, is there some relationship?  What mediates/moderates that relationship?

This new idea of conceptualizing autism as "intense world syndrome" clicked a few pieces into place of an enormous puzzle that I have been kicking around in my brain for years.  I very much look forward to learning from research on this theory in the coming years. 

Sensory Integration and Self-Injury

I spent the last semester working with children who have autism.  During this time, I heard the term "sensory issue" a bunch of times, but had no clue what it really meant.  Even after asking questions about it, I never felt like I really understood it.

I ended up learning the most about sensory integration issues at an unsuspecting event - at a writer's conference in NYC.  There, I so happen to have met Nancy Peske, the co-author of the book, Raising a Sensory Smart Child, and a mother of a child with the conceptually elusive sensory integration issue.  I figured she'd be the perfect person to ask about this stuff.

I ended up learning that some people are prone to either seek out intense stimulation or find even the most mild sensations aversive.  For instance, some children have an extremely high tolerance for what would cause most of us pain.  Conversely, the same child may find light tickling painful or aversive.  Although many people with autism have these types of sensory integration issues, we also see this in people who don't happen to have autism.

Relevant to my past research, we find that children who engage in self-injury are more likely to have a high pain tolerance and engage in repetitive behaviors.  While we previously thought that having a high pain tolerance was caused by repeated episodes of self-injury, I'm wondering if actually there is an underlying sensory integration issue here.  [In fact, we're finding that the traditional tolerance theory is not supported.]

On top of that, we have been conceptualizing repetitive behaviors as a precursor to self-injury; however, now I'm thinking that perhaps they both emerge out of the same sensory integration issue that may have been present from before / soon after birth.

And speaking of birth, in Deliberto & Nock, 2008, we report that in utero complications are seen more in children who engage in self-injury than in controls.  Like repetitive behaviors and in utero complications, these findings are also seen in people who have autism.  Although these data are correlational, the relationship among in utero complications and repetitive behaviors, self-injury, and autism is worth considering in my opinion.

In short, I'd bet that both self-injury and some of the underlying commonalities between this behavior and autism are sensory integration issues relating to touch.


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Why Do People Talk about Cutting Themselves?

I just received the following inquiry: I know some one thats very public about cutting themselves. Is this normal? And why do you think this is?

Here's my answer:

Good question. Although I cannot assume I understand this specific person, I can speak generally about the topic of openly discussing one's own self-injurious behavior.

My first inclination is that the person may be seeking what we call "social reinforcement." There are two types of social reinforcement - positive and negative.

What we call "positive social reinforcement" is what people not in the biz call "getting attention." This would come in the form of sympathy, interest, concern, or even people expressing shock. Particularly if a person feels disconnected / a lack of social support (and want these things), they may be prone to be seeking interaction with other people in this way.

So what we call "negative social reinforcement" does actually not mean punishment. In my experience, people in the public misuse the term "negative reinforcement" quite frequently. Negative reinforcement simply means to remove something aversive or to get out of a responsibility. For instance, an adolescent working on a boring group project might tell her peers that she's a "cutter" so they put less of a workload on her. In this example, if the teen gets out of doing something boring, she is negatively reinforced for telling people she cuts.

This brings us to an interesting point. It is my opinion - which is not shared among people with whom I've worked - that when people are socially reinforced (either negatively or positively) for telling people they self-injure, it isn't necessarily the cutting itself that is affected. What I think is more influenced is the actual disclosure of the behavior. This would mean that if someone is socially reinforced for telling people they cut, the actual act of cutting wouldn't necessarily increase, but the number of times self-injury is discussed would increase. To be crystal clear, I think that social reinforcement may shape the largely impulsive behavior of cutting itself, but not as strongly as the seemingly more deliberate act of discussing the behavior.

It is my opinion that people primarily engage in self-injury for emotion regulation purposes. In other words, to decrease their anxiety or to pull them out of a disoriented state (to learn more, I posted a link about this at the bottom of the page). It doesn't make sense to me that people engage in self-injury just so that they can receive attention for it later. My intuition tells me that the reinforcer of social approval is too far removed from that actual act of cutting to be incredibly potent. To my knowledge though, no research has been conducted to support this. In fact, self-report studies show that people report thinking they engage in self-injury to gain approval, therefore, it is advisable to take this into consideration when considering the thoughts previously expressed.

Perhaps self-injury can start out so that one may gain approval (positive social reinforcement) or even get out of something (negative social reinforcement). It could also be the case that someone starts cutting just for the emotional effects, but then starts telling people about it. I just can't buy into the idea that the only reason someone would cut is for social reinforcement.

Anyhow! I digress. Back to your question. It could be the case that this person is trying to connect with people, shock them, or remove his/herself from responsibility. On the other hand, perhaps he/she is just trying to work through previous shame about the behavior and finds it liberating to talk about it. I really don't know. But these are my best guesses!

Speaking to your question regarding whether or not it is normal: based on no data but my experience, about half of people who cut themselves report telling other people, while the other half don't tell anyone but maybe a mental health professional. While I'm not sure how normative it is for people to talk at length about their self-injury, I have some thoughts about this.

We can't make assumptions that talking about engaging in self-injury is necessarily a maladaptive / bad thing. For instance, perhaps the person will end up getting into the right treatment and get support for stopping the behavior. And as previously mentioned, perhaps the person used to feel much shame about the behavior and is working through it by speaking about cutting. Who knows?

On the other hand, one could make the case that if the person is socially reinforced for disclosing that he/she self-injures, the behavior could be maintained. I'm just not sure exactly why this person may be openly discussing engaging in self-injury.

As you can imagine, it is quite complicated!

Great question though. I've never been asked this.

To read more check this out: http://taradeliberto.blogspot.com/2011/02/why-do-people-cut-themselves.html

Near Death Euphoria and the Link to Suicide

I was asked by a friend if I ever came across someone who attempted suicide not to escape suffering, but because they knew it would feel good.  Although not suicidal, the person asking the question was curious because he had experienced a near-death situation in which he was injured and felt euphoria.

I thought this was a really thought-provoking question. The link between near-death euphoria and suicide never crossed my mind before.

This was my response:

I have heard of people recounting similar types of experiences, but I had never considered the link between near-death euphoria and the intention to commit suicide.

A brief discussion of Thomas Joiner's theory of suicide is in order. The basic gist is that people may build a tolerance for the negative feelings associated with hurting / killing themselves by engaging in self-injurious or thrill seeking activities. While it is not necessarily intentional, the negative feelings about death may lessen over time.

Let's just say a person regularly sky dives. Then, for whatever reason, they become suicidal. If you're already used to jumping out of planes, the idea is maybe you won't be that scared to jump off of a bridge.

There is another relevant example to this discussion as well. Namely, if a person regularly cuts themselves (without intent to die) when they're upset, they may not be scared to make life-threatening incisions when suicidal urges come up.

While I formerly thought of this concept as similar to "building up the courage" to attempt suicide via repeated episodes of cutting / dare-devil behavior, this question has me thinking differently. Perhaps there is an additional component here that is consistent with Joiner's theory.

When people cut their skin with no intent to die, it is thought that endorphins are released. This would create reduction in the negative feelings that may prompt self-injury, like shame, anxiety, sadness, etc. Perhaps people also feel mild euphoria, or positive feelings, from the endorphins. This might suggest that for some, self-injury has at least two psychological functions - reducing negative feelings and increasing positive feelings - perhaps produced by the same biological mechanism (i.e. endorphin release).

In any event, a link between injuring oneself and feeling good is formed. Maybe this association generalizes to suicide in the sense that injuring yourself is linked with feeling good.

Now, getting more to the point of suicide, endorphins are not only relesaed during self-injury, but during a traumatic / near-death event as well. This is very interesting to me because a link can be formed between feeling good and death, specifically. In the sky diving example used above, an association is formed between feeling good and jumping from a height, but not necessarily death. In the case of a traumatic event, the link is formed between feeling good and specifically being near-death.

While people may not report chasing the feeling of euphoria that comes with being close to death, if they've experienced it, the drive for this positive feeling could theoretically propel future suicidal behavior. Whether or not the person is aware that they are driven to suicide because of past feelings of euphoria when close to death, it could be a biological function maintaining the behavior.

In short, while I had formerly thought of suicide as a behavior maintained by the function of wanting to escape pain, this point raises the question of whether or not people want to commit suicide to actually feel better. Again, while I don't think people would necessarily report wanting to die to feel that euphoria, it could influence their suicidal drive and behavior.

[For people familiar with psychology lingo on this blog, the function may not necessarily just be automatic negative reinforcement, but automatic positive reinforcement as well.]

Truly, a fascinating point. Thank you so much for asking.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.

Self-Injury as an Inborn Fail-Safe

Where do we get the idea to eat or have sex? Maybe we don't. As Pinker argues, we're not a blank slate. Perhaps the impulse to engage in self-injury when under extreme emotional distress is also inborn.

We are starting to understand the havoc stress wreaks on the body. We are also starting to understand the strong endogenous physiological calming effect self-injury prompts.  In this context, I wonder if self-injury acts almost like an inoculation - when given a small amount of manageable physical adversity, the body's soothing and contentment system is able to overcompensate and fortify itself. Maybe the body intuitively knows to default to self-injury under periods of stress because there are dramatic and sudden decrease anxiety due to increases in endogenous calming agents, being that stress is particularly harmful to the body. [There's something about stress triggering autoimmune diseases here that should be looked at. Perhaps it isn't a coincidence that Benadryl can be used both as an antianxiety as well as an antihistamine.]

After all, humans are not the only animals that engage in self-injury (e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486411/). My first published study (cited in TIME here) mentions that a certain percentage of people report getting the idea to engage in self-injury from an outside source; however, the other side of that is that some people report never having learned the idea from anyone. Perhaps it is, in fact, an inborn impulse we have that is defaulted to in times of stress because it is protective to the body against stress. This is not to say, of course, that some people don't get the idea to cut from other people. Surely this must be the case. But what about the people who spontaneously start cutting without outside influence? How can that be explained?

I'm beginning to think that the impulse to hurt oneself is a hardwired fail-safe.

Why Do People Cut Themselves?

by Tara Deliberto

Celebrities like Megan Fox, Angelina Jolie, and Demi Lavato have all purposely cut themselves. But why?

Well, it isn't all that clear. And the answer "they do it just for attention" doesn't make too much sense.

Sure, getting attention could be part of the answer, but it's not that simple. If you've never cut yourself, consider this: of all the things you could possibly do for attention, is carving your skin with a razor really at the top of the list? Probably not.

After researching self-injury for several years, one thing seems certain - cutting immediately halts emotional pain. It might seem backwards that physical pain stops psychological pain. But we need to take a closer look.

Starting Generally

I would actually say a major contributing factor to self-injury is actually our tendency to make things too simple. Allow me to explain. Although judging what is right and wrong is super complicated - hence the whole legal system - we are quick to slap labels on people like "good" or "bad." But life is more nuanced than that! Of course labeling helps us communicate, but a lot of very important information gets lost when we stamp something as "good" or "bad."

More Specifically

Now getting more directly to the point of this post, the very same language we use to describe our world and communicate ideas to others, is used to communicate to ourselves. We think in words. We label ourselves as good or bad. We tell ourselves we are good or bad.

And what people are telling themselves right before they cut is nearly unbearable to hear. I'd imagine their mind is shouting things at them like "You're a worthless bitch. How could anyone love you? You disgust me."

The thing is, I don't think I've ever met a totally worthless, unlovable, and disgusting human being, whatever that is. It is usually very clear from a third party perspective that the self-talk of a person who cuts, is incredibly harsh and one-sided. Despite this, people go on labeling themselves anyhow.

Not only do people who cut tell themselves abusive things, they believe them too. This is a very important distinction. Once people learn to determine the difference between having a thought and believing it in therapy, we usually see symptoms improving a lot. It is one thing to think "Wow, I am a bad person," acknowledging it as just a thought, and moving on. It is another thing to think "Wow, I am a bad person" and believe it.

With a new understanding of abusive self-talk in the mind, let's shift to discussing the body.

The Body

Let's just say you're strolling along, thinking about how beautiful the sky is, when you walk into a telephone pole. The second after your toe smashes into the pole, are you still thinking about that beautiful sky? Probably not. You're just thinking about how much your damn toe hurts.

Now, what if you were thinking about how you're such a selfish slut? What if you believed it? Would you rather be in the emotional anguish that comes along with berating yourself or would it be easier to have your toe hurt?

Yeah, that's what I thought. You'd rather stub your toe, wouldn't you?

Right after the body sustains an injury, it is kind of hard to be caught up in your thoughts. The physical pain provides a mental break from really horrible self-talk. The pain becomes a vacation.

[It is worth mentioning that even if the emotional pain isn't necessarily tied to what some people might call irrational thought (but is from an actual loss or event), it still be halted by self-injury. Usually though, I'd bet there is some degree of extreme thought causing the pain to be increasingly intense.]

Now back to talking about cutting for attention. Sure, people could also be cutting for attention, but the picture is clearly a lot more complicated. On either side of the spectrum, you may have people who solely for attention, and on the other, people who cut and have never told anyone. Most likely, people cut for several reasons. Now, let's take this discussion a bit further from here.

While it seems that verbal thoughts like "You're a worthless cow" repeating over and over might be an important factor, there are many more pieces of the puzzle.

The Physiology of Self-Injury

There are some non-human primates, especially neglected ones, who tear out bits of fur when they're distressed. They actually harm themselves.

[Side note: The thought of a neglected monkey pulling out tufts of fur can be pretty upsetting, cant it? Unfortunately, while it is easy for some of us to have sympathy for monkeys who hurt themselves, it is more difficult to take a non-judgmental stance towards humans who cut.]

While these neglected monkeys harm themselves like humans, they don't have language capacities like us. Therefore, it's not very likely that abusive self-talk leads to self-harm in non-human primates. Percentage wise, the non-human primate self-injury may be maintained much more by the emotional, rather than a linguistic or symbolic system.

While language is a new development on the evolutionary scene, emotions are not. Emotions have been around for a while, without the complication of human language. As any loving pet owner like myself could tell you, animals have emotions.

What happens on a physiological level after someone cuts is not currently understood; however, my guess is that there is a release of endorphins, which make you feel good. We also know that heart-rate dramatically drops after cutting in people who often self-injure.

In short, on a mental/language level as well as an emotional level, there is likely some serious relief occurring right after cutting.

Wrapping Up

The way I see it at this particular point in time, is that very upsetting abusive self-talk is immediately halted, there a shift of attention to the cut, and endorphins are released, which serves to calm the body further.

Of course, the reasons people cut are diverse and they change over time. This may not be true for everyone. For instance, people may also cut to feel something if they're feeling nothing or numb. An additional reason people report cutting is to punish themselves. Perhaps sometime soon I'll write about these functions as well; however, it seems to me that the main function of cutting is to help reduce negative feelings in the moment.

Thankfully though, wonderful treatments like Dialectical Behavior Therapy (DBT) have been invented to help with cutting. If you or someone you love engages in self-injury, there are wonderful resources available. Go online and find a DBT therapist near you or join a DBT Skills Group near you.

Blog Info

For more posts on self-injury, check out The Psychology Easel's Self-Injury Section.

Feel free to follow me on Twitter at @TaraDeliberto and subscribe to this blog in the right sidebar.

Do You Self Harm?

If you engage in self-injury, an excellent resource is S.A.F.E. Alternatives, an absolutely wonderful organization devoted to the treatment of self-injury (you can visit their website at http://www.selfinjury.com/).



Also, a very helpful book on directly treating self-injury is Bodily Harm. Select this book in the icon above to purchase.

The best treatment for cutting is Dialectical Behavior Therapy (DBT).  Find a DBT therapist near you.

TIME Magazine Article that Refers to My Paper!!

by Tara Deliberto

And now for some shameful self-promotion:
Here is a link to a TIME Magazine article on self-embedding that refers to a paper I wrote with Dr. Matt Nock!

The statistic that 38% of people get the idea to self-injure from the peers and 13% from the media is from Deliberto & Nock 2008. Personally, I think the other 49% is more interesting (right?! if there is no external source of the idea, how does it come about?!?), but I'm extremely grateful that the information is getting out there.

Thoughts on the Course of Self-Injury

by Tara Deliberto

Non-Suicidal Self-Injury (NSSI) refers to the direct and delibertate destruction of one's own body tissue without intent to die. Most people who engage in NSSI use razor blades or knifes to break the skin in an attempt to regulate their emotions. I usually describe NSSI in this way to my friends: Did you ever see a movie where someone was losing control, a friend slapped them in the face, and then the person suddenly regained control? Well, NSSI is like that only it is the person who hurts themselves. To the shock of most of my friends, less often, people report engaging in NSSI for social gain- i.e. getting attention or eliciting sympathy.

Nock & Prinstien outline the four reasons/functions people report for engaging in NSSI; however, not only can one person be engaging in NSSI for two or more reasons in one instance, I think there is a more dynamic process of development and maintenance of NSSI through various functions at different times.

At first I thought social reinforcement ("doing it for attention") could certainly be a secondary gain of engaging in NSSI (exactly like social support being a "secondary gain" in treatment of medical illnesses) and therefore, help maintain the behavior after the first episode. Then I started thinking... well, for that matter, one could also initially engage in NSSI primarily for social approval and also feel a decrease in physiological arousal, right?. That lead me down the path of wondering what functions maintain the behavior over time.

Surely, one can start engaging in NSSI solely for social reinforcement, which then elicits a positive emotion. But then, after a while, perhaps engaging in NSSI in the absence of reinforcement from other people can decreases negative emotions without necessitating actually receiving support (Pavlov's dog style!!!). Again... for that matter... the reverse is probably true too! For example, some people could engage in NSSI for the first time in the total absence of social support and receive an automatic decrease in physiological arousal. Over time, after eventually sharing this information and gaining social support, the behavior that was once used as a tool for automatic physiological arousal decreases can be used to solicit social support.

I would certainly expect an even more complex and dynamic system of functions maintaining the behavior to develop over time, with each relevant function contributing a varying amount. Additionally, I would expect the range of situations prompting the usage of NSSI to range anywhere from narrow to broad/generalized over time (meaning that it can go from broad to narrow to broad... or narrow to broad to stopping completely... or any combination over time, NOT just narrow to broad!).

In short: NSSI is a multipurpose tool that is automatically picked out of the toolbox in response to a wide array of situations and can fix the problems in different ways over time.