Autism spectrum disorders and its role in adult psychiatry and psychotherapy

Autism spectrum disorders (ASD) are common with an estimated prevalence well above 1 %. Theoretical considerations as well as clinical observations point to a much higher rate in psychiatric and psychotherapeutic settings be it as in-or out-patients. The last decade saw a rather slow but steady increase in the awareness of the role of ASD in adult psychiatry and psychotherapy. However, in particular very high functioning ASD patients with normal or even above average IQ, normal language at superficial level of description and good compensatory skills often run un- or misdiagnosed with atypical depression, obsessive-compulsive disorder, borderline (in female patients) or narcistic or combined personality disorder (in male patients) or atypical psychosis being the most common diagnostic misconceptions. This often results in unsuccessful and frustrating therapeutic endeavors for therapists and patients alike because the autistic specificities are not identified and addressed properly. This however is a prerequisite for an effective management of such patients who are often regarded as "difficult to take". Respective unsuccessful treatment attempts also further compromise the already reduced self-esteem of many ASD patients. Even in subsyndromal variants the autistic personality structure is often the reason why specific and recurring interpersonal conflicts arise in private and vocational relationship. This is a particularly important issue for psychotherapy. In this constellation the autistic personality structure of the so called "broader autism phenotype" serves as basic structure for evolving and difficult to deal with conflicts, problems and experiences of mobbing and failure. It is important to recognize this pathogenetically relevant personality structure in order to adopt specific therapy strategies. In this paper we present a summary of the latest conceptual developments concerning ASD in DSM-5, of putatively helpful diagnostic strategies in an out-patient setting and discuss the relevance of respective findings for the further therapeutic management.