Running head: AUTISM SPECTRUM DISORDER AND SCHIZOPHRENIA …alfredadler.edu/sites/default/files/Björn Walter MP 2017.pdf · Schizophrenia ... To understand the concept of belonging,

Running head: AUTISM SPECTRUM DISORDER AND SCHIZOPHRENIA 1

Autism Spectrum Disorder and Schizophrenia

A Literature Review

Presented to

The Faculty of the Adler Graduate School

____________________

In Partial Fulfillment of the Requirement for

The Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

____________________

By

Björn Walter

____________________

Chair: Richard Close, DMin, LPCC, LMFT

Reader: Meghan Williams, MA, LMFT

____________________

August, 2017

AUTISM SPECTRUM DISORDER AND SCHIZOPHRENIA 2

Abstract

This literature review sets out to compare the similarities and the differences between autism

spectrum disorder and schizophrenia. To understand the relationship between the two disorders,

this project includes an examination of the historical timeline, an analysis of the diagnostic

criteria, the impact and effectiveness of various treatments for autism spectrum disorder and

schizophrenia. Emphasis is on Adlerian therapy, pharmacological treatment through

antipsychotic medications, and the legal and ethical issues as a result of misdiagnosis. To

achieve understanding around ethical and legal concerns regarding misdiagnosis, this project

includes a hypothetical case study to demonstrate potential harm after the wrong treatment. The

primary purpose of this paper is to increase awareness of the problematic situations that arise

when the autism spectrum disorder and schizophrenia are misdiagnosed.

Keywords: autism spectrum disorder, schizophrenia, Adlerian therapy, antipsychotic

medication, DSM-5


Acknowledgements

I would first like to thank my colleagues at the Autism Society of Minnesota. I would

like to particularly extend my gratitude to Dr. Barbara Luskin. You inspired me to complete this

project, and I will always be grateful for the support you gave me. I would also like to thank my

family for always being there for me. I would not be where I am without you. Lastly, I would

like to express the deepest gratitude to Ari Leuthner for his support and wisdom.



Copyright © 2017

Björn Walter

All rights reserved


Table of Contents

Adlerian Theory ....................................................................................................................... 7

Social Interest .................................................................................................................... 7

Belonging .......................................................................................................................... 9

Mistaken Beliefs .............................................................................................................. 12

Autism spectrum disorder ...................................................................................................... 14

DSM-5 Diagnostic Criteria ............................................................................................. 14

History of Autism Spectrum Disorder ............................................................................ 16

History of Asperger’s Syndrome..................................................................................... 19

Treatment for Autism Spectrum Disorder ....................................................................... 20

Therapeutic. ...............................................................................................................20

Pharmacological. ........................................................................................................23

Schizophrenia ........................................................................................................................ 25

DSM 5 Diagnostic Criteria .............................................................................................. 25

History of Schizophrenia ................................................................................................. 27

Treatment for Schizophrenia ........................................................................................... 30

Therapeutic. ...............................................................................................................30

Pharmacological. ........................................................................................................32

Comparison ........................................................................................................................... 34

Similarities ...................................................................................................................... 35

Differences ...................................................................................................................... 37

Ethical .................................................................................................................................... 40

Legal ................................................................................................................................ 40

Ethical.............................................................................................................................. 41

Case Study ............................................................................................................................. 43

Discussion .............................................................................................................................. 45

Recommendations for Future Research ................................................................................. 46

Conclusion ............................................................................................................................. 47



According to The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-

5; American Psychiatric Association, 2013a), the previously named autism disorder, along with

other disorders such as Asperger’s syndrome, were placed into an umbrella category called

autism spectrum disorder. However, individuals with autism spectrum disorder are still

subjected to receiving wrongful treatment or treatment more suitable for those diagnosed with

schizophrenia (Owen, et al., 2009). Wrongful treatment for those diagnosed with autism

spectrum disorder includes antipsychotic medications that focus on symptoms not present in

individuals with autism spectrum disorder, including hallucinations, delusions, and confused

thoughts (Rapoport, Chavez, Greenstein, Addington, & Gogtay, 2009). These symptoms are

common in schizophrenia and are positive symptoms (thoughts and behaviors present within a

mental disorder, but not in the population without it) (American Psychiatric Association, 2013a).

Antipsychotic medication may have side-effects, which can be worse than the problems

associated with autism spectrum disorder (LeClerc & Easley, 2015). In addition, there is no

correlation between the use of antipsychotic medication and improvement in areas such as social

withdrawal, apathy, and being able to live a meaningful life (Volkmar & Wiesner, 2013).

Woodbury-Smith, Boyd, and Szatmari (2010) found that therapy had a greater success rate with

schizophrenia and autism spectrum disorder than antipsychotic medication. Additionally,

therapy would eliminate potential side effects of medication.

One successful approach has been Adlerian therapy. This approach helps the client work

around their mistaken beliefs, gain social interest, and feel belonging. By working on these

components, clients of both disorders can improve their quality of life. This is done through not

only helping others but also by helping themselves. Adlerian therapy is encouraging in nature


and it places a great emphasis on finding belonging in society. Both schizophrenia and autism

spectrum disorder have problems rooted in lack of belonging and lack of social interest. In

addition, mistaken beliefs often hinder them from living meaningful lives. That is not to say

there are other problems that come up. There are still difficulties with the basics of everyday life,

not following through tasks, and in the case of individuals with schizophrenia: positive

symptoms, such as hallucinations and delusions. However, clients can get guidance through

these problems with Adlerian therapy (Ansbacher & Ansbacher, 1964).

The following sections will show why pharmacological treatment with antipsychotic

medication is not a sustainable treatment of autism spectrum disorder. Additionally, the reasons

why therapy, particularly Adlerian therapy, are beneficial forms of treatment. Furthermore, one

section will show a hypothetical scenario in which a person gets the wrong diagnose and the

problems associated with the misdiagnosis.

Adlerian Theory

Social Interest

The word social interest comes from the German word “Gemeinschaftgefūhl”, which can

be translated as “community feeling” or social interest (Ansbacher, 1991). Adler proposed that

social interest was the personality trait reflecting the relationship between an individual and its

environment (Ansbacher & Ansbacher, 1964). The actions and characteristics of humans are all

impacted by the degree of social interest the person has. Adler believed the desirable traits of

humans are affected by how much social interest a person has. For example, a person described

as optimistic, caring, courageous, and empathetic would have more social interest. Additionally,

the lack of social interest would leave us with more undesirable traits. Therefore, a person with

feelings of inferiority, isolation, neurosis, and lack of empathy would have less empathy


(Ansbacher & Ansbacher, 1964). One way of understanding social interest is to compare it to

empathy. Although empathy is a feeling, social interest is more of an evaluative attitude toward

life and others (Watts, 1998). Adler explained this with the phrase “To see with the eyes of

another, to hear with the ears of another, to feel with the heart of another" (Ansbacher &

Ansbacher, 1956).

Even after Adler’s death, many Adlerians affirmed his perspective of social interest.

O’Connell described it as the intellectual, affective, and behavioral aspects of the optimal

relationships to others (O'Connell, 1965). Ansbacher went further by stating that it was not only

the interest in others but more of the interest of others’ interests (Ansbacher, 1991). Through a

developmental perspective, there are three different kinds of processes in which social interest

affects us. In step one, social interest is an assumed tendency for cooperation and social living.

This can be developed through training and via family interactions, but the base of it is innate. In

step two, the social interest has been developed into objective abilities of being a contributing to

society, while also understanding others and being able to see others’ perspective. In the last

step, social interest has become more subjective. It is now used to evaluate choices influencing

our personal life. However, if any of these steps cannot be met, the attitude of social interest

may not be reached. This can be troublesome as humans need to be able to horizontally strive

toward a socially useful side, which not only helps themselves but also society as a whole

(Ansbacher, 1991). What is interesting about social interest is the fact it can be a predictor of an

individual’s adjustment and psychological health. Adler believed that social interest protects

individuals from inferiority feelings, brings us better coping mechanisms, and provides us with a

healthier attitude toward experiencing stressful situations. (Manaster, Zeynep, & Knill, 2003).


Adler emphasized that if not an adequate level of social interest is developed in children

and adolescents, this can lead to later psychological difficulties in adulthood (Ansbacher &

Ansbacher, 1964). This would include, but not be limited to depression, stress-related symptoms,

failure in relationships, neuroses, psychosis, and anger issues (Sweitzer, 2005). However, an

individual could learn how to develop self-worth, self-value, optimism, and treat others with

value and dignity. Individuals striving for social interest will be taught by others to treat humans

in an egalitarian way.

By focusing on helping and believing in other individuals, feelings of communion will

arise. With this, social interest arises, and it gives the individual the chance of being appreciated

for being themselves, while also finding meaning in giving to something greater than they

experienced before. This is one of the reasons why volunteering and having a community

feeling is rewarding. It makes us feel part of something that is greater than ourselves. However,

with our world becoming more individualistic and competitive, we start forgetting what is

important. This leads to a greater crisis in mental health and more stress related disorders which

affects our society negatively.

Belonging

When it comes to defining Adlerian psychology, the term individual psychology can be

confusing. Although it is focused on the individual and their experiences, one must recognize

the need to be part of something greater. However, personal prestige trumps the need for

wellness off humanity in the Western World, it can only exist on the condition belonging to the

total (Ansbacher & Ansbacher, 1964). An individual who only focuses on their own needs will

become isolated. In this stage, the person becomes more neurotic, which in turn can be


hazardous for the mental health. A neurotic attitude pushes away the positive feelings and

replaces them with negativity and despair (de Vries, 2017).

To understand the concept of belonging, it is crucial to know the concept of holism.

What holistic means is that something is dynamic, moving, and developing. It operates from

within, and everything that makes the system work is interconnected. Each part has a specific

role or place that enables them to perform their task. This movement is possible because of the

interrelations, and the contributes of each part. As we are social beings, more emphasis needs to

be given to establishing good connections in relationships, work, and love. Helping others and

gaining the same treatment back rewards and makes us gain a greater view of ourselves as

individuals. However, when we fall outside of the realms, we affect society. We cannot take

part of the benefits of being interconnected with others while still being lonely. In addition, we

are unable to help others who are struggling (Shifron, 2010).

Unfortunately, not all individuals move towards participation or cooperation with their

peers. Instead, they defend themselves against the demands of our society and move more

towards isolation and neurotic behavior. To understand someone’s style of life, it is crucial to

analyze their first years as newborns. Adler believed that children develop beliefs about

themselves, others, and the world before the age of six. These beliefs state who the child is, what

the child should be or do, what life is, the perception of people, men and women, and what are

their ethics and morals. Although children are good observers, they lack skills to make correct

interpretations of events. This is one of the reasons the child later develops mistaken beliefs and

behaviors that might be harmful to themselves (Mosak & Di Pietro, 2006).

During these early childhood years, many factors affect our lifestyle and how we come to

perceive the world (including family constellation, birth order, and family atmosphere). With all


these experiences in mind, this affects how a person makes sense of what they experience.

Therefore, what we remember is more important than what we forget, because our memories

affect our beliefs, morals, and how we view everything that happens in life. For example, with

an encouraging childhood and positive memories, an individual is more likely to have developed

social interest. Because of this, it is more likely that they want to take actions into becoming part

of society and the need to cooperate with others. However, a person who grew up in a colder

household will be more suspicious of others and will lean towards vertical striving and isolation.

Unfortunately, this is more likely to result in neurotic behavior as it does not provide the

individual with the needs to become self-actualized (John, 2011). Adler believed that any social

context can be crafted so that it fosters a sense of belonging. For example, Adler considered

schools to be an extension of families where the child’s sense of community and belonging

would be developed. This would be done with the encouragement from teachers and through the

bonding with peers (Adler & Brett, 2009).

Although the idea of belonging was coined during the twentieth century, research has

shown that belonging still has a huge impact on well-being. Huppert (2009), along with 400

scientists, did a study on how to improve mental well-being. They found five different

encouraging behaviors that improved the wellness of the participants. These were:

1. Connecting with people

2. Being active and doing physical activities with others

3. Mindfulness about others

4. Openness

5. Giving to others

All these behaviors are associated with striving for belonging (Shifron, 2010).


Mistaken Beliefs

Part of one’s lifestyle consists of the ability to interpret events that have deeply affected

our lives. This filter includes our views about ourselves, our peers, and the society around us,

and it helps us make sense of the future. However, the human mind is not objective and will,

therefore, make faulty interpretations of events. This can lead to mistaken beliefs in our private

logic. This reasoning, is what we use to stimulate and justify the decisions of our actions. Once

a person has let their mistaken beliefs affect their goals, the individual will construct other

misconceptions to support the “faulty logic” (Jones-Smith, 2014). If nothing is done about the

mistaken beliefs, they can be passed between generations, leading to more harm (Mosak & Di

Pietro, 2006). This is different compared to common sense, which represents society’s

consensual reasoning that recognizes the benefits of cooperation and helping others (Jones-

Smith, 2014). The problem with these distorted lifestyle beliefs is that they can interfere with a

person’s development.

Mistaken beliefs can be divided into five different categories:

1. Overgeneralizations

2. False or impossible goals of “security”

3. Misperceptions of life and life’s demands

4. Minimizations or denial of one’s worth.

5. Faulty values

An overgeneralization is an error involving assumptions based on information that is too broad.

For example, a person who grew up with abusive alcoholic parents may overgeneralize that

every person who drinks alcohol is abusive. The second mistaken belief describes the way we

view safety. In this category, we find individuals who believe they have security when they do


not and those who think they will never be safe. For example, a person who worries constantly

or believes they must hide inside their apartment to be secure has this mistaken belief. The third

mistaken belief is about how we view the demands of life. For example, a person in this

category could believe that a task is not worth doing unless it can be done perfectly. The fourth

mistaken belief is where an individual minimizes their self-worth. In this category, we find those

who constantly believe they do not deserve to be happy and those who think they will never be

good enough. In the last category, we find other, more outlying mistaken beliefs. For example,

in this category, we have people who believe they always get red lights, who believe that life is

always black and white, and who believe they must be right all the time. These distorted beliefs

make up part of our lifestyle (Mosak & Di Pietro, 2006).

Mistaken beliefs are generally found in personality disorders. People affected by this

often have strong faith in their mistaken beliefs. This is leading them to act upon them more

regularly and more devastatingly than neurotypicals who do not suffer from personality disorders

(Herbst, 2014). However, Adler believed that people can change and are therefore able to get rid

of these mistaken beliefs.

As stated earlier, it is important to note the individuals’ interpretation of facts is more

important than the facts themselves. To be able to understand a person’s lifestyle, one would

need to look at either the person’s birth order in the family of origin, the first childhood memory,

or the person’s dreams (Mosak & Di Pietro, 2006). To get rid of the “faulty logic”, the person

needs to build feelings of significance, belonging, safety, security, and worth. It is important to

understand the mistaken beliefs from the childhood. Although faulty, they developed for a

reason. It could have been a stormy family atmosphere, family values affecting them negatively,

or a disruptive relationship to someone close to them. However, to get rid of the mistaken


beliefs, a person needs to switch over to common sense and analyze it more objectively. The

person can no longer rely on their private logic. This is not an easy task, and it is helpful to

speak to a counselor or a therapist who has a neutral view. In addition, with encouragement and

the development of social interest, the client will have a greater chance of improving and getting

rid of the mistaken beliefs (Mosak & Di Pietro, 2006).

Autism Spectrum Disorder

DSM-5 Diagnostic Criteria

To be diagnosed with autism spectrum disorder (ASD), the client must meet certain

criteria that have been set up by the American Psychiatric Association. Before explaining the

criteria for ASD, it is important to note that disorders like autistic disorder, pervasive

developmental disorder and Asperger’s disorder were previously their own diagnoses. However,

with the DSM 5, they are now part of the greater umbrella diagnosis called autism spectrum

disorder (American Psychiatric Association, 2013a).

To be diagnosed with ASD, there are certain criteria that need to be fulfilled. In this

section, these will be described. First, the client must show persistent deficits in social

communication and social interaction. There are three different ways this can manifest itself.

They can appear in social-emotional reciprocity (abnormal social approach, failure to initiate or

respond to social interactions, and reduced sharing of interests, emotions or affect). They can

appear in nonverbal communicative behaviors used for social interaction (deficits in using and

understanding gestures, poorly integrated nonverbal communication, abnormalities in eye

contact, and lack of facial expressions). The final one appears in developing and maintaining

relationships with peers and family members (ranging from adjusting behavior in different

contexts, no interest in others, and difficulty making friends). In this category, the client must


present all three symptoms. The second criteria that must be met states that the client must

present restricted, repetitive patterns of behavior, activities, or interests, as manifested by at least

two of the following sub-categories, currently or history:

1. Stereotyped or repetitive motor movements, speech, or use of objects (for example,

lining up toys, idiosyncratic phrases, or simple motor movement)

2. Insistence on sameness in routines or ritualized patterns of verbal transitions (such as

the need to eat the same food every day, difficulties with transitions, rigid thinking

patterns, and distress with small changes)

3. Showing an abnormal intensity and/or focus in highly restricted and fixated interests

(for example showing strong attachment to unusual objects)

4. Hyper or hypo-reactivity to sensory input or unusual interest in the sensory aspects of

the environment (for example, excessive smelling or touching of objects, visual

fascination with lights or movement, and indifference to pain and temperature)

In addition, the symptoms must have been present in the early childhood (but it may not show its

true colors until increasing social demands were placed on them later in life). Furthermore, the

symptoms must cause clinically significant impairment in various areas of life (such as social,

occupational, relational, and other areas of functioning). The last criteria are that these problems

cannot be explained better by an intellectual disability or by a global developmental delay. This

makes it important to look at the social aspects of the client as they need to be below the global

developmental level to meet the requirements of ASD (American Psychiatric Association,

2013a).

Lastly, when diagnosing a client, the severity level should be specified. With ASD, there

are three different levels of severity based on social communication skills and repetitive


behaviors. The first level is called level 1: Requiring support. In the social communication skills

domain, it states that without support in place the client will cause noticeable impairments. It

will manifest itself through difficulty initiating social interactions with atypical and unsuccessful

response to social overtures of others. The person may show lack of interest in social

interactions. In the restricted, repetitive behavior domain, the person has trouble in one or more

contexts. This may manifest itself through difficulty switching between activities, problems of

organizing, and planning. All this hampers with the person’s independence. The second level is

called level 2: Requiring substantial support. This level demonstrates itself through marked

deficits in verbal and nonverbal social communication skills. Impairments will still appear even

with support in place. The person has limited initiation of social interactions with reduced or

abnormal responses to others. When it comes to restricted and repetitive behaviors, this level

manifests itself through inflexibility of behavior, difficulty coping with change, or with frequent

restricted and repetitive behavior that are obvious to the neurotypical person. Furthermore, it

causes distress and/or difficulty changing to focus of attention or action. The last one is called

level 3: Requiring very substantial support. In this stage, the person experiences severe deficits

in verbal and nonverbal social communication skills, which cause impairments in functioning.

The person displays limited initiation of social interactions, and minimal response to social

overtures from others. In addition, the person displays inflexibility of behavior, extreme

difficulty coping with change, or other restricted behaviors that interfere greatly with other areas

of life (American Psychiatric Association, 2013a).

History of Autism Spectrum Disorder

The word autism can be traced back to 1911 and the early days of schizophrenia. Bleuler

believed it was one of the subsets to the disorder. The term autism comes from the Greek word


“autos,” meaning “self.” Autism was used to describe those who were especially withdrawn and

self-absorbed. Minkowski, a student of Bleuler, believed that autism was the “trouble generator”

of schizophrenia. However, it would take almost 40 years before autism was given its first

diagnostic criteria (Moskowitz & Heim, 2011).

In 1943, American child psychiatrist Leo Kanner published a report on the 120 children

he had observed in his John Hopkins Child psychiatry clinic. What he found was these children

were highly intelligent. Many could perform extraordinary tasks of memory, such as reciting all

25 questions and answers of the Presbyterian catechism by 3 years of age (Eisenberg & Kanner,

1955). Yet they displayed a great desire for aloneness and an obsessive insistence on persistent

sameness. They would be completely oblivious to presence of others. This led him to name the

condition “early infantile autism”. In addition, Kanner would sharply distinguish autism from

intellectual disability. Many of the children who were nonverbal, he would describe as “feeble

minded” (Kanner, 1943). This label would be widely used to describe children in institutions

during the middle of the 20th century. Sadly, many of those children would only get minimal

psychological testing (Baker, 2013).

After the Second World War, many childhood psychologists started diagnosing children

at an earlier age. Children who only showed signs of autism were being interpreted as showing

signs of schizophrenia. The word autistic was now being used to describe the rejection of reality

many patients with schizophrenia felt (Baker, 2013).

The term “refrigerator mothers” became popularized as many child psychologists

believed that autism was caused by mothers not loving their children enough. This belief came

to be so accepted and popularized that this psychotic withdrawal was mentioned in the

Diagnostic and Statistical Manual of Mental Disorders – Second Edition (DSM-II) in the context


of childhood schizophrenia (American Psychiatric Association, 1968). One of those who

opposed the “refrigerator mother theory” was Bernard Rimland. A father of a son with Autism,

he would argue against this and instead believed it was a biological condition. He would found

the Autism Society of America for parents to have a voice against this movement (Rimland,

1964). Although Kanner did not believe in the “refrigerator mother theory” either, he did

propose that it had to do with the relationship between the child and the father. This belief

would later change into believing that autism was “inborn”. This would cause a great debate

among researchers about the causation of the disorders.

During the middle of the 20th century, psychologists would typically look at the impact of

life experiences. Other factors as genetics and biology would often be ignored in favor of the

behaviors the people were showing (Evans, 2013). However, in 1977, Rutter and Folstein

conducted an experiment on twins where at least one twin had infantile autism. What they found

was the disorder was largely caused by genetics and biological differences in the brain

development (Rutter & Folstein, 1977). This would later lead to infantile autism being included

in The Diagnostic and Statistical Manual of Mental Disorders – Third Edition (DSM-III).

Although, it was added as “infantile autism,” it was still helpful in differentiating autism from

schizophrenia (American Psychiatric Association, 1980). In The Diagnostic and Statistical

Manual of Mental Disorders – Third Edition - Revised (DSM-III-R), the definition infantile

autism would be replaced with a more expansive definition of “autistic disorder” with a checklist

of diagnostic criteria (American Psychiatric Association, 1987). In 1994, “autism disorder” was

expanded when Asperger’s syndrome and pervasive developmental disorder – not otherwise

specified (PDD-NOS) were incorporated into the diagnostic criteria (American Psychiatric

Association, 1994). The diagnostic criteria would again change in The Diagnostic and Statistical


Manual of Mental Disorders – Fifth Edition (DSM-5) as all the previous subcategories of

“autism disorder” were now folded into one umbrella diagnosis called autism spectrum disorder.

In addition to this, Asperger’s Syndrome is no longer considered a separate condition, although it

is still recognized as such in the international statistical classification of diseases and related

health problems – tenth revision (ICD 10) (World Health Organization, 1992; American

Psychiatric Association, 2013a).

History of Asperger’s Syndrome

Asperger’s Syndrome (AS) can be traced to 1944, where a German scientist by the name

of Hans Asperger would do similar research as Kanner. He would observe boys who were

highly intelligent but were struggling with social interaction and who had specific obsessive

interests. However, he would describe their behavior as a “milder” form of autism and chose to

name it Asperger’s Syndrome (Barahona-Correa & Filipe, 2015). Although Kanner and

Asperger published their work only one year apart, none of them had knowledge of the other’s

research. This was largely due to them being separated spatially and because of the Second

World War. It should be noted there were differences between the two. The first was that

Kanner’s descriptions were influenced by Arnold Gessell’s developmental beliefs, while

Asperger based his research on schizophrenia and personality disorders (Klin & Jones, 2006). In

addition, Asperger never tried to define the diagnostic criteria for the disorder he was describing.

Instead, he greatly emphasized about the positive features of those with Asperger’s. He saw

patterns of original thought, an interest in abstract and intellectual activities, and a rare taste in

art (Frith, 1991).

Although Asperger’s work was well-read when it was published in German, it remained

unknown to the international scientific community for almost half a century. The first English


translation of Asperger’s article “Autistischen Psycopathen im Kindesalter” did not appear until

1991, where it was included in Uta Frith’s “autism and AS” (Frith, 1991). However, a similar

term had been used in 1981 by British psychiatrist Lorna Wing. It was used to refer to the

special subgroup of children who were characterized by social isolation and lack of reciprocity in

social interactions, normal or precocious language, narrow focus of interest, clumsiness, and

above-average linguistic skills with subtle abnormalities in both verbal and nonverbal

communication (for example absent or stereotyped prosody and atypical syntax), and

overachievement in specific cognitive domains (Wing, 1981).

In 1992, the disorder became a distinct diagnosis as it was included in the ICD 10. Two

years later, it would be included in the fourth edition of The Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV) as Asperger’s disorder (World Health Organization, 1992).

However, with the DSM-5, the diagnoses were folded into one umbrella diagnosis called autism

spectrum disorder along with the previous subcategories of “autism disorder”. However, it is still

recognized as its own disorder around the world as it is still its own entity in the ICD 10 (World

Health Organization, 1992; American Psychiatric Association 2013a).

Treatment for Autism Spectrum Disorder

Therapeutic. Although there is no cure for ASD, treatments are available to make sure

people on the autism spectrum can experience fulfilling lives (in fact, many people with ASD do

not want a cure, as they see many benefits of the diagnoses). Even though ASD in its current

form was not present during Adler’s time, Adlerian therapy is as valuable today as it was almost

100 years ago, due to the holistic approach of Adler’s individual psychology. Adlerian treatment

acknowledges the different aspects and problems that correspond with having ASD. Treatments

based out of psychoanalysis, humanistic, and cognitive-behavioral all share components with


classic Adlerian theory (Hartshorne & Herr, 1983) and they have all been proven to work well

with clients on the autism spectrum. In the next sections, the other branches will be compared to

Adlerian therapy in how ASD is treated.

In psychoanalysis, therapists are interested in the child’s “conviction” about its early

years and especially in the infant-parent relationship. During the critical periods of the two first

years, the child grows frustrated with the world due to a lack of satisfying responses from

caregivers and decides to stop trying. The consequence of this is that the child is feeling

discouraged and only wants what is working for them. This psychoanalytical belief is similar to

Adler’s ideas about private logic, mistaken beliefs, and vertical striving. As the child is making

meaning of the world (private logic), discouragement leads them to perceive events differently

and sometimes more negative from what they are. In certain cases, events can lead the child to

create similar beliefs about other things (mistaken beliefs). As the child is growing up, their way

of striving turns them into a more self-focused person with values and beliefs that are based on

what is only good for themselves. As it is not socially driven, it does not give the person with

ASD a meaningful life. The difference between true psychoanalytical therapy and Adlerian

therapy is the approaches to treatment and how the client views the world. In psychoanalytic

therapy, the goal is removing the child from the world and creating something new for them. An

Adlerian would encourage the client to be part of the society and participate in social events that

are meaningful to them while still understanding that the client is the expert of their life

(Ansbacher & Ansbacher, 1964).

The humanistic approach is in certain ways similar to the psychoanalytic theory. The

basis here is that the growth of the self has been impaired because of rejection of others leading

to personal rejection. However, instead of creating a new world, the client establishes a


relationship with the therapist and works on the previous negative and diffused attitudes they

previously acquired about the world. The goal is to reach the client’s full potential and to

improve the self-regard, with the client wanting to establish new meaning and value in a

relationship with others. Moustakas (1959) stated that we need to look to the needs of the client

in the client-therapist relationship. He believed that it was necessary to participate in and

understand the activities of the person with autism. The result of this would be trust and

understanding between therapist and client (Moustakas, 1959). Again, the similarities between

the two styles are apparent as this existential approach is like Adler’s ideas about social interest

and encouragement. To help the discouraged client, an Adlerian would build a working,

therapeutic relationship. The therapist would emphasize the importance of the client being the

expert on their life. Furthermore, the therapist would encourage the client to challenge their

previous beliefs about themselves. They would bring out the positives in the client and help them

see what is good within them (Dreikurs & Soltz, 1991; Mosak & Di Petro, 2006).

The most common treatment for people with ASD is cognitive-behavioral therapy (CBT).

One of the pioneers was Loovas, who in 1964 began systematically using operant techniques to

develop language skills in children with ASD. Language was chosen because the researchers

believed that the language barrier separated the children with ASD from the neurotypical

children. At first, they would teach the children to imitate these behaviors to enable the

acquisition of verbal responses. When this was done, the researchers would teach these children

what the responses meant and how to handle them. (Hartshorne & Herr, 1983). Since then,

different variations of CBT have been used for treatment. The common ones emphasize

behavioral experimentation, parent-training, and school consultation. In CBT, all behaviors and


thoughts are considered learned and therefore new behaviors and thought patterns need to

replace the old ones (Wood et al., 2009).

For Adlerians, cognitive patterns and behaviors are of interest too. For example, working

with thoughts and values can be compared to private logic and mistaken belief. However, when

it comes to treatment, CBT and Adlerian therapy take two different routes. Instead of focusing

on behaviors as being stimulus bound or caused by a stimulus condition, Adlerians believe that

these behaviors are goal directed. The behaviors show the Adlerian therapist where the client is

moving with their life. It shows where the client is currently in their life cycle, it shows what the

client strives for and how it does so, and it shows what the client is willing to change to feel

better (Ansbacher & Ansbacher, 1956). However, one big difference between CBT and Adlerian

therapy is that the latter focuses on the early years rather than the behaviors. By looking at what

is causing the problematic behaviors and thoughts, a greater understanding of life can be reached

from the client’s side. Instead of treating the current symptoms to be included in society, the

client receives an encouraging approach where they are given a chance to understand what has

happened up until this point. Despite these differences, it is important to acknowledge both as

healthy approaches for individuals with ASD. With Adlerian therapy and cognitive behavioral

therapy focusing on the irrational beliefs and thought patterns, they both provide the groundwork

for a functioning treatment plan (Hartshorne & Herr, 1983).

Pharmacological. With the shared history of schizophrenia and ASD, it is natural that

the disorders have been treated similarly. Although antipsychotic medication is often used for

schizophrenia with positive results, the same treatment has been found to do more harm than

good for individuals with ASD. The reason for this is because of the positive symptoms that

schizophrenia has, but ASD lacks. It proves to be problematic to treat something that is not even


present. Instead, the medication brings more side-effects. In certain cases, these side effects can

be worse than what the client is already experiencing. (Woodbury-Smith, Boyd, & Szatmari,

2010). For example, the creativity that many people experience typically decreases with the

increase of medication. Furthermore, it does not help with the negative symptoms, which are the

main reason that people with autism spectrum look for help (Volkmar & Wiesner, 2013).

The most common pharmacological treatment for ASD is antipsychotic medications

(mainly risperidone and aripiprazole). Initially made to treat schizophrenia, these medications

block brain receptors for dopamine and serotonin. When used with ASD, they decrease the level

of irritability. These two are the only antipsychotic medications that are regulated by the U.S.

Food and Drug Administration (LeClerc & Easley, 2015). However, research has shown that

there is a very low success rate for both medications.

In 2009, Owen, et al. conducted an experiment to analyze the effects of aripiprazole on

children with ASD. Although the success rate proved to be higher than in the placebo group,

91.5% of the participants in the antipsychotic group experienced side-effects, including fatigue,

headaches, drooling, diarrhea, weight gain, and vomiting. Furthermore, it did not improve social

withdrawal (one of the primary symptoms of ASD, and a negative symptom) (Owen, et al.,

2009).

In 2015, Storch et al. conducted an experiment to see if children with ASD would benefit

more with therapy sessions or pharmacological treatment (aripiprazole). After 16 weeks of

treatment, 68.8% of those in the therapy group responded positively to the treatment, while only

26.7% did in the pharmacological group. Even more astonishing, 37.5% of the participants in

the therapy group no longer reported any anxiety symptoms, while 0% of the participants in the

pharmacology group improvement in this category (Storch et al., 2015).


For risperidone, the results have been similar. Although the level of irritability decreases

with the usage of risperidone, the side effects outweigh the benefits. On average, a child taking

risperidone gains 6 pounds during the first 8 weeks. It does not cure the core symptoms, and it

only focuses on the positive symptoms, which are primarily found in schizophrenia. As with

aripiprazole, it does not respond with everyone as the genetic components of people with ASD

are different (Anthes, 2014).

In recent time, scientists have started seeing a change between pharmacology and ASD.

Neurologists are now hypothesizing that ASD is the result of an imbalance between excitatory

glutamatergic and inhibitory GABAergic pathway. Medications such as valproate, acamprosate,

and arbaclofen may act on the GABAergic pathway, but the research has shown that the results

have been insufficient in treating those with ASD. However, it is worth to note that the data is

promising and could be helpful for future research. On the other hand, only short-term use of the

medications has been proven to be safe (Brondino, et al., 2015). It is worth to note that because

this is a new idea, side-effects have not been accounted for. This could mean that treating clients

on the autism spectrum for this imbalance could be as bad, if not worse, as treating them with

antipsychotic medication. Before this treatment can be of great help for the autism community, it

needs to be safer and more helpful than what it is right now.

Schizophrenia

DSM 5 Diagnostic Criteria

To be diagnosed with schizophrenia, certain criteria need to be met. Criteria A states that

two (or more) of the following symptoms must be present during a significant portion of a time

during a 1-month period:

1. Delusions


2. Hallucinations

3. Disorganized speech (such as frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (diminished emotional expression, lack of empathy, and

avolition)

Furthermore, at least one of the symptoms must be delusions, hallucinations, or disorganized

speech. Criteria B states that after a significant portion of the time since the onset, the level of

functioning in one or more major areas is well below the level achieved before the onset of the

disorder (in the case of children and adolescence, it is instead measured in the failure to achieve

expected level of interpersonal, academic, or occupational functioning). Criteria C states that

signs of disturbance must be lasting for at least 6 months, with at least one month of symptoms

specified in criteria A. Criteria D states that the symptoms cannot be better explained by mood

episodes or a mood symptoms. These are common in schizophrenia, but should not be the

reason to suspect a disorder. Criteria E states that the disturbance cannot be directly affected by

substance abuse or a medical condition. Criteria F states that if there is a relationship with ASD,

the diagnosis should only be given if hallucinations and delusions are present for at least a month

(in addition to not being a side effect from antipsychotic medication) (American Psychiatric

Association, 2013a).

The severity of the disorder can be measured by a quantitative assessment of the

symptoms of psychosis, including hallucinations, delusions, disorganized speech, negative

symptoms, and abnormal psychomotor behavior. Each of these symptoms can be rated for its

current severity, which is measured by what was the most severe in the last seven days. This is

done on a 5-point scale with 0 being non-present and 4 being present and severe. The diagnosis


of schizophrenia can be made with or without a specific specifier (American Psychiatric

Association, 2013a).

History of Schizophrenia

Although first identified as a discrete mental illness by Kraepelin in 1887, the illness is

believed to have accompanied mankind through history. Documents can be traced back to

ancient Pharaonic Egypt, where the heart and the mind were believed to have been synonymous.

Schizophrenia was regarded as symptoms of the heart and the uterus, and originating from the

blood vessels or from purulence, fecal matter, a poison, or possession by a demon. In Greek and

Roman literature, it showed that general population had an awareness of psychotic disorders, but

that no condition would meet the modern diagnostic criteria for schizophrenia. During this time,

it did not matter if someone was suffering from mental illness, physical deformities, or an

intellectual disability; they were all considered “abnormal” and treated the same. Early theories

supposed that mental disorders were caused by evil possession of the body, and the appropriate

treatment was then exorcizing these demons. The treatments of this ranged from harmless, for

example exposing the patient to different types of music, to sometimes dangerous and deadly

means such as drilling holes in the patient’s skull (Hawkes, 2010).

One of the first ones to classify the mental disorders into different categories was the

German physician Emilie Kraeplin. He used the term “dementia praecox” for individuals with

symptoms that we now associate with schizophrenia. In 1987, he was the first to make a

distinction in the psychotic disorders between what he called dementia praecox and manic

depression. It was believed to be a form of dementia (praecox translating into early). This was

done to distinguish it from other forms of dementia that typically occur late in life. The studies

Kraeplin had done were concentrated on young adults, and it would help him come up with


different clinical forms of dementia praecox. These included dementia praecox simplex

(impoverishment and devastation of the whole psychic life), hebephrenia (insidious change of

personality with shallow affect, senseless and incoherent behavior, occasional hallucinations and

fragmentary delusions), depressive dementia praecox (initial state of depression followed by

slowly progressive cognitive decline, with or without delusions), circular dementia praecox

(prodromal depression followed by gradual onset of hallucinations, delusions, mood swings, and

extreme impulsivity), catatonia (conjunction of peculiar excitement with catatonia dominating

the clinical picture), paranoid dementia (dominated by haunting delusions and hallucinations),

and schizophasia (confusional speech) (Jablensky, 2010).

In 1911, the Swiss psychiatrist Eugen Bleuler coined the term schizophrenia by grouping

together dementia paranoides, hebephrenia, and catatonia into a category. The reason he

changed the name was because it was misleading and had psychotic functions as defining

characteristics. These characteristics were unique to schizophrenia and would often be present

for these disorders (Bruijnzeel & Tandon, 2011). Furthermore, it would sometimes occur late in

life and did not always lead to mental deterioration. The word schizophrenia comes from the

two Greek words schizo (split) and phrene (mind), which he used to describe the fragmented

thinking of people with the disorder. However, this word has led to a common misunderstanding

by our society who thinks of it as split or multiple personalities (Hawkes, 2010).

The definition of schizophrenia has changed since Bleuler coined the term. Originally,

Bleuler defined the fundamental symptoms as the four A’s. These were associational

disturbances (tangential or loose-thought processes), affective disturbances (flat or inappropriate

affect), autism (withdrawal from reality to fantasy), and ambivalence (mental and/or physical

vacillation or indecisiveness) (Bruijnzeel & Tandon, 2011). Kurt Schneider, a German


Psychiatrist, did not agree with this and believed that the fundamental defect in schizophrenia

was an impairment of empathic communication. Schneider defined his own first-rank symptoms

that he considered to be diagnostic of schizophrenia. These were audible thoughts (hearing

thoughts echoed or spoken), voices discussing, commenting, or arguing, somatic passivity (the

belief that the body is under control of others), thought insertion and thought withdrawal (the

belief that thoughts are being inserted into one’s mind or being removed by an outside force),

thought broadcasting or diffusion (that other people can read one’s thoughts), delusional

perception, and delusions of control volition (Jablensky, 2010).

However, it has been difficult to accurately describe the disorder as it still is not clear

what causes it. Instead, scientists have based their classifications on the symptoms that have

tended to occur together. Kraepelin, Bleuler, and Schneider divided schizophrenia into

categories based on the prominent symptoms and prognoses. Since then, scientists have

continued to work on classifying the different types (Jablensky, 2010). In the DSM-III, five

different types of schizophrenia were used: disorganized, catatonic, paranoid, residual, and

undifferentiated. The first three categories had originally been proposed by Kraepelin (American

Psychiatric Association, 1980). However, these classifications did not prove to be helpful in

predicting the outcome of the disorder. Although used in the DSM-IV, many scientists would

instead base their prognosis on the positive and the negative symptoms, the severity of symptoms

over time, and the co-occurrence of other mental disorders and syndromes (American Psychiatric

Association, 1994). With the release of the DSM-5, changes were made to the classification of

the disorder and it was renamed schizophrenia spectrum and other psychotic disorders (American

Psychiatric Association, 2013). In addition to this, all the subtypes that had proven to be


unhelpful were dropped, except catatonia that was now given a separate diagnostic feature

(Zupanick, 2013).

In recent time, more evidence has appeared that schizophrenia is a biological-based

disorder. With dynamic brain imaging systems, researchers have could prove that brain tissue

destruction occurs in clients with schizophrenia. However, it is still unclear if the destruction of

brain tissue is causing schizophrenia or if the presence of schizophrenia is causing brain tissue to

be damaged (Teroganova, Girshkin, Suter, & Green, 2010).

Treatment for Schizophrenia

Therapeutic. As stated earlier, each person has specific psychological goals that they

want to reach throughout their lives, for example being special, feeling loved, becoming

superior, and feeling worthy. These goals are impacted by different factors throughout our

childhood, such as family atmosphere, family values, socioeconomic status, and birth order.

However, when a person fails to achieve these goals in a proper way, the individual’s

mind might use unconventional ways to help them reach those goals. For example, a person with

a desire to be important, but failed to do so in a socially acceptable way might develop psychosis

or paranoia. Because of this, delusions and hallucinations might develop. However, it does not

end there. Let’s say this person started believing everyone was conspiring against him. With

this, it is possible the person starts making up more beliefs. For example, the person might think

that because it is directed towards him only, he must be an important person. Paranoia in this

case is a defense mechanism to escape reality and to achieve the goal that the person could not

achieve (Ansbacher & Ansbacher, 1964).

Additionaly, not only did Adler believe that schizophrenia was rooted in inferiority, but

he also accepted the notion that schizophrenia could stem from abnormalities in the brain


structure. He stated that it was not impossible that genetic factors held the answer to why some

individuals would break away from reality. However, it is important to note that Adler believed

that schizophrenia was caused by a combination of physical and social factors (Sobel, 1981). An

Adlerian therapist would therefore look at the client’s childhood, their medical records, and work

with them on their perception of reality.

It is important to note that when working with a client with schizophrenia, it is important

to look at the world from their perspective. According to Adlerian theory, the client is the expert

on their life and this must be held true even if it can be more difficult to work with somebody

who is experiencing a psychosis. In the end, they are still human beings and although their reality

might be different, they still need to be treated with respect (Oberst & Stewart, 2003).

Adlerian therapy is not the only treatment method availble. For over 60 years, CBT has

been used in clinical settings to help individuals with schizophrenia live more meaningful lives.

As with ASD, CBT works well with the negative symptoms. In addition, it has been proven

useful in cases where the individual has been in need of improving relationships with their

family and friends (Morrison, 2009). The main point of CBT is to teach therapeutic techniques

and coping mechanisms to the client. Tarrier & Wykes concluded that the main characteristics

of coping training are to emphasize the normal and general process of dealing with adversity, use

simulation and role playing, teach coping strategies as they are happening in real life, provide

new responses to ongoing problems, help the client change external verbalization to become

internalized, and practice these behaviors until they are more natural. (Tarrier & Wykes, 2004).

Examples of successful CBT techniques are attention narrowing, social engagement and

disengagement, attention switching, modification of self-statements, and internal dialogue

(Tarrier & Haddock, 2004). These techniques can be summarized in four steps:


1. A therapeutic alliance is developed based on the client’s perspective.

2. Alternative explanations of the schizophrenia symptoms are made.

3. The therapist tries to help the client reduce the impact of the positive and negative

symptoms.

4. The client is given other alternatives to the medical model to help the client get less

devoted to their medication (Turkington, Kingdon, & Weiden, 2006).

However, CBT treatment has also been used with pharmacological treatments with positive

outcomes. This is due to the two treatment methods combating different areas. For example,

avolition has been treated with behavioral self-monitoring, amotivation with activity scheduling,

anhedonia with mastery and pleasure ratings, and active blunting with social skills training

(Morrison, 2009). For the positive symptoms, recent studies have shown that pharmacology is a

successful treatment method and it is improving every day (Rogóż, 2012). With these two

treatment methods combined, a client can have a steady brain level while also working on

strategies to handle their everyday life.

Pharmacological. When it comes to treating schizophrenia, antipsychotic medication

has been proven to be the most successful and used way of treatment (Edlinger et al., 2009).

Currently, there are two different types: first-generation (typical), and second-generation

(atypical).

The first generation of antipsychotics started being used in treatment in the 1950s and are

still used today. They are known as neuroleptics because they produce symptoms of neurolepsis,

such as affective indifference, emotional queting, and psychomotor slowing. However, the

downfall with this is that it comes with extrapyramidal symptoms, such as dystonia, Parkinsons,

and motor restlessness (Edlinger et al., 2009).


These symptoms have been described as one of the reasons why psychiatry saw a

movement between the two different mediations in the 1980s. This was when the second

generation of antipsychotics came out. This is the most common treatment for schizophrenia and

it includes medications such as risperidone, paliperidone, and iloperidone (Seida, Schouten, &

Mousavi, 2012). The only atypical drug that is no longer in use is clozopine, which was the first

one to be defined as a second-generation antipsychotic. It is not in use anymore is because it

lowers the amount of white blood cells to dangerously low levels (Patel, Cherian, Gohil, &

Atkinson, 2014).

What all atypical medications have in common is that they are dopamine and serotonin

antagonists. This means that they block a portion of dopamine and serotonin receptors in the

brain, which balances the different levels of brain activity (Seida, Schouten, & Mousavi, 2012).

The second generation antipsychotics have been preferred as they are associated with less

extrapyramidal symptoms, for example dystonia, parkinsons, and motor restlessness. In

addition, they have proven to greatly increase the life quality for people with schizophrenia.

However, atypical antipsychotics come with their own metabolic side effects, which often results

in weight gain. This has primarily been found in clozapine, but also in risperadone (Gilca, et al.,

2014).

For the drug treatment to be as helpful as possible, it is important to start it when

symptoms are first detected. Within the first five years after the first acute episode, most illness-

related changes in the brain occur. It is recommended that clients with schizophrenia keep using

their medication until they are ready to do therapy, in which they can improve their self-care and

their mood. If combined with maintenance therapy, the relapse level drastically decreases from

between 60-80% to 18-32% (Patel, Cherian, Gohil, & Atkinson, 2014). It is worth that neither


typical or atypical antipsychotics have been proven helpful with treating the negative symptoms

of schizophrenia (Guzman, 2017). What this shows is that antipsychotics do not meet all the

needs that people with schizophrenia have. In addition to medication, it demonstrates the need

for other treatment, such as therapy. Furthermore, it shows that these medications are ineffective

for people with ASD as it only treats the positive symptoms. Because individuals with ASD do

not experience these symptoms in the same capacity as those with schizophrenia, it is not

beneficial to use it as a treatment method. However, for those with schizophrenia, antipsychotics

can be helpful as long as it is combined with the right treatment.

Comparison

As ASD was once a subtype of schizophrenia, it is not strange that both disorders share

many characteristics. Up until 1971, ASD was still a subtype of schizophrenia; however, it

would take another nine years before it was given its own entity. Before this, it was still referred

to as childhood schizophrenia. One of the main reasons the two were separated was because of

the onset of the disorders, with ASD appearing in the early years while the earliest schizophrenia

manifests itself is in the adolescent years. (American Psychiatric Association, 1980). In Europe,

where the DSM-5 is not as prominent as in the US, it is still debated on how to separate the two

disorders. Furthermore, Asperger’s syndrome is its own illness in the ICD-10, making the

separation of the two even more complicated (Lugnegård, Hallerbäck, & Gillberg, 2015).

However, the ICD-11 is expected to be released in 2018 and is likely to align with the DSM-5

(National Autistic Society, 2016).


Similarities

As ASD and schizophrenia share clinical manifestations, cases of both co-occurring are

not rare. In fact, almost 30% of the youth diagnosed with schizophrenia had also been diagnosed

with ASD in their early years (Rapoport, Chavez, Greenstein, Addington, & Gogtay, 2009).

One of the factors of this is that both ASD and schizophrenia share negative symptoms.

The diagnostic criteria for ASD is stated by two major criteria:

1. Persistent deficits in social communication, social interaction, social-emotional

reciprocity, and communicative behaviors.

2. Restricted, repetitive patterns of behavior, interests or activities, and abnormally high

or low reactivity to sensory stimuli.

Similarities can be found in the diagnostic criteria for schizophrenia where there is a section

called negative symptoms. This includes symptoms such as asociality, low levels of emotional

expression, and alogia (American Psychiatric Association, 2013a). It is not uncommon to find

individuals from both groups with poor eye contact, social withdrawal, and communication

impairment (Dalmaso, Galfano, Tarqui, Forti, & Castelli, 2013).

For both groups, it is incredibly difficult reading other people’s mind, showing empathy,

and recognizing the true motives of others’ actions. Unfortunately, this causes many problems.

It makes it harder to communicate, building relationships, and finding a place in their social

settings. Many times, it ends with misunderstandings and misinterpretations causing harm to the

self-esteem (Fitzgerald, 2012). A great part of this is because of the flat affect shared by them.

This means that both groups often lack the ability to show facial expressions or showing

inappropriate ones (for example, laughing at a funeral). This has led to both groups being

perceived as violent and psychopathic. However, that is a common misconception about ASD


and schizophrenia. Although there are rare cases where this is true, most are not. Many of the

behaviors may be interpreted as aggressive, but they are often cries for help or just illogical

(these behaviors can appear as waving of arms, loud noises, and bizarre facial expressions). In

fact, clients with any of the disorders are more likely to be victims of aggression rather than

being the perpetrators (Fitzgerald, 2012).

The third symptom, alogia, manifests itself through poverty of speech. In addition,

repetitive conversations are common and have had a huge impact on misdiagnosing. In fact,

many individuals suffering from ASD with a thought disorder have often been given the

diagnoses of schizophrenia. Those on the autism spectrum often get sidetracked by their own

interests, which may lead them away from the topic that is being discussed. As the language is

tangential, it manifests itself similar to the illogical speech in schizophrenia (Fitzgerald, 2012).

Furthermore, the grossly disorganized motor behavior found in individuals with schizophrenia

includes several characteristics similar to criteria B of ASD. These include echolalia,

unpredictable agitation, repeated stereotyped movements, and decreased interaction with or

interest in one’s social surroundings (American Psychiatric Association, 2013a).

It is believed that both ASD and schizophrenia are caused by genetic components.

Research has shown that there is a positive correlation between maternal malnutrition, viruses,

and other antenatal factors with schizophrenia. With ASD, it has been proven that epigenetic

factors are a big factor in development of this disorder. It is true that there are overlapping

genetic factors between the two, however ASD is believed to have a much higher genetic

underpinning than schizophrenia (Fitzgerald, 2012). When examined, both disorders show

similarities at a morphological level. Through meta-analytic anatomical likelihood estimation

using multiple imaging data sets, overlapping brain abnormalities have been found. This is


especially prevalent in the right parahippocampal gyrus, posterior cingulate, claustrum, left

thalamus, and putamen. In addition, ASD and schizophrenia share structural and functional

abnormalities in the insular cortex and the cerebellum. In addition, fusiform gyrus can be found

in both disorders. When researchers examined brains of both groups during social cognition, they

found more similarities. When it comes to neuronal activation, both ASD and schizophrenia

reduces the activation in amygdala, fusiform gyrus, and ventrolateralprefrontal cortex (Meyer,

Feldon, & Dammann, 2011).

Differences

While both mental disabilities share many characteristics, there are several differences.

For ASD, the symptoms appear during the first few years. For schizophrenia, the symptoms do

not typically appear until the individual has reached adolescence (American Psychiatric

Association, 2013a). As positive symptoms are more psychotic than neurotic in nature, it can be

problematic to debate a child with schizophrenia as many of the positive symptoms could just be

due to a lively imagination. This was one of the major reasons that ASD became its distinct

disorder and was no longer referred to as childhood schizophrenia (American Psychiatric

Association, 1980).

If looked at through an Adlerian lens, ASD and schizophrenia would have two different

causes. For an individual ASD, the faulty lifestyle would be caused by neurosis. A neurotic

person often retreats from performing life tasks to avoid loss of self-esteem and to be classified

as a failure. This can often be caused by a poorly developed social interest (Abramson, 2015).

Schizophrenia on the other hand is affected by psychosis. There are similarities between neurosis

and psychosis as both are rooted in inferiority feelings. However, with psychosis, the individual

compensates by escaping into fantasy, delusion, and hallucination, while rejecting common


sense. The greater inferiority complex, the more the individual tries to compensate to reach their

fictional final goal (Stein, 2002). This goes along with the diagnostic criteria for both disorders

found in the DSM-5. As schizophrenia is based of psychosis, it is natural that the positive

symptoms such as hallucinations and delusions appear in clients with this disorder. However,

because ASD is neurotic in nature, it lacks the symptoms that withdraw the individual from

reality (American Psychiatric Association, 2013a). As the negative symptoms are more

applicable to ASD, it is easier to notice them in an individual with ASD compared to

schizophrenia. For example, a person with ASD is more likely to be “socially cynical” than a

person with schizophrenia (University of Texas at Dallas, 2012). That is not to say that all

people with ASD lack motivation to be social and are aloof. Many individuals on the spectrum

are socially motivated and want to connect with others. It is just that their attempts to engage

with others can be clumsy, inappropriate, and naïve (Woodbury-Smith, Boyd, & Szatmari,

2010).

When it comes to the biological component, studies have been made on ASD and

schizophrenia to identify global and regional brain volume differences. Compared to the group

with schizophrenia, the clients with ASD displayed smaller gray matter volume in the left insula.

Furthermore, the researchers found a positive correlation between mentalizing ability and the left

amygdala volume in ASD, and hallucinatory behavior and insula volume in schizophrenia

(Radeloff, et al. 2014).

In 2010, Thome et al., looked at the elevated mitchondrial complex I 75-kDa subunit

mRNA-blood concentrations in clients with early onset schizophrenia (after the age of 13, but

before the age of 18). The researchers compared the levels of complex I 75-kDa subunit mRNA-

blood concentrations in adolescents with ASD and a control group. This was done as both


mental illnesses share a mitochondrial dysfunction and increased oxidative stress. What the

researchers found was that the group with schizophrenia was the only one that altered expression

of complex I 75-kDa subunit mRNA-blood concentrations. This suggests that both disorders

have different biomarkers (Thome, et al., 2010).

In 2013, Baribeau and Anagnostou compared the neuroimaging findings across ASD and

schizophrenia to shed a light on biological components of both disorders. The results showed

again that there were alterations in the brain scannings. In the clients with ASD, the researchers

found a pattern of early brain overgrowth in the early life. This would later be followed by

dysmaturation in adolescence. In the group with schizophrenia, results showed deficits in

cerebral volume, white matter maturation, and coritical thickness were promiment in late

childhood and adolescence, with a great likelyhood of increasing in adulthood. This goes along

with differences in the course of both disorder, with ASD developing the early years and

schizophrenia starting later during adolesent years (Baribeau & Anagnostou, 2013).

In 2010, another study was made to assess the differences between high functioning ASD

and schizophrenia. The participants were asked to self-assess themselves on the features of ASD

and schizophrenia. The results showed that the group with ASD reported more problems in

communication, social skill, and attention compared those with schizophrenia. On the other

hand, the group with schizophrenia reported more characteristics of positive symptoms. Again,

this goes along with the notion that individuals with ASD struggles with social skill and the

negative symptoms instead of the positive symptoms. For the individuals with schizophrenia,

the results showed a strong relationship between acute psychosis and theory of mind impairment

(Spek & Wouters, 2010).


Ethical

Legal

In the United States, medical malpractice law is governed by each individual state. This

means that the framework and rules are established through decisions of lawsuits in state courts.

However, although the laws can vary between the different states, the principles are similar.

They all fall under the tort law that deals with professional negligence. The word tort means

wrong, and a tort law is a body of laws that provides solutions for civil wrongs. The word

negligence can be defined as the conduct that falls below a certain standard. In this case,

negligence occurs when an individual does not meet the standards of what is necessary to protect

another person from a foreseeable risk of harm.

To prove medical malpractice, the patient must prove four elements or legal requirements

to make a successful claim of medical malpractice. These four are:

1. The existence of a legal duty on the part of the doctor to provide care or treatment to

the patient.

2. A breach of this duty by a failure of the doctor to meet the standards of the

profession.

3. A causal relationship between such breach of duty and injury to the patient.

4. The existence of damages that flow from the injury that the legal system can amend.

However, it can be incredibly difficult for the patient to prove this unless there is an excessive

injury. Because of this, the patient must prove that the problems are stemming from the medical

treatment. In addition, medical malpractice cases rarely reach trial due to the fact the legal

system promotes self-resolution of civil disputes. Furthermore, medical malpractice lawsuits are

time and resource consuming, and emotionally charged experiences for both parties. In some


scenarios, both parties agree on terms with payment of money by the physician’s insurance

company. However, in other scenarios, the insurance companies can settle claims without

having the consent from the policyholder (Bal, 2009).

With ASD, the main harm comes from the side effects of the antipsychotic medications.

However, this makes it more difficult to reach a medical malpractice claim. This is because

experiencing a bad outcome is not always proof of medical negligence. Regarding

pharmacology, side effects impact everyone differently. It is unlikely that a case will be made if

the physician can prove the client was warned of the side effects or if written warnings were

placed on the label, the packaging, and/or the insert. The client will typically not have any

physical damages and it will prove to be incredibly difficult reporting this and getting any

compensation back.

Ethical

All psychiatrists dealing with pharmacological treatment must follow the principles of

medical ethics set by the American Psychiatric Association. This document is divided into nine

sections about how professionals should conduct themselves. Section 1 states that a physician

shall provide competent medical care, with an emphasis on compassion and respect for client

dignity and rights. Section 2 issues that a physician shall uphold the standards of

professionalism, by being honest and striving to report physicians deficient in character or

competence. Section 3 informs that a physician shall respect the law and recognize a

responsibility in seeking changes that impact the client positively. Section 4 describes how a

physician shall act and treat its patients, colleagues, and other professionals, while also

safeguarding privacy. Section 5 states that a physician shall continue to study and advance

scientific knowledge, maintain a commitment to medical education, and use the talents of other


health professionals when necessary. Section 6 gives the physician the alternative of who to

provide medical care to, that is unless there is an emergency. Section 7 recognizes the

physician’s responsibility to contribute to the improvement of public and mental health

community. Section 8 states that the physician shall regard responsibility to the patient over

everything else. Section 9 states that a physician shall support access to medical care for all

people (American Psychiatric Association, 2013b).

While looking at the misdiagnosing of schizophrenia to clients with ASD, it becomes

clear that not all sections are being followed. As previously stated, section 5 states that

professionals need to keep themselves updated on the scientific advances. However, clients with

ASD are still being diagnosed with schizophrenia and prescribed antipsychotic medication. This

shows lack of understanding of the disorder and that professionals do not know how to provide

the best treatment. While providing pharmacological treatment to the clients and not changing

the treatment process, more of these sections are being broken. First, by not reporting the

colleagues or themselves for doing these mistakes, the physicians break section 2 about being

honest and reporting incompetence. Furthermore, by focusing on the same treatment style,

section 3 is being broken as well. This is because the physician is not focusing on changing the

treatment to impact the client for the better. Instead, focus is placed on changing the dosages of

medication, which is not an effective model. In addition, section 1 is not followed either. It is

not a compassionate model to treat non-existing symptoms of a disorder that is not curable. The

side effects are often worse than the original problems and this means that the physicians may be

doing more harm than good. What is worse is that the clients will not be reimbursed for being

caused this harm. By not taking responsibility to the harm, the physicians are breaking section 8


about taking responsibility over the client above all. Even though the pharmacological treatment

is technically not breaking any laws, it is still highly unethical.

Case Study

Mr. D. is a 20-year-old man who is experiencing significant mental distress. He has

always felt different, as if nobody shared his way of looking at life. As a child, Mr. D. was

always very quiet. He would use a few words and would try to show his feelings through

gestures instead. Growing older, Mr. D. would become more outspoken, but was very much an

introvert who kept to himself. However, this was not the only thing that differentiated him from

the other children. Mr. D. had a limited range of facial expressions and would seldom show his

emotions. The only emotion that was apparent was anger, which Mr. D. would display when not

understood correctly. This in combination with feelings anxiety would cause Mr. D. to develop

panic attacks. Instead of learning to cope with these feelings in an appropriate manner, Mr. D.

tried to avoid them. He would develop an imaginary world in which he would not have to deal

with his problems.

During his late-teen-years, he would withdraw more than he previously used to. His

parents had always been tolerant and supportive of his lifestyle, but when it started affecting his

everyday life they took him to see a psychiatrist. After having described the symptoms, the

psychiatrist described the quietness and the lack of expressions (which he described as flat

affect) as negative symptoms that are characteristics of schizophrenia. As Mr. D.’s mother

described the imaginary world to the psychiatrist, he told her that Mr. D. was having delusions.

As at least two symptoms (delusions and negative symptoms) had been present for multiple

years, the psychiatrist gave Mr. D. the diagnose of schizophrenia. He told the mother of Mr. D.

that he would prescribe him antipsychotic medication.


Although the medication seemed to work well with the imaginary world, it only reduced

his speaking even more. Mr. D.’s behavior could best be described as catatonic. He would not

show any emotions at all. His body movements were delayed. He had problems speaking and

could not get his message across. Although the level of social interest was low before the

medication, it only seemed to decrease. His previous fixation about the weather and meteorology

had diminished and he would just sit in his room and do nothing. Even though it was a welcome

addition that Mr. D. was not as anxious anymore, his mother could not see the joy in his eyes

anymore. She called the psychiatrist and told him about the medication and how it had worked.

The psychiatrist responded that medications affect everyone differently and that they could try a

different antipsychotic medication. Mr. D’s mother thought this was reasonable and agreed on

giving this a chance. Although it did not make Mr. D. as catatonic as the other medicine had

done, it came with its own side effects. Mr. D started putting on more weight, seemed more

irritable than before, and still showed signs of withdrawal to his own world. It would take

multiple attempts for the family to find a good medication for Mr. D. and many of them came

with side effects that were even worse than the symptoms he presented in the first place. None

of them could truly reach Mr. D.

It was not until his mother approached a different mental health clinician that they

realized that schizophrenia might not have been the problem. Instead, the therapist mentioned

the possibility that anxiety and panic attacks caused Mr. D. to create another world where he

could he escape from his problems. This private logic made it possible for him to not face his

fears. However, these mistaken beliefs caused Mr. D. to lose his social interest, which made it

harder for him to improve his life satisfaction. The medication he had been given all these years

had only caused him to affect more side effects without looking what caused the original


problems. The therapist instead suggested a therapy style that was encouraging and

psychotherapeutic to get Mr. D. back to his feet.

It was acknowledged by the therapist that although his autism may never be cured, there

are multiple ways where he could use it to his advantage. Practicing social skills and

approaching his everyday life with a different mind-set have many benefits compared to

antipsychotic medications. They do not contain any side effects, there is no trial-and-error

method, and it gives them a professional who believes in them and provides them with the

knowledge they need to go through their everyday life. To be able to socialize for a person with

autism may never feel natural. However, to have it as a second language is more beneficial than

not having any at all.

Discussion

Schizophrenia and ASD share many components and their histories are intertwined. One

can argue that both disorders are connected by the negative symptoms they share. It is not a

ludicrous idea that therapy can be helpful to both. In fact, clients with ASD and schizophrenia

will benefit from working with their beliefs, thought patterns, and incorporating a community

feeling into their lives. However, by overlooking the differences between the two, many

difficulties arise. Is it worth prescribing side effects to get rid of non-existing positive

symptoms?

Furthermore, Adlerian therapy does not believe in treating symptoms to reach the

underlying situation. Instead, Adler’s approach is holistic in nature. What this means is that the

whole should be treated instead of looking at individual parts. For example, by just focusing on

the positive symptoms with antipsychotic medication, the negative symptoms are still present

and still affecting the client negatively. Instead, a more effective way of helping the client is to


help the client change their mistaken beliefs, encourage them to find a greater community

feeling, and figuring out the origins of the problems (Oberst & Stewart, 2003).

With schizophrenia, this way of treatment is applicable as well. However, it can be

helpful to use antipsychotic medications to dampen the effects of the positive symptoms. It

should be noted that Adler believed that the client is the expert of their life. The therapist is only

there to help the client with different thought patterns and to work around their mistaken beliefs.

This means that sometimes the therapist needs to walk into the world of the client with

schizophrenia, even though it may seem absurd at first. To be a good therapist, it is important to

be open-minded to other people’s lifestyles, to be encouraging, and to be caring. That is why a

therapist can never drag the person out of their current style of life. Instead, by questioning,

encouraging, and using empathy, therapists can see the world from the client’s eyes. By doing

so, it gives the therapist a chance of providing the client with more ways of overcoming their

problems through new ways of viewing the world (Oberst & Stewart, 2003).

Recommendations for Future Research

Compared to many other disciples of psychology, little information is available about

how well individual psychology works with ASD. Having empirical results available is

important for individual psychology (such as Adlerian therapy). It helps present Adlerian

therapy as a useful treatment. With more research, individual psychology can be widespread as a

successful way to help individuals with ASD. In addition, more research should be devoted to

how individual psychology can be used with schizophrenia. Instead of assuming medical

treatment is the only option, research can show that there are other ways to help people.

Furthermore, more research should be dedicated to the differences between individual

psychology and pharmacological treatments. The few articles available only compared cognitive


behavioral therapy to pharmacological treatments. With more research, the importance of

individual psychology would be emphasized. It would show that pharmacology is not the only

answer.

Conclusion

ASD and schizophrenia share symptoms and look similar through neuroimaging. They

are both genetic and can often be misinterpreted. However, autism does not have the positive

symptoms and trying to treat those symptoms is not an optimal solution. The chemical

imbalances of schizophrenia have a better chance of being treated with pharmacology than ASD.

Instead, a recommended intervention would be using a therapeutic treatment as it focuses on

exploring the person’s thoughts, feelings, and behaviors.

By using Adlerian therapy, the client will have access to an encouraging and open-

minded therapist. This will do wonders as many of the Adlerian techniques do wonder with the

autism spectrum population. For example, the lack of social communication among clients with

ASD can be worked on with Adlerian therapy. As the treatment is focused on community

feeling, social interest, and encouraging the individual to help others to help themselves, it

provides the client with new tools to connect with other individuals.

This is not to say that schizophrenia does not benefit from therapeutic treatment, which it

does as well. However, with schizophrenia, it can be beneficial to incorporate antipsychotic

medication to help the client to a more stable base level. Though antipsychotics take care of the

positive symptoms, such as hallucinations and delusions, they do not affect the negative

symptoms, such as social withdrawal and apathy.

As stated earlier, this is where therapy is advantageous. Adlerian therapy can be helpful

with schizophrenia as well as it provides tools for changing the mistaken beliefs. These mistaken


beliefs can be found in both the positive and negative symptoms. They can range from beliefs

that the person must avoid social contact to survive or what to do with the voices that are present.

In the building stones of Adlerian therapy, a man needs to find belonging to live a

meaningful life. This can be done through work, relationships, or love. This is the main

problem in ASD and it is a great part of schizophrenia as well. Instead of focusing on treating

symptoms with medications and finding a general cause for everyone, it can be more helpful to

find individual humane treatments through therapy. Every human being is different and should

be treated as such. When the antipsychotics cannot even generate 30% of a success rate for

individuals with autism, why is it still a used treatment method? It should not be necessary to act

unethical when treating a mental health disorder. With therapy, none needs to be broken to help.

Furthermore, success rate is higher and treating the clients can be accomplished without

providing them with terrible side effects that are in certain cases worse than the original problem.

To advance the treatment of schizophrenia and ASD, it is necessary to look at them as separate

entities. Both can be treated with therapy, but only of them has shown positive effects of being

paired up with antipsychotic medications. That is schizophrenia, not ASD.


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