Concepts and labels
Asperger syndrome, a form of autism, is defined solely by its symptoms (Box 9.1). However, our perception of autism together with its terminology and definitions are in flux. The original, florid picture, drawn by Leo Kanner in 1943 (see Chapter 8), still stands – someone who is aloof from or even averse to people, with peculiar speech and markedly rigid, stereotypical and repetitive behaviour. Often with an intellectual disability, sometimes with unusual talents, they represent only one facet of a very varied disorder. The other group, half of those with autism, have neither an intellectual disability nor the obvious anomalies of speech. Some marry or pursue a career, helped as well as hindered by their altered social sensitivity, focused interests, or detached pragmatism, the last being seen as a refreshingly alternative view, a blunt and objective focusing on fact, ‘thinking outside the box’ or simply eccentricity. It is this picture, initially identified by Hans Asperger as autistic psychopathy in 1944, that emerged as Asperger syndrome (van Krevelen, 1971; Wing, 1981), to become popularised in books, films and plays. Although recently discarded by DSM, the term remains in ICD for the present and continues to have a popular and useful currency, identifying people often overlooked by psychiatry.
The development of the concept, like others in psychiatry, is of clarity alternating with confusion. Bleuler coined the term ‘autism’ to describe the self-centred social withdrawal of schizophrenia and it was adopted separately by Kanner and Asperger to describe the main thread in their case series.
• Kanner thought autism to be a psychotic process but one separate from schizophrenia: a distinction that was soon lost as it came to be seen simply as the early onset of a unitary psychosis. It was only in 1971, when Kolvin and Rutter showed autism to be substantially different, that it was recognised as a developmental disorder. The defining criteria had passed from Mildred Creak's Nine Points, to Lorna Wing's Triad of Impairment, to those adopted by ICD-9 (World Health Organization, 1978) and DSM-III (American Psychiatric Association, 1980) and now to the latest variant in DSM-5 (American Psychiatric Association, 2013).