This narrative review is an argumentative reappraisal addressing three convergent failures — classificatory, sociocultural, and methodological — and asking what minimum evidentiary standards should govern adult ASD differential diagnosis in complex cases.
Abstract
Background The reported prevalence of Autism Spectrum Disorder (ASD) has risen nearly fourfold over two decades, fuelling debate about whether DSM-5 boundaries still demarcate a coherent clinical category. Between 2020 and 2025, multiple independent research groups have produced a convergent body of critical reflection on this question. Aim This narrative review is an argumentative reappraisal addressing three convergent failures — classificatory, sociocultural, and methodological — and asking what minimum evidentiary standards should govern adult ASD differential diagnosis in complex cases. Four sub-themes traditionally treated separately (sensory profile, female phenotype, personality-disorder differential diagnosis, care-pathway implications) are presented as convergent illustrations of one underlying problem. Methods Narrative integration of peer-reviewed publications (2015–2026) on ASD diagnostic validity, phenotypic and genetic heterogeneity (Type I/Type II partition; Litman et al. SPARK analysis), sensory processing specificity, female phenotype and camouflaging, and differential diagnosis with seven conditions: Borderline, Avoidant, and Schizotypal Personality Disorders; Complex PTSD; ADHD with affective dysregulation; Bipolar Spectrum; OCD-spectrum disorders; and adult disorganised attachment. Literature-identification methods and AI-assisted search with author verification are detailed in Section 1.3. Findings The category aggregates at least two neurobiologically distinct phenotypes — Type I, prototypical, often syndromic, with high genetic load; and Type II, polygenically driven, milder, overlapping with general psychopathology — differentially affected by routine-assessment limitations. The DSM-5 sensory criterion, though neurobiologically grounded, lacks diagnostic specificity. The cross-sectional, single-source, self-report-based model dominating practice is structurally inadequate for Type II presentations and the female phenotype. Recommendations Six minimum standards are specified: structured developmental history with ≥2 informants; multi-context behavioural observation; neuropsychological profiling; granular sensory assessment by modality, direction, and contextual stability; systematic evaluation of alternative diagnoses; and longitudinal formulation with revisability. Specialised pathways should use stepped multidisciplinary triage when differential diagnosis remains unresolved, directing individuals to appropriate parallel or alternative services rather than denying care. A minimum feasible standard for under-resourced settings is articulated alongside the ideal one. Conclusion Restoring diagnostic specificity to ASD is not opposed to the neurodiversity framework. It is the precondition for ensuring that the diagnostic label, when applied, identifies a population for which evidence-based interventions exist and the care pathway is appropriate.
Recent initiatives by the American Psychiatric Association to revise the DSM reflect renewed efforts to address enduring challenges in psychiatric nosology (e.g. absence of clear biological markers, substantial heterogeneity within disorders and high comorbidity across disorders). This article examines five key classification challenges emerging from successive diagnostic revisions in one of the most common childhood diagnoses: attention-deficit hyperactivity disorder (ADHD). Importantly, this theoretical analysis is anchored in prior empirical findings from a systematic textual analysis of all DSM descriptions related to ADHD, from DSM-III (1980) to DSM-5-TR (2022). Drawing on foundational principles from the philosophy of science, the analysis examines how diagnostic adjustments introduced in response to empirical findings or clinical concerns may carry broader implications for the structure, boundaries and conceptual coherence of psychiatric diagnosis. These include: (a) prevalence and the threshold of deviance; (b) gender and diagnostic heterogeneity; (c) aetiological framing and explanatory coherence; (d) medical framing and diagnostic boundaries; and (e) comorbidity and discriminant validity. Addressing these challenges, as well as the broader epistemic foundations of psychiatric diagnosis discussed in this article, may benefit clinicians facing complex diagnostic decisions in everyday practice and theorists developing future psychiatric classification systems.
Y. Ophir· The British journal of psych...· 0 citations
There is an urgent need for prospective longitudinal studies to adequately map the aging trajectories of this population of older adults with ASD, which constitute a vulnerable population.
J. P. S. Gontijo, Marcelo H S S Martins, L. M. Alves· Trends in Psychiatry and Psy...· 0 citations
This Perspective argues that best-estimate clinical diagnosis must be grounded in rigorous developmental anchoring, collateral information, and judicious clinical judgment, and proposes a set of core stratification domains for systematic phenotypic stratification.
Gabriela N. F. Guimarães· Frontiers in Psychiatry· 0 citations
Persistent comorbidity, diagnostic instability and the scarcity of disorder-specific causes have encouraged the proposal that a single superordinate dimension underlies liability to all common mental disorders. This proposition, expressed empirically as the general factor of psychopathology and framed conceptually as a general psychiatric syndrome, now shapes nosological reform, aetiological research and the design of youth mental health services. Its status remains contested. This critical narrative review evaluates the hypothesis across five domains of evidence: psychometric modelling, quantitative and molecular genetics, structural neuroimaging and neurocognition, developmental epidemiology, and clinical translation. Literature published between January 1999 and June 2026 was identified through structured searching of biomedical and multidisciplinary scholarly sources, supplemented by citation tracking of recent reviews and of a 2026 target-article exchange devoted to the topic. Sources were appraised for design adequacy, sample independence, replication, and the correspondence between statistical models and the substantive claims drawn from them. Evidence for a strong and replicable general dimension at the phenotypic level is robust. It accounts for the majority of reliable symptom variance from early childhood to adulthood, aggregates within families, and predicts impairment more consistently than narrower factors. Evidence bearing on its interpretation is considerably weaker. Competing accounts framing the dimension as negative emotionality, disinhibition, thought dysfunction, low cognitive ability or an index of impairment are only partially separable empirically, and several are close to statistically equivalent. Molecular genomic analyses supply the strongest disconfirming signal, repeatedly favouring several correlated genomic factors over a single dimension of genetic risk. Neuroimaging associations are modest, derive from a small number of overlapping cohorts, and have not produced diagnostic or prognostic utility. Transdiagnostic psychological treatments perform comparably to disorder-specific protocols, although this parity does not establish a shared causal mechanism. The general dimension is best regarded at present as a well-replicated descriptive summary of liability and impairment rather than a demonstrated syndrome with unitary aetiology. Clinical adoption should follow evidence of incremental decision-making value, which has not yet been generated.
Luiz Costa, Fernando Martins Castanheira, Giovanna Azevedo Rodrigues et al.· International Neuropsychiatr...· 0 citations
This paper introduces an autistic-led and developed narrative-based assessment protocol addressing the paradigmatic and systematic underdiagnosis of autism in adult females. Traditional diagnostic instruments, validated primarily on male cohorts, fail to capture the Female Autism Phenotype characterized by sophisticated masking, internalized traits, and distinct cognitive styles. Through analysis of 988 written narratives from autistic women worldwide, eight thematic domains emerged: observational detachment, social navigation challenges, masking/identity fragmentation, sensory-perceptual differences, relational patterns, distinctive cognitive styles, characteristic developmental trajectories, and ethical rigidity. In opposition to an often-accepted paradigm of autism, where the subject is a male child, often with accompanying intellectual disability, 70.7% of this study's participants held college degrees, challenging deficit-based stereotypes. The narrative methodology circumvents masking behaviors triggered by face-to-face assessments, with 76% of participants expressing experiences in writing they couldn’t verbalize. Drawing on Critical Autism Studies and Husserlian phenomenology, bridging the gap between Social/Behavioral Sciences and the Arts and Humanities, the Wilderwood Reflective Assessment and Diagnostic Indicator of Autistic and Neurodivergent Cognitive Expression (WRADIANCE) shifts diagnostic power from clinician observation to client self-report, honoring autistic women's capacity for self-knowledge. This neurodivergent-affirming approach represents a fundamental paradigm shift in autism assessment, offering a pathway to identification that validates rather than pathologizes female autistic experience.
Abstract
The prevalence of diagnosed autism spectrum disorder (ASD) has increased significantly over the past two decades, yet its diagnosis remains predominantly behavioral and developmental, lacking a validated biomarker to independently confirm the condition. The present report examines the hypothesis that conditions currently diagnosed as autism represent manifestations of screen addiction – including early screen addiction and screen trauma – whose impact on regulation, learning, communication, attachment, and social development – when coupled with inadequate therapies and interventions – produces an autistic phenotype. Consequently, the central problem under consideration is not solely autism, but a potential ecosystemic fallacy: once developmental dysfunction induced by screen addiction is classified as autism, the diagnosis reorganizes subsequent understanding, scientific research, therapy, familial behavior, institutional responses, and social identity around the presumed irreversibility of the condition.
The report analyzes the mutually reinforcing diagnostic, medical, scientific, therapeutic, familial, technological, institutional, economic, social, and cultural mechanisms that may perpetuate this error. It is argued that the failure to recognize screen addiction as a potential causal and maintaining factor diverts children and families toward symptom management, thereby leaving the underlying screen exposure and addictive structure intact.
The proposed framework calls for a systemic differential assessment of screen addiction in individuals presenting with autistic symptomatology, as well as a direct investigation into whether the elimination of screen exposure, combined with targeted therapy for screen addiction, can alter the developmental trajectory. Should this hypothesis be corroborated, a subset of conditions currently classified as irreversible autism may in fact represent preventable and potentially reversible, environmentally induced impairments. This would necessitate a fundamental paradigm shift in the diagnosis, research, and treatment of autism.
Keywords: Autism Spectrum Disorder (ASD), screen addiction, screen trauma, ecosystemic fallacy, diagnostic expansion, therapeutic chronification, tertiary gain, familial co-addiction, technoference, Munchausen Syndrome by proxy
Violeta Manolova, S. Vezenkov· Nootism· 0 citations
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