Going beyond the DSM in predicting, diagnosing, and treating autism spectrum disorder with covarying alexithymia and OCD: A structural equation model and process-based predictive coding account

Abstract

BackgroundThere is much overlap among the symptomology of autistic spectrum disorders (ASDs), obsessive compulsive disorders (OCDs), and alexithymia, which all typically involve impaired social interactions, repetitive impulsive behaviors, problems with communication, and mental health.AimThis study aimed to identify direct and indirect associations among alexithymia, OCD, cardiac interoception, psychological inflexibility, and self-as-context, with the DV ASD and depression, while controlling for vagal related aging.MethodologyThe data involved electrocardiogram (ECG) heart rate variability (HRV) and questionnaire data. In total, 1,089 participant's data of ECG recordings of healthy resting state HRV were recorded and grouped into age categories. In addition to this, another 224 participants completed an online survey that included the following questionnaires: Yale-Brown Obsessive Compulsive Scale (Y-BOCS); Toronto Alexithymia Scale 20 (TAS-20); Acceptance and Action Questionnaire (AAQII); Depression, Anxiety, and Stress Scale 21 (DAS21); Multi-dimensional Assessment of Interoceptive Awareness Scale (MAIA); and the Self-as-Context Scale (SAC).ResultsHeart rate variability was shown to decrease with age when controlling for BMI and gender. In the two SEMs produced, it was found that OCD and alexithymia were causally associated with autism and depression indirectly through psychological inflexibility, SAC, and ISen interoception.ConclusionThe results are discussed in relation to the limitations of the DSM with its categorical focus of protocols for syndromes and provide support for more flexible ideographic approaches in diagnosing and treating mental health and autism within the Extended Evolutionary Meta-Model (EEMM). Graph theory approaches are discussed in their capacity to depict the processes of change potentially even at the level of the relational frame.

Interoceptive awareness in a clinical setting: the need to bring interoceptive perspectives into clinical evaluation

“…Further analyses by Mul et al (2018) and Yang et al (2021) indicated that reduced interoceptive processing in individuals with ASD was linked to decreased self-reported IA, affecting their capacity to recognize bodily sensations and, by extension, identify and articulate emotions. These outcomes align with Edwards (2022) , who explored causal relationships involving alexithymia, obsessive-compulsive disorder (OCD), and ASD, discovering significant connections with IA, notably through the subscale of Self-Regulation. Furthermore, Edwards’ study revealed that IA, particularly the Attention Regulation subscale, could partially mediate the association between OCD and ASD, suggesting indirect pathways linking alexithymia and OCD with ASD severity via IA ( Edwards, 2022 ).…”

“…These outcomes align with Edwards (2022) , who explored causal relationships involving alexithymia, obsessive-compulsive disorder (OCD), and ASD, discovering significant connections with IA, notably through the subscale of Self-Regulation. Furthermore, Edwards’ study revealed that IA, particularly the Attention Regulation subscale, could partially mediate the association between OCD and ASD, suggesting indirect pathways linking alexithymia and OCD with ASD severity via IA ( Edwards, 2022 ).…”

“…Studies examining this theory show a link between IA and autistic traits, alexithymia, and empathy ( Mul et al, 2018 ; Yang et al, 2022 ). Edwards (2022) further integrate these findings into broader theories of interoception as predictive coding errors ( Seth, 2013 ; Barrett and Simmons, 2015 ; Barrett et al, 2016 ; Seth and Friston, 2016 ; Stephan et al, 2016 ; Owens et al, 2018 ). This interpretation suggests mindfulness and emotion recognition practices could mitigate autistic conditions by reducing interoceptive prediction errors.…”

“…Additionally, examining the gender composition within the study samples previously mentioned revealed a predominance of female participants, with mixed-methods studies occasionally overlooking gender-based analysis. Nonetheless, specific investigations (e.g., Willem et al, 2019 ; Di Lernia et al, 2020 ; Dunne et al, 2021 ; Edwards, 2022 ) into gender differences have confirmed that women have an enhanced ability to recognize emotions and bodily sensations. Table 2 summarizes the results described above according to MAIA subscales.…”

“…The “interoception-alexithymia-autism” theory ( Quattrocki and Friston, 2014 ; Tang et al, 2020 ; Edwards, 2022 ) posits that irregular IA may be a precursor to alexithymia, potentially heightening the risk for ASD. Studies examining this theory show a link between IA and autistic traits, alexithymia, and empathy ( Mul et al, 2018 ; Yang et al, 2022 ).…”