Emotional decision-making in autism spectrum disorder: the roles of interoception and alexithymia

Linking the inner and outer mental representations of the body to social cognition skills: A systematic review and meta-analysis

An interesting interpretation of embodiment highlights the critical role of mental body representations (BR), including motor, somatosensory, and interoceptive formats, for social cognition. However, the nature of this relationship is still debated at the empirical level, with various studies arriving at different conclusions. Here, we present a systematic review and meta-analysis aimed to summarize data from 3466 participants in 21 studies to provide a more comprehensive understanding of the relationship between inner and outer BR and social cognition. We focused on two core social cognition aspects: empathy and Theory of Mind (ToM). Concerning the inner BR, our meta-analytic findings reveal a significant correlation between specific interoceptive dimensions (i.e., interoceptive sensibility and accuracy) and social cognition, which was stronger for empathy than ToM. Conversely, although further research is needed, functional BR that mainly involve the outer body processing (i.e., nonaction-oriented BR) may show positive links with ToM. These findings point to specific interactions between BR and social cognition skills, supporting multi-faceted and embodied social cognition models. However, we also identified critical knowledge gaps and highlighted the need for further investigation to deepen our theoretical understanding of these relationships and their implications for clinical practice.

Highly logical and non-emotional decisions in both risky and social contexts: understanding decision making in autism spectrum disorder through computational modeling

In risky contexts, autism spectrum disorder (ASD) individuals exhibit more logical consistency and non-emotional decisions than do typical adults (TAs). This way of deciding could be also prevailing in social contexts, leading to maladaptive decisions. This evidence is scarce and inconsistent, and further research is needed. Recent developments in computational modeling allow analysis of decisional subcomponents that could provide valuable information to understand the decision-making and help address inconsistencies. Twenty-seven individuals with ASD and 25 TAs were submitted to a framing-task and the ultimatum game (UG). The Rescorla-Wagner computational model was used to analyze UG decisions. Results showed that in the UG, the ASD group exhibited a higher utilitarianism, characterized by lower aversion to unfairness and higher acceptance of offers. Moreover, this way of deciding was predicted by the higher economic rationality found in the framing task, where people with ASD did not manifest emotional biases such as framing effect. These results could suggest an atypical decision making, highly logical and non-emotional, as a robust feature of ASD.

The Relationship Between Brain Activation for Taking Others' Perspective and Interoceptive Abilities in Autism Spectrum Disorder: An fMRI Study

Objectives

In this functional magnetic resonance imaging study, we aimed to investigate the differences in brain activation between individuals with autism spectrum disorder (ASD) and typically developing (TD) individuals during perspective taking. We also examined the association between brain activation and empathic and interoceptive abilities.

Methods

During scanning, participants from the ASD (n=17) and TD (n=22) groups were shown pain stimuli and asked to rate the level of the observed pain from both self- and other-perspectives. Empathic abilities, including perspective taking, were measured using an empathic questionnaire, and three dimensions of interoception were assessed: interoceptive accuracy, interoceptive sensibility, and interoceptive trait prediction errors.

Results

During self-perspective taking, the ASD group exhibited greater activation in the left precuneus than the TD group. During other-perspective taking, relative hyperactivation extended to areas including the right precuneus, right superior frontal gyrus, left caudate nucleus, and left amygdala. Brain activation levels in the right superior frontal gyrus while taking other-perspective were negatively correlated with interoceptive accuracy, and those in the left caudate were negatively correlated with perspective taking ability in the ASD group.

Conclusion

Individuals with ASD show atypical brain activation during perspective taking. Notably, their brain regions associated with stress reactions and escape responses are overactivated when taking other-perspective. This overactivity is related to poor interoceptive accuracy, suggesting that individuals with ASD may experience difficulties with the self-other distinction or atypical embodiment when considering another person's perspective.

An ecological assessment of decision-making under risk and ambiguity through the virtual serious game Kalliste Decision Task

Traditional methods for evaluating decision-making provide valuable insights yet may fall short in capturing the complexity of this cognitive capacity, often providing insufficient for the multifaceted nature of decisions. The Kalliste Decision Task (KDT) is introduced as a comprehensive, ecologically valid tool aimed at bridging this gap, offering a holistic perspective on decision-making. In our study, 81 participants completed KDT alongside established tasks and questionnaires, including the Mixed Gamble Task (MGT), Iowa Gambling Task (IGT), and Stimulating & Instrumental Risk Questionnaire (S&IRQ). They also completed the User Satisfaction Evaluation Questionnaire (USEQ). The results showed excellent usability, with high USEQ scores, highlighting the user-friendliness of KDT. Importantly, KDT outcomes showed significant correlations with classical decision-making variables, shedding light on participants' risk attitudes (S&IRQ), rule-based decision-making (MGT), and performance in ambiguous contexts (IGT). Moreover, hierarchical clustering analysis of KDT scores categorized participants into three distinct profiles, revealing significant differences between them on classical measures. The findings highlight KDT as a valuable tool for assessing decision-making, addressing limitations of traditional methods, and offering a comprehensive, ecologically valid approach that aligns with the complexity and heterogeneity of real-world decision-making, advancing research and providing insights for understanding and assessing decision-making across multiple domains.

Autistic adults' experiences of financial wellbeing: Part II

LAY ABSTRACT

Money matters in people's lives. It helps to meet people's basic needs (food, clothes, shelter) and live the lives they want to. When people talk about 'financial wellbeing', they mean how much you feel in control over day-to-day finances and how much freedom you have to make choices to enjoy life. We don't know what autistic people think about these things. That's why we did our study. We spoke to 21 autistic adults (24-69 years) about how they felt about their financial situation. We deliberately spoke to people who had told us previously they felt 'financially well' or 'financially unwell' so we could hear a range of opinions. Autistic people told us financial wellbeing meant having enough money to pay for their basics needs, to have a safety net for unexpected bills and not having to worry about money now or in the future. But many felt that good financial wellbeing was not possible for them. They often did not have a stable income to cover day-to-day expenses. This limited the choices they could make. Despite these challenges, autistic people told us they worked hard to budget and save money when they could - because feeling financial insecure was just too stressful, especially when they could not rely on family or friends for support. It made them feel mentally unwell. Our study shows there are many factors that influence autistic people's financial wellbeing. We need more research to help us understand how autistic people can be supported to achieve financial security.

Autistic adults show enhanced generosity to socially distant others

LAY ABSTRACT

Autistic people show differences in their social behaviour. But how autism affects decisions to share resources, an important part of cooperation, was previously unclear. In our study, participants made decisions about how to share money with different people, including people they felt close to, such as a friend, and people they felt less close to, such as a stranger. We found that compared to a group of non-autistic participants, autistic adults shared more money overall and this was driven by greater generosity to strangers. The results suggest that autistic adults were more generous because they made fair decisions (an equal split of the money) more consistently regardless of how close they felt to the person they were sharing with. By showing that autistic adults display greater generosity, our results could help to change public perceptions of autism and potentially improve opportunities for autistic people.

Paranoia and Data-Gathering Biases in Autism

Previous research has identified contradictory patterns in autism upon probabilistic reasoning tasks, and high levels of self-report paranoia symptoms have also been reported. To explore this relationship, the present study assessed 64 non-autistic and 39 autistic adults on two variants of a probabilistic reasoning task which examined the amount of evidence required before making a decision and 'jumping to conclusions' (a neutral beads task and an emotionally-salient words variant). The autism group was found to require significantly more evidence before making a decision and to have significantly less jumping to conclusions than the non-autistic group. For those with relatively low levels of paranoia, the emotionally-salient variant impacted on the non-autistic group, but not the autism group.

Cognitive biases as an adaptive strategy in autism and schizophrenia spectrum: the compensation perspective on neurodiversity

This article presents a novel theoretical perspective on the role of cognitive biases within the autism and schizophrenia spectrum by integrating the evolutionary and computational approaches. Against the background of neurodiversity, cognitive biases are presented as primary adaptive strategies, while the compensation of their shortcomings is a potential cognitive advantage. The article delineates how certain subtypes of autism represent a unique cognitive strategy to manage cognitive biases at the expense of rapid and frugal heuristics. In contrast, certain subtypes of schizophrenia emerge as distinctive cognitive strategies devised to navigate social interactions, albeit with a propensity for overdetecting intentional behaviors. In conclusion, the paper emphasizes that while extreme manifestations might appear non-functional, they are merely endpoints of a broader, primarily functional spectrum of cognitive strategies. The central argument hinges on the premise that cognitive biases in both autism and schizophrenia spectrums serve as compensatory mechanisms tailored for specific ecological niches.

Differences in Art Appreciation in Autism: A Measure of Reduced Intuitive Processing

Art appreciation reflects an initial emotional and intuitive response to artwork evaluation, although this intuitive evaluation can be attenuated by subsequent deliberation. The Dual Process Theory of Autism proposes that individuals with Autism Spectrum Disorder (ASD) have a greater propensity to deliberate and reduced intuition compared to matched controls. Evaluations of high- and low-quality artworks were undertaken by 107 individuals with a diagnosis of ASD and 145 controls. Controls consistently evaluated high-quality artworks to be much better quality than the low-quality artworks, reflecting intuitive processing. The ASD sample showed a reduced difference in evaluations between high- versus low-quality artwork, which reflects reduced intuitive processing and greater deliberative processing and is consistent with predictions by the Dual Process Theory of Autism.

Interoception, alexithymia, and anxiety among individuals with alcohol use disorder

Background

Interoception (i.e., the ability to recognize bodily signals), alexithymia (i.e., the inability to recognize emotional states) and negative affect (i.e., unpleasant feelings such as anxiety) have been associated with alcohol use disorder (AUD). Previous research suggests that interoception may underlie alexithymia, which in turn may be associated with negative affectivity. However, this remains to be empirically tested. This study investigates whether alexithymia mediates the association between interoception and anxiety and whether this association differs across individuals with AUD and a healthy control (HC) comparison group.

Methods

The AUD group consisted of 99 participants enrolled in an 8-week abstinence-based inpatient treatment program. The HC group included 103 healthy individuals. The heartbeat counting task (HCT) was used to assess interoception (cardiac interoceptive accuracy). The Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. The Brief Symptom Inventory (BSI) was used to assess anxiety.

Results

The moderated mediation model with interoception as the predictor, alexithymia as the mediator, and negative affect (i.e., state anxiety) as the dependent variable was tested. The analysis showed that the conditional indirect effect of interoception on anxiety via alexithymia was significant for individuals with AUD [ab = -0.300, bootstrap 95% CI = (-0.618, -0.088)], as well as for HCs [ab = -0.088, bootstrap 95% CI = (-0.195, -0.014)]; however, the conditional indirect effect significantly differed across HCs and individuals with AUD. Namely, the mediated effect was greater among individuals with AUD compared to the HC group.

Conclusion

The results suggests that interoceptive impairment contributes to greater negative affect (i.e., state anxiety) via alexithymia especially for individuals with AUD. Improving emotion recognition via therapeutic methods focused on strengthening interoceptive abilities could improve outcomes for individuals receiving treatment for AUD.

A multidimensional investigation of the relationship between skin-mediated somatosensory signals, emotion regulation and behavior problems in autistic children

Introduction

Autistic children may have abnormal sensory perception, emotion dysregulation and behavior problems. The aim of this cross-sectional study was to explore the relationship between skin-mediated somatosensory signals and emotion/behavior difficulties in autistic children and adolescents, in comparison typically developing peers (TDP).

Methods

Thirty-eight autistic children and adolescents and 34 TDP completed a multidimensional assessment consisting of the measurement of somatosensory thresholds of touch, pain and temperature, a task on emotion knowledge and parent-reported questionnaires on sensory reactivity, emotion regulation and behavior.

Results

Autistic children had higher pain sensitivity, less sensory reactive behaviors and more behavior problems than their TDP. In contrast to TDP, several somatosensory thresholds of autistic children correlated with emotion regulation and behavior problems.

Discussion

Sensory dysfunction may affect the development of emotional processing and behavior in autistic children and adolescents. This knowledge can lay the foundation for future studies on co-occurring alterations in corresponding neural networks and for the implementation of early interventions, including sensory rehabilitation therapy, for promoting regulated behaviors in autistic children and adolescents.

COVID-19 stressor reduces risk taking: the role of trait interoception

The Framing Effect (FE) demonstrated that the way two alternatives are displayed affects people's inclination to make a specific choice, showing a risk aversion when alternatives are displayed on positive frames and risk seeking in negative frames. Risk seeking in negative frames is closely linked to loss aversion. Moreover, classical research and the salience-of-losses hypothesis argues that stress may enhance the FE and loss aversion. Recent studies also suggest that the trait interoception and alexithymia could interact and moderate the framing susceptibility. However, experimental paradigms on stress could ignore variables such as threat perception. In this sense, COVID-19 pandemic has become a powerful real-life stressor in many countries. We aimed to study how real-life stressors influence decision-making under risk. A total of 97 participants were divided into a control (n = 48) and an experimental group (n = 49). The experimental group were exposed to a stressor manipulation, a 5 min COVID-19 lockdown documentary. Our results show that COVID-19-related stressors significantly decreased bet acceptance regardless of the frame, also reducing loss aversion. Moreover, interoception was a significant predictor of loss aversion under stress conditions. Our results do not support classical research on stress and FE.

Thinking, fast and slow on the autism spectrum

What is already known about the topicDaniel Kahneman wrote a highly influential book titled 'thinking, fast and slow'. He proposes that people usually think in a rapid, automatic, intuitive style. When people realise their intuitive thinking may be wrong, a slower, effortful, deliberative style of thinking takes over. It has recently been proposed that thinking in autistic individuals can be characterised as usually thinking in the deliberative style (rather than the intuitive style that non-autistic people usually think in).What this paper addsAs intuitive thinking is fast and deliberative thinking is slow, this research manipulated the time available to complete a series of reasoning questions. These questions have been developed to have intuitive answers (which are incorrect) and deliberative answers (which are correct). For the first time, a fast time manipulation (you must answer quickly) and slow (you must think about your answer before responding) was undertaken with autistic individuals. Autistic participants did produce more deliberative answers than the non-autistic participants. However, both groups produced comparably more intuitive answers and less deliberative answers in the fast condition. This shows that while autistic people tend not to use their intuition, autistic people can be encouraged to use their intuition.Implications for practice, research or policyUsing rapid intuition can be useful in fast-changing contexts, such as some social situations. Future research can explore how to support autistic individuals to use their intuition when the need arises. In addition, the propensity for deliberation resulting in unbiased, correct responses reflects a strengths-based account of autism. This requires more mental effort and is less susceptible to bias and errors. This is called 'Dual Process Theory'.

Neural correlates of perceptual switching and their association with empathy and alexithymia in individuals with and without autism spectrum disorder

Individuals with autism spectrum disorder (ASD) often show limited empathy (poor recognition of others' emotions) and high alexithymia (poor recognition of own emotions and external thinking), which can negatively impact their social functioning. Previous experimental studies suggest that alterations in cognitive flexibility play key roles in the development of these characteristics in ASD. However, the underlying neural mechanisms that link cognitive flexibility and empathy/alexithymia are still largely unknown. In this study, we examined the neural correlates of cognitive flexibility via functional magnetic resonance imaging during perceptual task-switching in typical development (TD) adults and adults with ASD. We also investigated associations between regional neural activity and psychometric empathy and alexithymia scores among these populations. In the TD group, stronger activation of the left middle frontal gyrus was associated with better perceptual switching and greater empathic concern. Among individuals with ASD, stronger activation of the left inferior frontal gyrus was associated with better perceptual switching, greater empathy, and lower alexithymia. These findings will contribute to develop a better understanding of social cognition, and could be informative for the development of new ASD therapies.

The Development of Intuitive and Analytic Thinking in Autism: The Case of Cognitive Reflection

The cognitive reflection test (CRT) is a short measure of a person's ability to resist intuitive response tendencies, and to produce normatively correct responses that are assumed to be based on effortful, analytic thinking. A remarkable characteristic of the CRT is that although the questions are open-ended, for each item, the vast majority of people either produce a correct, analytic response or a typical incorrect (i.e., intuitive) response. This unique feature of the CRT makes it possible to investigate the question of whether autistic and neurotypical people share the same intuitions. We report a study that included adolescents and young adults. In both age groups, autistic and neurotypical participants were matched on age, gender, cognitive ability, and educational background. In line with previous findings, the results showed an age-related increase in analytic responding on the CRT, and a decrease in intuitive responding. Crucially, the proportion of both intuitive and analytic responses across autistic and neurotypical participants was identical in both age groups. The current results are in contrast with claims that autistic individuals have an increased tendency toward an analytic/rational type of processing, which is commonly attributed to an impairment within their intuitive reasoning mechanisms.

Emotional Dysfunction and Interoceptive Challenges in Adults with Autism Spectrum Disorders

People with autism spectrum disorder (ASD) frequently show impaired sensory processing in different senses, including the interoceptive system. Recent findings suggest that interoception is a fundamental component of emotional experience and that impaired interoception is associated with alexithymia. This study aims to explore the association and interrelation between interoceptive confusion, alexithymia, and the capacity for emotional regulation among a sample of 33 adults with ASD compared to a control group of 35 adults with neurotypical development and its mutual impact. The participants answered a series of questionnaires addressing these three variables. The results showed (1) significant differences between the groups in all dimensions, with dysfunctional emotional regulation, impaired interoception, and alexithymia in the ASD group, (2) significant correlations between interoceptive confusion, emotional clarity, and alexithymia in the ASD group but only positive correlations between interoceptive confusion and alexithymia in the CG, and (3) that emotional clarity, alexithymia, and autism explain 61% of the variance in interoceptive confusion. These results are in line with previous studies and suggest that training interoceptive ability may enhance emotional clarity and reduce alexithymia among those diagnosed with ASD, with significant implications in the planning of treatment.

Relationships between alexithymia, interoception, and emotional empathy in autism spectrum disorder

LAY ABSTRACT

Empathy, the ability to understand and share the emotions of others, is a necessary skill for social functioning and can be categorized into cognitive and emotional empathy. There is evidence to suggest that individuals with autism spectrum disorder have difficulties with cognitive empathy, the ability to imagine how another person is thinking or feeling. However, it is unclear if individuals with autism spectrum disorder struggle with emotional empathy, the ability to share and feel emotions others are experiencing. Self-report and interview data were collected to explore the relationships between interoception (individuals' self-reported awareness of sensation from their body such as thirst, heartbeat, etc.), alexithymia (an individual's ability to describe and distinguish between their own emotions), and emotional empathy in 35 youth with autism spectrum disorder and 40 typically developing youth. Greater personal distress to others' emotions and greater difficulty describing and recognizing self-emotions were associated with reporting fewer physical sensations in the body when experiencing emotion in the autism spectrum disorder group. The results of this study suggest that while autism spectrum disorder youth with concomitant alexithymia may experience emotional empathy differently, it should not be characterized as an absence of a capacity for emotional empathy.

Characterizing Interoceptive Differences in Autism: A Systematic Review and Meta-analysis of Case-control Studies

Interoception, the body's perception of its own internal states, is thought to be altered in autism, though results of empirical studies have been inconsistent. The current study systematically reviewed and meta-analyzed the extant literature comparing interoceptive outcomes between autistic (AUT) and neurotypical (NT) individuals, determining which domains of interoception demonstrate robust between-group differences. A three-level Bayesian meta-analysis compared heartbeat counting performance, heartbeat discrimination performance, heartbeat counting confidence ratings, and self-reported interoceptive attention between AUT and NT groups (15 studies; n_AUT = 467, n_NT = 478). Autistic participants showed significantly reduced heartbeat counting performance [g = - 0.333, CrI_95% (- 0.535, - 0.138)] and higher confidence in their heartbeat counting abilities [g = 0.430, CrI_95% (0.123, 0.750)], but groups were equivalent on other meta-analyzed outcomes. Implications for future interoception research in autism are discussed.

Decision-making in autism: A narrative review

LAY SUMMARY

Many autistic people report difficulties with real-life decision-making. However, when doing decision-making tests in laboratory experiments, autistic people often perform as well or better than non-autistic people. We review previously published studies on autistic people's decision-making, across different types of tests, to understand what type of decision-making is more challenging. To do this, we searched four databases of research papers. We found 104 studies that tested, in total, 2712 autistic and 3189 comparison participants on different decision-making tasks. We found that there were four categories of decision-making tests that were used in these experiments: perceptual (e.g. deciding which image has the most dots); reward learning (e.g. learning which deck of cards gives the best reward); metacognition (e.g. knowing how well you perform or what you want); and value-based (e.g. making a decision based on a choice between two outcomes that differ in value to you). Overall, these studies suggest that autistic and comparison participants tend to perform similarly well at perceptual and reward-learning decisions. However, autistic participants tended to decide differently from comparison participants on metacognition and value-based paradigms. This suggests that autistic people might differ from typically developing controls in how they evaluate their own performance and in how they make decisions based on weighing up the subjective value of two different options. We suggest these reflect more general differences in metacognition, thinking about thinking, in autism.

The relationship between alexithymia, interoception, and neural functional connectivity during facial expression processing in autism spectrum disorder

Neural processing differences of emotional facial expressions, while common in autism spectrum disorder (ASD), may be related to co-occurring alexithymia and interoceptive processing differences rather than autism per se. Here, we investigate relationships between alexithymia, interoceptive awareness of emotions, and functional connectivity during observation of facial expressions in youth (aged 8-17) with ASD (n = 28) compared to typically developing peers (TD; n = 37). Behaviorally, we found no significant differences between ASD and TD groups in interoceptive awareness of emotions, though alexithymia severity was significantly higher in the ASD group. In the ASD group, increased alexithymia was significantly correlated with lower interoceptive sensation felt during emotion. Using psycho-physiological interaction (PPI) analysis, the ASD group showed higher functional connectivity between the left ventral anterior insula and the left lateral prefrontal cortex than the TD group when viewing facial expressions. Further, alexithymia was associated with reduced left anterior insula-right precuneus connectivity and reduced right dorsal anterior insula-left ventral anterior insula connectivity when viewing facial expressions. In the ASD group, the degree of interoceptive sensation felt during emotion was positively correlated with left ventral anterior insula-right IFG connectivity when viewing facial expressions. However, across all participants, neither alexithymia nor interoceptive awareness of emotions predicted connectivity between emotion-related brain regions when viewing emotional facial expressions. To summarize, we found that in ASD compared to TD: 1) there is stronger connectivity between the insula and lateral prefrontal cortex; and 2) differences in interhemispheric and within left hemisphere connectivity between the insula and other emotion-related brain regions are related to individual differences in interoceptive processing and alexithymia. These results highlight complex relationships between alexithymia, interoception, and brain processing in ASD.

Emotional regulation deficits in autism spectrum disorder: The role of alexithymia and interoception

The aim of this study was to analyze emotional regulation, alexithymia and interoception in a group of people diagnosed with ASD (n = 27), a normative population with a technical academic training (n = 30), and another group with a humanities/health training (n = 20). Results showed significantly higher scores in alexithymia and emotional regulation problems, and lower scores in interoception in the ASD group. Also, alexithymia was found to correlate with emotional regulation, which was found to be significant in all three groups. In addition, interoception correlated negatively with alexithymia in the ASD group. Finally, the scores of the group with the technical training were closer to those of the ASD group compared to the humanities/health group.

Interoceptive accuracy correlates with precision of time perception in the millisecond range

It has been proposed that accuracy in time perception is related to interoceptive accuracy and vagal activity. However, studies investigating time perception in the supra-second range have provided mixed results, and few studies have investigated the sub-second range. Moreover, there is a lack of studies investigating the relationship between precision in time perception and interoceptive accuracy. A recent meta-analytic review of neuroimaging studies proposed a dynamic interaction between two types of timing processing-an endogenous time keeping mechanism and the use of exogenous temporal cues. Interoceptive accuracy may affect both accuracy and precision of primary temporal representations, as they are generated based on the endogenous time keeping mechanism. Temporal accuracy may vary when adapted to the environmental context. In contrast, temporal precision contains some constant noise, which may maintain the relationship with interoceptive accuracy. Based on these assumptions, we hypothesized that interoceptive accuracy would be associated with temporal precision in the sub-second range, while vagal activity would be associated with temporal accuracy. We used the temporal generalization task, which allowed us to calculate the indices of temporal accuracy and temporal precision in line with the existing research, and also compute the index of participants' sensitivity according to the signal detection theory. Specifically, we investigated whether (1) interoceptive accuracy would correlate with temporal accuracy, temporal precision, or sensitivity and (2) resting-state vagal activity would correlate with temporal accuracy, temporal precision, or sensitivity. The results indicated that interoceptive accuracy was positively correlated with temporal precision as well as sensitivity, but not with temporal accuracy, in the sub-second range time perception. Vagal activity was negatively correlated only with sensitivity. Furthermore, we found a moderation effect of sensitivity on the relationship between vagal activity and perceived duration, which affected the association between vagal activity and temporal accuracy. These findings suggest the importance of precision as an aspect of time perception, which future studies should further explore in relation to interoception and vagal activity, and of the moderation effects of factors such as participants' sensitivity in this context.

A capabilities approach to understanding and supporting autistic adulthood

There is little comprehensive research into autistic adulthood, and even less into the services and supports that are most likely to foster flourishing adult autistic lives. This limited research is partly because autism is largely conceived as a condition of childhood, but this focus of research has also resulted from the orthodox scientific approach to autism, which conceptualizes autistic experience almost entirely as a series of biologically derived functional deficits. Approaching autism in this way severely limits what is known about this neurodevelopmental difference, how research is conducted and the services and supports available. In this Review, we adopt an alternative research strategy: we apply Martha Nussbaum's capabilities approach, which focuses on ten core elements of a thriving human life, to research on autistic adulthood. In doing so, we identify areas where autistic adults thrive and where they often struggle, and highlight issues to which researchers, clinicians and policymakers should respond. The resulting picture is far more complex than conventional accounts of autism imply. It also reveals the importance of engaging autistic adults directly in the research process to make progress towards genuinely knowing autism and supporting flourishing autistic lives.

Ongoing pain facilitates emotional decision-making behaviors

Emotion toward anticipated and actual outcomes acts as a vital signal on emotional decision-making, and the Iowa Gambling Task (IGT) can mimic this decision-making process. Pain can impair emotional decision-making behaviors because it captures attention and distracts from the task at hand. Alternatively, pain may facilitate emotional decision-making behaviors by prompting alertness and mobilizing cognitive resources to maximize rewards. The present study investigated the influence of ongoing pain on emotional decision-making behaviors using the IGT. Our study recruited two groups of participants and applied capsaicin (pain group) or control cream (control group) to their forearms. We then compared performances and selections between the pain and control groups. The results revealed that participants successfully learned the required adaptive selection strategy as the task progressed. The study observed a tendency toward optimal choices for both groups under the condition of frequent–small losses. However, we observed a disadvantageous preference for the control group, but not the pain group, when faced with choices with infrequent but large losses. The study implies that a distressing pain experience motivates individuals to adjust goal-directed behaviors to maximize their rewards in a task. Thus, the finding suggests that ongoing pain facilitates emotional decision-making behaviors.

A network analysis of interoception, self-awareness, empathy, alexithymia, and autistic traits

Altered interoception has been consistently found in people with autism spectrum disorder (ASD), and this impairment may contribute to social cognitive dysfunctions. However, little is known regarding the intercorrelations between interoceptive sensibility, autistic, alexithymic, empathic, and self-related traits. We recruited 1360 non-clinical college students and adults to investigate the complex inter-relationship between these variables using network analysis. The resultant network revealed patterns connecting autistic traits to interoceptive sensibility, empathy, alexithymia, and self-awareness, with reasonable stability and test-retest consistency. The node of alexithymia exhibited the highest centrality and expected influence. As revealed by the network comparison test, networks constructed in high- and low-autistic subgroups were comparable in global strength and structure. Our findings suggested that alexithymia serves as an important node, bridging interoceptive deficits, self-awareness, and empathic impairments of autism spectrum disorder. The co-morbidity of alexithymia should be considered carefully in future studies of interoceptive impairments and social deficits in ASD.

Intergroup bias in punishing behaviors of adults with autism spectrum disorder

Groups are essential elements of society, and humans, by nature, commonly manifest intergroup bias (i.e., behave more positively toward an ingroup member than toward an outgroup member). Despite the growing evidence of various types of altered decision-making in individuals with autism spectrum disorder (ASD), their behavior under the situation involving group membership remains largely unexplored. By modifying a third-party punishment paradigm, we investigated intergroup bias in individuals with ASD and typical development (TD). In our experiment, participants who were considered as the third party observed a dictator game wherein proposers could decide how to distribute a provided amount of money while receivers could only accept unconditionally. Participants were confronted with two different group situations: the proposer was an ingroup member and the recipient was an outgroup member (IN/OUT condition) or the proposer was an outgroup member and the recipient was an ingroup member (OUT/IN condition). Participants with TD punished proposers more severely when violating social norms in the OUT/IN condition than in IN/OUT condition, indicating that their decisions were influenced by the intergroup context. This intergroup bias was attenuated in individuals with ASD. Our findings deepen the understanding of altered decision-making and socioeconomic behaviors in individuals with ASD.

Clarifying the relationship between alexithymia and subjective interoception

The long-standing hypothesis that emotions rely on bodily states is back in the spotlight. This has led some researchers to suggest that alexithymia, a personality construct characterized by altered emotional awareness, reflects a general deficit in interoception. However, tests of this hypothesis have relied on heterogeneous assessment methods, leading to inconsistent results. To shed some light on this issue, we administered a battery of self-report questionnaires of interoception and alexithymia to three samples from Italy, the U.S., and Singapore (N = 814). Correlation and machine learning analyses showed that alexithymia was associated with deficits in both subjective interoceptive accuracy and attention. Alexithymics' interoceptive deficits were primarily related to difficulty identifying and describing feelings. Interoception showed a weaker association with externally-oriented thinking as operationalized by the Toronto Alexithymia Scale (TAS-20) and no association with the affective dimension of alexithymia later introduced by the Bermond-Vorst Alexithymia Questionnaire (BVAQ). We discuss our results with reference to the theoretical and psychometric differences between these two measures of alexithymia and their shortcomings. Overall, our results support the view that interoceptive deficits are a core component of alexithymia, although the latter cannot be reduced to the former.

Paradoxical somatic information processing for interoception and anxiety in alexithymia

The concept of alexithymia has garnered much attention in an attempt to understand the psychological mechanisms underlying the experience of feeling an emotion. In this study, we aimed to understand how the interoceptive processing in an emotional context relates to problems of alexithymia in recognizing self‐emotions. Therefore, we prepared experimental conditions to induce emotional awareness based on interoceptive information. As such, we asked participants to be aware of interoception under an anxiety‐generating situation anticipating pain, having them evaluate their subjective anxiety levels in this context. High alexithymia participants showed attenuated functional connectivity within their ‘interoception network’, particularly between the insula and the somatosensory areas when they focused on interoception. In contrast, they had enhanced functional connectivity between these regions when they focused on their anxiety about pain. Although access to somatic information is supposed to be more strongly activated while attending to interoception in the context of primary sensory processing, high alexithymia individuals were biased as this process was activated when they felt emotions, suggesting they recognize primitive and unprocessed bodily sensations as emotions. The paradoxical somatic information processing may reflect their brain function pathology for feeling emotions and their difficulty with context‐dependent emotional control.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

A review of executive functioning challenges and strengths in autistic adults

Objective: There has been a steady rise in research characterizing executive functioning (EF) impairments in autistic individuals but limited research investigating EF strengths. This review provides a summary of current EF research in autistic adults with a focus on EF challenges and strengths and potential sources of heterogeneity in research findings. New avenues for addressing gaps in our understanding of EF strengths are proposed.Method: A review of the EF literature was conducted. One hundred twenty-four studies of inhibition, working memory, cognitive flexibility, fluency, planning, decision-making, and subjective measures of EF in autistic adults were included.Results: Autistic adults with average intellectual functioning demonstrate difficulties with cognitive flexibility, phonemic fluency, and working memory. Strengths in planning, decision-making, and semantic verbal fluency were evident in some but not all studies. Findings regarding inhibition are inconclusive. Key findings across each EF domain are discussed and sources of potential heterogeneity across studies were evaluated. The type of measure used appears to contribute to heterogeneous findings. Subjective EF measures revealed more consistent findings of deficits in autistic adults than objective EF measures.Conclusions: Research reveals areas of EF weaknesses as well as strengths in autistic adults. Unlike EF challenges, EF strengths are not well understood. Future research identifying EF strengths is needed to improve services and supports for autistic adults. Further investigation of potential factors that interact with or constrain EF such as comorbid disorders, verbal ability, sensory processing, and other factors specific to autism will be critical to move the field forward and increase understanding of how EF is related to everyday functioning in autistic adults.

Enhanced rationality in autism spectrum disorder

Challenges in social cognition and communication are core characteristics of autism spectrum disorder (ASD), but in some domains, individuals with ASD may display typical abilities and even outperform their neurotypical counterparts. These enhanced abilities are notable in the domains of reasoning, judgment and decision-making, in which individuals with ASD often show 'enhanced rationality' by exhibiting more rational and bias-free decision-making than do neurotypical individuals. We review evidence for enhanced rationality in ASD, how it relates to theoretical frameworks of information processing in ASD, its implications for basic research about human irrationality, and what it may mean for the ASD community.

Disentangling interoceptive abilities in alexithymia

In recent years, research on interoceptive abilities (i.e., sensibility, accuracy, and awareness) and their associations with emotional experience has flourished. Yet interoceptive abilities in alexithymia—a personality trait characterized by a difficulty in the cognitive interpretation of emotional arousal, which impacts emotional experience—remain under-investigated, thereby limiting a full understanding of subjective emotional experience processing. Research has proposed two contrasting explanations thus far: in one model, the dimensions of interoceptive sensibility and accuracy in alexithymia would increase; in the other model, they would decrease. Surprisingly, the contribution of interoceptive awareness has been minimally researched. In this study (N = 182), the relationship between participants’ level of alexithymia and the three interoceptive dimensions was tested. Our results show that the higher the level of alexithymia is, the higher interoceptive accuracy and sensibility (R² = 0.29 and R² = 0.14); conversely, the higher the level of alexithymia is, the lower interoceptive awareness (R² = 0.36). Moreover, an ROC analysis reveals that interoceptive awareness is the most accurate predictor of alexithymia, yielding over 92% accuracy. Collectively, these results support a coherent understanding of interoceptive abilities in alexithymia, whereby the dissociation of interoceptive accuracy and awareness may explain the underlying psycho-physiological mechanisms of alexithymia. A possible neurocognitive mechanism is discussed which suggests insurgence of psychosomatic disorders in alexithymia and related psychotherapeutic approaches.

Transdiagnostic Predictors of Impaired Recognition of Facial Emotion Expression in Adults with Autism Spectrum Disorder and Intellectual Disability

This study aims to evaluate the predictive capacity of executive dysfunction and social adaptation in performance in facial emotion recognition. The sample consisted of 31 adults with Intellectual Disabilities (ID) and Autism Spectrum Disorder (ASD). The variables that maintain significant correlations with emotional perception were taken as independent variables. Multiple regression analysis was used to identify the predictors of the facial stimuli perception in population with ASD. The results demonstrated a relationship between social maturity and emotional perception. Better scores in communication, socialization and daily life skills predict better performance in the perception of facial stimuli, both emotional and non-emotional.

The effect of autism on information sampling during decision-making: An eye-tracking study

Recent research has highlighted a tendency for more rational and deliberative decision-making in individuals with autism. We tested this hypothesis by using eye-tracking to investigate the information processing strategies that underpin multi-attribute choice in a sample of adults diagnosed with autism spectrum condition. We found that, as the number of attributes defining each option increased, autistic decision-makers were speedier, examined less of the available information, and spent a greater proportion of their time examining the option they eventually chose. Rather than indicating a more deliberative style, our results are consistent with a tendency for individuals with autism to narrow down the decision-space more quickly than does the neurotypical population.

Knowledge Gaps in Mobile Health Research for Promoting Physical Activity in Adults With Autism Spectrum Disorder

A growing body of research highlights that adults with autism spectrum disorder (ASD) have poor health outcomes, yet effective health interventions are lacking for this population. While mobile health applications demonstrate potential for promoting physical activity (PA) in adults with ASD, scientific evidence for supporting this tool’s long-term effectiveness on PA behavior change remains inconclusive. This study aimed to provide the latest information on PA research and the prospective role of mobile health applications for promoting PA in adults with ASD. A literature review demonstrated that a few available studies show contradictory results regarding PA levels in adults with ASD, and behavior change techniques and gamification-guided mobile health applications can be promising tactics to leverage autism’s strengths and increase PA in these individuals. Optimizing design decisions based on needs analysis and user feedback is crucial to identifying and developing a sustainable mobile health intervention for PA promotion in adults with ASD.

Interoceptive Awareness Is Negatively Related to the Exteroceptive Manipulation of Bodily Self-Location

The perception of being located within one's body (i.e., bodily self-location) is an essential feature of everyday self-experience. However, by manipulating exteroceptive input, healthy participants can easily be induced to perceive themselves as being spatially dislocated from their physical bodies. It has previously been suggested that interoception, i.e., the processing of inner physiological signals, contributes to the stability of body representations; however, this relationship has not previously been tested for different dimensions of interoception and bodily self-location. In the present study, using an advanced automatized setup, we systematically manipulated participants' perspective of their own body (first- vs third-person perspective) as well as the synchrony of visuotactile stimulation (synchronous vs asynchronous). The malleability of bodily self-location was assessed using a questionnaire targeting in-body and out-of-body experiences. Participants also performed a heartbeat discrimination task to assess their interoceptive accuracy (behavioral performance), interoceptive sensibility (confidence in their interoceptive abilities), and interoceptive awareness (meta-cognitive representation of interoceptive signals). Bodily self-location was significantly influenced by perspective, with third-person perspective being associated with stronger out-of-body experiences compared to first-person perspective. Furthermore, there was a significant perspective × stimulation interaction, with subsequent analyses showing that participants reported out-of-body experiences particularly under third-person perspective combined with synchronous visuotactile stimulation. Correlation and regression analyses revealed that meta-cognitive interoceptive awareness was specifically and negatively related to the exteroceptively mediated malleability of body experiences. These results indicate that the perception of the self being located within one's body relies on the interaction of exteroceptive input and higher-order interoceptive abilities. This has implications for theoretical considerations about the bodily self in health as well as for the understanding of disturbed bodily self-processing in clinical contexts.

Impact of past experiences on decision-making in autism spectrum disorder

People are often influenced by past costs in their current decision-making, thus succumbing to a well-known bias recognized as the sunk cost effect. A recent study showed that the sunk cost effect is attenuated in individuals with autism spectrum disorder (ASD). However, the study only addressed one situation of utilization decision by focusing on the choice between similar attractive alternatives with different levels of sunk costs. Thus, it remains unclear how individuals with ASD behave under sunk costs in different types of decision situations, particularly progress decisions, in which the decision-maker allocates additional resources to an initially chosen alternative. The sunk cost effect in progress decisions was estimated using an economic task designed to assess the effect of the past investments on current decision-making. Twenty-four individuals with ASD and 21 age-, sex-, smoking status-, education-, and intelligence quotient-level-matched typical development (TD) subjects were evaluated. The TD participants were more willing to make the second incremental investment if a previous investment was made, indicating that their decisions were influenced by sunk costs. However, unlike the TD group, the rates of investments were not significantly increased after prior investments in the ASD group. The results agree with the previous evidence of a reduced sensitivity to context stimuli in individuals with ASD and help us obtain a broader picture of the impact of sunk costs on their decision-making. Our findings will contribute to a better understanding of ASD and may be useful in addressing practical implications of their socioeconomic behavior.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

Jumping to conclusions in autism: integration of contextual information and confidence in decision-making processes

Individuals with Autism spectrum condition (ASC) present cognitive biases and a difficulty to integrate emotional responses in decision-making, which is necessary for adequate social functioning. Thus, understanding the underlying mechanisms of the altered decision-making in individuals with ASC may eventually have a positive impact on their social functioning. The Picture decision task was employed to observe the effect of new information (fragments of an incomplete picture), interpretative context (verbal cues), and the level of confidence on decision-making processes. Our study administered the task to 49 children with ASC and 37 children with Typical Development (TD). Children with TD showed a higher probability of success when an interpretative context was given. Conversely, children with ASC had an equal probability of success regardless of whether an interpretative context was provided or not. In addition, unlike children with TD, the level of confidence did not allow predicting the probability of successful decisions in children with ASC. Finally, children with ASC had more probability of jumping to conclusions, a decision made quickly with only one fragment of the picture while being completely sure of it. These results are discussed in light of current cognitive and emotional theories on ASC.

Non-Clinical Autistic Traits Correlate With Social and Ethical but Not With Financial and Recreational Risk-Taking

Previous research into uncertain and risky decision-making in autism spectrum disorder (ASD) has been inconclusive, with some studies reporting less uncertain and risky decisions by persons with ASD compared to neurotypicals, but other studies failing to find such effects. A possible explanation for these inconsistent findings is that aberrant decision-making in ASD is domain-specific, and only manifests itself in domains related to autism symptomatology. The present study examines this premise by correlating self-reported autistic traits to individuals' intention to engage in risky behaviours, their perception of how risky these behaviours are, and the amount of benefit they expect to obtain from engaging in them; all for five separate domains of decision-making: social, ethical, recreational, health/safety, and financial. In line with the hypotheses, persons with higher autistic traits reported reduced intention to engage in risky social behaviours and increased intention to engage in risky ethical behaviours. Furthermore, a positive correlation was found between autistic traits and risk perception in the social domain, indicating that persons with higher autistic traits perceive social behaviours as riskier than do persons with lower autistic traits. Correlations between autistic traits and individuals' intention to engage in risky recreational and financial behaviours were small, and supported the null hypothesis (as shown by Bayes Factors). Given that most studies on uncertain and risky decision-making take place in a financial context, the present results could explain previous inconsistent findings on decision-making in ASD. Therefore, future studies should also examine decision-making outside the financial realm.

Neural Correlates of Cardiac Interoceptive Focus Across Development: Implications for Social Symptoms in Autism Spectrum Disorder

Interoception involves the processing of sensory information relevant to physiological functioning and is integral to building self-awareness, emotional states, and modulating social behaviors. With the role of interoception in emotional processing and social functioning, there is growing interest in characterizing interoception in autism spectrum disorder (ASD), yet, there are mixed results regarding cardiac interoceptive accuracy in ASD. In this study, we explored the neural basis of cardiac interoception using an fMRI heartbeat-counting task in order to assess neural correlates of primary interoception. We predicted that interoceptive-specific response in the insula, a "hub" for interoception, would be related to ASD symptomatology. We investigated the relationship of insula responses during cardiac interoceptive focus and a self/caregiver-reported autism-related symptom scale (Social Responsiveness Scale-2 (SRS)). Participants included 46 individuals with autism spectrum disorder (ASD) (age 8-54, mean = 19.43 ± 10.68 years) and 54 individuals with typical development for comparison (TC, age 8-53, mean = 21.43 ± 10.41 years). We found no significant difference in cardiac interoceptive accuracy or neural response to cardiac interoception focus in ASD. Several insula subdivisions had a curvilinear relationship to age, peaking in early adulthood. Interoceptive-specific insula response was associated with adult self-report SRS scores; this association differed by diagnostic group and was not present for caregiver-reported scores. This work suggests that (a) there is no global deficit in cardiac interoception in ASD, but integrating interoceptive cues with social information may distinguish individuals with ASD, and (b) there is a developmental trajectory for interoceptive processing in the insula that may be relevant for socio-emotional health. Autism Res 2020, 13: 908-920. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We use internal sensory information from the body, such as signals from the heart, to understand our emotional response to the external world. We measured how accurately people with autism feel their heartbeat and how the brain responds to this type of information. We found no differences between the autism and comparison groups in how the brain senses heartbeats, or in how accurately people feel their heartbeats. However, for people with autism, brain responses while sensing heartbeats were related to social difficulties. This work suggests people with autism may use internal and external information in a different way.

Trait Autism is a Better Predictor of Empathy than Alexithymia

It has been proposed that atypical empathy in autism spectrum disorder (ASD) is due to co-occurring alexithymia. However, difficulties measuring empathy and statistical issues in previous research raise questions about the role of alexithymia in empathic processing in ASD. Addressing these issues, we compared the associations of trait alexithymia and autism with empathy in large samples from the general population. Multiple regression analyses showed that both trait autism and alexithymia were uniquely associated with atypical empathy, but dominance analysis found that trait autism, compared to alexithymia, was a more important predictor of atypical cognitive, affective, and overall empathy. Together, these findings indicate that atypical empathy in ASD is not simply due to co-occurring alexithymia.

Autistic traits influence the strategic diversity of information sampling: Insights from two-stage decision models

Information sampling can reduce uncertainty in future decisions but is often costly. To maximize reward, people need to balance sampling cost and information gain. Here we aimed to understand how autistic traits influence the optimality of information sampling and to identify the particularly affected cognitive processes. Healthy human adults with different levels of autistic traits performed a probabilistic inference task, where they could sequentially sample information to increase their likelihood of correct inference and may choose to stop at any moment. We manipulated the cost and evidence associated with each sample and compared participants’ performance to strategies that maximize expected gain. We found that participants were overall close to optimal but also showed autistic-trait-related differences. Participants with higher autistic traits had a higher efficiency of winning rewards when the sampling cost was zero but a lower efficiency when the cost was high and the evidence was more ambiguous. Computational modeling of participants’ sampling choices and decision times revealed a two-stage decision process, with the second stage being an optional second thought. Participants may consider cost in the first stage and evidence in the second stage, or in the reverse order. The probability of choosing to stop sampling at a specific stage increases with increasing cost or increasing evidence. Surprisingly, autistic traits did not influence the decision in either stage. However, participants with higher autistic traits inclined to consider cost first, while those with lower autistic traits considered cost or evidence first in a more balanced way. This would lead to the observed autistic-trait-related advantages or disadvantages in sampling optimality, depending on whether the optimal sampling strategy is determined only by cost or jointly by cost and evidence.

Children with autism can spend hours practicing lining up toys or learning all about cars or lighthouses. This kind of behaviors, we think, may reflect suboptimal information sampling strategies, that is, a failure to balance the gain of information with the cost (time, energy, or money) of information sampling. We hypothesized that suboptimal information sampling is a general characteristic of people with autism or high level of autistic traits. In our experiment, we tested how participants may adjust their sampling strategies with the change of sampling cost and information gain in the environment. Though all participants were healthy young adults who had similar IQs, higher autistic traits were associated with higher or lower efficiency of winning rewards under different conditions. Counterintuitively, participants with different levels of autistic traits did not differ in the general tendency of oversampling or undersampling, or in the decision they would reach when a specific set of sampling cost or information gain was considered. Instead, participants with higher autistic traits consistently considered sampling cost first and only weighed information gain during a second thought, while those with lower autistic traits had more diverse sampling strategies that consequently better balanced sampling cost and information gain.

Interoception is Impaired in Children, But Not Adults, with Autism Spectrum Disorder

Interoception (the ability to sense what’s going on inside one’s body) is considered integral to many higher-order cognitive processes. Some have speculated that impaired interoception may underpin some features of ASD. Yet, in Experiment 1, we found no evidence of a between-group difference in either cardiac or respiratory interoceptive accuracy among 21 adults with ASD and 21 matched controls. Bayesian analyses suggested the data strongly supported the null hypothesis. In Experiment 2, we measured cardiac interoceptive accuracy in 21 children with ASD and 21 matched controls. Here interoceptve accuracy was significantly diminished in the ASD group and was associated with a moderate-to-large effect size. Results suggest early interoception difficulties are resolved or compensated for by adulthood in people with ASD.

Compensatory strategies below the behavioural surface in autism: a qualitative study

BACKGROUND

Little is known about the compensatory profile in autism; that is, people with autism spectrum disorder who show few symptoms in their behavioural presentation, despite continuing to report autism-related cognitive difficulties or differences. Even less is known about the specific compensatory strategies that these individuals use to disguise autism at the behavioural surface, both in the clinic and everyday life. It is also currently unclear whether individuals without a formal autism diagnosis, but experiencing autistic-like difficulties, use similar compensatory strategies, potentially enabling them to sit below the diagnostic threshold. This study aimed to investigate social compensatory strategies, and their effect on diagnosis and clinical outcome, in adults with and without autism.

METHODS

In this study, individuals aged 18 years or older who responded to a study advert that was distributed worldwide via social media and the UK National Autistic Society formed a convenience sample. Participants self-reported their use and experiences of compensatory strategies using an online platform. Novel analyses, including a qualitative thematic approach, were used to interpret their responses and gain insight into compensatory strategies in autism.

FINDINGS

Between Oct 19, 2017, and Jan 2, 2018, 136 adults (58 had a clinical diagnosis of autism, 19 self-identified but were not formally diagnosed as autistic, and 59 were not diagnosed or self-identified, but nevertheless reported social difficulties) completed the online study questions. The findings suggested that there are multiple compensatory strategies with distinct characteristics, individual and environmental factors that modulate compensatory strategy use and success, positive (social relationships, independence, employment) and negative (poor mental health, late diagnosis) outcomes associated with compensatory strategy use, and that individuals without a diagnosis use compensatory strategies that are qualitatively similar to individuals with a diagnosis.

INTERPRETATION

Increased awareness and measurement of compensatory strategy use in autism should guide future diagnostic guidelines, towards improved diagnostic accuracy and support for people with autism spectrum disorder whose cognitive difficulties are not immediately evident in observable behaviour.

FUNDING

UK Medical Research Council and UK National Institute for Health Research.

The Feeling of Me Feeling for You: Interoception, Alexithymia and Empathy in Autism

Following recent evidence for a link between interoception, emotion and empathy, we investigated relationships between these factors in autism spectrum disorder (ASD). 26 adults with ASD and 26 healthy participants completed tasks measuring interoception, alexithymia and empathy. ASD participants with alexithymia demonstrated lower cognitive and affective empathy than ASD participants without alexithymia. ASD participants showed reduced interoceptive sensitivity (IS), and also reduced interoceptive awareness (IA). IA was correlated with empathy and alexithymia, but IS was related to neither. Alexithymia fulfilled a mediating role between IA and empathy. Our findings are suggestive of an alexithymic subgroup in ASD, with distinct interoceptive processing abilities, and have implications for diagnosis and interventions.

5-HTTLPR and COMT Val158Met are not associated with alexithymia: New evidence and meta-analyses

BACKGROUNDS

Alexithymia refers to the difficulties in identifying and describing one's own emotions, lacking of imagination, and an externally oriented thinking style. Studies up to date have examined the associations of 5-HTTLPR and COMT Val158Met polymorphisms with alexithymia. However, the previous findings were mixed.

METHODS

We replicated the associations by scoring on alexithymia with the 20-item Toronto Alexithymia Scale and genotyping the polymorphisms of 5-HTTLPR and COMT Val158Met in a large population of college students (N = 1698). Moreover, we also meta-analyzed the associations with five samples (N = 7517) for the 5-HTTLPR and with five samples (N = 2186) for the COMT Val158Met.

RESULTS

Neither the replicated study nor the meta-analyses indicated the 5-HTTLPR and COMT Val158Met were associated with alexithymia.

CONCLUSIONS

The findings suggest that the 5-HTTLPR and COMT Val158Met polymorphisms are not associated with alexithymia. However, genetic-environmental studies with different ethnicity and psychopathology should be carried in future.

A 'choice', an 'addiction', a way 'out of the lost': exploring self-injury in autistic people without intellectual disability

Background

Non-suicidal self-injury (NSSI) describes a phenomenon where individuals inflict deliberate pain and tissue damage to their bodies. Self-injurious behaviour is especially prevalent across the autism spectrum, but little is understood about the features and functions of self-injury for autistic individuals without intellectual disability, or about the risk factors that might be valuable for clinical usage in this group.

Methods

One hundred and three autistic adults who responded to an online advertisement were classified as current, historic or non-self-harmers in accordance with responses to the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT). Multinomial regression aimed to predict categorisation of participants in accordance with scores on tests of autistic traits, alexithymia, depression, anxiety, mentalising and sensory sensitivity. Linear regression examined relationships between these predictors and the range, frequency, lifetime occurrence and functional purposes of NSSI. Qualitative analysis explored the therapeutic interventions that participants had found helpful, and what they wished people understood about self-injury.

Results

Current, historic and non-self-harming participants did not differ in age, age at diagnosis, male-to-female ratio, level of employment or education (the majority qualified to at least degree level). The most common function of NSSI was the regulation of low-energy affective states (depression, dissociation), followed by the regulation of high-energy states such as anger and anxiety. Alexithymia significantly predicted the categorisation of participants as current, historic or non-self-harmers, and predicted use of NSSI for regulating high-energy states and communicating distress to others. Depression, anxiety and sensory-sensitivity also differentiated participant groups, and sensory differences also predicted the range of bodily areas targeted, lifetime incidence and frequency of NSSI. Sensory differences, difficulty expressing and identifying emotions also emerged as problematic in the qualitative analysis, where participants expressed the need for compassion, patience, non-judgement and the need to recognise diversity between self-harmers, with some participants perceiving NSSI as a practical, non-problematic coping strategy.

Conclusions

Alexithymia, depression, anxiety and sensory differences may place some autistic individuals at especial risk of self-injury. Investigating the involvement of these variables and their utility for identification and treatment is of high importance, and the voices of participants offer guidance to practitioners confronted with NSSI in their autistic clients.