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Everyday Hyperopia

Hyperopia is a visual impairment and affects near vision. Some of you will have had the sensation of seeing blurred objects close to you. But when you try to look at a distance you manage to recover the quality of your vision.

The aim of this text is not to talk to you about visual acuity difficulties, but about some issues that sometimes seem to simulate this very issue - difficulty seeing at close range, metaphorically speaking. In other words, many of you will have already used the expression "the object you were looking for just needed to bite you", right? In other words, the person was really close to what they were looking for but they couldn't find it, and this is not justified by difficulties in vision. And this seems to happen even more when we are not talking about objects but about issues or concepts that are not tangible and many of them are complex and subjective. For example, how many of you have not been in a situation where you were feeling something from an emotional point of view and the person you were with seemed not to be identifying? People often complain about this in love relationships and other relationships. But that's not really what I want to talk to you about.

What I want to tell you is that this type of situation also happens a lot in clinical practice. In other words, this difficulty in being able to understand the diagnosis of the person we're evaluating. Mainly because human nature is quite complex, but also because there is a great overlapping of characteristics and behavioural traits that belong to different conditions. Furthermore, the existing diagnostic manuals (DSM and ICD) don't help either because they classify diagnoses as categories, when everyone is already aware that they are dimensions and are often dynamic. In other words, they change throughout the person's life. They also vary depending on the psychiatric comorbidity that is found.

And we have all heard that autistic people experience a great number of other psychiatric disorders throughout their lives. Besides, we know that there is a different behavioural expression of autism in men and women. And that there is what has been called social camouflage. Also, when we are talking about screening for Autism Spectrum Disorder in adults, this difficulty increases significantly. It is also difficult to have reliable information about the developmental aspects of the childhood period.

Be it Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Obsessive Compulsive Disorder, Social Anxiety Disorder, Generalised Anxiety Disorder, Mood Disorder, Bipolar Disorder, Borderline Personality Disorder, Schizotypal Personality Disorder or Psychosis. Many of these other diagnoses are present in a significant number of autistic people. Or there may be behavioural traits within what is the profile found in these same diagnoses. In other words, it is very possible that when we are in front of an autistic person, it may be more difficult for us, health professionals or others, to recognise the person and his/her behaviours when the person and his/her behaviours are so close to us. Certainly, some of us have different responsibilities, but we still have them.

It will certainly be easy to say that it is depression or anxiety because a whole set of signs and behaviours compatible with the diagnostic criteria present in the mentioned manual, either DSM 5 or ICD-11 are being verified. But is it only that? Most probably the answer is NO. It has long been verified that there is no such thing as a watertight, single and pure diagnosis. What we observe most of the time is a mixture of other behavioural traits and characteristics that are also observed in other diagnoses. And that, in addition, these same traits and characteristics share similar cognitive and neuronal processes. And that also because of this they show such a great similarity to each other at times. These are things that are explained differently according to the person's life story.

And that is also why more and more clinicians and researchers have called for the introduction of a transdiagnostic vision that is interconnected in clinical practice but also in research when we talk about RDoC (Research Domain Criteria).

Even because in autism we can see that the expression of depression or anxiety seems to have a different presentation when interconnected with the characteristics of the diagnosis of Autism Spectrum Disorder in the functioning profile of that specific person. It is not by chance that some doctors refer the existence of some resistance to a certain pharmacological intervention to reduce certain symptoms, although there are other reasons of neurophysiological order which justify it. And in what concerns the choice of the psychotherapeutic intervention which best fits the autistic person, also here caution is needed in the decision making process.

The intervention process and its choice cannot be solely and exclusively based on what is evidence-based intervention. That is, we know that behavioural and cognitive intervention is the one that is often seen as the intervention of choice because it has been researched and concluded to be the evidence-based intervention. But when we use such an intervention programme to work on the aspects of depression and/or anxiety in an autistic person, we find that we need to make certain adaptations, with the risk of not seeing a change in the person's clinical situation if we choose to rigidly use the programme in a standard way. And this is not surprising. Even because if we have an autistic person in follow-up, but the person presents an anxiety and mood disorder and an attention deficit characteristic, we cannot be applying a different programme for each of these issues. Besides, there is not a scientifically tested intervention programme that includes an adequate clinical response for all these situations mentioned here. This is why it is important to rethink the importance of a transdiagnostic model, both from a clinical point of view and also in scientific research. And there are already several clinicians within the behavioural and cognitive model who suggest that this model of conceptualisation may go towards transdiagnosis. And if we think that in the autistic spectrum, the regulation of emotional and behavioural aspects, as well as anxiety due to uncertainty, continue to be such impacting aspects in the life of the autistic person throughout life. It will be fundamental that intervention proposals can respond to these needs.

And not to forget that it is fundamental that all these reflections may focus on the assessment tools used and on the training of health professionals to be aware of this intersection of characteristics. Even because there has been a scarcity of guiding guides in the evaluation process in clinical situations where other psychiatric conditions are frequent. This fact leads to the fact that many professionals may not be sufficiently aware of the importance of the instruments to be used. And as for the others, whether they are professionals in the educational area or not, as well as common people, try to have more tolerance and understanding in what is already complex in its nature and not make judgements according to a difficulty in seeing things close to you, since the difficulty is yours and not the others'.

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