viernes, 28 de diciembre de 2012

Adam Lanza a paranoid gunman made into a monster. 
It might be thought that the statement above is excessive but I feel under attack. The damage done to our children, and I here speak as the father of an autistic youngster, cannot be measured but it could be substantial:  one way or another that diagnosis, “Asperger” or “somewhat autistic” has reached neighbors, teachers, local politicians etc, all over the World and the stigma thus generated could be ammunition against us in the uphill struggle which fills our daily lives, in a context of lack of tolerance and resources.
I happen to be too a retired psychiatrist and I have been disappointed with the shallowness of the response by the “mental health” establishment. A galactic increase in the number of diagnosed disorders and prescription of psychotropic drugs seems to have been accompanied by a steady deterioration in the identification, understanding and management of the challenges that psychiatry faced 40 or 50 years ago: major mental illness, grave intellectual deficiency and sociopathy. The adoption of a politically correct language and obscure mathematical exercises cannot hide these failures, on the contrary they add to the prevailing conceptual confusion. This, I think, is manifested as one of the central aspects of the Newtown tragedy.
Let me try then to bring together the facts as I am able to access them from this rustic land, far away from the scene, with what I know about autism and psychiatry:
1-      Autism, that is Kanners autism, low or high functioning, is characterized by a marked interest in physical details and gadgets and, with the high functioning,  a good ability to learn mechanically, but  also by severe deficiencies in the understanding of meanings and contexts and in acting autonomously, improvising as necessary, to reach pragmatic ends. Even the highest functioning cannot understand that you have to pass the ball and run into space. Autistic persons do not like novelty and prefer routines. Adam Lanza carried out a whole plan, which was by any account a grand and bloody departure from routine, and seemed to do so alone, from beginning to end.

2-     His savagery can be defined as murder suicide” and “predatory”. Many children with autism have “autistic irritability” and adults can show challenging or excluding behaviors, euphemisms which include pulling hair, slapping, pushing etc, and very rarely serious forms of aggression. But these are reactive behaviors, and there is not any evidence whatsoever that any person with autism has ever undertaken actions of planned, predatory violence or murder-suicide. When murder suicide occurs in families of autistic individuals, this is perpetrated by parents, seemingly forlorn, exhausted, aging, who cannot bring themselves to leave their child in the hands of soulless institutions. It is a form of what used to be called “altruistic murder”. And an association between suicidal thoughts and behavior and autism has not been clearly established but when it occurs, it could be related to bullying.  
In this context it must be remembered that Adam´s family seemed to be quite prosperous and lived in one of most affluent areas of the USA, hence of the World, and they should have been able to provide for specific resources to reduce the “irritability” and other problems related to his autism if that is what he had.

3-     Autistic children are not that good at “pretend play”, and that includes toy weapons, a fact that is connected to a number of deficiencies in social behavior. A photograph of Lanza shows him capable of pretend gestures and there are suggestions that he was playing a role in an “assault”.

4-      Deficiencies of a “theory of mind” type have been recognized to be frequent in autistic individuals and this can be tested in Asperger syndrome, supposedly a mild form of autism. Adam Lanza not only killed his mother but smashed his hard disc so as not to leave information of any kind, hence making people wonder if others were involved. And cleverly did a sort of “Sally-Ann test” on the police by having his brother’s identification card on him and thus creating a false belief in the police and the public at large.  If Adam was “somewhat autistic”, the police need to look in the real world for his demoniacal accomplices. If he was a paranoid he did not need any. 

5-      From the descriptions of his school mates, his behavior could fit into the categories (DSM, ICD) of personality disorder relating to schizophrenia, for which those disorders can sometimes be precursors, as well if not better than into that of Asperger syndrome.  The insensitivity to pain they describe in Adam is doubtfully that seen in some autistic individuals in whom, besides, it is usually accompanied by a marked intolerance of loud, gun shot type noises. A mother of an autistic boy who attended one of his birthday parties, saw nothing autistic in him.  His own mother was said to be a “prepper” and had a small arsenal at home suggestive that at some point, there might have been a folie a deux, even a folie a plusieurs, with ideas of a paranoid, survivalist kind shared with other people.

The proposition that there was a co-morbid disorder (autism and schizophrenia) by either coincidence or some mysterious genetic link, is simply not acceptable. Or are the autistic characteristics cured with a bout of schizophrenia and affected people become thus able to imagine scenes, play roles and gain a “theory of mind”?. The psychosis that a few Asperger people might have in adolescence is doubtfully a schizophrenic one. It can be usually managed with environmental changes and support and if need be, short hospitalization and prudent use of medication. On the basis of the available information it must be concluded that Adam Lanza was not autistic.

The information on the tragedy is not very trustworthy and there are many issues that need clarification. My fear is that they will not be. Confidentiality here will be used not for the sake of the family, of that there has been none so far. But as they say, “shit sticks” and on this theme it does so on many vulnerable children and many people and their families. Therefore the diagnosis of Asperger or "somewhat autistic" should be clearly confirmed and explained by a clinical history or retracted and this done publically. Still, “with the DSM church have we collided, Sancho” as Don Quixote would say.

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