Adam Lanza a paranoid gunman, the tip of the iceberg.

II

The overpowering global triumph of DSM psychiatry, perhaps the main church of that religion called scientifism, is not based on its success in treating major mental illnesses, rather it is based on diagnosing more and more “disorders” and signing more and more prescriptions,  providing corporate and political complicities, legal addictions, excuses for uninterested or  poorly trained teachers and alibis, relief or hopes for uncommitted  or worn out parents in communities, with weakening bonds and values, which before provided them.

Practically anybody can use the DSM although only its highest priests can define or measure dogmas. Only they can classify, that the most metaphysical task of the discipline, and recycle ordinary adjectives into new diseases.

Critics underestimate grossly the power behind this global development. To start with, at a practical level, why take a critical position however balanced, and risk promotion, earn less money, lose friends or associates, have your stroppy kid excluded from school or your demanding mother from the day centre? 

Ongoing evaluations but with the clinician alert to the need of active intervention, and work outside the office are not efficient. Gone seem the times of hierarchical diagnosis when if a new disturbance appeared, it could be interpreted in terms of the evolution of the main one and the changing circumstances of the patient. Depression or anguish cannot any longer be considered as possible reflections of the gaining of insight by a patient and hence rather tricky propositions. They are just co-morbid disorders like any other.

Information about the possession of assault weapons might not be part of assessments. Excluding clauses are ignored. If you give various diagnostics surely one of them will be right and treatable. Given the contradictory properties of some of the “meds” prescribed, one is left wondering if some patients have more than one head.

World Health Organization studies that found that the long term outcomes of schizophrenia are better in the developing World, seem to be ignored by planners, researchers or trainers. There is no encouragement to observe and describe or to look at contexts and interpret; if one uses the right kit and tics the right box one gets the wanted answer. Egos and records are involved in this too. Some doctor in Florida, I read, prescribed over a million dollars of one neuroleptic alone over just a year. Added value is in numbers.

If tools such as PANSS or BPRS fail to demonstrate significant improvements in a majority of long term treated patients with psychosis, why bother with them?  The translation of psycho-pharmacological, brain imaging and genetic data into DSM categories has been as interesting as flat beer. So what? A bigger, DSM enlightened psycho-industry, that is the answer, an answer not that different from that of Mc Donald, Coca Cola or… mortgages even if they are sub-prime.  

 Am I am getting a bit paranoid myself?

No. I just think that the paranoid one was Adam Lanza, it does not matter which sub-category of the DSM or outside it.  His executive function, something deficient in autistic individuals, was in excellent shape. But, how is a professional to be so foolish as to diagnose a “folie a deux “or “a plusieurs” and get only a reimbursement, when you can diagnose one by one of the “plusieurs” and get many. Except that you cannot get to them, this is why they are paranoiacs.  Hence you end up with media diagnostics of “asperger”, “a little autistic” etc and neglecting the only real and dangerous epidemic in the USA which is that of paranoia.

Autism, that is Kanner’s autism, is not a mental illness but a grave neuropsychological deficiency which in the context of normal environments and without appropriate supports becomes a disability, frequently a very severe one.  And it is my opinion that people with autism and their families do not need more political correctness and surrealist denials or media circuses and stigma but the psychosocial equivalent to the ramps and wheelchairs that paraplegics use, that is: decent medical care, adapted educational and occupational environments, facilitated access and specific supports.

I will leave you with these considerations.

Spinoff.

Adam Lanza a paranoid gunman made into a monster. 

I

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.