People
come to like their diagnoses, or at least to feel that they have explanatory
power for the dissatisfactions in their lives.
by Theodore Dalrymple
Diseases that have no objective
tests to distinguish them from normality have a tendency to spread like fungus:
for example, it is years since I heard anyone say that he was unhappy rather
than depressed, and it cannot be a coincidence that 10 percent of the
populations of most western countries are now taking antidepressants. Yet the
state of melancholia undoubtedly exists, as anyone who has seen a case will
attest.
Likewise with autism. I remember an
isolated, friendless and uncommunicative patient who tried to kill himself when
his landlord could no longer tolerate the collection of light bulbs that he had
collected since childhood, was constantly enlarging, and that now threatened to
fill the whole house. For the patient light bulbs were the meaning of life. It
was difficult to believe in such a case that there was not something
biologically wrong with the patient, even if one could find it.
An editorial in the New England
Journal of Medicine traces the convoluted history of the diagnosis of
autism and Asperger’s syndrome. The pediatricians Leo Kanner and Hans Asperger
described the conditions in 1943 and 1944, respectively.
Kanner thought that two features
were essential to autism, a psychological separation from the world manifest
very early in a child’s life and an obsessive desire to prevent change in the
person’s immediate surroundings. Kanner thought that such children had similar
parents, often of high intelligence but who were better and happier with ideas
than with human relationships. This gave rise later to the concept of the
“refrigerator mother,” that is to say a cold and uncommunicative woman who did
not cuddle her child or provide it with any emotional warmth, and whose conduct
caused the child, by a mechanism of defense, to withdraw into its own world.
This was also the era of the “schizophrenogenic” mother, the mother who
communicated two messages in one verbal utterance, leaving the child uncertain
as to what was meant.
These theories have now been
abandoned; they were not only wrong but cruel, for they blamed the mother for
the child’s devastating condition. Biology is back in fashion.
Since Kanner described 120 cases,
autism has increased enormously in prevalence. There is a lively and often
bitter controversy over whether this increase in prevalence reflects a real
increase – there really are more children with autism – or whether doctors are
more aware of autism as a diagnosis and are therefore simply making up for
missed diagnoses in the past.
There is another possibility: the
criteria for diagnosis have become much looser so that more children fulfil
them. The latest edition of the Diagnostic and Statistical Manual of the
American Psychiatric Association tries to narrow the criteria again, but
not everyone is pleased by this attempt. People with children previously
diagnosed as autistic are afraid that, if their children are dis-diagnosed, as
it were, they will lose their entitlement to medical or psychological
assistance. The children will no longer be deemed disabled, and there are
advantages to being officially recognized as such.
Asperger’s syndrome is eliminated
from the new Manual as a separate category and this will not please
everyone either. People come to like their diagnoses, or at least to feel that
they have explanatory power for the dissatisfactions in their lives. In some
cases a diagnosis even give meaning to those lives: they devote themselves to associations
that care for or (more usually) campaign politically for other people with the
diagnosis. If much of your life you have been told that you have a condition
which has become the focus of your existence, only to be told years later that
no such condition exists, you are bound to feel a sense of loss or even of
bereavement.
*****
Theodore
Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at
the Manhattan Institute. His new book is Second Opinion: A
Doctor's Notes from the Inner City.
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