Friday, April 15, 2011

Fear as the key etiological factor in Autism

In most cases of autism, that I have come across, there were extensive obsessive-compulsive disturbances in the mother. And whenever I got the opportunity to examine the father, which was not often, for most mothers were divorced or single, they were quite likely to be rigid and distant as well.
The most striking thing about the mothers was their lack of feel, or rather defective feel, for the child's correct needs. They were often grossly out of tune with the affective and cognitive world of the child. Their expectations not only were unrealistic but often bizarre, paradoxical and not synchronous with the child's developmental stage. In areas where the child could excel there was little interest and appreciation. In contrast, where the child was a laggard, and could not perform, there were unreasonable hopes and demands.
The following case whom I treated for about six months - the treatment came to an abrupt halt when one day the mother realized that the boy was getting emotionally attached to me and gaining strength from it would pose opposition to her dictatorial control - best exemplifies this type of oddity in mothers of autistic children.
He was 19-year-old autistic boy, an only child, completely dependent on her; as much as she was dependent upon him. It was not quite a case of folie a deux but close to it.
What piqued my special interest in him was his exceptional gift in drawing cartoons. He could draw a person in remarkable details and in no time. And he noticed everything about your facial features, every quirk and flaw. But, as if he paid a prize for such profound interest in the physiognomy, by not noticing much else about you, especially your emotional nuances. As if a disproportionate share of his cognitive abilities got concentrated upon noticing the physical aspects of your face and the physical contours of the body and so none of it was left for noticing other things about you. Or was it that he had been prohibited from noticing the emotional aspects of his mother and other people under fear of getting punished and so his interest in them had got shifted (displaced) on to just noticing the physical aspects of them? 
He showed me his portfolio of comic strips, the quality of which was professional. They were about a Japanese adolescent [his alterego, he was African-American], who lived in a magical world, abounded with goblins, ghouls, villains and pretty girls, where wizardry ruled the day. It. The theme was typical action adventure where the hero after meeting the usual life threatening obstacles (father substitutes) and witchcraft (mother's spell to hold him back from rising up in the world) would impress the heroine so much by these feats that she would fall head over heels fall in love with him. All the heroines were exquisitely beautiful and blond [his ego ideal]. They all dressed in overflowing and frilly dresses - compensation for their lack of penis - a sharp contrast to his mother's drab flat style that eschewed all adornments.
Now, amazingly, the mother frowned upon this great gift. She considered his passion for art an obsession that would deviate him from his true vocation which was to become a professor at the University of Michigan. And she was making active efforts in grooming him for that wonderful achievement. As to what kind of professor he would become at the university was of no concern. The subject in which he would specialize was of no consequence. What mattered was becoming a professor at the University at any cost. But one glance at the boy and you knew how grossly off target the mother was. The boy spoke like a computer. He could barely make himself understandable. There was something completely rigid and artificial about his speech. It lacked variations of tones, which rendered him unfit for delivering lectures. And in his choice of words he was so pedantic that he verged on incomprehensibility And as if this was not enough, he spoke in a pompous British accent, sometimes so inappropriately that it was obvious he would be laughed out of any lecture room.
Yet she was convinced that he had in him to become a professor, and one day demanded of me that I double his dose of Abilify, an antipsychotic, to achieve this aim.
When I enquired as for what the poor boy had done to deserve such a punishment, and how would a medication that straitjackets one would help him become a University of Michigan professor, she said that at his school - which was exclusively for developmentally disabled and autistic children- he had flown in a rage  and physically attacked his teacher. 
 I asked the boy the reason for the violence and he replied that they were discussing the issue of capital punishment and the very idea was so barbaric to him that anybody who even suggested that it had some  value deserved physical attack. [To understand the boy's pathological abhorrence for capital punishment I must mention that in his unconscious mind he harbored extensive death wishes against his mother, and as a consequence feared for his life for he believed that his thoughts were powerful enough to cause her death one of these day, and the punishment for it then would be his own death. He even heard voices urging him to kill her - projection of his wishes/thoughts from inside his head to the outside world - and strongly believed that if under the promptings of the voices if he does kill his mother it is the voices who should be hanged and not him. So behind the attack upon his teacher was his fear that if capital punishment becomes legal then one day he would be hanged, for it is only matter of time before he will cause the death of his mother, though in all fairness he should not be held guilty of it because it is not him but the voices that were wishing her death.]
When I asked the mother how doubling Ablify will help, since he is already on 30 mg., maximum FDA approved dosage of that medication, she said that she expects him to go to University of Michigan - he was 19 and had still not cleared high school - and behaviors such as physically attacking one's professors in a prestigious University like that would not be tolerated for a minute and as a psychiatrist I should know that Abilify controls aggression.
Now to the Biological Psychiatrists the mother's logic would have made perfect sense and in fact they might have made her an honorary member of the College of Neuropsychopharmacology for such profound  thinking, but to us, governed more by common sense than mutual back scratching, there is something not quite right about the way the child and the mother were using the language. The boy just on hearing the teacher say that capital punishment could have merit physically attacked the teacher. The teacher was just facilitating the topic and had nothing to do with the actual capital punishment with real criminals. But the language, or rather the words of the language, were not quite correctly connected to the underlying concepts which those words were conventionally suppose to capture. And they certainly were not connected to the right emotional nuances that had accompanied them when he had first heard them, while acquiring language in his formative year. So while the discussion on capital punishment would have provoked at worst a little horror and queasiness in a sensitive individual, in this boy it provoked outright violence - he attacked the messenger (teacher) instead of dealing with the message.
And this disturbance in language was present in mother as well. Ambition for her son was associated in her mind with his becoming professor at the University of Michigan. The word 'ambition' in a regular mind would be associated with studying hard, burning the midnight oil, getting good grades, applying to different universities, entrepreneurship  invention etc. But in her mind there was only one association: her son giving a lecture at the University of Michigan.  What entails in becoming a professor and what her son could realistically achieve were not associated with her conception of ambition.  The way the mother and son used words, rather language as a whole, did not make comprehending the world easier but more confusing. The language was more a means of obfuscation than enlightenment.
In fact in this mother-and-child-autistic-bond, all communications occurred in a cloistered fashion and in a verbose and schizotypal language. Additionally, to make things worse with language, the mother often dealt with the son by keeping "morally uplifting" books in her reach from which she would quote to win  arguments, which they were always having. Her conversation with him was littered with references to the exemplary and literary people from the past, and as to what they would have said about the matter under discussion. So instead of teaching the child using normal language, she dealt with him, rather dealt with her  aggressive impulses towards her by bringing impersonal language of the high class books. The language, the faculty of communicating through sound, was being used to create distance not closeness between them.
And taking the cue from the mother the boy had developed his own peculiar way of speaking. Since mother had the upper hand because of her age, greater experience, and the means to support them, the boy to counter her aggression had acquired the British accent  to match mother's pedantry and pomposity. The mother was so out of touch with the boy's real emotional needs that she had made no attempt to understand as to why the boy had abandoned his Detroit ghetto accent for an English Lord's. She had accepted it as a matter of course, and made it a point to tell me that his speaking like a cartoon character - for that perfect English accent in the boy from Detroit appeared cartoonish - did not bother her a bit. She was completely insensitive as to how such an accent had made him an object of ridicule with his peers. She had no curiosity as to its psychological origins and had made no attempt to stop it.
In the six months that I treated the boy and the mother - for she always barged in in the sessions, convinced that what she had to say about him was infinitely more important and meaningful than what he had to say about himself - it became apparent to me that behind the pomposity, peculiar language, and high-mindedness lay excessive fear of the world from which the two were escaping not only from each other but with the world as a whole too together by denying its fearfulness through a deviant use of language. 
Instead of becoming physically aggressive - though that would break through once in a while as it happened against the teacher who dared to talk about - that happens in a lot of people as an adaptation towards fear, they had become pompous and full of stilted words, by which they could look down upon those who they feared. The pompous and peculiar use of words had become a shield (defense) against the frightening world.
However pedantry alone could not allay the fear completely and sometimes one could hear the fear behind the stilted language. Adoption of the British accent was the next step in dealing with that anxiety. By imagining himself to be a pompous Englishman the boy was trying to convince to himself and others that he was way above fearing them. Occasionally the fear would break through the British accent as well and strike upon individual syllables. For example he had to drop the sound "r" in many words to avoid a panic attack. Rabbit had to be enunciated as "vabbit" to forestall panic.  On other hand he could say r in many other words such as road with no problem at all. While he could say the word "thumb" perfectly well he could not say 'thought' or 'think' and had to substitute 'fought' and 'fink' respectively. Interestingly the mother showed same kind of difficulty with the language though not in pronouncing words. She one day claimed that it is the astrologist who predicts the weather. It took me some time to figure out that what she meant was that it is the meteorologist who predicts the weather The distortion in language and use of words and even sounds of words at its very bottom was nothing but ways to deal with fear..
What lies behind this extreme fear? Deep down these mothers - at least a majority of them that I came across - have great ambivalence towards their autistic child. Hatred exists alongside love. And the fear arises as a means to check acting out their hatred with punitive aggression. The aggression is not completely eliminated by fear though. It finds outlets in distortion and in obsessive behaviors. Trying to control obsessive impulses - behind which lie hatred of the child - exhausts the mother and leaves little room for love and understanding to emerge in her interactions with the child.
What are the roots of this hatred? Is the hatred primary because the mother did not find herself equal to the task of being an ideal mother - obsessive people place high demands upon themselves to be perfect parent and many postpone or never get married fearful that they will be too inadequate/intolerant towards their children - from the beginning, or does it arise from the emotional exhaustion that occurs in a parent from taking care, day in and day out, of such a time consuming task as bringing up an autistic child.
There is no question that an autistic child is a burden for the parents. Here we are reminded of high prevalence of autism in children who are born to older parents - in the eve of their birthing years - and with less ability to be spontaneous and truly emotionally interactive with their children. Autism also occurs more frequently in higher socioeconomic strata. The same class which has least number of children. As if the person who has all his or her desires fulfilled easily has little motivation left to beget children, postponing it to the very end of his/her biological clock. The greatest motivation for having children is to see fulfillment of one's own thwarted ambitions; to vicariously achieve through them the successes that one could not in one's own life. Successful people have little motivation to enjoy life vicariously. Even when they have children they have greater ambivalence towards them for having to give up their own pleasures in order to take care of the little ones.
It is not that these parents do not have love for their children. In fact the love by noisy exaggeration hides the true state of affairs to even experienced clinicians. Their [unconscious] realization that they are out of sync with the emotional world of the child makes them try their utmost to obsessively search for some wonder drug or some fancy gluten free or manganese loaded diet or some other snake-oil to cure their child magically.
Sometimes they spend a fortune chasing the newest fad even going as far away as Afghanistan or Mongolia to prove to themselves and the world at large as to how much they care for their child.
And how does the fear manifest in autistic children? There is little doubt that autistic children are extremely sensitive to noise and other stimuli. They startle easily and overreact to any unusual or jarring stimuli. This appears to be a genetic endowment. An exaggerated inborn fear of the outside world. As Freud put it in his "Instincts and their vicissitudes": The relation of hate to objects is older than that of love. It is derived from the primal repudiation by the narcissistic ego of the external world whence flows the stream of stimuli. This fear provokes premature and strong aggressive drives in children genetically predisposed to autism and in pell-mell. Their love for complete order such as fascination with trains whose compartments follow in such a sequence, or fans that go in a completely predictable fashion appears to be a reaction to this emergence of their aggressive drives in such a helter-skelter fashion.
When this premature aggessive way of relating meets a stonewall, and little emotional acceptance for aggression on part of the mother who herself is struggling vainly with her aggressive/obsessive drives and wants everything perfect and in order, the child withdraws into his own autistic world, taking out the aggression on his own self and in internal secretions.

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