Articles for the Month of February 2014

Is Religion Good For You?

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There is some evidence for an association between religious practice and positive mental health in the Irish context.  In a study of mothers coping with a child or adolescent or indeed adult with autism Patricia Coulthard and myself found that carers who sought comfort in prayer had significantly better mental health than those who did not.  There are many forms of prayer, one type is petitionary prayer, but all have the acknowledgement of a supreme being in common. Therefore not only is the person praying physically carrying out an activity, praying, they are also in some sense handing the problem on, by deferring to a higher authority.  This may lessen feelings of guilt and responsibility. This change of attribution away from the self, combined with the physical activity of doing something may aid the carer to cope more adequately.

 

In the Irish context in this study carers reported significantly more support from their personal beliefs than from organised religion.  The formal churches to which they belonged did not help them to cope and were rarely there as a resource.

 

The various clergymen did not seem to know how to relate to a mother who suddenly has an autistic child diagnosed. The churches to which the participants in our study belonged did not have an outreach to these isolated families with a child with autism.  The clergy seemed to need to be educated on how to manage this crisis situation and as to the spiritual support they could give to these families with an autistic or disabled child.  This may be just the occasional visit to acknowledge the existence of the child with autism in the family.  These children with autism have been baptised into their church and are just as valid members as the rest of the parish.

 

Around the time of the diagnosis of the child with autism 23 of the 60 mothers studied prayed to deal with the stress.  When the children were at the primary school age 37% of the families used prayer as a coping resource and indeed in some situations the mother’s faith kept her going.  At the time of adolescence 17 out of the 60 mothers sought comfort in their religious beliefs or prayed as a coping mechanism.  When these children with autism were adults 6 out of the 60 parents still prayed for a magic cure.  In all approximately half of the mothers used prayer as a coping strategy.  Those who sought comfort in prayer had statistically speaking better mental health.

 

Prayer was both a resource and a coping strategy.

 

In another study conducted in Ireland in the 1980s by Professor Hannah McGee and myself and published in Pathways to Child Hospitalisation which was about the home versus hospital care of children with gastroenteritis.  We found that statistically far more of the mothers who were able to manage their child at home and didn’t need to have their child in hospital often attended religious services and indeed often did this accompanied by their partner.  Clearly this association between religious practice and mental health needs to be teased out more in the Irish context.  There is no such thing as a ‘god gene’ indeed the concept is absurd but there is a personality predisposition to spirituality.

 

Geoffrey Kluger in an article Is God in our Genes?  Time, October 25th, 2004, Page 62 – 72 discusses the Temperament and Character Inventory (TCI).  ‘Among the traits that TCI measures is one known as self-transcendence, which consists of three other traits: self-forgetfulness, or the ability to get entirely lost in an experience; transpersonal identification, or a feeling of connectedness to a larger universe; and mysticism, or an openness to things not literally provable.  Put them all together and you come as close as science can to measuring what it feels like to be spiritual’.  “This allows us to have the kind of experience described as religious ecstasy” says Robert Cloninger.  Hamer studied spirituality using ‘Cloninger’s self-transcendence scale, placing them on a continuum from least to most spiritually inclined.  Then he went poking around in their genes to see if he could find the DNA responsible for the differences.  Spelunking in the human genome is not easy, what with 35,000 genes consisting of 3.2 billion chemical bases.  To narrow the field, Hamer confined his work to nine specific genes known to play major roles in the production of monoamines – brain chemicals, including Serotonin, Norepinephrine and dopamine, that regulates such fundamental functions as mood and motor control’.  He found ‘a variation in a gene known as VMAT2 – for vesicular monoamine transporter – seemed to be directly related to how the volunteers scored on the self transcendence test.  Those with the nucleic acid cytosine in one particular spot on the gene ranked high.  Those with the nucleic acid adenine in the same spot ranked lower’.  Twin studies have shown similarities in their spiritual feelings. Thomas Bouchard stated ‘whether we are drawn to God in the first place is hard wired into our genes’.  He also stated ‘it is completely contradicted my expectations’.  Michael Persinger states that the god experience ‘is a brilliant adaptation.  It is built in pacifier’ for example to do with the contemplation of our death. This is the opposite to novelty seeking. It is possible though that religious ecstasy might be more closely linked to novelty seeking.  A book on the topic is called God Gene:  How Faith is Hard Wired into Our Genes, Doubleday, 2004 by Dean Hamer.  In personality traits such as discussed here multiple genes of small effect are operating

Suicide, Parasuicide, Suicidal Thoughts and Persons of Genius.

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Dr. Arnold Ludwig studied the New York Times Book Review Biographies from 1960 to 1980 and found that 18% of the poets he studied had completed suicide.  According to Jamison Ludwig ‘compared individuals in the creative arts with those in other professions (such as businessmen, scientists, and public officials), he found that the artistic group showed two to three times the rate of suicide attempts’ (Jamison, 1993).

 

Jamison also points out that ‘biographical studies, as well as investigations conducted on living writers and artists, show a remarkable and consistent increase in rates of suicide’. She points out that ‘the artistic groups .. demonstrate up to 18 times the suicide rate’ compared to the expected rate in the general population.  This is higher than found in the Ludwig study.

 

Jamison points out (that the following artists completed suicide:  Heinrich von Kleist, Ann Sexton, George Trakl, Marina Tsvetayeva, Ernest Hemmingway, Malcolm Lowry, Virginia Wolff, Vincent von Gogh, Arshile Gorky, Mark Rothko, Nicolas de Stael, Thomas Lovell Beddoes, John Berryman, Thomas Chatterton.

 

Jamison also points out that the following made a ‘suicide attempt’: Charles Baudelaire, William Cowper, Edgar Alan Po, Percy Bysshe Shelley, Francis Thompson, Maxim Gorky, Hermann Hesse, Hector Berlioz, Eugene O’Neill, Mary Wollstonecraft, Robert Schumann, Dante Gabriel Rossetti.

 

Suicidal Thoughts:

 

A. Alvarez stated in his book The Savage God that ‘a suicidal depression is a kind of spiritual winter, frozen, sterile, unmoving.  The richer, softer, and more delectable nature becomes, the deeper that internal winter seems, and the wider and the more intolerable the abyss, which separates the inner world, from the outer.  Thus suicide becomes a natural reaction to an unnatural condition. Perhaps this is why, for the depressed, Christmas is so hard to bear.  In theory it is an oasis of warmth and light in an unforgiving season, like a lighted window in a storm.  For those who have to stay outside, it accentuates, like spring, the disjunction between public warmth and festivity, and cold, private despair’.  Lord Byron also suffered considerable suicidal thoughts. Percy Bysshe Shelley also experienced considerable suicidal thoughts.  Graham Green experienced suicidal thoughts.  William Styron in his book Darkness Visible wrote about his suicidal depression and stated ‘the pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come – not in a day, an hour, a month, or a minute.  If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul.  So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying – or from discomfort to relative comfort, or from boredom to activity – but moving from pain to pain.  One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes’.  For Leo Tolstoy ‘the thought of suicide came to me as naturally then as the thought of improving life had come to me before’.

 

It would appear that the great artist experiences both tremendously deep and complex emotions.  They have access to emotional experiences and the extremes. The complexity of their emotional life is great.  All this is very helpful for their creativity but also makes them more likely for suicidal thoughts and suicidal behaviour.  They are less logical and rational then non-artistic people and are governed by the logic of emotions.  Of course the logic of emotions is very often not logical. This makes them more vulnerable to suicidal experiences.

 

K. Jamison in her book Night Falls Fast states that ‘I have a hard-earned respect for suicides ability to undermine, overwhelm, outwit, devastate, and destroy’.  Jamison is an Honorary Professor of English at the University of St. Andrews in Scotland has Bipolar disorder and has attempted suicide. This experience appears to be more common in persons with major artistic creativity than the general population.

 

Of course one has to be very careful with selected samples of geniuses with artistic ability.  They are no way representative of the total population of persons with artistic creativity.  Of course there is clear association between depression, suicide, and artistic creativity.  What the prevalence of these might be in the total population of artists in Ireland is unknown. We can’t generalise the total population.

 

It is interesting that both Ann Sexton and Abbie Hoffman received Manic Depressive Disorder diagnosis and were given lithium but stopped taking the lithium and completed suicide thereafter. It is possible to reduce the suicide rate in artistic people with proper treatment of their psychiatric problems. It is likely that the vast majority of artistic people who complete suicide have psychiatric problems. Clearly an additional factor is that abuse of alcohol and drugs is not uncommon in artistic people.  There is a myth that alcohol increases creativity. What alcohol does is to increase depressive feelings and not creativity.  Alcohol and drug abuse is clearly also associated with depression. Indeed it appears to me that being creative is what keeps people alive.  It would appear to me that suicide and depression are much more common where the artist experiences a creative block and that they are particularly vulnerable at that point.  The great philosopher Ludwig Wittgenstein as illustrated in the book Autism and Creativity was able to resist suicide by a continuing ability to be philosophically creative as a research philosopher.  Indeed it may be that a creative block leads to depression leads to alcohol abuse leads to suicidal behaviour.

 

In terms of social drinking this is an entirely different matter.  It is unlikely that ordinary social drinking will have a negative effect on creativity and indeed might have a positive effect.  Stephen Pritzer points out that ‘many writers recognise they could not write well while they were drinking.  F. Scott Fitzgerald and Ring Lardner said they went on the wagon when they worked’.  He also points out that ‘writers who used alcohol occasionally saw it as an aid in getting started or a stimulus when they were tired’.  This makes sense.  Clearly excessive drinking is damaging but smaller amounts might be positive for social functioning and indeed for physical health generally.  One must also remember that there is often a depressed period following a creative spurt.  This has to be managed by a creative writer.  Of course in addition the vast majority of artists are poorly paid and suffer a great deal of financial stress.  It is a very insecure profession.  It is hardly surprising therefore then that it is stressful and this stress makes people in this profession more vulnerable to anxiety and depression. Clearly there are genetic factors in relation to creativity, alcohol abuse and depression. The alcohol abuse only makes it much more likely that the artist will not be able to produce their potential. I don’t believe the story that Coldridge wrote Kublai Khan while on opium.  If it is true then he could only have been taking very minor amounts. It is interesting to compare this with great mathematicians, scientists, and inventors (Fitzgerald, 2004).  The stress in their life was generally much less than those with artistic creativity.  In addition great scientists, inventors, etc. often find very useful places for themselves in society either in the academic world or in the industrial world and therefore do not have insecure lives from a financial point of view.  They are also in general far better paid financially. Not every highly successful artist is capable as well of dealing with fame.  They may feel they have to continue to produce great work which they may no longer feel able to.  They may engage in self destructive paths of drinking and notoriety with suicide as an outcome. Being successful may set the bar too high for them and they may be unable to repeat it and therefore develop writers block followed by depression and alcohol abuse.

 

Reference:

 

Ludwig A. M. (1992).  Creative Achievement and Psychopathology:  Comparison among Professions.  American Journal of Psychotherapy, 46, 330 – 356.

 

Jamison K. (1993).  Touched with fire.  Free Press: New York.

 

Jamison K. (2000). Night falls fast.  Picador.

 

Alvarez A. (1973).  The Savage God.  Random House: New York.

 

 

Styron W. (1990).  Darkness Visible.  Random House: New York.

 

 

Pritzer S. (1999).  Encyclopaedia of Creativity.  Academic Press:  San Diego. Edited by M. Runco and S. Pritzer.

 

 

Fitzgerald M.  (2004).  Autism and Creativity.  Brunner Rutledge Hove.

 

 

Suicidal Behaviour in Adolescents

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Worldwide there is about one death every 40 seconds and about one million suicides per year.  Suicide is the leading cause of death worldwide, particularly in younger people.

 

According to Dr. John Connolly there has been a twelve-fold increase in suicide between 1960 and 2000 in 15 to 34 year olds. The Union of Students in Ireland has estimated that 25 persons per year between the ages of 20 and 24 complete suicide. In data collected during 2002 the National Suicide Foundation Registry found that there was increased Parasuicide by 5.7% in the Midland Health Board, 11.9% in the Mid Western Health Board, 8.5% in the South Eastern Health Board, and 12.7% in the Southern Health Board.  They also pointed out that Parasuicide was highest among young women aged 15 to 19 with 1 per 160 of the total population of 15 to 19 year olds being involved.  Parasuicide rates were higher in urban areas and varied between 63 per 100,000 in Leitrim and 429 per 100,000 in Limerick.  They found that alcohol was involved in 46% of male suicides and 38% of female suicides.  Parasuicide made up 1% of all casualty attendances.  The types of drugs used in overdose include (a) 40% minor tranquillisers, (b) 43% at least one analgesic drug (Paracetamol involved in 30% of drug overdoses), (c) 23% antidepressants (18% SSRI), (d) Paracetamol was involved in 33% of overdoses by women and 23% of overdoses by men.

 

It is clear that there are major associations between suicidal behaviour and alcohol or drug abuse.  There is a higher risk if there is an easily available method and higher risk in populations of persons who are depressed and persons with schizophrenia.  Hopelessness is closely associated with suicidal behaviour.  Other factors include narcissistic wounds to the personality i.e. shame or public humiliation.  Imitation plays a role for example after Marilyn Monroe’s death. Unemployment and genetic factors are also important.  The social contact factors include anomie, alienation, western industrialised societies, sense of meaningless in life, ‘worship of the Euro’, a history of sexual abuse, drop out from education, and bullying can also be factors.  Other factors include poor problem solving skills, relationship problems and loneliness, as well as having a history of impulsivity and Attention Deficit Hyperactivity Disorder.  Another condition sometimes involved is persons with Asperger’s syndrome, which is a social relationship disorder.  Personality features associated with suicide and behaviour include antisocial behaviour, emotional dysregulation, and depressive personality.

 

Males are at increased risk of suicide because it is harder for them to find an identity in our society and they often have a sense of being lost.  They have greater difficulties in expressing their feelings particularly emotional feelings and describing interpersonal difficulties.  The female has better verbal skills, better empathy, better interpersonal skills than the male and this is important in reducing completed suicide. The male mind is more of a mechanical mind which is less good at emotional processing.

 

Almost anything can be a warning sign of suicidal behaviour in adolescents but the following have been noted:  truancy, poor school performance, anxiety and depression, withdrawn behaviour, change in behaviour, sleep disturbance, impulsiveness, and low frustration tolerance.  Protective factors against suicidal behaviour include prior experience of self-mastery and success, good mental health, and healthy socialising and coping strategies, as well as success at school and work.

 

In assessing the adolescent with possible suicidal ideas or actual suicidal ideas it is important first to listen and then not to panic and to realise that purely legalistic thinking will interfere with one’s ability to listen to the patient.  It is important to ask relevant questions including thoughts and intensions about suicide, plans, wills, available methods, family history of suicide, imitation issues, depression, and hopelessness.  If a school teacher or anybody else becomes aware that an adolescent is suicidal it is important to remain in touch with them to give them a telephone number or mobile and to take action to bring the matter to the attention of their family.  It is one of the few areas were confidentiality to a friend does not apply. Keeping the friend alive is all that matters.  The adolescent will often need to get first in touch with their G.P. and then with a Psychiatrist or Psychotherapist / Counsellor to deal with the matters that are concerning them.  Sometimes these contacts need to be on a daily basis in the early stages of treatment.

 

In terms of postvention that is dealing with a family post suicide it is important to avoid fault finding or blame. Truthfulness is very important. The family need time to work through the feelings they have in relation to the suicide and this may reduce the likelihood of intergenerational effects later on.

 

In terms of suicide prevention in schools it is important that adolescents are helped to deal with stress and distress and learn life skills.  They have to be thought to manage stress, loss, how to manage upset of a break-up of a relationship, and academic problems.  Developing problem solving is critical.  Some isolated students also need very much to develop social skills and active programmes to prevent bullying in school are of critical importance.

Effects of Substance Abuse on Children.

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The effect of chemical dependency either alcohol or drugs in children is very great.  Parental alcoholism or drug abuse of a serious kind has a hugely detrimental effect on the family atmosphere and on the parent’s ability to rear their children. Children in these families live in a climate of anxiety and fear.  There is enormous unpredictability and uncertainty in the families.  The children never know what to expect or what is going to come next.  They are in a state of bewilderment.  A recent advertisement on the billboards asked why is mummy strange after she works late? This was the best that a child could make out of mother’s drinking.  These children live with constant fear of catastrophe. They develop a sense of the world as being catastrophic and dangerous.  They mistrust everybody and everything.  They are confused by what is going on.  They witness domestic violence, parental blackouts, and the whole paraphernalia of drug addiction with syringes, needles, rolling paper, and indeed they may have to assist in this process by holding, buying or giving drugs to a parent.  They suffer enormous shame and also indulge in a great deal of self-blame and guilt. Young children tend to blame themselves for things that happen in the family.  They may also be frightened by the families contact with drug dealers and the lack of finances.  They will lack money for school books, clothes, and experience poverty.

 

There are huge communication deficits in the family and this is increased by the denial about what is going on in the family and the denial by parents of their chemical dependency.  They are aware of the importance of secrecy and not disclosing what is happening in the family.  Timothy Rivinus in his book Children of Chemically Dependent Parents published by Brunner-Mazel, New York, 1991, states that children of alcoholics live “thousands of little debts of their parents each year”.  These children are often ‘shell shocked’ by the traumas that they witness and show symptoms of Post Traumatic Stress Disorder with repetitive fearful dreams and intrusive thoughts about events that they have witnessed in the family. It is not uncommon for parents suffering from addiction to be hostile, abusive, and critical of their children.  The children have massive unmet needs in terms of nurturing, empathy, and the experience of normal family life.

 

It is not surprising that these children often suffer from depression, hopelessness and low self-esteem.  They develop a false self to protect themselves from the outside world. They are often mistrustful of people and can become masochistic and self-destructive themselves in their later behaviour.  In later life they can engage with destructive partners.  Suicidal behaviour is also not rare in these circumstances as children.  They can also become pseudo-adults and heroic figures looking after their parents. This reversed parenting is not healthy and can lead to later difficulties if not talked out.  Sometimes it can be used in a more healthy fashion by these children as adults becoming therapists or engaging in the helping professions themselves. These children often show symptoms of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, problems in attachment with human beings, as well as eating disorders, delinquency, substance abuse, and other acting out disorders.  In School they will often have educational problems and may engage in truancy. If mother drank very excessively during pregnancy they may show evidence of foetal alcohol syndrome.When these children grow up and become parents themselves they may either over indulge their own children and become enmeshed with them. As adults these children of alcoholics may not have a clear vision of their parents, they may not be aware of the positive aspects of their parents.  Recovering these positive aspects of their parents is of critical importance to mental health. When they marry they may expect their spouse to cure the hurt child in them and this is often an excessive and impossible demand.  They really have to come to terms with being a child of an alcoholic or chemically dependent parent but not become a victim.  This can be helped by them working out an accurate narrative of their life experience.

 

Protective factors for these children can include having a high I.Q., an easy temperament, support for these children from a sibling from a non-alcoholic parent, or from a mentor at School.  Al Teen where the secrets and denial in the family can be tackled and the child’s history can be spoken openly can be quite helpful.

 

Unfortunately professionals working with children do not often take sufficiently detailed drug and alcohol histories from parents. This can lead to very confused understanding of the family.  Unfortunately in Adult Psychiatry there is a huge denial of the impact of the alcoholic parent on the child and Adult Psychiatrists refer children for counselling or to a Child Psychiatrist only on the most infrequent occasions.  In addition the parents and indeed the children can have undiagnosed and untreated Attention Deficit Hyperactivity Disorder which may underlie many of the problems.  This lack of identification of this condition can also mean the treatment is either inadequate or misguided.  Early and proper early intervention with both psychotherapeutic behavioural and family interventions as well as active pharmacological treatment of Attention Deficit Hyperactivity Disorder can significantly reduce later problems.

 

Genius, Creativity and Savantism

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Persons with High Functioning Autism or Asperger’s syndrome can show considerable creativity.  Indeed they have the capacity for extreme creativity in a small number of cases.  Evidence of minor creativity would be more common.  The features of autism / Asperger’s syndrome that would enhance creativity would include intense focus on narrow interests.  It is rarely possible to make major advances in science without this narrow intense focus.  The lack of interest in emotional issues means that there is far more time available for intellectual mathematical, philosophical, and other scientific pursuits.  Their time is not taken up with interpersonal relationships and with ordinary everyday life. They are often workaholics and their whole life is devoted to their creative pursuit.  Persons with autism often have abnormal brain functioning and indeed brain structure and these deficits in some way enhance creativity. This kind of creativity has genetic underpinning of a type that has not yet been fully elucidated.  Heritability factors account for about 93% of the variants in the aetiology of autism / Asperger’s syndrome.  The following are some examples of this creativity.

 

Henry Cavendish

 

Henry Cavendish (1731 – 1810) had High Functioning Autism / Asperger’s syndrome.  He was an enormously successful scientist.  He had enormous difficulties in interpersonal relationships. He was a man of enormous routines and regularities in his conduct of his life. He was very poor at speech making. Nevertheless he could be very precise in his use of language.  He lacked empathy in interpersonal relationships and Berry notes Cavendish’s “striking deficiencies as a human being”.  Indeed “his habitual profound withdrawal lead one contemporary to characterise him as ‘the coldest and most indifferent of mortals’”.  He had an awkward gait and there is absolutely no doubt that like Newton and Einstein he had High Functioning Autism / Asperger’s syndrome.

 

Charles Babbage

 

Charles Babbage (1792 – 1871) also had High Functioning Autism / Asperger’s syndrome.  He was the father of the modern computer.  He was an autodictat.  He spent a great deal of his life trying to build calculating machines. The first one was called a ‘difference engine’ and the second an ‘analytical engine’.  According to Swade Babbage’s engine ‘gave new impetus to the notion of a “thinking machine” and stimulated the debate about the relationship between the mind and physical mechanism’.  He had major problems in interpersonal relationships.  He worked largely in isolation.  He had a socially immature personality not uncommon in persons with High Functioning Autism / Asperger’s syndrome.  He suffered from anxiety and depression.  He was an excellent mathematician.  He was described as an eccentric and comic figure. He was naïve and showed a lack of commonsense.

 

Archimedes

 

Archimedes (C 287 – 212 BC) also had High Functioning Autism / Asperger’s syndrome.  He was an extremely eccentric individual spending as much of his life isolated in solitary.  He had a good mechanical mind.  He invented what is called the Archimedes screw for pumping water which is still used to this day.  He was highly regarded as an engineer and inventor.  He only liked to talk to mathematicians.  He was the discoverer of what is called the Archimedes principal i.e. that the floating body will displace its own weight in fluid. He was an obsessive mathematician.  He neglected his personal hygiene.  Like Newton he left his meals untouched when he was deep in mathematics.

 

Norbert Wiener

 

Norbert Wiener (1894 – 1964) was another mathematician with High Functioning Autism / Asperger’s syndrome. He was an autodictat, a linguist, and a rather absent minded professor.  He was a socially immature child.  He lacked empathy and was tactless with people.  He was rather a lone wolf and was uncertain about how to conduct conversations.  He was a very poor teacher.  He was very routine bound.  He was a rather clumsy child which is not uncommon with HFA / ASP and indeed like many others he suffered from anxiety and depression.  He was described as being very eccentric.

 

Nikola Tesla

 

Nikola Tesla was a famous electrical inventor who had High Functioning Autism / Asperger’s syndrome. He had a photographic memory. He was a linguist.  He was an avid reader.  He had an obsessive compulsive personality type.  He was an autodictat. He had major difficulties in social relationships, was socially immature and naïve.  He was extremely controlling and spoke with a high pitched voice.  He was extremely naïve in dealing with people who would finance his inventions.  He was very much a loner and remained unmarried and was extremely interested in pigeons. He had no capacity to manage money.  His main interest was in inventions.  He was the inventor of radio among many other things.

 

David Hilbert

 

The mathematician David Hilbert (1862 – 1943) had High Functioning Autism / Asperger’s syndrome.  He was a great mathematician.  He showed eccentric interpersonal behaviour and was socially immature. His only interest was in discussing mathematical subjects.  He showed extreme self control.  Routines were extremely important to him.  He tended to show repetitive language.  Nevertheless he was very precise in his use of words. He showed lack of empathy.  He believed no scientist should marry.  He suffered from anxiety and depression.

 

G. H. Hardy

 

The great English mathematician G. H. Hardy had High Functioning Autism / Asperger’s syndrome.  He was a very eccentric man who never married. Routine was extremely important to him. His great interest in life was mathematics.  He loved cats.  He was extremely honest in his behaviour.  Later he suffered from depression and attempted suicide. Attempting suicide is not uncommon in persons with High Functioning Autism / Asperger’s syndrome.

 

Dimitri Mendeleyev

 

Dimitri Mendeleyev who developed the periodic table in chemistry had High Functioning Autism / Asperger’s syndrome. He had major difficulties in interpersonal relationships.  He was most eccentric looking.  He cut his hair once a year.  He had tremendous focus on chemistry and on chemical elements and it was this intense focus that brought him success.  Like so many successful people with HFA / ASP he performed poorly in school.

 

Edward Teller

 

The most classic person of all with Asperger’s syndrome was Edward Teller the father of the H Bomb and the subject of a recent book called Edward Teller – The Real Strangelove from Harvard University Press.

 

Asperger’s syndrome is characterised by avoidance of eye contact, problems reading non-verbal behaviour, being a loner with a lack of social know-how, having problems sharing thoughts, and problems with empathy. They often speak with a high pitched or unusual tone of voice and repeat phrases. Gillberg calculates that 0.3% to 0.5% of the population has it.  they like routine and have preservation of sameness.  As children they often line things up, flap their hands, and are fussy eaters. They often have narrow obsessive interests in engineering, mechanics, astronomy, science, palaeontology, etc.  It is one of the most missed diagnosis in adult psychiatry.  They are misdiagnosed as Schizophrenia Personality Disorder and a wide variety of other diagnosis.  This leads to inappropriate treatments which only aggravate the situation. hopefully the Irish Psychiatric Association, Irish College of Psychiatrists, and the Mental Health Commission will examine the issue.  Psychiatric CPD has failed in relation to Asperger’s syndrome and indeed adult Attention Deficit Hyperactivity Disorder which in reliable epidemiological studies in USA affects 4.4% of the population.

 

 

A Road to Homicide in Ireland

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The road to homicide in adolescents and young men can be quite a long one.  When you look back with 20-20 hindsight one can not uncommonly observe that the person when a small child had a difficult temperament.  They were unmalleable and very difficult to rear.  Temperament has genetic underpinnings.  The factors leading to homicide are a combination of nature and nurture or genes and environment.  By the age of three the child may be brought to a Child Psychiatrist because they are hyperactive and impulsive.  By the age of four they may very well have been in two or three preschool playgroups where they are unmanageable because of their poor attention and hyperactive impulsive behaviour.  At this stage they would meet the criteria for Attention Deficit Hyperactivity Disorder hyperactive type.  Unfortunately if they see professionals at this age their problems are likely to be attributed to parental management failures.  This is often absolutely untrue.  When they start primary school the same situation occurs in the classroom i.e. poor concentration, poor attention, forgetful, disruptive, hyperactive, impulsive.  Again the parents may be falsely blamed.

 

It is only a short time before an additional diagnosis is added in i.e. Oppositional Defiant Disorder.  This will cause the school and parents great problems, even more than the Attention Deficit Hyperactivity Disorder.  A few years later the diagnosis of Conduct Disorder will be added with significant disturbances of conduct including bullying, being cruel to people or animals, stealing, fire setting, staying out late at night without parental permission, etc..  Into adolescence indeed even early adolescence there will be the use of street drugs like cannabis and alcohol.  This drug and alcohol use will escalate during adolescence.  Suspension from school will not be uncommon and finally a pupil will be asked to leave school and will become a drop out. Then they are on the streets, which is probably the most dangerous place of any in Ireland where there is massive availability of drugs. Delinquent acts will then take place, which can escalate to assaults.  The drug and alcohol abuse will increase.  There will be linking up with peers of a similar persuasion and with similar problems and then grievous bodily harm or a homicide is waiting to happen.

 

For example on the night of the homicide it will not be uncommon for a group of these adolescents or young men to have taken a great deal of drugs and alcohol which make them even more impulsive and they will pounce on an innocent victim or possibly somebody who might have said something to them.  They will then go through the legal system, which will charge them with murder and give no credence to anything that has happened before.  Because persons with hyperactive impulsive behaviour are likely to have accidents it wouldn’t be rare as well that there might be some brain damage from previous accidents.  Over 18s receive a diagnosis of Antisocial Personality Disorder but their adult Attention Deficit Hyperactivity Disorder will be missed and therefore untreated.  What these children, adolescents, and adults need is early intervention and active treatment. Blaming parents so popular with right wing people.  This is completely unhelpful and only aggravates the situation.  Clearly this is not the only road to homicide as others will show evidence of psychosis, paranoid personality disorder, etc.. Clearly in Ireland the appalling abuse of alcohol in adolescents and young people is a major factor.  If the legal age for drinking was put up to 21 years it would help.  Unfortunately these very disturbed young men or adolescents would probably acquire it anyhow from some other source.  Nevertheless reducing availability could only help.

 

Early intervention is critical and it might be worth considering treating Attention Deficit Hyperactivity Disorder in those over age three with Dexamphetamine, which is licensed, in addition to behavioural interventions.  Oppositional and Defiant Disorder may need the addition of Clonidine or Risperidone which are both off label.  Anti-depressants will often need to be added in and these people in the course of their career will often show clear evidence of depression.  For adolescents and children who have difficulty remembering their medication there is an eight hour medication called Ritalin Long Acting is helpful. For those adolescents who have to study after school then Concerta XL which is 12 hours of duration once a day is helpful.  Finally for those adolescents and young men who need 24 hour treatment there is then Strattera the first non-stimulant treatment for Attention Deficit Hyperactivity Disorder which is available on a once daily medication. This is licensed in the U.K. and USA etc. and is available in Ireland at present on a named patient request.

 

Inappropriate focus on multidisciplinary teams means that there is wastage of professional time that could be used in seeing patients. This does not occur in adult psychiatry where the patient rather than the team is the major focus.

 

These very disturbed adolescents and young people described in this article need very energetic complex and multiple psychopharmacological intervention as well as multimodal other therapies including psychotherapy, family therapy, and behaviour therapy.  Schools also need small classes to deal with these very disturbed children and adolescents.  Ejecting them from schools something which is so common is the straw that ‘breaks the camel’s back’ and putting them on the streets massively increase their risks. Because of the disturbance in school they will not uncommonly need full time Special Needs Assistants and because they often have comorbid difficulties for example specific learning difficulties they will also need extra resource teaching.  What they don’t need is criticism or blame and their parents don’t need criticism or blame, which is so often available from a whole variety of professionals. Particularly those with right wing leanings.  The most negative factor that they can have in their career trajectory is endless criticism and blame.  This is an unnecessary and tragic environmental factor.  Children with ADHD should have equal rights to education and psychiatric treatment as all other children in the state.  Untreated the outcome may be tragic for themselves (e.g. completed suicide because of the impulsivity of ADHD) or fatal for other citizens because of homicide or death themselves in car accidents.  Adult ADHD is associated with high accident rates.

 

Attention Deficit Hyperactivity Disorder has highly significant genetic associations and occurs in 4.4% of the adult population. It is the most commonly missed adult psychiatric disorder in Ireland, the majority of persons with it not being diagnosed. Hopefully the Irish College of Psychiatrists / Irish Psychiatric Association will take up the matter soon. The Royal Academy of Medicine in Ireland is organising meetings on Attention Deficit Hyperactivity Disorder next year.

 

Adult Attention Deficit Hyperactivity Disorder is characterised by poor concentration, shifting of activities frequently, day dreaming, being easily distracted, problems organising time, poor attention to detail, difficulty listening, is impatient, acts without thinking, talks out of turn, has impulsive urges, has temper tantrums, has a restless feeling, has motor hyperactivity, has difficulty remaining seated during meetings, and difficulty working quietly.

 

Autism, Asperger’s syndrome, Stalking, and other reasons for legal contact.

Date: Author:

While most people with Asperger’s syndrome (who have higher functioning autism) are highly moral, highly ethical, a small minority get in trouble with the law.  This is probably slightly more common in those with Mild Learning Disability and Autism.  Persons with autism may get into difficulties with the law according to Denis Debbaudt an American expert on this issue because of:

 

(1)       Dangerous wandering.

 

(2)       May not respond to commands or instructions.

 

(3)       Lack of eye contact, may be misinterpreted as a sign of guilt.

 

(4)       May not recognise police uniforms, badges or vehicles.

 

(5)       Have a poor reaction to change in routine.

 

(6)       May reach for shiny objects.

 

(7)       May invade personal space of responder.

 

(8)       Inappropriate social responses.

 

(9)       Inappropriate laughing or giggling.

 

(10)      False confession or misleading statements during questioning.

 

(11)      Associated medical conditions like epilepsy.

 

(12)      Behaviour misunderstood by others resulting in calls for assistance.

 

(13)      A high pain tolerance.

 

(14)      Atypical responses during emergencies.

 

It is critical that professionals for example the police and staff working in forensic settings are aware of these features. Persons with autism are also easily led by others and as already stated misunderstand social cues.  Their obsessional thinking may have an aggressive theme. In one inpatient setting for Learning Disabled Offenders in the U.K. 12% had autism. There is insufficient training within forensic services on autism in most parts of the world.  Hopefully the Irish College of Psychiatrists, the Irish Psychiatric Association, and police authorities will deal with this matter in full. Police, parents and other professionals need to be able to identify the possibility that a person that they are interacting with may have autism or Asperger’s syndrome so that police and other contacts are less stressful for the person with autism or Asperger’s syndrome. In the U.S. research indicates that persons with developmental disabilities are approximately 7 times more likely to come into contact with law enforcement than others.  There is only a small likelihood that in the first instance the autism will be recognised either by the police or other professionals involved.

 

Persons with autism also can get involved in stalking and one of the reasons that persons with Autism Spectrum Disorders are predisposed to stalking according to Tom Berney a U.K. Psychiatrist is that they have impaired perception of social signals, misinterpretation of rules, misinterpretation of relationships, lack of awareness or concern for the outcome, and a focussed obsessive interest.  While this occurs it is not common.

 

Digby Tantum states that sexually motivated crimes are also unusual and when they occur may be a consequence of a lack of understanding on the part of the person with Asperger’s syndrome.  Persons with Asperger’s syndrome may be aggressive and commit offences against other people, but it is unclear how frequently and what proportion of people with Asperger’s syndrome are at risk of doing so. Many people with Asperger’s syndrome have a hypertrophied sense of right and wrong and are unusually conscientious and unwilling to break the law.  The Asperger’s syndrome are more likely to be victims than perpetrators.  Nevertheless even though it is uncommon persistent violence by a person with Asperger’s syndrome is a particularly difficult problem. Men with Asperger’s syndrome are over represented in a survey of one U.K. Secure Hospital.  Violence by a person with Asperger’s syndrome often has some special features.  It may be triggered by idiosyncratic stimuli nourished by rumination over past slights; displaced from provoking the person onto a safer target at a later date; and uninhibited by empathic response to the intended victims fear.  Sometimes the explanation for violence may be similar to that given by Raskolnikov in Dosteyevsky’s Crime and Punishment: that is it is of an experimental nature. It is often a wish to experience a sense of mastery and control over another person.  They may also do it to test their predictions about how others would behave in such extreme circumstances.

 

It is worth noting that Asperger’s syndrome can occur in people of talent like Casal, Kierkegaard, E. Hopper, A. J. P. Taylor, Goethe, van der Post, Columbus, O. Wells, and ‘H. G.’.

 

Kurt Cobain was wrong about the treatment of Attention Deficit Hyperactivity Disorder.

Date: Author:

Kurt Cobain was wrong – the treatment of Attention Deficit Hyperactivity Disorder with Methylphenidate does not predispose to substance misuse indeed precisely the opposite is true.  Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area with Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.

 

Kurt Cobain had Attention Deficit Hyperactivity Disorder, and was prescribed Methylphenidate when he was at school. Unfortunately he only took it for three months.  The impression was given later that this was a factor in his developing substance abuse. Indeed precisely the opposite is the truth.  Persons who are treated for Attention Deficit Hyperactivity Disorder on a continuous basis with Methylphenidate are less likely to abuse substances as they get older. The abuse of drugs like cannabis or cocaine is often a feature of self-medication for Attention Deficit Hyperactivity Disorder.  The increased use of cigarettes by persons with Attention Deficit Hyperactivity Disorder may also be done for the same reason.  There is no doubt that persons with Attention Deficit Hyperactivity Disorder have an earlier onset of cigarette smoking and a greater use of it. There is no evidence for long term risks for substance use disorders in persons prescribed Methylphenidate. Indeed there is a reduced likelihood of substance misuse if Attention Deficit Hyperactivity Disorder is properly treated with stimulants.  This doesn’t mean that there aren’t some risks from stimulants i.e. through diversion. A new medication for Attention Deficit Hyperactivity Disorder Atomoxetine has been shown to have no greater abuse liability than Desipramine an antidepressant or placebo. Unfortunately Attention Deficit Hyperactivity Disorder is a serious condition which requires early intervention and the misinformation about it is preventing some children from getting the treatment that they need.

 

Children with Attention Deficit Hyperactivity Disorder are at risk of increasing complications as they get older.  They start in childhood with Attention Deficit Hyperactivity Disorder alone and then can develop disruptive behaviour disorders, oppositional disorders, challenging behaviour, and later from about 14 years onwards they experience often school exclusion, substance abuse, mood disorder, conduct disorder, and finally antisocial personality disorder and often get involved with the law at the same time.  Of course this trajectory only occurs in those with severe Attention Deficit Hyperactivity Disorder and severe complications.  Comorbid Oppositional Defiant Disorder occurs in over 40%, Conduct Disorder in 20 to 56%, delinquent and antisocial activities in 18 to 30%. Many continue their problems into adulthood and they are more likely to enter the workforce at unskilled or semi skilled level. They are twice as likely to be dismissed from their employment, tend to have many more jobs than the average, and to show much lower work performance than the average.

 

In examining motor vehicle driving risks persons with Adult Attention Deficit Hyperactivity Disorder are 60% more likely to have a crash with injuries as compared to 17% of the general population. As well as having much more accidents they tend to have worse accidents.  They have four times higher risk of having sexually transmitted diseases because of their earlier onset of sexual activity and their increased number of sexual partners.  In addition they are less likely to employ contraception and spend less time with each partner than the average population.  Girls with Attention Deficit Hyperactivity Disorder are over 9 times more likely to have a teen pregnancy than those without Attention Deficit Hyperactivity Disorder.  The judicial costs of having Attention Deficit Hyperactivity Disorder are vastly increased as compared to people without Attention Deficit Hyperactivity Disorder. In America it has been estimated that the total criminal costs for persons with Attention Deficit Hyperactivity Disorder and Conduct Disorder combined are 37,830 dollars.

 

Unfortunately Adult Attention Deficit Hyperactivity Disorder is largely missed as a diagnosis.  It appears to me that the  next most missed diagnosis in adults is Asperger’s syndrome which nowadays tends to misdiagnosed as Mild Bipolar disorder.  It tended in the past (and this still occurs in the present) to be misdiagnosed as Personality disorder or Schizophrenia.  This meant they didn’t get the treatment they needed and got inappropriate treatment.  A typical example is the novelist who was nominated for a Nobel Prize Janet Frame who was diagnosed with Schizophrenia outside Europe.  She was put on a list for lobotomy in 1952.  She was told by the Maudsley Hospital later that she did not have Schizophrenia.  She died in 2004.  In actual fact she had Asperger’s syndrome.  There may be thousands in a similar situation throughout the world with misdiagnosis of psychiatric disorder.  Hopefully the Irish College of Psychiatrists, Irish Psychiatric Association and those responsible for C.M.E. will take up this issue.

 

Going back to Kurt Cobain he would have a much greater chance of having survived if he persisted taking his Methylphenidate on a regular basis and had intensive multimodal treatment for his Attention Deficit Hyperactivity Disorder and associated problems.  He showed the majority of comorbidities that one can get with Attention Deficit Hyperactivity Disorder.  It was not surprising that he completed suicide.

 

Road Traffic Accidents and Adolescent / Adult Attention Deficit Hyperactivity Disorder.

Date: Author:

Automobile crashes are one of the leading causes of deaths in adolescents.  Accidents are three to four times more frequent in persons with Attention Deficit Hyperactivity Disorder.  The Attention Deficit Hyperactivity Disorder driver is three to four times more likely to be at fault.  The Attention Deficit Hyperactivity Disorder driver is six to eight times more likely to loose their license.  The treatment of Attention Deficit Hyperactivity Disorder with stimulants improves the performance of the driver.  There is a serious lack of attention being given to the impact of Attention Deficit Hyperactivity Disorder on driver’s performance in relation to accidents in Ireland.  Unfortunately adult Attention Deficit Hyperactivity Disorder is not uncommonly missed as a psychiatric diagnosis.

 

Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area of Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.  Doctors can also have adult Attention Deficit Hyperactivity Disorder and the following questions are often worth considering:

 

(1)       Do you have difficulty concentrating or focussing your attention on one thing?

 

(2)       Do you often start multiple projects at the same time, but rarely finish them?

 

(3)       Do you have trouble with organisation?

 

(4)       Do you procrastinate on projects that take a lot of attention to detail?

 

(5)       Do you have problems remembering appointments or obligations?

 

(6)       Do you have trouble staying seated during meetings or other activities?

 

(7)       Are you restless or fidgety?

 

(8)       Do you often loose or misplace things?

 

In terms of driving behaviour Methylphenidate (Ritalin / Ritalin LA) significantly reduces inattentive driving errors.  It would appear that for those driving in the early evening including during the day Concerta XL (Methylphenidate) which lasts for 12 hours would be more relevant.  This is also a form of slow release Methylphenidate and is off label in Ireland for adults.  Of course accidents do occur in the evening and so good attention is particularly required at this time.  There is also a new medication the first non-stimulant medication available in Ireland for Attention Deficit Hyperactivity Disorder on a named patient basis called Atomoxetine (Strattera) which is active over the 24 hours. This has slow onset and has to be taken seven days a week. This would seem to have a place when you are particularly focussing on wanting to have a person on continuous treatment as it does not wear off.  It would particularly appear to be important for late evening / night, the time of maximum danger for accidents.  Adolescents with Attention Deficit Hyperactivity Disorder also benefit from cognitive / behavioural therapy which focuses on the inhibition of impulses, time management, organisational skills, problem solving skills, anger management, decision-making skills, social skills training, and improved social perception.  Persons with Attention Deficit Hyperactivity Disorder need to be educated about it.  Once the diagnosis is given to them it can suddenly make sense of their lives and sometimes of the chaos of their lives.  It is difficult to get a chaotic life into order if one doesn’t understand what the problem is.  Genetic factors play a major role in Attention Deficit Hyperactivity Disorder.  The problem of adult Attention Deficit Hyperactivity Disorder and accidents is a matter that should be taken up by professional psychiatric bodies and by consultants in Accident and Emergency Departments who are often on the receiving end of problems with Attention Deficit Hyperactivity Disorder.  Organisations involved in road safety should also examine this issue.

Book Review: Straight talk about Attention Deficit Hyperactivity Disorder

Date: Author:

by William K. Wilkinson. Published by the Collins Press: Cork, 2003

This book is essential reading for parents, children, and adolescents with Attention Deficit Hyperactivity Disorder and for General Practitioners, Paediatricians, Child Psychiatrists, and Doctors working in Community Services.  It is comprehensive, and very practical and answers most of the questions that parents and professionals ask about Attention Deficit Hyperactivity Disorder. In addition it has a useful Appendix of Organisational Contacts for parents and also a useful reading list for parents and professionals.  It discusses in detail the diagnosis of Attention Deficit Hyperactivity Disorder as well as the causes of Attention Deficit Hyperactivity Disorder.  It gives proper weight to biological and genetic factors. It also tackles the issue of ‘blaming’ the parents for the disorder.

In my experience the tragedy of Child Psychiatry / Child Psychology in the 1970s in Ireland, 1980s and indeed early 1990s was the tendency to see children’s problems with Attention Deficit Hyperactivity Disorder as being due to inadequate parenting.  This had a devastating and negative effect on parents.  The therapists of a family or psychodynamic orientation particularly took the view that the child’s problems were caused by the family dynamics.  Indeed this false view of Attention Deficit Hyperactivity Disorder still occurs. Wilkinson provides an accurate and balanced view of this complex topic.  Wilkinson gives a superb and detailed understanding of the Clinical and Educational Psychologist Assessment of persons with Attention Deficit Hyperactivity Disorder.  He answers in detail the kind of questions parents asked about what Psychologists do.

One minor quibble is that there is no index and in the next edition of this most valuable book I hope that he will add in a Chapter on Adult Attention Deficit Hyperactivity Disorder