The autism etiology: a traumatic hypothesis
* Sebastian Abram Salim
*
Didactic Psychoanalyst Psychoanalytic Society of Rio de Janeiro
* Didactic Psychoanalyst Psychoanalytic Society of Minas Gerais
* Didactic Psychoanalyst Psychoanalytic Society of Minas Gerais
* Member of the Brazilian Psychiatric
Association
Abstract
The autism etiology remains unknown. In this paper, I suggest
a hypothesis related to a traumatic event occurred during prenatal, perinatal
or initial postnatal period and felt by the victim with a vivid sense of death.
This event triggers two innate and
biological response reflex. The first aim to preserve life through the minimum
absorption and consume of cell’s oxygen to perform its vital functions.
The second response has the objective to appease the
fetus or the newborn death’s anxiety, promoted by a traumatic event. It
consists in the generation of physical sensations produced by the body's own
elements in touch with its sensory surfaces.
Both responses remains registered in cerebral amygdala
and answers for the predisposition.
I developed this hypothesis through interdisciplinary
studies between Psychoanalysis, Psychiatry, Experimental Psychology and
Neurobiology.
My clinical results justify the continuation of these
studies, as illustrated by clinical material presented.
Keywords: autism etiology; trauma; autistic withdrawal; sensation.
Introduction
The autism etiology has been studied by many sciences. They do not demonstrate a biological maker or a psychogenic factor.
The autism etiology has been studied by many sciences. They do not demonstrate a biological maker or a psychogenic factor.
I will propose in this paper is the hypothesis that
the autism etiology is related to a traumatic event occurred during prenatal,
perinatal or initial postnatal period and felt by the victim with a vivid sense
of death.
This event triggers two innate and biological response
reflex. The first aim to preserve life. It consists in reducing the consumption of oxygen by the
cell to perform its vital functions with the H2S latent in our
bodies (Blackstone, 2005). Probably this mechanism is responsible by the
hibernation state of animals and plants in adverse conditions of life.
The second response has the objective to appease the
fetus or the newborn death’s anxiety present in a traumatic event. It consists in
the generation of physical sensations produced by the body's own elements in
touch with its sensory surfaces, such as to touch the lips with the fingers.
Both responses remains registered in cerebral amygdala
(Kandel, 2000). In case of traumatic recurrence in any period of life, there is
a reactivation of these responses.
Therefore, they would be the basic predisposition
element to the development of autism.
As I will describe, this hypothesis was developed
by means of interdisciplinary studies between psychoanalysis, psychiatry, experimental
psychology and neurobiology that has improved my clinical practice as illustrative
clinical material.
My clinical results through interdisciplinary studies
with psychiatry, experimental psychology and neurobiology neurotic with
patients with autistic barriers, justify the continuation of these studies.
I present clinical material.
Tustin contributions
This psychoanalyst dedicated most
part of her life to study the autism and presented highlight contributions. However,
psychoanalysts, psychiatrists and psychologists, despite its clinical
importance, underestimate her work.
Tustin (1990) allow us to understand the autism
symptomatology formulating her concepts of the "autistic objects" and
"autistic shapes", responsible for the development of "autistic
barriers", described in her book "autistic barriers in neurotic
patients".
For her “the autistic forms are feeling vague shapes
and originate from the 'sense' of bodily substances such as watery stools,
urine, saliva, mucus, food in the mouth and even vomiting” and "the
autistic objects have the 'hardness' as a general characteristic ...”.
In our clinic, their clinical representatives are the
encopresis, eczema, bruxism, sucking the nose or mouth with your finger, tongue
movements into the mouth and many others ills and mannerisms. These objects and
forms could include elements from the outside world, such as sounds, letters,
numbers and others, represented by geniuses of music, physics, mathematics,
literature and others.
As I see, her valuables studies needs a revision. She
attributes the mechanism of auto generation of sensations to the principle
pleasure following Freudian sexual theory. I think that really it aims the auto
appeasement as mentioned.
We observe its presence in children, adolescents and
adults with autistic traits, as to handle keys in hand, swing the legs or body,
and many others mannerisms.
Most currently, Gilbert (2005) systematized the
autistic symptoms in three areas: "sociability, language and motor skills. It
includes the area of otherness and affection".
The autistic patient lives in a world almost lifeless, frozen, and unfeeling and its central feature is an idiosyncratic organization, which have remarkable ability to manage intellectual, motor and artistic issues.
The autistic patient lives in a world almost lifeless, frozen, and unfeeling and its central feature is an idiosyncratic organization, which have remarkable ability to manage intellectual, motor and artistic issues.
Ogden contributions
Among Ogden (1989b, 1994) contributions, I highlight
the concept of autistic-contiguous position and his studies on personal
isolation, as continuation of Tustin studies.
He describes an idiosyncratic psychopathology, derived
from the precocious sensory period, autistic by being the first, of psychic
development, when there is not the presence of an ego able to differentiate
self from non-self.
In this period, there is a universe without words, ruled
by sensations. It is anterior the paranoid-schizoid and depressive
position of Klein (1963), which are associated dialectically with the
autistic-contiguous position.
Ogden believes that the auto generation of physical
sensations give the fetus or the newborn the notion of who he is and where he
is. In this period of life, there is not a psychic ego to do so, allowing us to
consider that probably these sensations as precursors of Freud's (1923) ego. It
is important to mention that there is a big difference between the concept of
biological trauma related to survival exposed here and the Freud concept of
trauma, related to ego's inability to rationalize a sexual demand, responsible
for the spontaneous neuroses.
By the way, I think Tustin and Ogden’s contributions
important for an urgent update of psychoanalytic and psychiatry psychopathology. We
need to review the classical theories on neurotic, squizoparanoid and
depressive psychopathology.
Korbivcher contributions
Korbivcher (2006), other important psychoanalyst,
follows Tustin and Ogden’s studies and discuss with knowledge and impartiality
the existence of an earlier paranoid-schizoid and depressive matrix that
generates symptoms without psychic representation.
Referring
specifically to Bion, she wrote: "I believe that when Bion introduces the
idea of beta elements, he defines an area in which we could find the autistic
phenomena, though he would not highlight, not name them. It occurs to
me, however, that beta elements do not match the autistic phenomena, because of
the later belong to the sensory sphere without any trace of a psyche. I
conjecture that there is a difference in quality between autistic phenomena and
beta elements".
My studies led me to agree with her postulations. One
has to distinguish a normal genetic line that regulates the mental and
cognitive development of the individual, following his embryogenesis, his
ontogenesis and his morphogenesis from the Bion’s beta elements concepts.
Neurobiological contributions
As mentioned the biologicals responses to trauma events
with sense of death, remains recorded in cerebral amygdala (kandel, 2000) and
constitute the implicit memory. It behaves without the interference of
cognitive awareness, the same way as the Freudian unconscious. For
example, we avoid unconsciously pathways that may bring back a traumatic
memory. This is an innate and reflex biological resource, which aims to head
biological procedures related to survival. Therefore, we name it too as procedural
memory or long-term memory.
It is present since the embryogenesis beginning and is
responsible by events of fetal life as the described autistic withdrawal and the
biological resources facing the auto appease of death anxiety.
Symptoms generated by this initial matrix have a
sensory nature and do not contain psychological repressed material, so not open
to interpretation. We should refrain us from trying to give it a psychic
representation.
For the clinical analytic work, it is important to highlight
the diagnosis of the autistic patient or the neurotic patient with
"autistic barriers" in order to avoid iatrogenic procedures.
In fact, I consider important the
need to develop new technique to treat these patients.
Others interdisciplinary studies
Others interdisciplinary studies
Recent experiences of Blackstone et al. (2005)
confirms the concept of autistic withdrawal. These authors succeeded to
prolong the life of human organ transplants for transplants using a solution of
hydrogen sulfide (H2S). They substantiate this resource through the
proved fact that H2S was responsible by cell basic metabolism of
primitive life organisms in the beginning of life on earth, when the presence
of oxygen was minimum. Through the times, it goes on to predominate, but H2S
was maintained in our body in a residual state. In case of threat to life, this
mechanism become active again with great economy of oxygen. These authors
indicates that the same process answers for animals and plants in hibernation.
However, this autistic withdrawal in live human being leaves
him partially deprived of their cognitive functions through the disconnection
of cortex neural structures from that hypothalamic (Salim, 2004b) and the
victim follows himself in an innate and reflex way by the brain neural structures
of the nervous system limbic or reptilian. This explains why the exaggerated
visceral and violent actions of autistic patient when threatened on his
frameworks. In severe cases, we can say that they become savages.
In favor of the statement of psychopathological
importance of early trauma and future developments, are the experiences of
Harlow (1958) and Levine (1997) with monkeys and rats. These authors
observed that these animals, when separated from their matrix soon after birth,
when replaced after six months, reacted with isolation and devitalization
answers. On the other hand, when separated after ten days of birth they socialized
easily, return to living with the matrices, showing that this period of ten
days after birth happens significant changes in the central nervous system,
which are responsible for irreversible responses-defenses described.
Fetal ultrasonography (Piontelli, 1997) confirms
Tustin observations of “autistic objects” and “autistic shapes", since intrauterine
life. There is a fetus activity. He scratches with your fingers his own ear,
skin, sex organs and others.
Clinical material
Case A
Maria came to me worried with her son Julius, who was
at present quite sedate by his psychiatrist. Julius had his hands wrapped in
bandages because of deep cuts due to have threw against the windowpanes and was
physically immobilized. His caregiver insisted that he had to walk as fast
as the other patients did in the morning march, as they made every day in the
house, where he spent the day with other patients. Immediately, Julius
turned on him, physically assaulted him, and then threw himself against the
window.
The mother reports that until the age of three, his
father beaten him following doctor’s recommendation for corrective treatments due
his insubordination, until became convinced that the child was sick. Their
parents thought him deaf because of the insufficient lack of answers to peoples.
Since there numerous psychiatrists and psychologists
had treated him and his personal condition was worsening. He made use of
virtually all types of medication as happens nowadays.
Asked about childbirth, Maria said it was traumatic
for her and for him and that’s pregnancy was normal. Also said that Julio
had several mannerisms, how to balancing the body, biting his nails with his
teeth compulsively and others.
I thought it was difficulty to treat him in this
moment by psychotherapy in my office. I advised her mother to come to
psychotherapy.
Case B
S is a girl of six years, movie character of “The house
of cards”. The film began with the scene taken from an ancient tree
highlighting the thick trunk. Soon, emerge various reptiles walking
around. Such a start is suggestive of the genesis of humankind from the
reptile development and perhaps the precocious autism roots.
She had experienced, along with his brother and
mother, his father's death by falling from a ruin of very high rocks, when he was
dedicated to anthropological studies in Mexican city.
Back home in America, she did not remember her house.
When back to school presented idiosyncratic isolation behavior.
On the first day of class, she climbed a tree displaying
great skill to maintain balance. This fact repeated in other scenes in the
film, like the one that rose to the roof of her house to pick up a
ball thrown by his brother that became stuck in the pipeline or when she climbed
in the metal structure of a building construction.
The school psychiatrist notified her behavior and
diagnosed as autistic. He went to her house to inform her diagnosis to her
mother, just in the moment when the girl S was on the roof of her house next to
rail. Seeing her, all fear for her. The worried mother tried to
approximate by the attic window and when S saw her, started screaming desperate
and repetitive way. All became afraid because they did not understood the
reason for her cries and feared her to fall. The psychiatrist asked those
present if they are not noticing something different on the environment and his
brother attained to the fact that the mother was using the cap with the tab
back. When she put back on the right position, indicated by the
psychiatrist, the girl screaming stopped.
At one point scene, the filmmaker displayed the fixing
girl look into the seam of the bud of a ball, highlighting it. I wrote
(Salim, 2002c) a work named “Patches for a sensory surface”, in which I described
various symptomatic procedures and reflections by people seeking appeasement to
the anguish of death. I quote the symptoms as continuously talking or looking,
the obsessive manipulation of cellphone, and other accounts.
In another scene, his brother goes on into her room,
where she had isolated. Inadvertently, he knocked into a hub between the other
two. This falls and she began to scream the same way as she had done
before in the roof gutter. Her brother distressed, not knowing how to serene
she until he replaced, by casual, the cube in its correct position and she
became silent.
Finally, mention is made of the balance achieved with
the cards in the deck, which gives its name to the film.
I explain autistic skill as a demonstration of
continuous exercise the fragile psychological equilibrium obtained to feel safe
against the threat of death or madness. Keep everything as organized is
important to dispel the fear of impending death, just as his father died of an
imbalance. This idiosyncrasy refers to the need for delicacy and the
necessary tuning of the therapist to formulate the interpretation, making sure
that it is not violent for the patient.
At this point of the film, she was already receiving
therapy at school through exercises in which was encouraged to make personal
and verbal contact with the psychiatrist, that awards to her autism a
neurological nature. He was impatient in the absence of girl's response,
which in turn got angry and aggressive with him. The mother disagreed with
the opinion of the psychiatrist, who assigned the patient's behavior to a
neurological factor that cannot define. She strongly supported the belief
that her daughter was so because of the trauma of the loss of her father. She
was convinced that S needed empathy.
She started with his ability to make projects to build
a spiral with heavy material plates similar to that S had made with the cards and
at the end, the girl responds to her mother's attempt to understand her with the
end of the disconnection state.
I
understand this upward spiral as representing materialized desire to reach the father
in heaven and her continuous effort to leave the autistic position, where she
took refuge after his death.
Case C
R looked for my help when he was 30 years age. I made
the diagnosis of paranoid schizophrenia and soon after, he was retired from his
job. I started to treat him with two weekly sessions and drugs as olanzapine
and bromazepan.
He came to me because of voices he heard that
threatened and underestimated him. He admitted that they were voices of
spirits who came out ordered by the former bride father, as retaliation for the
termination of his engagement with her daughter. He lived since them
inside the room, only left to come to analysis. After two years of
treatment, he accepted the interpretation that voices were emanating from
within, a fact that changed the course of psychotherapy and his worries.
Even today, the patient hears expressions or words
that arise unexpectedly, with warning content or unworthiness. These happens more
spaced out and attenuated in intensity, over which S talks in the sessions and
shows, with great certainty, that the heard accusation, for instance, has not be
with him. The patient recovered the friendly contact with the family,
while spent most of the time inside the room, no one has access environment for
years. He does the housekeeping of his room, maintaining own material
(broom, mop, disinfectant, fertilizers, etc.) independent of those used for the
entire apartment cleaning. Your room was full of everything he joined with
little space to him walk. We hear and read news from television and newspapers
of peoples with these traits.
This room works as your second skin, according to Bick
(1968, 1986), a leading British psychoanalyst, contributing effectively to the
understanding of autistic psychopathy. This second skin brings is related to
the feeling of lack of protection from the helplessness and loss of the sense
of physical and psychological cohesion.
R never missed the sessions with me. He come driving
your car and park it always on one side of the street, forcing him sometimes to
give followed returns around the block. Troubled with this difficulty,
responsible for some delays in the session start time, once I suggested to him
to park the car in parking lot next to my office and he went angry with me,
indicating that I should not interfere in this matter. Similarly, only up
the elevator if it is empty and many times, he had to wait for this. R
gives up this mannerism, only when he realizes that the movement of people to
take the elevator is making him late for the session.
He handle by himself the money and payment of the
sessions.
At the beginning of treatment, it was difficult to
help him because of his slowness. His speech tedious and enigmatic sense transmitted
segmented and confusing content, difficult to understand. It was
repetitive and had slow modulation, which caused me sleepy sometimes difficult
to disguise.
Later, after my interdisciplinary developments that
began to help me with the patient, he makes surprising clinical recovery. I
observed that when I interfered with his speech, using a term without keeping
the same sense, R reacted with displeasure. I learned with him, it was
best to leave it without interfering in their attempt to understand the voices
and hearing expressions ears. He had his own way of organizing
psychically. Every word, even today, must have precise
meaning. Therefore, I elect to stay without understanding his speech, without
feeling exhausted, insufficient and sleepy, and this allow me to stay more
integrated during the session.
Quite significant is the positive way, like today, he
react to voices, who send him move away from me and from treatment because of
the understanding of his improvements and the feeling of trust established in
our relationship. These one founded on the regularity of setting that
includes my speech, my eyes and myself.
In some sessions, reports the presence of smells and
sounds inside and outside the office, a fact that I understand how sensations
activated to feel more cohesive.
Case D
L was fourteen when she was hospitalized because
physically assaulted her mother, escaped home, put fire in household objects,
cut herself with sharp objects, moved her body to front and back, beat her head
against the wall and tried to self-extermination with psychotropic drugs. These
violent actions alternated with periods of apathy, drowsiness and symptoms of
Anorexia Nervosa.
Her mother asked me to assist her. I went to hospital
and found that she had not any cognitive impairment, was emaciated, did
continuous rhythmic movements to curl the hair with her fingers and she had movements
of body and legs.
She
reported me that her mother since childhood hatred her and vowed that she will
revenge the physical abuses she submitted her.
I found in her medical slip the diagnosis of
schizophrenia or bipolar disorder. Psychiatrists could not determine the
diagnosis and drug prescription was continuously changed. My diagnosis was
autistic psychopathology associated with hyperactivity alternating with immobility. After
a few meetings, I established a basic trust of L with me, she get better and
went to home.
The first sessions in my office were difficult as I
expected. She insisted the mother's presence in them to convince me that her
mother did not understand her. With fine sensitivity, forced the mother to
say in front of me how she was feeling L. On these occasions, the mother
was confused. L said then that her mother had never understood or wept for
her.
In one session alone with me, she turned violent because
perceive that I was not paying attention to her. She tried to grab me by the
neck. I restrained her and told her that in fact had distanced her as she
spoke. This confession calmed her, giving a certain lucidity hit by observation. After
this, she became more docile with me and began moves to isolation and
immobility. When laid down in the couch she took the pillows in her arms,
contact that generated an autistic form of appeasement and so remains all the
session.
In another session, she drove up to the office’s bathroom
and closed the door. Earlier I was concerned about her stay there, but
then I understood this action as a desire to be alone, meeting their demand for
autistic withdrawal, probably caused by a look or talk of me out of tune with her.
On one such occasion, she told of an overwhelming desire to stay in bed all day
and described dreams that had not strength to move her arms and legs. These
were indicative elements of their tendency to autistic immobility.
In a session started feeling abdominal pain while on
the couch, which was accentuating and she fainted. These episodes had been
happening outside the office frequently and the family understood them as
personal settings to impress. The author understood these fainting as
result of a physical failure of the state to deal with her anxiety. She disconnected
and faint. These understanding keep me quiet, holding her hands and giving
her time to recover.
In another session, L made the report of nocturnal
enuresis and intense sweating, "autistic shapes" by engaging soft
body elements such as urine and sweat, as producers of sensations on the skin,
such as the cushion on the couch.
Then she mentioned auditory hallucinations, which
referred to the people pursuing her. I told her that because her state of
immobility and helplessness she really wanted to be met.
After four months, L began to show signs of more
stability and confidence in her ability to understand. She went on to show
brilliant culture to their chronological age. She knew the Egyptian
mythology, Greek mythology and knowledge of English language.
Two years later, she was able to return to social and
scholar life.
Conclusion
I think in nature everything tends to go well,
including the necessary changes as development of motor skills, thinking,
judgment, orientation in time and space, language, and others, each in its own
time and without disturbance.
If there are adversities and I am here considering the
prenatal, perinatal or initial postnatal period of life, as a physical,
infectious, toxic or other traumatic event, there will be activation of innate
biological responses to preserve life and to auto appease the victim from death
anxiety.
These ones contribute to a slow biological and newborn
psychic development, as Zuquer (2007) observation of some infants are born with
autistic traits. They are slower, sleep longer, present difficulties to catch
the mother's breast nipple and are less responsive to external stimuli, among
others.
If the mother do not understood these difficulties, it
happens to fail in object relations from the beginning, contributing for the
development of a paranoid-schizoid and depressive psychopathology. The
chaos instituted only finishes when they are properly cared for, as Winnicott
(1975) emphasized.
Autistic symptoms are few identified in the newborn by
parents and experts. Such unawareness fosters difficulties for their
caregivers, usually mothers, who ends up in failure in holding process
(Winnicott, 1975). This fact is disastrous for these babies, because the
external caregiver is critical to make possible a reorganization of the
biological and psychological disorders that trauma triggered.
This is an important reason to consider the
Psychoanalytic Psychotherapy as basic for this patient. The regularity of the
setting provided by the psychoanalyst with a rhythm, regularity and constancy
generates basic security for post-traumatic patients, especially the autistic
ones. It allows ending the trauma disorders between the cortical nervous system
structures and that of hypothalamus achieving the mental processes related to
cognition.
It is very important the therapist have a mind during
all the therapeutic process that the autistic patient is feeling in fragile
balance between death and life and between madness and normality. This is the
reason to respect his mannerisms and idiosyncrasies.
According Korbovicher (2015) there are reports from
their small patients of sleeps with water, reptilian animals, all primitive
elements of our phylogenies related to the beginning of life on earth,
demonstrating the primitive roots of autism.
I think it is important a broader discussion of autism
between psychiatrists, psychoanalysts and neurobiologists to continue these
studies in order to understand the complex autistic symptoms and to treat these
patients.
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