Autism etiology: a hypothesis traumatic

The autism etiology: a traumatic hypothesis

                                                         * Sebastian Abram Salim

* Didactic Psychoanalyst Psychoanalytic Society of Rio de Janeiro
*    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.

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.

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

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.

Bibliography
1. Bick, E. (1968). The experience of the skin in early object relations. International Journal of Psychoanalysis, 49, 484-86.

--------- (1986). Further considerations of the function of the skin in early object relations. British Journal of Psychotherapy, 2, 292-299.

2. Blackstone, E; Morrison, M; Roth, M. B. (2005) Hydrogen Sulfide induces the suspended animation-like state mice. Science, 308, 518-525.

3. Freud, S. (1923). The Ego and the ID. Brazilian Standard Edition of the Complete Works of Sigmund Freud. Vol.19. Rio de Janeiro: Imago.

       4. ------------- The ways of formation of symptoms. Brazilian Standard Edition of the   

       Complete Psychological Works of Sigmund Freud. Vol. XVI. Rio de Janeiro: Imago;

       1976.               

5. Gilbert, C. (2005). Autism spectrum disorders. Lecture on 10 October 2005 in the Auditorium of INCOR, Sao Paulo.

6. Harlow, H. (1958). The nature of love. American Journal of Psychology, 13, 673-686.

7. Kandel, E.  (2000). Biology and the future of psychoanalysis: a new intellectual framework for psychiatry revisited. Journal of Psychiatry Rio Grande do Sul, 25 (1), 139-165.

8. Klein M. (1963). Envy and Gratitude. Rio de Janeiro: Imago.

9. Korbivcher, C. F. (2006). The mind of the analyst and the autistic transformations. Journal of Psychoanalysis, 39 (1), 113-130.

10. Korbivcher C, F. (2015). The primitive mind and impediments to the ability to dream. XXV Brazilian Psychoanalytic Congress held in Sao Paulo. Brazil

11. Levine, S. (1962). Infantile experience and resistance to physiological stress. Science, 135, 405-406.

12. Ogden, T. (1989b). On the concept of an autistic-contiguous position. Journal of Psychoanalysis, 30, 341-364.

13. ------------ (1994). Personal isolation: the collapse of subjectivity and inter-subjectivity. In the subjects of psychoanalysis. Sao Paulo. House of Psychologist.

14. Piontelli, A. (1997). L'Observation des Jumeaux dès avant and Naissance. Baby dans tous le ses Etats (p. 41-48). Colloque Gypsy II. Paris: Éditions Odile Jacob.

15. Salim, S.A. (2004b). The trauma and the Disconnection. Revue of the Psychoanalytic Society of Rio de Janeiro, 5, 99-12.13.

16. ----------- (2002c). Patches to a sensory surface. Journal of the Brazilian Society of Porto Alegre Psychoanalysis, 4, 437- 449.

17. Tustin F. (1990). Autistic barriers in neurotic patients. Porto Alegre: Medical Arts.
18. Winnicott, D. W. (1975). Transitional objects and transitional phenomena. From Pediatrics to Psychoanalysis. Rio de Janeiro: Francisco Alves.

19. Zucker, N.L, et al. (2007). Anorexia Nervosa and autism spectrum disorders: guide                   investigation of social endophenotypes. Psychological Bulletin, 133