(This is the third of a three-part series. The full version is available under the "Articles.." section <-- to your left)
I want to make a few things clear here: I am not claiming that every parent in this study who was diagnosed as schizophrenic was misdiagnosed. I don’t doubt that there could be a correlation between schizophrenia in parents and Autism in their children. However, I am saying that any correlation this study claims is probably not nearly as strong as suggested. I suspect that it is highly probable given the timing of the study and the diagnostic tools available at the time, that at least some of the parents may in fact have Autistic Spectrum Disorders (ASDs) as opposed to true schizophrenia.
Epidemiologist: A person engaged in epidemiology (not confined to epidemics). Epidemiologists include people with an M.D., Ph.D., D.P.H. (Doctor of Public Health), M.P.H. (Master of Public Health), R.N., and a number of other degrees.
So I suppose Epidemiologists are kind of like the actuaries of the medical world. They assess risk. They are essentially number crunchers, not diagnosticians. They are much needed to track progression and potential distribution patterns of transmissible diseases such as flu and SARS. Their science works very well for this kind of information, because most of these diseases tracked are easily identifiable, and there are definite tests for them.
However applying the principles of epidemiology to something like the Swedish data is fraught with error potential. Especially when you consider the timeframe and the fact that several of the diagnoses in question did not exist for a lot of the first generation in the study. I think this means that the data sample is more than likely tainted, and Dr Daniels, -not being a psychologist, a psychiatrist or a neurologist, is not qualified to determine which of the cases (sorry . I cannot bring myself to say “cohorts”) in each dataset are real, and which may have been misdiagnosed.
Therefore I think Dr Daniels –in attempting to look purely at numbers- overlooked some circumstance of history and climate in Sweden at the time, and failed to establish if the diagnoses which may have been made years ago would hold up today, given the advances made in psychiatry and the changes in thinking which have transpired in the intervening years.
So in my opinion, the whole study was built on a house of cards. I would love to see someone like Dr Fitzgerald (keep going, he appears a bit later) get a hold of it.
...and speaking of him: I promised you some backup for me theory, didn’t I?
Well, I wondered if my hypothesis could be correct: i.e. that some people with Autism could have been misdiagnosed as schizophrenic, especially some years ago, before Autism made it onto the map –so to speak.
This is also an important limitation of the DSM system. Patients sharing the same diagnostic label do not necessarily have disturbances that share the same etiology nor would they necessarily respond to the same treatment. It is therefore critical to understand that the diagnostic terms and categories in the DSM represent only our current knowledge about how symptoms cluster together. We fully expect that, over the coming decades, the DSM system will be radically reorganized as the etiologies of mental disorders become better understood.
Recently, I found an interesting paper published by a couple of my countrymen a few years ago. It is a great read about how Asperger’s syndrome can be mistaken or misdiagnosed, and outlines the potential misdiagnoses and the differentials. Here is a excerpt from that paper.
Schizophrenia is a disorder in which psychotic symptoms (delusions or hallucinations), thought disorder and so called 'negative symptoms' cause social and/or occupational dysfunction over time. Because individuals with Asperger syndrome have normal cognitive ability, restrictive behaviours and impairments in social interaction and communication can be misinterpreted as evidence of schizophrenia. People with Asperger syndrome have difficulty understanding the subtleties of social behaviour, but this should not be confused with evidence of psychotic disorder. In a clinical setting, asking individuals with Asperger syndrome whether they hear voices may induce a positive response, and they might concur that they hear voices "when people aren't there", but they may be refering to the voices of people in an adjacent room. Deficiencies in concrete thinking and in understanding how other minds think may cause patients with Asperger syndrome to misinterpret what is said to them, and they might as a result be labelled paranoid. Misinterpreting social contacts can also lead to inappropriate emotional responses, contributing to this impression. Persons with Asperger syndrome sometimes speak their thoughts out loud, which again can be misinterpreted by a psychiatrist.
That is interesting, isn’t it? There’s more..
Schizoid personality in childhood (DSM-IV)
Schizoid personality in childhood is defined by solitariness, lack of empathy, emotional detachment, increased sensitivity, at times paranoid ideation, and single-minded pursuit of special interests. All these features are seen in Asperger syndrome, and comorbid issues (depression or behaviour problems in particular) are likewise similar for both conditions. On the basis of evidence presented in Wolff's (1998) discussion of schizoid personality in childhood, we have concluded that there is significant overlap between schizoid personality in childhood and Asperger syndrome.
Schizotypal personality disorder
The DSM–IV diagnosis of schizotypal personality isorder depends on odd beliefs or magical thinking, bizarre fantasies or preoccupations, odd thinking and speech, odd, eccentric or peculiar behaviour and appearance, lack of close friends and social anxiety. All of these criteria can also occur in Asperger syndrome, and Wolff (1998) regards "Asperger syndrome and schizoid/schizotypal disorders as interchangeable terms that identify roughly the same group of children". The conditions do differ in at least three important respects. First, there appears to be an increased rate of develop-ment of schizophrenia in schizotypal personality disorder. Second, schizotypal personality disorder and schizophrenia co-occur in families and appear genetically related. Third, prospective research of children at high risk of schizophrenia (Erlenmeyer-Kimling et al, 2000) suggests that some individuals later diagnosed with schizotypal personality disorder developed without impairments in reciprocal social interaction and communication.
And here is some interesting information that it can and has happened, even here in the States:
"David Mandell, an epidemiologist at the University of Pennsylvania medical school, recently surveyed the adult patients in Norristown State Hospital in Eastern Pennsylvania, nearly all of whom are labeled schizophrenic, and found that about 20 percent of them meet the behavioral criteria for being autistic."
...and a link to the Full Article http://www.post-gazette.com/pg/08037/854963-114.stm
You know, The more I dig into this issue and the more I question it, the more it seems very likely that Julie Daniels study had grossly exaggerated many of the numbers and ratios regarding parental mental illness and autistic children I believe history will show a more logical conclusion; that parents with an Autistic Spectrum Disorder (ASD) are more likely to have children with an Autistic Spectrum Disorder. I hope it will have a positive effect (negative for Dr. Daniels) of highlighting how misunderstood was Autism in the past, and how many ASD people –now adults- were misdiagnosed as mentally ill in the not-very-distant past.
Now, I gave Julie Daniels a chance. I read her full article on the Pediatrics Website (linked below), I figured somewhere in there she would give some kind of a nod to the fact that she was comparing contemporary apples to historical oranges. The only thing I found is this:
"Diagnostic practices in psychiatry continue to change, and case definitions become more narrow for both adult and childhood psychiatric disorders. Thus, it will be important to assess the relationships between parental psychiatric disorders and an offspring's risk of autism in other data with more detailed and complete ascertainment of psychiatric disorders for parents and offspring."
No shit, Sherlock.
Well Julie,. Perhaps you should have thought of that before you set a whole generation of parents –who have quite enough on their plates already, -thank you very much –back about 60 years.
Why not just be done with it bring back the term “Refrigerator Mother”?
I just thought of a new name for Dr. Daniel’s study. “Researcher vacuum-sealed researcher reinvents the refrigerator parent”.
Thanks, Julie Daniels. Thanks from the bottom of my arse.
Text of the study in Pediatrics magazine http://pediatrics.aappublications.org/cgi/content/full/121/5/e1357
Diagnosis and differential diagnosis of Asperger’s syndrome by Michael Fitzgerald and Aiden Corvin http://apt.rcpsych.org/cgi/content/full/7/4/310
The ICD-10 http://www.who.int/classifications/apps/icd/icd10online/
The DSM-IV-TR http://www.dsmivtr.org/index.cfm