There had been a great deal of debate regarding whether Sherlock is on the autistic spectrum.
I decided to ask the professional opinions of three psychiatrists specializing in autistic spectrum disorders, who also happen to be Sherlock fans, on whether Sherlock has autism or Asperger’s Syndrome.
- A consultant psychiatrist specialising in diagnosing autistic spectrum disorders in adults.
- A consultant child/adolescent psychiatrist
- A neuropsychiatrist currently researching Asperger’s Syndrome
A Disclaimer Before we Start
I hesitated a lot about publishing this: firstly because I’ve had so much hate mail over Sherlock and Asperger’s and secondly because this article is about to get me much more. The professional opinions of these psychiatrists may be very hard to read for a lot of people on the internet but I felt that so much of the debate is being conducted with any expert knowledge this needed to be out there.
All three doctors wanted to remain completely anonymous for understandable reasons. I actually talked to several other doctors but none of them wanted to be part of this article. I am afraid you will just have to trust me on the reliability of what I write. All of us are essentially anonymous on the internet, it is only fair that I extend this privilege to the people who will be “talking” to you through this article.
The writing below is not a transcript of our conversations – some of it has been paraphrased by me to fit into the same format; personal names, details etc had been removed. It’s not possible to give an exact transcript because the writing is a compilation of conversations held over several months and contain a great deal of confidential information, as well as digressions that have nothing to do with Sherlock.
My personal notes and explanations for readers are in square brackets.
The Specialist in Diagnosing Adults with Autism and Asperger’s
[Some background information: in the UK all psychiatrists are qualified medical doctors i.e. they have a medical degree. Only psychiatrists are allowed to diagnose serious and/or chronic psychiatric disorders such as autism or Asperger’s. Both autism and Asperger’s belong to the group called: pervasive developmental disorders. The vast majority of patients with PPD are diagnosed in childhood]
[I asked him to describe what he does for the benefit of readers]
I specialise in diagnosing pervasive developmental disorders in adults, though it’s not the only aspect of my job [depending on where a psychiatrist works, they may also do quite a lot of general adult psychiatry in hospital and/or the community as well] . My team and I are basically catching the people who were never given the opportunity to see a psychiatrist as children. About 80% are referred query Asperger’s and 20% query autism.
The majority of people I see are perfectly “normal” if slightly eccentric individuals. Somewhere along the line, a friend, relative or co-worker has come up with the bright idea of labelling their eccentricities “Asperger’s Syndrome” or “autism”. This is understandably very distressing for my patients and the best part of my job is when I can help alleviate their worry.
The people who don’t get diagnosed still have real problems, just not problems the NHS can help with and the worst part of my job is telling some patients who want a diagnosis that I cannot give an explanation for why they have such difficulty negotiating the trials of life.
[The psychiatrist’s view on Sherlock]
When I first watched season one, it struck me that the writers wanted the best of both worlds and this translated into a somewhat jumbled set of directions for the actor.
In some parts the actor really tries to emphasize Sherlock’s ignorance of the nuances of human social interaction and then five minutes later he is able to manipulate people into spilling their secrets or letting him into an apartment building. One moment he’s having symptoms of withdrawal [in reference to the scene in THoB when Sherlock is looking for his cigarettes], displaying aggressive agitation, and then suddenly he’s perfectly fine.
True addiction doesn’t work like that but it’s TV and I believe in artistic license. I’m happy to suspend my disbelief for the entertainment. What frightens me is when people actually starting thinking this character represents any kind of psychiatric disorder.
In my career I’ve seen hundreds of adults with actual undiagnosed Asperger’s Syndrome. Sherlock just doesn’t have undiagnosed Asperger’s. He’s not on the spectrum.
I find it disturbing that people jump to this conclusion so quickly and definitely. I’m not just talking about tumblr [This really amused me: apparently he has read some of the tumblr posts about Sherlock and Asperger’s], I walked in one morning and [the clinical psychologists] were talking about how Sherlock had Asperger’s!
[To put this into context: clinical psychologists are not allowed to diagnose patients with Asperger’s Syndrome because they are not doctors and have not had the same specialist training as psychiatrists. They are definitely an invaluable part of the psychiatric team, as they provide all kinds of therapy.]
In the case of Sherlock, people seriously need to stop saying that he has Asperger’s Syndrome, it’s giving the general public a misconception of how the condition actually presents in adults. Since Season 2 came out I’ve actually seen two patients who thought they had Asperger’s Syndrome because they saw a resemblance between their behaviour and Sherlock Holmes’!
People who post things on the internet and make TV shows may not realise this but their actions have real consequences for real people.
[I felt rather guilty at this point (even though I always argued that Sherlock wouldn't be diagnosed with Asperger's) because I hadn't really considered people would take my writing to heart]
Much of the stuff that has been written about Asperger’s is just wrong, but I can’t control the internet and I can only hope that everyone learns to properly evaluate the information they read.
I’m sure if Sherlock was a real patient some easily confused GP might refer him to me as potential patient with Asperger’s. If anyone writes “query autism” in the referral letter I would personally report them to the GMC for gross incompetence.
[Explanation: the GMC is the general medical council and it regulates all doctors in the UK. Professional misconduct and/or incompetence is reported to the GMC, which then looks into each individual case. It reserves the right to strike doctors off (i.e. revoke their medical liscences)]
Autism is out of the question – even the medical students should know that.
I assume the writers just wanted to create a genius with bad social skills. It’s a kind of media fad, everyone likes a flawed genius because you can admire their intelligence but then still feel good about yourself because at least you have better social skills.
[I inform him that many people with Asperger’s believe that Sherlock has Asperger’s]
It’s understandable but they are approaching the subject from a biased view point. Even if I thought I might have Asperger’s Syndrome, I wouldn’t diagnose myself; I’d see a qualified colleague. This is because I can’t have an impartial view of myself. It’s almost impossible not to see something of ourselves in fictional characters. Sherlock sometimes displays characteristics that appear in Asperger’s Syndrome but these characteristics aren’t just specific to Asperger’s. Having a stomach ache doesn’t mean you have appendicitis, having a headache doesn’t mean you’ve got migraine.
[I asked him what he thinks of other characters]
The only person who really needs to see a psychiatrist is Moriarty. In the BBC adaptation he’s definitely got psychopathic personality disorder with a whole load of co-morbidities on the side. Even though I’m not an expert on forensic psychiatry [the psychiatry of crimes and criminality] I would recommend indefinite detention in a high security mental institution for this guy.
[I’m so please he said this because it vindicates my diagnosis of Moriarty in this meta (Jim Moriarty…Hiiii)]
The Child/Adolescent Psychiatrist
[Information about the job – this doctor diagnoses psychiatric conditions in children. A significant aspect of his work is diagnosing Asperger’s and autism]
I have been doing this job for over 30 years. When I first qualified, Asperger’s Syndrome didn’t even exist as a separate diagnosis and now we’ve come full circle. DSM-V [the diagnostic manual published by the American Psychiatric Association] will join autism and Asperger’s as one condition but in the UK, Asperger’s Syndrome will stay as a separate diagnosis at least for the near future.
Asperger’s/autism receive a lot of media attention today – about 30 years ago most people hadn’t even heard either of these terms. It’s not necessarily a good thing; the media gives people a very skewed idea of what pervasive developmental disorders are really like. It’s also become a very emotive topic.
[I asked him whether Asperger’s/autism was a disease]
By including Asperger’s/autism in the International Classification of Diseases – psychiatrists are saying that the symptoms which make up these conditions are the result of an underlying disease process.
But many people don’t like the social implications of the world “disease”.
It's understandable that which is why I don't say to the parents that Asperger’s is a disease, which is still true because Asperger’s Syndrome is just a collection of symptoms. I don’t talk about the possible pathology behind the symptoms unless someone specifically asks.
[Views on Sherlock having Asperger’s/autism ]
I don’t diagnose Asperger’s adults - that requires a different set of criteria. Presentation of autism, on the other hand, is quite similar in adults and adolescents.
I can say that Sherlock definitely doesn’t qualify for a diagnosis of autism and he never will. You don’t need to watch a whole episode to come to that conclusion. As for Asperger’s, it’s highly unlikely. We never get to see what the character is like in his youth so I can’t say for sure. I’ve had the joy of watching many patients grow up to lead successful lives but none of my patients with Asperger’s has yet to turn out like Sherlock.
The general public have some strange ideas about Asperger’s Syndrome. When I mention the term, many parents think that their child will become a genius with bad social skills.
In reality 99% of my patients have normal intelligence, even if their parents refuse to believe it. Having Asperger’s does not make you any more likely to be a genius but it can give you an advantage on the non-verbal reasoning bits of standard IQ tests. But IQ tests are really bad at measuring high intelligence – they are really only good for giving an indication of who needs support for learning disabilities.
Most of my patients develop quite good social skills. They can seem a little forced at times but it’s just wrong to say that people with Asperger’s cannot learn good social skills, they can and they do. Many patients go on to become integrated and valued members of their communities with the right support. Few of my patients would ever be as rude as Sherlock and their rudeness is not a manifestation of their Asperger's.
[Views on other characters]
I personally don’t like how they remade Moriarty – he’s supposed to be this brilliant, ruthless, psychopath hiding behind a veneer of respectability. The most chilling thing about Moriarty was that he looked so respectable, held such a high position within society and no one even suspected what lurked under the surface. Conan-Doyle wrote him as a perfectly sane man – the new show makes Moriarty out to be some sort of unhinged, psychotic maniac and it just takes so much away from the original character.
[Background job information]
Psychiatry and neurology really belong to the same branch of medicine. My job is trying to integrate our psychiatric and neurological knowledge to improve our understanding of psychiatric illness. Psychiatry at the moment is stuck in the 19th century – diagnosing patients without really understanding what the underlying problem is. The conditions are grouped based on symptoms and not pathology.
I see patients and I do medical research. Just about every consultant in this hospital has [scientific] publications in respected journals; most of us have PhDs too.
Most of my colleagues specialise in epilepsy and brain injuries. I did my PhD on Asperger’s Syndrome and as a consultant I want to go back into this field.
My proposed area of research is the functional differences in the brain between “normal” people and people with Asperger’s Syndrome. I am currently collaborating in a minor capacity with [name omitted] using PET scans [these scans show which parts of the brain are most active] to image brain activity in response to social situations that require empathy. It’s all very artificial – but preliminary data supports earlier findings: there is a functional difference in brain activity between the two groups.
[One of the earlier papers she might be referring to can be found here, I never got around to asking her for references]
This isn’t really news, several other studies have made this conclusion before us but I want to investigate exactly where the functional differences lie and whether the pattern is consistent within a large a group of Asperger’s subjects and if can it be altered by intensive therapy. I’ve yet to get enough funding, but fingers crossed.
[Views on Sherlock]
I love BBC's Sherlock! [She insisted that I put this in] Benedict Cumberbatch is gorgeous! [I chose to quote her on this]
If Sherlock was a real patient, I’d never diagnose him with any psychiatric condition. If I had to present a differential diagnosis for him: I’d put several personality disorders before Asperger’s Syndrome.
[A differential diagnosis is just a list of likely things a patient might have, in order from most likely to less likely]
[I personally think Schizoid Personality Disorder should come top of the list (Schizoid not Asperger’s)]
I mean Asperger’s would be on the list, just because you need to be thorough, but it doesn’t take much experience to exclude him. If the writers of the show actually wrote Sherlock with Asperger’s Syndrome in mind, I’d be very angry because they really haven’t done their research. I mean if I try to interpret Sherlock as a person diagnosed with Asperger’s, I just end up thinking the writers are trying to make psychiatrists look incompetent.
Asperger’s Syndrome and autism are often misrepresented. TV likes extreme cases – maths geniuses with amazing IQs, child prodigies with specific talents, sensational things. I mean they need ratings. Sadly for most people that’s the only exposure they have and they just get really strange ideas. A paediatric psychiatrist friend of mine met a mother who thought her child had Asperger’s because he was good at maths! You have to wonder what GPs are doing these days.
[To clarity: you can only see a specialist doctor if you are referred by your GP, therefore in this case the mother had to convince the GP her child might actually have Asperger’s Syndrome first]
The Consultant Psychiatrist Specialising in Learning Disabilities
[I didn’t include this interview in the original post because I felt some of the views on emotive topics would produce a backlash but after an overwhelmingly positive response on Livejournal I have decided to include this because it adds a different dimension to the debate and also we had a discussion about Molly and female doctors in the media.]
I’m not a psychologist, so many people I meet, including my patients, seem to think that psychologists and psychiatrists are the same thing. We’re really not.
I’m a doctor – I diagnose the patients, prescribe drugs and devise management plans. I work with clinical psychologists because therapy is a large of part of psychiatric treatment but I don’t actually perform therapy.
The majority of new patients have learning disabilities with no know underlying cause. It is my job to diagnose the cause and find the best way to support them. I do diagnose adults with both autism and Asperger’s Syndrome, it’s an integral part of my job, but not as commonly as [the specialist psychiatrist in diagnosing adults with autism and Asperger’s].
My patients with Asperger’s Syndrome don’t have learning disabilities; they all, by and large, have normal IQs [70-110]. These patients have specific areas of learning difficulties, which is usually the reason why some of them don’t really reach their full potential in school. The state school system in the UK is really bad at catering for pupils with specific needs – everyone has to fit the same educational mold.
We provide them with expert support so that they can reach their full potential as adults. We have a large multidisciplinary team including occupational therapists, psychologists and psychiatric nurses to help in this endeavour.
Patients with autism usually come with the condition already diagnosed in early childhood. My job really is to devise the best plan to help them live independent and fulfilling adult lives.
[Views on Sherlock]
I have to say I do not like the BBC adaptation [this is why I was hesitant about publishing this]. For want of a better phrase: Sherlock is a completely arse. Conan Doyle’s Holmes was eccentric, unconventional, an extreme introvert and, in my professional opinion, bipolar but he is never deliberately discourteous or cruel. This modern version of Sherlock Holmes is self-centered, deliberately rude, inconsiderate and sometimes just plain nasty.
I mean in the first ever episode, he drags out a police officer’s sex life in front of all her colleagues at a crime scene! Sure, the police officer wasn’t that professional but Sherlock was much worse than unprofessional. The general impression of this new Sherlock is a person with a maladaptive approach to interpersonal relations. I can understand why people are looking around for a psychiatric illness.
Sherlock does not have Asperger’s Syndrome. I have watched all six episodes, that's 9 hours of footage. For anyone who says you can't diagnose a TV character because you don't see enough of them, that's just not true. I usually get an hour to an hour and a half max to diagnose a patient with Asperger's Syndrome. It may seem quite short but it's more than enough time to get the right information, you just need to know what to look for and that comes with experience. After 9 hours of watching Sherlock...I've definitely seen enough to say he doesn't have Asperger's.
His bad manner and general rudeness are not signs of Asperger’s Syndrome. My very real patients have all sorts of different personalities, the vast majority of them are: polite, considerate and well mannered people. They work very hard to be socially accepted. I have yet to meet a patient with Asperger’s who behaves anywhere near as appallingly as Sherlock.
I understand why people want to use Sherlock as a “poster boy” for Asperger’s Syndrome. It would be one very high profile way of getting others to understand the condition. I also understand how important it is for people with Asperger’s to be able to identify personally with a mainstream media character.
But Sherlock cannot and should never be allowed to represent Asperger’s Syndrome. This is would be a perversion of how the condition truly presents in adults. It would only add to the tangled maze of misconceptions the general public already have and produce a generation of people who are convinced they have a psychiatric condition when they do not.
This isn't about taking Sherlock "away" from people with Asperger's, it's about not using him as an example because he just isn't one. It's a bit like telling medical students jaundice is a sign of kidney failure [jaundice is when you turn yellow mostly due to liver failure], it would be a lie but they don't know that and they continue propagating this misinformation until real harm comes to a real patient.
[Views on other Characters]
I don’t understand why people don’t like Molly Hooper. I like her because she’s a doctor [for more information read Meet Miss Molly Hooper] but she’s also human. TV programs tend to portray female doctors as either: competent and utterly professional or incompetent and emotional. Seriously, we are people too! We can be professional and emotional. Why aren’t we allowed a private life? Why is it if female doctors have a crush on a hot guy it suddenly makes us less strong, independent professional but when the media portray male doctors flirting with nurses it somehow adds to their “personality”.
Double standards much? Molly deserves so much more credit than anyone has ever given her.
Most of my Sherlock metas were written before I went in search of psychiatrists who had watched Sherlock. If you think that the content has similar themes and ideas to my personal metas – I am most honoured. I have done my revision well, and I have been vindicated by the actual doctors.
I never thought what we write on the internet can have such a profound effect on people until I talked to these psychiatrists. I realise I have never said this before: please do not try to diagnose yourself or others around you with the diagnostic criteria I have published in my metas.
It’s takes more than the ability to read to diagnose a psychiatric condition.
Please do not take my metas that seriously either. They are just for entertainment.
Sherlock is a fiction character. Do not use him as a template for what you think Asperger’s Syndrome or Schizoid Personality Disorder or Sociopathy (which doesn’t actually exists as diagnosis) or any other psychiatric condition presents.
Hate mail is not welcome. If you do not agree with the professional views of these doctors then that is your prerogative. Please do not waste your time denigrating the medical profession and flaming me with your messages. It will not change psychiatry.