wellingtongoose (wellingtongoose) wrote,

Walking Nightmares for Medical Student - In Defence of Sherlock and Mycroft's Normalcy

Warning: Semi-professional rambling ahead

Having read many comments, posts and extended essay on the subject of the Holmes Brothers and their myriad of psychiatric problems – I feel that I too should throw something into the psychoanalysis pot. In my case it’s going to be a much loved copy of the Oxford Handbook of Psychiatry. I explore Sherlock's "autism" and his incredibly arrogant declaration of being a "high functioning sociopath".

As a medical student everyone is compelled to study psychiatry (if only to pass finals) and unfortunately once psychiatry gets into your brain it never truly leaves you. You find yourself reading ICD-10* (the European equivalent of the DSM-IV diagnostic manual for mental illnesses) in the morning – only to diagnose yourself with ten different disorders by lunch time. It’s called Medical Student Syndrome. Sadly this illness seems to have affected Sherlock and Mycroft by virtue of being over psychoanalysed. Between them,  I believe they have managed to rack up: sociopathy, psychopathy, narcissistic personality disorder, autism and Asperger’s syndrome to name but the most common diagnoses.

*A side note on diagnostic manuals – they are the Bible of psychiatry. Most of the world uses ICD-10, which is produced by a convention of world leading psychiatrists and endorsed by the WHO. America uses its own DMS-IV manual, which is slightly different but just as comprehensive. Most psychiatrists believe if it’s not in the manual it’s not a real disease (but if it is in the manual it may not be a real disease either…)

I believe from spending far too long on the psychiatry rotation that Mycroft and Sherlock Holmes are completely healthy human beings and if you find this conclusion terribly dull please feel free to stop reading.

Needless to say their behaviour alone would make them dearly loved by all medical examiners to utterly befuddle the poor students trying to pass their finals. Why? Because when you’re looking at a man sitting in a hospital cubicle you want there to be something wrong with him. You want to find an underlying reason to every tiny detail about him that doesn’t fit your idea of the norm. You are compelled to make the facts fit a diagnosis even if the correct answer is that the patient is completely healthy. That is exactly what happens in Sherlock Fandom – we are presented with a flawed genius and we have this obsession to pinpoint a reason. This can lead people to overstress and over-analyses behaviours that in the wider context may not be “normal” but certainly to not fall in the “diseased” spectrum.

Sherlock is to Autism as Eeyore is to Depression

If most lay people were compelled to psychoanalyse Winnie the Pooh, the first character to get a diagnosis would inevitably be Eeyore. Why? Well, it’s obvious that he’s depressed – always sounding so glum and ever the pessimist. Even his tail looks so sad dangling down like that.

However if you could take Eeyore to a GP (you don’t need to even imagine a psychiatrist for this) you would both leave empty handed, which is saying something as prescriptions of fluoxetin (Prozac) are flying through the roof.

Eeyore, if you question him closely, is not actually depressed. He might look like he’s in a permanently low mood but it doesn’t affect his life. Crucially he is still able to function perfectly well within his society. He also doesn’t display the other hallmarks of depression (anhedonia, low energy, sleep disturbance, early morning waking, low appetite). So what is wrong with Eeyore? Well in one word – nothing – he’s just a rather sad talking donkey, and he likes it. Eeyore doesn’t want to cheer up, being sad is what defines him.

Putting donkeys aside – Sherlock Holmes is in exactly the same situation. As obvious as it may seem to many viewers he doesn’t have autism or even Asperger’s Syndrome (a separate condition but under the same umbrella group pervasive developmental disorders).

There are several reasons why no psychiatrist would label Sherlock (in his current state) autistic:

He understands human emotion – Sherlock repeated emotionally manipulates people (most strikingly in TBB when he actually produces fake tears). Throughout the series we can see that Sherlock has an insightful understanding of human emotion and it is invaluable to understanding motivations behind crimes. Humans are inherently emotional and the vast majority of crime is emotionally motivated. If Sherlock was autistic he would be a rubbish detective. He definitely wouldn’t have worked out Irene’s password.

Human social interaction and understanding of human emotional behaviour is mostly innate, which is why despite intensive therapy it is never possible to get people with autism to fully understand human emotions in the way that a “normal” person could. If you had autism you certainly could never be trained understand human emotions to the extent that Sherlock does.

He’s a genius – his IQ score would be phenomenal if he ever bothered to get it tested (but he doesn’t need affirmation of his brilliance, he has John Watson). One of the defining features of autism is below average IQ. Only a small percentage of people with autism have an IQ score within normal (>70) and above average intelligence is almost unheard of in autism.

So does he have Asperger’s Syndrome instead? Consider the following:

He has empathy –  empathy is different from conscience although they both require the ability to “put yourself in someone else’s shoes”. Empathy is the ability to deduce how other people feel and then feel the emotion yourself(and then experience your own guilt, sorrow, joy etc). This requires an intricate network of neurones within the brain to be fully present and fully functional. This does not occur in people who have Asperger’s Syndrome. They are physically unable to experience empathy as evidenced by brain scans.

Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the Multifaceted Empathy Test

Who cares? Revisiting empathy in Asperger syndrome.

However Sherlock is visibly moved in many occasions during the series: after the bomb goes off and kills an old lady in TGG, when John gets dressed up as a suicide bomber, when he upsets Molly during the Christmas party, when Irene Adler “dies”, to name but a few.

More importantly Sherlock displays empathy. The diagnostic criteria is not so much about what emotions you are experiencing, its how you display the emotions.

Amendment: I personally think this definition of empathy is clinical, superficial and really doesn't get to true heart of what it means to feel empathy. The truth is we diagnose people with Aspergers syndrome on the lack of ability to display the normal human range of empathy. Maybe deep down inside people with Asperger's do feel empathy - just not in a way they can explain or express.

He doesn't demonstrate any of the other symptoms of Asperger's Syndrome - not being able to understand human emotion and lack of empathy are just two symptoms in the one category of the Adult Asperger's Assessment. Sherlock doesn't demonstrate symptoms in several other important categories:

  1. Qualitative impairments in communication - Sherlock does not have: limited range of intonation, poor prosody and  rhythm, inappropriate pitch, tangential content, sometimes incoherent content with mark verbosity (many words when few will suffice).
    Sherlock gets this message across really well. Although John has difficulty understand why he does things, he has no difficulty understanding what Sherlock wants to do.

  2. Disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. Sherlock appears to function perfectly well in society. He gets to do what he loves and makes a living from it whilst contributing to society.

  3. Restricted repetitive and stereotyped patterns of behaviour, interests and activities. If there is one person who doesn't follow a routine - it's Sherlock. At least John can normally be seen drinking regular cups of tea. This detective appears to alter his schedule to suit his cases and is amazingly adapative to new environments (the cross keys pub for example) than we would expect of someone with Aspergers. Yes Sherlock only has one passion in life but this passion actually encompasses an incredibly diverse range of activies and is not the general narrow hobby we see in people with Asperger's.

  4. Motor impairments - mostly apraxia and propriceptive impairment. Classic suffers are often clumsy and physically awkward. Sherlock is far too agile.

Diagnosing Asperger's syndrome require more than just one group of similar symptoms. In the same way that a high blood creatine level does not mean someone has kidney failure - poor social skills does not mean Sherlock has Asperger's syndrome. You need much more than this to reach a diagnosis.

I completely agree with many viewers who have pointed out that Sherlock demonstrates some features classically associated with Aspergers and that is possibly enough to get him a psychiatrist appointment but ultimately he would not be diagnosed with the disorder by the vast majority of psychiatrists.

Amendment: Could you find a psychiatrist who would diagnose him with Asperger's? Yes, of course you can. Pyschiatric diagnoses are almost entirely subjective. Psychiatrists like their patients are on a spectrum with some outliers who will have a very low threshold for diagnosing Aspergers. However does this mean that the general body of psychiatrist would agree with their opinion? Of course not.

Does this mean Sherlock doesn't have Asperger's? This is a much trickier question - diagnosing Asperger's is not like diagnosing pneumonia. There is no obsolute way of saying you have it or you don't. It is actually entirely psychiatric/clinical opinion whether he has the disease or not and in real life on the NHS, if there is doubt that Sherlock has Asperger's because he does display only a narrow range of symptoms, he would not be diagnosed because he wouldn't benefit from the medical support any way. As it's a matter of clinical opinion if Sherlock isn't offically diagnosed then he does not have Asperger's Syndrome.

The Rainbow Spectrum

Every disease has a spectrum from pneumonia to autism - doctors know this. We also know that the diseased and the normal spectrum can overlap and that's what makes our lives very difficult. We see this phenomon all the time with blood test results. The result may be within the range of normal but actually be catastrophic for the patient. The same is true of the reverse - I've seen people with sodium levels in the their blood that technically aren't compatible with life but they are perfectly fine.

So you need to look at the patient - and identify their norm. This includes taking a detailed family history and social history of the patient. For example, the patient with a horrendously high sodium - this might be a family trait or she's got a mutation that means she always high sodium. If we actually look at Sherlock's family - we can immediately see that his brother (not matter which way you slice it) is probably just as eccentric as he is. Therefore Sherlock may display symptoms of Asperger's syndrome but no psychiatrist would actually give him that diagnosis. Firstly because we don't like labelling people with unnecessary diagnoses (does marking Sherlock with Asperger's improve his quality of life?) and secondly because his behavioural problems are not organic in nature (they are a nasty by product of his campaign to dehumanise himself).

I have written a more detailed meta on Sherlock and his Asperger's

Conclusion: Sherlock is no more on the autistic spectrum than John is, so what is wrong with Sherlock Holmes? In one word – nothing – he just can’t be bother navigating the maze social niceties we all feel obliged to do every day. It’s all part of his grand plan to make himself a machine dedicated to the pursuit of logic. You could say he was just plain rude but he’s so brilliant you feel compelled to forgive him for it

Three psychiatrists specialising in diagnosing autistic spectrum disorders also agree that Sherlock doesn't have either Asperger's or Autism.

Sherlock is not qualified to diagnose himself – and never will be.

For everyone who bought Sherlock’s line “I am a high functioning sociopath – do your research!”, I am afraid to burst your bubble with two boring psychiatric facts:

  1. There is no such thing as a high functioning sociopath

  2. Sociopaths no longer official exist – at least not countries that use ICD-10 diagnostic manual.

Sociopaths (and psychopaths) are now all given the charming label “dissocial personality disorder” in ICD-10 (antisocial personality disorder in DSM-IV). It may conjure up images of troubled teenagers who pay loud music but the defining hallmark of DPD is a lack of conscience and empathy. Now you might think that everyone who was ever mean to you lacks a conscience but it can be demonstrated by PET scans that people with DPD lack fundamental hard wired emotional responses to gruesome images and pain. Therefore many psychiatrists argue that conscience actually exists as a physical end result of a certain pathway of neurone excitation, like pain.

There is an organic difference between people with DPD and people who are just mean/anti-social/criminal. It is true that DPD is more prevalent in the prison population but if you have no conscience there is nothing to stop you from murdering someone for the smallest of personal gains. So much of what we motivate us as individuals and as a society is driven by our conscience and our empathy. When that is stripped that only thing left is self-gratification.

Sherlock as I have already written does demonstrate that he is physically capable of empathy and given that he has chosen a career bring justice to the worst criminals, what can we deduce from his heart?

From a professional point of view - I am quite certain that if anyone ever managed to drag Sherlock into a consultation with a psychiatrist, he would simply be impossible to correctly diagnose if he refuses to co-operate. Sherlock is a brilliant man and I would not stretching plausibility to suggest that he knows the diagnostic manuals for psychiatric disorders pretty well. He is also a talented actor (given he can cry on command in TBB). Combine these two and you get a patient who can convincingly mimic any disorder he wants.

Psychiatry is very much pattern recognition - it becomes very difficult to recognise the correct pattern if the information you are presented with is skewed or false.

The Psychopath Test - many people have pointed that Sherlock ticks several boxes on the Hare Check List for Psychopathy.

Psychopathy has been suggested as “sub-disorder” of DPD which has more severe characteristics than general ASPD.  (Sociopathy, by the way, has never been readopted the psychiatric community. However there are still a few psychiatrists that use it to describe patients who develop ASPD symptoms due to social rather than biological reasons. There is very little scientific evidence to suggest that a subgroup like this even exists but that is a study for another time. )

The checklist for psychopathy PCL has never been officially recognised in DSM-IV or ICD-10. Psychiatrists who work with the most extreme cases of DPD such as those at Broadmoor Hospital in the UK fine the PCL is useful in identifying the most dangerous patients.

However you must remember it is a checklist (and a very long one at that) o fpersonality traits. A personality trait is a set of behavioural responses that are both consistent and persistent in time and social context. This means that everyone at sometime has displayed “lack of remorse or guilt” or “impulsiveness” or a myriad of other points on the checklist but they don’t do it all the time, everytime.

Sherlock is positively inconsistent with his “Lack of remorse or guilt” and “Callous/lack of empathy” or “Failure to accept responsibility for own actions”. For example: he demonstrates great (if restrained) remorse at having help Irene Adler bring the nation to its knees and he accepts responsibility for his actions – even apologising to his brother at the end. His apology is anything but “Emotionally Shallow”.

Besides, in order to qualify as psychopath you need to tick 30 out of 40 traits, even with a gun-hoe medical student attitude you would be hard pressed to label Sherlock a psychopath based on the Hare checklist.

The checklist can be used to describe some of Sherlock’s actions some of the time but his personality traits are definitely not on that checklist.

Conclusion -I cannot deny that Sherlock has issues and behaves eccentricly but this does not mean he has a psychiatric illness. One of the hardest things to grasp in medicine is that the range ofnormalextends way beyond our own narrow comfort zone and the hardest thing to acknowledge is that in the diagnosis of psychiatric conditions we are greatly influenced by our own prejuices. Therefore it is wrong to jump to conclusions.

Other Parts in the Series

2. Mycroft on the Examination Couch

3. Sherlock, Himself and His Aspergers.

Feedback is always welcome! I love to discuss things with commenters.

Tags: character: sherlock holmes, meta: sherlock holmes

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