If I had Sherlock as a patient in my medical finals...I wouldn't know whether to laugh or cry.
In this meta I explore whether Sherlock would be diagnosed with Asperger’s syndrome from a purely medical perspective
- I get out the diagnostic criteria and attempt a diagnosis,
- Explore reasons why Sherlock might not be diagnosed with the condition on the NHS (I'm a UK medical student with some interest in psychiatry - I am by no means an expert).
- And the difficulty of diagnosing an adult with Asperger's.
Please note this meta is from a medical perspective not a patient's perspective, which is why it sounds very clinical. The general opinions of the medical profession are not my own. I am just stating them.
My conclusions are just my clinical judgement - this is not a serious scientific paper, nor an expression of my personal opinions and should not be taken serious at all.
If you want to read about the expert opinions on whether Sherlock has Asperger's Syndrome or Autism - I have interview three psychiatrists specialising in autistic spectrum disorders (Sherlock Does not Have Asperger's or Autism, Thanks, from 3 Psychiatrists)
Comment if you like it
If you just want to skip to the diagnosing part go to Sherlock finally snaps his brother’s umbrella…
A Disclaimer before we start
This article is from a medical perspective. Given that few doctors actually understand what is it like to live with Asperger's or autism in society, some of the medical professions opinions may sound offensive to people who do.
This article is not about this debate, it basically states what the current medical view is, how a psychiatrist approaches a diagnosis and goes through the diagnostic criteria.
Facts are checked against textbooks - I will not list them, they give me enough grief as it is. Textbooks I will admit can be wrong/out of date but they are the ones that psychiatrists in the UK use in learning and teaching. It is sadly the best I can do.
Why Psychiatry is like John’s Jumper
Psychiatry is an odd speciality; it seems as far apart from the rest of medicine as an oatmeal jumper is from a Spencer Hart suit. Sadly the oatmeal jumper of medicine is not the most popular subject with medical students because psychiatry, from a medical student’s perspective, is a bit…woolly.
The thing with psychiatry is that the actually diseases are not clear cut. There are no distinct boundaries between the people who suffer from certain disorders and the extend spectrum of “normal”. In contrast, most non-psychiatric diseases are well defined and diagnosed according to objective investigations. For example: you have pneumonia if there is inflammation in the parenchyma (tissue) of your lungs as seen on a chest x-ray. Healthy people do not have inflamed lungs – if you had inflamed lungs you would have pneumonia.
The other thing with psychiatry is that there are no definite pathological models.
A pathological model describes how the causative agent/factor (the aetiology) leads to the development of the symptoms that we can clinically recognise as the disease. For example: HIV, the virus, causes AIDS by infecting your white blood cells, getting your immune system to kill your own white blood cells and then leaving you without much of an immune system. This directly leads to the symptoms of AIDS. This kind of knowledge simply does not exist for many psychiatric diseases; we have no idea how schizophrenia occurs or why some people become depressed. There are many theories but not enough scientific evidence to conclusively prove or disprove any of them.
Without a pathological model or clear distinctions between “disease” and “healthy”, defining disease in psychiatry is very hard and diagnosing diseases are even harder.
If we look through the ICD-10 diagnostic classification of mental disorders (this is the standard diagnostic manual for psychiatry in much of the world) – the main method of diagnosis is via a check list of symptoms. For example you must fulfil 3 out of 6 listed criteria to be diagnosed with Dissocial Personality Disorder.
However the diagnosis criteria for psychiatric illnesses are entirely subjective and often very vague. There are no blood tests for depression, or x-rays for bipolar disorder. We have no objective method of investigation for any psychiatric diseases (unless you include organic psychiatric diseases like vascular dementia).
Even psychiatrists CAN'T give a definitive answer to "does Sherlock have Asperger's Syndrome?". I can only attempt the accepted diagnostic method and my clinical knowledge/experience to reach my conclusion. I encourage everyone else to use the template later in the meta to reach their own conclusions if they so wish.
What is Asperger’s Syndrome?
Asperger’s is seen as a completely separate condition from autism by most psychiatrists in the UK (but not so in the US), but the two share many common classical features.
AS is classed under the umbrella term of Pervasive Developmental Disorders – these are disorders that affect the normal social, intellectual and emotional development of children creating persistent defects in their interactions with the world around them. Other disorders in PDD are Autism, Rett’s Syndrome and Childhood disintegrative syndrome. There is also something called PDD-NOS which is a diagnosis we give to patients who have the symptoms of a pervasive developmental disorder but we are not sure which one. Yes, the lengths that doctors go to in order to not sound stupid.
Although some people think AS is an extended part of the “autistic spectrum” it is not accepted as fact by all of the psychiatric community in the UK. This is probably because people on the autistic spectrum need a slightly different set of healthcare support to people with Asperger’s syndrome.
A short description of AS:
“a syndrome first described by Hans Aspergers in 1944 characterized by severe persistent impairment in social interactions, repetitive behaviour patterns and restricted interests. IQ and language are normal or in some cases superior.” – The Oxford Handbook of Psychiatry.
Doctors agree that Asperger's syndrome manifests differently throughout life and should really be diagnosed in childhood. However psychiatrists also feel that Asperger's syndrome is something that can be tricky to diagnose even in children. Therefore the chances of miss diagnosis are high.
Note “severe and persistent”: patients should be reviewed if, as an adult, they no longer display the symptoms of the disorder. Psychiatrists like to review the diagnoses of new patients because it is good clinical practice. Many disorders can easily be over diagnosed or miss diagnosed. Medical mistakes have often been made by taking the predecessor doctor's word on the diagnosis.
Thus if Sherlock came into clinic as a new patient, he would get a review of a his past psychiatric diagnoses. This does not mean they would be revised, just rechecked.
Why the medical profession classifies Asperger's Syndrome as a syndrome, disorder and "disease", not reflection of my personal views! (link coming soon)
(I decided to move this part because 1. the article is already too long, 2. it's generated a debate all of its own)
When Sherlock Finally Snaps his brother’s umbrella…
…Mycroft sends him to see a psychiatrist.
So suspend your disbelief and imagine for a moment that Sherlock has come into an afternoon clinic in Maudsley Hospital because Mycroft is going to break his violin if he doesn’t comply. John goes with him just to make sure he doesn’t make the medical students cry.
The referral letter just says: “Sherlock Holmes, 35 year old man, family are worried about his poor social skills, and are wondering whether he suffers from Asperger’s Syndrome.”
Taking a History
The first thing psychiatrists always do is take a history. Although his family have suggested a diagnosis the psychiatrist needs to have an unbiased and impartial approach to diagnosing patients.
Sadly, I can see that Sherlock would refuse to cooperate, but that is something all doctors encounter in their jobs. However we have the next best thing: John.
John, his flatmate, knows much more about Sherlock than any doctor ever will. He lives with Sherlock and works with Sherlock. He can tell us all about the detective's antisocial behaviour, lack of caring, lack of understanding of John’s feelings, weird sleeping patterns, weird eating patterns (he’s only had one mince pie since Christmas!).
However – John (and the viewers) have no idea about the most important part of Sherlock’s history, his childhood. Autism and Asperger’s Syndrome are predominantly diagnosed in childhood and this is done by specialist child/adolescent psychiatrists. Diagnosis of Asperger’s in adults is harder and follows different criteria because of learned behavioural modifications throughout life.
Because we have no baseline to compare him to, we do not know if Sherlock’s social skills have improved or deteriorated since childhood. This makes life much harder for the doctor because we have lost the most valuable source of information.
At this point - in real life - the psychiatrist might actually arrange a second appointment and ask the Sherlock bring his family along to the consultation so that we can get a picture of his behaviour as a child.
For the purposes of this essay and because of any evidence to the contrary, we are just going to have to say Sherlock wasn’t diagnosed with anything as child.
(He couldn't have been diagnosed with Asperger's as a child anyway because it has not been officially recognised in the ICD-10 at that point.)
The lack of a diagnosis does not mean Sherlock did not have symptoms as child. His mother might not have to take him to see a psychiatrist. The psychiatrist in turn might have miss the diagnosis. Therefore we cannot use the lack of evidence as evidence to the contrary. (Please Moffat and Gatiss give us something to go on in Seaons 3!)
At this point there is enough information from John for us to think that getting out the Adult Asperger’s Assessment is probably worthwhile.
The Adult Asperger’s Assessment is a fairly new checklist based on several older versions that were used for both child and adult diagnoses. It has been specifically modified to help identify adults with Aspergers.
It is used quite widely throughout the UK but there are no national guidelines on how to diagnose Asperger’s Syndrome, so technically a psychiatrist can use anything they want provided they can prove another psychiatrist would do the same (Bolem Test).
Diagnosing two disorders with one stone.
Even though Asperger’s Syndrome is distinct from autism we actually use very similar checklists just with different thresholds.
The major diagnostic categories are exactly the same; the symptoms differ in severity. Also there are features of autism that are not present in the diagnostic criteria for Asperger's.
Direct quote from ICD-10: "The disorder differs from autism primarily in that there is no general delay or retardation in language or in cognitive development. Most individuals are of normal general intelligence but it is common for them to be markedly clumsy; the condition occurs predominately in boys (in a ratio of about eight boys to one girl)"
Good signs so far for Asperger's Syndrome: Sherlock's a boy (good odds), has a genius IQ, language skills - extraordinary.
However we must be very wary of coming to conclusions. The most important thing when approaching a diagnosis is to keep an open mind. We never open the checklist with the intention to produce a positive diagnosis. Psychiatrists like to work on the idea that no-one is ill unless proven otherwise.
If I already make up my mind that Sherlock has Asperger's Syndrome than no matter how I look at the diagnostic criteria, I can skew my observations enough to give him a positive diagnosis.
Sherlock on the Examination Couch:
After the history comes the examination. For children this be an hour of play where we try to direct the child towards doing activities that will give us an idea of their social, communication and motor skills. For adults we literally sit them on a couch and ask them questions from a pre-approved check list. Sounds crazy? The psychiatrists aren't loving it either but it's the best method we have so far.
The checklist below is used to assess both Asperger’s Syndrome in adults and “high-functioning” autism in adults.
I have reorganised the diagnostic criteria to suit the format of this meta but not changed any of the wording (if you do not like the wording please take it up with the Royal College of Psychiatrists and not me)
This is just my clinical judgement of Sherlock - I might have easily missed things or gained the wrong impression. Happy to be corrected please send me a message!
Qualitative impairment in social interaction –
· Marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction: Sherlock has “normal” eye contact. There is never a time when you feel his eye contact/of lack of eye contact seems out of place or uncomfortable. Apparently this is what you are supposed to look for in this part of the criteria. Personally I saw a lovely child in clinic who had perfectly normal eye contact but was diagnosed with Asperger's syndrome because she fulfil enough of the remaining criteria.
Sherlock's facial expressions are just brilliant, lovely subtle but still speak volumes (the really sad scene where Sebastian says how much every hates Sherlock and he just looks so sad). I have no problem interpreting Sherlock’s neither facial expression nor do I feel that his expressions are inappropriate for the emotion he should be feeling. In terms of body language, Sherlock conveys his agitation, excitement and sorrow in a very natural way via his body’s movements. He does take up some weird positions but that in itself does not mean his postures are generally inappropriate. No tick for this one
· Failure to develop peer relationships appropriate to developmental level – we don’t know what Sherlock’s life was like before John came into the picture. He certainly rubbed Lestrade’s team up the wrong way, and didn’t have friends at university. However he has developed deep meaningful relationships with John, Mrs Hudson, Molly (in the end) and possible even Angelo. He has managed to develop a beautiful friendship with John and most of all; he initiated the first move by dragging John along on one of his cases. Although Sherlock hasn’t been to any raves lately (or ever), this doesn’t mean he doesn’t enjoy social situations. He was clearly having a rather good time playing the violin at the Christmas party and everything would have been fine until he insulted Molly. Yes, Sherlock doesn’t have many friends but the ones he does have are willing to die for him, kill for him and fake his death for him. Another no then...don't worry though the list goes on for a while.
No interest in pleasing others; no interest in communicating his/her experience to others, including:- lack of spontaneous seeking to share enjoyment, interests or achievements with other people; lack of showing, bringing or pointing out objects of interest – Sherlock definitely does not care about pleasing others but he does appear to enjoy sharing his deductions with John. Sherlock was the one to spontaneously ask John to come along to the crime scene in ASiP, though on the surface this was because he needed an assistant. Once they arrived at the crime scene, he didn’t appear to need John for anything other than sharing his brilliance at deduction with. No tick for this one
Restricted repetitive and stereotyped patterns of behaviour, interests and activities
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus – there is no denying that when Sherlock is on the case, nothing will be able to distract him from solving the mystery. He does get strongly absorbed and gets upset when he can’t pursue his interest. However he does not have a restricted pattern of interest: Sherlock doesn’t just solve car crimes or homicides. The repertoire of cases he devotes himself is very diverse and usually the cases have very little in common. Possibly...but my clinical view is yes - tick
Apparently inﬂexible adherence to speciﬁc, nonfunctional routines or rituals – oddly enough we haven’t noticed anything along the lines of an unwavering dedication to routine in Sherlock’s life. He appears to be entirely flexible should the situation call for it, even travelling down to Devon to pursue a mystical hound. We don’t see any non-functional rituals in Sherlock life. John at least seems to drink tea at regular intervals, but Sherlock’s life is at best unpredictable. No tick for this one
Stereotyped and repetitive motor mannerisms (e.g. hand or ﬁnger ﬂapping or twisting, or complex whole-body movements) – We have never seen Sherlock demonstrate any of the above. He does occasionally do odd things like sitting on the couch with his knees against his chest but that in itself is not a stereotyped or repetitive movement. No tick for this one
Persistent preoccupation with parts of objects/systems – This section is all about noticing small inconsequential things. Sherlock definitely sees many things that a normal person would not and it appears that this is a reaction he usually has no control over. However he does not display a persistent preoccupation with details that prevents him from seeing the bigger picture. Additionally, most of the details he notices are important and useful to his line of work and this is does not hinder his ability to function in society. I would be cautious to tick this box - I think in this instance I will say no.
Tendency to think of issues as being black and white (e.g. in politics or morality), rather than considering multiple perspectives in a ﬂexible way – this one is very difficult to judge for Sherlock. He doesn’t appear to have political views or even a specified morality. In fact his morals are can only be described as flexible. There is no indication that Sherlock has an uncompromising view of the world, though he can be uncompromising when driving a point home. He is able to listen and understand John’s point of view to a certain degree but he certainly does not share John’s views nor is John able to convince him of their merit. Difficult...but no I don't think this one deserves a tick.
Qualitative impairments in verbal or non-verbal communication
· Tendency to turn any conversation back on to self or own topic of interest and tangential speech, – Sherlock’s conversations do not appear to be particularly self-centered or repetitive. His conversations with John tend to be about Sherlock, mostly because John complains about Sherlock’s domestic habits/social interactions/general anti-social behaviour. Sherlock doesn’t bring up his crime solving and general genius at every opportunity regardless of context and usually doesn’t deliberately change the conversation to be about himself and his interests. He hasn’t demonstrated a persistent tendency to wonder off on a tangent or to arrive at an important point via different tangents in conversation. Another no then.
· Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superﬁcial social contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity. – Oddly enough on the surface this sounds like Sherlock’s entire attitude towards others but when we look at his interactions with John, we see that their conversations are much more than just necessities of two people sharing a flat. Although Sherlock does not see the point in most social niceties, that in itself does not mean that we can tick this box, given that he is very able in initiating and sustaining conversation when he wants to. Well, you have to fulfil all the points in the criteria so sorry no tick.
· Pedantic style of speaking, or inclusion of too much detail. – Sherlock isn’t particularly pedantic. He does like making grammatical puns though. At no point during the series does he include too much detail in his conversations – everything he says about his deductions are useful in the long run. No tick.
· Inability to recognise when the listener is interested or bored. Even if the person has been told not to talk about their particular obsessive topic for too long, this difficulty may be evident if other topics arise – difficult to say because no one has ever been bored by what Sherlock’s had to say: horrified, amazed, annoyed maybe but never bored. In cases like this we err on the side of caution and say no.
· Frequent tendency to say things without considering the emotional impact on the listener (faux pas) – yes we can definitely say that Sherlock does not consider the emotional impact his words have on people. YEAH! Score 2
· Impairments in speech including (but by no means an exhaustive list):
- Verbosity (using 10 words when 1 will do)
- abrupt transitions (difficult to follow train of thought/conversation)
- literal interpretations and miscomprehension of nuance,
- use of metaphor meaningful only to the speaker,
- auditory perception deficits,
- unusually pedantic, formal or idiosyncratic speech,
- oddities in loudness pitch, intonation, prosody, and rhythm,
- echolalia (compulsively repeating what someone else has said)
Sherlock sadly doesn't demonstrate any of these symptoms...so no tick for this one either - unless someone can think of an example?
Other general signs to look for in clinical assessment:
General language development: According to the textbook: "patients with autism usually have language delay as a child and their language skills may not be on par with their peers as adults (depends on where on the autistic spectrum they are). Asperger’s patients should not have any language delay but do demonstrate signs of language impairment as an adult. At least one or more of these symptoms should be present in people we are considering for a diagnosis of Asperger’s syndrome". In reality life does not always fit the nice neat boxes doctors would like it to...but as Sherlock's language appears to be appropriate and there is no functional impairment, no tick for autism, tick for Asperger's
Cognitive development – According to the psychiatrists (not textbook): doctors must evaluate the cognitive development of their adult patients by taking into account to their life experiences, education, family and society. Sherlock is extraordinarily intelligent. He is clearly able to put his intelligence to good use and has found a nice niche job. No cognitive impairment then tick for Asperger's
Delay/abnormal functioning, with onset prior to 3 years, in social interaction, language as used in social communication, or symbolic/imaginative play – Sadly we do not have the information to judge this.
Impairments in imagination - Sherlock doesn’t appear to have difficulty fitting his deductions together and using his imagination to devise scenario/motives for crimes. When he first finds the dead body in the trunk (ASiB) he can imagine over 8 scenarios after just a few seconds. However we can never assess this properly because we really need to see if he can engage in imaginative play. Now Sherlock would never cooperate in such a degrading experiment and we missed the chance to do this to him as a child. The only other thing we can do is ask if he has any interest in fiction, fictional dramas, operas, theatre etc. We haven’t been shown anything in the series to suggest that he doesn’t like these things so we cannot conclude that Sherlock has impairments in imagination. Sadly another no because of lack of positive evidence.
Disturbance causes clinically signiﬁcant impairment in social, occupational, or other important areas of functioning – According to psychiatrists I have worked with and ICD-10: "this is an absolute requirement for the diagnosis of Asperger’s Syndrome" (why is it not a pre-requisite of autism? I don't know). If the patient does not suffer from significant impairment (according to the psychiatrists: this means needs specialist support), doctors will not consider them for a diagnosis of Asperger’s Syndrome. Sherlock would not benefit from specialist support, nor does he need it. He is able to function perfectly well in society and appears to have more of a social life than Mycroft. Sadly no tick for this one...
Symptoms/signs that are a recognised part of the syndrome of Asperger's Syndrome but do not appear on the checklist:
- Lax joints are often observed (eg, an immature or unusual grasp for handwriting and other fine hand movements)
- there is not enough physical evidence to make a decision.
- Clumsiness - I wouldn't say that Sherlock is clumsy, he appears to be very agile: climbing into people's apartments, jumping from balconies and scaling his own furniture. No tick for this one
- Abnormalies of locomotion, balance, manual dexterity, handwriting, rapid movements, rhythm, and imitation of movements - well we've never seen Sherlock's handwriting, it might be worse than the doctor's. However his manual dexterity, rapid movements, rhythm are all very good given how well he plays that violin. I am a violin player myself (one reason why I started reading the books) and it does take a great deal of motor skills to actually produce something resembling a nice piece of music. So no tick for this one
- Individuals exhibit impaired ball-playing skills - you can test this by asking the patient to catch a stress ball. Sadly I think Sherlock would let my stress ball fly out the window with a really big smirk -so no conclusion on that one.
Keep Calm and Carry On
So we’ve gone through the checklist of sign/symptoms and can now breathe a sigh of relief. (If you’re still imagining Sherlock in a psychiatrist’s consulting room, he would probably be sprawled dramatically on the examination couch pulling all the leaves off the pot plant.)
The result of the exceedingly long section is that Sherlock convincingly tick 2 boxes:
Frequent tendency to say things without considering the emotional impact on the listener (faux pas)
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (possibly)
Surprisingly he does not fulfil any of the criteria for qualitative impairment in social interaction. The thing to remember is that psychiatrists have a much higher threshold for diagnosing patients with Asperger’s syndrome than most lay people. This may be a general undercurrent of unwillingness to diagnose people on the borderline because of the very cynical reason that the NHS is heavily in debt and cannot cope.
Looking at the diagnostic criteria, Sherlock does not have enough signs/symptoms to be diagnosed with either autism or Asperger’s.
Autism diagnosis in adulthood requires all of the following:
- at least 2 out of 4 symptoms in “qualitative defect in social interactions” (Sherlock scores 0)
- at least 1 out of 4 symptoms in “repetitive behaviour”, (Sherlock scores 2)
- at least 1 out of 4 symptoms in “qualitative impairment in communication”. (Sherlock scores 1)
- Delay/abnormal functioning, with onset prior to 3 years, in social interaction, language as used in social communication, or symbolic/imaginative play (We have no idea but if this does exist it rules out Asperger's Syndrome)
Asperger’s Syndrome diagnosis in adulthood requires exactly the same thing but also needs:
- clinically significant impairment in social, occupational, or other important areas of functioning (no)
- no delay in language development/cognitive development (yes)
- demonstrated impairment in imagination (not sure about this one...)
Asperger's is a more appropriate diagnosis than autism in the present circumstance because Sherlock does not have "general language or cognitive delay/impairment".
However Sherlock does not display enough of the symptoms on the checklist nor does he meet all the pre-requites and thus a diagnosis of Asperger's is in, what we call, "reasonable doubt" (I know it sounds like a legal term, perhaps it's our subconscious fear of litigation?)
This means that we believe that there is a bigger probability that he does not have Asperger's Syndrome but because the examination is subjective we cannot rule out the possibility of him having Asperger's Syndrome entirely. On the grounds of the examination we will not diagnose him with Asperger's.
...Can I hear rage boiling in the background against the stupidity of doctors? Can they not get anything right? Sherlock has the signs! Open your eyes!
But Even I can see the resemblance...
Sherlock does show some characteristics that some viewers recognise as classical Asperger’s Syndrome, particularly if they know someone with the condition. However, this does not mean that every psychiatrist would diagnose him with the disorder. The presence of other symptoms and other factors need to be taken into consideration first.
To give an analogy: in renal medicine a raised creatinine level in the blood is a hallmark of kidney failure. However this does not mean everyone with a raised creatinine level has kidney failure. Firstly there are many other causes of this sign, and secondly there needs to be actual clinical symptoms of kidney failure. The patient be ill. Many people walk around perfectly happily with creatinine levels that would make medical students faint, but that is their norm and they do not suffer any disorder from it.
It is also very easy to let our personal experiences and other people's views (be they patients or doctors) colour our diagnosis.
For example: when I recovered from pneumonia and went back to work on the respiratory ward: I ended up putting "pneumonia" at the top of the differential diagnosis list for every single new patient. As it so happens none of them had pneumonia. Whenever I saw people coughing up green phelgm, I thought: pneumonia! I didn't think about other possibilities like chronic bronchitis. When people complained of pleuritic chest pain, I thought: pneumonia, not pneumothorax which is a much more dangerous condition.
An open mind and an impartial approach are difficult things to master. Just because everyone else thinks the diagnosis is one thing, does not mean you should approach the patient with your mind already made up.
The John Factor...
Most of the conclusions I have drawn are from Sherlock's interactions with John. This is not an uncommon thing to happen in real life psychiatric diagnoses. When we assess an adult or child we usually diagnose them based on their "highest performance", i.e. as long as we can see that they can do certain things even if it is with only one person, we are happy not to tick the box.
There needs to be a consistent and persistent demonstration of a symptom before we are able to tick any particularly box.
This does mean that people who are able to act end up completely skewing our data. Doctors have to assume that all their patients are telling the truth and being themselves or else we wouldn't be able to do anything.
If you came looking for answer...
There is actually no right answer to "Does Sherlock have Asperger's Syndrome"because the syndrome itself is not a well defined coherent condition with a known cause, or pathogenesis. It is actually an entirely human construct that we are sticking to because we don't understand what really goes on. It may turn out in the future that Asperger's Syndrome should not be seen as a condition at all but just an extended part of the normal spectrum!
...The Final Countdown?
So how do you reach a final decision on what to tell the patient?
As psychiatrists we do not usually see our patients after they have been diagnosed with Asperger's Syndrome or autism. In the UK neither condition is managed by psychiatrists. All patients have a team of allied healthcare professionals who provide support for school, home, work etc.
Therefore we need to think very carefully about all the factors involved before giving a diagnosis because we don't usually get a second chance to see our patients again. A misdiagnosis can sometimes last for a lifetime. A missed diagnosis is still harmful to the patient but we usually safety net by ensuring that the patient can come for a second opinion whenever they want. Therefore it is usually better to not diagnose than to give a wrong diagnosis.
Like most psychiatric disorders, Asperger’s/autism requires the patient to tick enough boxes first and then this, in addition with the general clinical impression of the patient, will be considered when making a diagnosis. Just because a patient happens to fulfil enough of the criteria does not mean that they should be given a positive diagnosis.
Psychiatrists have to consider whether the diagnosis will do more good than harm.
Being diagnosed with a pervasive developmental disorder (PDD) can be very liberating for both the patient and their family. However mental disorders still carry social stigma. Depending on your own views and that of your society, a diagnosis can either allow you to better understand yourself, or give you a whole lot of grief. The personal circumstances must always be taken into account if the patient does not fulfil all the criteria when it comes to diagnosis.
On the surface Sherlock doesn't appear to need or want a diagnosis. He would never have come into clinic had his brother not been determined to avenge his umbrella. We do see Sherlock asking his brother if there is anything wrong with them in a very poignant scene. Sherlock clearly feels the divide between himself and the people he encounters. Perhaps Sherlock does want a way in which he can better understand his differences but whether a medical diagnosis is going to be the best route to take, we cannot tell. On the other hand he does quite clearly state that practically everyone is an idiot, so even if we give him a diagnosis would he even listen to us?
It is possible diagnosed with a PDD will actually adversely affect Sherlock's mental health. On the balance of harm to good, psychiatrists usually err on the side of not giving a diagnosis if there is reasonable doubt.
Another factor is whether the patient will benefit from specialist support. Psychiatrists play an integral role in diagnosing PDDs but not in managing them. This is usually done by a specialist team of multidisciplinary support workers, which help with education, independent living skills, work etc.
Sherlock appears to be functioning perfectly well on his own without any specialist support;
Many people need help but they do not need specialist help. They need family, friends, neighbours, carers, and general emotional support.
Sherlock needs all of these things, or else he would probably end up homeless and possibly on drugs. However he does not need specialist help. He does not need educational psychologists, occupational therapists, physiotherapists or to see a psychiatrist ever again.
The NHS doesn’t have the tools to help someone like Sherlock because he doesn’t need help:
- Finding a job – he has one.
- Assistance with work – he’s the best at what he does, for everything else there’s John. No OT can do what John does.
- Looking after himself – as long as he can get dress, keep himself clean and feed himself, the mental health services wouldn’t get involved because we have too many patients that can’t do any of those things.
- Training or education – he would have some choice words to say to an educational psychologist.
- He doesn't have apraxia (impairment of motor skills) – physiotherapy is not going to help.
The gap of what Sherlock needs and what the medical profession can provide has to be filled with people like Mrs Hudson, John and Mycroft. Yes, Sherlock requires assistance but not from the mental health services. I think we would actually make his life worse rather than better.
In fact I have a hilarious image of Sherlock’s expression if I unleashed the entire range of allied health professionals onto his life. Also I think my life might be in danger if I did!
If we can see that the patient is currently functioning well and has good support i.e. able to attend to personal hygiene, house fit for habitation, has an occupation that satisfies them, has meaningful relationships we will decide not to diagnose them if their diagnosis is in “reasonable doubt”.
Given these two important factors: most psychiatrists on the NHS would be reluctant to give him a positive diagnosis.
Currently, good clinical practice dictates that doctors should err on the side of caution with conditions that do not pose a danger to the patient or the public.
A psychiatrist did point out that in practical terms Sherlock would not be diagnosed with Asperger’s or autism as an adult on the NHS because the mental health budget has been slashed in many regions. A positive diagnosis qualifies Sherlock for a whole host of expensive support services that the NHS cannot afford. Thus without a terribly convincing display of symptoms, doctors do end up weighing up the money as well as the patient. It is the sad reality of a healthcare system that is chronically in debt.
However if Sherlock lived in the US, the situation might be entirely different. They have the highest rate of mental health diagnoses per capita. Cynically, psychiatrists in the UK would say that this was the result of over diagnosis. Their support guidelines for PDDs include medications which is almost unheard of in the UK so there is a significant financial incentive to give positive diagnoses on a private healthcare system.
Getting a second opinion…
I believe that if Mycroft tried enough psychiatrists he could eventually find one on the NHS who would diagnose Sherlock with Asperger’s Syndrome/autism. This does not mean to say that the majority of the psychiatric profession would agree with this diagnosis. Psychiatric diagnoses are very subjective. Ulterior motives can influence diagnosis particularly where targets need to be met or the British Government is breathing down your neck.
Additionally psychiatrists only get a snap shot of their patients in the hour long diagnosis session; we generally do not see our patients very much after that. The actual method and timing of the diagnosis also varies from doctor to doctor and region to region but generally on the NHS there are always time constraints (too many patients not enough doctors). They would not have the leisure of watching their patients over days, weeks or months. Therefore it is easy to over-diagnose or misdiagnose disorders like Asperger’s Syndrome. This does not mean that most people with Asperger’s syndrome should not have been diagnosed; it does mean in some cases it is difficult to make the correct diagnosis.
The truth is whether the psychiatrist says yes or no to the diagnosis can often be a somewhat spur of the moment decision and is greatly influenced by the patient’s behaviour during the consultation. Another psychiatrist reviewing the patient at a different time may completely disagree with his predecessor’s conclusion.
I informed a child/adolescent psychiatrist that I was writing this meta and he found the idea hilarious. Sherlock, being such a great actor, could easily mimic all the signs of Asperger’s disease or autism and then lie about his childhood history (if he needed to). It is almost impossible to diagnose someone like Sherlock if he refuses to behave. He's an extremely intelligent adult, in full control of his own capacities - he'd easily lead any psychiatrist on a wild goose chase. Sherlock is a walking nightmare!
It is my professional opinion that you cannot say Sherlock definitely has Asperger's Syndrome or autism. From a medical point of view, until he is diagnosed by a qualified psychiatrist he doesn't have either condition and he should be treated medically as "normal" or "neurotypical".
This does not change the fact that he does have some defects in social interactions but we can see that he has the support in place to help him tackle that aspect of his life.
I am not an expert in the area of diagnosing pervasive personality disorders. In this meta I have merely applied the tools that the vast majority of psychiatrist would use and tried to give an answer to a difficult problem.
If you feel like this cat...
....have a cup of tea and just see Sherlock as the brilliant character he was always meant to be regardless of whether he has a condition or not.
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