Tuesday, November 3, 2009

Asperger’s: Here today, gone tomorrow?

Would erasure from DSM impact forensic use?

It was just a few years ago that Asperger's Disorder exploded into the public consciousness. But just as suddenly, if the DSM-V authors have their way, it may disappear, absorbed back into the spectrum of autism disorders from whence it came.

An intriguing story in today's New York Times describes the controversy that is heating up as the DSM-V work groups prepare to issue their final diagnostic proposals in January.

As Times reporter Claudia Wallis notes, Asperger's is "one of the most intriguing labels" in the diagnostic book:
"Children with Asperger's syndrome, a mild form of autism, are socially awkward and often physically clumsy, but many are verbal prodigies, speaking in complex sentences at early ages, reading newspapers fluently by age 5 or 6 and acquiring expertise in some preferred topic -- stegosaurs, clipper ships, Interstate highways -- that will astonish adults and bore their playmates to tears."
The sudden rise of this "once obscure diagnosis," diagnosed four times more often in boys than girls, accounts for much of the apparent rise in autism, which now has a prevalence rate of about 1 percent among U.S. children.

Although self-described "Aspies" and their families distinguish Asperger's from the more stigmatized label of autism, experts quoted by the Times say the distinctions are confusing and not scientifically based.

Asperger's in the forensic context

At the same time that it faces formal extinction, Asperger's is seeing ever-escalating use in the criminal courts, in cases ranging from violent crime to computer hacking and child pornography possession.

Typically, the diagnosis is proposed by defense attorneys seeking to mitigate the mental state required for a crime. A hallmark of the disorder is severe problems understanding social rules and nuances, and therefore navigating social situations. Sometimes, the profound deficit in social reasoning explains crimes that otherwise are simply bizarre, and lacking in rational motivation. Consider this scenario, adopted from a case I worked on:
You’re on an excursion with a recreational group, walking through a downtown area. The group encounters a red light. Seeing no traffic, everyone jaywalks. All except the young man with Asperger’s, whose can’t break a rule. No one notices as he gets left behind. When he finally finds the group again, he is furious, and punches the group leader in the face.
In this case, the defendant had a particularly severe and clearcut case that had been diagnosed and treated at a specialty clinic from the time he was a toddler. Thus, it could not be argued that the diagnosis was being manufactured with a pretextual goal in the legal context.

In other cases, especially when an alternate and rational motivation is at least equally plausible, the defense has met with less success. For example, as I blogged about last year, it was unsuccessfully advanced in the case of Hans Reiser, the oddball computer programmer who killed his wife and buried her body in the hills of Oakland, California.

In an article on "the geek defense" in Slate magazine, science writer Erica Westly gives other examples of Asperger's recent deployment in court, some successful and some not.
  • Astonishingly, a jury in Galveston, Texas acquitted billionaire real estate heir Robert Durst in the murder and dismemberment of his neighbor under the theory that Asperger's made him incapable of premeditating the crime.
  • Lisa Brown of the United Kingdom was not so lucky. The 22-year-old woman was sentenced to life in prison in the murder of her mother after a judge ruled that her lack of empathy did not mitigate the gravity of the crime.
Explanation for collecting child porn

The compulsive behaviors and zealous collecting of many individuals with Asperger's is being invoked to explain certain types of criminal conduct, such as computer misconduct or child pornography collecting.

Computer hacker Gary McKinnon

The Slate article features the high-profile case of Gary McKinnon, the British computer geek who hacked into U.S. military and NASA computers looking for proof that the U.S. government had covered up evidence of UFO landings. He claims Asperger's made him compulsively driven to search for evidence of alien spacecraft.

This type of defense is ready-made for compulsive collecting of child pornography images. In an Iowa case this year, a judge reduced a pornography possession sentence after concluding that Asperger's "might very well explain the number of images" the man had acquired. Similarly, across the Atlantic a 21-year-old student in the United Kingdom was sentenced to just four months in jail for possession of 922 pornographic images of children. Other courts have been less sympathetic to this version of a diminished capacity defense.

Anecdotally, I have heard of Asperger's arguments backfiring. Introduced as mitigation in cases of violent and/or sexual offending, Asperger's may become aggravating by increasing jurors' fear of a defendant because he is perceived as strange and therefore more unpredictable.

At risk in prison

In a final forensic angle, the extreme social awkwardness of Asperger's sufferers puts them at risk in prison, where social interactions are highly scripted and regulated. In one case I was involved in, a prisoner incurred new criminal charges stemming from a bizarre fight triggered by his misperception of social cues.

Indeed, computer hacker McKinnon is raising this issue in an attempt to avoid extradition to the United States. Given his condition, incarceration in a U.S. prison would amount to torture, he contends. As evidence, he cites a 2007 study by psychiatrist David Allen finding that imprisonment is extremely stressful and confusing for men with Asperger's, who find it hard to successfully interact with guards and other prisoners and thus spend much of their time hiding out in fear.

No one knows whether or how exclusion from the upcoming DSM-V, due to be published in 2012, might affect deployment of the diagnosis in court. After all, even if it is not a separate diagnosis, Asperger's will still presumably exist as a condition on the autism spectrum. And, as regular readers of this blog know, plenty of less valid diagnoses are invoked in court despite their absence from the DSM.

Although I understand the logic of the DSM-V work group, I cannot help but wonder -- given the massive influence of the pharmaceutical industry in shaping and perpetuating psychiatric diagnoses -- whether they would be proposing Asperger's for elimination if a money-making drug was available to treat it.

Somehow, I think not.

Further resource:

Barry-Walsh, J.B., & Mullen, P.E. (2004). Forensic aspects of Asperger's Syndrome. Journal of Forensic Psychiatry and Psychology, 15, 96-107.

9 comments:

  1. Asperger's has never been in the DSM, only autism. So it's not being "erased" from the fifth version of DSM.

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  2. Hi Bluestem,

    Sorry to differ, but I've got my trusty DSM-IV-TR right in front of me here, cracked open to p. 80, where "Asperger's Disorder" is listed as diagnostic code 299.80. The diagnostic criteria run for five full pages.

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  3. Karen, fads do truly run amok in our profession. If it is not Aspergers, it is Bi-Polar or some type of dissociative disorder. Science? I fear not. Sadly.

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  4. Amen, Dufferman12. And it's one thing when the diagnoses are only being used as aids to providing clinical services, but quite another when experts are testifying in court with straight faces about the legitimacy of conditions such as "Parental Alienation Syndrome" or "Paraphilic Disorder Not Otherwise Specified - Coercion."

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  5. Perhaps the next testimony will include some type of past life work? Maybe the emprical movement is not entirely off base.

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  6. I'm amazed - the DSM-V people are proposing to take a diagnosis out! That has to be a first for them.

    Seriously though, in one sense it's an academic question, because if you get rid of "Asperger's", you're going to get a lot more people who end up labeled with "High Functioning Autism".

    I'm not sure there is any difference between the two concepts really, but some experts do e.g. Simon Baron-Cohen
    http://www.nytimes.com/2009/11/10/opinion/10baron-cohen.html?_r=1&ref=opinion
    So it seems premature to just declare that the question's closed.

    ReplyDelete
  7. Neuroskeptic:

    Thanks for posting the link to the op-ed, for readers interested in more perspective.

    The difference may be mainly academic, as you say, but people currently labeled Asperger's (and their families) feel less stigmatized than if they were labeled as autistic.

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  8. AnonymousJuly 13, 2010

    I am an Asperger. One that is unmistakible. I have been identified through concepts of genetic testing. I have redeined this "dysfunction" and am baffled why nobody wished to believe this potential is true. The implications are more than the public's psyche can handle; therefor, cannot be true. Why can't people believe the purest of sciences in genetics? HLA DQ8/ CHD9. It is solved by an unpublished and non formally educated man, therefor, it is impossible to be true. Common man cannot think outside of a box! Who has the dysfunction? For some reason I cannot post Paul R. Dierks. URL Illegal!

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  9. excellent phrase I really like it.

    ReplyDelete

 
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