High Functioning Autism, Ethnic Jokes, and Purim

Ordinarily I wouldn't get started on this, knowing that it is likely to upset at least one reader. But because some of you will propose theses for doctorates and masters degrees, it feels like the right thing to do, open up a topic for further study. Also, this is Purim Torah. And despite what's going on in the world, I'm in a better mood.

Purim isn't the topic for further study, not unless you're Jewish and like studying up on stories from days of old. But the story is about genocide, which is related to racism, and racism affects our mental health because (a) it hurts and provides people with excuses (bad ones) to kill, and (b) racists sometimes tell bad jokes.

Purim is one of those, the joke's on you, holidays. The story is a tale of monumental reversal, salvation, victory, fasting, love, sexual exploitation, and plots inside the kingdom. We're talking Persia, 369 BCE.

Briefly: The Persians beat the Babylonians, and Jews exiled from Jerusalem by the Babylonians wound up there. The king, Achashverosh, has done away with his wife Vashti because she wouldn't dance naked for his friends at a feast. These feasts go on for days and days, and people get wildly drunk They expect to be entertained.

Having banished Vashti from the kingdom, Achashverosh orders that all the beautiful virgins in the country come to the palace to interview for the job, queen.

Esther, a Jewish orphan, adopted and raised by her older cousin Mordechai, becomes the king's top pick. The king loves Esther dearly. He has no idea she is Jewish.

An officer of his court, Haman, is a huge anti-Semite. Haman is narcissistically injured (angry) at Mordechai who refuses to bow down to him at the palace gate. (Jews only bow to God, or sometimes to marshal arts teachers to be polite). Haman has made it in politics, has influence with the king. He requests the annihilation of the Jews, ostensibly because they follow a different set of rules. Achashverosh, a simple guy who just wants to feast, can't see why not. Differences between people are threatening. He signs off to the execution of the Jewish people.

Mordechai gets word to Esther that she has to stop the edict, must intervene somehow. She's not so quick to accept the mission. The king will put to death anyone who visits him without an invitation, and she has not been invited in 30 days. Mordechai tells Esther that if she does not take the initiative, then salvation for the Jewish people will come from somewhere else. She steps up.

An aside to therapists: When working with patients who feel hopeless about their lives, who cannot see a way out, not a single possibility, yet have some faith in God, you can use the following line from the story, even tell an abridged version of the story. Try to say it in Hebrew, because it makes an impression, lends authenticity. The transliteration is in the picture to the right:

The (salvation) solution will come from someplace else, is beyond what you might expect or are looking for.

Solutions come in two dresses, either creative thinking, or seemingly random events.

it isn't our call

But back to the story: The Jews pray and fast for three days, hoping to curry God's favor. Esther gets her audience with the king, liquors him up and outs Haman as a bad man with murderous intentions. The king is outraged and reverses the decree. He hangs Haman and his sons, and permits the Jews to kill their enemies within his kingdom (it is a huge kingdom). They take no spoils, but declare another holiday, a good reason to knock off work early.

It is an eating and drinking holiday, but before any feasting, there is running around town with gifts of food and charity. Kids dress up as kings and queens, and the story is read from a scroll. A younger adult generation entertains with a video, kids who should have gone into film making, not medicine or law, roasting the rabbi and almost everyone else.

Why bring up Purim? It is a lesson that with the stroke of a pen, kings and potentates can order the end of life. It starts with advisers, meetings, influence, maybe someone whose ego couldn't take a hit. Such attitudes are passed down in families and communities, but mostly, families. We trust our parents.

There is a connection to high functioning autism.

Once I saw a man with high functioning autism (or I made him up for this post). We called it Apsergers Disorder until the DSM did away with Aspergers in 2013. The man, like his father, put people into racial and ethnic categories. The Blacks. The Mexicans. The Polacks, The Asians, The Obese. Everyone had a box, and the man, like his father, couldn't describe anything that a person might do or say without first putting the person into the box.

He's a nice doctor for a Jewish guy.

Why does he have to take seconds. Look at him!

At first I thought it a racist thing, then realized he had indeed learned it from his father. But more than that, he honestly didn't see anything wrong with it. He thought it was great that he could do this, organize people, understand them by labeling them. He didn't see the labels as gross generalizations, ridiculous simplifications, or that 99% of our DNA is the same.

(Once I went to China and said something about the Chinese, thinking my experience mattered. FD said, "You really can't generalize about 1.5 billion people.")

When I got to know the patient better, I realized that for him, everything had to go into a box. He had to organize somehow. Having high functioning autism, unable to empathize, he also didn't know he had the disorder. As often happens with such patients, he came to therapy for his wife, who had issues with him and his social/marital insensitivity.

He and his father had made an ethnic or physical trait category into a social cue. Labeling people appealed to his obsessive compulsiveness, helped him gain some control in a world of humans who otherwise mystified him.

Moral of the story: When you have a patient who sees nothing wrong with telling ethnic or racist or very insensitive joke, it is a sign that he might have a disorder, such as high functioning autism. He may not mean any harm. You'll know if he is completely confused by your efforts at correction.

Now, Haman? A total racist, calling for the annihilation of a people he didn't respect, hated for their differences, their values. Today he might be put in jail for conspiracy to commit a genocidal (terrorist) act, duping an innocent king on the sauce. And he would see a therapist, undoubtedly, to work on his narcissism  and sociopathy.

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Another diagnosis heard from: more Cho

Jeffrey Kluger, in this week's issue of TIME MAGAZINE interviewed several forensic psychiatrists and proceeded to propose a theory about Cho's psychology not much different than the one I did on Slow Burn, except that he adds a feature I left out. Narcissism.

It's worth a look as it adds another plausible diagnosis to the soup. Cho fit the features of the disorder, listed below.

Narcissistic Personality Disorder, 301.81.

The DSM IV-TR:

A pervasive pattern of grandiosity (in fantasy and behavior), need for admiration, and lack of empathy, beginning by early childhood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) shows arrogant, haughty behaviors or attitudes

Although it may look like a match, based on the video, keep in mind that people with Narcissistic Personality Disorder (NPD) usually aren't mute. They interact socially with people who respect and flatter them, and can be as physically attractive as anyone else, so they have something of a social network, although it's usually small and the turn-over is high. They're not real likable, despite thinking they should be.

Cho never interacted with anyone, which is why I skipped right over NPD to Schizoid Personality Disorder, premorbid to Schizophrenia, Paranoid Type, which presented later in his early 20's, probably the year before the massacre.

Mr. Kluger says that mass murderers like Cho and Harris and Kliebold (the Columbine murderers) suffered from "clinical narcissism"

a condition characterized by "disablingly low self-esteem, requiring the sufferer to seek almost constant recognition and reward."

He goes on to say that if a narcissist is denied recognition, especially if he has had a history of abuse and marginalization, he can become enraged, gradually moreso. A sense of powerlessness is replaced by a (my addition in parenthetic italics)

"heady experience that may produce an implacable serenity on the one hand (Cho), or the eerily jocular banter that surveillance tapes picked up between Harris and Klebold in Columbine on the other."

Kluger says that the gunman is calm because he knows he's right

". . .the world has brought the carnage upon itself."

I would say that yes, it looks like that, like Cho was confident in his decision to kill and felt justified, like he'd been harmed and was delivering vengeance. But in this case the gunman was calm, very probably, because he knew he was following the orders of the voices in his head that said, They've harmed you, cheated you, ignored you. Kill them. Soon.

The narcissist would be thinking for himself, the person with schizophrenia has help. The thoughts are the same, but the person with schizophrenia is hearing voices and is fearful, not righteously indignant like the narcissist.

This is why I'm not quick to join Time Magazine's journalist who concludes by saying that we can predict these things because murderers who suffer from clinical narcissism do tell people, even brag to others that they intend to perpetrate their crimes. Harris and Kebold said so on the Internet. I don't remember reading that that was the case with Cho at all. Who did he talk to? Did he tell someone? Am I missing something? It would have been difficult for anyone to read his mind. Again, it's very possible that we're missing information. We're only one week from the event. More will tumble out over the coming weeks, months and years.

So I'll stick to my original diagnosis of schizophrenia for now.

Nevertheless, this is a perfect example of why diagnosis per se is often a dead end and tells us little.

On the surface, Cho had most of the symptoms, if not all, of Narcissistic Personality Disorder. But it certainly wasn't a pervasive disorder as it didn't manifest until the episode, the massacre.
We don't even know if he slept. Perhaps he had a manic episode.

And if we add narcissism to Cho's Axis II disorders, does that mean we have to be very careful with every narcissistic adolescent we see? Normal adolescents can go through a very narcissistic phase but the grow out of it and everyone is grateful. Also, in NPD there is typically a LACK of self-destructiveness, impulsiveness, or concern with abandonment. You did this to me might be saying something about abandonment. Suicide IS self-destructive.

I think the key word to look at, forget the clinical diagnosis for a minute, is arousal. Screaming anxiety/anger, uncontrollable, painful arousal, likely caused by dysfunction of the limbic system and perhaps voices in his head or perhaps, as Kluger says, righteous indignation.

Thus when we send psycho-educational teams of mental health professionals and peer counselors to our schools to teach children about mental illness, as I've suggested on other posts, they will focus on communication and anger management. I am working on the program right now.

I base that trajectory, by the way, the Schizoid Personality Disorder premorbid to Schizophrenia upon what the American Psychiatric Association finds statistically significant in the data analysis of studies in the general and clinical populations. The DSM is a product of 13 Work Groups and a Task Force, consensus scholars without previously held views, who analyzed cross-cultural data.

By the way. This is not to say that people who do have personality disorders don't have some kind of genetic predisposition that presents as lacking empathy. We'll save empathy, however, for the next discussion.

Copyright 2007 TherapyDoc