27 8 / 2012

Walking Nightmares for Medical Students – or In Defence of Mycroft’s and Sherlock’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.

The first part of this post is expanded upon in 3. Sherlock, himself and his Asperger’s

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 why. 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).

Note: A much better, more detailed account of why Sherlock would not be diagnosed with autism or Asperger’s Syndrome is available here

You can read the next part but bear in mind it was written in my lunch break. Also diagnosing autism and Asperger’s Syndrome in adults is very hard due to the behaviour modifications. 

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

He has an exceptional understanding of human emotion and motivation – 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. 

Many scientific studies have demonstrated that patients with Asperger’s Syndrome have impaired Theory of the Mind (i.e. cognitive empathy) - the ability to recognize and understand other people’s desire, emotions, beliefs and motivations. The same effect is seen in many other psychiatric disorders though through different pathological mechanisms. 



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).

For a diagnosis of autism patients must demonstrate irreversible cognitive developmental delay.  One of the defining features of autism is below average IQ. Only a small percentage of people with autism have an IQ score within the normal range. If a patient has a very high IQ and no sign of cognitive developmental delay - autism is not an appropriate diagnosis. 

So does he have Asperger’s Syndrome instead? No, sorry because:

He has unimpaired cognitive and affective 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 apparently does not occur in people who have Asperger’s Syndrome. This is not my personal opinion but widely cited fact within psychiatry and medicine at large. They are physically unable to experience empathy as evidenced by brain scans.

For references and a more in depth discussion on Asperger’s and empathy refer to this post. 

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.

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. More importantly his quality of life would not benefit from any medical intervention.
  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 requires 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. However these classical features are not unique to Asperger’s Syndrome. Just because Sherlock demonstrates poor social skills does not automatically mean he has AS.

Diagnosis in psychiatry is not just about ticking a checklist. If reading through a checklist was all you had to do then anyone could be a psychiatrist!

It takes 8 years of medical training to be a fully qualified psychiatrist. Diagnoses are done based on the patient’s entire clinical picture. Not just whether he fulfills certain characteristics. 

Four psychiatrists have give their professional views on Sherlock and autism/AS

The overwhelming conclusion is that Sherlock’s entire clinical picture does not fit a diagnosis of autism/AS. 

DMS-IV, the American diagnostic manual is similar but not entirely the same and different weightings are given to different categories (I am by no means an expert on diagnosis in the US). Therefore if someone was determined enough - they could find a psychiatrist that would be willing to diagnose Sherlock with Asperger’s syndrome because the checklist is very subjective. However this does not mean the majority of psychiatrists would agree. 

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. 

We don’t like labelling people with unnecessary diagnoses (does marking Sherlock with Asperger’s improve his quality of life?) and his behavioural problems are mostly likely not organic in nature (they are a nasty by product of his campaign to dehumanise himself). 

Psychiatry is very different from psychology. Psychology is the academic study of both normal and abnormal human behaviour, psychiatry is a branch of medicine aimed at diagnosing and treating mental diseases

Sherlock may be a very interesting psychology case study but we, as psychiatrists, do not care whether he fits society’s idea of “normal” and neither should he. 

A more detailed analysis is available in Part 3 - Sherlock, Himself and His Asperger’s

So what is wrong with Sherlock Holmes? In one word – nothing – he just can’t be bother navigating the maze of 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.

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 been mean to you lacks a conscience but DPD is something completely different.

It has been 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 a measurable organic difference between people with DPD and people who are just mean/anti-social/criminal. Although 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 bringing justice to 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. 

"Sociopathy" has never been formally used by the psychiatric community. However there are still a few psychiatrists that use it to describe patients who develop DPD 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 find 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) of personality traits. A personality trait is a set of behavioural responses that are both consistent and persistent through time and different social contexts.

Everyone sometimes displays “lack of remorse or guilt” orimpulsiveness” or a myriad of other points on the checklist but they don’t do it all the time, every time.

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 helped 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 Swallow”.

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 Asperger’s

Reblog if you liked it!

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  6. 221behavior reblogged this from wellingtongoose and added:
    A very valuable diagnostic look at Sherlock Holmes and the psychiatric illnesses often projected on to him.
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