The Disordered Mind

by Eric R. Kandel

  Some psychiatric disorders, at least, do not appear to involve permanent structural changes in the brain and therefore are more likely to be reversible than disorders stemming from obvious physical damage. For example, scientists have found that increased activity in a particular area of the brain is reversed in successful treatment of depression. That said, newer treatments may eventually reverse even the physical damage caused by neurological disorders, as is now being done in some people with multiple sclerosis.

  As research into the brain and mind advances, it appears increasingly likely that there are actually no profound differences between neurological and psychiatric illnesses and that as we understand them better, more and more similarities will emerge. This convergence will contribute to the new, scientific humanism, offering a chance to see how our individual experiences and behavior are rooted in the interaction of genes and environment that shapes our brains.

  2

  OUR INTENSELY SOCIAL NATURE: THE AUTISM SPECTRUM

  We are by nature intensely social beings. Our success in adapting to the natural world over the course of evolution has resulted in large part from our ability to form social networks. More than any other species, we depend on one another for companionship and survival. As a result, we cannot develop normally in isolation. Children are innately prepared to construe the world they will encounter as adults, but they can learn the critical skills they will need, such as language, only from other people. Sensory or social deprivation early in life can impair the structure of the brain. Similarly, we need social interaction to keep the brain healthy in old age.

  We have learned a great deal about the nature and importance of our social brain—the regions and processes that are specialized for interaction with other people—by studying autism, a complex disorder in which the social brain does not develop normally. Autism appears during a critical period of development early in life, before the age of three. Because autistic children are not able to develop social and communication skills spontaneously, they withdraw into an inner world and do not interact socially with others.

  Autism includes a spectrum of disorders ranging from mild to severe, all of which are characterized by difficulty connecting with others. People with autism have an impaired ability to engage in social interactions and communications, both verbal and nonverbal; in addition, their interests are restricted. Such barriers to interaction with others profoundly affect social behavior.

  This chapter explores what autism has taught us about our social brain, including our ability to read the mental and emotional states of others. It describes cognitive psychology’s contribution to our understanding of autism and the insights into the neural circuitry of the social brain that autism studies have given us. Scientists have yet to discover the causes of autism, but genes appear to play a leading role. Remarkable new advances in genetics show how mutations in certain genes disturb key biological processes during development, resulting in autism spectrum disorders. Finally, we will touch on what we have learned from social behavior in animals.

  AUTISM AND THE SOCIAL BRAIN

  Based on their studies of chimpanzees, David Premack and Guy Woodruff of the University of Pennsylvania proposed in 1978 that each of us has a theory of mind—that is, we attribute mental states to ourselves and to others.1 Each of us has the ability to appreciate that other people have a mind of their own, that they have their own beliefs, aspirations, desires, and intentions. This innate understanding is different from a shared emotion. A very young child will smile when you smile or frown when you frown. But realizing that the person you’re looking at may be thinking about something different from what you’re thinking about is a profound skill that arises only later in normal development, around the age of three or four.

  Our ability to attribute mental states to others enables us to predict their behavior, a critical skill for social learning and interaction. When you and I talk, for example, I have a sense of where you are going in the conversation and you can sense where I am going. If you are joking with me, I will not interpret you literally and will predict different behavior from you than I would if I had the sense that you were speaking seriously. In 1985 Uta Frith, Simon Baron-Cohen, and Alan Leslie at University College London applied the concept of theory of mind to people with autism.2 Frith (fig. 2.1) describes how this came about:

  How does the mind work? What does it mean to say the mind is created by the brain? Since my student days in experimental psychology I have been passionately interested in these sorts of questions. Pathology was the obvious way to get at possible answers, and I trained to be a clinical psychologist at the Institute of Psychiatry in London. Here I met autistic children for the first time. They were completely fascinating. I wanted to find out what makes them behave so strangely with other people, and what made them so totally untouched by the kind of everyday communication we take for granted. I still want to find out! Because even a lifetime of research is not enough to get to the bottom of the enigma that is autism.…

  Figure 2.1. Uta Frith

  I wanted to know why autistic individuals, even when they had good language, were so difficult to involve in a conversation. The concept of “theory of mind” was just then being developed by bringing together studies from animal behavior, philosophy, and developmental psychology. It seemed to me and my then-colleagues Alan Leslie and Simon Baron-Cohen [to be] of extreme interest to autism, possibly the key to their social impairments. And so it proved to be.

  We started systematic behavioral experiments in the 1980s and showed that autistic individuals indeed do not show spontaneous “mentalizing.” That is, they do not automatically attribute psychological motives or mental states to others to explain their behavior. As soon as neuroimaging methods became available we scanned autistic adults and revealed the brain’s mentalizing system. This work is still ongoing.3

  Research into autism has taught us a great deal about social behavior and the biology of social interactions and empathy. Some social interactions, for example, occur through biological motion—walking toward another person, reaching a hand out in greeting. In 2008 Kevin Pelphrey of Yale University, then at Carnegie Mellon University, discovered that autistic children have difficulty distinguishing biological motion.4 In an experiment with autistic and non-autistic (neurotypical) children, he monitored two regions of the brain while the children were looking at biological or non-biological motion. One brain region was a small visual area known as MT or V5 (MT/V5), which is sensitive to any motion; the other was the superior temporal sulcus, which in neurotypical adults responds more strongly to biological motion. The biological motion Pelphrey showed the children was a person or a humanlike robot walking; the non-biological motion was a disjointed mechanical figure or a grandfather clock. In both groups of children, the motion-sensitive MT/V5 region of the brain responded about equally to the two kinds of motion. But in typically developing children the superior temporal sulcus responded more strongly to biological motion. In autistic children the same brain area did not register any difference between the two kinds of motion (fig. 2.2).

  The ability to identify and integrate biological action with the context in which it occurs—for example, to integrate our observation that a person is reaching for a glass of water with our surmise that that person is thirsty—enables us to recognize intention, which is critical to a theory of mind. Thus, one of the reasons people with autism have difficulty with social interactions is that they have limited capacity to read socially meaningful biological actions such as reaching to shake hands.

  People with autism have a similar difficulty reading faces. When autistic people look at another person, they avoid the eyes and instead tend to look at the mouth (fig. 2.3). Neurotypical people do the reverse: they look primarily at the eyes. Why? Because a person’s gaze—where he or she is looking—gives us important clues about what that person desires, intends, or believes. The words “desire,” “intend,” and “believe” describe mental states. States of mind
are not actually open to direct observation, but most of us behave as if we can directly observe another person’s mental states, as if we can read minds.

  Figure 2.2. Responses to biological and non-biological motion in two regions of the brain in typically developing children and children with autism. MT/V5 is a region of the occipital lobe.

  Take the marvelous painting The Cheat with the Ace of Diamonds, by Georges de La Tour (fig. 2.4). What do you see when you look at it? You are probably attracted to the strange gaze of the lady sitting down. She is obviously communicating with the woman standing to her right. The standing woman has seen the cards in the hands of the player on the left. This player is a cheat: you can see that he is hiding the ace of diamonds behind his back. The player at the right is a rich young man who will be cheated out of the heap of gold coins in front of him.

  How can we interpret this scene, painted almost four centuries ago, so confidently? How can the painter rely on us to put together all the clues he has given—the gaze, the pointing finger, the hidden card—and arrive at the correct interpretation? Our uncanny skill derives from our ability to formulate a theory of mind. We use it all the time to explain and predict other people’s behavior.

  Figure 2.3. Eye movement patterns in an autistic versus a neurotypical person

  Figure 2.4. Georges de La Tour, The Cheat with the Ace of Diamonds, ca. 1635, Louvre, Paris

  A major disturbance in autism occurs in the connections between gaze and intention. Although we still have a long way to go to understand the biological causes of autism—the genes, synapses, and neural circuitry that are altered—we do know quite a bit about the cognitive psychology of autism and, through it, about the cognitive systems in our brain that are responsible for the theory of mind.

  THE NEURAL CIRCUITRY OF THE SOCIAL BRAIN

  In 1990 Leslie Brothers of the UCLA School of Medicine took advantage of the insights into theory of mind that had been derived from studies of autism to propose a theory of social interaction.5 She argued that social interaction requires a network of interconnected brain regions that process social information and together give rise to a theory of mind; she coined the term social brain to describe this network. The regions include the inferior temporal cortex (involved in face recognition), the amygdala (emotion), the superior temporal sulcus (biological motion), the mirror neuron system (empathy), and the areas in the temporal-parietal junction involved in theory of mind (figs. 2.5 and 2.6).

  Brain science is only now beginning to decipher how the regions of the social brain identified by cognitive psychology are connected and how they interact to affect behavior. Stephen Gotts and his colleagues at the National Institute of Mental Health have used functional brain imaging to confirm that the neural circuit of the social brain is indeed disrupted in people with autism spectrum disorders. Specifically, disrupted connections occur in three regions of the social brain: those involved in the emotional aspects of social behavior, those involved in language and communication, and those involved in the interplay between visual perception and movement. Normally, patterns of activity in these three regions are coordinated with one another, but in people with autism they are not. Rather, they are out of sync with one another and with the rest of the social brain.6

  Of particular interest are anatomical findings regarding the timing of brain growth and development in autistic children. Before the age of two, the circumference of an autistic child’s head is often larger than that of a typically developing child. In addition, some regions of an autistic child’s brain may develop prematurely during the first years of life, particularly the frontal lobe, which is involved in attention and in decision making, and the amygdala, which is involved in emotions.7

  Figure 2.5. The network of regions that makes up our social brain

  Figure 2.6. Theory of mind: the neural mechanism in the temporal-parietal junction that is recruited when thinking about someone else’s thoughts, beliefs, or desires

  This is important because when one or more regions of the brain develop out of sequence, they may seriously disturb the patterns of growth in other regions of the brain to which they connect.

  THE DISCOVERY OF AUTISM

  Autism was recognized as a separate disorder in the early 1940s by two scientists who had no contact with each other: Leo Kanner, working in the United States, and Hans Asperger, working in Austria. Until then, children with the disorder had been diagnosed as mentally retarded or as having behavioral disorders.

  Remarkably, Kanner and Asperger not only came up with similar descriptions of what they were studying, they even gave the disorder the same name, autism. The word had been introduced into the clinical literature by Eugen Bleuler, the great Swiss psychiatrist who coined the term schizophrenia. Bleuler used “autistic” to refer to a particular group of symptoms that characterize schizophrenia: social awkwardness, aloofness, and an essentially solitary life.

  Kanner was born in Austria and educated in Berlin. He moved to the United States in 1924 and took a position at the state mental hospital in Yankton, South Dakota. From there he went to The Johns Hopkins University, where he founded the Children’s Psychiatric Clinic in 1930. In 1943 he wrote his classic paper “Autistic Disturbances of Affective Contact,” in which he described eleven children.8 One of them, Donald, was happiest when he was alone. Kanner prefaced his own observations of Donald with a description written by the boy’s father: “‘He seems almost to draw into his shell and live within himself … oblivious to everything about him.’ In his second year, he ‘developed a mania for spinning blocks and pans and other round objects.’ … He … developed the habit of shaking his head from side to side.” Based on his analysis of Donald and the ten other children, Kanner presented a vivid picture of the three important features of classic autism in childhood: (1) profound aloneness, a strong preference for being by oneself; (2) a desire for things to be the same, not to change; and (3) islets of creative ability.

  Asperger was born just outside Vienna. He received his medical degree from the University of Vienna and worked at the university’s pediatric clinic. Asperger realized that autism does not take the same form in all people with the disorder. It covers a wide spectrum, from people who are below average in some intellectual activities and have great difficulty with language, to those who are very bright and have no difficulty with language. Moreover, he found that autism persists and is evident in adults as well as children.

  The children Asperger saw were on the mild end of the autism spectrum. Some of them functioned on a very high intellectual level; for example, Elfriede Jelinek, who was awarded a Nobel Prize in Literature, was a patient of Asperger’s. Until quite recently, high-functioning autistic children and adults were diagnosed as having Asperger’s syndrome. Today, Asperger’s syndrome is generally considered part of the autism spectrum.

  LIVING WITH AUTISM

  Being the parent of an autistic child is difficult. Alison Singer, the president of the Autism Science Foundation, who has a daughter with autism, describes it as “a challenge and a struggle every day.… It’s financially exhausting. It’s emotionally exhausting. It’s 24/7 taking care of someone who can’t really communicate, with whom I can’t really communicate. I have to surmise most of the time what she’s trying to say.”

  As Singer explains:

  Living with an autistic child is really about trying every day to find a balance between loving your child for exactly who she is and constantly pushing for more. And by “more” I mean more language, more social interaction, more restaurants or other places in the community where she can go without having a meltdown.

  My daughter exhibited a lot of the typical early warning signs of autism. When she was a baby, she never babbled. She never had social gestures. She never waved bye-bye. She never shook her head yes or no. She had tantrums that were off the charts. She really struggled to make eye contact when I would take her to the playground or to play groups. She never showed any interest in the other children. S
he did have some words, but all of them were words she had heard from books or videos and she didn’t use them in a meaningful way, to communicate. She just repeated them over and over. And she played with toys in very unusual ways. She would sort them by color, line them up by size; she never really played with them in the way that the toy manufacturers intended them to be played with. Don’t be fooled into thinking your child is using toys in some sort of “creative way.” Really, toys should be used the way the manufacturer intended.

  As she’s gotten older—she is nineteen and a half now—some of those symptoms have become more ingrained, more entrenched, but in other ways she has improved. Autism is a developmental disorder and as they get older, most kids show improvement. Some is the result of intensive therapy, and some is just maturity.9

  In the 1960s Bruno Bettelheim, a Viennese-born psychologist who specialized in emotionally disturbed children, popularized the unfortunate term refrigerator mother to explain the origins of autism. Bettelheim argued that autism did not have a biological basis but was the result of a mother withholding affection for a child she did not want. Bettelheim’s theories about autism, which caused great pain to many parents, have been completely discredited.

  Singer is grateful that research has revealed the biological basis of autism:

  At least now we no longer have to struggle with the idea that autism is the result of bad parenting and that parents of children with autism were too cold to bond properly with their child and that that is what caused the child to retreat into her own world. The parents of children with autism love their children more than you could ever understand. We do everything, everything to help them gain skills and participate in community activities.