DECEMBER 10, 2018
FOR NEARLY FOUR DECADES now, the Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM for short, has exercised a stranglehold of sorts over the mental health sector in the United States, and indeed around the world. Since the publication of the manual’s third edition in 1980, psychiatrists have used a symptom-based approach to name and categorize varieties of mental disturbances — which essentially mirrors the 18th century’s approach to physical illness. As was also true then, there do not exist today any technologies that lend authority to psychiatric diagnoses: no x-rays or MRIs, no blood tests or laboratory analyses that would allow us to make even the most basic distinctions between mental health and mental illness. This unsatisfactory situation has invited controversy and led some misguided souls to deny the very reality of mental illness.
The fact that the DSM has passed through three editions and two interim revisions since 1980 is eloquent testimony to the psychiatric profession’s struggle with delineating its territory. Yet, however haphazard, the diagnostic category or categories to which patients are assigned have profound social and medical ramifications. And American professionals — even clinical psychologists who reject the DSM’s model — have no choice but to use (and thereby uphold) these categories if they expect to be paid by insurance companies.
It is hardly any wonder that the steady proliferation of psychiatric “illnesses” has met with skepticism, alarm, and ridicule. Are “hoarding disorder” and “school phobia” genuine diseases? What of hyper-sexuality or temper dysregulation disorder or oppositional defiant disorder? Some of us are extremely shy. Are we then suffering from social anxiety disorder? If we are prostrated by grief, are we then candidates for a diagnosis of depression? This kind of blurring of the boundaries between normal human variations and mental pathology has not only elicited plenty of criticism, but accusations of professional imperialism — of psychiatry colonizing every area of human life. Not coincidentally, it has also provided a pretext for vast increases in psychoactive drugs prescriptions, and for even larger increases in Big Pharma profits.
But the DSM giveth, and the DSM, in its various versions, taketh away.
The second edition of the manual, for example, declared that homosexuality, previously labeled a mental illness, was nothing of the sort. This change derived from a decision taken by a majority vote of America’s psychiatrists — surely an odd way to decide a scientific question, though, to be sure, one that all but the most bigoted would eventually endorse as appropriate. But that very evolution of public opinion demonstrates how deeply intertwined with social and moral concerns many psychiatric diagnoses turn out to be. As for the third edition of the manual, and its first revision seven years later, these iterations stripped away all the forms of neurosis that had previously grounded psychoanalytic practice, including a psychiatric diagnosis like hysteria, which had existed for centuries. Carefully orchestrated by Robert Spitzer, the Columbia University psychiatrist in charge of the project, the elimination of these categories helped to end Freudian domination of American psychiatry, ushering in the biological reductionism that has taken its place.
As the fifth, and latest, edition of the DSM neared completion in 2012, critics railed against yet another prospective deletion from the psychiatric pantheon. Other features of the new manual were drawing fierce criticism from within the profession, but in this case some of the loudest cries now came from patients — or rather patients’ families. Why? Because the press began to report that, alongside the inclusion of a host of new kinds of “illness,” such as attenuated psychosis symptoms syndrome, the new manual would eliminate a category of mental disorder called Asperger’s syndrome, whose prevalence had increased exponentially over the previous decade and a half. This news provoked enormous pushback from families with children who had been diagnosed with the disorder. The reality of the problems their children presented (at home, in school, and in the community) was about to be denied by those who had authority in these matters. And with the disappearance of the diagnosis, the social and educational services the label afforded these families might vanish — a disturbing, even frightening prospect.
Parents’ protests were in vain. When the new edition of the DSM appeared in May 2013, Asperger’s syndrome had indeed been cast on the historical scrap heap, swallowed up in the much larger, more amorphous category of autism spectrum disorders. Mainstream psychiatrists argued that distinctions among different developmental disorders — autism, Asperger’s syndrome, childhood disintegrative syndrome, Rett syndrome, and pervasive developmental disorders not otherwise specified — were inconsistently applied and obscured the existence of a continuum of disabilities. Parents on the one hand resisted the assimilation of Asperger’s syndrome into what was perceived as the more devastating diagnosis of autism, and on the other hand worried that their offspring might find themselves denied a diagnosis that was crucial to their eligibility for the social and educational services they had come to depend upon.
In everyday life, psychiatry’s decision to deny hysteria the legitimacy of a professional diagnosis has not prevented ordinary folk from using the term, attaching to it certain kinds of emotional and behavioral performance. The same is likely to happen, one suspects, with Asperger’s syndrome. Almost certainly it will survive in the popular consciousness, and perhaps also in doctors’ consulting rooms, though it will doubtless disappear from official medical records. Families who shrink from having their children labeled as autistic will doubtless continue using it. Yet the label itself was coined less than a half century ago, and its history is murky in many senses of the term. It is that history that the Stanford historian Edith Sheffer has now uncovered in her fascinating and disturbing new book published earlier this year, Asperger’s Children: The Origins of Autism in Nazi Vienna. An impressive piece of historical detective work, it deserves a wide readership.
Rumors have circulated for some time that Hans Asperger was a Nazi collaborator who sent autistic children to their deaths. Two recent books on autism, John Donvan and Caren Zucker’s In a Different Key (2016) and Steve Silberman’s NeuroTribes (2015), advanced radically discordant views on the subject, the former denouncing Asperger as an opportunist who was complicit in the murder of disturbed children, and the latter arguing that he was a compassionate clinician who under extraordinarily difficult and perilous conditions tried his best to save such children. Neither interpretation was grounded in a careful review of the historical record, so it was a debate that was difficult to settle. Sheffer’s research does much to resolve the issue, and in light of her findings, perhaps the label Asperger’s syndrome ought to be cast aside after all.
The practice of giving an eponymous name to a disease — naming it after someone as in Bell’s palsy, Parkinson’s disease, Crohn’s disease — was once relatively common in medicine. Typically, as in these cases, the label honors the physician who first delineated the disorder, though occasionally, as in the case of Lou Gehrig’s disease (amyotrophic lateral sclerosis), the “honoree” was an unfortunate sufferer from the disorder. Asperger’s syndrome is true to type, being named after the Viennese psychiatrist who supposedly first linked a particular set of symptoms and behaviors into a single entity, or rather advanced the hypothesis that autism was not a single entity, but a spectrum of disorders. In reality, though, it was a British child psychiatrist, Lorna Wing, who first coined the label “Asperger’s syndrome” some decades later, in 1981, using it as a shorthand for high functioning autism. It bears mentioning that Wing’s own daughter was autistic, as is Sheffer’s son. These were not abstract issues for either of them.
Both autism and Asperger’s syndrome are identified with Austrian child psychiatrists, albeit men of very different backgrounds, temperaments, and career paths. Autism as a diagnosis is most commonly associated with Leo Kanner, who had relocated to the United States in 1924, first to take up a post at the Yankton State Hospital in South Dakota. In 1928, he obtained an appointment in the psychiatry department at Johns Hopkins, and it was here that he wrote his 1943 paper on “Autistic Disturbances of Affective Conduct,” a summary of his clinical observations of 11 children who were highly intelligent but displayed “a powerful desire for aloneness” coupled with “an obsessive insistence on persistent sameness.” Kanner borrowed the term “autism” from Eugen Bleuler, who is famous for being the first to diagnose and describe schizophrenia. Bleuler had used autism to describe the disconnection of schizophrenics from the outside world. But it was Kanner’s paper, and his application of the concept to children, that brought autism to public attention and inspired subsequent generations of researchers. Such children, he argued, exhibited characteristic patterns of social withdrawal, characterized by restricted social relationships, limited speech, repetitive language and behavior, and obsessions with the routine.
Many parents were grateful to Kanner for providing a diagnostic label that helped give some semblance of order to the chaotic world into which their child’s social isolation and often self-harming behavior had plunged them, and Kanner’s formulation encouraged others to attend to and undertake research on the condition. But for over a decade in the 1950s and after, that sense of gratitude curdled. Kanner openly entertained the idea that it was the emotional constipation of the parents, and most especially the mother, that explained their children’s psychosis. It was a notion he came to repent of and recant by the late 1960s, but for a generation the idea of the refrigerator mother inflicted blame and misery on already traumatized families, largely through the self-promoting efforts of another Austrian refugee, the psychoanalyst and charlatan Bruno Bettelheim. Bettelheim suggested that a crucial element in “curing” autism was a parentectomy — a severing of all ties between pathological parents and the child they had brought into the world.
Kanner was a Jew, and it is not hard to guess what his fate would have been had he remained in Germany. Instead, he was able to play an important role in rescuing hundreds of Jewish physicians from the death camps, even welcoming some of them into his own home. Kanner was also active in socially progressive causes. For example, local judges in cahoots with prominent lawyers, had arranged for some mildly disturbed mental patients to be released from state mental hospitals and placed in the homes of wealthy Baltimoreans, where they served as unpaid “servants.” Kanner exposed their fate (sexual exploitation, descent into prostitution, imprisonment, and death) and so forced the abandonment of what amounted to a program of state-sponsored slavery.
The creation of the diagnosis of childhood autism was an instance of what the distinguished American sociologist Robert Merton dubbed simultaneous and multiple discoveries in science. For in Vienna, at almost the very moment Kanner was articulating his vision of the disorder, the aforementioned child psychiatrist Hans Asperger was also arguing for recognition of the condition. Indeed, he had given a lecture on the subject as early as 1938, though his key paper on the subject did not appear until five years later, just as Kanner was publishing his own findings. Some have suggested that Kanner borrowed his ideas from Asperger, but Sheffer rightly rejects this idea, pointing out that Asperger’s 1938 lecture was published only in the ephemeral Viennese Clinical Weekly. The more likely explanation is that both men borrowed from the clinical work of Georg Frankl and Anni Weiss, a Jewish couple who had begun their work in Vienna. Kanner had helped rescue one of them from the clutches of the Nazis.
Given that the Austrian Anschluss meant that Vienna had now become part of the Third Reich, it is perhaps unsurprising that, in the English-speaking world, Asperger’s work was ignored and overlooked for several decades until Lorna Wing discovered and publicized it. Before the rise of Austrian fascism in the 1930s, Sheffer reminds us, the capital of the old Austro-Hungarian empire had been called Red Vienna, and with good reason. In the 1920s, the political program of the municipal authorities was detached from the policies and preferences to be found in the rural and conservative remnants of the empire. The Viennese authorities had pioneered programs of social welfare, public housing for the working classes, and free medical care. Hyperinflation and the depression, however, began to unravel these experiments, which then withered in the face of the rise of the authoritarian right. In the ’20s, government intervention in the lives of the poor was increasing, particularly when it came to child-rearing, with predictable and distinctly mixed consequences. Social workers built an extensive apparatus to mold child-rearing practices among the lower orders, and at times did not shrink from removing children from parents whose child-rearing practices offended their professional sensibilities, consigning the “rescued” to institutions where they were frequently neglected or abused. As the country slid toward fascism, the capture of this apparatus by those with a different agenda allowed for the realization of ever-more sinister possibilities to be realized. It was within this context and working within established child welfare services that Hans Asperger made his career.
Where Kanner was a progressive Jew, Asperger was a conservative Catholic. From the earliest stages of his career, he was associated with and sponsored by extreme right-wing elements. Franz Hamburger, for example, who appointed the 25-year-old Asperger to his first post at the University of Vienna’s Children’s Hospital, employed a strict ideological test for all appointments at the institution he ran. He purged liberal and Jewish faculty appointed before he took charge, and most of his own appointees went on to be major Nazi enthusiasts and proponents of the euthanasia of children deemed mentally ill. Some had a direct role in the killing. Hamburger was zealous from the start: he joined the Nazi Party in 1934 when it was still illegal and regarded as a terrorist organization. Another of his other protégés, Erwin Jekelius, a close associate of Asperger’s over the years, would become the leading figure in the extermination of the mentally ill, adult and child alike. Asperger idolized Hamburger, continuing to praise him in extravagant terms as late as 1977.
As a devout Catholic, Asperger never took the fateful step of joining the Nazi Party, even after the Anschluss of 1938. That was fortunate for his later reputation, and for his ability to continue his career after the war. But those who try to portray him as some sort of Schindler figure, using his position to rescue children from Nazi extermination will have to reckon in the future with the materials Sheffer has uncovered.
Engelbert Dollfuss, the Austrian chancellor from 1932 onward, seized dictatorial power within months of his appointment, dissolving Parliament, banning the Austrian Nazi Party, and ruling by decree. In February 1934, he also banned the socialist movement, provoking civil unrest that was violently put down. He then cemented the rule of an Austro-fascist movement modeled on Mussolini’s regime in Italy. (Though he was assassinated in July 1934 as part of a failed coup, the fascist regime endured until Hitler annexed Austria in 1938.) Within days of Dollfuss’s consolidation of Austro-fascist rule, Sheffer informs us, Asperger had joined the ultra-nationalist Fatherland Front. He subsequently held leadership positions in a variety of extreme nationalist and antisemitic organizations, including the Bund Neuland.
Asperger had a long-standing commitment to far-right politics. As Jews were systematically purged from academic positions and from medicine, he seized opportunities to advance professionally, and after the Anschluss when violence against Jews became yet more extreme, he swore an oath to Adolf Hitler, and registered his Aryan bloodline. In the years that followed, he became a compliant and willing partner in the macabre version of psychiatry that flourished under the Nazis. Some will dismiss these activities as the actions of a careerist, as if that is sufficient excuse for his behavior. Others will be tempted to see a consistent pattern linking his politics to his conduct. Like Sheffer, I incline to the latter view.
Asperger’s defenders have constructed a benevolent image of him. His writings on autism emphasized that children of this sort existed on a continuum, and that the higher functioning among them — those who would later be diagnosed with Asperger’s syndrome — could, with proper “understanding, love and guidance” find “their place in the organism of the social community.” Some of them, he stressed, possessed special talents, and with proper attention and therapeutic measures could become of particular “social value,” especially in specialized technical professions. In other words, autistic children who “did not really fit into this world” might, through professional intervention and care, be transformed into useful contributors to the community — an argument, one might say, for neurodiversity avant la lettre. “The example of autism,” he wrote in 1943, “shows particularly well how even abnormal personalities can be capable of development and adjustment.”
But Asperger was, it turns out, a Janus-faced figure. Sheffer’s meticulous archival research into Asperger’s writings and professional activities has brought to light an entirely different facet of the man. For those Asperger saw as remediable, he indeed served as an advocate, but that was only part of the story. Others were, in his view, irremediable, undesirable versions of humanity: their biological defects pushed them into the ranks of autistic psychopaths incapable of connecting with the collective, examples of the “useless eaters” depicted in Nazi propaganda. For creatures such as these, death was the preferred treatment option.
Steve Silberman, who has been one of Asperger’s primary defenders, acknowledged in a revised edition of NeuroTribes that Asperger had sent a single patient, Herta Schreiber, to her death in the wards of Am Spiegelgrund, the children’s wing of Steinhof, the huge mental hospital that had been constructed above Vienna in the early 20th century. Silberman excused that action by arguing that brutal regimes like the Third Reich can compel even well-intentioned people to do monstrous things. Despite the fragmentary nature of the surviving records, Sheffer is able to document not one but dozens of such cases. She reminds us that in 1941, Asperger co-founded an organization that went under the Orwellian name of the Vienna Society for Curative Education (Wiener heilpaedagogischen Gesellschaft) with his one-time lieutenant, the ardent Nazi, Jekelius — a man once engaged to Hitler’s sister Paula, and by this time a notorious mass murderer, having sent 4,000 adult patients and more than a hundred children to their deaths. (As early as 1940, Jekelius was referred to by the Viennese as “the mass murderer of the Steinhof.”) The society’s other co-founder was Franz Hamburger, who had acted behind the scenes to organize and construct the killing machine, and who openly decried how “excessive care of the inferior allows inferior genetic material to circulate,” a problem that could be resolved by allowing children with “poor constitutions” to die.
In 1942, Asperger was a member of a seven-person commission for the city of Vienna that collectively examined children who had fallen into the “care” net. Sheffer cites the Austrian scholar Herwig Czech who discovered that, in a single day, these men examined the files of 210 children at the Gugging care facility, determining that nine girls and 26 boys were “incapable of educational and developmental engagement.” All were sent to Am Spiegelgrund, their files stamped “dispatched for Jekelius Action.” “Jekelius Action” was a euphemism for death. Asperger referred children to Am Spiegelgrund in his other capacities as well, and many of these referrals survive as well. Though not himself administering euthanasia, he was without any doubt “trusted in the highest echelons of the killing system” and, if not as active as some of his colleagues, “he was in the club.”
Some of the more disturbing sections of Sheffer’s book are the passages where she uses archival materials, including the desperate scribblings of children sent to Am Spiegelgrund. Here, they weren’t just “allowed to die.” Rather, alongside neglect and starvation, they were injected with barbiturates designed to induce infections (pneumonia in particular) to hasten their demise and to provide a medical cover-story for their deaths. For the children, fright turned into desperation and then despair. Only death provided a release, and the pathway to death was often prolonged and agonizing. Brains of some 400 hundred children who had died were pickled and preserved by one of the psychiatrists, Dr. Heinrich Gross. The jars into which they were placed survived the war, becoming the basis for his on-going research.
After the war, there were a few feeble attempts at a reckoning. At a trial of three of the perpetrators, the defendants took care to emphasize just how “scientific” the killing process had been, and how those in charge had conducted experiments to determine the most effective killing methods. The deaths, they explained, were acts of compassion. Of the three doctors, only one was sentenced to death, and though the other two received sentences of eight and ten years of imprisonment, they actually each served only two.
And they were the unlucky ones. Like the architects of the mass murder of adult mental patients in Germany, the so-called T4 program that ended up gassing and killing nearly a quarter million mental patients, the Austrian medical personnel who had slaughtered the children they were charged with treating mostly escaped serious consequences. Children who had survived often lived out their lives haunted by what had happened to others, and almost happened to them. But their torturers and murderers, and their assorted accomplices, emerged essentially unscathed. Jekelius was captured by the Russians and sentenced to 25 years’ imprisonment. He died in captivity from bladder cancer. But his and Asperger’s superior Hamburger, who had reached emeritus status in 1944, never faced trial. As previously mentioned, Gross, who had preserved the hundreds of brains of murdered children was able to use that forensic material as the basis of his research career for more than three decades after the war.
And Asperger? He was cleared of all wrongdoing, and because he had never joined the Nazi party, he benefited once again from a professional vacuum, in this case created by the mild measures of de-Nazification. Between 1946 and 1949, he served as interim director of the University of Vienna Children’s Hospital, and for decades afterward denounced the Nazis’ child euthanasia policies, which he claimed to have resisted at some considerable personal risk. His postwar research, however, had little to do with autism, the field for which he is now remembered, and he was dead by 1980, the year before Lorna Wing proposed that high-functioning autistic children might be referred to as examples of Asperger’s syndrome.
Andrew Scull is a writer and educator whose work has appeared in British Journal of Psychiatry, Psychological Review, and European Journal of Sociology among others. His most recent book is titled Madness in Civilization: A Cultural History of Insanity(Princeton).