Thinking in Pictures

Nosology is a domain of scholarly activity in which I've trodden from time to time. The word doesn't mean the scientific study of noses, as one of my friends derisively remarked years ago after a learned article on the subject was published under my name. Nosology is the systematic classification of diagnostic labels. This is a necessary prerequisite if we are to think constructively, rationally and critically about diseases, injuries, disabilities, causes of death, and especially about causes of mental, emotional and personality disorders. The Diagnostic and Statistical Manual of Mental Disorders is an attempt to create an authoritative classification or nosology of the ill-defined, often murky world of disturbances that can afflict the mind.  Its fifth edition, DSM5 for short, has been the latest word on nosology of mental disorders since 2013. Like its predecessors DSM5 has been heavily criticized.  The most cogent criticism is that it attempts once again to define the boundary between 'normal' and 'abnormal' human behaviour. It draws a sharp line where the reality is an extremely vague and fuzzy blur. Nowhere is this truer than in its discussion of autism.

DSM5 provides a lengthy description of symptoms and signs of autism, emphasizing deficits in social communication and interaction, and restricted range of behaviour,  interests and activities. By DSM5 criteria, appreciable numbers of epidemiologists and medical statisticians are autistic.  When I was compiling the first edition of the Dictionary of Epidemiology, I presided over a fascinating scholarly exchange of views about the definition of several important basic terms all epidemiologists must understand and agree upon.  One of these scholars thought about and defined these terms in words and concepts; the other scholar defined the same terms in mathematical formulae. This was an example of two fundamentally different thought processes, both equally valid.* One is the customary way most of us think, i.e in words and concepts; the other is comparable to Temple Grandin's description of the way she thinks: in pictures. Perhaps the experts who compiled DSM5 should have consulted Temple Grandin. She is a renowned veterinary scientist who has exceptional empathy with animals. Her best known achievement is the design of humane slaughter houses in which sheep and cattle proceed placidly along a curved ramp and cannot see the fate that is in store for them. Her designs are now used by over half the slaughter houses in the USA and many in other countries.

By the accepted criteria of DSM5 - and her own criteria - Temple Grandin is autistic. She has exceptional capacity for introspection and analysis of her own thought processes. She says that while most of us think in words, she thinks in pictures. Her analysis is probably correct. I'm sure some people do think in pictures, or in symbols or concepts. But Temple Grandin can think, or at any rate can write, in words too. Her memoir, Thinking in Pictures, is a clearly written account of some aspects of her life and work, notably an insightful account of how she adapted to her autism, her adaptation to her physical need to be constrained when she wants to relax or sleep.  She invented and built a device she calls her 'squeeze machine' which tightly embraces her body, providing a substitute for the hugs of loved ones that she can't tolerate. Like many autistic people, she can't tolerate intimate interaction with other people.  In a moving clinical essay about her, published in his collection called An Anthropologist on Mars, Oliver Sacks implies that he may be an exception in that he does seem to have established rather intimate interaction at any rate with her thoughts and emotions; Temple Grandin's account of their relationship, and a photograph reproduced in Thinking in Pictures, reinforce my impression that he and Temple Grandin did achieve a degree of emotional interaction that is highly unusual in autism. But then Oliver Sacks is not only a physician, a clinician who first encountered Temple Grandin in a doctor-patient relationship, he is also a man of exceptional empathy and charisma, despite his assertion that he is a very shy man. Temple Grandin describes how using her 'squeeze machine' enabled her to relax, and to interact more effectively with animals - to think as animals do, to acquire empathy for them. That is perhaps a large part of the reason why she is such a brilliant veterinary scientist, particularly in the field of behaviour and emotions of animals.

Oliver Sacks and Temple Grandin are each in their own way demonstrations of the difficulty, indeed the futility, of attempts to establish a workable nosology of mental disorders, in which diagnostic labels are, so to say, carved in stone. The problem arises with that word 'disorder' - what is a disorder, and what is an unusual variation of normal that makes a person exceptional in the highly desirable way that Temple Grandin and Oliver Sacks are both exceptional?   I doubt if we will ever satisfactorily answer this question.  

* This exchange of ideas in letters to me from these two eminent epidemiologists is now among my collected papers and correspondence held in the National Archives of Canada.