It pains me to write these comments, critical of one of my favorite neuroscience writers, but it must be done.

V.S. Ramachandran has just published an online article that has taken an enormous amount of flak on Twitter, some of that from me. Also, the very first comment to the article cites a study that seems to indicate his claims are questionable at best.

UPDATE 4/19: One of my tweeps told me that the link just given was a transcript of an old interview, so he had complained. Evidently, the editor took it down. I’m not sure why, since as far as I know, it still represents Ramachandran’s point of view. The text of the interview appears here, but seems also to have generated some controversy on that site, so it could be removed from there as well, I suppose.

UPDATE 12/9/14: I notice it was indeed taken down, so I’ve put a copy on my own site, of the original post I saw and also a plain text version (not edited, so it may be a bit confusing, but it has all the words).

His punchline is

So if you make a list of all the properties, emotional empathy, imitation, pretend play and you look at all those functions of mirror neurons and make a tabular column of the functions that are deficient in autism, there’s almost a perfect fit.  This is what led us to suggest over 10 years ago that mirror neuron dysfunction might be the basis of autism, it might be one of the major causes of autism.

Really? A “cause” of autism? Based on my own experience, I can see that, having an autistic brain, my mirror neuron functioning might be impaired much in the same way many other brain functions are hindered. Sensory overload. But “dysfunctional” — I don’t think so. And, I think he has his causality backwards.

He then modestly claims that his speculation that “mirror neuron dysfunction might be the basis of autism” is

better than any other theory that’s around regarding autism

Really? Really?

Perhaps he also has a theory regarding lefthandedness.

Based on his descriptions of autism, it seems to me he doesn’t understand what it is like to be autistic. In the article, he says that autistic people

are lacking in empathy, … unable to adopt somebody else’s point of view … [and there is] also a lack of pretend play

These things are all completely untrue, in my experience.

I wrote a post a month or so ago about empathy. There is also a huge catalog of writings on this topic. I don’t know a single autistic person who doesn’t experience empathy (aside, perhaps, from those who are also alexithymic). As I noted in my post, autistic people may have trouble expressing their empathy, and so give the appearance of not being empathic, but that is a communication issue, not one of empathy.

And then there’s the old “theory of mind deficit” myth — these things are pretty much of the same piece.

And lack of pretend play? Not for me, I can assure you! Growing up, I was the oldest of five siblings, and was often the oldest in a group of kids eager to play. They would look to me to decide what we would play that day — would it be Cowboys and Indians? (and who would be which?) or would it be building a fort? or digging a hole to China? I got to decide. And I didn’t need playmates, either. I had plenty of imaginary friends.

According to Ramachandran,

Pretend play by definition in normal children or non-autistic children requires that you put yourself in the shoes of that doll or that action figure.  Pretend you are Superman.  Suspend reality for a short while and pretend you are Superman.  This autistic children are incapable of doing…

Superman was my favorite comic book and TV show when I was young. I didn’t have to pretend to be Superman. I was Superman. I even had a Superman costume, including the cape. I could fly.

All of these myths about autism may have been believed ten years ago, when Ramachandran devised his theory. But, he should know better than anyone that science evolves rapidly, and there are fewer and fewer people who believe them to be so.

Part of the problem, I believe, is that what is in the common wisdom surrounding autism is based in some large measure on ancient studies that were done in the days when autism diagnoses were rare. Only children were diagnosed, and only those who exhibited very noticeable behavioral differences. Kids who couldn’t speak, or who were  aggressive or self-injurious. Many of these children also had intellectual impairment.

It was thought, not too many years ago, that 70% to 80% of autistic kids were also intellectually impaired. Over time, researchers came to realize that the number was probably the reverse of that, and even more recently it has become clear that there is no connection between autism and intellectual or functional capacity.

This, in my opinion, is why we have seen the “explosion” of autism diagnoses. We have been here all along, but there was little awareness that most autistic people had learned to “fit in” and adapt.

I have a lot more to say about all of these things, including mirror neurons, but I’ll leave it at that for now. I simply felt a need to protest the appearance of this antiquated speculation that seems not to be based on our current understanding of autism.

The Ramachandran article, by the way, appears to be a transcript of a video which appears on the same site.

Receptive and Expressive Language

All communication has two aspects: receptive language and expressive language. Receptive language is what we hear and understand. Expressive language is what we say to others.

I believe that empathy is also a form of communication; one that is as essential to each of us as is spoken, written, or signed language in understanding the feelings of other sentient beings and in conveying our reaction to them. To oversimplify, one might think of language as the cognitive component of communication, whereas empathy is the emotional component. Of course, in reality, they overlap and complement each other.  

Receptive empathy is the ability to perceive the feelings that others are experiencing. Expressive empathy is the ability to convey that understanding to others.

Definition of Empathy

“Empathy” is a complicated word — it means so many different things to different people. And, a discussion of whether autistic people have a capacity for empathy that is different from most other people further complicates the conversation.

A web search on the single word “empathy” produced for me these top 5 results, defining the word in 5 different ways:

1. Empathy is the capacity to recognize emotions that are being experienced by another sentient or fictional being. (wikipedia)
2. the imaginative projection of a subjective state into an object so that the object appears to be infused with it (Mirriam-Webster)
3. the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another (dictionary.com)
4. Empathy is the experience of understanding another person’s condition from their perspective. (Psychology Today)
5. Identification with and understanding of another’s situation, feelings, and motives. See Synonyms at pity. (thefreedictionary.com)

So, which is it? “recognize emotions” or “imaginative projection” or “intellectual identification” or “vicarious experience of understanding perspective” or “identification and understanding” or “pity”?

It is probably all of those things and more, including sympathy and compassion. Trying to understand what people intend to convey by using the word is a bit like Justice Potter’s infamous definition of pornography. Empathy is something you know when you experience it, even though it is hard to describe in words.

Are there “Types” of Empathy?

Modifying the word “empathy” with “cognitive” and “affective” represents an ill-advised attempt to deconstruct empathy, in my view . Much has been made of the idea that these two aspects of empathy (to the extent that this dichotomy has any validity at all, which I doubt) arise from different parts of the brain, and that one or the other is deficient in certain personality types. This kind of hair-splitting is a distraction, it seems to me, when it comes to understanding the role and functioning of empathy.

I’m sure there is a wide range of empathic capacity, both in terms of experiencing empathy (whatever it is) and in expressing it. Those with alexithymia may have empathic capacity but may not recognize what they are experiencing or be able to express it. And all of my discussion here so far has nothing directly to do with autism. Empathy is a universal human trait. And beyond. Clearly, many other animals have empathic capacity as well.

Empathy arises from, or at least is related to, mirror neurons. In the famous incident of the discovery of mirror neurons, a monkey watched an object being picked up, and his brain region for picking things up fired as if he were doing it himself. So, he experienced what it was like to pick up an apple (or whatever it was), but not from the perspective of the other monkey (he’s not inside that brain) but from the perspective of how he would feel if he were doing what he was observing.

And What Does All of This Have To Do With Autism?

Now comes the tricky part with respect to autism. It’s twofold. The descriptions that follow are experiential (my own experiences and those of other autistic people I’ve spoken with), and represent my own speculations. What I report here may or may not be generalizable to other autistic people. See the link in the previous paragraph for a discussion of some of the controversy surrounding the linkage (if any) between autism and mirror neurons.

Autism and Receptive Empathy

It may be (1) that the mirror neuron system in the autistic brain is impaired because of the usual sensory overload that is always going on. It’s not that the mirror neurons are defective, it’s just that their functioning is clouded by the brain having so much else to deal with at the same time. Distractions, if you will. So the autistic person will not have the receptive clarity that matches the neurotypical — what is being called by some “cognitive empathy.” The emotional state of another being is recorded, but not processed with the same clarity because of the other demands on attention. The TMS experiments I participated in at Beth Israel demonstrated this. The experiment involved suppressing activity in a small area in the right hemisphere of my brain. Neuroscientists know that, through a process called neuroplasticity, when one area of the brain is compromised, another area will attempt to take over the lost functionality. That often involves the equivalent region in the opposite hemisphere of the brain.

Broca’s area is heavily involved in language and (therefore) social cognition,and much more. It is a complex and important region of the brain that is somewhat imprecisely located in the part of the brain known as Brodmann’s areas 44 and 45. I say “it” although, in my understanding (I have no formal training in neuroscience), there are two equivalent areas, one in each hemisphere, and the lion’s share of language processing occurs in the dominant hemisphere (the left one for right-handed people like me). Broca’s area, besides its central role in language comprehension and creation, also seems to serve as a bridge between the prefrontal cortex (cognition), and regions that control motor and somatosensory (tactile and other sensory) systems of the body. It is also thought to be rich in mirror neurons.

For all of these reasons, the scientists in the TMS Lab hypothesized that by temporarily and artificially suppressing the right side of my brain in the area just described, the left hemisphere would be more strongly activated than usual, thereby improving language and social (empathic) cognition. How right (so to speak) they were! I experienced (both subjectively and in their computerized measurements) sharpened ability to interpret emotional content more accurately. The difference in clarity was astounding to me and to others I spoke with who were subjects in the experiment.

Caitlin, for example, was shocked to find that she could see emotional content in written sentences and in video clips which, with the benefit of hindsight, she had not been able to see before. My clarity was more intellectual. I was able to solve (computerized) tasks faster than the computer could feed them to me, whereas before I had struggled and was unsure of the answers. Subjectively, it was like night and day, although I’m sure that the difference in my performance was measured in milliseconds. The difference in what Caitlin and I experienced (and John had a musical revelation, among many other experiences) was probably a function of where we started. I was relatively better (compared with her) at emotional reception. She, for example, had once been floored to find out that her brother knew more (much more) about the personal life of her receptionist than she did, although he lived in a distant city. It was just that when he called to speak with Caitlin, he would chat with the person who answered the phone about vacation plans and the like. It never occurred to Caitlin to make that kind of emotional connection.

The Irrelevancy of “Cognitive” Versus “Affective” Empathy

Which brings me around to the other bit (2) about autism and empathy. Take the Psychology Today definition: “Empathy is the experience of understanding another person’s condition from their perspective.” Please. Think of the monkey. Picking up a banana is probably a pretty universal monkey experience, so it’s easy to imagine that the mirror neurons of monkeys allow them to experience watching another monkey and essentially experience (vicariously) a nearly identical experience. Now, take an autistic brain. Not mine, please. I need it. If I watch a neurotypical pick up a banana, I am likely to be less clear about how that feels to them because they experience the world in a way that is very different from mine. I’m being metaphorical here, in case you didn’t pick up on that (so to speak). A physical action is one thing, but a more complex emotional reaction is quite a different level of experience. How can I empathize what you are going through if your way of experiencing the world is vastly different from mine? This works both ways, of course. How can a neurotypical person empathize with me if they have no clue what my brain is experiencing? So, it’s not a lack of empathy, or a lack of empathic capacity, it’s a knowledge or experiential gap. I can tell when my horse is happy to see me, or when he is in a playful mood, or frightened; these are fairly universal emotions. But my empathy doesn’t go too deep because I don’t really know what it’s like to be a horse. Or, maybe at some fundamental level, I do. I don’t always grok why he’s upset, but I know when he is.

Now, all of that is about receptive empathy; taking in and appreciating the emotional state of another being. This may be what is meant by “cognitive” empathy. But I also think receptive empathy includes components (or maybe all) of what has been termed “affective empathy” or “pity” or “compassion” — not just understanding, but sharing the emotional state of another. I believe this must naturally flow via the mirror neuron system that enables us to take in the feelings of another. If one is truly understanding what another is experiencing, it naturally follows that one is experiencing their emotions, too. From an evolutionary point of view, the value of being able to understand how someone else is feeling is being able to predict their behavior. If someone picks up a banana and smiles, that’s pretty non-threatening, but if someone picks up a rock and scowls, it might be better to take protective action. To truly take in another’s emotions, in the process I’m calling receptive empathy, one must also experience an approximation of those emotions. Although I’m aware these emotions are yours, and not mine, I experience my version of your anger, your pain, and your joy. It can’t be any other way.

And yes, there are people who have difficulty comprehending what they are experiencing emotionally, and conveying it, too. But, as alluded to earlier, that is a condition called alexithymia, not autism. Although studies about this are scant, I’m not aware of any definitive study that shows that alexithymia is more prevalent in the neuroexceptional population than it is in the neurotypical one. In my work with neuroexceptional couples (in a support group setting), I observe a fairly high proportion of alexithymia among the partners who are not neurotypical, but my sample is a highly self-selected subgroup of all neuroexceptional people, and I don’t have a control group to compare with.

For me, when I experience high receptive empathy (which includes sympathy, compassion or pity), such an experience is likely to lead to an emotional state of shock that requires me to tone down my feelings, because the nerves are too raw and exposed. So, I withdraw, I put up barriers to keep the world out, to keep things from getting worse. I can only take so much. Most autistic people with whom I have talked about this agree. We have too much empathic capacity. It is paralyzing. Why is that? I’m not sure. Excess myelination? I’ll get back to you on that.

Autism and Expressive Empathy: The Challenge for Autistic People

The biggest complaint in my couples support groups is that the (typically) Asperger’s partner does not express empathy. I explain the bit that I’ve just gone through, that those of us who are autistic experience a high degree of understanding (what I have called here receptive empathy), and that our flat affect or silence does not mean we lack comprehension or sympathy. It’s just that dealing with these raw emotions is too frightening.Thus, we exhibit a lack of what I have come to call expressive empathy.

To partners who are feeling emotionally isolated, and are in need of validation, it’s not comforting to hear this. To them, there is no empathy if it isn’t expressed. And they have a good point. We autistics often stop one step short of what empathy is all about; connecting with another human being, to validate and comfort them. Without that piece, it does not serve its purpose. The result is, from the outside observers point of view, a “lack” of empathy. No reaction. Or an “inappropriate” (oh, how I hate that word) reaction. In fact, the reaction is an internal volcano that is about to erupt. Sometimes it does, and that is one form of meltdown. Sometimes it is contained, and the world is shut out.

I remember a time in my second marriage when things were not going well, and I was talking with my shrink about it. At one point, he said to me (in frustration), “Can’t you just tell her you love her? That’s what she wants to hear!” And, I realized (for complex reasons) that, no, I was not capable of that at that time. It seemed like lying to me. Yet, it would have been a harmless lie that could have made all the difference to her. I was empathizing with her distress, but I was not able to communicate that to her in a way that would have been helpful.

The terms I have used here, receptive and expressive, are often used to describe forms of language communication, which is where I started this post. And that’s really what empathy is, in its fullest expression; communicating emotional states. Autistics are really good at receptive empathy, but some of us fall short when it comes to using expressive empathy.

This is a failure of execution, not of cognition. Our brains work just fine, thank you. We just need to learn how to let other people know that. The good news is called neuroplasticity, and there is a way to use that, in neurally-inspired therapies and techniques that can change our patterns of behavior. Stay tuned. Much more to come on those subjects.

Meanwhile, I will be practicing my expressive empathy.