Theodore Shapiro Responds

January 17, 1995

I had hoped that my response to Frances Tustin would be clarifying; instead it seems to have generated more confusion, as represented in the letter by Gardner Jacobs. Autism, as used by Jacobs and by Tustin, has the status of a defense, which is not the meaning implied in the diagnosis Early Infantile Autism, which is designation of a disorder seen in preschoolers with dramatic consequences for later development. The milder forms are designated Pervasive Developmental Disorders NOS.

The cases cited in the letter are not Pervasive Developmental Disorders by current standards. The famous Kubie case is well described and does not have the requisite early onset or stereotyped behaviors. The second case may be simply retarded with some selective language delays. Moreover, there is no evidence from what is written that there was a trauma. In the third case the dramatic withdrawal of a caretaker may have had psychological consequences but the history is very sketchy, as the author notes. Most important, the onset at 4 suggests a disintegrative psychosis. The case reported by Cecchi, IJP 1990 Vol 71, is similarly incomplete in its description and is most likely a post-traumatic stress disorder with severe withdrawal. The author of that report opts for the drama of the therapeutic encounter rather than descriptive clarity, so that the material presented is inconclusive for comparison.

There certainly is a spectrum of severity, but the diagnosis has rather good boundaries, which, by the way, have better reliability than almost any other diagnosis in DSM-IV. To avoid further confusion, the children with PDD, when more cognitively advanced, do have dynamic constellations, but the application of a generalized dynamic, as in Tustin's formulation, has not received wide acceptance from analysts, including the late Margaret Mahler. In short, I would opt for PDD and Autism as nouns defined by descriptive criteria and