Igor Makarov: There is no epidemic of autism, there is hyperdiagnostics

For the first time, children's autism was described in detail in 1943 by one of the founders of childhood psychiatry Leo Canner. And for a long time, the number of children with such a diagnosis turned out to be stable. And suddenly, at the end of the 20th century, the percentage of autistic children began to grow. What is the reason?

About this Olga Orlova , the host of the Hamburg account program on public television of Russia, spoke with Igor Makarov , the head of the Department of Children's Psychiatry of the National Medical Research Center for Psychiatry and Neurology named after V. M. Bekhtereva.

Igor Vladimirovich Makarov was born in 1969 in Leningrad. In 1992 he graduated from the Leningrad Pediatric Medical Institute, after which he worked at the Department of Psychiatry of his university. In 1996, he received the degree of candidate of medical sciences with a degree in Psychiatry. From 1999 to 2004, he worked as deputy chief physician at the St. Petersburg Center for Restorative Continuing Treatment "Children's Psychiatry". Since 2002-Associate Professor and then Professor of the Department of Psychiatry and Narcology of the North-Western State Medical University. I.I. Mechnikova. Since 2004, he has been leading the department of child psychiatry of the National Medical Research Center of Psychiatry and Neurology named after V. M. Bekhtereva. In 2005, he defended his doctoral dissertation with a degree in psychiatry on the topic “Psychotic disorders in children: epidemiological, clinical and socio-organizational aspects”. Since 2012, he has been the main freelance children's psychiatrist of the Ministry of Health in the North-Western Federal District. The author/co -author of more than 10 monographs, textbooks and manuals in the field of child and adolescence.

- Igor Vladimirovich, the theme of our conversation is autism and autistic diseases, mainly in children. Please tell us why recently the number of children with this diagnosis is growing both in Russia and abroad. This is evidenced by statistics and personal experience. As far as I see, there are more and more families around this problem ...

- Neither I nor a number of my colleagues do not agree with this point of view. The number of autists was always assessed as follows: from 4 to 8 by 10 thousand children. Somewhere in the early-invention of the 1980s, some foreign authors, primarily American, began to consider this problem wider. They began to talk not only about children's autism, but also, for example, about the continuum of autism. Then they decided to replace the word “continuum” with the word “spectrum” (presumably, borrowed from physics) and began to talk about the fact that there were disorders of the autistic spectrum. And the expansion of the diagnosis went an avalanche -like. In my opinion, there is no increase in the prevalence of children's autism and there is no, as they sometimes even say, blazing epidemics of children's autism. There is an epidemic of hyperdiagnosis. Many children with mental retardation, with mental retardation, with delays in speech development fell into the category of autistic. A number of other patients with mental illness. But they began not even autism, but these notorious autistic spectrum disorders.

Autism, if we take a classic definition, is divided into a Canner type, Aspergeer and the so -called organic. Everything that does not apply to them is an expansion diagnosis.

You know, one of my teachers spoke about this topic something like this: “ What radioactive or chemical cloud the Earth should go through so that the number of autistic children increases? Even if this happened, it would not have increased for children's autism, but others, the so -called organic mental disorders, not autism . ”

- What caused hyperdiagnosis?

- The first factor: this diagnosis began to be made not only by psychiatrists, despite the fact that the diagnosis is psychiatric. Both national and international classifications of mental illness recognize this. But, alas, I can regret it: neurologists began to be made this diagnosis. With all my respect for neurologists, they are not psychiatrists. In addition, pediatricians and, moreover, psychologists, speech therapists, defectologists. In my practice, there were times when the nannies in kindergarten informed my parents: “We authoritatively declare to you: your child has an autistic spectrum disorder.” It is unnecessary to say that non -specialists cannot have deep knowledge in the field of psychiatry. Imagine. I work as a child psychiatrist. I chose this specialty. I would like to hope that she chose me and reciprocates me. But I am less interested in problems, for example, neurology, endocrinology. I am not even trying to make endocrinological or neurological diagnoses. If a specialist is in his field, but not a psychiatrist makes these diagnoses, apparently, his specialty is not interesting to him? Is it really not satisfied with the boundaries of the specialty? It surprises me.

The second point. Some children's psychiatrists also began to act more actively this diagnosis. In my opinion, these are the problems of education in the field of teenage psychiatry.

There are other factors. It came to the funny. In one of the regions of the North-West of Russia, the governor proposes to introduce the position of chief specialist in children's autism. Because the numbers about the growing prevalence of this disease reach it. But, in my opinion, the number of autists from 4 to 8 by 10 thousand children's population remains the same.

Imagine the situation. The patient came to see the obstetrician-gynecologist. And he says to her: “You, my dear, have such a conclusion: a spectrum of pregnancy.” - “Doctor, let me. So pregnancy or spectrum of pregnancy? " - “Well, my dear ... why so? You have a spectrum. " - "Doctor, explain." - “You have a manifestation of a pregnancy spectrum. You have a spectrick. " Do you think such a patient will go to another specialist? There is reason to think what will go. Similarly with autism. He is either or not. And the diagnosis of "spectrum of autism" does not exist.

By the way, if you look at the international classification of diseases adopted in Europe (ICD), or at the classification adopted in North America (DSM), there is no diagnosis of “autistic spectrum disorder”.

- Let's talk about those cases when there is definitely autism. What do modern scientists know about the causes of this disease? First of all, what is the genetic component in such a diagnosis?

- Indeed, with a number of types of autism - both the Canner and Asperger type, - presumably, genetic determination works. Unfortunately, there are no global finds that would give answers to questions about the origin of autism.

- That is, there is no clear answer yet?

- No. It must be assumed that primary failures are possible. Everything is in order in the family, but the primary this child has a failure, and he can convey this heredity to his children.

We do not know the inheritance mechanisms. Here, I think, in the coming years, geneticists have something to work on. But even if we know the cause of the disease, because we do not have a time machine to go back and fix everything. Therefore, the psychiatrist works with the disease itself. But this can be said about himself any clinical doctor, not only a psychiatrist. And part of autism is due not to genetics, but by the so -called organic brain lesions.

- And what is it?

- Fruit hypoxia. Sometimes it is intrauterine infections. This is damage to the brain of the fetus, still intrauterine. Locking factors during pregnancy. There is no talk of a genetic failure. But most of the autism, indeed, is apparently due to genetics. However, we cannot predict anything. If the family has a child with children's autism (suppose, with Autism of Kanner), it is impossible to say for sure whether the next child with autism will be whether there will be an autism transmission through a generation or through two generations. To date, there is no answer to these questions.

-Due to the fact that autism becomes a kind of social problem, quite a few myths and rumors arise around this disease. They say that autism can develop in children who were born as a result of artificial insemination (the so -called IVF). This is true?

- I saw a couple of publications on this subject. To date, there are no convincing data confirming this judgment.

- Another common opinion among the people. There is a movement of anti -pristes. In particular, they spread the horror story that autism is one of the consequences of mass vaccination of the population.

- Yes, such opinions were expressed in Israel and in a number of other countries. To date, again, there are no facts convincing confirming this. The problem is different. And I understand the concern of my parents. In some cases when a child receives a vaccine, especially some types of complex vaccinations, in the first year of life or shortly after a year, he has a discharge back in the development of the psyche, he has previously called some child psychiatrists called mental retardation. Is the vaccination the cause of this? No, in no way. But it can be a provoking factor. And this is not due to the vaccination itself, but with the fact that the child was not fully examined before vaccination.

We know very well (this is in all the instructions of the Ministry of Health) that the child should be absolutely healthy. But imagine the usual practice. What happens before vaccination? With a spatula, the child is looked into the mouth - and that’s it. But in fact, ideally, a complete immunological status of a child, a pediatric examination, a complete neurological status, the absence of any acute respiratory and other diseases, need a complete immunological status of a child. In this case, the child is vaccinated, and in this case the consequences are reduced to the most minimum. There is no need to say that vaccinations do not give complications. This is stated all over the world.

If a child is vaccinated against a background of some disease ... I cannot say what mechanisms are triggered, but in some cases the child has some mental disorders. Not autistic manifestations, but rather a lag in mental development.

I really hope that it will be possible to conduct a large cohort study not only by neuropsychiatric, but also together with colleagues-immunologists, infectious disease specialists. That would be interesting. This problem cannot be soaked. She is now polarized. Some say: it is massively. Others say: do not invent. Vaccinations are the greatest achievement of mankind. It is necessary to calmly, from the standpoint of the same evidence -based medicine, conduct an examination and figure it out.

- There is such a social problem: almost any child with deviant behavior is trying to immediately diagnose autism. How much is this specificity of Russia?

- This problem is specific, in my opinion, not only for Russia. Before talking about deviant behavior, I want to say about the difference in approaches to the same schizophrenia. In the 1970s, the Soviet Union conducted a study: they calculated the number of patients with schizophrenia in the clinics of Leningrad and in Moscow clinics. There were almost twice as much clinics in Moscow clinics. What is it connected with? What, Muscovites are more likely to suffer from schizophrenia? No. Moscow psychiatrists put it more often. Leningrad psychiatrists put it less often. But more often some other diagnoses were made. Therefore, this is the difference in schools, the difference in approaches. It manifests itself in both childhood and adult psychiatry.

As for behavioral violations, the issue is very, very difficult. Look, if an adult begins, for example, to steal, to climb into the pockets of other people - in transport, in a trolley, in a tram - it is difficult to assume that he will be sent to a psychiatrist under general equal conditions.

- He will be sent to the police.

- He will probably be recognized as a thief and will go according to the stage. The same thing, if someone fights, hooligan, beats another person. Under general equal conditions, it will be sent to law enforcement agencies. But in children's practice, it is far from always the case. If the child begins to steal or becomes quite aggressive, he can be sent to a psychiatric hospital. This occurs in a number of children in orphanages and boarding schools, or in children living in families.

You see, only theft in a child does not mean a mental illness. In this regard, I am embarrassed by the now operating in Europe and we have a classification of diseases of the tenth revision (ICD-10). There are diagnoses of the so -called and socialized and non -socialized behavior disorder.

- Is the ICB an international classification of diseases?

- That's right. And when I read comments on these diagnoses, for example, a socialized behavior disorder may be included “theft in the context of membership in the gang”. How do you like it? And in the non -socialized - "theft alone." Of course, behavioral disorders in children-teenage, and in adulthood can be in the structure of a number of diseases. Nobody disputes this, and we must agree with this. And such people are observed in a hospital or outpatiently.

But if we are not talking about a mental illness, then the theft in itself should not be evaluated as behavioral deviation. This is probably a deviation from the generally accepted norms of behavior of most of society. But, you see, if theft is evaluated as a psychiatric pathology, then maybe when people dress not like everyone else, they think not like most or vote differently, they also need psychiatric diagnoses? There should not be a pangshiatrication of everything. The psychiatrist has “its” diseases. If this is a person who loves his specialty, he loves these nosological forms, does them, he has enough of this. He should not go into the mental, psychiatric norm.

Therefore, I will honestly say. I do not know what to do in some cases. When a child living, for example, in an orphanage or a boarding school, runs away from there, begins to steal, he is often sent to a psychiatric hospital.

-This problem of hyperdiagnosis again pops up due to the fact that there is no social solution ...

- That's right. I do not see how to solve this issue.

-It turns out some kind of archaic, punitive psychiatry, which we seem to have already experienced. No?

- This method is archaic, maybe. But only this is a method used almost throughout the world. I will return to the fact that this is an international classification of diseases. Therefore, what does the so -called punitive psychiatry of the Soviet period have to do with it? The punitive psychiatry did not arise with us. You can recall the work "Flight over the cuckoo nest" and a number of others. Probably, in this way, society wants to protect themselves from those who are not very desirable in this society. But, in my opinion, it is not always the hands of psychiatrists that must be done. Psychiatrists can help the patient and protect society only if the patient is mentally ill. In all other cases, lawyers, psychologists, philosophers should solve this problem, if you like, social services, sociology as a whole as a science, but not psychiatry. Psychiatry is a humanistic specialty. It was created as humanistic. Not at all as a punitive specialty. And psychiatry is actually often on guard and interests of the patient himself, and his relatives and friends. Who, besides a psychiatrist, remains on the other side of the barricades with the patient? Sometimes it happens that no one else.

- What do you think, who most talentedly portrayed autism in fiction or cinema?

- Of course, traditionally everyone recalls the film with Dustin Hoffman "The Rain Man".

- And what is this type of autism?

- For this, I would like to get an answer to the question: was the intellect of this patient preserved or not? After all, the film does not specifically shows exactly to the slightest details as the character has intelligence. If this is Caner's autism, there, unfortunately, in most cases, such patients are reduced by intellectual abilities.

When it is Asperger's autism, then there, on the contrary, the intelligence is completely preserved. There are very highly intellectual patients with Asperger syndrome. I can say one thing: Dustin Hoffman played well. And, indeed, he must be prepared theoretically. Probably, in practice, he had the opportunity to communicate with people with autism.

- And the last question. If you take doctors of any other areas, over the past 50 years, they have received unique tools related to technological development. Urologists, ophthalmologists, cardiologists - they have ultrasound, robots. And what did you get from technological progress?

- You know, there are specialties that develop faster, but there are specialties that develop more slowly by force and objective in the first place, but sometimes subjective reasons. Take at least such a situation: you can take intravital biopsy with kidney disease. And what about the brain? This is impossible.

-It turns out that, again, this problem of hyperdiagnosis, on the one hand, is caused by an unresolved social complex, and on the other hand, just psychiatry in this sense does not receive those tools that doctors of other areas receive. And you are so lucky?

- No. I would not say that. You know, in psychiatry the situation is such that no computer tomogram, nor electroencephalograph, no other additional, auxiliary (whatever you like to name them) methods will not replace the doctor’s head. Психиатрическая диагностика — это прежде всего умение понять пациента, правильно провести с ним беседу, поговорить правильно и корректно с его родными, близкими, иногда с другими людьми. Это наблюдение за пациентом. Без этого никакая компьютерная томограмма или МРТ не позволят поставить диагноз.

На приеме очень часто можно видеть родителей с психически больным ребенком, которые приносят результаты большого количества обследований. Это просто «Война и мир». Четырехтомники, пятитомники, огромные фолианты. А для диагностики многие обследования просто не нужны. Психиатрия — это все-таки субъективное воззрение того или иного специалиста. Отсюда и разница в школах.

На самом деле, конечно, психиатрия тоже движется в русле доказательной медицины. Но, с другой стороны, мы не можем поручить психиатрическую диагностику только компьютеру или всё разложить по баллам и по полочкам. Иногда качественные феноменологические психиатрические явления вообще невозможно выразить количественными методиками и указать всё в баллах.

Вы оцените больных с бредом в баллах, условно говоря, скажете: «У этого 70 баллов, бред не тяжелый, а у того 80 баллов, очень тяжелый бред». Но тот, который с 70 баллами, совершил гораздо более опасные действия и попал на принудительное лечение, а того, у которого 80, всё относительно в порядке. Это очень условно.

Прежде всего психиатр должен быть думающим человеком. Наверное, это относится не только к психиатрам. На мой взгляд, и высококультурным. В свое время профессор Самуил Мнухин, основатель ленинградской школы детских психиатров, когда набирал интернов и клинических ординаторов к себе на кафедру, спрашивал не о психиатрии (об этом мне рассказывал один из его учеников и мой учитель). Спрашивал о том, читали ли они «Темные аллеи» Бунина, читали ли Куприна и других классиков отечественной и зарубежной литературы. Он считал, что без этого психиатр никогда не станет высококлассным специалистом. И если кандидат в интерны или ординаторы этого не знал, он отказывал ему в приеме на обучение, на работу.

Igor Makarov
Olga Orlova talked
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