Thoughts from John Elder Robison's "Switched On" Book re: his rTMS (repetitive Transcranial Magnetic Stimulation) Experiences

John Elder Robison (prominent adult ASD Advocate) wrote a Book earlier this Year called "Switched On" (www.amazon.com/Switched-Memoir-Change-Emotional-Awakening/dp/0812996895) regarding his Experiences from the rTMS Trials @ the Beth Israel Deaconess Medical Centre (Boston, Massachusetts) in 2008.

I was very privileged to take Part in the initial ASD rTMS Trial @ Monash Alfred Psychiatry Research Centre (MAPRC) in November 2010, and was therefore very interested to read a more detailed Account from John.

My old Blog Posts about my rTMS Experiences are below:
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive.html
http://aamsio.blogspot.com.au/2011/07/my-experience-from-repetitive_30.html

Recent ABC Coverage on rTMS:
http://www.abc.net.au/radionational/programs/lifematters/john-elder-robison:-switched-on/7322548
www.abc.net.au/radionational/programs/lifematters/transcranial-magnetic-stimulation-explained/7330468

I'm very grateful that Dr. Peter Enticott (of MAPRC) notified me about the Book, and I emailed him my initial Thoughts after reading John's Book, as attached below in raw un-edited (and "binge-typed") Form. I'm sure there are some other Thoughts / Opinions missing, but I might add them on into a future Blog Entry after reading it for the second Time during Annual Leave later on.
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I ordered a Copy of "Switched On" and read it about a Month ago, and very glad I read it. but didn't have Time to reply. I'll send you another Email after reading it the second Time during my Annual Leave later on, if there's Points that I forgot to include below.

I found it very painful (emotionally) to read @ Times, coz some of it reminisced with my Sentiments and Experiences.

I think his Account of his TMS Experiences were very well-written, and will provide much Discussion re: future Treatments for ASD Adults.

I feel like John Elder Robison gained a Lot more distinct Changes following the TMS, and he was able to present the Advantages and Disadvantages of becoming more emotionally labile and intuitive to other People's Feelings. It's like a Blindfold was temporarily removed from him, but since the Release, he won't be able to forget it. His Awareness has increased and provided more Stress, but also more Opportunities/Options to respond in Order to achieve a Resolution.
- I briefly felt very embarrassed when I read about his previous "social Faux Pas" coz I have done plenty prior to becoming more Aware post-Diagnosis.

And I could understand his Thoughts where he flips between seeing his AS as a Gift or a Curse. I did find it upsetting/painful when @ some Point he saw himself as "defective", probably coz it's Something I think about on a daily Basis @ Work. I feel like I have to use my Strengths (eg Attention to Detail and Hyperfocus) to (over)-compensate for my other Deficits in clinical Medicine. It's worked so far, but @ great mental Expense, which is why I'm trying to get into the Pathology Training Program ASAP (with minimal Patient Contact etc).

I can relate to John's "Release" by being able to tolerate Eye Contact after TMS, coz it always felt uncomfortable prior. So now, I know what it's like to look @ People in the Eye without flinching, and this has improved my "Ability" to "appropriately" communicate with Patients, other Hospital Staff, and People outside of Work.

The other Things that John Discusses re: understanding People's Feelings and reading facial Expressions is Something that I learnt manually from rote-Memorization and Experiences. I still have flat Affect most of the Time (not depressed), and I only naturally change facial Expression when I'm euphoric / very upset / very angry.

I think what makes Part of it painful is how both me and him are in the Minority of ASD Adults who have been privileged to receive some Form of Assistance / "Treatment", and even afterwards we are still having to work hard to maintain our Livelihoods coz we're in the statistical Minority, and Adult Society is currently unlikely to provide much Accommodations. There's so many other ASD Adults (diagnosed and undiagnosed) who are struggling with Employment / Bullying etc.

Another Thing which I found painful was as John Recounts his Experiences, I also looked back and saw how many wasted Opportunities I had, and all the Mistakes I made pre-Diagnosis. But Past is Past, you can only learn from those Experiences and move forward.

I still make Mistakes post-Diagnosis, but I'm very self-critical, and I think it contributes to my low self-Esteem post-Diagnosis, coz I know how vulnerable I am, and how Others (in and outside Medicine) could easily exploit me if they knew my Weaknesses. I don't feel Shame coz this was how I was born, and sometimes I wonder whether Life is worth Living, but I look @ how many Hurdles I've jumped over so far, and even if I "fall down" later on, I can still act as a Source of Inspiration for some ASD People.

A Point of Interest would be whether John's Experiences will influence the Direction that ASD Research takes as he is on the Autism Speaks Panel, eg towards Something more socially-oriented, rather than Something to improve short-Term / Working Memory or Verbal Fluency etc. Certainly the frontal Lobes are implicated in ASD / ADHD, so these Functions are inter-related, but I feel there's a Risk of Bias.

I think for John, his TMS Experience seems so intense, like "getting thrown into the deep End of the Pool", mystical and profound, almost psychadelic, but it came @ the Expense of making his "Ego" more prominent. Not in the "arrogant" Sense, but the improved Awareness of himself and other People seemed very difficult to take in @ the Time, but he was able to cope eventually.
- A Bit like how in the Bible, Adam and Eve ate the "Fruit of Knowledge" and suddenly realized they were naked.

- Once you see it, you can't "un-see" it.

Whereas for me, I was like "dipping my Feet into the Wading Pool". Concretely / Directly, I only benefited from improved Eye Contact, but it served as a Catalyst for understanding other Neurotypicals in general coz I can spend more Time looking @ their facial Expressions, processing their Speech and direct / implied Meanings, and less Time thinking about how I'm uncomfortable with their Eye Contact. I'm still very flat and "Swiss" although there have been Occasions where I'm close to breaking down emotionally.

I also resonate with John about the constant Anxiety about whether TMS or becoming more "socially aware" will impair one our special Interests and ASD-related Strengths.

For me, even after reading his Book, I wonder if the Reason why I have my Ambitions, Strengths and Special Interests (Mahjong, Accordion) is coz of my Deficits. For me, interacting with NTs in general costs more than it benefits, and while there are general Rules of Behaviour, there's still significant Heterogeneity. Whereas with a Board Game or learning a musical Instrument, the Rules are much stricter and clear-cut, and the Gains are easier achieve and therefore more rapidly gratifying.

- Temple Grandin's Comment @ the Back of the Book totally hit how I felt:

"Switched On is a mind-blowing book that will force you to ask deep questions about what is important in life. Would normalizing the brains of those who think differently reduce their motivation for great achievement?"

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In short, I've enjoyed reading John's TMS Account (as demonstrated by finishing the Book within 2 Days) to see how his Experiences and Opinions were similar / different to mine.

I think TMS has much Potential to help ASD Adults / Children, but it must be done in a Way to avoid totally converting them to NTs (not that it's possible with the current Technology anyway), and hopefully there'll be a Way to help preserve their Strengths whilst reducing their Weaknesses. I don't think it's a Zero-Sum Issue, but unfortunately I suspect this won't be 100% possible.

I think for ASD People, the possible Goals of TMS are very variable depending on Level of Function.

I do think that for non-verbal ASD Children / Adults, the core Goal of TMS should be to facilitate Speech Development coz that's crucial for independent Living, regardless of whether you have Friends or not.

Also, what I think can be done now is to help educate ASD Adults on how to "respond appropriately" if they happen to recognize a facial Expression or Feeling in another Person. So that Way, an ASD Adult who becomes more self-aware of others (via TMS or gradual Knowledge Acquisition) can feel less anxious / awkward about how to react, and just say what "needs to be said".

ASD and Getting Bullied - WAYS OF GETTING BULLIED (Part 3/7)

- Intentionally disrupting one’s non-pathological routines.

- Intentionally disrupting one’s preference for sameness not from therapeutic attempts to improve cognitive flexibility (eg hiding favourite objects, constantly changing their positions).

- Intentionally causing sensory overload by making local environment overstimulating (especially audio/visual), constantly staring, touching* or standing/sitting near them --> impairing their work or study (as if there’s a presence of “Qi” that can be detected by the ASD person).

                * Exceptions are hard hugs/grips.

- Harassment (especially homophobia) based on erroneous assumptions about an ASD person’s physical traits (eg gait, possible hypotonia or motor incoordination, notably in childhood), behaviour or “unusual” special interests.

- Stereotyping an ASD person and penalizing without understanding their scattered cognitive profile of strengths, weaknesses and personal compensatory techniques (many of which are intellectualized, especially algorithms for social situations and piecing details to form general concepts).

- Physical abuse

                - Can easily trigger a meltdown + “violent lashing” from an ASD child/teenager, especially if     

                   ganged-up on.

                - Even worse is when they claim that the ASD person started it.

- Verbal abuse

                - Can also trigger a meltdown.

                - Bullies love to see a reaction, and this is more so the case with Aspies/HFA who have better 

                  verbal comprehension.

                - Difficulty in giving a successful impromptu retort --> frustration, humiliation.

- Sexual harassment, coercion (especially female ASD people, initially reduced street-smarts).

- Getting framed for sexual harassment (especially male ASD people, initially reduced street-smarts, overly trusting of others but this quickly converts to cynicism/caution following adverse events).

- Lying, exploitation, blackmail (ASD person has initially reduced abilities to read people and check for situational red-flags).

- Framing an ASD person when they were led to believe that they were doing something harmless. Often paired with bully appearing to be the “innocent victim/bystander”.

- Passive-aggressiveness, and withholding of relevant information to get an ASD person into trouble. Refusal to give details, and intentionally use vague language to make an ASD person confused or doubt their ability, and then claim that the ASD person is being unreasonable or aggressive.

- Spreading rumours about an ASD person who has more difficulty defending it in a “believable” manner to the others, because they’re more inclined to believe the BS-artist, and also his difficulty in figuring out how to convince them due to his statistically reduced TOM.

- Taking credit for an ASD person’s work and presenting it as if it were his own, often in a more charming, fluent manner.

- Wilfully misinterpreting what an ASD person says and responding negatively (especially in front of others), this is often done by over-generalizing what an ASD person says about a topic or targeting a specific bit and going on a tangent, even though he meant it in relation to that specific situation only.

ASD and Getting Bullied - WHY MANY ASD PEOPLE GET BULLIED (Part 1/7)

My dictionary defines bully (noun) as “A person, esp. a schoolboy or schoolgirl, who hurts or intentionally frightens weaker people.” and bully (verb) as “To act like a bully towards, often with the intention of forcing someone to do something.”

Whilst it’s clear to many that these definitions are rather basic, it’s also important for people to realize that for ASD people, there are additional complexities on top of what already exists for NTs.

Of all of the formally diagnosed ASD people I’ve met in person, pretty much all of them have been bullied at some point, even as adults. The ways they’ve been bullied isn’t particularly different from that of NTs, but the presence of an ASD makes them much more vulnerable and sensitive to such suffering to the point where it becomes a ubiquitous, ie near 100% guaranteed experience.

I’ll try to explain this increased vulnerability as best as I can based on personal experiences, observation, and from speaking to other ASD people. In short, from how I see it, the (increased) vulnerability of ASD people to bullying is essentially a combination of:               

                - NEUROLOGICAL WIRING (NEURODEVELOPMENT)

                - ACQUIRED KNOWLEDGE & SKILLS

                - ENVIRONMENTAL FACTORS

In this basic model, all 3 categories are inter-related, influencing each other for the positive or negative. Even the factors within a category can affect each other. Significant deficits in any category without sufficient compensation from the others greatly increases the chances of bullying occurring and/or adverse outcomes from it. It’s difficult for me to quantify the impact on a factor from one category on another, but I’ll try to list as many as I can (how Aspie of me), and then explain some relationships.   

NEUROLOGICAL WIRING (NEURODEVELOPMENT)

Given the heterogeneous nature of ASDs, ASD children / adults develop at various rates. What is universal though is the relative developmental delay of various skills, particularly social / linguistic. My impression is that the altered neurological wiring (as with ADHD) results in a relative frontal lobe deficit compared to NTs which underlies several of the symptoms.

                1.  Speech delay, statistically reduced verbal fluency.

                2.  Initially reduced language pragmatics, a tendency to take things literally with difficulty understanding the intended meaning by the speaker due to the context and external cues.

                3. Focusing on details initially, difficulty integrating the information and seeing the big picture.

                4. Initially reduced “TOM” (Theory of Mind towards NTs), ie reduced ability to understand the true intentions of the NT, again influenced by context and external cues.

                5. Initially reduced ability to read social situations and to follow (arbitrary) hierarchies as established by NTs.

                6. Relatively more repetitive behaviours, routines and cognitive rigidity, more difficulty being flexible in (social) situations. More likely to have a preference for narrow interests and orderliness. Tendency to brood/hyperfocus on things (inc. things that made them angry or upset).

                7.  Lower threshold for sensory overload and meltdowns (further exacerbated by any communication issues). More likely to be irritated by direct eye contact.

                8. Strong preference for honesty, dislike of dishonesty, superficial rules/norms, and perceived injustice.

                9. Relatively poorer short-term memory / Executive Dysfunction.

                10. Relatively poorer motor skills (esp. in childhood)

ACQUIRED KNOWLEDGE & SKILLS

                1. Internal algorithms for communication / different Social Situations, Social Scripts. A lot of “polite” or “flowery” phrases (as deemed by NTs) have to be rote memorized because they’re less literal and are often more lengthy.

                2. Intellectualization of socio-emotional (including adult) issues & rules that would more likely be intuitive to NTs. A lot of it is acquired by rote memorization.

                3. Problem solving strategies / Troubleshooting, including those relating to First Principles so they can be generalized to other areas and / or be used in Emergencies.

                4. Pattern-recognition abilities, that are applied to both social and non-social situations, to facilitate the use of learned Internal algorithms and Problem solving strategies. Helps recognize danger too. Helps promote internal comfort due to perceived repetitions of previously seemingly un-related phenomena.

                5. Knowledge of personal strengths and weaknesses (esp. from life experience) and numerous attempts. Understanding why one does the things they do and how to maximize productivity and happiness.

                6. Knowing how to incorporate newly acquired knowledge to internal database and known paradigms.

                7. Coping mechanisms for meltdowns, stress, burnout, knowing when to move on / have a break / seek help.

ENVIRONMENTAL FACTORS

                1. Parents

                                - Educating the ASD child.

                                - Personal beliefs (may help or irritate ASD child).  

                                - Support, monitoring & feedback.

                                - Implementation of home environment amenable to ASD cognition.

                                - Access to a Specialist (Paediatrician, Psychiatrist, Psychologist etc).

                2. School

                                - Staff (knowledge of ASDs / bullying, supervision of students in classroom and breaks, care factor, student & work-loads, communication with parents, presence of teaching aides).

                                - Students (awareness of ASDs, level of diversity, upbringing, internal disposition).

                                - Anti-Bullying Policies, enforcement of it.

                                - Extracurricular and lunch-time activities.

                                - “School Culture”.

                3. Workplace

                                - Anti-Bullying Policies, Diversity Policies, enforcement of them.

                                                - Willingness to provide workplace accommodations.

                                - HR (care factor, level of bureaucracy).

                                - Staff (awareness of ASDs, upbringing, internal disposition).

                                - “Work Culture”.

                4. Adult Society (extremely basic)

                                - Public awareness of ASDs and care factor.

                                                - The ability to differentiate between aggression and (provoked) meltdowns in ASD adults (esp. by Police and Healthcare Staff).

                                - Laws on Disability Discrimination and implementation.

TBC...

Quoted in New Scientist Article Regarding Trial TMS for ASDs

I was contacted by Linda Geddes, a writer for the New Scientist magazine regarding my experiences with TMS (Transcranial Magnetic Stimulation). She asked me 4 questions and for permission to quote a bit from my entries regarding my experiences. The article is available in the New Scientist magazine (August 27th 2011 edition, No. 2827) if you're able to get it at a store/library.

While she didn't misquote me, she left out a lot of detail due to word limits etc, and I felt that she didn't fully express how I felt, and gave the impression that ASDs were primarily about social issues and empathy when in reality it's a condition that completely changes the way in which one processes information, leading to subsequent symptoms and effects in behaviour etc. Below are my complete answers (at the time) to her questions:

1. How did you hear about the trial, and what made you want to get involved?

Very soon after getting officially diagnosed with Asperger Syndrome (at age 21) in May 2010, I was extremely relieved to understand numerous causes of my difficulties in childhood and adolescence. In addition to obtaining numerous books regarding ASDs (Autism Spectrum Disorders) prior to and soon after the diagnosis, I also checked Mr. Tony Attwood’s home page (international expert on AS/HFA) as my initial reference website for Asperger Syndrome.

As a medical student, and Neuroscience being one of my special interests, I was very interested into learning about the Neurological basis of AS and HFA, and finding out what research studies were being conducted. Several neurological studies and double-blinded treatment trials on AS/HFA individuals have already been conducted with peer-reviewed papers published (also available on Pubmed) in the past 15 years or so, but the studies were often “unsuccessful”, the study samples were often rather small (N < 20) or the plethora of neurological/psychological theories were a bit dubious to me.

I looked at the “Research Studies” section of Tony Attwood’s site to see what research was currently conducted internationally, and most particularly in Australia. I was very excited to see that a TMS (Transcranial Magnetic Stimulation) trial was being conducted in Melbourne at the Alfred Psychiatry Research Centre to see if rTMS (repetitive TMS) of a specific part of the brain (mostly Medial Prefrontal Cortex + Anterior Cingulate Cortex IIRC) would improve social intuition in adults with AS/HFA.

I wanted to take part in this study coz the rTMS treatment may symptomatically improve my social intuition (eg intuitive empathy in regards to non-Autistic people, reading facial expressions rapidly) so I wouldn’t have to constantly exhaustingly learn social skills at an intellectual level. I was very willing to be a “guinea pig” and make a contribution to ASD research by being 1 of 20 volunteers for this exclusive and pioneer rTMS trial, so hopefully I’ll help the researchers become one step closer to figuring out the neurological basis of Asperger Syndrome.

HOWEVER, I was very concerned that the rTMS treatment would affect my other Asperger traits, some which I value and consider an advantage, such as my hyperfocus ability, intuitive honesty, integrity and strong ability to see details. I wanted improved social intuition but not any other parts of my Asperger’s to be affected. I did a Pubmed search regarding TMS and Asperger / Autism, which only resulted in 2 or 3 papers at the time IIRC, none which were directly relevant to social effects.

A Google search indicated that rTMS trials were also being heavily conducted in 1 other place in the world, which was the BIDMC (Beth Israel Deaconess Medical Hospital) in Boston. More importantly, I thoroughly read the account of John Elder Robison (an author with AS who published his autobiography “Look Me in the Eye”) whose blog entries in early 2010 thoroughly described his experiences of taking part in the BIDMC rTMS trials, whom in conclusion described improved “sociability” while still preserving his other Asperger traits, so the rTMS seemed sufficiently selective for me. His blog entries however didn’t mention which parts of his brain was being targeted, and the Alfred trial may be targeting a different area, so I had to contact Dr. Peter Enticott of the Alfred for an extensive preliminary interview to gather extra details about the trial.

I was content with the way the rTMS trial was being conducted, and I had a strong prediction that the rTMS wouldn’t totally remove my AS, and may potentially improve my intuitive social abilities, so I agreed to take part in this double-blinded treatment trial.

2) How long have the effects lasted on you? And do you feel different as a person? What is the biggest change?

It turned out that I was part of the placebo treatment group in my 2-week rTMS trial in Monday 2^nd August – Friday 13^th August 2010.

I was offered the TRUE rTMS treatment in 15^th – 26^th November 2010, in which I definitely felt effects soon after.

I only received one definite effect from the true rTMS treatment, which was painless eye contact. I no longer have pain looking at people straight in the eyes when speaking to them, or them speaking to me. It literally doesn’t hurt or feel “piercing” anymore, and I don’t automatically feel anxious or threatened when looking at somebody’s eyes even though I knew that they weren’t going to hurt me. In the past, the only times where I could have painless eye contact with anybody was when I was under the influence of CNS depressants such as alcohol and benzodiazepines, but now I can have painless eye contact when I’m sober.

I was extremely surprised that the rTMS on the Medial Prefrontal Cortex and Anterior Cingulate Cortex had effects on my eye contact, as previous info that I read regarding those 2 regions through medical textbooks and literature don’t really discuss about it. Personally I’m supportive of more double-blinded rTMS trials to further investigate the functioning of these and other brain regions of ASD individuals.

I still have difficulties in intuitive empathy and certain language pragmatics, so I still have to learn about social issues manually as if it was an academic subject like a foreign language. I still have difficulties communicating with patients in a smooth manner, so I have to compensate by memorizing a large number of polite phrases and responses, to simulate the appearance of “politeness”, “empathy” and “professionalism”.

I have manually learnt to read certain facial expressions, but it’s still hard for me to read them on the spot in conversations when my mind is automatically focusing on the verbal words, and it’s hard for me to multitask different modes of communication. I still have difficulties with executive functioning and still strongly prefer plans and routines, even though the unpredictability of the Hospital environment makes me rather irritable. My sensory issues still exist at the same (mild) level, and I didn’t gain or lose any synesthesia abilities (I have ordinal-linguistic personification). I still space out a lot and have trouble modulating the volume of my voice in a conversation (especially too loud). I’m still quite bad tempered and have to manually suppress my rage in public when little things irritate me.

Nevertheless I’m extremely pleased that I gained the ability of painless eye contact only, and it hasn’t waned. When I talk to staff and patients at the hospital, they don’t think I’m ignoring them coz I’m looking at them during a conversation. The painless eye contact also means that I’m less distracted by the “pain” (in the past) and can attempt to use more of my cognition to read their facial expressions or look at their mouth (partially reading lips) without having to mentally block out the discomfort of eye contact.

I’m also very pleased that the rTMS didn’t interfere with my other Asperger traits, so I still feel pretty much like an Aspie (I definitely do not feel “Neurotypical” at all), but with a reduction in daily anxiety previously due to eye contact. I still get anxious about other things, but I have benefitted from having one anxiety-inducing factor removed.

3) In your first blog you talked about your worries about betraying the ASD community by having this treatment. How do you feel about that now?

When exposed to the Autistic Community (especially in the Western World), it becomes EXTREMELY obvious that there are several major dichotomies:

a) The “Neurotypicals” vs the ASD individuals.

b) “Pro-Neurodiversity” / Anti-cure vs “Curebies” (people who want a cure for ASDs)

c) Asperger / HFA individuals vs Non-verbal / LFA individuals

d) Neurotypical parents of ASD children vs ASD adults

My worries of betraying the ASD community was due to b), but my assessment prior to and after the true rTMS treatment was that it wouldn’t be immoral, unethical, or betraying for an ASD ADULT to give consent to a treatment that could symptomatically treat one aspect of their condition while preserving other traits, and improve their overall quality of life. Currently I am against AS / HFA children receiving rTMS treatments as they are under the age of consent, may not want to receive the treatment, and/or may not have the ability to fully express how they feel from it.

I don’t feel guilty or ashamed at all about having painless eye contact, and I think that any treatments that have been medically proven (after extensive double blinded-Clinical trials, probably up to Phase V imo) to reduce debilitating aspects of a condition should be available to adults who can conscientiously choose to receive it.

I feel that the ASD world is extremely divisive, and I’m personally feel that it is this division in addition to several medical blunders/exploitations (especially the Vaccines-causing-Autism controversy, and fake practitioners selling quack therapies to “cure Autism”) that has delayed progression into understanding the true nature of ASDs.

I’m grateful for the effects, and I’m happy and proud that I’ve made a contribution to authentic, proper ASD research.

4)How old are you, and whereabouts in Australia do you live?

I’m 22 years old, but received the real rTMS treatment when I was 21. I live in Melbourne, Australia.

My Experience from a Repetitive-Transcranial Magnetic Stimulation (rTMS) Trial (Part 2/2)

In 22^nd and 29^th June 2010, I visited the Alfred Psychiatry Research Centre in preliminary sessions to fill in my personal details and provide my official diagnosis to Dr. Peter Enticott. I also filled in several questionnaires that aimed to primitively gauge my severity on the Autism Spectrum (eg the Autism Spectrum Quotient created by Simon Baron-Cohen) along with answering his questions regarding my condition, what I’m doing in life and how I cope with it etc.

After the interview, I then had to take part in a “social stories” tests (not multiple-choice) where different social scenarios were read out to me, and I had to answer questions regarding the characters’ feelings, in addition to some questions with very obvious answers as they were “controls”. I was able to answer the questions correctly IIRC, but I had to assess it intellectually and not intuitively like how most other NTs do it, I was unable to answer the questions immediately. I also had to watch several videos of these shapes moving around on a computer (laptop) screen, and I had to explain the “story” behind what the shapes were doing. I could explain some of them, based on the speed of movement and the positioning of them (eg “The big triangle is chasing after the small triangle, and the small triangle is trying to hide from the big one”), but there were others where they were just bouncing around the screen in a pattern but with insufficient substance for me to create a “social/story” description. For the pattern-bouncing ones, I just said that they were bouncing along the walls at angles which is uncorrelating to physics in real-life (hitting angle vs bouncing angle), and that I was unable to make up a story regarding them.

For a paper that involved ASD and NT individuals and the “social” comprehension of animated shapes, you can check out this paper: http://brain.oxfordjournals.org/content/125/8/1839.full

Afterwards, a demo rTMS was performed on the area of my motor cortex which controls my hand muscles. The rTMS was done to calculate the minimum (threshold) induced current required to trigger muscle twitching in my hands (more accurately my right index finger IIRC). This minimum induced current would then be used as a reference to personalize the rTMS intensity (frequency is kept the same) of my Anterior Cingulate Cortex. It felt really weird to see my right index finger twitching upon rTMS stimulation without me wanting to move it in the first place!

On 20^th July 2010, I had to undergo an fMRI prior to the rTMS treatment. The fMRI was to assess my brain activity while I performed simple cognitive tasks in the machine, to determine which side of my brain shall receive the rTMS. I was supposed to push a button when I saw a certain action in the video monitor (visible to me via various mirror positionings) such as a hand grabbing a cup, or hands waving about. I think this has something to do with the “Mirror Neuron Theory” of Autism, where there’s a disputable hypothesis that there’s an underactivation of “mirror neurons” in ASD individuals. The fMRI was VERY LOUD, even though I was wearing earplugs.

I was then allocated to the placebo or active treatment group. Either treatment group received rTMS sessions for each weekday in a 2 week period. One rTMS session was supposed to last for 30 “trains”, where one “train” lasts for 10 seconds with 50 rTMS pulses (hence the 5 Hz). There was a 20 second interval after each “train”, therefore each rTMS session was supposed to last for 900 seconds, ie 15 minutes. My rTMS intensity was first initiated at “30%” (of maximum strength), but soon increased to 46% for my remaining sessions.

My initial 2 week period was from Monday 2^nd August to Friday 13^th August 2010. In each rTMS session, I wore a blue cap on my head (same cap for all sessions), with small measuring tape measuring stuck along its mid-sagittal line. The cap was tied to my head in a tight manner and then Dr. Enticott or Ms. Peachey positioned the rTMS “helmet” above my head to target the area of my brain to be stimulated. During the rTMS “trains”, I could hear a clicking noise with each pulse, along with a tapping sensation in my head, and it wasn’t painful. The coils performing the rTMS heat up quickly, so there was an aircon continually operating within the helmet to slow down the heating. I could feel my head being cooled down a bit.

1 month after that 2 week period, I had to fill in the same questionnaires, do the same social stories test, and do the same shape animation analysis as a follow up. I gave similar answers to before, and I didn’t feel that much different in terms of cognition, although I suspected that my eye contact slightly improved, although that could be a placebo effect. It turns out that I received the placebo treatment, and was then offered the REAL “Open Label” rTMS treatment in November 2010 instead. This time, I could feel a bit more pain at the top of my head after each pulse, although I clenched my teeth and beared it.

Below is the record sheet for the REAL “Open Label” rTMS treatment (Click on image for better resolution):

I can definitely confirm that after the real “open label” rTMS treatment, my eye contact has improved dramatically, far more so than the placebo rTMS treatment; it doesn’t hurt at all to look at people in a conversation anymore, I was completely shocked. In the past, I could look at people in the eyes but always felt a piercing intrusive sensation, like they were threatening me even if I knew that they were perfectly harmless (eg old ladies). Now, I can talk at somebody and look straight at their eyes for 15 minutes straight without feeling any pain or threat at all!!! Most notable was one case, where I hated maintaining eye contact with one of my Aunts, even though she was polite and kind to me, but when I saw her several months after the treatment, I could look at her the entire time she spoke to me without flinching or cringing inside!

I find this result bizarre given that the Anterior Cingulate Cortex doesn’t seem to have much relevance to sensory processing (according to my brief literature search at least). I experienced no other improvements/changes in other areas of cognitive, sensory and emotional processing. But certainly for the eye contact, this was a significant change and I have informed Dr. Enticott about this. Having improved eye contact means that I can now spend more time comfortably looking at a Neurotypical’s face in a conversation and attempt to analyze their facial expressions while listening to their speech, even though multi-modal (of communication style) processing is still hard for me and most other ASD individuals. It has given me more motivation to study the facial expressions of these NTs, so I can try to detect subtle cues in case they try to bully me, or manipulate/stab me behind my back.

The rTMS treatment has given me drastically improved eye contact while predominantly preserving my other positive Asperger traits. My other negative Asperger traits still exist, but the removal of one undesired trait (pain in eye contact) is more than excellent for now. This will be an important tool for me to mildly improve my communication with NTs, and to help defend myself from persecution from NTs for the rest of my life. I hope my eye contact status will remain like this without ever waning. I think rTMS for selective symptomatic treatment of specific ASD traits has great potential, and I support further research into rTMS and its effects on consenting ASD adults.