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".

Geriatrics (Part 3/3, RETROSPECTIVE POST)

I was trying to gain as much Experience as possible prior to my Semester 12 Rotations and (deferred) Internship with regards to Paperwork and Physical Exams (Visual Acuity, UL & LL Exam, also Ankle-Brachial Pressure Index), and was very proactive in asking the Interns and Residents for Things I could assist in. Part of me wonders if my Motivation to do all this was also to please and be liked by Colleagues? I didn’t want to be known as a People-Pleaser, but having been through my horrible Childhood, wanting to gain Approval was quite tempting. Is this low Self-Esteem or Insecurity speaking? The more things I did for them, the happier they seemingly became, and I became even more motivated to help them. It was like a Positive Feedback Loop. It was almost as if I was doing the Extra Work not because I wanted to bend over my back to help the Patient, but because I wanted to help the Doctors, to do something important and be valued by them.

It was during this Elective in which I frequently came to the Hospital on the Weekends to work on the Draft Discharge Summaries. The Nurse Unit Manager was so impressed by my Diligence that she even bought me a little Cake the following Monday, which I wasn’t able to eat coz I was at a Medical Appointment IIRC. On the final Day of the Elective though, the Registrar actually told me that whilst she appreciated my Efforts to be helpful, I needed to look after myself as well, and that it was important to rest on the Weekends when off-duty for the purposes of sustaining yourself.

Doctors are Human after all, they’re not G-ds or Machines, and they also need to have their Physical Needs satisfied, so they’re more likely to perform at an appropriate Level when at Work. Interestingly she also said that there wasn’t much Point in doing all these Discharge Summaries for Internship Preparation coz she believed I was going to forget all of that Knowledge, and would be better off learning it soon before/after Internship started. She believed that I was taking a long time to complete the Discharge Summaries coz I wasn’t the main Doctor looking after them, and thus wouldn’t be able to recall the Patient’s “Story” quickly off the top of my Head. That may be true, but I was also concerned that it was also due to my intuitively reduced Ability to see the “Big Picture” and instead process all the Medical Issues and Management as little Details, thus bogging me down. I’ve identified a possible weak point and will explore this later on.

She also said it was a common Phenomenon for new Interns to go through a Phase where they get paranoid about the Medication they’re prescribing, that it might accidentally harm the Patient, eg “Panadol causing Acute Liver Failure” even though people buy it Over-the-Counter at Pharmacies and use it all the time. It was comforting in that I wasn’t alone. My Experiences during this Elective really hit me, that if uncontrolled, I could easily go overboard with Work, which is facilitated by the Aspie Hyperfocus Tendencies, and let Medicine take over my Life. I will need to actively recognize and set Boundaries in order to maintain a Work-Life Balance…

I was extremely satisfied from my Geriatrics Elective, not only from the Patient Aspect (as with Paediatrics), but from the Staff who I interacted with. My Impression is that how much you enjoy a Rotation can also be influenced by the Staff (Doctors and Nurses) you meet from that Specialty. I appreciated that the Staff made the Effort to help the Patients each Day even though the Recovery Process frequently seemed rather slow. In Fact, a Handful of Patients I met at the start of the Elective were STILL at the Hospital when I was nearing the End!!!

From an Academic Perspective, I’d strongly recommend a Geriatrics Elective for Medical Students who aren’t sure what Specialty to do an Elective in, given the high prevalence of elderly Patients in Hospitals, or want to gain some Generalist Experience in “General / Internal Medicine” but with a “Twist”. It’s very eye-opening and heart-breaking at Times, but one could learn a LOT, both Medically and Socio-Emotionally.

Paediatrics (Part 5/5, RETROSPECTIVE POST)

I enjoyed Paediatric Outpatients a lot. I remember where there were a few days where I forgot to take my Medication, yet I was still fully alert and engaging with the Children and Parents without any major Issues.

I had to ask myself why I loved Paediatric Outpatients so much at the time? Being honest with myself, I came up with the following 3 reasons:

1. I was socially isolated and talking to People in Outpatients filled a void in my Social Life (as pathetic as it may sound).

2. I found it easier (less cognitively exhausting) to relate to and communicate with Children than Adults, and the Adults (Parents) seemed easier to please indirectly by me interacting positively with the Children.

3. I felt like a productive Member of the Medical Team, Clerking Patients for the Paediatricians in advance whilst they were busy seeing other Patients (but then again, this could apply to any Medical Specialty if given the opportunity to work at Outpatients).

After finishing the Paediatrics Rotation, I had a weird feeling. Could I possibly be more suited to training in Paediatrics than Pathology (if I stay in Medicine)???

Really, an Aspie working in Clinical Medicine for the long-term? Surely that would burn me out eventually?!

I liked that Children were easier to talk to and were less likely to have complications from lifestyle-related / self-inflicted issues, and that they were more amenable to positive changes. However sometimes, Children's Medical outcomes were impaired from poor Parental Care or Chaotic Environments outside of their own will, which made me really frustrated inside.

Paediatrics is also saturated in Melbourne, so apparently it's hard to collect referrals, but if you're really good at your job, I suppose that may be a non-issue.

Medically, I could see myself having trouble with Procedural Skills on Children, particularly Cannulation and Venepuncture. Their veins are just so small! Physiologically, due to Children's atypical Presentations of various Medical Conditions, especially Infections (like Bacterial Meningitis), I was worried that the high prevalence of Undifferentiated Presentations will increase my Risk of missing something dangerous, or that I want to treat it as something dangerous, but am unable to do so due to restraints in resources (eg limited ED Beds in Emergency, “Not everyone can be given Antibiotics”). The Swiss-Cheese model means that something's got to give eventually, which has lead to cases of Children dying from Bacterial Meningitis in the past → Litigation. I was also told that Parents in Paediatrics are actually very annoying, but they seemed tolerable to me during my Rotation. As a Single Male, along with reasons 1 & 2, I was worried that my Enthusiasm may eventually make me susceptible to being falsely accused of Paedophilia, as is already the case with numerous Male Primary School Teachers in Australia and the UK, hence the current under-representation of Males in that Field.

I suppose Reason 1 could be abolished by having a Social Life outside of Medicine, it's just that I need to put an active effort into it and not let Medicine take over my life like it has in the past. I would like to think that I could be a positive role model for ASD Children, but I might be able to achieve that as a GP instead (shorter Training Path) and still have Patient Contact.

Hmm decisions decisions...