Keywords
Autistic Disorder - Psychiatry - Asperger Syndrome
Palavras-chave
Transtorno Autístico - Psiquiatria - Síndrome de Asperger
THE UNTOLD HISTORY
Whenever the historical review of autism is presented, it begins with Kanner and Asperger.
According to the official story, in 1943, Kanner, an American child psychiatrist of
Austro-Hungarian origin, described a clinical picture in 11 children that was later
considered classic early infantile autism.[1] In 1944, Hans Asperger, an Austrian pediatrician, described “autistic psychopathy”
in four boys, which, many years later, took the name Asperger syndrome.[2] However, there is an author who is little explored in this story, whose role has
not been given due importance: Grunya Efimovna Sukhareva (1891–1981), a Jewish psychiatrist
and researcher born in Kiev.[3]
[4]
[5]
In 1921, Sukhareva founded a therapeutic school for children with psychiatric problems
in Moscow. She was head of the Department of Psychiatry of the Kharkov Psychoneurological
Institute in 1933 and, between 1938 and 1969, she was head of the Psychosis Pediatric
Clinic at the Institute of Psychiatry of the Union of Soviet Socialist Republics.[3]
In 1926, Sukhareva published part one of a detailed description of autistic traits
in 6 boys, in the Monatsschrift für Psychiatrie und Neurologie, a German scientific journal of psychiatry and neurology.[6] In 1996, Sula Wolff[7] translated this article into English, originally published in Russian in 1925 and
in German the following year, entitled “Die Schizoiden Psychopathien im Kindesalter”.
Sukhareva initially used the term schizoid (eccentric) psychopathy and later replaced it with autistic psychopathy (pathological avoidance) to report the clinical picture of what is now described
as autism. Her original paper was available almost two decades before the studies
by Kanner[1] and Asperger.[2] However, Sukhareva's pioneering work is rarely even cited.
In 1927 she published “Die Besonderheiten der Schizoiden Psychopathien bei den Mädchen”
in the same journal as a follow-up to the first article, presenting 5 cases of girls
and a discussion of the differences between the sexes in the presentation of schizoid
psychopathy, potentially being considered part of the autistic spectrum now. This
study was translated and published in 2020 by Charlotte Simmonds.[8]
In the report of her first six patients, Sukhareva[6]
[7] presents the entire family history of parents, grandparents and uncles, the detailed
neurological and psychological clinical examination as well as the evolution observed
during their stay in the therapeutic school. Her final impressions involved a clinical
opinion, course, and diagnosis that resembled classical features of autism. At the
end of the descriptions, Sukhareva pointed out that despite the individual differences
in the clinical picture of the cases, of what she initially called schizoid personality
disorder, it was possible to define common characteristics to all children. These
included:
-
A strange kind of thinking: a tendency toward abstraction and schematization. This
trait of thought was often combined with a tendency towards rationalization and absurd
rumination, and the latter feature often marked the personality as strange.
-
An autistic attitude: all affected children kept aloof from their peers, had difficulty
adapting, and were never fully themselves among other children. They also manifested
a tendency to loneliness and withdrawal from other people since early childhood. They
kept themselves isolated, avoided community games, and preferred fantastical stories
and fairy tales.
-
Emotional life: there was a certain flatness and superficiality of emotions. This
mixture of insensitive and supersensitive elements was observed in all cases, from
affective slowness and exaggerated sensitivity, to increased irritability, resulting
in emotional outbursts, according to Bleuler's description of spasms and paralysis
of emotions. Still, a generally calm and at the same time passionately tender mood
towards some of the people close to them was noted.
-
Other characteristics: tendency towards automatism, manifesting itself as adherence
to initiated tasks and psychical inflexibility with difficulty in adapting to new
situations; impulsive and strange behavior; tendency to stereotyped neologisms; tendency
to obsessive-compulsive behavior and increased suggestibility; motor alterations:
clumsiness, awkwardness, sudden and superfluous movements, synkinesis. Lack of facial
expressiveness and expressive movements; decreased postural tone; lack of speech modulation.
Recovering contribution
The precision and detail in the description of these cases is surprising, since Sukhareva
evidenced the presence of sensory abnormalities, which only recently regained their
proper relevance in the description of autism spectrum disorder (ASD) in DSM-5.[9]
Manouilenko and Bejerot[3] presented a comparative analysis between the clinical description highlighted by
Sukhareva in her original article and the similarity with the description of ASD in
DSM-5. They also discussed her anonymity and trajectory and asked if Kanner and Asperger
really knew about her early work. Interestingly, these three pioneers who began to
describe the clinical picture of autism were all German-speaking and born in Ukraine
and Austria, but died as citizens of the United States, Austria, and the Soviet Union.
Being Jewish, a citizen of the Soviet Union, and publishing in German and Russian,
as well as being a woman, may not have been a successful formula for achieving international
acclaim at that time.
Sukhareva and Asperger studied Kretschmer's early work on schizoid personality in
adults and cited different editions of the book Körperbau und Character.[3] Sula Wolff, who introduced the English translation of Sukhareva's original article
in 1996,[7] speculated that Hans Asperger should have known about Sukhareva's article, but this
cannot be confirmed in contemporary times.
It is understandable that the ASD is more heterogeneous and complex than the original
description given by Sukhareva, but to deny the originality and accuracy of her descriptions,
almost 100 years after her publications, would be a historical error, which we hope
to repair.
Bibliographical Record
Cristina Maria Pozzi, Rudimar dos Santos Riesgo, Francisco Baptista Assumpção Junior.
Revisiting the history of autism before Kanner and Asperger: a tribute to Grunya Sukhareva.
Arq Neuropsiquiatr 2024; 82: s00441788269.
DOI: 10.1055/s-0044-1788269
