The Image of the Mother's Eye: a Possible Link between Early Narcissistic Injury and Autism Maxson J. McDowell Ph.D., C.S.W. 20 Stuyvesant Oval, Apt 9F New York, NY 10009 (212) 995-2892 Submitted 11/10/01 Copyright Summary At six weeks an infant makes eye-contact with the mother thereby stimulating her 'containing' behavior (she meets and regulates her infant's needs). Eye-contact enables the subsequent development of intersubjectivity. To accomplish reliable eye- contact, the infant must acquire an image of the mother's eyes. Once acquired, this image becomes associated with containment. The acquisition of this image is therefore a crucial very-early step in psychological development. Evidence for these assertions comes from (1) analyses of patients with early narcissistic injuries, (2) the evolutionary development of the appearance of the primate eye and of its signaling function, (3) experiments on infant visual preferences, and (4) observation of nursing mothers. Existing developmental models have not addressed the acquisition of the image of the eye. A variety of biological predispositions or injuries, together with congenital blindness and severe infant deprivation, all increase the risk of failure to acquire this image. The likely result is a pervasive cascade of developmental failure. Failure to acquire this image might, therefore, represent the primary deficit in autism. Like narcissism and neurosis, the primary deficit in autism may be psychological. This model suggests that autism may be investigated via the analyses of high-functioning patients with mild autistic symptoms. Introduction At birth the infant emerges from the womb, a container which had previously met all needs. Both physically and psychologically the infant still needs to be contained. This means that the infant personality must organize itself to ensure containment. At about six weeks, for example, the infant learns to make eye-contact with the mother. Eye-contact stimulates the mother to play more with the infant. She plays with facial expression, with voice, with face presentations, with head movements, and with proximity games (Stern, 1977, p. 37). Thus the mother meets and regulates (contains) the infant's need to play. To ensure eye contact the infant must learn to recognize the mother's eye. This means that the infant must acquire an internal sensory image of the eye. (In order to recognize something I must have a stored internal image to compare it with.) Several lines of biological evidence show that an image in the cerebral cortex cannot be genetically pre- wired: the total number of genes is too small, human evolution is too fast relative to genetic change, and most wiring in the cortex is determined by sensory input (see McDowell, 2001 for a discussion of this evidence). Since the image of the mother's eye cannot be pre-wired in the cortex, it must necessarily be acquired through the senses from the environment. The infant's situation is analogous to that of a newly-hatched gosling. A gosling must imprint an image of its mother during a critical period soon after hatching. During this period it will imprint an image of any agent to which it is exposed (the agent must satisfy some general parameters concerning height and clarity of edge). From then on only that agent will elicit following behavior. If the gosling imprints the wrong image then its following behavior will be bizarrely maladaptive (Lorenz, 1970). For the gosling the image of the mother releases an instinctual behavior. Because the human infant's behavior is more malleable, the image of the mother's eye must function in a more complex manner. Once acquired, the image is associated with containment. Therefore the image begins to represent or symbolize containment. That is, when the infant seeks containment, the infant seeks an external agent that resembles the image; when the infant perceives the image, the infant feels contained. The image will then retain this function throughout life. It will recur, for example, in dreams. I propose that it is the image of the mother's eye which is first associated with containment. I show that the infant is directed to acquire this image by biological factors in the infant-mother pair. Because it is a pre-requisite for containment, the acquisition of this image is a critical event in early psychological development. To my knowledge, no existing model of psychological development addresses the acquisition of the image of the mother's eye. We cannot observe an intrapsychic event directly. We must infer it, therefore, from indirect evidence. My proposal is based on four lines of indirect evidence: (1) analyses of patients with early narcissistic injuries, (2) evolutionary developments in the appearance of the primate eye and in its signaling function, (3) experiments on infant visual preferences, and (4) observation of nursing mothers. My proposal is consistent with concepts from self psychology and with Daniel Stern's model of the development of an intersubjective sense of self. A new model is only productive if it leads to a new line of enquiry. In the second part of this paper I suggest a connection between the image of the mother's eye and autism. The case of Kate Throughout the work described here I did not at any time mention to my patient, "Kate", the image of the eye. I feared that to do so would interfere with her archaic transference. My interpretations concerning the eye remained part of my silent reverie. Nor did Kate herself interpret her images in terms of the eye. Never-the-less, in the context of an archaic transference, images suggesting the mother's eye recurred over five years. ... clinical details omitted for confidentiality ... She would not mirror Kate's qualities and accomplishments. (To be "mirrored ... is to be looked upon with joy and basic approval by a delighted parental selfobject": Kohut 1984, p. 143). .......clinical detail ommited....... Thus Kate's mother looked at her not with mirroring, but with envy. She did not affirm Kate's sense of self; she devoured it. (Mirroring supports healthy grandiosity, a sense of being powerful, admirable, and desirable, of having something of worth to give the other. Such feelings are central to a healthy sense of self (Kohut, 1971, pp. 25-28; Kohut 1978, pp. 489- 494). A narcissistically wounded mother, deficient in her own sense of self, may react to her infant with envy and rage and may therefore withhold mirroring. Unable to develop a healthy sense of self, the infant may compensate with an archaic defense: the infant feels grandiose, that is, central to everything and boundlessly powerful, or negatively grandiose, that is, boundlessly worthless, or boundlessly deprived. If my parent is envious then I experience my parent (or my parent's eye) as a vortex into which I put more and more of myself, seeking in vain for affirmation. If, as an analyst, I am unconscious of my own narcissism, then I may withhold mirroring and thus deepen my patient's narcissistic injury.) Kate was not allowed to have her own needs or to complain. She became prematurely controlled and self-reliant. She began her life-long habit of harsh self-criticism. Though this may have guarded her from even greater attacks by her mother, it was also a manifestation of negative grandiosity. .....clinical detail omitted ......... A related image occurred in the case of Rachel (McDowell 2001). Like Kate's mother, Rachel's mother was severely narcissistic. Rachel dreamt that her mother was a witch who flew over the town and burnt up the lawns. Green lawns suggest new life. There are similar images in mythology. In Egyptian myth Sakhmet, the avenging eye of the sun-god, flew over the desert and burnt up the people, turning them into pools of blood which she meant to drink. Thus the eye both burned and devoured. In Indian myth Kali burns up the world with his third eye. There is also the myth of the evil eye (of envy) which must be averted. .....clinical detail omitted ........ Thus Kate's healthy narcissism was undermined not only in her mother's eyes but also in her father's eyes. a. Archaic mirroring Sometimes Kate would look at me with a particular fixity of gaze. She would talk and I could only listen. I had to meet her gaze continuously. I could not move. If I moved or spoke she would show by a frown, or a shake of the head, or by pointedly noticing my movement, that I was intruding. With Kate these intervals of fixed gaze lasted only minutes. With some patients they last the whole session. One narcissistic patient sat mostly in silence, three sessions a week, for several months. If my gaze wandered she would protest silently with a smile and use her eyes to bring my gaze back to her. If this goes on too long my eyes ache; I want to rub them and let them move around freely. My physical eye strain is real but it is also a metaphor for psychological strain. My attention is fixed. In the counter-transference I may feel panic and claustrophobia. Perhaps I envy the attention my patient is getting. I imagine that a mother sometimes feels this way with her new-born baby. I am describing what Kohut (1984, pp. 66-67) called an archaic mirroring transference. Kate's healthy grandiosity had been injured. At these intervals of fixed gaze Kate showed an archaic "need for immediate and perfect mirroring". Everything I did had to reflect her being; there could be no evidence of my independent being. My impression in the room with Kate was that she was immersing herself and finding herself in my eyes. Listening and understanding were essential to the mirroring. But seeing her with my eyes seemed to be primary. A narcissistic wound often begins in infancy and Kate's somatic problems suggested pre-verbal injury. Therefore it made sense that a non- verbal interaction would be part of the healing process. Kate needed me to "have eyes only for her." Because I could accept her need, she could internalize the image of my admiring eyes and thereby transform her internalized image of her mother's envious eyes. ..clinical detail omitted..... b. Bathing in the mother's eyes ...clinical detail omitted....... I call Kate's lagoon image "bathing in the mother's eye." I have seen similar images in my work with other female patients who were poorly mothered. One woman, she who earlier had been silent for several months, dreamt repeatedly that she took showers with other women. Another patient had large breasts as a teenager. Her mother had molested her repeatedly by "grabbing at them". She dreamt that, while she showered, she was exposing her breasts without fear and was being admired for their beauty. Another patient told me of her thirteen-year-old daughter. Her daughter took prolonged showers and wanted her mother to stand beside her as she did so. Her mother had to hand her the soap and the flannel, and talk to her, and witness her new body. She too was "bathing in the mother's eye." The image also appears in myth. Aphrodite would return to her temple to be bathed by the three female graces. This restored her youthful beauty and virginity, that is, her feminine self. In Celtic myth, warriors who had been wounded in battle would be healed, no matter how serious the wound, if they immersed themselves in the 'Cauldron of Rebirth' (Green, 1993 p.76). Thus Kate's image of "bathing in the mother's eyes" was repeated independently in other patients, in an adolescent girl, and in myth. It appears to be a universal image, one that recurs in many places and at many times. c. The devouring eye So far I have discussed only the positive transference. After the first three years negative feelings came to light. ....clinical detail omitted..... A web-with-spider is a container that devours. The orb of a web with a spider at its center resembles the orb of the eye with its pupil. Thus Kate's image suggested that she felt trapped in the mother's devouring eye. In view of Kate's image, I asked myself to what extent I was entrapping her in order to meet my own needs. Certainly Kate's mother had used Kate to feed her own narcissism. I asked Kate if she felt I was feeding at her expense. ...clinical detail omitted...... d. Discussion The image of the mother's eye appeared repeatedly in several analyses. That the image sometimes represents an archaic transference suggests that it is acquired early. The dreams and fantasies described here show that the image functions throughout life. In normal development the constructive function of the image predominates. In narcissistically- disturbed development its destructive function is more apparent. The evolution of social gaze in primates We can deduce an evolutionary sequence by comparing modern primates. Humans evolved from ancestral monkeys and apes which were very like modern monkeys and apes. Within that evolutionary sequence social gaze became increasingly important. In most primates the visible eye consists mainly of dark iris with only a very small proportion of sclera. The sclera is almost always brown or light brown rather than white. But in humans the visible eye has a large expanse of white sclera which provides a sharp contrast to the dark iris (Emery, 2000, pp. 583,585). This helps an observer to determine the precise direction of a human's gaze. When viewing faces, a monkey shows an extreme bias for looking at the eyes and the small region surrounding the eyes. The eyes play a central role in a primate's facial expression and thus in emotional communication (ibid., pp. 585-586). Staring and frequency of eye-contact are key social signals. The direction of one monkey's attention, coupled with its facial expression, conveys crucial information to a second monkey about the object of attention (joint attention). It may inform the second monkey about the social status of a third, or about food or about danger. Apes, but not monkeys, seem to use the direction of another's gaze as a clue to the other's intended behavior. This is more complex than joint attention because it requires an awareness of the other as a repository of potential behavior. Only humans, however, seem to practice shared attention (ibid., pp. 588, 594). Shared attention is mutual. Two individuals are each aware of the direction of the other's gaze (I know that she sees it and she knows that I see it). Shared attention is a component of what cognitive psychology terms theory of mind, that is, of the knowledge that self and other have independent but comparable awareness. In psychoanalytic terms the equivalent is intersubjectivity, the inter-relatedness which occurs when two people are aware of each other's subjectivity. Thus, as the primate's eye has evolved in appearance (towards more visual contrast between iris and sclera and hence towards a better signal of gaze direction), so it has evolved in psychological function (towards enabling intersubjectivity). The evolutionary evidence is objective. It suggests that the visual appearance of the human eye (the visual image which the other internalizes) is a key component of intersubjectivity. This deduction is confirmed by experiments with human subjects (Baron-Cohen et al., 1997; Baron-Cohen et al., 2001). Subjects were asked to identify complex emotional states (scheme, admire, interest, thoughtful, arrogant) from photographs of the whole face, from cropped photographs showing only the mouth, and from cropped photographs showing only the two eyes and eyebrows. When either the whole face or the eyes alone were observed, accuracy of identification was equally high. When the mouth alone was observed, accuracy was low. Thus the other's complex subjective state is accurately conveyed by the image of the eyes. An intersubjective sense of self Daniel Stern (1985, p. 139) described how the infant develops a sense of self within the infant-mother interaction. He identified four successive senses of self: emergent, core, intersubjective, and verbal. At the intersubjective level, beginning around eight months, the infant senses that infant and mother each have inner mental states which they can share (I want that toy, and she knows that I want it.) The mother contains the infant not only physically but also psychologically. Just as the infant's body develops 'within' the physical container of the mother's body and her actions, so the infant's sense of self develops 'within' the psychological container of the mother's inner life. That is, it develops 'within' the mother's awareness of and inner response to the infant. This is particularly the case for the sense of subjective self. If the infant had sufficient language the infant might say: I see that my mother sees me as lovable, so I see myself that way too. This is confirmed by Stern et. al. (1998, pp. 907-8) ... the intersubjective goal ... [is] a mutual recognition of each other's motives, desires, and implicit aims that direct actions, and the feelings that accompany this process ... [This] also implies a signaling or ratifying to one another of this sharing ... The work is asymmetrical, with the caregiver ... doing the lion's share. Stern's model of development shows why the eyes are so important. The mother senses the presence of the infant's inner life in part through the infant's eyes. Likewise, the infant senses the mother's inner life in part through the mother's eyes. Thus the infant's sense of self develops in the container of the mother's eye. Smell, taste, touch and sound are also involved. Infant and mother engage each other in each of these sensory modalities. Young infants recognize the smell of their own mother's milk (Stern 1985, pp. 39-40). By four months the infant-and-mother pair have developed vocal rhythm coordination, the degree of which predicts both attachment and cognition at twelve months (Jaffe et al., 2001). If the baby is born blind then it must detect the mother's inner life through its other senses. Infant- observation studies compared blind and sighted infants (for both groups the mothers were sighted). With a blind infant, the mutual awareness of the infant's and mother's inner lives developed more slowly and less reliably. The mother had to make a much more conscious effort (Fraiberg 1977, pp. 3-9; Als et al., 1980, p. 201). These observations are evidence that, for a sighted infant, the visual image of the mother represents containment. The inheritance of reflexes. Neither a cortical image, nor a pattern of behavior which is peculiar to humans, can be genetically inherited (McDowell 2001). A reflex, however, is genetically inherited. A reflex is not peculiar to humans but is intrinsic to the function of an organ. Blinking and coughing are examples. When the eyelid evolved in reptiles it necessarily had a movement reflex (Gans and Parsons, 1973, p. 104). A reflex is a simple element of behavior which involves only a few muscles. It is hard- wired into the nervous system. I will show that such reflexes help to predetermine the image which a newborn chooses to represent containment. How does the infant choose the image of the mother's eye? In a new-born infant some behaviors seem to precede learning. For example, Spitz and Wolf (1946) and Ahrens (1954) found that an infant gazed preferentially at a human face or at a schematic drawing of a face. A line drawing of two eyes, a nose, and a mouth was sufficient. Spitze and Wolf suggested that the infant inherits a schematic image of the human face and seeks a match for that image in its immediate environment. Subsequent experiments (Friedman 1964; Haaf and Bell 1967), however, showed that the infant was not gazing preferentially at the whole image but only at some elements of it. It made no difference if the elements were scrambled in the drawing. The infant preferred to gaze at moving edges. The most attractive moving edges within the mother's face were the sharp angles at the corner of the eyes (two edges intersecting), the light/dark contrasts between the pupil and the white sclera of the eye (an edge), and the contrast between eyebrow and skin (an edge) (Stern, 1977, p.37). There are also edges around the lips and around the outer rim of the head. Further experiments (Haith, 1966; Karmel et al., 1974; Salapatek, 1975, p. 226) showed that from birth to about one month an infant seeks out any visual stimuli which includes both movement and 'edge density', that is, the concentration of edges in a given space. After two months the infant's vision begins to mature: like an older child, the two-month-plus infant begins to recognize when facial features are scrambled and shows a preference for naturally-ordered features. But the controversy is not yet settled. Johnson and co-workers claim to have detected two separate mechanisms, one sub-cortical, the other cortical, both of which affect the infant's preference for faces. At birth, they claim, there is a sub-cortical mechanism which, when shown a schematic drawing of the face, produces a small preference for the natural arrangement of features over a scrambled arrangement; at one month this first mechanism is replaced by the cortical mechanism (described above) which prefers edge density but does not distinguish between naturally-ordered and scrambled features (Johnson et. al.,1991; Morton & Johnson, 1991). Johnson et. al.'s experimental design seemed rigorous but, in an even more rigorous experiment, Easterbrook et. al. (1999) obtained contradictory results: newborns showed no preference for naturally- ordered rather than scrambled features, though they were able to distinguish between the two. Further experiments will be needed to clarify the issue. Whether or not there is an inherited sub-cortical mechanism, it remains true that a cortical image of the mother could not be inherited and must therefore be acquired via the senses. a. Visual edges and the cortex That the infant has a preference for visual edges is well established. Research on the vision of adult vertebrates (fish, frogs, cats, and monkeys) helps to explain this preference (Michael, 1969). All vertebrates analyze visual input primarily into a series of moving edges. The analysis is done by neurons in the retina of the eye and by neurons in areas of the visual cortex which are adjacent (closely connected) to the retina. This means that my brain does not 'see' a whole image. Rather it 'sees' a series of moving edges. An analogy may help with this distinction. In a camera, a photographic film absorbs an incoming image, made of photons, and converts it directly into changes in the chemicals of its emulsion. That which is on the emulsion is an analog of (the same shape as) the incoming image. The neurons in the retina and in the adjacent cortex do not function like a photographic film. Rather they function like a computer. A computer analyzes an image into a stream of digits, zeros and ones, which it records. The stream of digits contains all the information needed to recreate the image, but it is not itself an analog of the image. In a similar fashion the retina and the adjacent visual cortex analyze the image into multiple streams of moving edges. Subsequent computation is done upon this raw data by groups of neurons 'deeper' in the cortex, that is, further 'downstream' from the retina. There my brain analyses these moving edges and reconstructs an image. Thus my mental image is not achieved whole, like a photograph, but by the synthesis of moving edges. Once my brain has reconstructed and somehow recorded an internal image, that internal image becomes a visual concept or hypothesis which my brain uses to explain future input that it receives from the retina. I sometimes become aware of this when I mis-recognize someone I see. For a moment I seem to be seeing a different person. Then, as I realize my mistake, the image transforms itself into an image of the person who is really in front of my eyes. My brain has substituted a more accurate hypothesis to explain the visual data. An optical illusion has the same effect: at first my brain is fooled, then it gets it right. The experiments of Friedman and Haaf and Bell (above) apparently distinguished a stage through which the infant must pass before it learns to see like an adult. Since the newborn recognizes moving edges, we know that the neurons in the newborn's retina and adjacent cortex must be pre- wired (or very quickly wired) to analyze visual input into edges. We know that the newborn also has functioning muscle reflexes which enable it to focus its eyes, to fix upon an object, and to track an object (Stern 1977, pp. 35-37; Stern, 1985, p. 40). All this pre-wiring (or quick wiring) provides for the visual reflexes by which the newborn tracks the visual edges in its mother's face. It takes several months for the infant to learn to synthesize these moving edges into an image of a human face. This learning must occur deeper within the cortex. Neurons in deeper areas of the cortex have been identified which only fire when the infant recognizes a face (Elman et. al., p. 116). Only after it has learned to re-synthesize an image of the face can the infant discriminate between naturally ordered and scrambled images of the face. This explains what Salapatek (above) observed experimentally, that at two months infants begin to distinguish between scrambled and ordered features. Although the newborn can focus its eyes, it can only do so within a limited focal range. When it feeds, therefore, it cannot see the breast. But when the infant feeds the mother's eyes are within the infant's focal range, provided that the mother is looking at the infant. Stern (1997, pp. 35-36) observed that, during breast feeding, a mother spends about 70% of her time gazing at her infant's face. Thus the human infant-and- mother pair is designed to ensure that the newborn will stare at the sharp, high-contrast, moving edges of its mother's eyes. Hence, through learning, the infant will reconstruct a cortical image of the mother's eyes and face and associate that image with the breast. What I have just described is the mechanism which ensures that the infant chooses the image of the mother's eye to represent containment. a. Other mammals It is perhaps my conscious sense of self which most distinguishes me, as a human, from other mammals. It is remarkable, therefore, that my sense of self is initiated by the geometry of human breast feeding. A cat's eyes are equally sensitive to moving edges. Because of the way the kitten feeds, however, it does not begin life gazing at its mother's eyes. A clinical prediction: the case of Timothy. It follows from the forgoing that every patient who suffered an early narcissistic injury probably, as an infant, acquired a disturbed or threatening image of the mother's eye. This image would likely reappear in the patient's material, particularly when narcissism was being analyzed. As I was writing this paper a patient produced such an image. ....clinical detail omitted..... Autism I have identified a very early step in psychological development, the acquisition of the image of the eye and its association with meaning. How would development proceed if this step were blocked? I explore this question in what follows. Between 0.1 and 0.2 percent of children are autistic (Gillberg & Wing, 1999). The syndrome varies greatly in severity. A child with Asperger's syndrome has normal intelligence and language but has a social deficit and a narrow range of interests and activities (Rapin, 1997). Adults with Asperger's syndrome/high-functioning autism were tested by Baron-Cohen and co-workers (in experiments described above) for their ability to identify 'complex' emotional states from photographs of whole faces and from cropped photographs. They were significantly less accurate than normal adults when tested with images of whole faces and even less accurate with images of the eyes alone. Thus Asperger's syndrome/high- functioning autism entails a deficit in "reading the mind in the eyes." A child with classic autism has more severe symptoms including, in social behavior: marked impairment ... of nonverbal behavior such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interactions; failure to develop peer relationships; ... lack of showing, bringing, or pointing out objects of interest; lack of social or emotional reciprocity; failure to distinguish among persons; language that is not used for ... interpersonal communication, but is characterized by echolalia ... and references to the self in third person (Rapin, 1997). There is a deficit in symbolic thinking: play with toys is replaced by stereotyped manipulation of objects, for example, by unscrewing and screwing jar lids (Hobson, 1999, p. 45). Baron-Cohen has suggested that autism represents an extreme on a continuum of normal psychological styles. Many symptoms associated with autism seem to be extreme versions of the normal gender differences between men and women. Autism is three times more prevalent in men. The symptoms of mild autism are more common in scientists and mathematicians than in the general population ( Baron-Cohen,1999; Baron-Cohen et al., 2001). Baron-Cohen's observations notwithstanding, autism is clearly a pervasive developmental the disorder: a primary deficit in fetus or infant begins (to a greater or lesser degree) a cascade of developmental failure. Deficits in social behavior, language and play are secondary (Ungerer, 1989). But what is the primary deficit? After decades of research this question has not been answered (Sigman & Capps, 1997; Wimpory et al., 2000). A biological deficit? At present there is a bias towards biological explanations for mental disease. In the literature on autism the overwhelming weight of opinion is that the primary cause is biological. Rapin (1997), however, who argued for a biological cause, noted that: The existence of a large literature describing a wide variety of neural abnormalities in autism ... has led to much speculation ... however, no coherent anatomical or pathophysiologic theory, nor a biologic diagnostic test has yet been developed. Rodier (2000), who also argued for a biological cause, said that: In utero exposure to rubella (German measles) or to birth-defect- causing substances such as alcohol ... increases the chances that autism will develop. People with certain genetic diseases, such as phenylketonuria and tuberous sclerosis, also have a greater chance of developing autism. None of these factors, however, is present frequently enough to be responsible for many cases ... Researchers do not know how the multiple factors combine to make some people display symptoms, while allowing others to escape them. Rodier's group have identified an allele (that is, a mutant form of a gene) which plays a role in autism. The allele's ... presence does not guarantee that autism will arise. The variant allele occurs in about 20 percent of the people who do not have autism, and in about 40 percent of those who do. The allele doubles the risk of developing the condition. But in about 60 percent of people with autism, the allele is not present (ibid.) In identical twins, one twin may be autistic and the other not. Thus many biological factors are associated with autism but none of them is always present and none of them always cause it. A true primary cause would be both necessary (without it, no autism) and sufficient (when present, so is autism). None of the biological factors is either necessary or sufficient. The logic of causation in a cascade also argues against a biological cause for autism. The event which first sets a cascade in motion, that is, the event which is the primary cause, is the same in kind as the events which comprise the cascade. A factor of a different kind may increase the frequency of the primary cause but such a factor is not itself the primary cause. While a thaw or a thunderstorm increases the risk of an avalanche, the primary cause is the first movement of snow. The following example shows why this distinction is important. Death results from a cascade of bodily failure. Households with handguns show an increased frequency of death. But households with a high-cholesterol diet also show an increased frequency of death. A gunshot wound is neither necessary nor sufficient to cause death. A high-cholesterol diet is likewise neither necessary nor sufficient. The cessation of the heart beat, however, is both necessary and sufficient. It is also the same in kind as the other bodily failures which lead to death. It is the primary deficit which begins the cascade. When we identify the primary deficit we can see how other factors (gunshot and cholesterol) increase the frequency of that deficit. None of the suspected biological factors is the same in kind as the cascade of failures which is autism. Therefore none of the biological factors can be the primary deficit. The primary deficit should be a very early failure in psychological development. Visual stimulus by a care-giver The following is further evidence that no biological factor is the primary deficit. The correlation between autism and congenital infant blindness (Brown et al., 1997; Hobson et al., 1999) is stronger that the correlation between autism and any other biological factor. If the mother of a blind baby relates to it actively by means of touch and sound then her baby's development may be close to normal; if the mother does not do so then her baby is very likely to develop autism (Als et al., 1980). These autistic children do not have higher-than-normal rates of any other biological factor. What they have in common is blindness and a consequent failure to relate to the mother in infancy. There is also a high incidence of autism in children who were institutionalized at birth (Fraiberg, 1977, pp. 185-187). There was a high incidence, for example, in children who were adopted in the U.K. from orphanages in Romania (Rutter et. al., 2001). These children are normally sighted but were neglected in cribs during infancy. The Romanian children do not have higher-than-normal rates of any biological factor. The two different groups, congenitally blind children and children institutionalized at birth, share a common deficit: they both lack early visual stimulus by a care-giver. In the absence of any biological cause, therefore, early deprivation in visual stimulus by a care-giver often (but not always) leads to autism. This evidence tends to be ignored or discredited. Rutter et al. (2001, p. 101), for example, argued that such deprived children have "quasi-autistic features" which do not represent "ordinary" autism. But autism is diagnosed by the presence of such "quasi-autistic features". There is no reason to doubt that these deprived children are suffering from a form of autism. This is a familiar manoeuver in the history of science: in order to preserve a prevailing theory, evidence which cannot be made to fit the theory is rejected. Since the above evidence is sound it is rather the prevailing theory which should be rejected. Like the proposed biological causes, the lack of early visual stimulus by a care-giver is neither necessary nor sufficient to cause autism. It is not the primary deficit but it somehow increases the incidence of the primary deficit. Inherent intersubjectivity Trevarthan & Aitken (2001, pp. 3-4) argued that an infant is born with genetically determined brain structures which provide for "inherent intersubjectivity", that is, for a complex pattern of interrelatedness with the mother: Regulation of this primary communication depends on an innate 'virtual other' process in the infant's mind. Trevarthan & Aitken argue, therefore, for a biological cause. Autism is caused by embryonic deficits in the above-mentioned brain structures (ibid., p. 30). Trevarthan & Aitken's concept of "inherent intersubjectivity" assumes that the genetic apparatus specifies complex behavior. But this is not so. Complex structure is emergent, that is, it is the product of a hierarchy of increasingly complex levels of self-organization. Each level organizes itself spontaneously by the interaction of simpler components (see McDowell 2001 for a fuller explanation). Genes specify only the structure of enzymes and the timing of their appearance. Such timing, together with information from the environment, provides constraints which guide self-organization. Just as self-organization creates anatomical structure out of simpler anatomical components, so must self-organization create behavioral structure out of simpler behavioral components. "Inherent intersubjectivity", therefore, must arise from the self-organization of simpler components of behavior. It follows that autism must also be explained in such terms: when a simple component of behavior is blocked, the subsequent organization of intersubjective behavior is derailed. This argument is related to my earlier argument about cascades. A very early step in development An autistic child seems not to know that his or her mother has a subjective self. An autistic boy, for example, was playing with his mother when she hurt her finger with a toy hammer and gave a sudden exclamation of pain. Though he was emotionally attached to his mother the boy paid no attention to her exclamation. Evidence of this kind led Hobson et al.(1999, p. 55) to suggest that the "final common pathway" (primary deficit) is a failure to develop a "theory of mind": the child does not know that the child and the mother each have a psychological perspective which can be shared. This failure is "critical for the development of many of a cardinal features of autism". A theory of mind (or the lack thereof) can be inferred from a child's visual behavior. An autistic child makes little eye-contact and pays little attention to his or her mother's face. The child ignores the mother's facial expressions. Consequently the child lacks social referencing: it cannot evaluate an ambiguous situation by checking the mother's expression. The child also lacks shared attention, that is, it cannot follow the mother's eyes see what she is seeing, nor point to share feelings about something with the mother. Deficits in intersubjectivity have recently been demonstrated at less than six months. These studies used home movies of infants who were later diagnosed as autistic (Maestro et al., 2001). Since eye-contact begins at about six weeks, a deficit in eye-contact might also begin at six weeks. From evidence of this kind, Trepagnier (1998) proposed the following: autism may be the resultant of [genetically-linked] very-early-onset anxiety/affective disorder [with] consequent interruption of establishment of face-processing during a biologically important period. In this account, brain differences in autistic individuals [biological factors] reflect (1) underlying pathology shared with 'typical' neuropsychiatric disorders, and (2) subsequent developmental experiences. Thus Trapagnier argued that brain differences are secondary. She suggested that anxiety/affective disorder is necessary but not sufficient and that face-processing is the key. Both Hobson and Trepagnier have proposed that developmental deficits cause autism. My hypothesis adds to theirs by identifying the primary deficit more precisely, and by putting it in a developmental and analytic context. I suggest that the primary deficit in autism is the failure to acquire the image of the mother's eye. A blind infant who is actively mothered acquires an equivalent image through the other senses. A blind infant who is not actively mothered may fail to acquire an equivalent image. A sighted infant who is neglected may also fail to acquire the image. The other biological factors associated with autism (rubella, alcohol during pregnancy, phenylketonuria, etc.) all increase the risk that the infant will not acquire the image. Temple Grandin (1996, pp. 65-76) is a scientist who is an expert on sensory stimulation in cattle. She has special insight into autistic sensations because she herself is autistic. Grandin argued that an autistic person suffers primarily from sensory overstimulation. In particular visual and auditory sensations are often overwhelming. "Rapid shifting of attention between two different stimuli is very difficult." Grandin quoted Jolliffe: Reality to an autistic person is a confusing interacting mass of events, people, places, sounds and sights. There seem to be no clear boundaries, order, or meaning to anything. A large part of my life is spent just trying to work out the pattern behind everything. Set routines, times, particular routes and rituals all help to get order into an unbearably chaotic life. Touch may also be overwhelming but "can sometimes provide the most reliable information". Smell is usually not overwhelming. An autistic person withdraws in part to reduce sensory overstimulation. An autistic person often has severe body boundary problems ... [one woman] described a fractured perception of her body in which she could perceive only one part at a time. [She] tapped rhythmically and sometimes slapped herself to determine where her body boundaries were. Grandin believes that the primary deficits in autism are biological. Her descriptions, however, are evidence to the contrary. The mother 'contains' eye and voice stimulation for the infant, both initiating stimulation and regulating its intensity. Through this play the infant learns to modulate sensory input. Through sensory play with the mother the infant also learns body boundaries. All this learning must be compromised if the infant fails to enter an early eye and voice dialogue with the mother. Modulation of input from touch and smell, which are independent of eye and voice, would be less compromised. Grandin likens the sensory experience of an autistic person to that of a wild animal. A wild animal is overstimulated by unfamiliar sensation. A tame animal has learned to modulate sensory input from human culture. A rural person first coming to a big city has to learn, likewise, to modulate sensation. An autistic person, then, has not been 'tamed': he or she did not enter, as an infant, that sensory dialogue which is required for development within human culture. Implications I have argued that autism, like narcissism or neurosis, results from the disruption of normal psychological development. This implies that autism may be studied analytically. A high-functioning adult with mild autistic symptoms might be a good subject. If a very early disruption in development can lead not only to narcissism but also to autism, then some narcissistic patients should also have autistic symptoms. This seems true for Timothy whom I discussed earlier. ......clinical detail omitted....... Grandin (1996, pp. 62-66, 79-81) invented a machine with which she could apply compression to her own body. She reported that she, along with other autistic people, craved this mechanical pressure. Such pressure is now used to calm autistic children. The images which emerged in Timothy's analysis often had an impersonal or non-human quality. ......clinical detail omitted........ (The sun recalls Sakhmet, the devouring eye of the sun god.) Another patient who had mild autistic symptoms dreamt that he was a planet in an alien solar system. Grandin (ibid., p. 97) noted "I vividly remember learning about the solar system by drawing it on the bulletin board ..." A solar system resembles an image of the eye with the sun as the pupil. These observations suggest questions for further work. Does the material of other mildly autistic patients include disturbed images of the mother's eye? Is there a clinical overlap between early narcissistic injury and mild autism? Acknowlegements Thanks to my wife, Joenine Roberts C.S.W., for her generous insights and criticisms. References ARENS, R. (1954). Beitrage zur Entwicklung des Phsyiognomie und Mimikerkennens. Zeitchrift fur Experimentall e und Angewandte sychologie, 2: 412-54; 599-633. ALS, H., TRONIC, E. & BRAZELTON, T. B. (1980). Stages of early behavioral organization: the study of a sighted infant and a blind infant in interaction with their mothers. In High-Risk Infants and Children, ed. T. M. Field. New York: Academic Press, pp. 181-204. BARON-COHEN, S., WHEELWRIGHT, S. & JOLLIFFE, T. (1997). Is there a "language of the eyes"? Evidence from normal adults and adults with autism or Asperger syndrome. Visual Cognition, 4(3): 311-31. BARON-COHEN, S. (1999). The extreme male-brain theory of autism. In Neurodevelopmental Disorders, ed. H. Tager-Flusberg. Cambridge: MIT Press, pp. 401-29. BARON-COHEN, S., WHEELWRIGHT, S., HILL, J., RASTE, Y. & PLUMB, I. (2001). The "reading the mind in the eyes" test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J. Child Psychol. Psychiatry, 42(2): 241-51. BARON-COHEN, S., WHEELWRIGHT, S., SKINNER, R., MARTIN, J., & CLUBLEY, E. (2001). The autism spectrum quotient (AQ): evidence from Asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Developmental Disorder, 31(1): 5-17. BROWN, R., HOBSON, R. P., LEE, A & STEVENSON, J. (1997). Are there "autistic like" features in congenitally blind children? J. Child Psychol. Psychiat., 38(6): 693-703. EASTERBROOK, M. A., KISILEVSKY, B. S., MUIR, D. W. & LAPLANTE, D. P. (1999). Newborns discriminate schematic faces from scrambled faces. Canadian Journal of Experimental Psychology, 53(3): 231-41. ELMAN, J. L., BATES, E. A., JOHNSON, M. H., KARMILOFF-SMITH, A., PARISI, D. & PLUNKETT, K. (1998). Rethinking Innateness: A Connectionist Perspective on Development. Cambridge: MIT Press. EMERY, N. J. (2000). The eyes have it: the neuroethology, function and evolution of social gaze. Neuroscience and Biobehavioral Reviews, 24: 581-604. FRAIBERG, S. (1977). Insights from the Blind: Comparative Studies of Blind and Sighted Infants. New York: Basic Books. FREEDMAN, D. (1964). Smiling in infants and the issue of innate vs. acquired. Journal of Child Psychology and Psychiatry, 5: 171-84. GANS, C. & PARSONS, T. S. (1973). Biology of the Reptiles, vol. 4, Morphology D. London: Academic Press. GRANDIN, T. (1996). Thinking in Pictures and other Reports from my Life with Autism. New York: Vintage. GILLBERG, C. & WING, L. (1999). Autism: not an extremely rare disorder. Acta Psychiatry. Scand., 99(6): 399-406. GREEN, M. J. (1993). Celtic Myths. Austin: University of Texas Press. HAAF, R. A. & BELL, R. Q. (1967). A facial dimension in visual discrimination by human infants. Child Development, 38: 892-9. HAITH, M. M. (1966). The response of the human newborn to visual movement. J. Experimental Child Psychology, 3: 235-43. HOBSON, R. P., LEE, A. & BROWN, R. (1999). Autism and congenital blindness. J. Autism and Developmental Disorders, 29(1): 45-56. JAFFE, J., BEEBE, B., FELDSTEIN, S., CROWN, C. L. & JASNOW, M. D., 2001. Rhythms of dialogue in infancy: coordinated timing in development. Monogr. Soc. Res. Child Dev.,66(2): i-viii, 1-132. JOHNSON, M. H.,DZIURAWIEC, S, ELLIS, H. & MORTON, J. (1991). Newborns' preferential tracking of face-like stimuli and its subsequent decline. Cognition,40: 1-19. KARMEL, B. Z., HOFFMANN, R. F. & FEGY, M. J. (1974). Processing of contour information by human infants evidenced by pattern-dependent evoked potentials. Child Development,45: 39-48. KOHUT, H. (1971) The Analysis of the Self. Madison: International U. Press. _____ 1978. The Search for the Self. Madison: International U. Press, Vol 1. _____(1984). How Does Analysis Cure? Chicago: University of Chicago Press. LORENZ, K. (1970). Studies in Animal and Human Behavior, trans. R. Martin, 1:245-246. Cambridge: Harvard University Press. MAESTRO, S., MURATORI, F., BARBIERI, F., CASELLA, C., CATTANEO, V., CAVALLARO, M. C., CESARI, A., MILONE, A., RIZZO, L., VIGLIONE, V., STERN, D. D. & PALACIO-ESPA SA, F. (2001). Early behavioral development in autistic children: the first 2 years of life through home movies. Psychopathology, 34(3): 147-52. MCDOWELL, M. J.(2001). Principle of organization: a dynamic systems view of the archetype-as-such. J. Analytical Psychol., 46(4): 637-54. (Also available online as 'The three gorillas: an archetype organizes a dynamic system' in Cogprints). MICHAEL, C. R. (1969). Retinal processing of visual images. Scientific American, May: 104-15. MORTON, J. & JOHNSON, M. H. (1991). Conspec and con lern: a two-process theory of infant face recognition. Psychological Review, 98(2): 164-81. RAPIN, I. (1997). Autism. New England Journal of Medicine, 337(2): 97- 104. RODIER, P. M. (2000). The early origins of autism. Scientific American, February: 56-63. RUTTER, M. L., KREPPNER, J. M. & O'CONNOR, T. G. (2001). Specificity and heterogeneity in children's responses to profound institutional privation. British Journal of Psychiatry, 179: 97-103. SALAPATEK, P. (1975). Pattern perception in early infancy. In Infant Perception: from Sensation to Cognition, I: Basic Visual Processes, eds. L. B. Cohen & P. Salapatek. New York: Academic Press, pp. 144-248. SIGMAN, M. & CAPPS, L. (1997). Children with Autism: a Developmental Perspective. Cambridge: Harvard University Press, pp. 147-74. SPITZ, R. A. & WOLF, K. M. (1946). The smiling response: a contribution to the ontogenesis of social relations. Genet. Psychol. Monogr., 34: 57- 125. STERN, D. N. (1977). The First Relationship. Cambridge: Harvard Univ. Press. _____(1985). The Interpersonal World of the Infant. New York: Basic Books. STERN, D. N., SANDER, L. W., NAHUM, J. P., HARRISON, A. M., HARRISON, LYONS-RUTH, K., MORGAN, A. C., BRUSCHWEILER-STERN, N. & TRONIC, E. Z. (1998). Non-interpretive methods in psychoanalytic therapy: the 'something more' than interpretation. Int. J. Psycho-Anal., 79: 903-31. TREVARTHEN, C. & AITKEN, K. J. (2001). Infant intersubjectivity: research, theory, and clinical applications. J Child Psychol Psychiatry, 42(1): 3-48. UNGERER, J. A. (1989). The early development of autistic children: implications for defining primary deficits. In Autism: Nature, Diagnosis and Treatment, ed. G. Dawson. New York: Guildford Press, pp. 75-91. WIMPORY, D. C., HOBSON, R. P., WILLIAMS, J. M. G. & NASH, N. (2000). Are infants with autism socially engaged? A study of recent retrospective parental reports. Journal of Autism and Developmental Disorders, 30(6): 525-36.