“Of course I don’t have my underwear. I’m definitely not wearing my underwear…. These are not boxer shorts. Mine are boxer shorts. These are Hanes 32… My boxer shorts have my name and it says Raymond…I get my boxer shorts at K-Mart in Cincinnati”. (Rain Man, 1988) This quote from the popular movie Rain Man perfectly captures the disorder that plagues Raymond Bobbitt, one of the main characters. He is a very particular man who must always do everything on a schedule; any disruption in this schedule completely turns his world upside down. He shows very little emotion, unless something happens to upset him, in which case he completely melts down. His behavior is almost that of a young child. However, he also has a very unique gift. He has an absolutely astounding memory and can recall the smallest details from events that occurred when he was just a young child. At one point in the movie, a lady drops a box of toothpicks and Raymond is able to immediately determine how many of the toothpicks spilled out of the box. The behaviors of Raymond Bobbitt, while very interesting, are nowhere near normal and they prevent him from functioning in any kind of normal society. It is because of this that I have determined he has a mental disorder and could benefit greatly from treatment. In order to diagnose Raymond, it is important to look at all of the factors that may contribute to his behavior. The DSM-IV multiaxial system is a great way to break everything down and do this. It has 5 sections that take a deeper look in to all of the factors that contribute to the possible mental disorder of a patient and provides a standard for classifying mental disorders. Because of this, it is heavily relied on when making an accurate diagnosis and will be used to diagnose Raymond.
Axis one of the DSM-IV system is reserved for the clinical symptoms of the disorder. Raymond showed many of the typical clinical symptoms of a person with autism. The first symptom that they generally display is developmental regression. Most sufferers of autism do not show any signs of developmental
problems until around 15-30 months. Since Raymond was a young child and not an infant when he was sent away to live at the care home, it can be assumed that he did not start to show problems until he was a young toddler, which is consistent with the autism diagnosis. Another clinical symptom of autism is abnormal reactions for environmental stimuli. This is clearly seen by Raymond when we see him completely melt down when the fire alarm goes off. The loud noise, which is not something that would bother normal people, is too much for him to handle. Abnormal social interactions are another thing that Raymond displays that is also characterized by autism. He cannot hold a normal conversation and has big problems understanding the social intentions of his brother as he takes him on their trip. It is also clear when you listen to the way that Raymond talks that he might suffer from autism; he refers to himself as “Raymond” instead of “I” and he often rambles on to no one in particular about his schedule or whatever else he is thinking at the time. The final characteristic of autism that is seen in Raymond is the stress that he feels whenever his routine is broken. (Brasic, 2013) When his brother takes him away from the care home and changes everything, Raymond displays significant anxiety. He insists that they watch Jeopardy at 5:00 and is constantly talking about what he should be doing at any given time. He starts to melt down when he is not doing what he normally does and continues on until his brother finally lets him get his way.
Under axis II, the personality disorders and intellectual disabilities are assessed. There are several of these that are associated with both Raymond and Autism, specifically and autistic Savant. The biggest personality disorder that is shown by Raymond and that is also exhibited by autistics is that he has extreme anxiety. (Mayo Clinic, 2013) It is clear by the way that he will not get on an airplane because there are no available airlines that have never experienced a plane crash. A normal person would not think that much in to getting on a plane, and they definitely would not know the statistics of every airline that there is. Even after they start driving, Raymond starts rambling off statistics about driving and car accidents, making it clear that he is not even comfortable riding in a car. You can also look back at some of the other examples that we have already looked at to show his elevated anxiety levels. When the fire alarm goes off, and he starts breaking down, he is reacting abnormally (the symptom from axis I); it is because of his extreme anxiety that he starts to display this behavior. The same goes for why he is constantly rambling and is so distressed about missing his shows, not having dinner at the right time and everything else that has changed in his schedule; he does all of this because he is suffering from constant anxiety due to his autism and his change in routine. Another thing to look at under axis II is his intellectual abilities. While he is not able to function as a normal person intellectually (another symptom of autism), he shows extraordinary abilities intellectually in other areas. He remembers specific events from his childhood starting at a very young age, and he remembers them with extreme accuracy and detail. He is also able to store things in his memory that no normal person would be able to, such as when he knew the one and only airline that had never had a plane crash (it was a very small and unknown airline at that) or when he knew all of the highway statistics concerning car accidents. It is also made clear that he is brilliant at math, counting and patterns when he is in Vegas and is counting the cards with ease. All of these amazing intellectual abilities that he shows are characteristics of a savant as well. (Hiles, 2002)
Axis III is reserved for and physical problems that may be relevant in diagnosing or treating the mental disorder. For example, if a person is suffering from a mood disorder and they also have a disease which causes them pain or discomfort, then that might be something that contributed to their depression. (Edelson, 2013) Raymond does not display any of these however, so there would be no diagnosis for him under this axis.
Axis IV is used to assess any environmental stressors that may affect the diagnosis or treatment or the mental disorder. This was a big factor in Raymond’s diagnosis and his display of symptoms. He was doing fairly well at the care home and, even though he was still displaying some symptoms of an autistic savant, he was able to live happily and relatively stress free.
However, when his brother took him from his place of comfort, his symptoms got significantly worse. His anxiety levels went through the roof and it was clear that he was not handling the change well. He had lost his primary support group, which included all of the nurses at the hospital and he was left only with his brother who he had not seen since they were young children. This caused him anxiety because he was not familiar with him and his brother was not prepared to deal with all of the behaviors that Raymond displays. He was also showing elevated levels of anxiety due to his environment. When they left the care home, it was clear that Raymond did not want to go because he said it and started acting out. But his brother made him, and his actions just got worse from there. Every night Raymond would insist that they at least follow his schedule and he would start throwing a tantrum if they didn’t. Also, when they were in the casino, he could not handle all of the flashing lights and the ringing of the bells. This eventually led to another melt down. After being with his brother for almost their whole trip, it seemed like Raymond started to warm up to him a bit. Since his brother was the only constant during their trip, this again shows how much Raymond needs something consistent and some sort of routine, a need that is very common in autistic. (Bellini, 2013)
Axis V is used for the Global Assessment of Funtioning (GAF). It is an evaluation of the patient’s ability to function in daily life and is based off of a 100 point scale (100 being the most functioning and 0 being the least). When looking at Raymond, I would assign him two separate GAF scores. When he is in an comfortable environment, such as when he is living in the care home, I would give him a GAF of 40 because he still displays symptoms and would not be able to keep a job and function in society, but he is not extreme. However, when taken out of his environment and put out in the world, I would give him a GAF of 20 because he starts to display extreme behavior and even becomes a threat to himself or others. (PsyWeb, 2013) There was a point when one of his melt downs became so bad that he started banging his head and hurting himself. He is in need of constant supervision when he is not in a comfortable familiar place.
After taking a look at the symptoms that Raymond displayed (which include things like not making eye contact and constantly fidgeting, not seeming to hear when people talk to him and not being able to hold a conversation, and resting touch and changes in routine) and breaking them down with regard to the DSM-IV multiaxial system, I have determined that he suffers from Autism, and more specifically, he is an Autistic Savant. He would be classified as a Savant because he, while lacking in many areas, does have extraordinary skills in other areas. There was a time in the movie when his brother takes him to Vegas and tells him to count cards in blackjack and Raymond (having to prior training) is able to do it with ease. His symptoms under the DSM-IV model are extremely consistent with those of an autistic savant. He displays all of the clinical symptoms (axis I) that an autistic would display, including abnormal social behavior, the inability to hold a normal conversation and the constant fidgeting. These behaviors are also consistent with the autistic and savant personality disorders and mental abilities (axis II), including the extreme anxiety and the extraordinary abilities in specific areas. There are not necessarily any physical problems (axis III) that contribute to being an autistic savant, and Raymond did not show any of these either. His environment (axis IV) however, did play a significant role his behavior and that is very common with autistics as well. (First Signs, 2012)
After diagnosing Raymond as an autistic savant, the most important treatment that I would recommend for him would be to return to the care home and live the rest of his life there. When treating autism, there is no one set treatment because every person with autism is unique. (Autism Speaks, 2013) Since we were able to see how Raymond responded to living in the care home and sticking to a strict routine, we were able to see that it worked for him. This plan, and the routine that was tailored for him, worked to minimize his symptoms and reduce his behavioral problems. As far as him being a savant as well, there really is no treatment needed for that because it does not pose a problem in his life. It is a talent that he lives with and not something that needs to be fixed. If Raymond is returned to the care home and his familiar schedule, there is no reason that he cannot live out the rest of his life as happily and comfortably as possible.
Autism Speaks. (2013). How is Autism Treated? Retrieved from: http://www.autismspeaks.org/what-autism/treatment Bellini, Scott. (2013). The Development of Social Anxiety in Adolescents With Autism Spectrum Disorders. Retrieved from: http://foa.sagepub.com/content/21/3/138.short Brasic, James. (2013). Autism Clinical Presentation. Retrieved from: http://emedicine.medscape.com/article/912781-clinical Edelson, Steven. (2013). Research: Autistic Savants. Retrieved from: http://www.autism.com/index.php/understanding_savants First Signs. (2012). DSM-IV Criteria Pervasive Developmental Disorders. Retrieved from: http://www.firstsigns.org/screening/DSM4.htm Hiles, David. (2002). Savant Syndrome. Retrieved from: http://www.psy.dmu.ac.uk/drhiles/Savant%20Syndrome.htm Mayo Clinic. (2013). Autism. Retrieved from: http://www.mayoclinic.com/health/autism/DS00348/DSECTION=symptoms PsyWeb. (2013). Axis V- Global Assessment of Functioning Scale. Retrieved from: http://www.psyweb.com/DSM_IV/jsp/Axis_V.jsp