Violent Fantasies in Young Men With Autism Spectrum Disorders: Dangerous or Miserable Misfits? Duty to Protect Whom?

Introduction

Over the past almost 30 years, a number of studies have examined the issue of violence and criminality in the context of autism, most notably in connection with Asperger syndrome (AS; Woodbury-Smith & Dein, 2014). The majority of the works was either in the form of case reports or consisted of small samples of patients who had been violent or who entered into contact with the law (Mouridsen, Rich, Isager, & Nedergaard, 2008). A few studies have specifically examined institutionalized youths and hence may have suffered from a selection bias as well as from the considerable overlap in developmental disorder phenomenology (Stahlberg, Anckarsäter, & Nilsson, 2010), some even resorting to retrospective diagnosis in search for a best estimation of the presence or absence of illness with the obvious shortcomings of such an approach to inquiry. The apparently relative ease in making the diagnosis when applying previous Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) diagnostic criteria has even led to syllogistic equations of behaviors seen in heinous crimes and to facile, a posteriori, diagnoses (Palermo & Bogaerts, 2014).

Nonetheless, considerable attention is given to autism as a risk factor for deviance, and, contrary to the available evidence, the link between crime and autism spectrum conditions is consolidating over time. In this qualitative case-series study, the subjective experience of violent fantasy life in a small clinical sample of five young men with an autism spectrum disorder (ASD) will be studied. The purpose of the study is to bring not only attention to the possible presence of violent ideation and to address it clinically rather than legally, cognizant of the underlying vulnerabilities of our patients, but also aware of the social environment in which, with many obstacles, they live.

ASDs, including AS, are disorders of social cognition, emotional regulation, and executive function. They are typically characterized by abnormalities evident in the areas of communication, socialization, and by a number of diverse repetitive and stereotyped behaviors and interests. Also present are cognitive and behavioral rigidity (Lauritsen, 2013). Signs and symptoms vary depending on where the affected person falls on the spectrum of severity. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) diagnostic criteria for ASD are dimensional in nature, perhaps more so than in the previous edition in which they were based on a somewhat artificial classification (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR]; APA, 2000), and reflect the clinical variability typical of spectrum conditions. Deficits in social communication may be qualitative and/or quantitative. Quality refers not only to the characteristics of socialization, for instance, the clumsiness in interpersonal skills, but also to the unusual prosody sometimes evident in speech. Quantity indicates the amount of interpersonal exchange. In the case, for example, of social reciprocity, one may see problems in initiating and maintaining an interpersonal interaction or a total lack in response to other’s attempts to engage in conversation. Most notably, particularly in higher functioning individuals, is a general social “immaturity” with difficulties in understanding turn taking, respect of others’ personal space, and so on. Repetitive behaviors and interests may take the form of seemingly purposeless motor movements, in a person on the lower functional end of the spectrum (Militerni, Bravaccio, Falco, Fico, & Palermo, 2002) or perseverative interests in restricted topics, in someone in the higher functioning range (Woodbury-Smith & Volkmar, 2009). The criteria for diagnosis, but also the complexity of the diagnosis itself, are best exemplified by the number of assessment tools available to the clinician, not reflected in classificatory systems such as ICD (International Classification of Diseases) or DSM. The current edition of the DSM-5 lists, in fact, criteria which are indeed only relatively descriptive. This is, possibly one of its strong points, as in the recent past it seemed to be rather “simple” to make a diagnosis of autism, applying too easily over-inclusive diagnostic criteria in the absence of thorough longitudinal and developmental histories, allowing for a likely inflation of recent prevalence estimates, as well as facile and stigmatizing associations (Palermo & Bogaerts, 2014).

Several studies have examined the association between violent crime and AS. AS can be described as a social-emotional and social-cognitive disorder. It is now blended within the ASD DSM-5 dimensional framework (Woodbury-Smith & Volkmar, 2009). While recent nosographic changes have removed it from DSM-5 as a separate category, the condition does exist in itself and has been described since Hans Asperger’s very early cases (Frith, 2004). It affects, as other ASDs, males more often than females with a 4:1 ratio (Rubenstein, Wiggins, & Lee, 2015). The main social difficulties experienced by individuals with AS are secondary primarily to problems in interpersonal pragmatics and idiosyncratic or extreme, at times quasi-obsessive interests, often not shared by peers or shared with considerably lesser degrees of absorption, or without the commonly seen single-mindedness of persons with AS (Soderstrom, Rastam, & Gillberg, 2002). Language development is normal as it pertains to milestones, at times being precociously attained. However, the pragmatics or even the articulation of language may differ from that of typically developing peers, with regard to melody and prosody (Simms & Jin, 2015). Also, individuals are often, as are persons with ASD in general, clumsy and may, in addition to the social, emotional, and behavior difficulties, have abnormalities or idiosyncrasies in sensory processing affecting all sensory modalities (Suarez, 2012). AS is a lifetime condition and can vary in phenomenology over time. It may be complicated by a variety of psychiatric comorbidities, the phenomenology of which may also differ at different ages (Mazzone, Ruta, & Reale, 2012).

AS, Criminal Behavior, and High Functioning Autism (HFA)

AS has received much attention in the forensic literature because of an alleged link to criminal behavior (Haskins & Silva, 2006). In fact, there is a sizable literature linking ASD, including AS, to deviance, crime, and offending, three very diverse terms that unfortunately are often hastily and erroneously used interchangeably (Ghaziuddin, 2013; Lerner, Haque, Northrup, Lawer, & Bursztajn, 2012). It is likely, in fact, that ASDs, as other developmental disorders, rather than criminal behavior are more a risk factor for victimization (Palermo, 2004).

While undoubtedly offending behaviors have been reported in AS, the majority have been violent and threatening behaviors commonly reactive in nature and secondary to social exclusion and anger over bullying or sexual rejection (Allen et al., 2008; Bogaerts, Vanheule, & DeClercq, 2005). Furthermore, as in other clinical situations, the risk for violence in ASDs increases with comorbid psychopathology and substance abuse (Långström, Grann, Ruchkin, Sjöstedt, & Fazel, 2009). Nonetheless, it seems probable that AS, in particular, may be linked to specific criminal behaviors, such as arson or sexual offenses (Newman & Ghaziuddin, 2008). A number of predisposing factors that are probably linked to the core features of the condition do exist. Most likely, the features which render persons with AS more vulnerable to trouble in the social arena, and hence to trouble with the law, are the core aspects of the condition: the problems in social reciprocation, manifested also as extreme egocentricity, and the difficulties with nonverbal communication, both on the decoding and on the displaying end (Allen et al., 2008).

When it comes to association studies, one confounding factor that has been compounded by the removal of the diagnostic category AS from the recent DSM-5 (APA, 2013) may be the lumping together of individuals with a range of problems that are clearly not just dimensional in nature but more likely represent different categories altogether. So-called High Functioning Autism (HFA) differs on a number of substantial aspects from the often eccentric, odd, egocentric, and, at times, highly intelligent person with A (Chiang, Tsai, Cheung, Brown, & Li, 2014). The original differentiation between HFA and so-called Low Functioning Autism (LFA) was based on IQ. An IQ greater than 70 was considered sufficient to place an individual with autism in the “higher functioning” group. Likewise, it was felt that AS differed from HFA, or even classical autism tout court, on the basis of a lack of language delay. In spite of the distinctions shown in numerous clinical studies, all three categories were classified under the umbrella of autism. Furthermore, recent evidence seems to support the “lumping” together of the various entities based on cognitive performance similarities between AS and HFA (Wilson et al., 2014). However, as the mean normal IQ is of 100, the term High Functioning on the basis solely of an IQ greater than 70 may be misleading at best.

Nonetheless, if, on one hand, AS has been incorporated in the general ASD category, also on the basis of genetic, neuroanatomical, and neuropsychological commonalities across the spectrum of autistic conditions, on the other, the qualitative nature of behaviors, whether or not they are offending, differs substantially between a person with HFA and one with clinical characteristics compatible with AS. It is actually possible that using current diagnostic criteria, several of Asperger’s original cases would not even meet the requirement for a diagnosis. AS individuals, while clearly being clinically and socially impaired, have higher verbal IQs compared with HFA individuals (Noterdaeme, Wriedt, & Höhne, 2010; Saulnier & Klin, 2007). This is not unimportant as language is crucial in social interaction. Furthermore, given the substantial difference between an IQ of 70 and one of even 90, the fact that AS is most often associated with higher IQs is another confounding element (Chiang et al., 2014). The lumping together is not likely to help from the forensic and criminological perspective, and it indeed will make causal correlations much more complex.

Notwithstanding the fact that most studies in the published literature certainly do not support a significant association between violence and ASDs (Allen et al., 2008; Mouridsen et al., 2008), undoubtedly individuals falling on the spectrum do enter into contact with the justice system.

In many countries, autism spectrum conditions have been invoked to diminish responsibility or as exculpatory evidence in criminal cases ranging from manslaughter to arson and sexual misconduct (Draaisma, 2009; Freckelton, 2011; Katz & Zemishlany, 2006). Being able to predict violence may be, for the psychiatrist and for the forensic psychiatrist in particular, akin to possessing the philosopher’s stone for the alchemist. To foresee violence in anyone, including psychiatric patients, one must rely on knowledge and information. There are some elements that have been demonstrated to be valid in predicting imminent risk of violence, including presence or absence of threats to identifiable potential victims, access to the victim, and the availability of a weapon (Shaw, 2000). Nonetheless it remains difficult at best. Most certainly, the first step in assessing dangerousness in a known patient is to ask about violent thoughts.

Violent Thoughts, Fantasies, and Offending

Violent thoughts are also referred to as violent ideation. The 1989 Webster dictionary defines ideation as “the process of forming ideas or images.” One of its synonyms is fantasy, defined as “the act of imagining something.” Without entering into the psychodynamic ramifications of the concept of violent fantasy, the cathartic preventive effect on violence of which has actually been seriously questioned, if not clearly disproven (Buschman et al., 2010; Bushman, 2002), there is evidence that many recent severely violent acts were preceded by a rich fantasy life which included themes of revenge and retaliation (Buschman et al., 2010; Mullen, 2004). Fantasies, and in particular violent fantasies, not uncommonly precede sexual offending (Carabellese, Maniglio, Greco, & Catanesi, 2011), although likely, in this case, with a phenomenology closer to a mental rehearsal. In the case of the violence connected to revenge and retribution, it may, perhaps, be envisioned as a form of angry rumination. Nonetheless, the link between aggressive fantasy and later aggressive behavior has been demonstrated in several studies (Guerra, Huesmann, & Spindler, 2003), especially when coping strategies such as suppression, distraction, and cognitive reappraisal to control aggressive intrusive thoughts are absent (Nagtegaal, Rassin, & Muris, 2006). In the United States, following the Tarasoff decision ¹ (Felthous, 2006), violent fantasy, ideation, and thoughts are sufficient cause for actions, which may lead to coercive treatment of a patient. This is not the case in most European countries, including Italy, where, save for cases of sexual violence, including sexual acts with a minor, breeching confidentiality, is a crime for (Italian Penal Code, Article 622) contemplated under the crimes against personal freedom. Likewise, it is a behavior sanctioned by the code of ethics of Italian medical societies (Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri, 2014). Nonetheless, clinicians are commonly asked to assess the possibility of violence and prognosticate relatively to it becoming a probability. Or they may encounter patients who endorse violent themes, not uncommonly following the request of family members (not the justice system), with whom most Italian patients with AS live. Clinicians hence find themselves in a situation of needing to balance patient confidentiality with a need to protect, irrespective of existing legislation. Furthermore, in the case of high functioning developmental disorders, and in situations of quasi-normality, it becomes even more complex, as there is a need to mediate between a patient’s only relative autonomy and the need to foster the same (Newman & Ghaziuddin, 2008; Palermo, 2004).

The Present Study

The purpose of this study is to explore the potential for dangerousness of subjective fantasy. This is an instrumental qualitative study (Stake, 1994), which hopes to provide insights into the phenomenon of violent ideation in a population at risk for social isolation but also misunderstanding. The goal is not to dispute the association, or lack of, between ASD and offending, an issue which has been addressed with evidence to the contrary (Ghaziuddin, 2013), but rather to try and tackle a technically and legally complex matter such as prediction of violence in a low probability situation, particularly in a country where duty to warn legislation does not exist.

We report a small series of five young Italian men diagnosed with AS who endorsed recurrent, extremely violent fantasies of murder and torture of women. We use Gellerman and Suddath’s (2005) definition of Violent Fantasy, namely, a thought in which the individual imagines physically harming another person in some way, such as by murder, sexual assault, or inappropriate sexual activity. The young men were brought to clinical attention because of irritability in the context of what parents felt was excessive computer gaming.

Below we will focus in more detail on what are some common variables shared by all five patients which we believe to be pathoplastic with regard to the violent ideation.

Instruments

Given the high prevalence of affective comorbidities in Asperger patients who enter into contact with the law (Newman & Ghaziuddin, 2008; Palermo, 2004), subjects were screened for depression (CES-D, Center for Epidemiologic Studies Depression Scale). The CES-D is a brief, 20-item self-report scale that was developed to measure depressive symptomatology (Radloff, 1977). Respondents are required to indicate the frequency with which they have experienced depressive symptoms over the past week on a 4-point scale, ranging from 0 = rarely to 3 = most or all of the time. It is reported to exhibit high internal consistency, adequate test–retest reliability, and good construct and discriminant validity (Radloff, 1977). In addition, all patients filled out a self-report Aggression Questionnaire (AQ; Buss & Perry, 1992). The AQ is a widely used and well-validated self-report instrument for the measurement of aggressive tendencies (Buss & Perry, 1992). The AQ describes four domains of aggression: physical, verbal, hostility, and anger. Finally, patients were asked for information regarding computer and Internet use with specific regard to aggressive gaming and pornography. They were asked to describe the type of game, the weekly amount of time spent on it (this was corroborated by parents at least as far as waking hours were concerned), and the type of pornography they mostly consumed, if they did (this was not shared with the parents). Finally, they were asked detailed information regarding the violent themes of their fantasies. Parents were involved as collateral informants and in light of their necessary role in an ongoing connection with the clinician, despite the patients’ age (Redley et al., 2013).

Patient Characteristics

As can be seen in Table 1, all five patients had previous diagnoses of AS. Three of the five were in high school and two were attending university. All patients scored in the normal range on the CES-D, an epidemiologically validated tool for the screening of depression (Fava, 1983), suggesting the lack of an ongoing episode of a depressive disorder. All scored significantly higher than the average on the AQ (mean score for AQ is 104 in our small series, while the norm average for males was 77 in the original study). While some of the answers could be related to the relative disinhibition of persons with AS (e.g., “ When people annoy me, I may tell them what I think of them”), the social clumsiness is commonly out of the person’s awareness, who, in fact, needs to be reminded of social behavior rules by parents, caregivers, or treating personnel. Interestingly, the high score did not correspond, according to parental knowledge and perception, to overt behaviors, except in one case. But it was indeed the patients’ self-perception of their level of aggression as well as their capacity for it. None of the patients had a circle of friends and none participated in group activities on a regular basis. All described themselves as heterosexual, but none had ever been involved in a romantic relationship, having been repeatedly romantically rejected. All were avid First Person Shooter (FPS) game players. The average time spent was 29 hr per week, thus representing about 4 hr per day. All patients were daily consumers of online pornography with a predilection for violent pornography involving women as victims (defined as aggressive sexual images with evidence of probable physical suffering and bodily harm as well as obvious humiliation and defiling through actions or words). The viewing of pornography included but was not limited to masturbatory activity. One patient had attended a sex awareness group for adolescents with AS.

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Table 1.

Patient Characteristics.

Case	AA	AD	Edu	Dep	BP	FPS	VP
1	18	8	13	No	85	25-30	Yes
2	21	13	16	No	95	30	Yes
3	20	13	14	No	115	20-30	Yes
4	18	10	13	No	120	30-35	Yes
5	19	11	13	No	105	30	Yes

Note. AA = age at assessment; AD = age at diagnosis; Edu = years of education; Dep = depression by CES-D; BP = Buss and Perry score; FPS = First Person Shooter player hours per week; VP = violent pornography utilizer.

All five patients reported recurrent, intrusive, homicidal ideation, or, as they themselves described them, fantasies. All fantasies revolved around murdering women. Patients were not disturbed by the mental imagery. They all had a very negative view of females in general, whom they claimed to simply hate. All had one or more episodes of romantic rejection. In three patients, murder ideation was associated with torture imagery. No sexual excitement was reported in response to homicidal fantasies. All endorsed a desire to behead women, specifically with a sword or alternatively to kill by stabbing. In four of the patients, the ideation was commonly triggered by what they felt were mocking attitudes of women on the bus, on the street, or in class. They had little externally apparent emotional turmoil when recounting the fantasies. When asked whether they would murder, torture, or behead, if given a chance to do so, they all denied they would.

Discussion

Assessing risk for violence and establishing criteria for imminent danger are a complex matter. It becomes even more tortuous in situations of low probability and low frequency, such as risk associated with mental illness. Heightened awareness of a potential for dangerousness in psychiatric patients is certainly well established given the presence of certain variables, such as psychotic disorders associated with substance abuse, for example (Marzuk, 1996). And this connection, although uncommon, paradoxically represents common “knowledge” even among the public and, more worrisome, the judiciary (Berryessa, 2014). Much of this can be attributed to media reports and a sensationalistic approach to crimes committed by a person with a psychiatric disorder or assumed to have one (Stuart, 2006). This pseudo-awareness furthers stigma surrounding mental disorders. The case of AS is perhaps exemplary of such a state of affairs. People with AS are seen as either geniuses or villains in light of a number of stereotypes (Draaisma, 2009). These are frequently based not on facts but rather on improper media divulgation and on trivialization of some of the more captivating and intriguing signs and symptoms of a disabling condition.

The five patients presented are, as patients with AS are concerned, and not in relation to the quality of the intrusive violent fantasy life, fairly common and representative of this population. They are solitary, isolated, upset, living at home, lacking autonomy, and unable to fend for themselves. And while it is the rule, rather than the exception, in Italy for 20-year-olds to live in the family home and not “go off to college,” for a number of simple social and cultural issues, this is indeed the case of the vast majority of people with AS who achieve full financial and social independence with great difficulty, if at all (Baldwin, Costley, & Warren, 2014).

The patients of this small series have a number of worrisome commonalities. They all endorse extremely violent ideation toward women. They all fantasize of beheading a woman. They all are relatively collected and not agitated when discussing such troubling thoughts. They all are avid users of violent video games and all almost exclusively use violent online pornography both in the context of solitary sexual activity and as a quasi-habit, even when not in search of a sexual outlet. As is common in people with AS, they have been bullied (e.g., Sofronoff, Dark, & Stone, 2011).

Regardless of models of violence causation and issues of predictability, clinicians and families are often left alone in dealing with the possibility of violence. Causation is based on inferences that are mostly probabilistic in nature (Anckarsäter, Radovic, Svennerlind, Höglund, & Radovic, 2009) and resting on epidemiology which commonly and understandably suffers from methodological problems implicit in the issue at hand, where scientific inquiry based on anything but a posteriori observation is simply impossible.

Most literature deals specifically with a posteriori interventions, in the aftermath of violent episodes involving either single homicides, homicide-suicides, or, very rarely, mass killings. The latter, while obviously attracting media and public attention, are not representative of the vast majority of violent offenses committed by mentally ill or mentally disordered individuals (Aitken, Oosthuizen, Emsley, & Seedat, 2008). Yet, also thanks to the media, AS, in particular, has been often associated with disquieting multiple murders. Furthermore, most efforts are directed toward prevention of recidivism, not uncommonly with the consequence of actually increasing lengths of stay in situations of “unpredictability,” as are those typical of the one-time offenses characteristic of violence in the throes of a mental disorder.

Violence assessment, in addition, should consider the degree of action (ideation vs. threat vs. actualization) and planning (reactive vs. planned or even predatory; Ash & Alonso-Katzowitz, 2011). However, while in the context of social settings such as schools, stadiums, or even political unrest, this may follow relatively predictable dynamics, in isolated cases it becomes very complex.

The five young men presented in this study experienced anger, hostility, loneliness, and, by virtue of their clinical problems, rigidity. Similar traits have been described in pseudo-commando solitary mass murderers not affected by an ASD, along with suspiciousness and chronic resentment due to historical antecedents of social rejection, all culminating in fantasies of violent revenge preceding their crimes (Bogaerts, Vanheule, & Desmet, 2006; Mullen, 2004).

Does it make a difference in threat assessment, therefore, if there is no identifiable victim, but rather a category of victims: women? An identifiable victim is at the basis of most violence assessment approaches as well as grounds for coercive interventions in countries allowing them or expecting them of psychiatrists and mental health workers in general. A previous history of violence is a known risk factor for future violence. However, this is not the case in the vast majority of mentally ill or mentally disordered offenders. In fact, many tools are gauged at measuring the risk of violence in such persons, yet with only limited predictive value (Buchanan, 2008). Furthermore, a sizable sample of 50 Italian secure hospital inmates guilty of committing homicide were clinically and demographically quite far from what is thought of the mentally ill offender, and only one murdered a total stranger (Fioritti, Ferriani, Rucci, & Melega, 2006). The study reported that except for isolated levels of hostility and suspiciousness in the Brief Psychiatric Rating Scale (BPRS), their levels of “measured psychopathology” were overall lower than their nonhomicidal clinical counterpart. The ability to prognosticate relatively to violence, and more specifically murder, may therefore be less than ideal. In fact, no model is truly able to predict the majority of violent cases (Haas & Cusson, 2015).

It is noteworthy that homicidal fantasies and thoughts about killing are relatively common, at times even frequent (Kenrick & Sheets, 1993, in Gellerman & Suddath, 2005). However, it is the incessant and recurrent nature of the ideation of our patients which may be more troubling. Furthermore, the lack of an identifiable victim but the intense hostility and anger displayed could indeed render predictability even more problematic.

Certainly, a link between aggressive fantasy and aggressive behavior has been established (Bushman, 2002), and while “fantasy may serve as a preparation for action,” no study of nonincarcerated individuals has adequately addressed the question of whether violent fantasy may predict future dangerous behavior (Gellerman & Suddath, 2005). It has been theorized that aggressive fantasizing may serve as a mental rehearsal, which, over time, transforms fantasy into a normative belief. One study reported that exposure to violence was found to be a variable linked to later development of aggressive behavior (Smith, Fischer, & Watson, 2009).

Can playing a FPS game for an average of almost 30 hr a week (probably underreported by our patients) over a period of several years qualify as being exposed to violence? It is noteworthy and rather disconcerting that just 10 hr of playing an FPS game may induce neuroplastic changes (Wu et al., 2012). Furthermore, while time spent may correlate with the development of hostility (Barlett, Harris, & Baldassaro, 2007), one fMRI (Functional Magnetic Resonance Imaging) case-control study demonstrated differences between players and nonplayers in limbic system activation, and a reduction in brain response to emotionally laden images, suggesting plastic changes in areas of the brain which are crucial in integrating emotion and cognition and hence in the processing of empathic responses (Montag et al., 2012). This is a troubling consequence particularly as it affects the capacity to empathize with strangers (Fraser, Padilla-Walker, Coyne, Nelson, & Stockdale, 2012) and prosocial behaviors (Anderson et al., 2010). This is of concern especially in light of the already lonely existence lived by these persons who have little exposure to social “learning” and of the consequences on an emotional level of chronic loneliness (Bogaerts et al., 2006; Schinka, van Dulmen, Mata, Bossarte, & Swahn, 2013; Surjadi, Bullens, van Horn, & Bogaerts, 2010).

Furthermore, while watching pornography online may be even considered a normative experience (Romito & Beltramini, 2011), the seemingly obligatory use of violent and defiling pornography may be more worrisome. This, along with the other variables of loneliness, hostility and desensitization to violence, even if secondary to virtual exposure, is of great concern (Hald, Malamuth, & Yuen, 2010).

Violence in the context of mental disorder is commonly attributed to firearm use, particularly in relation to the sizable number of mass shootings in the United States (but also in other countries), and the media attention these incidents understandably receive (McGinty, Webster, & Barry, 2013). Access to firearms is not easy in most European countries and most notably in Italy, where a medical certificate is to be presented attesting soundness of mind, when requesting a permit to own or carry a firearm even for hunting or sporting purposes (Italian State Police, 2015). This is a situation that is rather different than that in the United States where the right to bear arms is embodied in its Constitution. Most certainly, the desire to behead or stab may suggest a possible different modus operandi, in case of fantasy actualization and, by the very nature and proximity to their fantasized victims, intense rage, not dissimilar from what is described as “overkill” in the context of uxoricides or of homicides of homosexual men (Bell & Vila, 1996). Interestingly, in a series of juvenile murderers, sexual femicides were all by stabbing and characterized by overkill (Myers, Scott, Burgess, & Burgess, 1995).

The five cases presented exemplify the quandary faced by clinicians in dealing with the potential for violence, particularly in the absence of “duty to warn/protect” legislation. Even more so in light of the absence of evident imminent danger posed by the chronic nature of the symptoms.

Regardless of the “potential” for violence, and the suggestion of dangerousness relative to the patients presented, preventive approaches can, and in the present cases should, only be clinical. Italy’s relationship with psychiatric commitment and institutionalization is a complex one. Since deinstitutionalization in 1978, involuntary commitment to a psychiatric hospital is no simple matter, involving physicians, the mayor, and the police. Understandably, and in a way not dissimilar from other countries, it requires, among other criteria, imminent danger (Di Fiorino, Saviotti, & Gemignani, 2004). The implication of “imminence,” suggesting the impending quality of a situation, is crucial. Obviously, the chronic nature of symptoms, in theory, argues against imminence. Furthermore, the concept of social dangerousness, often invoked to apply restrictive measures, applies essentially only to individuals, mentally ill or not, who have already offended, and are considered at risk for recidivism. The notion of dangerousness, therefore, applies only ex post. The reasons for this may be multifactorial, not least of which are civil liberty issues and the dangerousness implicit in preventively hospitalizing “ideas.” The leap to preventively commit to an institution because of dissent, a leap backward in time as it relates to Italian history (Palermo, 2015), is not that uncommon even today in less democratic countries.

Importance for Clinical Practice

The role of psychiatry and psychology is to treat and relieve mental health problems. Involuntary commitment to prevent crime does not necessarily do either. In addition, to date it is far from evidence based, and its use is not universally agreed upon, even among professionals. Nonetheless, safety and caution when predicting dangerousness are commonly preferred by psychiatrists and psychologists (Arrigo, 1992).

Clinicians, psychiatrists and psychologists, must look beyond the questionable link between AS and deviance, given the complexity of any casuality-correlation relationship. More importantly in is necessary to explore underlying factors that in the context of autism spectrum conditions, perhaps more so than in normality, may contribute to criminal behavior. Notwithstanding the impossibility of accurately preventing or prognosticating violence, or of changing neurobiology, efforts must be directed, as a matter of professional and social responsibility, at minimizing or eliminating those variables that may be pathoplastic, such as extremely violent video games, or free and indiscriminate access to aggressive and demeaning violent pornography, both of which have been clearly demonstrated to be linked to aggression. Not doing so is no different than doing nothing.