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Adults with Asperger disorder misdiagnosed as schizophrenic.

Perlman, Lawrence. Maimonides Medical Ctr, Developmental Ctr, New York, NY, US

Professional Psychology: Research and Practice, Vol 31(2), Apr, 2000. pp. 221- 225.

Prof Psychol Res Pr

US : American Psychological Association

Professional Psychology

0735-7028 (Print) 1939-1323 (Electronic)

English

misdiagnosis of Asperger disorder as schizophrenia, adults

Psychologists have a prominent role in the diagnosis and treatment of developmental disorders. With the inclusion of Asperger disorder in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; American Psychiatric Association, 1994), there is an explosion of interest in mild autistic disorders. This syndrome, which is characterized by problems in interpersonal relatedness, empathic communication, and imagination, has only recently become known in this country. Practicing psychologists may encounter adult psychiatric patients who have erroneously been diagnosed as having chronic schizophrenia when a careful examination and history would reveal that they have lifelong deficit conditions within the autistic spectrum. Opportunities are available for psychologists to contribute to the proper diagnosis and treatment of these individuals. Some case illustrations and suggestions for the role of psychologists in providing more appropriate treatment of these individuals are provided. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Journal Article

*Autism Spectrum Disorders; *Misdiagnosis; *Schizophrenia

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Developmental Disorders & Autism (3250)

Human Male Female

Adulthood (18 yrs & older) Middle Age (40-64 yrs)

Psychiatric Grand Rounds, Oct, 1993, Brooklyn, NY, US

Print

Journal; Peer Reviewed Journal

Accepted: Nov 3, 1999; Revised: Oct 29, 1999; First Submitted: May 4, 1999

20060710

20151207

American Psychological Association. 2000

http://dx.doi.org/10.1037/0735-7028.31.2.221

pro-31-2-221

2000-15236-014

40

Adults With Asperger Disorder Misdiagnosed as Schizophrenic

By: Lawrence Perlman

Listen American Accent

Maimonides Medical Center; Biographical Information for Authors: Lawrence Perlman received his PhD in clinical psychology from New York University (NYU) in 1972. He is coordinator of behavior management services at the Developmental Center of Maimonides Medical Center, adjunct associate professor in the Department of Applied Psychology at NYU, and founding director of the Child/Adolescent Psychotherapy Training Program at the Brooklyn Institute of Psychotherapy and Psychoanalysis. His research interests include treatment of autistic spectrum disorders, behavior therapy of severe mental disorders, and solution focused brief psychotherapy.

Acknowledgement: An earlier version of this article was presented at the Psychiatric Grand Rounds at Maimonides Medical Center, Brooklyn, New York, on October 11, 1993.

Many psychologists have encountered patients diagnosed with chronic undifferentiated schizophrenia who do not properly fit the criteria for this disorder. Working in a day program for chronic psychiatric patients, I met several such individuals. They had the appearance of people with the negative symptoms of schizophrenia, for example, social withdrawal, apathy, lack of ambition, and communication difficulties. Yet their way of relating was curiously unlike that of the other schizophrenic patients. Their histories revealed a lifelong pattern of relational problems, without psychotic episodes or acute exacerbations. Furthermore, several of them did not take neuroleptic medications.

My discovery of the European literature on Asperger’s syndrome provided the key to rediagnosing these puzzling cases. This condition is characterized by early onset (in infancy or early childhood), severe deficits in social relatedness, and an absence of the positive symptoms of schizophrenia. The following discussion is intended to heighten the awareness of practicing psychologists to these diagnostic issues and to provide a handy list of criteria and case examples to assist in this task.

This disorder was first identified in 1944 by Hans Asperger (1991), an Austrian psychiatrist and educator, at virtually the same time that another Viennese trained psychiatrist, Leo Kanner (1943), published his description of early infantile autism in the United States. Asperger’s work was largely neglected until Wing (1981) published a review of the syndrome based on her sample of 34 cases. Although there continues to be some controversy about the use of the label to designate a distinct disorder, it is now generally recognized that Asperger’s syndrome is a form of mild autism (Bowman, 1988; Cox, 1991; Gillberg, 1989; Green, 1990; Kerbeshian, Burd, & Fisher, 1990; Szatmari, Bremner, & Nagy, 1989; Szatmari, Tuff, Finlayson, & Bartolucci, 1990). Thus, it defines the opposite end of the continuum of autistic disorders from Kanner’s syndrome (Wing,

1988). Persons with Asperger’s syndrome manifest the social difficulties and some of the other symptoms associated with severe autism but do not exhibit the pronounced language problems. They also tend to be higher functioning and more intellectually competent.

Asperger disorder only recently found its place in the official taxonomy of American psychiatry. It is now included in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), receiving the same code as Pervasive Developmental Disorder, Not Otherwise Specified. However, psychologists who are not well versed in developmental disabilities may not consider giving adults the diagnosis of an autistic disorder. Thus, individuals who were not diagnosed with pervasive developmental disorders in childhood may subsequently be misdiagnosed as chronic, undifferentiated schizophrenics.

To compound the problem, many patients who were diagnosed as children received the label of childhood schizophrenia, a term that erroneously suggested a continuity between the childhood deficit disorders and later onset deteriorative conditions (i.e., schizophrenia). The term childhood schizophrenia is no longer used in the way that it was 25 years ago, having largely been supplanted by pervasive development disorder. (However, there is a rare child onset variety of schizophrenia that usually appears in late childhood.)

Adults With Asperger’s Syndrome

No single set of clinical criteria exists for Asperger’s syndrome in adults. Wing has identified the following triad of social deficits characteristic of mildly autistic persons (Wing, 1981; Wing & Gould, 1979):

Severe Impairment of Reciprocal Social Interaction “The problem arises from a lack of ability to understand and use the rules governing social behavior” (Wing, 1981, p. 116). Individuals with Asperger’s syndrome may like to associate and may like to be with and talk with people but are unable to maintain more than a superficial level of relating. They are rarely able to respond empathically to others. They are generally unaware of the strangeness of their social presentation (i.e., they lack self-consciousness in the sense of being able to see themselves from another’s point of view). “Some are overly sensitive to criticism and suspicious of other people” (Wing, 1981, p. 116), which can lead to a misdiagnosis of paranoid ideation.

Abnormalities in the Use and Comprehension of Language, Both Verbal and Nonverbal Persons with mild Asperger’s syndrome have language that is frequently described as being

stilted, gauche, or pedantic. Their ability to make small talk is practically nonexistent. If the conversation shifts beyond a favorite area of interest, they are likely to withdraw or to perseveratively return to the initial topic. They may use words in odd ways and have equally idiosyncratic postural or gestural accompaniments to their speech. They seem to lack a sense of humor in that they do not understand subtle jokes.

There may be little facial expression except with strong emotion such as anger and misery. Vocal intonation tends to be monotonous and droning, or exaggerated. Gestures are limited, or else large and clumsy and inappropriate for the accompanying speech … Comprehension of other people’s expressions and gestures is poor and [they] may misinterpret or ignore such non-verbal signs. (Wing, 1981, p. 116)

The Absence or Impairment of True, Flexible, Imaginative Activities, With the Substitution of a Narrow Range of Repetitive, Stereotyped Pursuits People with Asperger’s syndrome are often described as having special skills and talents or of fanatically pursuing some narrowly defined interest. “They have excellent rote memories and become intensely interested in one or two subjects … to the exclusion of all else. They absorb every available fact concerning their chosen field and talk about it at length, whether or not the listener is interested, but have little grasp of the meaning of the facts they learn” (Wing, 1981, p. 117).

Szatmari and his colleagues (1989) expanded on these categories to generate five clinical criteria: solitariness, impaired social interaction, impaired nonverbal communication, odd patterns of speech, and an interest in repetitive activities. Gaze aversion and poor eye contact have been commonly noted. However, some autistic individuals make good eye contact but earnestly stare into other people’s faces, as if trying to decipher the meaning of what is being communicated.

Although Asperger and some others (Tantam, 1988, 1991; Wing, 1981) include physical clumsiness as a criterion for the syndrome, it is not a defining characteristic. Poor coordination or problems with fine motor control may be, but are not necessarily, present. Sensory abnormalities, such as oversensitivity to sounds and tactile defensiveness, have also been reported (Grandin, 1995).

Diagnostic Criteria

I abstracted a list of diagnostic criteria from the work of various experts (e.g., Frith, 1991; Szatmari et al., 1989; Tantam, 1991; Wing, 1981), which can be used as a guide by the practicing psychologist.

The core characteristics of Asperger’s disorder are as follows:

1. Social isolation or impaired social interaction

2. Egocentricity and lack of empathy

3. Socially inappropriate behavior

4. Idiosyncratic speech and peculiar use of language

5. Odd thinking, abnormal sense of humor

6. Rituals and repetitive activities

7. Overdeveloped, circumscribed interests

The secondary characteristics of Asperger disorder (i.e., those that are not always present) are as follows:

1. Special abilities, “splinter skills”

2. Morbid preoccupations

3. Odd responses to sensory stimuli

4. Postural and gestural peculiarities

5. Motor awkwardness, stereotyped movements

6. Rigidity and resistance to change

7. Behavior problems, negativism, and anger

Case Illustrations

As it is often difficult to make the differential diagnosis of Asperger disorder from other conditions, I have provided two case illustrations.

Case 1: Mike Mike, a 40-year-old man who has been in the day program for 10 years, views the center as a second home. He is a valued member of the community and takes on many responsibilities, such as being chairperson of the daily community meeting. He is usually the first to spot a new face and introduce the person at the meeting.

Mike is quite verbal and outspoken and can be inappropriately loud. He has an extraordinary memory for dates, especially birthdays and astrological signs, and functions as the informal historian of the program. He frequently reminisces about former patients or staff members and

reflects on activities that took place years before. Mike publicly announces birthdays (including the ages of staff members, to their great dismay) and leads the community in singing “Happy Birthday.” He has a particular fascination with the dates of historical events. Many of the other patients view Mike as bright and competent as a result of these special skills.

By his own admission, Mike has no friends, has never had a friend, and has no desire to make friends. Outside of the community meeting, he tends to sit by himself, listen to music, and occasionally talk to himself. He may start a conversation around a favorite topic, such as old rock and roll tunes, but drifts away if the subject is changed. On the rare occasions when he attends a therapy group, Mike participates as long as the conversation is superficial but leaves or falls asleep when emotionally charged topics are introduced.

Mike has an oddly shaped, wide head with a low brow and protruding low-set ears. He is lean and physically fit but has an abnormal appearance, accentuated by his loping, bowlegged gait. When walking down the street with arms askew, grinning, laughing, or talking to himself, he clearly appears deviant.

Mike frequently wears a serious, earnest expression, particularly when discussing one of his favorite subjects. This attitude can easily give way to silliness and grotesque laughter. His speech has certain peculiarities, including exaggerated emphasis and shifting tones. It may take on a sing- song quality when he repetitively intones a favorite phrase.

In spite of the fact that Mike talks and sometimes curses to himself when alone, he does not experience auditory hallucinations. Rather, he appears to be immersed in obsessive preoccupations. There is no evidence of thought disorder or other positive signs of schizophrenia.

Mike manifests various self-abusive behaviors. He bites or picks at his wrist so much that a large, dark callous has developed there over the years. This behavior waxes and wanes in response to his level of anxiety. He rips pieces off of intact garments until they are ruined. He appears to have ritualistic behavior, some of which takes place in the bathroom and may be connected with masturbation, but he is loath to discuss it. At times, he beats his chest, rocks energetically, and makes vulgar remarks about members of his family. Mike enjoys cigar smoking and likes to chew not only his cigars but also the cardboard container.

Although he may express longing for people who have left the program, Mike exhibits little depth of feeling regarding attachments and losses. In general, he has difficulty with intimacy and feels most comfortable when provoking negative reactions from people. For instance, Mike revels in his

“gross” behavior, such as bizarre food combinations, and is fond of using expressions that are vulgar. He seems to get pleasure out of the disapproving reactions he elicits.

For many years, both Mike and his 35-year-old sister, with whom he lives, denied that he had any history of psychiatric treatment. They eventually revealed that he had been removed from the family at 7 years of age and placed in a child psychiatric facility until he was 11.

I was fortunate to obtain the records, which clearly describe a youngster who would now be diagnosed as autistic. He was fearful and sensitive to loud sounds, covering his ears when the phone rang. He was distractible and hyperactive; he rocked, grimaced, and had motor mannerisms. His affect was flat or depressed, and he was apathetic in response to demonstrations of affection by his mother and aunt. Command of language was adequate, but Mike occasionally used the second-person pronoun to describe himself when parroting instructions (e.g., “You must make in the bathroom”—he still speaks to himself in this way). He appeared to be bright, though lacking in knowledge. Mike was diagnosed as having childhood schizophrenia. Small doses of neuroleptics were used during the first half of his stay and none thereafter.

During his hospitalization, Mike was timid and avoided other children. He adhered strongly to routine and was quite disturbed by any deviation from it. He made considerable progress in the hospital school and achieved third- to fourth-grade reading and math competency by the age of 10.

Mike is proud that he managed to graduate from high school, apparently without receiving any special educational assistance. He describes high school as difficult and acknowledges that he was a loner but denies having been teased. Psychological evaluations over the years have revealed IQs in the borderline to average ranges.

Case 2: Pat Pat, a 42-year-old woman, has been a member of the day program for 4 years. She lives in a furnished room with a family in the neighborhood and visits her mother on weekends. Her father, a Holocaust survivor, died in 1981 of heart failure. Her mother is described as a disturbed woman who can be “volatile, angry, and aggressive” toward Pat.

Pat is an obese woman with a pleasing face and a deep voice. She is generally well groomed and dresses like a schoolgirl in a simple blouse, skirt, and bobby socks. She tends to keep to herself and occupy her time with eating, smoking, listening to the radio, and rocking with her eyes half- closed, hands folded, and a worried expression on her face. Pat is frequently observed to be speaking to herself subvocally and sometimes counting with her fingers. (When questioned on one

occasion, she claimed to be counting her burdens!) Pat never attends therapy groups and only comes to community meetings under duress. Her most appropriate interactions with other patients are around cigarettes. She generally seems out of touch but may make some loud exclamation when excited (e.g., by the announcement of a party).

Pat has several obsessive preoccupations around which she relates to other people. These ideas are as follows: her continued possession of a plastic button given to her by a trusted counselor many years ago, her hope to never again see G. (a former residence counselor), and her wish to be “dead in the grave” or “a skeleton in the coffin.” These preoccupations may be restated or combined in various ways. She is also obsessed with a former schoolmate, whom she repeatedly telephones, though they have no current relationship. Pat apparently envies this woman for having a husband and children.

A typical interaction consists of Pat politely requesting permission to ask a question. If the person is reluctant, she might persist and implore him to listen. When granted permission, Pat will slowly and intently intone a query, such as, “Can I be dead in the grave with the tiny, little ivory button beside me?” or “Will I ever, ever, ever, ever have to see G. again for as long as I live?” She repeats the statement or a part of it in a ritualistic way many times (often counting with her fingers) and becomes agitated and tearful if interrupted or if given the wrong answer. At these intense moments, she speaks loudly with both arms raised and palms facing each other. Her agitation can be brought under control by firm limit setting (e.g., a threat to suspend her for the day). She then abruptly ceases crying and apologizes profusely.

Pat is not shy about approaching strangers. She has been observed begging money from passersby on the street and was once seen conducting a conversation from the sidewalk with a group of girls on the second floor of a school, who assured her that she would never have to give up the ivory button. They continued to repeat these statements at her behest, in much the way a crowd responds to a cheerleader.

As a result of her limited social repertoire, Pat remains isolated from the other patients and gives the appearance of being mentally defective. In fact, her IQ is well within the average range, and her memory, particularly for the large number of psychiatric facilities with which she has graced her presence, is extraordinarily clear. In reflecting on an interview she once had with Dr. Arieti, Pat found him nice because he had told her that the American public gave its permission for her to die.

On several occasions, Pat was hospitalized after threatening suicide and walking in front of cars. Most of these incidents were in response to arguments with her mother. When asked if she had

ever heard voices or had delusional ideas, Pat asserted, “No, I’m not so sick.” She clearly has a good understanding of the difference between her condition and schizophrenia.

The history reveals that Pat was referred for psychiatric evaluation prior to her fifth birthday. From that time until the age of 21, she lived in various institutions. She was described as a dainty, pretty girl with delicate features and a solemn, dreamy expression, who seemed to be absorbed in fantasy. Her parents reported inappropriate laughter, manneristic movements, ritualistic behavior, and language peculiarities (e.g., calling people by colors instead of names and monotonous repetition of certain words). She was “different from the start, ate and slept poorly, never wanted to grab anything with her hands as an infant.” Developmental milestones were delayed (e.g., walking and speaking words at 17 months). Self-abusive behavior, such as hair pulling and head banging, were reported by her parents.

Pat developed a fascination with bright, shiny buttons early on and continued to be preoccupied with buttons, elastic bands, nail polish, and jewelry. She seldom related to other children or did so in a negative, aggressive manner (e.g., pinching or pulling hair). She could have temper outbursts in response to changes of any kind or interference with her rituals. At 5 years of age, Pat was examined by Dr. Lauretta Bender and diagnosed as having childhood schizophrenia.

Numerous psychological evaluations have been performed on Pat over the years. At 7 years of age, her Stanford–Binet IQ was only 65, which was viewed as a gross underestimate. Seven administrations of the Wechsler Intelligence Tests between the ages of 12 and 42 yielded IQs in the average range. The variation in verbal IQ scores was rather small, considering the different forms of the test that were used and the span of years involved. Thus, her intellectual functioning has not deteriorated despite many years of institutionalization and social isolation.

Treatment Implications

Individuals with Asperger disorder grow up experiencing the world in a quite different way from the rest of us. They are consistently handicapped in those developmental tasks that require affective attunement and social relatedness. Over the years, they often become aware of their differentness and develop defenses against feelings of social isolation. Thus, secondary withdrawal and depression are commonly seen. These symptoms are well suited to psychological interventions.

In approaching these patients therapeutically, it is important to be aware of their profound handicaps in social relatedness and affective expression. One young, high-functioning autistic man (Sinclair, 1992) reported that he did not know what feelings were until a college companion, who

was especially verbal in describing and labeling her every feeling, “taught” him the meaning of emotional states by her example. One should recognize that such individuals, who may have adequate cognitive capacity, lack basic social skills. It is easy to misinterpret disengagement or obtuse behavior as motivated by hostility or a lack of interest in others. It is particularly easy to make this error with the people Wing described as the “active-but-odd” subgroup (Wing, 1992).

Accurate differential diagnosis is important because the more passive, high-functioning autistic people can easily be overlooked in an institutional setting. They may sit on the sidelines and be largely ignored by other patients and staff, so that their cognitive skills are not recognized. Some of these individuals will respond to structured skills training, which enhances their chances of becoming employed in a sheltered vocational setting or an appropriate job. Szatmari and his colleagues (1989) commented on the treatability of both the learning and social deficits with the use of cognitive behavioral techniques.

Maintenance on neuroleptic medication may be unnecessary for these patients because they do not manifest acute, positive symptoms and do not suffer from a deteriorative condition. It is fruitless to try to remove symptoms that are, in effect, their baseline functioning. On the other hand, they may experience tremendous anxiety in response to stress, which eventuates in their internal fantasy life spilling over into reality. Low doses of antipsychotic medications can be useful at these times. In a similar manner, antidepressants may be helpful in alleviating the distress these individuals experience in reaction to their perceived differentness. However, the primary goal of treatment should be education and rehabilitation—that is, helping these people to understand the nature of their limitations and trying to ameliorate these handicaps whenever possible.

Contrary to popular opinion, many examples have been reported of autistic persons improving their social skills with age and making adequate social and vocational adjustments. Autobiographical and parental accounts (e.g., Dewey, 1991; Sinclair, 1992), as well as case studies over the years, have made it clear that high-functioning autistic people are capable of change and do respond to therapeutic interventions. In fact, they are a most gratifying group of patients with whom to work, if one takes the time to make contact and understand their peculiar ways of relating. Psychologists have skills that are uniquely suited to working with this population.

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Submitted: May 4, 1999 Revised: October 29, 1999 Accepted: November 3, 1999

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Source: Professional Psychology: Research and Practice. Vol. 31. (2), Apr, 2000 pp. 221-225) Accession Number: 2000-15236-014 Digital Object Identifier: 10.1037/0735-7028.31.2.221

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