AAAP Today

Asperger’s or not? Notes from a clinical exchange

By Lirio Sobrevinas-Covey, Ph.D.

Asperger’s syndrome (AS) is a condition that is on the high functioning end of the Autism Spectrum. AS is characterized by impairments in social interaction and repetitive and persistent behaviors, but not by deficits in intellectual ability or normal language development. In some cases it is recognized or diagnosed only during adulthood. Persons with Asperger’s may be regarded diagnostically as High Functioning Autisms.

Below are notes from an exchange in response to an inquiry emailed by a reader of our AAAP Internet materials. The inquiry has many interesting and important aspects relevant to understanding Asperger’s syndrome, possibly typical of the quandary experienced by some persons with Asperger’s-like symptoms. The maker of the inquiry gave me permission to share elements of our exchange. Her name is withheld.

The Inquiry:

“Truth is, I cannot point a finger on what made me suspect that I have Asperger’s. All I know is that I can’t connect with people in ways that I should.

For example, I am unable to tell a joke from a serious request. I take everything by heart, and then they’ll laugh at me and say "Of course we’re just kidding!" like it’s a no-brainer. I also unknowingly turn people off and break unwritten rules on many, many occasions. I’m pretty naive at times, and pretty offending at times. And the crazy thing is, I am not even aware when I look naive and when I look offending. It feels like everybody’s got their copy of social rules and I haven’t gotten mine.

I am learning how to act better in social situations though- smile, avoid bringing up ‘boring’ topics like design and macroeconomics, and try to respond in two or more sentences. That said, I often have trouble with the latter. The most common topics in social situations are TV shows and employment, and neither are in my large pool of thoughts and interests.

From all these small social defects sprung a lot of personal problems. And from all these personal problems sprung flares of anxieties. Or maybe not– I’m a constant worrywart since time immemorial and panic attacks just got worse after I’m 21. Whichever, the most difficult part is dealing without support- family and friends think that I’m just a hypersensitive, odd, and overreacting kid, all while I’m dragging from one anxiety bout after another. It gets me frustrated that nobody ever understood. I guess this problem has got to be named.

My response:

From your account, it looks to me that you have traits that could comprise Asperger’s syndrome. Whether you meet the diagnosis fully is not clear, however.

Do you also find yourself hampered by the need to do certain things over and over, and have difficulty changing routines? In addition to social interaction issues, problems with repetitive and restricted behaviors constitute one of the two basic criteria of Autism Spectrum Disorders (ASD).

About the anxiety issues, it is possible that those symptoms are occurring independently of whether you are diagnosable with Autism. If the anxiety symptoms are impairing your general functioning, seeking treatment for the anxiety would be beneficial. There is considerable knowledge regarding how to manage and treat anxiety.

Inquirer’s response:

“That’s odd. I don’t usually think hard about these things, but now you’ve mentioned routines, I suddenly got conscious about these:

-I only play one song, looped for the whole session in my Ipod. I do it that way because I don’t like it when one song changes to another.

-I cannot go to bed without my notebook beside me. I never used a notebook after laying down to sleep, but it just feels right. When I sleep over to another house (which I usually don’t unless I have no choice), I still look for a notebook to put beside or under my pillow.

-I have this habit of prancing when I’m walking. Prance when I just got out the door, prance when I’m in a wide pavement. I guess it steadies my nerves.

-Oh, and when I’m thinking hard, I walk fast, counterclockwise and then clockwise in an oblong pattern. It’s very comfortable, but I don’t do it anymore when somebody’s around. Already learned my lesson when I was a kid.

There could probably more I didn’t notice.

My Comment:

The behaviors the inquirer describes give the clinical impression of Asperger’s but more extensive assessment is required to make a confirmed diagnosis. There are no specific treatments that would “cure” Asperger’s syndrome. Behavioral treatments are the current approach for addressing the impairing social skills and obsessive-type symptoms.

Can oxytocin, the “love hormone” treat a core symptom of Autism?

By Lirio Sobrevinas-Covey, Ph.D.

Social skills deficits – in communication, ability to interact with others, and lack of empathy, mark one of the two defining criteria of Autism Spectrum Disorders (ASD). (The other is repetitive and restrictive behaviors).

This background underlies the measured excitement among autism researchers in the possibility that oxytocin, found to play a positive role in the neuroanatomy of bonding and intimacy relationships, might be effective in ameliorating one of the two core symptoms of ASD. No drug has been found to treat the debilitating social skills deficit of persons with ASD.

In animal and human studies, oxytocin, a natural peptide found in the hypothalamus, has demonstrated promise for enhancing response to social stimuli and improving social interactions and communication. Oxytocin has been dubbed – “the love hormone”, “the cuddle hormone”, or “the bonding hormone”.

In human studies, oxytocin was administered intra-nasally. Observed outcomes included improvements in social cognition, empathy, and reciprocity. Adverse effects were not reported.

Not all studies yielded positive outcomes, however. These early studies also suggested that intermittent rather than chronic oxytocin treatment is prefferrable.

It remains unclear if oxytocin treatment effects are moderated by differences in dosage, duration of use, the patient’s age, and environmental influences. Combining oxycotin with behavioral treatments has been considered as a possibly desirable approach.

Oxytocin and Asperger’s Disorder? In my view, results of research studies on the "love hormone" offer special promise for persons with Asperger’s Disorder (AD), one of the conditions that fall under the rubric of Pervasive Development Mental Disorder, along with Autism, in the DSM-IV. Children and adults with AD have characteristics that meet the core symptoms of ASD, notably, impairment in effective social interaction and communication; but, differently from the other ASD subgroups, they are not typically impaired in cognitive functioning, language ability, or academic skills. Thus, Asperger’s adults are often characterized by achievement in the educational area; however, the social skills deficits handicap them in gaining employment commensurate to their academic training and occupational skills. The job interview, for instance, where social impact on the potential employer is important, can function as a formidable barrier.

Investigations into the potential therapeutic application of oxytocin are still in early stages. Available data are insufficient for physicians to prescribe oxytocin. Still, in the face of a lack of treatment for the core symptoms of ASD, oxytocin is an exciting potential treatment.

Reference:

Larry J. Young an Catherine E. Barrett. Can oxytocin treat autism? Science. 2015 February 20; 347(6224): 825–826.

Diagnosis of Asperger’s Disorder

By Lirio Sobrevinas Covey, Ph.D.

In DSM-IV (American Psychiatric Association, 1994), Asperger’s Disorder was one of four syndromes classed under the overall rubric of Pervasive Development Disorder (the others were Autistic Disorder, Rett’s Disorder, and Childhood Disintegrative Disorder).

In the recently published DSM-V (2013), autism symptoms are classed into two groups – social/communication group and the restrictive and repetitive group, all under a single overall classification labelled as Autism Spectrum Disorders (ASD). This new classification is intended to reflect the range in severity of autism symptoms, rather than to reflect a qualitative difference. Persons previously classified as AD in DSM-IV are likely to still fall under the rubric of ASD and regarded as high functioning autisms.

Asperger’s Disorder is characterized by abnormal social functioning and repetitive behaviors but not with reduced cognitive functioning, intelligence, or language ability. There is ongoing controversy regarding the validity of AD as separate from autism, in particular, “high functioning autism’’. Notably, in ICD-10 (the diagnostic classification associated with the World Health Organization), Asperger’s Disorder is classified as a subgroup of ASD.

Questionnaires specific for assessing Asperger’s Disorder have been developed. More work is required according to a review of five third-party AD rating scales that described the existing measurements as – promising but demonstrating significant weaknesses (Campbell JM, J Autism and Developmental Disorders, Volume 35, Feb, 2005). One of the five, the Krug Asperger’s Disorder Index (KADI) is considered the most sound and reliable. These instruments, although not defining of Asperger’s Disorder by themselves, can provide the diagnostic team with basic information for pursuing a more complete and intensive inquiry. Arriving at a correct diagnosis is so imperative for helping the ASD-affected individual receive appropriate clinical assistance and reach a positive life outcome.

Following are excerpts on diagnosing Asperger’s Disorder from a recent review article by FL Tarazi et colleagues from the Department of Psychiatry and Neuroscience Program, Harvard Medical School, published in Expert Reviews, 2015.

“The diagnosis of Asperger’s syndrome is complicated by the lack of a standardized diagnostic test. Asperger’s, and other ASD, are usually diagnosed as part of a two-stage process.

The first stage begins with developmental screening during physical checkups with a family doctor or physician. Interview of the child should include open-ended questions, awkward pauses, inquiring about special interests, relationship with friends and family, insight into other people’s intentions and beliefs and understanding of figurative language.

The interview should be conducted without the support of the parent. Direct observation, ideally starting in the clinic’s reception area, is essential to assess the child’s social interactions.

If any AD or ASD related symptoms are noted, the child is referred for comprehensive evaluation by a team of specialists that typically includes a psychologist, neurologist, psychiatrist, speech therapist, and additional professionals who have expertise in diagnosing children with AS and other ASD.”