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Are You a Bit Aspey?

 

When Hans Asperger, a Viennese Paediatrician, published his paper “Autistic Psychopathy’ in childhood”[1] in 1944 it is unlikely that he realised its significance. Because he was working in a part of Europe that was increasingly isolated, his paper failed to reach a wide audience. In fact, it was not until 1991 that the first description of what came to be known as Asperger Syndrome was translated from German into English. However, its significance had already been recognised by Lorna Wing, a leading British researcher into Autism based at the Institute of Psychiatry in London [2]. It was she who first brought the term. Asperger Syndrome to a wider English speaking audience. Now it is widely recognised and increasingly Psychiatrists are being asked to assess, diagnose and treat it. What it is and can it be treated? Not easy questions to answer.

The features Asperger described included social impairment, communication difficulties and rigid, restricted, repetitive, focal interests. Other features include sensory, motor and psychological problems and comorbid psychiatric disorders. However, it is associated with normal intelligence and clumsiness. There are associations with other developmental disorders and Tourette’s. The clumsiness described by Asperger could well have been dyspraxia, one of the several developmental disorders that are associated with Asperger Syndrome.

What does this mean for Clinicians? I find I am increasingly asked to assess patients who, I am told, seem to have “a bit of Asperger’s”. It has become a bit of a game to comment upon people who have problems with communication and may be obsessional as “a bit Aspey”. I find wives and girlfriends (the condition is up to ten times more common in men) [3] complain about their partner’s behaviour and want to know if they have Asperger Syndrome. The current thinking is that social communication and the other features of Autism are on a spectrum and where the line is drawn is arbitrary. A widely held belief is that Bill Gates, CEO of Microsoft, has Asperger Syndrome and it hasn’t done him any harm! Men seem “more autistic” than women. To quote the famous book, is that “Why Men Don’t Listen and Women Can’t Read Maps”?[4] However, this gender difference may be due to underdiagnosis in women. Lack of empathy and social and emotional reciprocity is possibly the most dysfunctional aspect of Asperger Syndrome [5] and can lead to misunderstandings and even problems with the criminal justice system although this association remains unproven even though it is thought that stalking may well be associated with Asperger Syndrome.

What about Treatment? The features of Asperger Syndrome imply a neuropsychological developmental disorder so treatment focuses on co-morbidities such as depression, paranoid thinking and obsessional behaviour and improving functioning. Antipsychotic and antidepressant medication can be helpful although they will have little impact upon the underlying deficits and can be overused. However, as with all disorders of this kind a combination of innate maturation, compensatory learned behaviour and environmental changes will mitigate the condition’s effects and levels of disability. The mainstay of management is behaviour therapy, focusing on specific deficits addressing poor communication skills, obsessive and repetitive routines and physical clumsiness [6].

Diagnosis can be difficult. Social impairments and communication difficulties are, by their nature, subjective. Questionnaires and rating scales have their place but lack sensitivity and reliability. A comprehensive assessment is essential and this should include a good developmental history, obtaining educational records and information from third parties such as parents, friends and acquaintances and teachers. There can be considerable diagnostic confusion with generalised anxiety disorder, schizophrenia, drug and alcohol problems and personality disorder particularly implicated.

As with all diagnoses, as medical knowledge advances, they need to be modified and refined. Although it is likely that Asperger Syndrome will drop out of the textbooks to be replaced by less exotic diagnoses such as Autistic Spectrum Disorder (ASD) and Social Communication Disorder (in plans for DSM-5 in 2013 and ICD-11 in 2014/15), we owe a debt of gratitude to a little known Viennese Paediatrician who has contributed a great deal to our understanding of Autism.

References

1. Asperger H; tr and annot. Frith U (1991) [1944] ”‘Autistic Psychopathy’ in childhood” CUP

2. Wing L (1998). “The History of Asperger Syndrome”. In Schopler et al New York: Plenum

3. Mattila et al (2007). An epidemiological and diagnostic study of Asperger Syndrome according to four sets of diagnostic criteria”. J Am Acad Child Adolesc Psychiatry 46(5) : 636-46

4. Pease and Pease (2001): Orion Press

5. Baskin et al (2006). “Asperger Syndrome Revisited”. Rev Neurol Dis 3(1): 1-7

6. National Institute of Neurological Disorder and Stroke (NINDS) (2007-07-31).
Asperger Syndrome fact sheet

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