Is an adult with Asperger syndrome sitting in your waiting room?
ABSTRACTThe prevalence of Asperger syndrome, a mild form of autism, appears to be rapidly increasing. This developmental disorder affects children and adults and can present challenges to providing medical care. In this update on Asperger syndrome, we offer guidance on how to interact with adult patients with the disorder. We also address proposed diagnostic changes scheduled to take effect in 2013.
KEY POINTS
- Indicators of Asperger syndrome include lack of eye contact, inappropriate comments, odd posture, high anxiety, and intensely focused interests.
- Asperger syndrome is evident in childhood, but it also presents undiagnosed in adulthood.
- Physicians should be aware of patients’ social differences and increased sensitivities in order to improve health care delivery.
- Episodic cognitive behavioral therapy addressing interpersonal skills can dramatically improve quality of life and independence.
- Proposed diagnostic changes scheduled to take effect in 2013 involve including Asperger syndrome as an autism spectrum disorder.
In 1944, Hans Asperger described a subset of children who exhibited “a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest, and clumsy movements.”1
In recent years, Asperger syndrome has become increasingly recognized in the medical community and by the general public. It has been popularized in the media in John Elder Robison’s bestselling book, Look Me in the Eye; with the television character Sheldon Cooper in The Big Bang Theory; and in the 2009 film, Adam, a romantic comedy with the title character accurately portraying a young man with Asperger syndrome.
In this article, we discuss the causes and characteristics of Asperger syndrome, with special focus on adults: how it presents, how to treat it, and how to enhance the delivery of care.
PREVALENCE SEEMS TO BE INCREASING
One in 88 children is diagnosed with an autism spectrum disorder, and the rates of Asperger syndrome and other autism spectrum disorders appear to be increasing.2 Whether this increase is the result of more thorough assessment and identification or of environmental changes is hotly debated.3 The rise began before the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to combine autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified to simplify diagnosis.4 Asperger syndrome affects males three to four times more often than females.5 For most patients, the effects persist throughout life.
BEHAVIORAL IMPAIRMENTS CHARACTERIZE THE SYNDROME
Poor social skills are a hallmark
People with Asperger syndrome struggle with social interaction and face challenges in forming and maintaining relationships. They tend to have less eye contact (often the first indicator), smiling, animated speech, and physical communication such as hand gestures. They tend not to solicit another’s attention to something they themselves find interesting. They often lack social and emotional reciprocity and have difficulty understanding another person’s thoughts or feelings,6 and they have marked difficulty reading social cues. Some adults may appear rigid, selfish, or narrow-minded.
Sometimes behavior is in the normal range but is out of context for a particular situation.7 For example, a preprofessional student with Asperger syndrome might walk into a psychiatric evaluation to assess fitness for duty and take a seat cross-legged on the floor and have a snack. Poor grooming inappropriate for the occasion may also be observed, such as showing up for a formal photo with unkempt hair and in a stained shirt that is half tucked in.
Many adults with autism spectrum disorders are oblivious to their social reputation.8 They are often unaware that their behavior is out of place and only learn that it is not normal when they are told. Others recognize that they have trouble empathizing with or understanding the perspectives of others, but they are at a loss as to how to improve. The syndrome has a tremendous impact on broader aspects of life, such as employment, functional independence, relationships, and social networks.
Other odd behaviors are common
Repetitive behaviors. Many patients with Asperger syndrome have repetitive behaviors, which can manifest as repeating phrases or expressions, attempting to imitate others, and rocking. They tend to follow routines, do not enjoy spontaneity, and are more inflexible and uncomfortable when their planned regimen is altered.
Gait or balance issues may be observed on physical examination.9 Uncoordinated motion and clumsiness are common,10 and some patients may have a bouncy, stilted gait or may walk on their toes, although the latter is more common in children than adults. Many patients have illegible handwriting.11
Fixations. Many Asperger patients have unusual and intense obsessions with subjects like numbers, dates, or aerodynamics of planes. Children with such fascinations are described as “little professors” or as having “geek syndrome.”12 Certain obsessions often continue into adulthood, although one area of interest may fade and another may take over. Such “expertise” in adults may gain them respect, even though they may seem very odd in other ways.
Lack of boundaries. Patients with Asperger syndrome tend to have poor spatial awareness and to be unaware of physical boundaries, standing too close for others’ comfort or unusually far away. Lack of boundaries may extend beyond the physical, as patients may inappropriately help themselves to food or use an item belonging to another without invitation, being unaware that the behavior may be intrusive or inappropriate.
