Cases That Test Your Skills

The angry patient with Asperger’s

Author and Disclosure Information

Mr. A’s social skills are poor, and he has threatened and hit people when angry. What would you recommend for this anxious, depressed, developmentally disabled young man?


 

References

CASE ‘Sad, worried, and angry’

Mr. A, age 24, is referred to our university psychiatric clinic. He reports that he’s sad, worried, angry, and wants to hurt people. He endorses having chronic depressive episodes that last >2 weeks and consist of poor sleep, low energy, anhedonia, poor concentration, and psychomotor retardation.

He is developmentally disabled and has been living in a group home for almost 1 year. In former group homes, Mr. A threatened and assaulted other patients and staff. In 1 incident Mr. A broke a patient’s nose and was incarcerated for 4 days. With the help of a job coach, Mr. A has been working in a department store for 8 months. He was fired from other jobs because he threatened co-workers.

The author’s observations

Problem behaviors in patients with pervasive developmental disorders include aggression and self-injury. These behaviors may improve with behavioral or pharmacologic interventions.1 For example, risperidone is FDA-approved to treat irritability associated with autistic disorder in children and adolescents age 5 to 16 years.2 Violence has been reported in patients with pervasive developmental disorders, and such symptoms can lead to psychiatric referral.1

HISTORY Difficult childhood

Mr. A’s medical history is unremarkable. He has no history of hypomania, mania, psychosis, substance use, tics, seizures, genetic illnesses, head trauma, or physical or sexual abuse. He has never attempted suicide nor been hospitalized for psychiatric illness.

With Mr. A’s permission, his mother is consulted. She says that as a child Mr. A would become extremely interested in various topics—including Pokémon, Magic cards, and video games—and had a strong desire to tell everyone the details of each. However, he rocked back and forth, had few friends, and would bite other children.

Mr. A has no history of language delay but received speech therapy during his childhood to help him “work on eye contact and social skills.” He is estranged from and angry with his father, who has difficulty accepting his son’s developmental disability.

At the time of referral, Mr. A is receiving paroxetine, 30 mg/d, for depression, risperidone, 1.5 mg/d, for aggression, and dextroamphetamine/amphetamine extended-release, 30 mg/d, for hyperactivity/inattention. The efficacy of these medications, which were prescribed by an outside psychiatrist, is unclear.

Table 1

Diagnostic criteria for Asperger’s disorder

A. Qualitative impairment in social interaction, as manifested by ≥2 of the following:
  1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
  2. failure to develop peer relationships appropriate to developmental level
  3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (eg, by a lack of showing, bringing, or pointing out objects of interest to other people)
  4. lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by ≥1 of the following:
  1. encompassing preoccupation with 1 or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
  2. apparently inflexible adherence to specific, nonfunctional routines or rituals
  3. stereotyped and repetitive motor mannerisms (eg, hand or finger flapping or twisting or complex whole-body movements)
  4. persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language (eg, single words used by age 2 years, communicative phrases used by age 3 years).
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.
F. Criteria are not met for another specific pervasive developmental disorder or schizophrenia.
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000
On the Wechsler Adult Intelligence Scale-Revised, Mr. A’s full scale IQ is 77, verbal IQ is 77, and performance IQ is 81, indicating borderline intellectual functioning. He feels frustrated with his job and depressed because he is not in a romantic relationship. Although Mr. A worries about his job and lack of relationships, he does not meet criteria for an anxiety disorder.

Based on Mr. A’s impaired social interaction, repetitive interests and behaviors, and lack of language delay, Mr. A meets criteria for Asperger’s disorder (Table 1). He also meets criteria for major depressive disorder, recurrent, moderate.

The author’s observations

Psychosocial interventions for patients with an autism-spectrum disorder consist of educational, vocational, behavioral, and family interventions. Individual, group, and family psychotherapy may benefit patients with Asperger’s disorder who have comorbid depression.1

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