Diagnosis and Assessment
Adults With Asperger Disorder Misdiagnosed as Schizophrenic
Lawrence Perlman, Professional Psychology: Research and Practice, 2000, Vol 31, No. 2, 221-225.
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 Edition: American Psychiatric Association, 1994), there is an explosion of interest in mild autistic disorders. This syndrome, which is characterized by problems in interpersonal relatedness, empathetic 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 is provided.
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. Individuals who were not diagnosed with pervasive developmental disorders in childhood may subsequently be misdiagnosed as chronic, undifferentiated schizophrenics.
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 defences against feelings of social isolation. Thus, secondary withdrawal and depression are commonly seen. These symptoms are well suited to psychological interventions. Accurate differential diagnosis is important because the more passive, high-functioning autistic people can easily be overlooked in an institutional setting. 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.
Review of the Asperger's Syndrome Diagnostic Scale
Goldstein S Journal of Autism and Developmental Disorders, Vol 32, 2002, pages 611-614.
The Asperger's Syndrome Diagnostic Scale (2001) was reviewed to determine it's reliability, validity, and clinical utility in the diagnostic process for pervasive developmental disorder, specifically Asperger's Syndrome. Concerns were raised about validity of the instrument, population upon which the instrument was normed, capability of the instrument to provide accurate differential diagnoses, and properties of the scale. The measure was determined to hold promise ass a research tool, but there appears to be little evidence that it can distinguish among the various types of pervasive developmental disorder or diagnosis of Asperger's Syndrome specifically.
Myles, Bock, and Simpson have developed and published the Asperger's Syndrome Diagnostic Scale (ASDS) (2001, Pro-Ed Publishers). The manual indicates that it is appropriate for use with individuals between the ages of 5 and 18 for the purpose of identifying AS, developing treatment and educational goals, and monitoring progress. It contains 50 items grouped into five subscales (Language, Social, Maladaptive, Cognitive, and Sensorimotor). Items are summed across all categories to provide an overall Asperger Syndrome Quotient (ASQ) that indicates the likelihood that an individual has AS. It can be filled out by either parents or professionals/teachers who have had sustained direct contact with the individual and takes approximately 15 minutes to complete.
Assessment Instruments for Asperger Syndrome
Howlin, P. (2000) Child Psychology & Psychiatry Review 5, (3) 120-129.
This review describes the current situation with regard to diagnostic instruments for Asperger’s syndrome. The paucity of such instruments, and the lack of adequate standardisation data amongst the few that do exist, represent a serious omission for both clinicians and researchers. The major problem limiting the development of effective diagnostic or screening instruments is the confusion inherent in ICD-10 and DSM-IV systems in differentiating autism from Asperger syndrome. In the absence of clear and clinically satisfactory diagnostic criteria, efforts to develop valid assessment instruments may be attempting to put the horse before the cart!
Clinicians, understandably confused by all this conflicting evidence, have tended to adopt their own working definitions, with variable degrees of consistency.
Given the persisting confusion as to what Asperger syndrome actually is, it is hardly surprising that very few diagnostic instruments have been designed specifically to identify it.
Despite the fact that the recent figures form the National Autistic Society, London (1997) and data based on Wing (1993) and Elhers and Gillberg (1993) suggest that Asperger syndrome may be much more common than autism, there are no adequately standardised diagnostic instruments specifically designed for this client group.
First, the few that do exist still require further research if they are to demonstrate acceptable levels of validity, reliability, specificity and sensitivity. Moreover, these are mainly being developed as screening instruments only.
Second, it is unrealistic to assume that a single instrument, no matter how thoroughly researched, can be used in isolation to ascertain diagnosis. Detailed information on cognitive and linguistic levels, family history, medical, social, psychiatric and, if possible, genetic background will also be required in order to differentiate similar conditions that may result from different causes.
Finally, there can be little doubt that, at least in part, ‘the absence of replicable, reliable, and valid instruments in this area is related to the absence of clear diagnostic criteria for these disorders’ (Lord, 1997). Unless problems of classification can be satisfactorily dealt with in future revisions of ICD and DSM, the development of effective and reliable diagnostic instruments will continue to be compromised.
Misdiagnosis of Asperger's Syndrome as anancastic personality disorder, Letters to the Editor
Michael Fitzgerald Professor Child and Adolescent Psychiatry, Trinity College Dublin Autism 4 Page 435.
Clinical experience suggests that there are quite a number of patients in adult psychiatric hospitals who have been misdiagnosed as having anancastic personality disorder rather than Asperger's Syndrome. While the misdiagnosis of Asperger's Syndrome as simple schizophrenia and other conditions is very familiar, anankastic personality has not been given sufficient consideration in the differential diagnosis. The diagnosis of anankastic personality in ICD-10 is as follows:
- The individual's characteristics and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culturally expected and accepted range.
- The deviation manifests itself in a pervasive way with inflexible mal adaptive behaviour.
- There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behaviour.
There must be evidence that the deviation is stable and of long duration, having it's onset in late childhood or adolescence. This is one factor that differentiates it from autism which must have an onset in early childhood. The person must meet at least four of the following criteria:
- preoccupation with details, rules, lists, order, organization or schedule
- perfectionism that interferes with task completion
- excessive conscientiousness and scrupulousness
- excessive pedantry
- rigidity and stubbornness
- unreasonable insistence that others submit to exactly his or her way of doing things or unreasonable reluctance to allow others to do things
It is quite clear that autism could easily be mistaken for anankastic personality disorder which has significant implications for clinical interventions.
The Asperger Syndrome (and high-functioning autism) Diagnostic Interview (ASDI), A preliminary study of a new structured clinical interview
By Gillberg,C. and Gillberg, C., Rastam, M and Wentz, E. (2001) Autism Vol 5(1), 57-66.
The development of the Asperger Syndrome (and high-functioning autism) Diagnostic Interview (ASDI) is described. Preliminary data from a clinical study suggest that inter-rater reliability and test-retest stability may be excellent, with kappas exceeding 0.90 in both instances. The validity appears to be relatively good.
Development of the ASDI
The interview was developed over several years on the basis of experience with several hundred patients with high-functioning autism spectrum disorders, including a large number with Autistic Psychopathy, Sschizoid Personality Disorder and Asperger Syndrome.
The set of operationalised criteria was based on Asperger’s first case histories (Asperger, 1944) and was gradually reworked so as to make them all fit the criteria (Gillberg, 1991). The six criteria comprise twenty different items (four Social, three Interests, two Routines, five Verbal and Speech, five Non-verbal Communication and one Motor.