Autism and Asperger’s

Autism Spectrum Disorders and You

The main contrast between Autistic Disorder and Asperger’s Disorder is severity.  Those most unfortunate tend to suffer with autism.  The main features of both disorders are impaired social relations, impaired social communication, and stereotyped/repetitive behaviors.  While many readers may be thinking of those they know who meet these criteria, it is not likely your friends suffer with either disorder.  Autism is a severe impairment leaving most sufferers institutionalized after adolescence.  Most, but not all, autistic patients become aggressive after childhood.  The aggression seldom has a precipitant; a root stimuli that escalated the frustration to violence.  Most autistic patients have very noticeable impairments of cognition and language development.  A huge difference between those who are classified as Asperger’s or Autistic Disorder is the normal cognitive and linguistic development of  Asperger’s patients.

Both disorders suffer with social impairment, though at a different level of severity.  There is difficulty using nonverbal (bodily) communication to regulate social interaction.  Eye contact is poor or eerily constant, and facial expressions are bizarre and not appropriate to the situation.  Bodily gestures are bizarre and inappropriate as well.  Both disorders exhibit a lack of age appropriate peer relationships.  It is rare that either disorder spontaneously desires to share their experiences for the enjoyment or interest of others.  There is an aspect of poor emotional reciprocity, where one fails to note and respond appropriately to the emotional needs of others.

Many child and adolescent schizophrenic patients share some of the social impairment of the autistic spectrum disorders, but they rarely share the stereotyped and repetitive movements.  These movements are bizarre and intense, such as hand flapping and twisting, finger flapping, and flipping objects.  There are often whole body stereotyped movements; e.g., an autistic patient of mine constantly put his arms around his head.  He sometimes twisted or grimaced while performing this wrapping of arms around his head.  Once one is exposed to autistic movements, they are hard to mistake for nearly any other disorder.  Asperger’s sufferers experience similar movements, but rarely so bizarre and intense as Autistic Disorders.  I have witnessed many forms of neurological movement disorders over the last 20 years, and none mimic those of the autistic spectrum disorders.

There is an occasional diagnostic confusion with Obsessive-Compulsive Disorder.  Both Asperger’s and autism share an intense preoccupation with routines and rituals.  These restricted interests focus narrowly and to the exclusion of necessary routines one needs to accomplish each day.  It is difficult to label this as something other than a compulsion, though the diagnostic criteria for the autistic spectrum disorders make no mention of obsessions.  In my limited work with autistic patients, primarily while in training, every patient I observed suffered with severe obsessions.  The significant difference I noted was that the in the O-C, the cognitive obsession was strongly linked to the compulsive behavior.  For the autistic, the repetitive thoughts might result in nearly any behavior; related or not to the automatic repetitive thoughts.

While I have had to diagnose children with Autistic Disorder in institutions, I’ve never diagnosed someone with Asperger’s Disorder in my outpatient practice.  It is not uncommon to be referred a new patient with a diagnostic question regarding Asperger’s, but none have met the published diagnostic criteria.  Many people have difficulty with social relationships, and fortunately for them, it is rarely secondary to an autistic spectrum disorder.  A hallmark of these disorders is the bizarre and nonfunctional stereotyped/repetitive movements.  All the other symptoms overlap with other conditions.

In terms of treatment, most Autistic Disorders require institutionalization by mid-adolescence.  Those that are not aggressive, typically with nearly normal cognition, may be kept within the community.  Asperger’s Disorder is not generally treated on an inpatient basis.  The typical treatment is social skills training; making the patient aware of behaviors that distance or offend others.  These patients will never be socially comfortable or smooth, but the quality and success of their social interactions may be significantly improved.

What it Means to be Normal

It is often overlooked.  How do clinicians diagnose mental illness without knowing what it is to be normal?  This is not a trivial question.  Defining normalcy is a central issue in the training of psychologists.  Researchers focus on symptoms that reliably differentiates normal from abnormal functioning.  It is the path of least resistance to dwell on symptoms, since through the use of informants, the researcher may obtain some degree of objectivity.  What is overlooked, for the sake of objectivity, is what normality actually feels like to those who experience this state.  Unfortunately, the feeling of being in a normal state of mind is hopelessly subjective.

People who are labeled as mentally ill often comment that they just want to be “normal like everyone else.”  Like looking over the fence into the neighbor’s yard, people imagine the thoughts and emotions of others.  Implicit assumptions are made with a minimum of data.  It is often assumed that a labile (roller-coaster) mood is a sure sign of mental illness.  Patients often assert that they are more tense and anxious than normal people.  Everyone knows that seeing bugs that aren’t there definitely means one is crazy.  This could be termed a trinity of assumptions regarding normal people; that they are less moody, less tense, and never experience hallucinations.

There is some truth to the trinity, but more often than not, it serves as an ideal that is always out of reach.  Most people seriously under appreciate the degree to which normal people suffer with low moods, anxiety and transient hallucinations.  A large distinction is that for normal people, these symptoms ebb and flow, whereas for the mentally ill, these states of mind merely continue to flow.  Stated another way, normal people suffer low moods and anxiety states.  It surprises many people to learn that most normals experience transient hallucinations.  Large well-controlled studies of average people reveal how often they experience bizarre sensory phenomenon.  Almost on a weekly basis, the average person is prone to experience a bug crawling on their skin or up a wall, only to have it disappear when they look again.  If the bug disappears when they again look, psychologists call this normal, if they multiply when the person takes another peek, then we label these unfortunates as psychotic.

Do not be deceived as to what normal people experience.  Normalcy is not an ideal state of being, often imagined as being in a good mood and free of tension.  If this were the average state of the individual, most would never be motivated to leave their homes.  Tension drives behavior.  Tension is interwoven with life and abandons us at our death.  It is a river that needs to be channeled, not dammed into a confined space.  Similarly, bad moods are inescapable, yet they also may be a vector for change.  Research into the sensory experiences of normal people should convince us that we are all a little crazy.  Psychotherapy is typically more effective and rapid when the patient entertains realistic goals.  The ideal of the normal person is often a fantasy, and it may drive people towards emotional goals that are impossible to obtain.