Autism & Asperger’s Disorders

Dr. Holzmacher's Business Logo for Orlandopsych.comThe 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.

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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.  Please leave comments about this article in the space below.

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categories Asperger's/Autism, Psychology | | datetime April 15, 2010 3:27 pm | comments Comments Off on Autism & Asperger’s Disorders

Stroke

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Stroke is the common term for a blocked or ruptured blood vessel in the brain.  What differentiates stroke from other neuropsychological conditions is its rapid onset.  Alzheimer’s Disease can manifest for years without much functional impairment, but a stroke is sudden and without definite rules.  Some people suffer with transient ischemic accidents, that are defined as transient neural vascular events without any lasting impairment.  The perception of no lasting impairment is made from brief conversations, and the observation that the patient is still ambulatory and functioning in their environment.  Over the last twenty years, every patient I have tested with a history of transient ischemic accidents possessed measurable cognitive impairment.

Many people wonder, especially if older, if they are experiencing a stroke, or question if they have suffered a stroke.  The most obvious sign of stroke is paralysis on one side of the body.  The paralysis evolves over a period of hours, and typically diminishes after the main damage has been realized.  It may take several months to regain strength in limbs, even longer to regain coordination, and longer still to recover visual-spatial skills affected by the stroke.  Unfortunately, most people are left with lasting impairment.  The primary question for the clinician and family is whether the patient can be made functional in their environment.  Many strokes do not present with hemiparesis.  These less common forms are often misdiagnosed and blamed on psychological distress or malingering.

For those people wondering if they are currently experiencing a stroke, there is not much firm research on early warning symptoms.  Family members often note periods of disorientation or even confusion prior to the onset of the stroke.  The patient often complains of headaches or visual disturbances, but rarely are they self-aware of clouded consciousness.  Long-term research into early warning signs has implicated depressive and anxious episodes occurring in an atypical fashion for up to two years before a stroke.  I have not interviewed a stroke patient in the last twenty years that talked about a depressive or anxiety disorder onset prior to their stroke.  Nearly all the hundreds of stroke patients I have tested denied any early warning sign(s) prior to the actual event.  While I used to question early warning signs actively as a young clinician, I rarely do so now.

Another big question is, if I have one stroke, will I have another?  The research available to this clinician suggests that the chance of having a second stroke after having only one stroke is no greater than the base rate in the general population.  A second stroke increases the statistical possibility of having a third or fourth stroke significantly.  As with so many medical conditions, high blood pressure and smoking cigarettes significantly increases the chance of stroke.  If you have endured one stroke, not two or more, do not smoke cigarettes, and keep your blood pressure under control, then you are at no greater risk for another stroke then anyone else you pass in the street.

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What can be done to minimize the effect of a stroke?  The physician’s job is to keep the blood pressure down and observe the patient.  The neuropsychologist’s job is to establish a cognitive baseline, theorize about the patient’s premorbid level of functioning, and give behavioral recommendations regarding specific symptoms.  As a clinician, one has to keep in mind that brain scans performed on the day of the stroke will not display the full extent of the damage, and many scans that display brain damage are secondary to old strokes or a congenital malformation of the brain.  The neuropsychologist, therefore, is focused on the patient’s capabilities in the present, and how to maximize their functioning in all areas.  For example, I will place a greater clinical weight on a patient who is delirious after a stroke, who is not able to repeat three digits in a row, than a brain scan that reveals less damage than anticipated.  The brain scans are important, but the neuropsychologist will pay the most attention to current brain/behavior functioning.  The neuropsychologist is also focused on what factors in the patient’s life, especially medications, that could be slowing rehabilitation.  The rehabilitation research is clear that clinical depression slows the patient’s progress.

Neuropsychological treatment of stroke is heavily biased towards current cognitive and behavioral functioning.  We are focused on factors that could slow or halt progress in physical, occupational and speech therapy.  The main negative factors experienced by my patients are depression and medications.  The medications are likely helpful for most people, but may have unwanted effects in particular stroke patients.  Lastly, there is a strong outpatient planning in neuropsychology.  Often seemingly trivial relationship factors can sour a return to one’s home, such that mediating these troubles before a discharge is very desirable.  The neuropsychologist attempts to make the extended family a “treatment team.”  Please leave your comments on this post in the space provided below.

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categories Neuropsychology, Stroke | | datetime April 6, 2010 1:46 pm | comments Comments Off on Stroke

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