Asperger’s Syndrome: A Psychologist’s Insight

August 22, 2014 at 12:17 pm

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Asperger’s, like ADHD, is a neurobiological disorder. It differs from ADHD in that it is a form of autism, or as the experts say, is on the autism spectrum. Conditions on the autism spectrum are characterized by difficulties in social functioning paired with high verbal intelligence and a tendency to have very narrow and focused interests.
Asperger’s syndrome (AS) was first identified by the Austrian pediatrician Hans Asperger (1906-80) who, in 1944, published a paper describing a pattern of behavior he had detected in a number of young boys who had normal intelligence and language skills but who also displayed marked deficiencies in social and communication skills. It was not until 1994, however, that AS was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook that lists and categorizes mental disorders and provides practitioners with criteria for diagnosing them. If a condition is not listed in the DSM, it is not recognized as a mental disorder. Even so, it is only within the last several years that AS has been widely recognized by physicians and parents. Today, it is estimated that 400,000 Americans have AS.

SYMPTOMS OF ASPERGER’S

The DSM IV lists six criteria used to diagnose AS. They are:
1. Measurable impairment with social interaction.
2. Restricted, repetitive stereotyped behaviors and interests.
3. Significant impairment in areas of function.
4. No measurable delays in language and speech.
5. No significant delays in cognitive development, self-help skills, or adaptive behavior other than social functioning.
6. Other developmental disorders or schizophrenia do not better explain the symptoms.
In practice, people with AS may have a variety of symptoms, and the disorder can range from mild to severe. Many people with the syndrome dislike change and prefer stable routines. Many are obsessive about their routines and may be focused on a narrow set of interests. These interests may include areas that most people consider normal, such as music, or the weather, or snakes. Some people with AS, however, are fascinated with such seemingly odd or trivial things as train schedules, deep-fry cookers, or telegraph-pole insulators. People with AS are often extremely knowledgeable about these subjects and may talk at length about them without recognizing that other people are not quite as interested. Children with AS may have highly specialized, pedantic vocabularies; it was, in fact, this characteristic, combined with their extensive knowledge, that caused Asperger himself to dub his patients “little professors.”
Individuals with AS have difficulty in behaving appropriately in social situations. They miss nonverbal signals and crucial social cues and often cannot empathize with others or understand complex emotions. They may also be unable to imagine how their own behavior looks to others. Many have trouble recognizing faces. Several studies confirm that the brains of people with AS react quite differently from those of normal individuals to tasks that involve mentalizing—intuiting other people’s mental states from behavior or facial expressions.

Fact Or Fiction?

“I have heard that people with Asperger’s can be very violent. There have been several recent high-profile cases in which young men with Asperger’s have committed murder.”

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The Facts: While there have been instances in which people with Asperger’s have become violent, violence is not commonly associated with the syndrome. Usually, any violent behavior on the part of a young person with a neurobiological condition stems from frustration and the inability to control impulses. Research demonstrates that three of five teens with Asperger’s say they were bullied at school, and their parents report that they are frequently teased. When they are extremely frustrated, people with Asperger’s can be disruptive, but they are seldom violent.
People with AS may seem naive and lacking in common sense, and some may have learning disabilities in reading, writing, or, most commonly, math. Some people with AS may be unusually sensitive to sensory stimuli and may be bothered by sounds or light levels that no one else notices. People with AS may also have gross motor deficits and may be seen as clumsy or awkward.

Asperger’s in Girls

For every 10 boys diagnosed with AS, only one girl is identified with the condition. Researchers believe that the real ratio should be more like four to one, as it is in autism, and they speculate that girls go undiagnosed because of basic gender differences and social expectations of girls. While boys with AS may be interested in science, chess—or telegraph poles—girls may be obsessed with animals (especially horses) and classic literature. Neither of these interests is likely to alert parents to a potential problem, since many girls who do not have Asperger’s love horses and reading. The difference is in the degree of the obsession and the depth of focus.
Researchers also believe that girls are more able than boys to imitate socially acceptable behavior and may, therefore, not seem to be quite so socially awkward. Liane Holliday Willey, who has Asperger’s, entitled her autobiography Pretending to Be Normal—a title that could well apply to the life stories of many girls with the syndrome. Many boys are first diagnosed with AS because of aggression and other kinds of behavior problems. Girls, who are better at expressing their emotions and less inclined to act out aggressively, may slip under the diagnostic radar.
The Australian psychiatrist Tony Attwood, a leading expert on the syndrome, says that while boys with AS may be little professors, girls are more like little philosophers, wondering, for example, if everyone sees the color red in the same way.

TREATING ASPERGER’S

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There is no medication to treat this condition, although AS is often associated with obsessive-compulsive disorder (OCD) and depression, both of which can be treated with a variety of medications. Because AS can differ so much from person to person, there is no one standard treatment. As with many such conditions, the younger the child is at diagnosis, the easier it is to make an impact with various forms of intervention. Social skills training is very important; because children with AS do not easily understand social cues, they must be taught acceptable responses to situations that other children might simply know by intuition.
AS4On the television sitcom The Big Bang Theory, the character of Sheldon is portrayed with many AS-like characteristics. When his neighbor Penny tries to persuade him to buy a gift for his roommate’s birthday, he demands to know why he should. She tries various explanations, all of which Sheldon rejects. She gives up until another friend whispers, “Try telling him it’s a non-optional social convention.” She does; this satisfies Sheldon’s need for a logical explanation, and he goes shopping with her. This is in some ways a model of the sort of training children with AS need—making explicit and rule-bound social conventions, which for most people are automatic. It is important to teach social skills to boys and girls separately, since their needs and deficits are so dissimilar.
People with AS who are overly sensitive to sound or light may benefit from sensory integration training, which is usually provided by an occupational therapist. This involves gradually exposing children to the offending stimuli in order to desensitize them. In addition many therapists employ a routine known as the Willbarger protocol to help treat children who have difficulties with sensory integration. Although the technique has not been validated by research, many occupational therapists report remarkable improvements using the protocol, which involves a sort of deep massage using a surgical brush and compressions to various joints and the sternum.
As children with AS grow older, and especially through their teenage years, psychotherapy and/or cognitive-behavioral therapy may be important to help with some of the scars that can come from being different. People with AS can suffer from depression and may be lonely, longing for more social contact, yet unsuccessful in making friends.

INTO THE FUTURE

What the future holds for young people with AS depends very much on the help and advice they get from friends, family, and teachers. Many successful adults who thought they had ADHD or OCD or were thought to be simply odd or eccentric have recently been diagnosed with AS, and their stories seem to have something in common: These people pursued their passions and found the right niche in life. Lars Perner, a professor of marketing at the University of Southern California and winner of the Nobel Prize in economics, was diagnosed with AS at the age of 32. He believes that his choice of profession has helped him. He said in a paper presented at the annual meeting of the Autism Society of America in 2002 that “As an academic, I have come into an environment where eccentric people, at least within reason, are tolerated and sometimes even admired,” and he notes that he gave up the idea of being a trial lawyer when he realized that he was not very good at “getting things ‘right’ on the first try.” His chosen profession does not require him to think on his feet and allows him time for revision and reflection.
Temple Grandin, who has been diagnosed as having high-functioning autism, is another remarkable success story. She transformed her love of animals and orderliness into a career in which she has become one of the world’s most distinguished designers of animal-handling facilities.

 

FURTHER READING

Attwood, Tony. The Complete Guide to Asperger’s Syndrome. London: Jessica Kingsley, 2006.
—–, et al. Asperger’s and Girls. Arlington, Tex.: Future Horizons, 2006.
Griffiths, Jonathan, and Hugh Jones. Asperger Meets Girl: Happy Endings for Asperger Boys. London: Jessica Kingsley, 2008.
Liane, Holliday Willey. Pretending to Be Normal: Living with Asperger’s Syndrome. London: Jessica Kingsley, 1999.

Psychologists Treatment of Veterans

August 14, 2014 at 3:20 pm

In the years after the war, this shifting emphasis radically altered the nature of the mental health professions, which previously had been more connected with mental institutions, chronic patients, and severe mental illnesses. The psychoanalytical approach, concerned with neuroses rather than severe psychosis, was particularly adept at responding to the psychological needs of soldiers.

soldier in distressRoy R. Grinker, John P. Spiegel, and their counterparts helped to train a new generation of physicians in psychoanalytical concepts. By the end of the war, psychiatry was on equal footing with other medical specialties of the Army Medical Corps and boasted 2,400 members. Military need, combined with evidence of psychiatry’s usefulness to combat veterans, helped to produce greater visibility and acceptance of mental health professionals. It also helped to solidify the idea that environmental factors were at least partially responsible for some mental illnesses.

PTSD Concept.During and after World War II, the term “battle fatigue,” also known as “combat fatigue” or “combat exhaustion,” was developed for conditions that might now be called post-traumatic stress disorder (PTSD). In their 1943 publication War Neurosis, Grinker and Spiegel used psychoanalytical concepts to describe the effect of environmental trauma in developing war neurosis. Battle fatigue was a concept distinct from the concept of “shell shock” developed during World War I because it emphasized environmental factors over biological factors. The unprecedented access of psychiatrists to soldiers brought about further observations of battle fatigue. In an effort to provide relief from the traumas of war, various branches of the military began to implement rotation policies by the spring of 1945 in addition to employing greater numbers of psychiatrists to treat fatigued soldiers in non-institutional settings.

 

Institutions, Professional Organizations, and Legislation

At the beginning of the decade, there were about 560 mental institutions across the United States, about 300 of which were under state, county, and municipal authorities. These institutions housed 469,000 patients and, in 1940 alone, admitted 105,000 new patients. The years during and after World War II saw a substantial increase in patient admittance, culminating in a new patient count of 446,000 in 1946. Institutional treatment peaked in the mid-1950′s, at which time the move away from institutional care began to gather serious momentum.

Habitually understaffed, overcrowded, and underfunded, state institutions lost many of their staff members to the war effort. Although standards set by the American Psychiatric Association required a minimum of one attendant for every six patients, one nurse for every forty patients, and one psychiatrist for every two hundred patients, these standards rarely were achieved. In 1949, the Council on State Governments conducted an investigation into the conditions of state institutions. This culminated in a 1950 report, The Mental Health Programs of the Forty-eight States, that made clear the failing conditions of American mental hospitals.

The American Psychiatric Association was a strong presence in 1940′s American psychiatry beyond the institutional setting, and in 1948 it assigned a small group of members to discuss the regularization and standardization of psychiatric classifications. This effort ultimately resulted in the 1952 publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although the classification of mental illness had a long tradition, it was not until 1949 that the World Health Organization included mental disorders in its International Statistical Classification of Diseases and Related Health Problems (ICD). This sixth edition of the ICD and the first edition of the DSM established for the first time a national and international regularization of shared psychiatric knowledge.

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The year 1949 also marked the establishment of the Committee for the Preservation of Medical Standards in Psychiatry (CPMSP). Along with the Group for the Advancement of Psychiatry, which was founded in 1946 with army chief of psychiatry William Menninger at its head, the CPMSP made efforts to promote the authority of psychiatry over psychology. Members of the field of psychology, however, had long been at work organizing and expanding. In 1938, the American Psychological Association formed the Committee on Displaced Foreign Psychologists (CDFP) to represent displaced European scholars. By October, 1940, the American Psychological Association had established the Emergency Committee on Psychology (ECP) to assist federal agencies and address issues of civilian morale during the war. The American Psychological Association began to include a section on “Psychology and War” in its official publication, the Psychological Bulletin, and in 1942 formed the Office of Psychological Personnel (OPP). For the American Psychological Association, the war years were important for emphasizing the efficacy of applying psychological theory to social problems, a trend that continued in the postwar years.

During the postwar years, American psychology became increasingly organized and regularized. In 1947, for example, the American Psychological Association established the American Board of Examiners in Professional Psychology. Despite the resistance of some in the psychiatric profession, psychologists increasingly participated in private practice.

During the midst of these professional debates and in response to growing demand for federal intervention, President Harry S. Truman signed the National Mental Health Act (NMHA) into law on July 3, 1946. The act called for the formation of a National Advisory Mental Health Council (NAMHC) and a National Institute of Mental Health (NIMH), and it was designed to help prevent, treat, and research mental illnesses. On April 15, 1949, the NIMH was formally established and replaced the Division of Mental Hygiene, with Robert Felix as its director.

Debates Concerning Treatment and Practice

During the 1940′s, particularly in the postwar years, the professions of psychology and psychiatry experienced increased external influence as well as decreased professional solidarity. A large proportion of internal debates centered on increased interest in biological treatment methods, therapeutic approaches, and the social role of psychiatry and psychology.

One of the most controversial methods of the 1940′s was the treatment of severe psychosis with a neurological surgery known as lobotomy. Walter Freeman, an American neurologist convinced of the somatic, or bodily, origins of mental illness, introduced the surgery to American neurologists and psychiatrists in 1936. In this procedure, the nerves that connect the patient’s frontal lobe to the thalamus are cut. In January, 1946, ten years after he and neurosurgeon James W. Watts performed the first lobotomy in the United States, Freeman performed the first transorbital lobotomy. This procedure was much quicker than the prefrontal procedure, allowing the frontal lobe to be detached by a sharp instrument that could be inserted into the brain through the patient’s eye cavities. By 1949, the number of lobotomies performed annually in the United States had reached five thousand, despite bitter conflicts within the profession.

At nearly the same time that Freeman was introducing American practitioners to the lobotomy procedure, electroconvulsive shock therapy was on the rise. The American Journal of Psychiatry first covered the procedure in 1937, and by 1940 it was widely in use. Over the course of the 1940′s, practitioners attempted various modifications in an effort to reduce the procedural side effects. Modifications included the introduction of muscle relaxants and short-term anesthetics that were thought to make the patient’s experience less frightening. The introduction in 1954 of Thorazine (chlorpromazine), nicknamed the “chemical lobotomy,” ushered in a new era of psychotropic drugs that in many ways replaced earlier and more invasive procedures.

In sharp contrast to the biological emphasis of practitioners such as Freeman and Watts, Karen Horney, a German psychoanalyst, argued that therapeutic approaches should emphasize the workings of the conscious mind and the isolating effects of a highly competitive, modern society. Her early writings on female sexuality successfully destabilized Freudian assessments of female psychology. Horney moved to New York City in 1934 and published her first of five books, The Neurotic Personality of Our Time, in 1937. During the 1940′s, Horney’s work focused on revitalizing psychoanalysis through an emphasis on the ego, or conscious mental awareness, and on developing theories of what came to be known as narcissism. Horney came to be perceived as a radical within the profession, and in 1941 she started the Horney Institute in New York City to promote her ideas.

Like Horney, B. F. Skinner sought to expand the uses and functions of psychiatry beyond the institution. Skinner was an American psychologist who emphasized the interplay between humans and external forces and was most widely known for The Behavior of Organisms (1938) and Walden Two (1948). In the first of those books, he laid out the fundamentals for a behaviorist theory of human nature that emphasized the role of punishment and reinforcement and the interaction between humans and their environment. Walden Two was a utopian novel that conceived of a type of human community that would be governed by the basic principles put forth in The Behavior of Organisms.

Skinner’s ideas on “behavioral technology” represented a greater shift during the 1940′s that sought not only to emphasize environmental factors but also to expand the influence of psychiatry into the realm of the social sciences. The growing emphasis on environmental factors and the widespread acceptance by psychiatrists also opened a space for the increased influence of psychoanalytic and psychodynamic methods of treatment. The emphasis of psychodynamic methods dovetailed with psychiatry’s growing interest in the late 1940′s in psychological life beyond the mental institution. During the last years of the 1940′s, the Group for the Advancement of Psychiatry helped to further the ideas of psychoanalysis by reorienting psychiatry toward a psychosocial model emphasizing community care and social outreach.

Impact

pillsThe expansion of psychiatry, psychology, and psychoanalysis during the 1940′s had great import for the direction of these professions over succeeding decades. Psychoanalytic and psychodynamic methods of therapy dominated the psychiatric profession for decades to come. The late 1950′s and 1960′s saw the widespread use of psychological and psychiatric drugs such as Thorazine and lithium to treat severe psychosis. With the introduction of psychotropic drugs, lobotomies and electroconvulsive shock therapy largely fell out of favor. Large mental institutions came to be viewed as an unnecessary social evil, and professional emphasis continued to shift toward noninstitutional, community-based mental health care. The antipsychiatry movement gained momentum during the late 1950′s and the 1960′s, bolstered by such works as Erving Goffman’s Asylums (1961), Thomas Szasz’s The Myth of Mental Illness (1961), and Ken Kesey’s novel One Flew over the Cuckoo’s Nest (1962), which negatively dramatized inpatient psychiatric treatment. Many social movements of the 1960′s, particularly the feminist and collectivist movements, drew heavily on the works of such notable theorists as Skinner and Horney in their critiques of American society.

 

Further Reading

El-Hei, Jack. The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness. New York: John Wiley & Sons, 2007. A judicious biography of Walter Freeman that details the rise and fall of the use of lobotomy procedures in mid-century medical thought and practice.

Grob, Gerald. From Asylum to Community: Mental Health Policy in Modern America. Princeton, N.J.: Princeton University Press, 1991. A concise yet thorough overview of twentieth century changes and developments in mental health policy.

Hilgard, E. R. Psychology in America: A Historical Survey. New York: Harcourt Brace Jovanovich, 1987. A comprehensive overview of the rise of American psychology.

Jones, Edgar. Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War. New York: Psychology Press, 2005. A comprehensive analysis of twentieth century developments in the treatment of soldiers and war veterans.

Mitchell, Stephen A., and Margaret J. Black. Freud and Beyond: A History of Modern Psychoanalytic Thought. New York: Basic Books, 1996. An overview of major conceptual developments in twentieth century psychoanalytic thought and practice.

Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, 1997. A concise yet thorough introduction to the history of psychiatry in the United States.

Wallace, Edwin R., and John Gach, eds. Encyclopedic Handbook of the History of Psychiatry and Medical Psychology. New York: Springer, 2007. A highly recommended, wonderfully diverse collection of articles covering the history of psychiatry and psychology.