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Cases that Test Your Skills

Anxiously looking for love

33-year-old single woman seeks a companion but cannot maintain relationships. Does she have anxiety, a personality disorder, or a less obvious problem?

Vol. 5, No. 10 / October 2006

History: a lovelorn life

Ms. F, age 33, presents with one complaint: “I want to know how to maintain a relationship.” Problem is, social situations have made her feel anxious since childhood. She has trouble keeping a boyfriend; she left two intimate, extended relationships at different times.

She says she is too ashamed to invite people over because she cannot keep her apartment neat. She is also sick of her job as a filing clerk and wants a new career.

Ms. F reports no other anxiety symptoms or mood changes but often cannot concentrate. She denies impulsivity or poor judgment but admits that she makes decisions without getting important facts. For example, she enrolled at a community college without knowing what skills her new career would require. About 6 months ago, she left her boyfriend after realizing—18 months into the relationship—that he does not share her interests.

poll here

The authors’ observations

Information on all the above factors is crucial to diagnosing a socialization problem. Outline your differential diagnosis as the interview progresses.

Ask the patient:

How did you fare in school? A childhood history of pervasive inattention or impulsivity in at least two settings (at home and in school, for example) can signal attention-deficit/hyperactivity disorder (ADHD).fragile X syndrome). Boys with the fragile X premutation have a higher rate of ADHD symptoms and autism spectrum disorders than do boys without this premutation.3 Ms. F’s test showed two normal alleles, thus ruling out fragile X premutation.

Table 1

Mental status examination signs that suggest a PDD

Little direct or sustained eye contact
  Eyes flit around the room
  Patient talks without looking at anyone

Few facial expressions
  Flat affect

Impaired speech production
  Although prosody (intonation) is normal, rate is rapid, with cluttered bursts followed by long pauses and occasional unusual emphasis on certain words

Tangential thought process
  Patient changes topics quickly without transition
  Non-sequitur responses

Brief responses to questions, offering little spontaneous information

Very detailed answers that include irrelevant information

Pedantic phrasing

Repetitive use of language

Does not pick up on nonquestions

Concrete answers to questions about emotion
  Patient cannot describe how emotions “feel”

Appears uncomfortable during conversation with examiner
  Rapport strained; patient does not seem to enjoy interaction

PDD: pervasive developmental disorder

Treatment: medication and exploration

Ms. F agrees to an ADOS test. Her total score of 9 (7 in social, 2 in communication, and 0 in stereotyped/repetitive behavior) suggest a moderate PDD. We rule out autism based on the test score and Asperger’s syndrome because of her early language development delays (Table 2).

We start escitalopram, 10 mg/d, to address Ms. F’s anxiety. We see her weekly for medication management and start weekly psychotherapy to explore her two previous relationships and her desire to find a partner.

Ms. F, however, reacts anxiously to the therapist’s exploratory techniques. She has difficulty taking the lead and becomes extremely uncomfortable with silences in the conversation. The therapist tries cognitive-behavioral tactics to engage her, but Ms. F does not respond.

The therapist then conceptualizes her role as “coach” and tries a more-direct, problem-solving approach. She addresses specific challenges, such as an overwhelming class assignment, but Ms. F does not discuss or follow through on the problem.

After 6 months, Ms. F asks to stop psychotherapy because she has made little progress. She also asks to reduce medication checks to monthly, saying that weekly sessions interfere with her schoolwork. She says she would consider resuming psychotherapy.

At this point, Ms. F’s anxiety is significantly improved based on clinical impression. She continues to do well 6 months after stopping psychotherapy, though she is still without a boyfriend.

poll hereTable 2

Autism or Asperger’s? Watch for these distinguishing features

Clinical feature


Asperger’s syndrome

Impaired nonverbal behavior



Language delay


Stereotyped behavior (routines, mannerisms)



Impaired social relationships



Cognitive delay


+: Present –: absent ±: Might be present

The authors’ observations

The ability to possess a theory of mind—or “mentalize”—helps us understand others’ beliefs, desires, thoughts, intentions, and knowledge. Attributing mental states to self and others helps explain and predict behavior, which is critical to social interaction.

A therapeutic relationship can help teach patients to handle social situations.4 In autism or PDD,5,6 however, theory of mind deficits typically frustrate relationship building.4 Because ability to mentalize is critical to psychodynamic psychotherapy,7 exploration does not help patients with PDD. By contrast, therapists can be more successful by being active in sessions and giving directions, suggestions, and information.

Which psychotherapy models work? Limited data address psychotherapy for adults with PDD; most studies have followed children.

CBT for persons with autism or PDD is directive, problem-focused, and targets automatic reactions.8 Social skills groups and CBT focusing on day-to-day problem solving can help older children and adolescents.9 A 20-week social skills intervention employing a CBT approach, paired with psychoeducation for parents, has helped boys ages 8 to 12 with autism, PDD, or Asperger’s syndrome.10

Other interventions use pictures, cartoons, and other visuals to help patients identify and correct misperceptions and determine how different responses might affect people’s thoughts and feelings.9,11 Role play allows the patient to practice social interaction but requires make-believe,11 so getting a PDD patient to participate can be challenging.

Medication can help manage comorbid anxiety, obsessive-compulsive, and mood symptoms in PDD. Limited data support using selective serotonin reuptake inhibitors for this purpose.12

Related resources

  • Ozonoff S, Dawson G, McPartland J. A parent’s guide to Asperger syndrome & high-functioning autism: how to meet the challenges and help your child thrive. New York: Guilford Press; 2002.
  • MAAP Services. A global information and support network for more advanced persons with autism and Asperger syndrome.

Drug brand name

  • Escitalopram • Lexapro


The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

2. Lord C, Risi S, Lambrecht L, et al. The Autism Diagnostic Observation Schedule-Generic: A standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord 2000;30:205-23.

3. Farzin F, Perry H, Hessl D, et al. Autism spectrum disorders and attention-deficit/hyperactivity disorder in boys with the fragile X premutation. J Dev Behav Pediatr 2006;27(S2):S137-S144.

4. Ramsay JR, Brodkin ES, Cohen MR, et al. “Better strangers:” using the relationship in psychotherapy for adult patients with Asperger syndrome. Psychotherapy: Theory, Research, Practice, Training 2005;42:483-93.

5. Hill E, Frith U. Understanding autism: insights from mind and brain. Philos Trans R Soc Lond B Biol Sci 2003;358:281-9.

6. Castelli F, Frith C, Happe F, Frith U. Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain 2002;125:1839-49.

7. Gabbard GO. Psychodynamic psychiatry in clinical practice, 4th ed. Arlington, VA: American Psychiatric Publishing; 2005:60.

8. Beebe DW, Risi S. Treatment of adolescents and young adults with high-functioning autism or Asperger syndrome. In: Reinecke MA, Dattilio FM, Freeman A, eds. Cognitive therapy with children and adolescents. A casebook for clinical practice, 2nd ed. New York: Guilford Press; 2003.

9. Atwood T. Frameworks for behavioral interventions. Child Adolesc Psychiatr Clin N Am 2003;12:65-86.

10. Solomon M, Goodlin-Jones BL, Anders T. A social adjustment enhancement intervention for high functioning autism, Asperger’s syndrome, and pervasive developmental disorder NOS. J Autism Dev Disord 2004;34:649-68.

11. Rajendran G, Mitchell P, Rickards H. How do individuals with Asperger syndrome respond to nonliteral language and inappropriate requests in computer-mediated communication? J Autism Dev Disord 2005;35:429-43.

12. Namerow LB, Thomas P, Bostic JQ, et al. Use of citalopram in pervasive developmental disorders. J Dev Behav Pediatr 2003;24:104-8.

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