Cases that Test Your Skills
The angry patient with Asperger’s
Mr. A’s social skills are poor, and he has threatened and hit people when angry. What would you recommend for this anxious, depressed, developmentally disabled young man?
CASE ‘Sad, worried, and angry’
Mr. A, age 24, is referred to our university psychiatric clinic. He reports that he’s sad, worried, angry, and wants to hurt people. He endorses having chronic depressive episodes that last >2 weeks and consist of poor sleep, low energy, anhedonia, poor concentration, and psychomotor retardation.
He is developmentally disabled and has been living in a group home for almost 1 year. In former group homes, Mr. A threatened and assaulted other patients and staff. In 1 incident Mr. A broke a patient’s nose and was incarcerated for 4 days. With the help of a job coach, Mr. A has been working in a department store for 8 months. He was fired from other jobs because he threatened co-workers.
The author’s observations
Problem behaviors in patients with pervasive developmental disorders include aggression and self-injury. These behaviors may improve with behavioral or pharmacologic interventions.1 For example, risperidone is FDA-approved to treat irritability associated with autistic disorder in children and adolescents age 5 to 16 years.2 Violence has been reported in patients with pervasive developmental disorders, and such symptoms can lead to psychiatric referral.1
HISTORY Difficult childhood
Mr. A’s medical history is unremarkable. He has no history of hypomania, mania, psychosis, substance use, tics, seizures, genetic illnesses, head trauma, or physical or sexual abuse. He has never attempted suicide nor been hospitalized for psychiatric illness.
With Mr. A’s permission, his mother is consulted. She says that as a child Mr. A would become extremely interested in various topics—including Pokémon, Magic cards, and video games—and had a strong desire to tell everyone the details of each. However, he rocked back and forth, had few friends, and would bite other children.
Mr. A has no history of language delay but received speech therapy during his childhood to help him “work on eye contact and social skills.” He is estranged from and angry with his father, who has difficulty accepting his son’s developmental disability.
At the time of referral, Mr. A is receiving paroxetine, 30 mg/d, for depression, risperidone, 1.5 mg/d, for aggression, and dextroamphetamine/amphetamine extended-release, 30 mg/d, for hyperactivity/inattention. The efficacy of these medications, which were prescribed by an outside psychiatrist, is unclear.
Diagnostic criteria for Asperger’s disorder
A. Qualitative impairment in social interaction, as manifested by ≥2 of the following:
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by ≥1 of the following:
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language (eg, single words used by age 2 years, communicative phrases used by age 3 years).
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.
F. Criteria are not met for another specific pervasive developmental disorder or schizophrenia.
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000
On the Wechsler Adult Intelligence Scale-Revised, Mr. A’s full scale IQ is 77, verbal IQ is 77, and performance IQ is 81, indicating borderline intellectual functioning. He feels frustrated with his job and depressed because he is not in a romantic relationship. Although Mr. A worries about his job and lack of relationships, he does not meet criteria for an anxiety disorder.
Based on Mr. A’s impaired social interaction, repetitive interests and behaviors, and lack of language delay, Mr. A meets criteria for Asperger’s disorder (Table 1). He also meets criteria for major depressive disorder, recurrent, moderate.
The author’s observations
Psychosocial interventions for patients with an autism-spectrum disorder consist of educational, vocational, behavioral, and family interventions. Individual, group, and family psychotherapy may benefit patients with Asperger’s disorder who have comorbid depression.1
TREATMENT A rocky start
At Mr. A’s initial assessment, the clinic psychiatrist increases risperidone to 1 mg twice daily to target aggression. Even after receiving this dosage for 1 month, however, Mr. A continues to display physical aggression toward peers in the group home whenever he becomes angry.
The psychiatrist refers Mr. A to a social worker for supportive therapy to help him cope with worry and chronic sadness. The social worker uses general cognitive-behavioral strategies for anxiety and aggression for 12 sessions over 8 months until scheduling conflicts end therapy. The efficacy of this therapy is minimal; Mr. A remains depressed, anxious, and aggressive. During this time, the psychiatrist increases paroxetine to 40 mg/d, but Mr. A continues to feel depressed after 1 month. Mr. A is cross-tapered to duloxetine, but continues to feel depressed after receiving duloxetine, 60 mg/d, for 1 month.
My first visit with Mr. A occurs 3 months after his last visit with the social worker. He states he does not remember anything from those sessions. Mr. A’s goals for therapy are to reduce anxiety, manage anger, and improve relationship skills.
I begin the first 4 months of Mr. A’s therapy with cognitive-behavioral interventions based on the Treatment of Adolescents Depression Study (TADS) manual.3 Although Mr. A is an adult, I choose a manual that targets adolescents because my clinical impression is that his cognitive developmental level is more like an adolescent’s than an adult’s.
I assign homework such as mood monitoring. I ask him to use a form from the TADS manual to rate his mood on a scale of 0 to 10 every morning, afternoon, and evening, and write down what he is doing that makes him feel that way at the time he rates his mood. Mr. A never completes any homework; during each session he states he “just forgot to do it.”
I discuss concepts such as goal setting, for a novel Mr. A says he wants to write, and relaxation strategies to address anger; in session, I work with him on filling out the “What Helps Me to Relax?” form from the TADS manual. Mr. A lists “play games,” “write my book,” “listen to music,” “go outside,” and “exercise” as strategies to help him relax. We also work on visual handouts—such as “Safety Plan” and “What Can I Do to Relax”—to post in his room.
Mr. A does not show up for 3 sessions. When I call the group home, a staff member tells me they were busy with other patients and forgot about Mr. A. I decide to call the group home the day before each appointment as a reminder. This increases Mr. A’s attendance rate.
During each session, Mr. A complains about the quality of the group home, the staff, and other patients. To get my own perspective of Mr. A’s living environment, I consider visiting his group home, similar to how a geriatric psychiatrist sees patients in a nursing home or an assertive community treatment team psychiatrist sees patients in their home environments. Because I am concerned about boundary crossings/violations, I first discuss this action with 2 psychotherapists not involved in Mr. A’s treatment. They recommend that I limit this action to a one-time visit.
I visit Mr. A’s group home 2 months after my first session with him. Located in front of a dairy farm in a rural part of the state about 1 hour from our clinic, the isolated facility has a secured keypad entry. When I meet Mr. A there, he says he feels as if he is in jail. I meet the staff and find them willing to help with various aspects of Mr. A’s treatment, such as discussing events, reporting behaviors, and helping carry out interventions.
For example, I ask staff to remind Mr. A of his relaxation strategies when he becomes angry. On the “Safety Plan” handout, I had Mr. A identify 5 people he could talk to when he becomes angry; I ask staff to remind him of those people when Mr. A becomes angry. I also ask staff to ask Mr. A every day if he is writing the novel he wants to complete. After my visit, Mr. A starts putting more effort into therapy. When I set a daily goal of working on his novel for 15 minutes, he starts bringing pages of his writings to sessions.
Social skills training for patients with Asperger’s disorde
Starting a conversation: “Hi, how was your day?”
Staying on topic: “Oh, that sounds interesting. Tell me more about…”
Making eye contact: Look at people’s eyes when talking to them
Greetings: “Hi, how are you?”
Ending a conversation: “Well, I have to go now. I’ll see you later!”
Shifting topics: “Speaking of…, did you hear about…?”
Two months into therapy, Mr. A is crosstapered from duloxetine to bupropion extended-release, 150 mg/d. This attempt to improve his restricted affect is ineffective. Risperidone and dextroamphetamine/amphetamine extended-release dosages are unchanged.
The author’s observations
In a study in rural Appalachia, telephone reminders increased attendance at psychiatric intake appointments.4 Calling the group home before each of Mr. A’s appointments took extra time out of my schedule but improved Mr. A’s attendance rate.
In residential treatment of children, Monahan notes that childcare workers could contribute useful observations and benefit from the therapist’s advice.5 Establishing rapport with the staff at Mr. A’s group home helped me proceed with therapy.
TREATMENT Social skills training
In the second 4 months of therapy, Mr. A changes jobs to become a greeter in a local video game store. He is happy, and group home staff members are pleased they no longer spend 2 hours each day transporting him to his previous job.
Soon after, during a reminder phone call, a staff member tells me that Mr. A’s brother and father were murdered the prior week. Three staff members attend Mr. A’s brother’s funeral, which he appreciates. Mr. A refuses to attend his father’s funeral because of continued anger toward him.
When I ask Mr. A if he wants to talk about the deaths, he declines. I subsequently spend half a session discussing strategies to address grief,6 such as imagining a conversation with his deceased brother.
I decide to review Mr. A’s therapy goals because he still has a lot of anger toward his recently deceased father. I am concerned he might discharge this anger onto a staff member, coworker, or fellow patient. Mr. A states he wants to focus on relationships, especially his anxiety around women. He discusses his anxiety with starting and maintaining conversations with women.
I begin role-playing in sessions by pretending to be a woman for Mr. A to speak with, but he feels this is silly. I teach him exercises from a social skills training workbook developed for patients with Asperger’s, such as “Starting a conversation,” “Staying on topic,” and “Making eye contact” (Table 2).7 Mr. A says group home staff members occasionally take him out to a nearby nightclub and encourage him to talk to women.