Asperger with psychotic features ?

[Sarah_libertad]

Patient is 20 something , treated with Abilify 5 mg for more than a year and have been stable for the last 4 years on previous medication .
His diagnosis is Asperger with psychotic features ,he gives an excellent summary of his situation in the following document he gave :

The disease appeared gradually, here are its key steps:

Phase 1: It started with reference ideas that make delusion adhere like cement: brick by brick. It is only a world where the impossible becomes possible progressively by projecting my dreams and fantasies in it, forcing it to agree with reality that contradicts it objectively.

Phase 2: It was followed by a depressive period: I spent all my day lying almost never going out, I remember a detail perhaps insignificant, is that I found my shoes too heavy to walk with them. It was in this phase that I was building a new mental referential with its characters and logical mechanisms all in complete isolation in my dorm room having lost all my friends, because I was no longer attending classes.

Phase 3: The ideas of persecution came only after the depressive phase and are a prediction in this delusional system of the reaction of others of my actions or things that I said in discussions with people on private conversations, perhaps, it is a defense mechanism against an imagined danger.​

What do you guys thinks of this case ?

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[MacDonaldTriad]

This isn't a good place to get validation for your wish to go against professional advice.

 

[Sarah_libertad]

Hello, I'm part of a team in a psychiatric facility and we're all thinking how to solve this special case .
Patient is known for his superior intelligence and creativity but can't do any work since the introduction of medication .
It's always a bad idea to go against professional advice but we're a team and we're exploring all the possibilities .
But there's lack of information on withdrawal of patients on below therapeutic level of Aripiprazole .
Good day and thanks for your help.

 

[dl2dp2]

Since we are all just all spitballin' on the interwebs: I can say with almost 100% certainty that this is neither psychosis nor autism. Most likely diagnosis is a case of narcissistic personality disorder. This patient needs twice a week transference focused psychotherapy (TFP). I'm only half-joking.

His case is also not particularly "special". See this all the time ("high functioning autism with treatment-resistant X Y Z") in the outpatient setting. These are BS labels. How is the Autism diagnosed? Did he get ADOS? Did he get a 360 comprehensive inventory? Of course, no meds will work because he's a self-defeating narcissist. His symptoms are also not "delusions". Whoever makes these diagnoses 1) have never actually worked with people with primary psychotic illnesses or 2) don't give a crap (i.e. 15 min med check MDs) or 3) lazy or 4) all of the above.

The annoying thing, of course, is that when you actually use your DSM by the books make a diagnosis of personality disorder, the patient refuses to get the evidence-based treatment he needs, which is TFP or maybe schema therapy. BPD pts also have this problem, but at least it's a bit more acceptable now to say you need to sit your butt down in the damn DBT group for 6 months before I'll write you Abilify.

 

[calvnandhobbs68]

Since we are all just all spitballin' on the interwebs: I can say with almost 100% certainty that this is neither psychosis nor autism. Most likely diagnosis is a case of narcissistic personality disorder. This patient needs twice a week transference focused psychotherapy (TFP). I'm only half-joking.

His case is also not particularly "special". See this all the time ("high functioning autism with treatment-resistant X Y Z") in the outpatient setting. These are BS labels. How is the Autism diagnosed? Did he get ADOS? Did he get a 360 comprehensive inventory? Of course, no meds will work because he's a self-defeating narcissist. His symptoms are also not "delusions". Whoever makes these diagnoses 1) have never actually worked with people with primary psychotic illnesses or 2) don't give a crap (i.e. 15 min med check MDs) or 3) lazy or 4) all of the above.

The annoying thing, of course, is that when you actually use your DSM by the books make a diagnosis of personality disorder, the patient refuses to get the evidence-based treatment he needs, which is TFP or maybe schema therapy. BPD pts also have this problem, but at least it's a bit more acceptable now to say you need to sit your butt down in the damn DBT group for 6 months before I'll write you Abilify.

I don’t know if I’d call 5mg of Abilify treatment resistant...

Also, why so quick to write off psychotic disorders in people with ASD? It’s been shown multiple times that people with ASD are at higher risk for psychotic symptoms, most recently in JAMA psychiatry

Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: a population-based study - PubMed

A diagnosis of ASD is associated with a substantially increased risk for NAPD and BD. This finding contributes to our understanding of these disorders and has implications for the management of ASD.

www.ncbi.nlm.nih.gov

I mean I get you'd want to make sure this guy didn’t self diagnose his “aspergers syndrome” and he’d have to have more than whatever delusions that are being referred to above (although it could be the case that he has a persistent delusional disorder, it’s be unlikely to respond to medications so we’ll) but it sounds like you’re completely writing off cases of ASD with psychosis. Sorry if I’m interpreting that incorrectly.

 

[Sarah_libertad]

Ok good questions.
Asperger was diagnosed by a group of psychiatrists and psychologists and confirmed by an Asperger diagnosis center several years ago.

 

[Shufflin]

Me thinks the OP is the patient. Funny hunch.

 

[Sarah_libertad]

Even our chief psychiatrists admit the case isn't easy . The interplay between Asperger and psychosis isn't fully understood and here we ask ourselves what is the utility of low dose Abilify in this case .
I'm serious when i said we've never had any patient like him usually patients only complain of sexual dysfunction and rarely about higher cognitive functioning to be more precise this is generally considered a red flag that the patient is showing delusions of grandeur but that's really not the case here.
Anyone can analyze the document he's written and find a "new" point of view ?
Does constructing an alternate reality based on self-reference ideas should be viewed purely as a psychotic phenomena or with an ASD basis ?

 

[Old&InTheWay]

Sorry i think you got me wrong i'm not a patient ,i'm part of a team in a psychiatric facility and we're all thinking how to solve this case .
Are there any succesful withdrawals of Aripiprazole 5 mg or studies in this matter ?
Patient is known for his exceptional analytical skills and creativity but can't do any work since the introduction of medication .

OP, are you a native English speaker? I ask because your syntax is unusual. Also, what exactly is your role on the team?

 

[Liquid8]

There is too much information missing to make sense of this. 5mg Abilify is hardly what I’d consider to be an effective dose to manage psychosis, and I’m struggling to see the reasoning for keeping a patient on it for a year if it wasn’t effective. What was the previous medication that he was stable on, what specific symptoms was it targeted to address and why was it stopped if it was supposedly effective?

From the patients account the lack of meaningful descriptors does not convince me the patient is truly psychotic.

Phase 1 refers to “reference ideas” and “delusions.” I would like to know what was the contents of the delusions, and what the patient means exactly by “reference ideas” as this likely differs from what I understand the terms to mean.

Phase 2 sounds more in keeping with a depressive disorder, likely secondary to social withdrawal and isolation which could well be related to ASD.

Phase 3 references a delusional system, a term that has a specific phenomenological definition. The “persecutory” thoughts appear associated with the reactions of others which sound more suggestive of social anxiety rather than classic persecutory delusions. As with the comments made re: Phase 1, I am not confident that what the patient means when using these terms is what I would understand them to actually be. If one is to accept that the persecution is of a psychotic nature, then it clearly follows a depressive episode – so Depression with psychotic features would be a more applicable diagnosis framework to with. However, overall it reads to me like the patient has learnt some phenomenological terminology, but I’d question if this is being applied correctly.

It would be more useful to present the treating psychiatrist’s assessment – but I would be somewhat concerned if they simply accepted that someone has delusions because the patient says they did. From the information presented there is no mention of anything resembling hallucinations. The patient’s summary does not indicate any obvious degree of disordered thought. There is nothing I read that makes me think the patient actually has a persecutory delusion or is involved in a systematised delusion. While the social withdrawal could represent a prodrome or negative symptoms of schizophrenia, ASD and depression seem like more likely explanations.

 

[Sarah_libertad]

Thanks a lot for your responses .
He was started on the max dose of Abilify 30 mg then 15 mg then 10 then finally 5 mg with 9 months increments between every lowering of the dosage .
Everytime the patient responded well to treatment and is asymptomatic to this day .
No hallucinations or disordered thoughts were observed besides some minor tangentiality during his first interview with the medical staff that resolved fast with Xanax.
Finally brain scans were done using MRI and showed no abnormality .

 

[Old&InTheWay]

Thanks a lot for your responses .
He was started on the max dose of Abilify 30 mg then 15 mg then 10 then finally 5 mg with 9 months increments between every lowering of the dosage .
Everytime the patient responded well to treatment and is asymptomatic to this day .
No hallucinations or disordered thoughts were observed besides some minor tangentiality during his first interview with the medical staff that resolved fast with Xanax.
Finally brain scans were done using MRI and showed no abnormality .

Why is he being treated in a psychiatric facility if he has been and continues to be asymptomatic? What exactly is your question?

 

[Sarah_libertad]

He was a patient in our psychiatric facility 4 years ago . He stayed a few weeks and was discharged, lately he contacted us about his problems .
His actual psychiatrist keeps him on Abilify 5 mg as he probably thinks that it would keep him at bay from having persecutory delusions even the psychiatrist who gave the first diagnosis thinks now that it's at worse some weak form of psychosis combined with strong ASD traits.
If 5 mg can't control psychosis then why give it to an Asperger ?

 

[MacDonaldTriad]

Me thinks the OP is the patient. Funny hunch.

I agree, look at the first response.

 

[Sarah_libertad]

@MacDonaldTriad You can believe what you want. Do you have anything constructive to say ?
I can't disclose more information but everything in this story is true .
If you think all your patients are dysfunctional lunatics you're never going to get a real satisfaction from your work,i mean working on healing patients doesn't really end until they are contributing positively to society in a sense.

 

[MacDonaldTriad]

You don't have enough grasp of psychiatry to communicate the pathology of this patient to a degree that we could allow us to have a constructive opinion. Second and third hand opinions don't work very well. Autism can be associated with psychosis, but Asperger's is high functioning by definition and an other explanation for the psychosis is likely and you haven't said anything that rules any of the other causes of psychosis out.

 

[calvnandhobbs68]

@MacDonaldTriad You can believe what you want. Do you have anything constructive to say ?
I can't disclose more information but everything in this story is true .
If you think all your patients are dysfunctional lunatics you're never going to get a real satisfaction from your work,i mean working on healing patients doesn't really end until they are contributing positively to society in a sense.

Come on OP, there's no question now

 

[hamstergang]

Hello, I'm part of a team in a psychiatric facility and we're all thinking how to solve this special case .

He was a patient in our psychiatric facility 4 years ago . He stayed a few weeks and was discharged, lately he contacted us about his problems .

So he's no longer a patient at your facility yet the psychiatric team in that facility is still trying to figure out how to solve his case based on what he's writing to you?

 

[dl2dp2]

Me thinks the OP is the patient. Funny hunch.

So he's no longer a patient at your facility yet the psychiatric team in that facility is still trying to figure out how to solve his case based on what he's writing to you?

Exactly. This is ridiculous.

 

[dl2dp2]

I don’t know if I’d call 5mg of Abilify treatment resistant...

Also, why so quick to write off psychotic disorders in people with ASD? It’s been shown multiple times that people with ASD are at higher risk for psychotic symptoms, most recently in JAMA psychiatry

Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: a population-based study - PubMed

A diagnosis of ASD is associated with a substantially increased risk for NAPD and BD. This finding contributes to our understanding of these disorders and has implications for the management of ASD.

www.ncbi.nlm.nih.gov

I mean I get you'd want to make sure this guy didn’t self diagnose his “aspergers syndrome” and he’d have to have more than whatever delusions that are being referred to above (although it could be the case that he has a persistent delusional disorder, it’s be unlikely to respond to medications so we’ll) but it sounds like you’re completely writing off cases of ASD with psychosis. Sorry if I’m interpreting that incorrectly.

Cases you are referring to in JAMA is a completely different profile. People who have ASD who are also psychotic usually have low IQ.
It's a little hard to communicate this because the information we have is so sparse. Suffice it is to say, clinically, there are two types of "autism" patients. One group is essentially low IQ [broadly, say going somewhere between 60-90] and overlap with people with schizophrenia and other developmental delay. Other group is people with personality disorder pathology [often in superior IQ]. The current diagnostic system obscures distinctions.

In a purely pragmatic, clinical sense, the big picture treatment goals have little to do with the ASD/psychosis label. Let's say you have psychotic symptoms and high IQ, the goal is to enliminate positive symptoms and get you to regular work using fairly targeted psychotherapy. If you have psychotic symptoms and low IQ, the goal generally is "palliative" (i.e. supportive employment, SSI, etc.), and it's questionable if heavy duty use of antipsychotics are even appropriate in these cases, and whether the supposed psychotic symptoms are "real" psychotic symptoms. There is clear documentation that low IQ patients on antipsychotics have a high mortality rate. That said, that group of patients frequently get put on antipsychotics [off label] for "behavioral" issues. Treatment plan design has more to do with pre-morbid functioning than the diagnostic label.

This applies to the case as presented above, we don't have a good sense of what this patient's premorbid functioning is like and other relevant parts of the story. Just spitballing tho, people who write these long drawn out paragraphs of nothing generally have personality disorder. LOL just a clinical observation. No scientific evidence at all.

More importantly, people who have worked many years in mental health don't present the case history in this way. Lay people and patients tend to think diagnostic labels are important, and in particular people with personality disorders internalize and identify with their diagnoses ("bipolar", "autism") to posthoc justify their BEHAVIORAL symptoms (i.e. self injure, aggression, isolation, etc). Anyone who has some experience with mental health knows that diagnostic labels are typically only useful in conjunction with a "functional" assessment. People with "major depressive disorder" or "alcohol use disorder" can have such a broad spectrum of presentations that the treatment plan design can be completely different, even though they have the same diagnostic label.

 

[dl2dp2]

Ok good questions.
Asperger was diagnosed by a group of psychiatrists and psychologists and confirmed by an Asperger diagnosis center several years ago.

We need premorbid IQ and overall functioning to propose a design of treatment plan. Still, until proven otherwise I think he has a personality disorder. "Real" primary psychotic disorder doesn't present in this way. Regardless, the exact diagnosis doesn't really matter except to the extent to affect the correct psychotherapy assignment. Perhaps.

Whether antipsychotics can be used is also not strictly a question of diagnosis. People with BPD is on Abilify all the time off label for "impulsivity", to varying degrees of success.

 

[clausewitz2]

We need premorbid IQ and overall functioning to propose a design of treatment plan. Still, until proven otherwise I think he has a personality disorder. "Real" primary psychotic disorder doesn't present in this way. Regardless, the exact diagnosis doesn't really matter except to the extent to affect the correct psychotherapy assignment. Perhaps.

Whether antipsychotics can be used is also not strictly a question of diagnosis. People with BPD is on Abilify all the time off label for "impulsivity", to varying degrees of success.

At the end of the day it is just a few written paragraphs and not at all the same as experiencing the patient's actual intersubjectivity but what is written frankly just doesn't have the "praecox feeling." Just not how people with true psychotic disorders tend to write about their experiences.

Sometimes BPD does benefit a bit from anything that can just introduce a delay between thought and action. See also the popularity of cannabis in this population.

 

[Sarah_libertad]

Premorbid IQ is around 145 (was evaluated at 20 years old,Weschler scale ) and short term memory was determined as superior .
Thanks everybody for the help,actually he ruminates constantly on his inability to think and solve abstract problems .
What is the utility of Abilify 5 mg from a pharmacological point of view in this case ?

 

[thepoopologist]

Why is this thread not locked. This person is either the patient in question or a relative/caregiver of the patient.

 

[dl2dp2]

Premorbid IQ is around 145 (was evaluated at 20 years old,Weschler scale ) and short term memory was determined as superior .
Thanks everybody for the help,actually he ruminates constantly on his inability to think and solve abstract problems .
What is the utility of Abilify 5 mg from a pharmacological point of view in this case ?

Again, spitballing, not a diagnosis, since diagnosis is officially neither allowed on SDN nor even possible: Personality disorder NOS. The foundation of the treatment would be twice-weekly transference focused psychotherapy or full dialectical behavioral therapy group and individual for a minimum of 1 year. Meanwhile, he needs to get a job or volunteer or go to school. You can tweak around with meds here and here, a little upper a little downer a little SSRI a little antipsychotic, but let's not kid ourselves, the patient has a character pathology--the supposed "psychotic" symptoms are qualitatively different from that of patients with schizophrenia. There is also usually either a primary or secondary gain, disruptive family or outright history of trauma.

This is like my typical caseload LOL. I hope you have enough money/insurance to afford someone like me who is trained to deal with this kind of thing. Again I'm only half-joking.

 

[MacDonaldTriad]

Premorbid IQ is around 145 (was evaluated at 20 years old,Weschler scale ) and short term memory was determined as superior .
Thanks everybody for the help,actually he ruminates constantly on his inability to think and solve abstract problems .
What is the utility of Abilify 5 mg from a pharmacological point of view in this case ?

We know you want us to tell you that 5 mg of Abilify is causing your inability to think and solve abstract problems and that it is OK to stop your Abilify but no one will because none of us have evaluated you and therefore we don't know. We do know that it is unlikely for such a small dose to be causing much of a problem, not impossible, but unlikely. I also would guess that you do ruminate some because almost everyone else would have just stopped it without seeking permission with 8 posts. But then again, I'm the psychiatrist who "thinks all my patients are dysfunctional lunatics" so there is that.

 

[dyachei]

SDN is not intended for medical advice of this sort. Closing thread.