Interesting CAPS case that highlights a misconception

[DD214_DOC]

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I did an intake earlier today that is kind of interesting and help me realize something. To preface, I admit that evaluating ASD, or at least the more mild to moderate presentations that aren't clear cut, is a weak area of mine. I am pretty conservative with this label and a lot of people get it completely wrong. I also do not believe that clinical interview and observation alone are sufficient, unless it's a pretty obvious presentation.

Anyway, peds psychology friend and colleague in my clinic referred to me and asked that I see an older adolescent patient of his. Pt has a history of seeing psych since the age of 5, primarily for anxiety, depression, and tics. Pt described to me as, "odd and somewhat eccentric" in how he interacts socially, with a severe obsession about his plans for the future, which involves him getting multiple advanced degrees from MIT and building some type of radical invention, which I actually can't remember at the moment. He actually has a lot of anxiety about this, especially related to the fear that he may not accomplish his goals.

He is primarily the psychologist's patient, who has a prelim diagnosis of schizotypal personality traits. We've discussed the case in passing previously and that was tossed around. He was referred to me because a neurologist has been prescribing his meds, and the regimen is a complete nonsensical mess, which he has been taking for several years. Neurologist diagnosed him with OCD, ADHD, and Tourette's. I have no idea why he was seeing neuro instead of psych. I guess due to the tourette's diagnosis?

Anyway, my initial session and ROS revealed an adolescent male with a long history of restricted and repetitive interests, difficulty forming and maintaining peer relationships, difficulty understanding social cues, difficulty understanding humor, especially sarcasm, impaired emotional reciprocity, hyperactivity, anxiety as discussed, and chronic sleep problems. No speech/language delay. To me, this all sounded like a straightforward ASD, or what would have previously been called Asperger's.

So, since I of all people honestly felt this was most likely ASD, I had no idea why everyone has missed it for the past 10 years. While the patient has the restricted interests and difficulty with social interaction and engagement, he has always WANTED to interact and socialize with others -- he was just terrible at it and really didn't understand how. This was actually mentioned to me specifically by the psychologist and mom reported this feature was mentioned by several previous docs as eliminating ASD as a possibility, despite literally every other possible feature being present. I actually thought the same thing during the session.

Since I thought it everything else too closely fit with ASD and the overall picture didn't make sense, I went back to review the DSM as well as other texts and literature. I'm sure this is obvious to many, but a lack of interest in social interaction is not a requisite for the diagnosis -- it is merely one possible manifestation of this symptom cluster.

I have actually had to re-read my references more than twice to make sure I wasn't missing something, because it was so difficult to believe that so many of us held that misconception. It's still a bit difficult to believe, so I welcome anyone's feedback, especially if I'm wrong about it not being a requirement. I'll certainly need all the evidence I can find for tomorrow when I tell my friend I think he's wrong 😀

Also, I think it's useful to talk about the times we were wrong or stumped by a case just as much as when we nail it.

 

[hamstergang]

It's still a bit difficult to believe, so I welcome anyone's feedback, especially if I'm wrong about it not being a requirement. I'll certainly need all the evidence I can find for tomorrow when I tell my friend I think he's wrong 😀

I have no evidence on me, but I believe you to be correct. The desire for social relations without the skills for obtaining and keeping them leads to a lot of the anxiety and depression seen in this population, I believe.

 

[calvnandhobbs68]

I have no evidence on me, but I believe you to be correct. The desire for social relations without the skills for obtaining and keeping them leads to a lot of the anxiety and depression seen in this population, I believe.

Abso-friggen-loutely. I've seen this as well with higher functioning autistic children (what would have been called Asperger's previously), especially when they get to the grade school/teenage years. There's certainly a population who don't give a crap about social interaction, couldn't care less about what other people think about their plans and restricted interests and would be just fine doing their own thing. That's certainly not everyone and you're both right that at a certain point these individuals realize that their social skills are impaired, that they have trouble finding friends and fitting in and just "getting" what everyone else gets in social interactions. It can be a significant contributor to distress, anxiety and depression as hamstergang posted above and it's really sad (in my opinion). They realize that they're "missing" something socially but because of the disorder it can be very difficult to get to the point where they're fluid enough in social interactions for others to want to be around them and hold conversations consistently (essentially having friends...). It usually helps if they can connect with others who share an interest that can generate a lot of interaction around that interest (computer gaming, models, collecting, etc) so a lot of the interaction is grounded in facts connected with that interest.

As an aside, that's why, in my experience, you'll see a lot of these kids spending a lot of time on the internet, where they can get some of that interaction they want without the problems of face to face social interaction.

Nobody with any experience in diagnosing or working with patients with ASD should have ruled out ASD as a possibility based on him wanting to socialize with others. I'm honestly shocked that both the psychologist and neurologist thought that. A general pediatrician should have at least been suspicious about ASD as well, although what probably happened is the pediatrician referred to neurology and just accepted whatever diagnosis they put on there.

As you correctly pointed out, straight out of DSM 5:
"Deficits in developing, maintaining, and understand relationships, RANGING (my own emphasis), for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers."

To give you some more ammo, you can reference this as well:
https://depts.washington.edu/dbpeds/Screening Tools/DSM-5(ASD.Guidelines)Feb2013.pdf
Under A3:
"Has an interest in friendship but lacks understanding of the conventions of social interaction (e.g extremely directive or rigid; overly passive)"

Edit: Not saying there aren't co-existing disorders with this kid. Mainly that you can't rule out ASD simply because he'd like to have friends.

 

[PikminOC]

Any psychotic Features? any obsession or Compulsions ? besides mit?

 

[PikminOC]

Clear Cut? would neuropsych testing be helpful ?

 

[Ceke2002]

It's still a bit difficult to believe, so I welcome anyone's feedback, especially if I'm wrong about it not being a requirement. I'll certainly need all the evidence I can find for tomorrow when I tell my friend I think he's wrong 😀

I have no evidence on me, but I believe you to be correct. The desire for social relations without the skills for obtaining and keeping them leads to a lot of the anxiety and depression seen in this population, I believe.

Obviously not a professional opinion, but my nephew who has ASD absolutely wants to socialise, just because he struggles with how to socialise properly certainly doesn't mean he has no desire to at all. And yes it does cause him quite a lot of anxiety when he is trying hard to socialise, and things aren't quite going right for him, and he can't, or at least struggles to understand why.

 

[OldPsychDoc]

I wonder if there's been a collective conflation with Schizoid PD in our minds--which does specify the lack of interest in social interaction in the criteria.

 

[Ceke2002]

I wonder if there's been a collective conflation with Schizoid PD in our minds--which does specify the lack of interest in social interaction in the criteria.

That's interesting, and would match up with general observations of my own regarding family members. Although never officially diagnosed my Dad most likely had some sort of schizotypal or schizoid PD going on (based on speculative discussions I've had with my Psych); he was perfectly capable of social interaction he just preferred to exist in his own little world alongside myself and Mum. In contrast my nephew with ASD wants to socialise with others, and obviously enjoys doing so, he's just not always very good at it and other kids can get a bit frustrated with him not fully understanding certain aspects of social play, etc.

 

[clausewitz2]

I wonder if there's been a collective conflation with Schizoid PD in our minds--which does specify the lack of interest in social interaction in the criteria.

And weirdly, 100% of the unequivocal Schizoid PD I have seen to date was in people who had been slapped with an ASD diagnosis.

 

[WisNeuro]

Clear Cut? would neuropsych testing be helpful ?

Could be, mainly in teasing out some possible differentials which can also look like a spectrum disorder in some ways. Additionally, they may be able to do some of the longer eval instruments like the ADOS, which can be helpful in clarifying communication deficits above and beyond simple parent report.

 

[Ceke2002]

And weirdly, 100% of the unequivocal Schizoid PD I have seen to date was in people who had been slapped with an ASD diagnosis.

I'm surprised the two things get mixed up so much, from the sounds of it. Now that OPD has me thinking about it comparing my Dad's presentation/behaviours with my nephew's it's like 'okay, that is two very different diagnoses right there', obviously so. Then again I suppose it might be obvious to family members, but if those same family members don't correctly report or corroborate information it may not be obvious to a Psychiatrist.

 

[WisNeuro]

I'm surprised the two things get mixed up so much, from the sounds of it. Now that OPD has me thinking about it comparing my Dad's presentation/behaviours with my nephew's it's like 'okay, that is two very different diagnoses right there', obviously so. Then again I suppose it might be obvious to family members, but if those same family members don't correctly report or corroborate information it may not be obvious to a Psychiatrist.

Diagnoses can be obviously different looking at DSM checklists and descriptions, but when you get poor historians with poor or even no collateral informants, these things get tough to suss out at times. Oftentimes we're working with discrepant and contradictory information. This can also get very tricky when you don't have much in the way of chart notes on a patient and you're trying to proffer a diagnosis after one meeting with the patient and limited data.

 

[Ceke2002]

Diagnoses can be obviously different looking at DSM checklists and descriptions, but when you get poor historians with poor or even no collateral informants, these things get tough to suss out at times. Oftentimes we're working with discrepant and contradictory information. This can also get very tricky when you don't have much in the way of chart notes on a patient and you're trying to proffer a diagnosis after one meeting with the patient and limited data.

I can definitely see how that would happen. 38 years of marriage, and 7 years after my Dad passed away my Mum has only just recently come to the conclusion that my Dad's behaviour may not have been normal even before he was diagnosed with Dementia. Apparently believing that mice were capable of performing complex ballet routines, regularly digging up the garden looking for listening devices, and remaining convinced that Doctors have a mafia that puts hits out on patients wasn't quite enough to convince Mum something wasn't quite right with my Dad at the time.

edited to add: Sorry my point being my Mum would have been terrible at giving an adequate or accurate history in regards to diagnosis, so it's not all that surprising that other people would come under the same heading.

 

[Merovinge]

Also, I think it's useful to talk about the times we were wrong or stumped by a case just as much as when we nail it.

Completely agree with above. Also I agree this is very likely an ASD case - many patients with ASD desire social relationships! I guess the issue is that outside of an SSRI and behavioral interventions for sleep/anxiety, it may be difficult to explain the diagnosis and how it will help improve the patients life. Good luck!

 

[PistolPete]

I did an intake earlier today that is kind of interesting and help me realize something. To preface, I admit that evaluating ASD, or at least the more mild to moderate presentations that aren't clear cut, is a weak area of mine. I am pretty conservative with this label and a lot of people get it completely wrong. I also do not believe that clinical interview and observation alone are sufficient, unless it's a pretty obvious presentation.

Anyway, peds psychology friend and colleague in my clinic referred to me and asked that I see an older adolescent patient of his. Pt has a history of seeing psych since the age of 5, primarily for anxiety, depression, and tics. Pt described to me as, "odd and somewhat eccentric" in how he interacts socially, with a severe obsession about his plans for the future, which involves him getting multiple advanced degrees from MIT and building some type of radical invention, which I actually can't remember at the moment. He actually has a lot of anxiety about this, especially related to the fear that he may not accomplish his goals.

He is primarily the psychologist's patient, who has a prelim diagnosis of schizotypal personality traits. We've discussed the case in passing previously and that was tossed around. He was referred to me because a neurologist has been prescribing his meds, and the regimen is a complete nonsensical mess, which he has been taking for several years. Neurologist diagnosed him with OCD, ADHD, and Tourette's. I have no idea why he was seeing neuro instead of psych. I guess due to the tourette's diagnosis?

Anyway, my initial session and ROS revealed an adolescent male with a long history of restricted and repetitive interests, difficulty forming and maintaining peer relationships, difficulty understanding social cues, difficulty understanding humor, especially sarcasm, impaired emotional reciprocity, hyperactivity, anxiety as discussed, and chronic sleep problems. No speech/language delay. To me, this all sounded like a straightforward ASD, or what would have previously been called Asperger's.

So, since I of all people honestly felt this was most likely ASD, I had no idea why everyone has missed it for the past 10 years. While the patient has the restricted interests and difficulty with social interaction and engagement, he has always WANTED to interact and socialize with others -- he was just terrible at it and really didn't understand how. This was actually mentioned to me specifically by the psychologist and mom reported this feature was mentioned by several previous docs as eliminating ASD as a possibility, despite literally every other possible feature being present. I actually thought the same thing during the session.

Since I thought it everything else too closely fit with ASD and the overall picture didn't make sense, I went back to review the DSM as well as other texts and literature. I'm sure this is obvious to many, but a lack of interest in social interaction is not a requisite for the diagnosis -- it is merely one possible manifestation of this symptom cluster.

I have actually had to re-read my references more than twice to make sure I wasn't missing something, because it was so difficult to believe that so many of us held that misconception. It's still a bit difficult to believe, so I welcome anyone's feedback, especially if I'm wrong about it not being a requirement. I'll certainly need all the evidence I can find for tomorrow when I tell my friend I think he's wrong 😀

Also, I think it's useful to talk about the times we were wrong or stumped by a case just as much as when we nail it.

Nice writeup. Sounds like ASD. Good point mentioning that WANTING social interaction doesn't automatically rule out ASD.

So.... what did your psychology friend say??!!

 

[DD214_DOC]

He actually didn't say much. He wasn't dismissive. I simply told him my initial thoughts but admitted it was the first session and started late. Even if this ultimately is my diagnosis, it doesn't really change my plan or role. I'm still going to taper and DC meds I don't think are necessary and simplify as best I can, then dispo back.


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