Tuesday, July 13, 2010

On the Relationship Between Schizoid Disorder and Asperger's Syndrome

Several mental health professionals have diagnosed me with Schizoid Personality Disorder.  Ben Bregman, M.D. suggested at my consult with him on July 12, 2010 that I might have Asperger's Syndrome.  

The following discusses the relationship between Schizoid disorder and Asperger's.  It's a murky area.

Asperger regarded the syndrome he described as a disorder of personality that could be distinguished from other types of personality abnormalities although he recognised the similarities to early childhood autism. Wolff & Barlow (1979) argued that it should be classified under the heading of schizoid personality. In support of this view, Wolff & Chick (1980) reviewed the literature in which schizoid characteristics are described. As discussed above, the syndrome can be placed in this group, and further work in this field would be of interest, but, at the moment, classification under this heading has no useful practical implications. Although Wolff & Chick have listed five features, operationally defined, that they regard as core characteristics of schizoid personality, this term, as generally used, is so vague and ill-defined a concept that it covers a wide range of clinical pictures in addition to Asperger syndrome. The aim should be not to enlarge, but to separate sub-groups from the broad category and thus to increase diagnostic precision. Furthermore, the word schizoid was originally chosen to underline the relationship of the abnormal personality to schizophrenia. The latter can occur in a person with Asperger syndrome, but, as already discussed, there is not firm evidence of a special link between this syndrome and schizophrenia, strictly defined. To incorporate such an untested assumption into the name of the condition must give rise to confusion.

The reasons for personality variations are so obscure that classifying Asperger syndrome under this heading does not lead to any testable hypotheses concerning cause, clinical phenomena, pathology or management. A more limited, but more productive, view of the problem is to consider it as a consequence of impairment of certain aspects of cognitive and social development.

As mentioned above, Wing & Gould (1979) carried out an epidemiological study of all mentally or physically handicapped children in one area of London, in an attempt to identify all those with autism or autistic-like conditions, whatever their level of intelligence. The results confirmed the following hypothesis. Certain problems affecting early child development tend to cluster together: namely, absence or impairment of two-way social interaction; absence or impairment of comprehension and use of language, non-verbal as well as verbal; and absence or impairment of true, flexible imaginative activities, with the substitution of a narrow range of repetitive, stereotyped pursuits. Each aspect of this triad can occur in varying degrees of severity, and in association with any level of intelligence as measured on standardised tests.

When all children with this cluster of impairments were examined, it was found that a very few resembled the description given by Asperger and some had typical Kanner's autism. A number could, tentatively, be classified as having syndromes described by authors such as De Sanctis (1906, 1908), Earl (1934), Heller (see Hulse, 1954) and Mahler (1952), although the definitions given by these writers were not precise enough for easy identification. The remainder had features of more than one of these so-called syndromes and under the general, but unsatisfactory, heading of early childhood psychosis. The justification for regarding them as related is that all the conditions in which the triad of language and social impairments occurs, whatever the level of severity, are accompanied by similar problems affecting social and intellectual skills. Furthermore, individuals with the triad of symptoms all require the same kind of structured, organised educational approach, although the aims and achievements of education will vary from minimal self-care up to a university degree, depending on the skills available to the person concerned.

This hypothesis does not suggest that there is a common gross aetiology. This is certainly not the case, since many different genetic or pre-, peri- or post-natal causes can lead to the same overt clinical picture (Wing & Gould, 1979). It is more likely that all the conditions in which the triad occurs have in common impairment of certain aspects of brain function that are presumably necessary for adequate social interaction, verbal and non-verbal communication and imaginative development. It is possible that these are all facets of one underlying in-built capacity - that is, the ability actively to seek out and make sense of experience (Ricks & Wing, 1975). Included in this would be the innate ability to recognise other human beings as distinct from the rest of the environment and of special importance. If this basic skill were diminished or absent, the effects on development would be profound, as is the case in all early childhood psychoses.

The full range of clinical material can be sub-divided in many different ways, depending on the purpose of the exercise, but no aetiological classification is possible as yet. Sub-grouping on factors such as level of intelligence (Bartak & Rutter, 1976) or on degree of impairment of social interaction (DeMyer, 1976; Wing & Gould, 1979) has more useful practical implications for education and management than any based on the eponymous syndromes mentioned above.

In the light of this finding, is there any justification for identifying Asperger syndrome as a separate entity? Until the aetiologies of such conditions are known, the term is helpful when explaining the problems of children and adults who have autistic features, but who talk grammatically and who are not socially aloof. Such people are perplexing to parents, teachers and work supervisors, who often cannot believe in a diagnosis of autism, which they equate with muteness and total social withdrawal. The use of a diagnostic term and reference to Asperger's clinical descriptions help to convince the people concerned that there is a real problem involving subtle, but important, intellectual impairments, and needing careful management and education.

Finally, the relationship to schizophrenia of Asperger syndrome, autism and similar impairments can be reconsidered. Although they are dissimilar in family history, childhood development and clinical pictures, both groups of conditions affect language, social interaction and imaginative activities. The time of onset and the nature of the disturbances are different, but there are similarities in the eventual chronic defect states that either may produce. It is not surprising that autism and schizophrenia have, in the past, been confused. Progress has been made in separating them and it is important to continue to improve precision in diagnosis, despite the many difficulties met in clinical practice.

1 comment:

Anonymous said...

You are interchanging schizoid with schizophrenia. They have different meanings.