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.
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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 | Autism | 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