NADD Bulletin Volume III Number 4 Article 1

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“I Feel Like an Alien”: Individual Psychotherapy for Adults with Asperger Disorder Using a Cognitive Behavioral Approach

Valerie Gaus, Ph.D.

Asperger Disorder has only recently been formally recognized in the United States when it was included in the DSM-IV (1994) as a pervasive developmental disability. There it is defined as a disorder involving "severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interests and activities.... In contrast to Autistic Disorder, there are no clinically significant delays in language....In addition, there are no clinically significant delays in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior and curiosity about the environment in childhood." This syndrome was first described 50 years earlier by Hans Asperger, an Austrian pediatrician who wrote about it in 1944. It received little attention until 1981, when Lorna Wing connected writings of Hans Asperger to the cases she was seeing clinically (Attwood, 1998; Ryan, 1994; Wing, 1981). Internationally, there continues to be controversy about the specific criteria to be used when making the diagnosis, but most authors on the subject agree that it is on the same spectrum as Autistic Disorder and that it involves severe problems in social perception and behavior (Attwood, 1998).

The features of Asperger Disorder place individuals at risk for developing other AXIS I disorders. There is a need for more systematic study of co-morbidity issues, but it has been suggested that among individuals with Asperger Disorder there is a higher incidence of anxiety disorders (especially obsessive-compulsive disorder) (Attwood, 1998; Ryan, 1994), mood disorders (especially major depression) (Attwood, 1998; Ryan, 1994, Tantam, 1991), alcohol dependence (Attwood, 1998) and suicide (Wolff, 1995). For these reasons, many people with Asperger disorder will seek mental health service at some point in their lives. The types of services sought may be medication evaluation and management, inpatient psychiatric treatment or psychotherapy.

The focus of this paper is on the mental health needs of adults with Asperger Disorder, with a special emphasis on the utility of psychotherapy. People with Asperger Disorder who are over the age of 20 have lived most of their lives without a correct diagnosis and therefore have missed out on the benefits of the educational and therapeutic programs that are available to today's children diagnosed with the syndrome. Attwood (1998) has suggested that the current generation of children receiving appropriate training and treatment for their disorder may actually grow up to be less vulnerable to mental health problems than their older counterparts. Despite the disadvantages to this cohort, today's adults can learn and grow tremendously with therapeutic support.

Assessment and Diagnosis: Most adults with Asperger Disorder are referred to psychotherapy for problems other than the syndrome per se. Some common presenting problems are anxiety, depression, loneliness, social skill deficits, problems with dating, poor judgement and poor problem-solving ability. Because the diagnosis was not formally available until five years ago, many are still living with inappropriate or nonspecific diagnoses such as "undifferentiated schizophrenia", "schizoaffective disorder", "atypical bipolar disorder" (Ryan, 1994), "atypical anxiety disorder", "schizoid personality disorder", "psychotic disorder NOS", "PDD-NOS", or "autistic-like". The presence of a developmental disability is easy to overlook because, by definition in DSM-IV, persons with Asperger Disorder are not mentally retarded. Many have above-average IQ's, never received special education and have attained college and graduate degrees. Naturally, an inappropriate diagnosis has led to inappropriate treatment for many of these adults. The therapist who receives a referral to treat such an individual must start by unraveling the often confusing tangle of conflicting information.

When a therapist is referred a case in which Asperger Disorder is suspected, a thorough assessment of past social functioning is crucial to make an accurate diagnosis. Accessing family members for interviews about early history is a first step. Questions about developmental milestones, language development, special interests and peer relationships in childhood must be included in such an interview. The individual him/herself will be a valuable source of information about past history. School records that may contain narrative descriptions of the individual's childhood behavior and interactions are also helpful, if available.

Assessment of current functioning should focus on the quantity and quality of interpersonal relationships, special interests and occupational achievement. Direct observation of the individual's behavior during the interview combined with self-report about life situations will contribute to the therapist's diagnostic impression. The initial interview should also include a mental status exam, with a particular emphasis on mood states, anxiety symptoms and suicidal ideation. This is necessary for the therapist to conceptualize secondary mental health problems and to prepare for interdisciplinary collaboration (e.g., referral for a psychiatric evaluation).

Psycho-Education: It is important to start the therapy process by helping the individual understand the disorder and how it may be impacting him/her in life. Adults who are receiving the diagnosis and psycho-education for the first time often report a sense of relief. For example, one 46-year old man said, "I always knew something was wrong and that I did not fit in with other people. I felt like an alien - a freak. Now I understand what the problem is and it all makes sense to me now." Once the individual begins to see that there is an explanation for many of the struggles he/she has encountered, the rationale for psychotherapy can be explored.

Rationale for Psychotherapy: Mental health problems that are secondary to Asperger Disorder are related to the struggle of trying to fit in with society. The interaction between the individual and his/her social surroundings is strained by two major factors. Both are appropriate points of intervention in therapy. They are 1) idiosyncratic processing of social information (internal) and 2) unusual social behaviors leading to recurrent rejection and ridicule by others (external).

1) Idiosyncratic Information Processing: Social cognition (organizing and interpreting social information) is idiosyncratic for people with Asperger Disorder. Therapists with a cognitive-behavioral orientation would describe their tendencies as "cognitive distortions" (e.g., Beck, 1976) or "irrational beliefs". They are prone to a rigid and inflexible style of thinking. All information is taken literally, and once a "rule" is set in the mind of the individual, it is not subject to change easily. One adult with Asperger Disorder described his reasons for not driving. Although he had attained his driver's license, he opted never to use it because the rules of the road could not always be followed literally; e.g., one may need to break a rule by crossing a double yellow line to avoid hitting a cyclist. These driving dilemmas were too stressful for him because of his need to rigidly follow the rules. Other cognitive distortions include "all or nothing thinking" and "catastrophizing" (Beck, 1976; Burns, 1980). For example, another adult with Asperger Disorder described his sensitivity to feedback and constructive criticism. When his roommate commented on some crumbs he had failed to clean up after a midnight snack, he likened the mistake to a criminal offense, stating that he should be arrested, should be thrown out of his apartment, did not deserve to live independently and would probably end up homeless.

2) Recurrent Experiences of Social Rejection and Ridicule: Individual's with Asperger Disorder have a very unique way of utilizing language and relating to others. For example, some individuals use pedantic or overly precise speech, making them sound odd to the listener. There may be lack of reciprocity in conversation where the individual does all of the talking, leaving little room and showing no interest in letting another person speak. For others there may be a paucity of spontaneous speech and they appear to talk too little, answering questions with short sentences and flat affect. There is also a tendency to develop a very special interest in a particular topic, which consumes the individual's time and attention (e.g., astronomy, airplanes, trains, public transportation systems, sports, geography, computers). The individual may become extremely knowledgeable about the subject and will only be able to focus on it in any conversation with another person. They may also display motor clumsiness, facial grimaces or odd hand gestures. As mentioned above, social cognition (organizing and interpreting social information) is idiosyncratic. Cognitive distortions may lead to misinterpretation of social situations and result in behaviors that are seen as socially inappropriate or at times, bizarre.

Any one or a combination of the above features makes the person look different from his or her peers, leading to very early experiences of rejection and being bullied in school. As adults they may suffer different forms of rejection such as being ignored by co-workers, being turned down for a job after the interview or having difficulty getting dates. There is a wide range of abilities and deficits in this population, but all will experience social isolation of one form or another. The worst scenario may involve a person being the victim of violence and exploitation; the best scenario would be simply a lack of social contact and loneliness. Therapists must be careful not to jump in too soon with attempts to change the individual's behavior and to increase social skills; time must be taken to empathize with the long history of social isolation that the person has experienced.

Cognitive-Behavior Therapy: Most of the patterns of thinking and behavior described above are subject to intervention. The author has found success working with these individuals using cognitive-behavior therapy (CBT). The basic assumptions behind CBT are as follows (Dobson & Block, 1988):

1. Cognitive activity affects behavior and emotions.

2. Cognitive activity may be monitored and altered.

3. Desired behavior change may be affected through cognitive change.

For a current description of the utility of CBT in helping people with all types of developmental disabilities, the reader is referred to Kroese, Dagnan and Loumidis (1997).

Adults with Asperger Disorder can be taught to recognize, challenge and slow down the process of automatic maladaptive thoughts. They can also learn to reconceptualize social interactions and to more accurately "read" the behavior of others. These individuals can process complex, abstract information more easily if it is presented visually. Symbols, pictures and/or structured written materials are useful tools in therapy. Therapists can work with their clients to custom design these materials or may use items that are available on the market. For example, Carol Gray has created a plethora of tools geared toward educational settings (Gray, 1994, 1995), but which are easily adapted for use in psychotherapy with this population

In conclusion, psychotherapy for adults with Asperger Disorder can be an effective means of minimizing the stress of living with this syndrome. Crucial components for successful treatment include 1) a thorough assessment, 2) an accurate diagnosis, 3) empathy and support, 4) a method of teaching the individual new ways to understand and negotiate social interactions. A cognitive-behavioral approach provides a useful framework for designing the treatment plan.

References

American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4thedition. Washington, DC: Author.

Asperger, H. (1944). Die "autischen Psychopathen" im Kindeshalter. Archiv Psychiatr. Nervenkrankenheiten, 117, 76-136.

Attwood, T. (1998). Asperger syndrome: A guide for parents and professionals. London: Jessica Kingsley Publishers Ltd.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Avon Books.

Dobson, K. S. & Block, L. (1988). Historical and philosophical basis of the cognitive-behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive -behavioral therapies (pp. 3-38). New York: The Guilford Press.

Ellis, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New York: McGraw-Hill.

Gray, C. (1994). Comic strip conversations. Arlington, TX: Future Horizons.

Gray, C. (1995). The original social story book. Arlington, TX: Future Horizons.

Kroese, B.S., Dagnan, D., & Loumidis, K. (Eds.) (1997). Cognitive-behaviour therapy for people with learning disabilities. London: Routlege.

Ryan, R. (1994). Asperger syndrome. The Habilitative Mental Healthcare Newsletter, 13, 1-6.

Tantam, D. (1991) Asperger syndrome in adulthood. In U. Frith (Ed.), Autism and Asperger Syndrome. Cambridge: Cambridge University Press.

Wing. L. (1981) Asperger syndrome: A clinical account. Psychological Medicine, 11, 115-130.

Wolff, S. (1995) Loners: The life path of unusual children. London: Routledge.

For further information contact:

Valerie Gaus, Ph.D.
YAI - National Institute for People with
Disabilities
460 West 34th Street
New York, NY 10001
(212) 273-6388
gaus@concentric.net

For access to materials by Carol Gray contact:

Future Horizons
720 North Fielder
Arlington, TX 76012
(800) 489-0727