Asperger’s Syndrome psychiatric case presentation

1. Mohamed sedky
Psychiatric specialist
BMHH
Feb. 2015

2. Identification Data
 Mr. TA a 28 years old, single, saudi gentleman, lives in
buraidah, a college graduate works as a primary school
teacher in algouf area, non smoker.teacher in algouf area, non smoker.
 Mr. TA presented to our medical committee one month
ago for psychiatric assessment.

3. Past History
 Mr. TA presented to our hospital for the first time 21 years
ago, when he was 7 years old.
 The main complain was low mentality observed by his
parents since he was 4 years old:parents since he was 4 years old:
“‫ﻓﯿﮫ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ ‫ﻛﻤﺎ‬ ‫طﺒﯿﻌﻲ‬ ‫ھﻮ‬ ‫ﻣﺎ‬ ‫اﻟﻮﻟﺪ‬ ‫ان‬ ‫ﻣﻼﺣﻈﯿﻦ‬ ‫ﺳﻨﻮات‬ ‫ﺛﻼث‬ ‫ﻟﻨﺎ‬ ‫ﺻﺎر‬ ‫أﺣﻨﺎ‬
‫اﻟﻌﻘﻠﻲ‬ ‫ﻧﻤﻮه‬ ‫ﻓﻲ‬ ‫ﺗﺄﺧﺮ‬,‫اﺧﻮاﺗﮫ‬ ‫و‬ ‫اﺧﻮاﻧﮫ‬ ‫ﺑﺎﻗﻲ‬ ‫ﻋﻦ‬ ‫ﻣﺨﺘﻠﻔﺔ‬ ‫ﺗﺼﺮﻓﺎﺗﮫ‬”
 Also he had bedwetting.

4. Past History
 The provisional diagnosis was:
Mental retardation ( mild)
 IQ test was ordered

5. Past History
 The result of the IQ test was: 80 – 90 (average IQ)
“‫اﻻداء‬ ‫و‬ ‫اﻟﻤﻘﺎﺑﻠﺔ‬ ‫ﺧﻼل‬ ‫ﻣﻦ‬,‫ﺑﻨﺴﺒﺔ‬ ‫ﺗﺘﺮواح‬ ‫ﻟﺪﯾﮫ‬ ‫اﻟﻌﺎم‬ ‫اﻟﺬﻛﺎء‬ ‫ﻧﺴﺒﺔ‬ ‫أن‬ ‫ﻧﺘﻮﻗﻊ‬٨٥—٩٠
‫اﻟﻤﺘﻮﺳﻂ‬ ‫ﻣﻦ‬ ‫اﻻﻗﻞ‬ ‫اﻟﻌﺎدي‬ ‫اﻟﺬﻛﺎء‬ ‫ﻓﺌﺔ‬ ‫ﻓﻲ‬ ‫ﯾﺼﻨﻒ‬ ‫ان‬ ‫ﯾﻤﻜﻦ‬ ‫و‬”
He was given:
Tofranil 10 mg tab. 1x1
B complex syrup 5 ml x 2
He did not show back up till 11 years later.

6. Past History
 11 years later, when the patient was 18 years old (secondary school), he was
brought to OPD by his parents, with the following complaints:

7. Past History
 Differential diagnosis:
ADHD
Conduct disorder – personality disorder
Impulse control disorderImpulse control disorder
 He was given tofranil 25 mg tab. 1x2 ( 2 weeks)

8. Past History
 2 weeks later in OPD: his father reported that no
improvement.
 Physician noted that patient still avoiding eye contact
and looks indifferent.and looks indifferent.

9. Past History
 One week later he was presented to the medical
committee (for the purpose of diagnosis) with the
following conclusion:
“No ADHD disorder, and patient has antisocial traits”
"‫ﻣﻼﺣظﺔ‬ ‫ﻣﻊ‬ ‫اﻟﺣرﻛﺔ‬ ‫ﻓرط‬ ‫و‬ ‫اﻻﻧﺗﺑﺎه‬ ‫ﻧﻘص‬ ‫اﺿطراب‬ ‫وﺟود‬ ‫ﻋدم‬ ‫اﻟﻠﺟﻧﺔ‬ ‫ﻗررت‬
‫اﻟﺣﺎﻟﻲ‬ ‫اﻟوﻗت‬ ‫ﻓﻲ‬ ‫ﻋﻼج‬ ‫ﯾﻌطﻰ‬ ‫ﻻ‬ ‫و‬ ‫اﻟﻣﺳﻠك‬ ‫اﺿطراب‬ ‫ﺳﻣﺎت‬ ‫ﺑﻌض‬"

10. Past History
 The school social worker called the treating
psychiatrist and informed him by the following:
‫اذن‬ ‫ﺑدون‬ ‫ﯾﺗﻛﻠم‬ ‫اﻟوﻟد‬–‫ﻏﯾر‬ ‫ﻣن‬ ‫او‬ ‫ﻣﻧﺎﺳﺑﺔ‬ ‫ﻟﮫ‬ ‫ﺳواء‬ ‫ﻣﻌﻧﻰ‬ ‫ﻣﺎﻟﮫ‬ ‫ﻛﻼم‬ ‫ﯾﺗﻛﻠم‬ ‫اذن‬ ‫ﺑدون‬ ‫ﯾﺗﻛﻠم‬ ‫اﻟوﻟد‬–‫ﻏﯾر‬ ‫ﻣن‬ ‫او‬ ‫ﻣﻧﺎﺳﺑﺔ‬ ‫ﻟﮫ‬ ‫ﺳواء‬ ‫ﻣﻌﻧﻰ‬ ‫ﻣﺎﻟﮫ‬ ‫ﻛﻼم‬ ‫ﯾﺗﻛﻠم‬
‫ﻣﻧﺎﺳﺑﺔ‬–‫ﺻوﺗﮫ‬ ‫وﯾرﻓﻊ‬ ‫اﻻﺻوات‬ ‫ﯾﻘﻠد‬ ‫و‬–‫ﺗﻛﻠﻣﮫ‬ ‫ﻋﻧدﻣﺎ‬ ‫ﻻﻣﺑﺎﻻة‬–‫ﯾﻣزح‬
‫زﻣﻼﺋﮫ‬ ‫ﻣﻊ‬ ‫ﺑﺎﻟﯾد‬ ‫واﺣﯾﺎﻧﺂ‬ ‫ﺑﺛﻘل‬–‫ﻣﺗزن‬ ‫ﻏﯾر‬ ‫ﺑﺷﻛل‬ ‫ﯾﻣﺷﻲ‬–‫ﻋن‬ ‫ﯾﺗﺄﺧر‬
‫اﻟﺣﺻص‬–‫ﺑﺄس‬ ‫ﻻ‬ ‫اﻟدراﺳﻲ‬ ‫اﻟﺗﺣﺻﯾل‬.
‫اﻟﺧﻼﺻﺔ‬:‫و‬ ‫اﻻدارﯾﯾن‬ ‫و‬ ‫ﻟﻠﻣدرﺳﯾن‬ ‫اﻟﻣدرﺳﺔ‬ ‫داﺧل‬ ‫ﻣﻘﻠﻘﺔ‬ ‫و‬ ‫ﻣزﻋﺟﺔ‬ ‫ﺣﺎﻟﺗﮫ‬
‫ﺣﺎﻟﺗﮫ‬ ‫ﻋن‬ ‫ﯾﺗﻛﻠم‬ ‫اﻟﻛل‬ ‫ﺻﺎر‬ ‫و‬ ‫اﻟطﻼب‬–‫ﻣﺷﻛﻠﮫ‬ ‫ﻓﯾﮫ‬ ‫اﻟوﻟد‬.

11. Past History
 He was reviewed by the medical committee, with the
conclusion that:
“The patient has no psychotic or neurotic disorder, no“The patient has no psychotic or neurotic disorder, no
personality disorder, but he shows some antisocial traits.
And he in need for CBT”.
"‫ﯾوﺟد‬ ‫ﻟﻛن‬ ‫و‬ ‫اﻟﺣﺎﻟﻲ‬ ‫اﻟوﻗت‬ ‫ﻓﻲ‬ ‫ﻋﺻﺎﺑﻲ‬ ‫او‬ ‫ذھﺎﻧﻲ‬ ‫اﺿطراب‬ ‫ﯾوﺟد‬ ‫ﻻ‬
‫ﺳﻣﺎت‬ ‫ﺑﻌض‬ ‫ﺳﻠوﻛﻲ‬ ‫اﺿطراب‬)‫اﻟﻣﺳﻠك‬ ‫إﺿطراب‬(‫اﺿطراب‬ ‫ﯾوﺟد‬ ‫ﻻ‬ ‫ﻟﻛن‬ ‫و‬
‫واﺿﺢ‬ ‫ﺷﺧﺻﯾﺔ‬.‫ﺗﺣﺗﺎج‬ ‫و‬ ‫ﻋﻘﻠﻲ‬ ‫ﻋﻼج‬ ‫اﻟﻰ‬ ‫اﻟﺣﺎﻟﻲ‬ ‫اﻟوﻗت‬ ‫ﻓﻲ‬ ‫ﺗﺣﺗﺎج‬ ‫ﻻ‬ ‫اﻟﺣﺎﻟﺔ‬
‫اﻻﺟﺗﻣﺎﻋﻲ‬ ‫و‬ ‫اﻟﻧﻔﺳﻲ‬ ‫اﻻﺧﺻﺎﺋﻲ‬ ‫ﺑواﺳطﺔ‬ ‫ﻣﻌرﻓﻲ‬ ‫ﺳﻠوﻛﻲ‬ ‫ﻋﻼج‬ ‫اﻟﻰ‬"

12. Past History
 He did not show back up till 10 years later
(One month ago).(One month ago).

13. History Of The Present Illness
 One month ago he was presented to the medical
committee (upon request from the court) for psychiatric
assessment.assessment.

14. History Of The Present Illness
 Mr. TA and his mother was interviewed
 Sample of the mother’s talk:
‫ھو‬‫ﻟﮫ‬‫ﻗﺿﯾﺔ‬‫ﻓﻲ‬‫اﻟﻣﺣﻛﻣﺔ‬‫ﻻﻧﮫ‬‫ﻓﯾﮫ‬‫ﻋﺎﻣل‬‫ﺑﺎﻛﺳﺗﺎﻧﻲ‬‫ﺣﺎول‬‫ﯾﺳﺗدرﺟﮫ‬,‫اﺳﺗدراج‬‫ﺟﻧﺳﻲ‬
‫ﺑﻣﺑﻧﻰ‬‫ﺗﺣت‬‫اﻻﻧﺷﺎء‬‫ﺑﻌﯾون‬‫اﻟﺟواء‬‫و‬‫ﻣﺳﻛﮭم‬‫اﻟﺣﺎرس‬‫وﺳﻠﻣﮭم‬‫ﻟﻠﺷرطﺔ‬.‫اﻟﻣﺷﻛﻠﺔ‬‫ان‬ ‫ﺑﻣﺑﻧﻰ‬‫ﺗﺣت‬‫اﻻﻧﺷﺎء‬‫ﺑﻌﯾون‬‫اﻟﺟواء‬‫و‬‫ﻣﺳﻛﮭم‬‫اﻟﺣﺎرس‬‫وﺳﻠﻣﮭم‬‫ﻟﻠﺷرطﺔ‬.‫اﻟﻣﺷﻛﻠﺔ‬‫ان‬
‫اﻟوﻟد‬‫ﻋﻧده‬‫ﻗﻠﺔ‬‫ﺗﻣﯾﯾز‬‫ﯾﻌﻧﻲ‬‫ﻣﻣﻛن‬‫ﻟو‬‫طﻔل‬‫ﺻﻐﯾر‬‫ﯾﺎﺧد‬‫إﻟﻠﻲ‬‫ﻓﻲ‬‫إﯾده‬‫ﺑدون‬‫ﻣﺎ‬‫ﯾﻌﺗرض‬,
‫ھو‬‫ﻋﻠﻰ‬‫ﺳﺟﯾﺗﮫ‬‫و‬‫ﯾﺻدق‬‫أي‬‫ﺷﻲ‬‫ﯾﺗﻘﺎﻟﮫ‬.‫أﺣد‬‫زﻣﻼﺋﮫ‬‫أﺧذ‬‫ﻗرض‬‫ﻣن‬‫اﻟﺑﻧك‬‫ﺑﺎﺳﻣﮫ‬‫ب‬
١٨٠‫اﻟف‬‫و‬‫اﺷﺗراﻟﮫ‬‫ﺳﯾﺎرة‬‫ﺑﺣواﻟﻲ‬١٠٠‫أﻟف‬‫و‬‫أﺧذ‬‫اﻟﺑﺎﻗﻲ‬‫و‬‫أﺧذ‬‫ﻣﻧﮫ‬‫رﻗم‬‫ﺣﺳﺎﺑﮫ‬
‫اﻟﺳري‬‫و‬‫ﻛل‬‫أوراﻗﮫ‬.
‫و‬‫ﻓﻲ‬‫ﻣرة‬‫ﻗﺎﻟﮫ‬‫زﻣﻼﺋﮫ‬‫ﻧﺑﻲ‬‫ﻧﺣط‬‫ﻋزﯾﻣﺔ‬‫إﻧت‬‫ﻋﻠﯾك‬‫اﻟذﺑﯾﺣﺔ‬‫و‬‫إﺣﻧﺎ‬‫ﻋﻠﯾﻧﺎ‬‫اﻟطﺑﺦ‬‫وواﻓق‬.
‫ﻣدﯾر‬‫اﻟﻣدرﺳﺔ‬‫ﻗﺎﻟﮫ‬‫اﻧت‬‫ﻣﺎ‬‫ﺗﺻﻠﺢ‬‫ﻟﻠﺗدرﯾس‬‫و‬‫ﻟﻛن‬‫أﻧﺎ‬‫ﻣﺎ‬‫أﺑﻲ‬‫أﻗطﻊ‬‫رزﻗك‬.‫اﻟوﻟد‬‫أﺣﯾﺎﻧﺂ‬
‫ﯾﺿﺣك‬‫ﻋﻠﻰ‬‫أﺷﯾﺎء‬‫ﻣﺎﻓﯾﮭﺎ‬‫ﺿﺣك‬‫و‬‫أﺣﯾﺎﻧﺂ‬‫ﯾﻔﻛر‬‫ﺑﺻوت‬‫ﻣﺳﻣوع‬.

15. History Of The Present Illness
 Sample of the patient’s talk:
‫أﻧﺎ‬‫أﺷﺗﻐل‬‫ﻣدرس‬‫ﻣن‬‫ﺣواﻟﻲ‬‫ﺳﻧﺗﯾن‬‫ﺑﺎﻟﺟوف‬,‫ﻣﺷﻛﻠﺗﻲ‬‫اﻧﻲ‬‫ﺿﻌﯾف‬ ‫أﻧﺎ‬‫أﺷﺗﻐل‬‫ﻣدرس‬‫ﻣن‬‫ﺣواﻟﻲ‬‫ﺳﻧﺗﯾن‬‫ﺑﺎﻟﺟوف‬,‫ﻣﺷﻛﻠﺗﻲ‬‫اﻧﻲ‬‫ﺿﻌﯾف‬
‫اﻟﺷﺧﺻﯾﺔ‬,‫ﻋﻧدي‬‫ﺿﻌف‬‫ﻋﻘل‬‫و‬‫ﺗﻣﯾﯾز‬‫و‬‫إدراك‬.‫ﻓﻲ‬‫اﻟﻣدرﺳﺔ‬‫ﻣﺎ‬‫أﻋرف‬‫اظﺑط‬
‫اﻟﺻف‬,‫اﻟطﻼب‬‫ﯾﺿﺣﻛون‬‫ﻋﻠﻲ‬,‫ﯾدﺧﻠون‬‫و‬‫ﯾطﻠﻌون‬‫ﻣن‬‫اﻟﻔﺻل‬‫ﻣﺎ‬‫أﻗدر‬‫أﺳﯾطر‬
،‫ﻋﻠﯾﮭم‬‫ﻣدﯾري‬‫ﯾﻘول‬‫اﻧﻲ‬‫ﻣﺎ‬‫اﻋرف‬‫ادرس‬‫اﻟطﻼب‬.
‫ﺟﺎﻧﻲ‬‫ﻋﺎﻣل‬‫ﺑﺎﻛﺳﺗﺎﻧﻲ‬‫و‬‫طﻠب‬‫ﻣﻧﻲ‬‫أوﺻﻠﮫ‬‫ﻟﻌﯾون‬‫اﻟﺟوا‬‫و‬‫ﻓﻲ‬‫اﻟطرﯾق‬‫ھددﻧﻲ‬‫و‬
‫أﺧذﻧﻲ‬‫ﻟﻌﻣﺎرة‬‫ﻣﮭﺟورة‬‫ﺑﻌﯾون‬‫اﻟﺟواء‬,‫ﻣﺎ‬‫أدري‬‫إﯾش‬‫ﯾﺑﻲ‬,‫و‬‫أﺣﻧﺎ‬‫داﺧﻠﯾن‬‫ﺟﮫ‬
‫اﻟﺣﺎرس‬‫وﻗﺎل‬‫أﻧﺗم‬‫ﺗﺑون‬‫ﺗﺳرﻗون‬‫و‬‫ﺑﻠﻎ‬‫اﻟﺷرطﺔ‬‫و‬‫ﺟﺎت‬‫أﺧذﺗﻧﺎ‬‫و‬‫ﺻﺎرت‬
‫ﻗﺿﯾﺔ‬.

16. Mental State Examination
Mr. TA is a 28 years old male, who looks slightly older than
stated age, he is overweight shows adequate grooming and
hygiene, he showed average psychomotor activity, but with
clumsy gait, During interview he was cooperative, yet,
appearing anxious with limited facial expressions and wasappearing anxious with limited facial expressions and was
trying to avoid eye to eye contact. Speech is both
spontaneous and induced, of average rate, shows low
volume and monotonous tone. No hallucinations, and no
delusions can be detected, shows slow thinking process and
needs extra time to comprehend questions. Shows restricted
anxious affect with euthymic mood. No suicidality or
homicidality can be elicited.

17. psychometry
 IQ test result was: 79±5
 With discrepancy between verbal and performance scores: With discrepancy between verbal and performance scores:
 Verbal IQ Score: 87
 Performance IQ Score: 72

18.  The patient was diagnosed as a case of:
Asperger’s Syndrome

19. What is Asperger’s Syndrome?

20. What is Asperger’s Syndrome?
 Asperger’s Syndrome is a neurobiological
disorder named for a Viennese physician,
Hans Asperger, who in 1944 published a
paper which described a pattern of behaviorspaper which described a pattern of behaviors
in several young boys who had normal
intelligence and language development, but
who also exhibited autistic-like behaviors and
marked deficiencies in social and
communication skills.

21. Demographics
 gender:
 Estimated male-to-female ratio is approximately 4:1.
 Prevelence: Prevelence:
 Two out of every 10,000 children have the disorder
 Asperger’s Syndrome is usually diagnosed between
the ages of 5 and 9.

22. Asperger’s Syndrome: Symptoms
•Difficulty with social interactions
•Odd Speech/Communication Style
•Difficulty with Social Imagination
•Obsessive interests•Obsessive interests
•Routine/Repetitive behaviors
•Hypersensitivity to lights, sound, smells
•Other Possible Symptoms

23. Difficulty with social interactions
 Lack basic social skills: they may stand too
close, stare inappropriately or not make eye
contact, have marked lack of concern over
appearance, be oblivious to others’ reactions,
change topics idiosyncratically.
 unaware of others' feelings.
 Difficulty empathizing or taking another
person’s perspective.person’s perspective.
 Lacking in ability to show compassion,
sympathy, and sincere happiness.
 naive and gullible.
 Behave in what may seem an inappropriate
manner.
 Difficulty in distinguishing intimate
relationships from friendships.
 Easily manipulated and often an easy target for
bullying due to naïvety.

24. Difficulty with social interactions
 Impairments in establishing peer
relationships (don’t know how to engage
an appropriate way).
 Sometimes appearing shy or
withdrawn, but willing to speak when
spoken to.spoken to.
 Find people unpredictable and
confusing.
 Can become withdrawn and aloof.
 Cannot understand the unwritten
social rules that most of us take for
granted.

25. Odd Speech/Communication Style
 literal in speech with difficulty understanding jokes,
sarcasm and metaphor
 Needs extra time to process questions or comments.
 repeat words and phrases i.e. because meaning is not repeat words and phrases i.e. because meaning is not
understood
 Talks in a flat affect: Speech may lack tone, pitch, and
accent (like a “robot”).
 Difficulty knowing when to start or end a
conversation.

26. Odd Speech/Communication Style
 Few facial expressions and difficulty reading others’
body language
 Lack of “common sense” and an inability to identify
social cues
 Intrusiveness or difficulty recognizing social
boundaries
Intrusiveness or difficulty recognizing social
boundaries
 show little eye contact
 Low to no sense of humor.
 Lacking in ability to greet others in a warm and
friendly way.
 Acting in a somewhat immature manner.

27. Difficulty with Social Imagination
 Rigid/solid thinking e.g. emphasis on learned
routines/little flexibility.
 Limited intuition / little instinctive understanding.
 Problem in generalizing. Problem in generalizing.
 Little connection between Action and Consequence.

28. Difficulty with Social Imagination
 Disconnects - sees the detail rather than the whole
picture.
 Poor problem-solving and organisational skills.
 Difficulty imaging alternative outcomes to situations Difficulty imaging alternative outcomes to situations
and finding it hard to predict what will happen next.

29. Obsessive interests
 Preoccupation with narrow area of interest.
 Fascinated with numbers and letters.
 Preoccupation with objects.
Obsessions with a single topic such as music, Obsessions with a single topic such as music,
dinosaurs, or cars.

30. Routine/Repetitive behaviors
 Intense need for routine and consistency
with anxiety when routines are not followed.
 Stereotyped Behaviors, Activities, and
Interests.
Repetitive motor movements. Repetitive motor movements.

31. Hypersensitivity to lights, sound, smells
 Can be hypersensitive to or bothered by lights,
sounds/noises, smells, strong tastes or textures

32. Other Possible Symptoms
 Low self-esteem and self-
concept: they are aware of their
difference and blame themselves
rather than the disability.
 Often self-described “loners”.
 Motor clumsiness, and physically
awkward in sports.
 Poor handwriting or trouble with
other motor skills (i.e. riding a
bike).
 May show aggression.

33. Here … We Have Tow Questions
Is this man legally
responsible for his act?
Is he fit to work as a
teacher?