Professional Documents
Culture Documents
ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0001-690X
Case report
attended kindergarten. The patient appeared socially na ve for his age. He used toys in a predictable,
stereotyped and repetitive manner and had a
number of unusual preoccupations and interests.
He disliked any change in his environment and
would restore objects in his living room to their
original position if any of them were moved. His
activities never involved role-playing and was
usually restricted to some repetitive activities.
However, his academic performance was good
through his elementary and junior high school
life. Although often received academic awards, he
could not establish adequate peer relationships.
Unfortunately, obvious deterioration in academic performance was noted after he moved to
a dierent city in the second year of his senior high
school life. He repeated committed theft after he
learned how to steal from his elder classmates
when he was 17 years old. He even collected
objects such as paper, boxes, cups and plastic
bags. The objects he had stolen or collected were
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Chen et al.
hoarded in his living room. He was easily annoyed
if others touched his collections. As a consequence
of his repeated stealing, he was expelled from
senior high school.
The patient was admitted to a psychiatric ward
for the rst time after he was expelled from school.
He was diagnosed as an early case of schizophrenia because he showed the elements of idiosyncratic interests, aective disturbance and a withdrawn
attitude at home. He received sulpiride 200 mg per
day in the ward. His collecting behaviour and poor
personal care were noted in the ward. Lack of
social and emotional reciprocity was also observed.
On the Wechsler Adult Intelligence Scale-Revised
(WAIS-R) test results showed verbal intelligence
quotient (VIQ) 121, performance intelligence
quotient (PIQ) 96 and full intelligence quotient
(FIQ) 111. He answered the questions with a
stilted attitude, good attention and memory were
also noted on examination. Neither hallucinations nor delusions were noted. In addition, the
Rorschach test showed no bizarre thoughts and his
reality was relatively good. He was discharged after
2 months.
During his follow-up at our out-patient department for 1 year, he showed poor drug compliance.
Collecting objects, aloofness, independent daily life
and poor social interaction persisted after his
discharge. Unusual behaviours that had been
noted after his discharge included liking to touch
his fathers face, staring at girls in the streets and
washing excessively. He demonstrated childlike,
gleeful expressions, although there was little inection in his voice and only subtle variations in his
facial expressions. He was, therefore, either gleeful
or at in expression. Little improvement was noted
even after he received sulpiride 200 mg per day for
2 years. Although admission to hospital was considered necessary, this did not happen for another
2 years because of his mothers refusal.
He passed the entrance examinations for university and became a freshman in 1997 when he was
19 years old. However, his stealing behaviours
again caused problems at school. So he dropped
out 2 months later. He was admitted to our ward
again in December 1997 and risperidone 6 mg day
was given under the previous impression that he
had schizophrenia. Two months after admission,
he was transferred to day hospital. The evaluation
for his occupational rehabilitation programme
showed marked diculty in interpersonal relationships. Unfortunately, stealing behaviours recurred
repeatedly during the time he was in day hospital.
As a result, he was discharged from the day
hospital half a year later. His mother cared for him
full-time at home.
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Aspergers disorder
repertoire of interests and activities. As such, this
case can probably be best understood as one of the
pervasive developmental disorders of childhood.
Because he had exhibited life-long eccentricity,
social isolation and awkward movement. This case
is probably best understood in the context of
Aspergers disorder (1).
How should his disturbed behaviours since
childhood and his more recent history of stealing
since he was 17 years old be interpreted in the
context of such a diagnosis? Should the aspects of
his psychiatric diculties be considered in a
secondary diagnosis? His explanation for the
stealing was self-centred, showing limited understanding of its consequences and little empathy for
the distress he might have caused. He admitted that
he enjoyed stealing. He obviously did have a
conduct problem. However, he had no other
behaviour usually associated with the diagnosis
of conduct disorder, his presentation did not meet
the diagnostic criteria for a secondary diagnosis of
conduct disorder. Although he had been diagnosed
as having schizophrenia in the past, the evidence
for this was unconvincing. In particular, there had
been no incontrovertible evidence of rst-rank
symptoms, abnormal beliefs or perceptions. In
addition, the aective disturbance was a feature
from a very early age, and remained largely
unaltered at the age of 21. These features do not
support the diagnosis of schizophrenia. Besides,
the patient neither tried to ignore nor suppress the
impulses of stealing. In other words, it was not egodystonic. Thus his stealing behaviours did not meet
the diagnostic criteria of obsessivecompulsive
disorder or impulse control disorder (kleptomania). Moreover, Tc-99m HMPAO brain SPECT of
the patient showed hypoperfusions in the bilateral
frontal, temporal and posterior parietal lobes. The
presence of these hypoperfusions is consistent with
previous reports that suggested there may be quite
precise areas of the frontal lobes, in particular, the
medial frontal region or Brodmanns area 8, that, if
impaired in early childhood, could produce the
pattern of behaviours and abilities of Aspergers
disorder (2, 3).
Current case reports highlight the special problems shown by Aspergers patients from adolescence onward (4). Tantam noted that such young
adults are prone to suer from a range of
additional psychiatric disorders. It appears that a
minority of individuals can be involved in severe,
strange or even criminal activities such as violence, arson, and even murder (5, 6), because of
their inability to empathize with perspectives of
others and because of their extreme repetitive
interests. Although the literature on Aspergers
Invited comment
Chen et al.
The authors describe a very interesting and
challenging aspect of the relation between schizophrenia and Aspergers disorder. The authors
conclude that some people with Aspergers disorder might be falsely diagnosed with schizophrenia
and this fact might actually apply in most countries psychiatric services.
Aspergers syndrome is apparently more
common than previously believed (1). The condition was rst described by Hans Asperger as
psychopathy in childhood in 1940s (2). The diagnosis was relanced by Lorna Wing (3) in the early
1980s and included in the diagnostic systems the
International Classication of Diseases, Tenth
Revision (IDC-10) (4) as well as Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) (5) as, respectively, Aspergers
syndrome and Asperger disorder. The disorder is
characterized by higher intellectual ability with
more advanced language skills than those shown
by children with autism. People with Aspergers
syndrome show empathy diculties and eccentricities with impaired understanding of social convention, severe impairment in reciprocal social
interaction, and circumscribed interests of an
unsocial nature. Supercially excellent language
skills usually coexist with stilted or pedantic
speech, poor understanding of metaphors and
non-verbal communication diculties. Clumsiness
is common. The term is often used to describe the
milder end of the autistic spectrum.
Although the age of onset is dierent from early
onset schizophrenia, many cases of Aspergers
syndrome remain undetected (either because of
their compensating mechanisms, or lack of recognition of this particular condition). They may be
referred for psychiatric or psychological treatment
in the adolescent years because of late recognition
of social problems, odd behaviour, and lack of
empathy, which might in itself cause problems with
peers, school activities, etc. or they might be
referred because of the presence of comorbid
diagnosis such as depression or suspected psychotic
symptoms. The comorbidity between Aspergers
syndrome and schizophrenia is low and the risk of
developing schizophrenic symptoms in people with
Aspergers syndrome is rather limited. However,
there is suggestive evidence that children diagnosed
with schizophrenia often have an early history
indicating an autism spectrum disorder (6). Furthermore, some young people with Aspergers
syndrome might de-compensate and experience periods with psychotic symptoms, such as
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