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Copyright Blackwell Munksgaard 2003

Acta Psychiatr Scand 2003: 107: 7376


Printed in UK. All rights reserved

ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0001-690X

Case report

Aspergers disorder: a case report of repeated


stealing and the collecting behaviours
of an adolescent patient
Chen PS, Chen SJ, Yang YK, Yeh TL, Chen CC, Lo HY. Aspergers
disorder: a case report of repeated stealing and the collecting behaviours
of an adolescent patient.
Acta Psychiatr Scand 2003: 107: 7376. Blackwell Munksgaard 2003.
Objective: To discuss special behavioural problems shown by a patient
with Aspergers disorder from adolescence onward.
Method: The case and treatment of a 21-year-old male patient is
described.
Results: A 21-year-old male developed obstinate stealing behaviours
when he was 17 years old. He was regarded as a schizophrenic at rst,
and was suspected of kleptomania later. Aspergers disorder was
diagnosed after we reconsidered the relationship between the schizoid
psychopathy in childhood and the stealing behaviours which occurred
in adolescence.
Conclusion: A wide variety of bizarre behaviours and so-called
borderline behaviours occur in late adolescence and adult life of
patients with Aspergers disorder. But classic schizophrenia is very
rare. Psychiatrists unacquainted with the clinical diagnosis context
may nd it dicult to evaluate concrete, childish, or bizarre
symptoms in patients with Aspergers disorder, and thus are prone to
misdiagnose them as having schizophrenia disorders or other similar
disorders.
Introduction

The case presented here is of a 21-year-old man


with Aspergers disorder and a 4-year history of
stealing. It is interesting because very few studies of
criminal activity in cases of Aspergers disorder
have been conducted previously.
Case summary

The 21-year-old male was the older of two children,


his father was an engineer and his mother had been
a bank clerk. He was born following a full-term and
uncomplicated pregnancy. Apart from enteritis in
infancy, his medical history was unremarkable.
Speech and language skills early in his life were
apparently normal. Socially, he had always been
remote and isolated, having had very few friends
throughout his childhood. Diculty with interpersonal relationships and reluctance to go to public
places were also noted starting from the time he

P. S. Chen1, S. J. Chen1, Y. K. Yang1,


T. L. Yeh1, C. C. Chen1,2, H. Y. Lo1
1

Department of Psychiatry, National Cheng Kung


University Medical College and Hospital; and
1,2
Pharmacia Taiwan Inc., Taipei, Taiwan

Key words: Asperger's disorder; adolescence;


stealing; schizophrenia
Dr Po See Chen, Department of Psychiatry, National
Cheng Kung University and Hospital, Tainan 704, Taiwan
E-mail: chenps@mail.ncku.edu.tw
Accepted for publication July 24, 2002

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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His repeated commissions of theft made his


mother lock him in their apartment. However, he
would climb out of the window to steal letters from
mailboxes in the neighbourhood. Collecting
objects, temper tantrums, aggressive behaviours
and poor self-care aected him very much. So he
was re-admitted when he was 21 years old. Since
admission, he had been noted to be physically
clumsy and awkward. He kept a close distance
when talking to females and displayed marked
sexual interest. He liked to be with other people
and talk about the idiosyncratic interests that
preoccupied him. He overemphasized his own
ability and importance. Regarding theft and collecting, he would act under obsessive impulses. He
showed aggressive attitudes when these acts were
prohibited.
He was started on uoxetine 40 mg with 2 mg of
risperidone per day because of his repetitive
behaviours. In addition, 30 mg propranolol and
400 mg carbamazepine were given for his aggressive behaviour. Behaviour therapy using contracts
to target the stealing and collecting behaviours
were carried out at the same time. His stealing and
collecting behaviours were often noted in the ward,
but he did not try very hard to resist impulses to
steal. We gradually increased the dosage of uoxetine to 80 mg per day. Risperidone was withdrawn after the second month of admission
because of extra-pyramidal side-eects. The frequency of committing theft decreased but the
collecting behaviour persisted. In addition, the
patient was still eccentric in the patient group. He
often tried to avoid group activity in his occupational programme. Because the patient expressed
restlessness, euphoric eects and anxiety after high
dosage of the uoxetin treatment, the dosage was
reduced to 20 mg per day. Tc-99m hexamethylpropylene amine oxime (HMPAO) brain singlephoton emission tomography (SPECT) showed
hypoperfusion in the bilateral frontal, temporal
and posterior parietal lobes. The diagnosis was
revised to Aspergers disorder after reconsidering
the relationship between schizoid psychopathy in
the childhood and the stealing behaviours that
occurred in adolescence in a longitudinal view.
Discussion

The problems aecting the young man had been


present since an early age. The WAIS-R test
performed when he was 17 showed statistically
signicant dierence between his verbal and nonverbal abilities. His diculties included severe
impairment of his reciprocal social interactions in
addition to a restricted, stereotyped and repetitive

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

disorder includes reports of individuals who have


committed criminal oences, there have been no
reports of the commission of theft prior to this
report. The actual incidence of violent oences is
remarkably low (7). Cases included individuals
who had been brought before the criminal justice
system for a variety of oences that had been
caused by their peculiar interests, sensory sensitivity, or strong moral codes (8).
Superimposed psychiatric problems are also
common in the adult life of such patients, a wide
variety of bizarre behaviour and so-called borderline behaviours occur in late adolescence and adult
life in Aspergers disorder, but classic schizophrenia is very rare. Asperger stated that only one in
200 of his cases went on to develop symptoms of
schizophrenia (9). Psychiatrists unacquainted with
the clinical contexts may nd it dicult to evaluate concrete, childish or bizarre symptoms in
Aspergers disorder and thus are prone to misdiagnose them as having schizophrenia or other
similar disorders such as schizophreniform disorder or similar constructs.
References
1. Tantam D. Aspergers syndrome. J Child Psychol Psychiatry
1988;29:245255.
2. Margaret LB. Brief report: neuroanatomic observations of
the brain in pervasive developmental disorders. J Autism
Dev Disord 1996;26:199203.
3. Happe F, Ehlers S, Fletcher P et al. Theory of mind in the
brain. Evidence from a PET scan study of Aspergers syndrome. Clin Neurosci Neuropathol 1996;8:197201.
4. Baron-Cohen S. An assessment of violence in a young man
with Aspergers syndrome. J Child Psychol Psychiatry
1988;29:351360.
5. Everall IP, Lecouteur A. Fire setting in an adolescent boy
with Aspergers syndrome. Br J Psychiatry 1990;157:
284287.
6. Mawson D, Grounds A, Tantam D. Violence and Aspergers
syndrome: a case study. Br J Psychiatry 1985;147:566569.
7. Ghaziuddin M, Tsai L, Ghaziuddin N. Brief report: violence
in Asperger syndrome a critique. J Autism Dev Disord
1991;21:34993354.
8. Tantam D. Lifelong eccentricity and social isolation I. Psychiatric, social and forensic aspects. Br J Psychiatry
1988;153:777782.
9. Asperger H. Die autistischen Psychopathen im Kindesalter.
Arch for Psychiatrie Nervenkrankheiten 1944;117:76136.

Invited comment

The case of the month by Chen, Chen, Yang, Yeh,


Cheng and Lo describes a case of Aspergers
disorder. The authors point to the very important
fact that some people with Aspergers disorder
might be diagnosed with schizophrenia or other
diagnoses, which do not include the aspects of a
pervasive developmental disorder.
75

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

76

delusions and hallucinations. Those psychotic


symptoms are typically seen in periods of psychological stress, which is the reason why some people
with Aspergers syndrome are referred during
puberty.
The treatment of Aspergers syndrome dier
from that of schizophrenia. First, antipsychotic
medication is needed in Aspergers syndrome only
in cases where psychotic symptoms predominate,
and where support and structure is not sucient.
In some cases of Aspergers syndrome the preoccupations might resemble obsessivecompulsive
urges as seen in obsessivecompulsive disorder.
The case presented by the authors illustrates this
and points to the ecacy of treatment with
selective serotonin reuptake inhibitors (SSRIs),
which in some of these cases, reduces obsessive
manners and compulsive stereotyped behaviour.
Follow-up studies on Aspergers syndrome show
large variety in prognosis, mainly depending on the
level of social skills, the type of the narrow
repertoire, the cognitive functioning, the social
support and resources in the persons family, and
psychiatric comorbidity. Increased awareness of
the disorder is warranted. Further studies on the
prevalence of Aspergers syndrome in an adult
psychiatric clientele (i.e. to what degree is Aspergers syndrome under- or mis-diagnosed?) and on
the naturalistic course of the disorder, especially
regarding the development of psychiatric comorbid
conditions in adulthood, is needed.
Per H. Thomsen MD, Dr.Med.Sci.
Psychiatric Hospital for Children
and Adolescents
Harald Selmers Vej 66, 8240 Risskov
Denmark
References
1. Fombonne E. What is the prevalence of Asperger disorder?
J Autism Dev Disord 2001;31:363364.
2. Asperger H. Die Autistischen Psychopathen im Kindesalter. Arch Psychiat Nervenkr 1944;117:76136.
3. Wing L. Aspergers syndrome: a clinical account. Psychol
Med 1981;11:115129.
4. WHO. The ICD-10 classication of mental and behavioural
disorders. Geneva: World Health Organisation, 1992.
5. APA. Diagnostic and statistical manual of mental disorders.
Washington, DC: American Psychiatric Association, 1994.
6. Asarnow JR, Ben-Meir S. Children with schizophrenia
spectrum and depressive disorders: a comparative study
of premorbid adjustment, onset pattern and severity of
impairment. J Child Psychol Psychiatry 1988;29:477488.

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