A Suicidal Adult in Crisis: An Unexpected Diagnosis of Autism Spectrum Disorder.

Autor: Spencer, Lee, Lyketsos, Constantine G., Samstad, Eric, Dokey, Adrian, Rostov, Debra, Chisoim, Margaret S.
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Zdroj: American Journal of Psychiatry; Sep2011, Vol. 168 Issue 9, p890-892, 3p
Abstrakt: "Mr. A" is a 44-year-old married man who presented to the emergency department stating, "I cut my wrists to attempt suicide because I was thoroughly depressed." He was admitted to the psychiatric unit, and a detailed history was obtained. Mr. A was a healthy child but of- ten got into fights at school. He was the salutatorian of his high school class and earned a bachelor's degree in chemistry. His first psychiatric contact was in college. At that time, he experienced depression and anxiety while drinking large amounts of alcohol and abusing illicit drugs, and he attempted to take his life by cutting his wrists. He was admitted to the local psychiatric hospital, stabilized, and discharged to an alcohol treatment center for 30 days of further treatment. After college, Mr. A found stable work as a chemist. He ran chromatography and spectroscopy machines and took great pride in his systematic work. He has been married for 11 years and has three young adopted daughters. He describes himself as a quiet, "mellow" person who minds his own business and tries not to draw attention. One year before the current admission, Mr. A was in an altercation at work, where he bit a coworker, who required wound care in an intensive care unit. Mr. A was court-ordered to psychiatric hospitalization, where he was treated for major depression and impulse-control disorder with quetiapine, haloperidol, and supportive psychotherapy. After he was discharged, his outpatient clinicians continued quetiapine and psychotherapy, discontinued haloperidol, and added escitalopram to his treatment regimen. Three days before the current admission, Mr. A had another altercation at work after discovering that his boss had hired an employee to assist him with his duties. He was upset by this, as he did not want an assistant and felt he could not tolerate another person's presence. He was unable to articulate these concerns to his boss. Instead he reacted by cursing heavily and throwing a chair at his boss before walking away in a rage. He was fired on the spot. Mr. A became so upset that he decided to drive to a distant city to kill himself. He chose this particular city in part because it is where his favorite TV program had been filmed. En route, he bought two hunting knives, with other camping gear so as not to arouse suspicion. He also bought two gallon-bottles of tequila and checked himself into a hotel. After drinking a large amount of alcohol, he cut two deep longitudinal wounds in his wrists while taking a bath. He refilled the bathtub with water several times and continued to drink tequila before going to bed, Upon awakening the next morning, he left a note apologizing for the "mess," wrapped his wrists, put on a Iong.sleeve shirt, and went sightseeing. After touring locations where his favorite TV program had been filmed, he decided to go to a casino in a different city to gamble and then drown in a bathtub. By this time, however, his wife had filed a missing persons report, and Mr. A was stopped by the police and brought to the emergency department for a psychiatric evaluation. He was admitted voluntarily to the psychiatric ward. On admission, Mr. A appeared moderately well groomed and was wearing a tattered brown T-shirt and pajama pants. His eyes moved little, maintaining a fixed stare at the mouth of the interviewer. His speech was clear, but his words were cautiously chosen and there was little rhythm to his sentences. He reported his history circumstantially and discussed emotionally charged occurrences matter-of-factly. He recounted events with a smile incongruent with the circumstances he was describing. He stated that he was depressed, but his affect was surprisingly calm and complacent. He had no thought disorder and endorsed no hallucinations or delusions. Mr. A was initially formulated as having an adjustment disorder with depressed mood and a cluster B personality disorder. However, after a few days on the unit, a pattern of awkward social interactions and stereotyped mannerisms became evident. Mr. A continued to stare at the clinicians' lips when interviewed, answering questions with almost scripted verbal responses, and he showed little capacity for discussing his own and others' feelings. The team recognized these as autistic traits and conducted further evaluation to elucidate the full story behind Mr. A's unusual symptoms. A telephone interview with Mr. A's adoptive family revealed that he had grossly normal language development as a child but had always exhibited social awkwardness, a poorly developed regard for the feelings of others, and preoccupation with routine and rigidity. As an infant, he rebuffed his mother's affection and coddling. As a toddler, he engaged in independent or parallel but not reciprocal play, often playing intensely and exclusively with toy trucks. As a school-age child, he kept to himself and was picked on by other students for being different. Although Mr. A had never been diagnosed with autism as a child, the team and consulting faculty members agreed that Mr. A's history and current phenomena were consistent with an adult with Asperger's disorder. The combination of rigidity, poor reading of social cues, suspiciousness of others, and poor coping skills in handling frustration are characteristic of Asperger's disorder, and for Mr. A, they likely precipitated the violent actions that led to his firing and his previous and current suicide attempts and hospitalizations. [ABSTRACT FROM AUTHOR]
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