Asperger's Comorbid Conditions-depression, anxiety, OCD, ADHD, alcoholism, etc.

Advances in Psychiatric Treatment (2004) 10: 341-351
© 2004 The Royal College of Psychiatrists

Asperger syndrome from childhood into adulthood
Tom Berney
Tom Berney is a consultant in developmental psychiatry with the Northgate & Prudhoe NHS Trust (Prudhoe Hospital, Prudhoe, Northumberland NE42 5NT, UK. E-mail: t.p.berney@ncl.ac.uk) and at the Fleming Nuffield Child Psychiatry Unit, Newcastle upon Tyne. He is also honorary consultant to European Services for People with Autism, a registered charity that provides community services.




Asperger syndrome, a form of autism with normal ability and normal syntactical speech, is associated with a variety of comorbid psychiatric disorders. The disorder is well known to child psychiatry, and we are beginning to recognise the extent of its impact in adulthood. The article reviews the diagnosis and assessment of Asperger syndrome and its links with a wide range of psychiatric issues, including mental disorder, offending and mental capacity. It also describes the broader, non-psychiatric management of Asperger syndrome itself, which includes social and occupational support and education, before touching on the implications the disorder has for our services.



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Asperger syndrome comes not only with its own characteristics (Box 1), but also with a wide variety of comorbid conditions such as depression, anxiety, obsessive–compulsive disorder, attention-deficit hyperactivity disorder (ADHD) and alcoholism, and relationship difficulties (including family/marital problems) (Tantam, 2003). It may predispose individuals to commit offences and can affect their mental capacity and level of responsibility as well as their ability to bear witness or to be tried. The syndrome can colour psychiatric disorder, affecting both presentation and management, for children and adults across a wide range of functional ability. Families have taken an active legalistic approach, alleging misdiagnosis and mistreatment and demanding clarity as to the relationship between Asperger syndrome and other diagnostic concepts.




Box 1 Characteristics of Asperger syndrome in adulthood
Childhood onset

Limited social relationships – social isolation


Few/no sustained relationships; relationships that vary from too distant to too intense

Awkward interaction with peers

Unusual egocentricity, with little concern for others or awareness of their viewpoint; little empathy or sensitivity

Lack of awareness of social rules; social blunders

Problems in communication


An odd voice, monotonous, perhaps at an unusual volume

Talking ‘at’ (rather than ‘to’) others, with little concern about their response

Superficially good language but too formal/stilted/pedantic; difficulty in catching any meaning other than the literal

Lack of non-verbal communicative behaviour: a wooden, impassive appearance with few gestures; a poorly coordinated gaze that may avoid the other’s eyes or look through them

An awkward or odd posture and body language

Absorbing and narrow interests


Obsessively pursued interests

Very circumscribed interests that contribute little to a wider life, e.g. collecting facts and figures of little practical or social value

Unusual routines or rituals; change is often upsetting

(After Gillberg et al, 2001)

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Schizophrenia
Despite Asperger’s early intent, it was only in 1971 that autism was distinguished from schizophrenia, although a number of subsequent reports have suggested that it might yet be identified as a predisposing factor. The similarity of Asperger syndrome to a preschizophrenic, schizoid personality disorder as well as to residual schizophrenia, in both clinical presentation and neurobiology, has led to a diagnostic confusion that has not taken account of their differing developmental trajectories. Such suggestions of a return to the concept of the unitary psychosis arise where association has been mistaken for causation – both may have similar underlying anomalies giving rise to similar, but not identical symptomatology (Box 3).


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Box 4 Forensic presentations
The following criminal behaviours might indicate undiagnosed Asperger syndrome:


Obsessive harassment (stalking)

Inexplicable violence

Computer crime

Offences arising out of misjudged social relationships




Box 5 Characteristic features of Asperger syndrome that predispose to criminal offending

An innate lack of concern for the outcome can result in, for example, an assault that is disproportionately intense and damaging. Individuals often lack insight and deny responsibility, blaming someone else; this may be part of an inability to see their inappropriate behaviour as others see it.

An innate lack of awareness of the outcome that allows individuals to embark on actions with unforeseen consequences; for example, fire-setting may result in a building’s destruction, and assault in death.

Impulsivity, sometimes violent, can be a component of comorbid ADHD or of anxiety turning into panic.

Social naïvety and the misinterpretation of relationships can leave the individual open to exploitation as a stooge. Their limited emotional knowledge can lead to a childish approach to adult situations and relationships, resulting, for example, in the mistaking of social attraction or friendship for love.

Misinterpreting rules, particularly social ones, individuals find themselves unwittingly embroiled in offences such as date rape.

Difficulty in judging the age of others can lead the person into illegal relationships and acts such as sexual advances to somebody under age.

Overriding obsessions can lead to offences such as stalking or compulsive theft. Admonition can increase anxiety and consequently a ruminative thinking of the unthinkable that increases the likelihood of action.

In formal interviews, misjudging relationships and consequences can permit an incautious frankness and the disclosure of private fantasies which, although no more lurid than any adolescent’s, are best not revealed.

Lacking motivation to change, individuals may remain stuck in a risky pattern of behaviour.