People with Asperger’s Syndrome who are high functioning are often undiagnosed as having AS. They are often diagnosed as having depression, anxiety, OCD, ADHD, ODD, personality disorders, or a psychotic illness — and the AS is missed. The lack of severity of AS symptoms doesn’t correlate with the severity of stress people experience, since many have been struggling with the internal pain of isolation, bullying, not fitting in, feeling overwhelmed and difficulties with work that seems easy for others.
Comorbidity, when you have both an autism spectrum disorder (ASD) and another clinically significant diagnostic disorder, is common. (In research, AS isn’t separated out from ASD, although most studies are of “high functioning” ASD, meaning individuals with at least average intelligence.) Children with an ASD are 2 to 4 times as likely to experience co-morbid disorders than the general population. 7% to 16% of teen or adult patients in psychiatric facilities end up diagnosed with ASD. The seven most common co-morbid conditions are major depressive disorder, bipolar disorders, anxiety disorders, ADHD, schizophrenia, PTSD, and various personality disorders.
ASD is a risk factor for depression and bipolar disorder. The rates of diagnoses of depression vary among studies. From 18% to 22% of those with ASD are diagnosed with clinical depression; the most commonly quoted rate of a depression in the general population of the US is 6.7%. Most of the research shows both genders have these high rates of depression. 6% to 21% of patients with ASD also diagnosed with bipolar disorder, compared to 2.4% of the general population. Obviously, having AS can be depressing if one internalizes negative experiences as a self-image, creating low self esteem. The bipolar overlap can be hard to diagnose – there is a tendency of some with AS to overreact and “melt down” which can be seen as explosiveness indicating bipolar disorder.
To make the diagnoses of a mood disorder in addition to AS, I look at the severity of the depression (sleep disturbance, appetite changes, feelings of hopelessness, difficulty concentrating) or bipolar symptoms (some indications of cycling, of “hyper” behavior of pressured thoughts and speech, grandiosity) and the family history both of mood disorders and alcoholism.
Anxiety is a very common symptom of AS. Most AS patients have social anxiety, and many demonstrate general anxiety. Again, it’s hard to say that this is a separate clinical disorder or the result of the daily experiences of social confusion or rejection, teasing, feeling overwhelmed, etc. I usually look at the severity of the anxiety symptoms, the triggers and any family history of anxiety disorders.
OCD is generally thought of as related to anxiety. The diagnostic criteria for obsessive compulsive disorder includes obsessions, which can seem similar to having areas of obsessive interest, and compulsions, which are the need to perform repetitive behaviors. AS individuals are often described as having OCD symptoms, but individuals with OCD don’t necessarily have problems with social relationships.
ADHD is very common and it can be difficult to differentiate whether it’s part of the AS or a separate problem. I tend to go by how disruptive ADHD symptoms are to a person’s ability to function, and recommend treatment for ADHD if inattention or fidgetiness/inability to hold still are really in the way of daily life and not a reasonable response to the environment.
Many children have a diagnosis of oppositional defiant disorder (ODD), characterized by arguing or refusing to go along with directions from adults, as well as having an angry or irritable mood and vindictiveness. ODD reflects deliberate behavior to annoy others. Most AS children argue or refuse to comply because of inflexible thinking and not negative intentions. ODD children don’t have the lack of social understanding typical of AS.
ASD has been considered a risk factor for psychotic experiences and PTSD. The prevalence of PTSD in individuals with ASD is 11% to 17%, compared to 0.3% to 6.1% of the general population. There are some researchers who feel AS patients can have intermittent psychotic episodes; usually these are people who have a greater level of odd behaviors and obsessions.
AS individuals are often diagnosed with personality disorders because of the similarity of the criteria. 9% to 14% of ASD individuals are diagnosed with borderline personality. Borderline diagnostic criteria include black and white thinking and emotional outbursts, but people with borderline personality tend to have very intense personal relationships. Other personality disorders with some overlapping symptoms include schizotypal personality (difficulty with social relationships and odd behavior) and avoidant personality (extreme shyness and withdrawal). Taking a detailed family history of personality disorders and a nuanced evaluation of what underlies behavior help differentiate AS and these disorders.
Both the AS and the other diagnostic problem need to be understood to fully help the AS individual understand him or herself. Any of us can have more that one diagnosis. Mood disorders, anxiety and ADHD are common and often improve with treatment. What’s important about identifying co-morbid diagnoses is that many can be treated, which significantly improves the lives of AS individuals.