Cases That Test Your Skills

The angry patient with Asperger’s

Current Psychiatry. 2009 February;8(2):49-54

References

1. American Association of Child and Adolescent Psychiatry. Practice parameters for autism in children, adolescents, and adults. Available at: http://www.aacap.org/galleries/PracticeParameters/Autism.pdf. Accessed December 25, 2008.

2. Risperdal [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc; 2008. Available at: http://www.risperdal.com/risperdal/shared/pi/risperdal.pdf. Accessed December 25, 2008.

3. Curry JF, Wells KC, Brent DA, et al. Treatment for adolescents with depression study (TADS): cognitive behavior therapy manual. Available at: https://trialweb.dcri.duke.edu/tads/tad/manuals/TADS_CBT.pdf. Accessed August 2, 2007.

4. Shoffner J, Staudt M, Marcus S, et al. Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia. Psychiatr Serv. 2007;58(6):872-875.

5. Monahan RT. Individual and group psychotherapy. In: Lyman RD, Prentice-Dunn S, Gabel S, eds. Residential and inpatient treatment of children and adolescents. New York, NY: Plenum Publishing; 1989:192.

6. Shear K, Frank E, Houck PR, et al. Treatment of complicated grief: a randomized controlled trial. JAMA. 2005;293(1):2601-2608.

7. Baker JE. Social skills training for children and adolescents with Asperger syndrome and social-communication problems. Shawnee Mission, KS: Autism Asperger Publishing Company; 2003.

8. Zimmerman DP. Psychotherapy in residential treatment: historical development and critical issues. Child Adolesc Psychiatr Clin N Am. 2004;13(2):347-361.

9. Kendall PC, Hedtke A. Coping cat workbook. 2nd ed. Ardmore, PA: Workbook Publishing; 2006.

10. Schwartz K. Remembering the forgotten: psychotherapy groups for the nursing home resident. Int J Group Psychother. 2007;57(4):497-514.

I ask him to divide his automatic “E” thoughts into “she” and “I” thoughts. Examples of automatic “she” thoughts include “She probably won’t like me” and “She thinks I’m not cute.” Examples of automatic “I” thoughts include “I’m probably not smart enough for her” and “I think we won’t have anything in common.”

Table 3

The FEAR plan*

F=feeling anxious
E=expecting bad things to happen
A=attitudes and actions that can help
R=results and rewards
Developed to help anxious children and adolescents recognize signs of anxiety, relax, and modify anxious self-talk and thinking.
Source:Reference 9

I instruct him to first rate how sure he is of each automatic thought, then to find evidence for or against each thought, and finally to come up with a coping counter-thought. I educate his caregivers about this process and ask them to work through these steps when they take Mr. A out in public.

The author’s observations

Schwartz¹⁰ discusses countertransference challenges in nursing home patients, where therapists identify with patients’ hopelessness. Schwartz recommends addressing these challenges by thinking of realistic expectations. Even though a facility might be far from perfect, it may be “good enough.”

Mr. A’s group home was far from perfect and located in an isolated setting. Even so, I was able to help him complete psychotherapy at our clinic by adapting my practice to his needs, including:

making reminder phone calls for appointments
visiting the group home
enlisting the help of caregivers with therapeutic techniques.

As a result of our psychotherapy and medication changes, Mr. A displays no aggressive behaviors during the last 9 months of therapy.

Clinical Point

Psychotherapy and medication changes result in Mr. A displaying no aggressive behaviors during the last 9 months of therapy

OUTCOME Improving

In the final 4 months of therapy, we continue to work on social skills lessons, practice exercises in the hospital, and the FEAR acronym. I continue to include caregivers in these efforts.

During 1 session, I tell Mr. A I will be leaving at the end of my fellowship. In the final month, I gradually transition him to a new therapist. I decided to transition him to a male therapist so Mr. A will continue to feel comfortable sharing his feelings, rather than shutting down from anxiety with a female therapist. As I end therapy, Mr. A is promoted to a cashier at the video game store and enrolls in classes to study for a General Education Development (GED) certificate.

Related resource

National Institute of Mental Health. Autism spectrum disorders. www.nimh.nih.gov/health/publications/autism/complete-publication.shtml.

Drug brand names

Bupropion extended-release • Wellbutrin XL
Dextroamphetamine/amphetamine extended-release • Adderall XR
Duloxetine • Cymbalta
Paroxetine • Paxil
Risperidone • Risperdal
Ziprasidone • Geodon

Disclosure

The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgment

The author thanks Dr. Ann Lagges, PhD, for her assistance with this patient’s treatment.

The angry patient with Asperger’s

References

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