How do you diagnose autism in women
Highly Functional Autism: Shattered Identity
A psychological psychotherapist is diagnosed with Asperger's Syndrome in middle age. About a possible "disguise" for this highly functional autism spectrum disorder.
When I was diagnosed with Asperger's Syndrome (AS) in 2010 at the age of 39, this - after the first shock - proved to be a key to my various difficulties. At that time I was working as a psychological psychotherapist. The AS is one of the highly functional autism spectrum disorders (ASD) (1, 2, 3). In this article I describe autistic features and difficulties as well as possible therapeutic approaches in adult patients with AS. For the sake of simplicity, the terms autism / autistic and Asperger's syndrome are used synonymously here. Autistic disorders have hardly been an issue in further training to become a psychological psychotherapist. My own experiences with psychotherapy, with the Asperger's diagnosis and with my psychotherapeutic professional life round off the article.
Core Symptoms of Autism
Abnormalities in communication and social interaction as well as stereotypical behavioral patterns (rituals, routines), which serve to find some security in the seemingly uncontrollable environment, are core symptoms of autism (4). There are difficulties in using and reading non-verbal interaction (facial expressions, gestures, prosody) and in the reciprocal design of relationships and interactions in general. Affected people have difficulties in reacting emotionally to other people's expressions of feelings, such as joy or fear, or in grasping them intuitively. The empathy for feelings and thoughts of another person is disturbed in this respect, whereby empathy can be felt through cognitive detour strategies or through direct experience, for example, of an accident, misfortune or the like (5). A not inconsiderable number of people with AS suffer from alexithymia, making it difficult for them to access their own feelings. This does not mean that there are no feelings, but that these are very difficult for those affected to identify and communicate and often have to be inferred from body sensations. The gaze behavior is usually noticeable. Direct eye contact is often avoided, is very fleeting, or those affected have a somewhat rigid gaze in an effort to adapt and yet want to make eye contact, although the spontaneous need to do so is not there (6). Often there is motor clumsiness.
There are stereotypes in the use of language, movements or objects. These can be simple motor stereotypes, but also the perceived need to be at home at 5 p.m., for example, to always take the same route or resistance to change. Dealing with so-called special interests can take up a large part of the life of Asperger's autistic. Autism is a perception and information processing disorder. There are often peculiarities in sensory perception, hyper- or hyposensitivity and a fixation on details instead of the whole. Language is mostly understood literally, which significantly affects the understanding of irony, and many people with autism think in pictures. The phrase “paint the devil on the wall” can be understood, for example, by an Asperger's autist insofar as he first imagines this formulation in order to then translate it into its figurative meaning.
The atypical can be typical
If the AS is not recognized early enough, additional psychological disorders can develop as a result of excessive social and practical demands. The autistic symptoms can hide behind a supposed personality disorder, a depression, an eating disorder or an anxiety disorder. Often the atypical aspect of a psychiatric diagnosis, i.e. atypical psychosis or atypical obsessive-compulsive disorder, is typical for people with AS (3).
At this point I will report a little from my own experience to illustrate how much an AS can “dress up”.
When I was in my early twenties, I had completed analytical group psychotherapy because of an eating disorder and symptoms of self-alienation. Here I was able to practice being part of a group and making personal contact with other people in a safe environment. When I was in my mid-twenties, due to a family death, I went to regular socio-educational discussions at a contact and advice center. When I was in my mid-thirties, I began a psychoanalysis that lasted several years because of a depressive illness that had intensified over the years. I also went to psychiatric treatment. All of these therapies have helped me or brought me further in my development - but they have not uncovered my core problem. None of these practitioners realized that my basic disorder was an autistic one (7).
During the psychoanalysis I had repeatedly had the impression that there was something else with me than “just” depression. While reading an autobiography (8) and a novel (9) I came across the subject of Asperger's Syndrome by chance. To my amazement and horror, I recognized myself in the descriptions there. The school days, with the exception of the breaks - I never knew how to spend them - and the psychology studies I had completed without any major difficulties. I had also worked well in my job as a psychologist and psychotherapist. I had never received any feedback that I had done a bad job - even though these activities had cost me a lot of energy from day one.
At one of the few outpatient clinics in Germany specializing in adult autism diagnostics, I first had to fill out a long pile of questionnaires. External observation data were also included. When I finally sat across from the psychiatrist, he said after a two-hour anamnesis interview and with reference to my behavior during the interaction: "I have no doubt that you have the AS." Then a world collapsed for me. There is still an opinion among our population that autistic people are always severely disabled, do not speak and live in care homes (10). In this context, it is not easy to come to terms with the fact that you belong to this group yourself. At the same time, of course, it is also a relief to have finally found a name for being different.
Years of being overwhelmed
The AS diagnosis completely shook and changed my sense of identity. If I had previously developed a kind of “bogus identity” or “professional self”, which had enabled me to do my professional life quite well, at least outwardly, this identity collapsed completely when the diagnosis was made. I stopped working and couldn't work anymore. Due to years of excessive professional demands, I got into a permanent burn-out from which I could not fully recover afterwards. The AS diagnosis was a drop in the ocean here. Various therapies did not lead to my becoming "functional" for my job again. My theoretical interest in psychiatry and psychotherapy goes hand in hand with a practical overstrain through human contact and eye contact, as well as through psychotherapeutic work.
Psychotherapy for autism
Depth psychological and psychoanalytic procedures are less likely to be considered helpful in AS therapy (except in the case of existing comorbidities), but more instructive behavioral therapy settings that do not exclude practical everyday aids (11). For me, however, the relationship with my analyst was the first that I could really allow myself to be. Autism is a disorder of the ability to communicate. By having the experience of being able to come into real contact with my analyst, I was later able to come into better contact with other people. Psychodynamic interpretations of the autistic symptoms are to be avoided in any case.
What is therapy now about after an AS has been correctly diagnosed? First of all, the diagnosis must be integrated into the self-image. Riedel (2013) describes that following an AS diagnosis, space often has to be created again for autistic needs (12). In many cases, it is necessary to “practice” again, for example, to pursue stereotypical movements such as rocking with the upper body, as these have a clear stress-reducing and calming effect. Many autistic people had long abandoned such “typically autistic” movements because they are socially conspicuous. For me it was actually the case that I had a kind of "autistic attack" after the diagnosis. Everything that I had pinched off of autistic peculiarities for years now pushed to the surface with all my might.
In addition, the living environment and the living situation - as far as possible and if not already done - should be adapted to the autistic peculiarities and limitations. Conflicts and excessive demands at work, in partnerships or families and in everyday life are typical issues for people with AS. If, for example, Asperger's autistic is overwhelmed by their work situation or the interpersonal contacts there, then therapy can try to remedy the situation by means of various stress management techniques. But it can also be that the person concerned is simply overwhelmed at the workplace (for example in an open-plan office with constant exposure to noise from all sides). Or that it is not possible to get through an eight-hour day, since one to two hours of sleep are necessary at noon to be productive again. Then it could be considered whether working from home or switching to part-time work would be a possible solution. Careful consideration must also be given to whether the employer should be informed of the diagnosis.
In the private sphere, loneliness can be a problem. Contrary to what is often assumed, most autistic people also have a greater or lesser need for social contact, friendships or a relationship (13). Social skills can be partially trained and learned with reference to previous skills (14). On the other hand, however, there is the enormous effort that establishing and maintaining such social contacts often represents for Asperger's autistic people. There are no universal solutions here. Some of those affected live in a partnership, but have no more energy left for other contacts (15). Many people with AS live alone because a couple or even a family demands too much energy from them (16).
In the further course of therapy, everyday difficulties in the life of the AS sufferer should also be discussed. It can always be a matter of providing assistance in interpreting the behavior of one's “neurotypical”, i.e. non-autistic, fellow human beings in order to clear up any misunderstandings (17).
The teaching of diagnostic and therapeutic skills with regard to ASA in training to become a psychological psychotherapist is poor. Of ten randomly selected psychoanalytical depth psychology training institutes, none of them had a training block on the subject of autism. After all, three out of ten behavioral therapy institutes offered an explicit seminar of eight to 16 hours on highly functional autism. ASS should be regularly integrated into the training of young colleagues. After all, the prevalence of one percent is similar to that of schizophrenic psychoses, for example.
- How this article is cited:
PP 2015; 13 (9): 410-2
Author's address: Birgit Saalfrank, Willemerstraße 25, 60594 Frankfurt am Main,
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