Differential or Co-Morbid Diagnoses? Asperger's Disorder and PTSD in a Pre-Schooler

Background:

To date, there exist few empirical or anecdotal studies of individuals with autism spectrum disorders (ASD) presenting with posttraumatic stress disorder (PTSD). The deficits associated with ASD may make this population especially susceptible to traumatic experiences. Autistic individuals frequently present with an inability to read social cues including gesture, affect and body language. Caregivers may interpret their non-comprehension as defiance. They are often living in group care, they may not be able to communicate their experiences effectively, and their ASD diagnoses may overshadow the significance of other symptoms. Most importantly, the dearth of literature about co-morbid diagnoses results in a lack of professional knowledge about how to recognize, diagnose and treat PTSD in autistic individuals.

Objectives:

We present a case of co-morbid ASD and PTSD in PL, a 4 year old male with retinoblastoma since age 9 months. The goal of this case study is to add to the literature about PTSD diagnoses in the ASD population, consider overlapping behaviors in differential diagnoses, and invite discussion about how best to diagnose and treat similar cases moving forward.

Methods:

Evaluations of PL included:

1)      3.1 years: Comprehensive diagnostic interview and cognitive evaluation to assess ASD and PTSD

2)      4.2 years: Diagnostic re-assessment while still in cancer treatment

3)      4.7 years: Follow-up assessment including ADOS and ADI-R following ASD intervention and cancer remission

Results:

3.1: PL was diagnosed with PDD-NOS based on language delay, social impairment, and a questionable preoccupation with letters and numbers.

4.2: PL met criteria for Asperger’s disorder and PTSD secondary to repeated monthly invasive procedures consisting of general anesthesia followed by two days of complete eye bandaging. PL expressed resultant anxiety by naming areas of his home after city intersections and avoiding the area named for the hospital address. The symptoms were chronic and characterized by flattened affect punctuated by irritability, outbursts of anger and hypervigilance. His avoidance of the “map” locations fulfilled the ASD criteria for non-functional routines and rituals. There was also a repetitive element as PL ceaselessly drew accurate maps of various parts of the world (particularly the Balkan States and Eurasia) and labeled walls of the examination room with city intersections. PL could read fluently and perform basic math. His social and communication deficiencies stood in great contrast to his non-verbal cognitive ability.

4.7: PL is in remission and enduring fewer invasive procedures. He receives regular therapy and music lessons which contribute to a predictable weekly schedule. His PTSD symptoms are significantly diminished; he no longer perseverates on maps or avoids areas of his home. Scores on the ADI-R and ADOS indicate ASD, though the clinical impression is that his social engagement, interests, verbal and non-verbal communication have all improved. The most marked remaining deficits are atypical social initiation, stereotyped speech, and failure to develop peer relationships.

Conclusions:

With little empirical research to address the interplay of PSTD and ASD, clinicians face limited diagnostic and treatment precedent. We will present a model for characterizing differential diagnoses and co-morbidity of these disorders.