Submitted June 4, [redacted], for [redacted] (supervisor) approval and signature.
Referral: Subject's self.
Background information: Subject is a [redacted]-year-old [redacted] who presented in The Examiner's office at the urgent and repeated request of Subject's spouse's best friend. This best friend seems knowledgeable, having been a patient his whole life due to paraplegia secondary to congenital spina bifida, and is deeply trusted by Subject's spouse. Subject seeks adequate explanation for Subject's turbulent history and current social, vocational and emotional challenges, particularly that which Subject described as "an omnipotent, ever-present feeling like I am an alien on the wrong planet" [paraphrase].
Data sources: A targeted clinical interview was conducted by The Examiner, PhD, clinical psychologist specializing in the care and guidance of Asperger's and autistic patients. Collateral interviews with Subject's spouse and Subject's biological parents were conducted via telephonic communication [non-recorded]. When The Examiner reported to Subject that Subject's female parent spoke for the majority of the interview, Subject expressed surprise and said, "That is very unusual" [paraphrase].
Additionally, the following assessments were administered by The Examiner:
Weschler Intelligence Scale for Adults - 4th Edition (WAIS - IV)
Trauma Symptom Inventory - 2nd Edition (TSI - 2)
Personality Assessment Inventory (PAI)
Mini Mental Health State Exam
Behavioral Rating Inventory of Executive Function (BRIEF), self- and informant report
Selected Subtests of Advanced Clinical Solutions (ACS): Social Cognition
Autism Diagnostic Observation Schedule (ADOS, Module 4)
Records review: No records were provided to The Examiner at any point.
Purpose: Because Subject has been informed directly by peers, family members, and co-workers, as well as through experience, that Subject's way of being in and thinking about the world diverges significantly from the norm, a careful and comprehensive examination of Subject's selfhood/concept of selfhood, as well as narratives from selected informants, was conducted. Subject's sensitivity (sensory and emotional); expecting people to mean what they say literally; robust preference for order; fixations on objects/people/ideas others, particularly in her peer group, do not concern themselves with (e.g., looming global problems, local injustice, personal slight or injury); difficulty with shallow/routine social contact were all cited by Subject's spouse's best friend as warranting diagnostic attention. Subject concurred with the list, stating, "Those, plus more, are all true. And that does make me feel like an alien, but I also don't know if I want not to be."
Detection of the presence of an autism spectrum disorder requires close observation and interrogation of a subject's developmental history and patterns of behavior. The most common developmental concerns include delayed language acquisition; atypical social responsivity; sensory and somatic hyper- or hypo- sensitivity; nonspecific medical problems; and difficulties related to attention, eating and sleeping. Stereotyped behaviors, rote motor mannerisms, and unusual or restricted interests onset later in childhood.
Collated and edited report of [Subject]'s backstory: Subject is a first-born. Subject's female parent did not use drugs or alcohol during gestation. Subject's female parent went into preterm labor at 29 weeks, which scared her to death, and was given labor-prevention medication until Subject was born vaginally at 37 weeks, "beautiful and perfect, loved and adored," Subject's female parent said [direct quote].
Subject's parents reported Subject's immediate and intense difficulties with sleeping and emotional regulation; "these persist to this day," Subject says [paraphrase]. Subject's female parent was so exhausted by Subject's lack of regular sleep that she reported hearing voices. Subject's parents had to rotate dressing Subject each day because Subject's tantrums were so overwhelming. "This was easily resolved," Subject reports. "As soon as I was verbal, I demanded to be dressed only in purple. This, too, is largely still true today" [paraphrase]. Subject loved the park; when it was time to leave, Subject would shriek as if being abused and resist both parents physically.
Major developmental milestones were met easily, for the most part. Subject's female parent recalled Subject had some difficulty learning to roll over, stating [direct quote], "[Subject] would grunt and [Subject's] face would turn red. Such a contrast to [Subject's] sister, [Subject] was mad and frustrated." Subject also had trouble learning to ride a bike and kick a soccer ball; Subject remained unsure about which side of the plate to swing the bat from in softball. "This," Subject says, "is also easy to explain. I was left-handed, but every time I picked up a crayon or pencil with my left hand, my mother would take it out of my left hand and put it in my right hand. I don't blame her. It's just what her mother did to her, but, as a result, I never got confident with either hand. I can now write with both hands, it's just equally illegible" [paraphrase].
Subject acquired language early and employed it often. "The only time I would stop talking was when I fell asleep, usually in the middle of a sentence. This talking wall is still present, triggered by anxiety or discomfort. Though I don't stay asleep for long, I can fall asleep anywhere, anytime—movies, the shower, in the middle of fights with [spouse], walking across a busy street —and when I do, I sleep like a fire hazard" [paraphrase].
"Even [Subject's] play was serious," Subject's female parent reported. "[Subject] would line up LEGOs according to color and then size, and plastic animals according to the patterns on the rug or carpet." Subject reports this to still be true today, only with books and clothes. "And LEGOs," Subject states. "I still play with—and by that I mean organize—LEGOs" [paraphrase]. Subject is a deeply auditory learner. "I would be able to tell by the time [Subject] was in first grade if they'd had a sub that day," Subject's female parent reported [direct quote], "because [Subject]'s reports of what they learned that day included direct quotes from the teacher and they would be in a different inflection or cadence than how [Subject] normally relayed the day at school." Subject confirms. "If I've heard a song or seen a movie once, it's in there forever [taps right pointer finger to right temple]. I'm probably the only person who still has people's phone numbers memorized" [paraphrase]. Subject was also very good at recontextualizing funny quotes from movies into everyday life and retaining their humor.
Subject loved books, being read to, and making [Subject]'s own books, including intricate, detailed drawings. "All of that, with the exception of that last item, is still true," Subject says [paraphrase]. Subject struggled to learn to play Subject's male parent's female parent's baby grand piano. "It's hard to do different things with each hand simultaneously," Subject reports [paraphrase]. "I have inherited this piano. I just have to figure out how to get it and me in the same geographical state in our respective single pieces." Subject took private saxophone lessons and marched in the high-school and college bands. Subject taught Subject's self the flute. Subject would go through distinct phases of interests—the Beatles, the Back to the Future series, dolphins—and would want to redo the entire decorating scheme of Subject's room and wardrobe to match her fixations. "When I love something, I fully commit," Subject says [paraphrase].
"The flip side is also true; when I hate something, I repel it" [paraphrase]. When prompted by The Examiner for examples, Subject provided: being interrupted, not completing [Subject]'s to-do list each day, and having schedules or plans change, particularly with little or no notice. Having no routine at all was and is intolerable. "Hugs seemed to be as well," Subject's female parent reported [direct quote]. "I would attempt to hug [Subject] and [Subject]'s eyes would go wide and [Subject]'s whole body would stiffen. Like [Subject] did when [Subject] felt a clothing tag on [Subject]'s skin or when the seams of [Subject]'s pants or socks weren't hitting the same place on [Subject]'s body every time."
"But I'm not uniformly overly sensitive," Subject says. "Taking tests always made me crazy. I could hear a failing light bulb buzzing like a crazy bee and I could hear all the pens writing, but I can't tell if there's too much garlic in my food. I can tell if there's too much ginger, but all beer tastes and smells the same to me. I'm overwhelmed by people talking at the same time, but it takes me so long to register that something's hot that, by the time I react, I've burned myself. I'm extremely sensitive to language and how words are used. I am not approximate in my use of language; I am exact and literal, and that's how I listen to others, which a friend recently pointed out was odd since I'm a poet" [paraphrase]. Subject turned Subject's gaze toward the window, perhaps in a continued effort to avoid The Examiner's eyes. "But then, 'odd' is the reason I'm here, isn't it" [paraphrase]. Subject answered this question by the way she asked it.
Where Subject's black-and-white tendency really gets Subject into trouble, Subject reports, is with people. "I made my first friend in kindergarten, before we each got our final sibling, and, though this friendship ended a few years ago, eight months before my wedding, I still miss it. I think of [redacted] every year on [redacted]'s birthday. I still have the meeting minutes from our Garth Brooks/Colorado Rockies/NSYNC club, which held regular meetings from 1994-2000 in either of our closets. [Redacted]'s entire house was so messy you couldn't see the floor, which turned my skin into stinging ants. I tried to help [redacted] clean once; I only got a corner of [redacted]'s room clean, but it was the most organized, sparkling-clean corner that house had ever seen" [paraphrase].
When Subject learned in kindergarten that not all children were going to like Subject or one another, Subject experienced notable emotional deregulation. Each time a friend would move away or a kid would decide not to play with Subject at recess, Subject would need iterative processing. "Subject was an emotional roller coaster as a child; at some point I simply had to get off," Subject's female parent stated [direct quote]. "Subject remember that day," Subject reports. "Subject had just discovered that trees could die. Subject was three and inconsolable. It was around that time Subject started having dreams where the world was being covered in oil and everything was trapped underneath it. Subject would wake up just before Subject suffocated" [paraphrase].
Subject's male parent stated, "Subject would bring home strays—animals, kids from single-parent homes or absent-parent homes—all the time" [paraphrase]. Subject explained that Subject did that because Subject knew what it was like not to fit in. "Could have been the weird behavior," Subject's female parent stated [direct quote]. "[Subject] would pretend to be an animal, mostly a dog. [Subject] was still doing this—at school—in 5th grade!" Subject's parents had no knowledge of whether Subject was teased at school for this, or bullied in general; Subject made no comments in the course of the interview or testing procedures that could be directly related to this.
Adolescence was rough, Subject's parents concurred. "For everyone involved" [direct quote]. Subject did well at school. "Not like top-ten-in-Subject's-class well," Subject states [paraphrase], "like top-ten-percent-well. Subject could never figure out how everyone else was so smart. And it was a big deal to be smart, not just in Subject's family, but to Subject's self, too. Subject still, over a decade after graduation, remembers Subject's class ranking because it wasn't high enough (29/707). Seemed like the only thing Subject had a chance at being good at" [paraphrase]. Subject participated in swim team in the winter, after marching band season was over. "[Subject] should have been born a fish," Subject's male parent said [direct quote]. "He means that Subject is graceful and beautiful in the water, not that Subject is competitive," Subject explained [paraphrase]. "Subject is not. Subject's not good enough to be and Subject has no spirit to be. Subject's not so competitive that Subject will rearrange important plans just so Subject doesn't have to say no to another friend's request to hang out and create too much of an inconvenience for the friend. Subject doesn't want to beat people. Subject just wants to be loved" [paraphrase].
Subject's difficulty came largely in interacting socially with peers and clashing repeatedly with Subject's parents, particularly Subject's female parent. "It was really hard," Subject's female parent reported [direct quote]. "Mainly," Subject explains, "because Dad would always defer to her on all things, as far as Subject could tell" [paraphrase]. Subject's childhood friend somehow managed to start fitting in with the popular crowd. "Yeah, no way Subject would be accepted there. Subject was ignored even among the band nerds. Not really bullied, but is being ignored and not sought after really any better? Especially when you've been doing a lot of searching and going after others," Subject states [paraphrase]. Subject's female parent reported continued struggles with emotional regulation—vacillating between withdrawal and outbursts of rage at perceived injustice. "Even when it didn't have to do with [Subject], [Subject] would get so angry. Like, at homelessness, or bad things on the news. It really confused me. We were trying our hardest to give [Subject] the skills to avoid these things that were so calamitous for [Subject] and [Subject] was repeatedly pulled under emotionally by rage and grief about them anyway," Subject's female parent stated [direct quote]. Subject reports that this has only increased.
Subject's parents both noticed increased signs of hypervigilance, "which I had been under the impression was not possible," Subject's male parent stated [direct quote, laughing], after the Columbine High School shootings of April 1999. Subject was a mile away in lockdown for eight hours. "This was before the ubiquity of cellphones, before Facebook, Twitter, all of that. We heard what Subject thought were gunshots—turned out to be one of the pipe bombs planted around the city as diversions for the police—but were told nothing about what was going on. My middle school's administration said it was 'to cut down on anxiety' but Subject thinks it's because no one knew what was going on until well into the next day" [paraphrase]. Subject talked at great length about the details of the shootings, most of which Subject did not learn until very recently because "no one talked about it. If you wanted to talk about Columbine, it's because you wanted to repeat it, not because you wanted to heal and process."
Subject distinctly remembers the shift Columbine caused. "Before 1999, every child was a gift from God to be molded by their parents in concert with His loving hands, prepared for a life of glorious, easy-to-find, fulfilling service to the world, which every kid would naturally attain if given the right doses of education, discipline, and carefully managed recreation time. After 1999, any kid could be a terrorist. No one else outside of Littleton calls it that, but those of us who were there know that it was a terrorist attack, and it worked. The suspicion adults suddenly viewed kids with seeped into how we viewed each other. The news kept repeating how 'if only their peers had reported suspicious behavior.' Then what? This whole thing could have been stopped? But they never specified what 'suspicious behavior' was, so now Subject's even more alienated from people because Subject doesn't want to be responsible for the next Columbine. Subject has already felt this huge distance from people, which seems to only grow bigger with each of Subject's attempts at sincerity and expressions of longing for connection, and now, any act could be abnormal" [paraphrase]. Examiner notes that it appears Columbine is one of Subject's fixations.
Current functioning: Subject lives in the apartment Subject rents with Subject's spouse, but is currently undergoing a separation, their second one in the three and a half years they've been married. Subject reports being too anxious, socially and in terms of performance, to finish [Subject]'s master’s degree program. Subject has completed one year. But dropping out, as well as marital toil, has made [Subject] depressed. "Subject doesn't fail to finish things," Subject states [paraphrase]. "Subject even finishes reading every word of books Subject doesn't like. Subject likes the act of reading. Or Subject did." Subject could not provide examples of presently enjoyable activities. "Subject just sits around and thinks all day and it's mostly useless. Except Subject did realize recently that all that 'paranoia' Subject exhibited after Columbine was not due to Columbine. Subject knows this because it was there before the shootings. Subject's hyper-vigilance about Subject's environment doesn't stem from OCD, either. It comes from the fact that Subject experiences the world as fast, loud, bright, hard, smelly, and sharp on sometimes traumatic levels. Imagine driving at 70 miles an hour with the windows down through a tunnel and you're being passed by semis left and right. That's a good approximation for how things like normal traffic, applause, toilets flushing and airplanes passing overhead sound to Subject. If you've ever worn a suit made of camel hair or sat on a cactus, you might understand how seams, tags, and clothes that don't fit right feel against Subject's skin. If you've ever had a migraine, you've experienced what walking into a grocery store with those infernal buzzing tubes of fluorescence look, sound, and feel like to me. If you've ever had searing tinnitus, you know what a phone ringing sounds like to me. Everyday life is a rapid-fire series of blazingly intense events that do not settle into an undifferentiated blur when you've got a nervous system turned up to maximum" [paraphrase].
Test conditions: All measures were conducted according to standardized administration protocols and best practices.
Subject is tall and of lean build. Subject appears Subject's stated age of [redacted]. Subject was oriented to time, date, location, and all other aspects of reality. Subject presented well-groomed and approximately fifteen minutes late for each session. Examiner's note: When asked to proofread this report for factual accuracy before completion, Subject left this among Subject's many comments: "This is probably true. Subject used to be on time everywhere and would have to wait at least ten minutes for anyone else to show up, so Subject started loosening up about time because Subject hates waiting. But, in the name of fair reportage, it should be included that The Examiner often arrived later than Subject for testing sessions. As for the 'many comments' comment made by The Examiner, in Subject's defense, it was requested that Subject proofread for factual accuracy, which Subject took to mean not only watching out for the overwhelmingly amount of incorrect facts and correcting them—like Subject's birthday, which was listed in the header on every page—but also supplying remedial grammar support where needed" [paraphrase]. Subject readily entered the testing environment and did not appear to The Examiner to make any efforts to describe Subject's self, behaviors, or thoughts in either a more positive or a more negative manner than the truth.
Test findings, results:
Subject seemed distressed upon The Examiner's reporting of scores. The examiner explained that research indicates that an uneven cognitive profile is commonly seen in individuals with Autism Spectrum Disorder; processing speed is often lower when compared to other tasks. In other words, The Examiner stated, Subject's results were normal and/or anticipated by the research.
PAI: Results indicate clinically significant levels of depression. Levels of suicidal ideation significantly elevated; Subject denied plans or means to end Subject's life. Subject experiences stress emotionally as well as somatically; physical relaxation is only possible to a point; Subject does not allow Subject's self to experience emotional relaxation until chores are done and to-do lists are completed (when asked by The Examiner how often this is, Subject replied, "hardly ever" [paraphrase].) High emotional responsivity overall. It is likely that, when this manifests in relation to events outside of Subject's control (global problems, social and environmental issues, etc.), it is likely that Subject's friends observe and possibly even comment on [Subject]'s over-concern regarding subjects over which Subject has no control.
TSI-2: Results indicate clinically significant levels of anxiety. Levels of suicidal ideation were significantly elevated; levels of suicidal behavior were within normal limits. Subject reports brief but intrusive bursts of anger over minor events, such as stubbing a toe or lightly knocking Subject's head. It is likely that Subject does not perceive these outbursts as being entirely under Subject's control. Subject indicated difficulty in forming personal thoughts and opinions, especially when in a group, that go against consensus. It is likely that Subject lacks self-knowledge and struggles to think for Subject's self.
BRIEF: Moderately impaired range, as self-reported and reported by Subject's spouse. This result is strongest in Subject's ability to be flexible. It is likely that Subject's excessive attention to detail inhibits Subject's ability to multitask as well as think creatively and quickly when problem-solving, especially in a social setting.
ACS Social Perception: Low range overall. Results indicate inability to interpret speech in any other way but literal (i.e., Subject will experience high levels of stress and confusion when what a person expresses verbally does not line up with the person’s behaviors and actions). It is likely that Subject experiences high levels of social isolation.
ADOS: Subject demonstrated above-average vocabulary and a stark lack of stereotyped language. It could be said that one of Subject's "fixations" is language. ("Nature, too, maybe,” Subject said [paraphrase], "but not like being in it. Subject just wants people to stop wantonly screwing it up.") Subject in general answered questions with an avalanche of detail. "Subject doesn't know what details are relevant and what aren't in order to answer questions, so Subject just states anything Subject thinks could be helpful. Subject doesn't want to seem rude or evasive, like Subject is not trying to answer questions. Subject just doesn't know the rules, which is stressful, because rules are Subject's only concrete guideline. Subject feels like Subject talks too much and then, inevitably, Subject will get a vulnerability hangover and also be perceived as rude anyway" [paraphrase]. Subject appeared socially motivated and responded to social bids from The Examiner; however, Subject displayed difficulty initiating social contact. "You just don't ask adults questions. What if you come off as rude or nosy? That monkey in the children's story? Curious George? Didn't he get into all kinds of trouble that really bawled his handler out? But Subject would ask those deep, uncomfortable questions. Small talk is a lot of effort with very little pay-off for Subject" [paraphrase]. Subject averted eyes the majority of the time and did not regulate social interaction with much detectable body language or gestures. Subject's barrage of details significantly abated during the discussion of emotional perception in others and Subject's self. The only direct quote worth noting: "Subject is suspicious of happiness. Subject doesn't know if Subject trusts it. It seems invalidating anyway; the world is in such great and unflappable pain" [paraphrase]. Subject described fear as being on a hamster wheel, and indicated its presence before making a phone call (to anyone), when thinking about close relationships (Subject fears rejection and abandonment because of real and perceived differences in functioning and understanding; Subject is socially motivated enough to feel social pain even though Subject's ADOS score does indicate the presence of an autism spectrum disorder) and when thinking about the future.
Testing; summary: Subject's developmental history gained through collateral contact with informants (Subject's parents and Subject's spouse) together with Subject's test scores suggest a diagnosis within the autism spectrum disorders (ASDs). Subject is an extremely bright, socially-motivated individual with a scattered cognitive profile, including a strikingly high score in the verbal comprehension area. Research indicates that many people with ASD maybe also have a "superpower." Language/verbal comprehension may be Subject's. Uneven cognitive profiles usually involve a combination of intact rote processes and impaired capacity for abstract or hypothetical thought as well as a markedly decreased ability to empathize with others and, relatedly, a disability in Theory of Mind (ToM), or the recognition that others have distinct inner lives and thoughts. Subject struggles with detecting and interpreting more nuanced interpersonal behavior and likely puts strain on personal relationships with Subject's consistent, direct and abundantly detailed communication.
Testing; diagnosis (from the DSM-IV):
- Axis 1: 299.80 Asperger's Syndrome.
- R/O 309.81 Posttraumatic Stress Disorder.
- R/O 296.33 Major Depressive Disorder.
- Axis 2: No diagnosis.
- Axis 3: Scoliosis (as indicated by Subject's verbally conveyed history).
- Axis 4: Interpersonal stressors, trauma.
- Axis 5: GAF - 51 (current).
Recommendations: Subject should be allowed an individualized education plan, which includes alternative assignments to group projects, being allowed to take exams in solitude, being given extra time for exams, being allowed to audiotape all lectures for future review, and being given as much advanced notice of syllabus, quizzes and any changes in plans as possible.
Subject will be greatly helped by identifying triggers, signs, and coping strategies for varying states of emotional arousal. Passive coping strategies (how to calm down), as well as active coping strategies (how to solve problems), are recommended. Different strategies are often needed for different types and levels of agitation. It is important to understand that emotional states have physical correlates for human beings; Subject would do well to become more aware of and grounded in Subject's body.
In order to address symptoms consistent with PTSD, depression, and anxiety, Subject would benefit from work with a warm, direct, and emotionally supportive therapist who specializes in autism spectrum disorders. To refocus away from larger issues over which Subject has no control and back onto personal issue, Subject requires evidence-based treatment modalities, such as Cognitive-Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT). Additionally, Dialectical Behavioral Therapy (DBT) has been shown in trials to be especially effective at dealing with feelings of sadness, emotional overwhelm, and deregulation. Referrals can be found on Psychology Today, or The Examiner is happy to be contacted for recommended clinicians. Subject will likely also benefit from social skills classes to help bring Subject's behavior more in alignment with peers to help ease social anxiety and tension in service of relieving isolation and establishing longed-for connections. Referrals to such groups can be found on Psychology Today, or The Examiner is happy to provide references.
Moving forward with a diagnosis of ASD as an adult can prove challenging. Subject and Subject's spouse are encouraged to contact the local university for family support resources, as well as The Families of Adults Affected by Asperger's website. Subject is a kind, extremely bright individual who values loyalty and honesty and has much to offer and many strengths upon which to build. It was a pleasure for this examiner to work with Subject; The Examiner can be reached at [redacted]. Should new information come to the attention of The Examiner, The Examiner reserves the right to modify the opinions stated in this report, including [redacted].