Conditions That Often Accompany Asperger’s Syndrome

There are a number of conditions that are more commonly found among those with autistic spectrum disorders such as Asperger’s syndrome (AS) than in the general population.

Anxiety Disorders

Common anxiety disorders among those with AS include:

    • Generalized anxiety disorder (chronic anxiety)
    • Panic disorder (panic attacks)
    • Agoraphobia (may include fear of going outdoors, unfamiliar places, crowds, or anywhere such as a bridge or elevator where the individual feels trapped)
    • Post-traumatic stress disorder
    • Social phobia
    • Obsessive-compulsive disorder

According to Attwood (2007), possible causes of anxiety disorders include sensory anomalies (i.e., fear of loud noises) and the strain of having to use one’s intellect rather than natural social intuition to succeed in social situations, which requires maintaining high alertness and triggers fearful anticipation of making errors. Children with AS may suffer from post-traumatic stress disorder as a result of frequent bullying, and a few even refuse to go to school and/or develop social phobias. Some anxious teens and adults self-medicate with alcohol or drugs, which creates a risk of addiction and can exacerbate anxiety problems in the long run.

Anxiety disorders can usually be treated effectively with cognitive-behavioural therapy and, when anxiety is extreme, medication (Attwood, 2007).

Additional anxiety disorders such as obsessive-compulsive disorder and selective mutism (a rare disorder) are described in the following sections.

Obsessive-Compulsive Disorder

Autistic spectrum disorders are similar to obsessive-compulsive disorders (OCDs) in that they are characterized by obsessive interests and compulsions to engage in repetitive or ritualistic behavious (Gillberg & Billstedt, 2000). However, special interests themselves don’t qualify as OCDs because they’re enjoyable rather than unpleasant (Attwood, 2007).

According to Attwood (2007), approximately 1 in 4 of those with Asperger’s syndrome also meet the diagnostic criteria for obsessive-compulsive disorder, the hallmarks of which are intrusive, distressing thoughts and compulsive actions (i.e., excessive hand washing, repeatedly checking that electronic items are unplugged and stoves turned off, etc.). Among those with AS, obsessive thoughts most often relate to cleanliness, teasing or bullying, criticism from others, and the risk of making social mistakes. Common compulsions include (but are not limited to) hand washing, checking things, lining up/counting/hoarding objects, and needing to complete certain rituals before sleeping. OCD most commonly arises between the ages of 10 and 12 or in early adulthood.

Selective Mutism

Selective mutism is a rare anxiety-related condition that causes the individual to be completely silent in certain social situations (i.e, school) but not others (selective mutes usually talk freely with family members at home) (Sharp et al., 2006). Research conducted by Kopp and Gillberg (1997) found that 20% of selective mutes met the diagnostic criteria for Asperger’s syndrome.

Mood Disorders

Rates of depression and bipolar disorder are higher than average not only in those with autistic spectrum disorders, but also among their close family members (Gillberg & Billstedt, 2000).

Approximately one-third of those with Asperger’s syndrome suffer from clinical depression (Attwood, 2007). This depression often shows up in adolescence or early adulthood, suggesting that increasing awareness of being different plays a significant role (Barnhill, 2007). In particular, frustration at not fitting in or receiving criticism for social mistakes can trigger the onset of depression, and common AS traits such as catastrophic thinking, perfectionism, and a tendency to suffer alone rather than seeking social support can increase the risk for depression (Attwood, 2007).

Although most symptoms of depression in people with AS are similar to those of neurotypicals (those not on the autistic spectrum), a key difference is that one or more of a depressed AS person’s special interests may be morbid (i.e., a preoccupation with some aspect of death). Those with AS may also suffer sudden attacks of intense depression after what neurotypicals perceive as minor incidents, and at such times have a heightened risk for self-harm (Attwood, 2007).

Depression can be treated with medication, cognitive-behavioural therapy, and other therapies designed to increase optimism and self-esteem (Attwood, 2007).

Faulty Emotional Regulation Leading to Angry Outbursts

Attwood (2007) notes that if anger is conceived as a volume control with a scale of 1-10, those with AS can jump from 1 to 10 quite rapidly. AS creates a tendency toward extreme emotional responses: joy, pain, pleasure, fear, and rage can all be magnified. As a result, anger may be expressed in sudden, explosive outbursts that others find distressing. This unusual anger profile may result from the fact that the amygdala, a brain structure involved in the regulation of emotion, is often functionally and structurally abnormal in those with autistic spectrum disorders.

Anger may also be used as a tool to keep others at bay if the individual with AS wants to be left alone, or as a countermeasure to prevent further bullying. In the latter case, a child who has been bullied by another child in the past may launch what appears to be an unprovoked strike against the other, but this is actually a pre-emptive strike, considered a means of self-defense by the individual with AS. In some cases, expressions of rage may actually be altered expressions of sadness, and engaging in some sort of aggressive or destructive action (throwing or smashing something, hitting a pillow, etc.) can be therapeutic.

According to Attwood (2007), the best way to deal with a rage attack is to redirect the individual toward an enjoyable activity (i.e., one related to the person’s special interest) or an energetic physical activity such as running (many people with autistic spectrum disorders enjoy running, and a number of them have become accomplished marathoners – see Autism, Asperger’s Syndrome, and Sports for more information).

Tourette’s Syndrome

Studies suggest that between 8% and 20% of those with Asperger’s syndrome also meet the diagnostic criteria for Tourette’s syndrome, and an even greater proportion have tics (sudden, rapid movements or uncontrollable vocalizations) of some sort without meeting the full Tourette’s criteria (Gillberg & Billstedt, 2000).

Attention-Deficit Hyperactivity Disorder (ADHD)

Asperger’s syndrome can create attention deficit issues similar to those seen with ADHD, and those on the autistic spectrum are commonly either hyperactive or hypoactive (underactive) (Gillberg & Billstedt, 2000). An individual may have both ADHD and Asperger’s syndrome, but hyperactivity in those with AS doesn’t necessarily signify ADHD (it can be caused by anxiety or stress), and distractibility may result from sensory overload or anxiety rather than ADHD (Attwood, 2007).

Eating Disorders

Von Wendt et al. (2005) found that 60.3% of those with Asperger’s syndrome have aberrant eating habits. Various studies have shown a link between autistic spectrum disorders and anorexia nervosa in particular (likely due to texture/taste/smell aversions associated with certain foods and food-related anxieties), with 18-23% of anorexic teen girls also showing signs of AS (Attwood, 2007).

Other eating disorders or anomalies that may be present include eating only a small selection of foods, compulsively arranging food in certain ways, food hoarding, overeating, and pica (eating non-food items)(Gillberg & Billstedt, 2000).

See Asperger’s Syndrome and Anorexia for more on the link between AS and food refusal.

Sensory Processing Anomalies

Unusual responses to certain sights, sounds, tastes, smells, textures, or touches are common with autistic spectrum disorders. For example, an individual may be over-sensitive to certain noises, or fail to notice someone calling his or her name (under-responsive or temporarily “tuned out”). Auditory and tactile (touch) are the senses most likely to be affected (Gillberg & Billstedt, 2000).

For information on sensory processing issues associated with autism and Asperger’s syndrome, as well as sensory integration therapy, see Sensory Problems Associated with Autistic Spectrum Disorders.

Sleep Problems

The majority of those with autistic spectrum disorders suffer from abnormal sleep patterns. As babies they are likely to cry until late in the night (Gillberg & Billstedt, 2000), and sleep difficulties often persist as they grow older.

According to Goldberg and Berkman (2011), 73% of children with Asperger’s syndrome suffer from sleep problems, and anxiety may exacerbate sleep difficulties. A tendency to suffer insomnia can be reduced or eliminated by:

    • Getting more exercise (not shortly before bedtime, however, as this can interfere with sleep)
    • Avoiding caffeine, tobacco, alcohol, high-fat foods, and MSG
    • Not eating large meals within 3 hours of bedtime, though a very small snack with lean protein and good carbs (whole wheat, brown rice, etc.) shortly before bed can be helpful
    • Limiting intake of all fluids 2 hours before going to bed
    • Avoiding napping in the daytime
    • Having “calm time” for at least half an hour before bed during which stimuli (bright lights, noises, etc.) are limited
    • Taking a bath 90 minutes before bedtime (getting out of the bath causes a drop in body core temperature that may assist in promoting sleep)
    • Using the bedroom only for sleeping
    • Maintaining a regular sleep schedule even on weekends

Prosopagnosia (Difficulties with Face Recognition)

Up to two-thirds of those with autistic spectrum disorders also have prosopagnosia, a condition that makes it difficult to recognize faces (Lawton & Reichenberg-Ullman, 2007). Prosopagnosia may be mild (difficulty recognizing the faces of near-strangers or acquaintances) to severe (problems recognizing close friends and family members). The condition is usually mild in those with AS.

For more information on prosopagnosia, see Asperger’s Syndrome and Face Recognition.

Topographic Agnosia (Tendency to Get Lost)

Up to one-third of those with AS suffer from topographic agnosia, or “place blindness” (Lawton & Reichenberg-Ullman, 2007). In other words, they get lost easily and have difficulty finding their way around (on the other hand, some people with AS have exceptional wayfinding abilities). For more information on this, see Asperger’s Syndrome and Wayfinding.

Epilepsy

According to Epilepsy Ontario (n.d.), between 20% and 35% of those on the autistic spectrum also have a seizure disorder, with seizures often beginning during puberty, possibly due to hormonal changes. Seizures may be dramatic in some cases, including noticeable convulsions, but they are often subclinical and thus difficult to identify. Signs of subclinical seizure activity may include:

    • Behaviour problems (self-injury, aggression, severe tantrums)
    • Academic stagnation in an adolescent student who previously did well in school
    • The loss of cognitive or behavioural skills

Of course, other problems may cause these symptoms. For example, academic stagnation is often a sign of depression, a common mood disorder afflicting those with AS that often comes on during the teen years, and tantrums may be caused by anxiety.

Non-Verbal Learning Disability (NVLD)

According to Kutscher (2006), this broad umbrella category encompasses symptoms arising from difficulty integrating information within the non-dominant hemisphere of the brain (usually the right hemisphere). Symptoms may include some or all of the following:

    • Gross motor problems (clumsiness, general lack of coordination)
    • Fine motor problems (messy handwriting, difficulty using scissors or tying shoes, etc.)
    • Fixating on detail at the expense of the whole (not seeing the forest for the trees)
    • Needing to process visual-spatial information verbally (label everything with words)
    • Atypical body language
    • Misinterpretation of social cues
    • Black-and-white thinking
    • Trouble reading between the lines or detecting hidden messages
    • Exceptional reading skill, rote speech, and memory
    • Pedantic adult speech pattern in childhood (little professor)
    • Difficulty with the give and take of conversation (tendency to give monologues rather than interact)
    • Uneven math skills (may be very good with some aspects of math but have difficulty with others)

Because the symptoms of NVLD overlap significantly with those of AS, some have argued that they are really the same condition. However, Forrest (n.d.) notes that those with NVLD but not Asperger’s don’t typically have narrow, obsessive interests and are not inclined to develop special skills.

Semantic-Pragmatic Communication Disorder (SPCD)

According to Kutscher (2006), this disorder, which is characteristic of AS, affects the understanding of abstract language such as idioms and metaphors (semantics) and the capacity to use language appropriately in social contexts (pragmatics). Symptoms (many of which are similar to those of NVLD) include:

    • Difficulty understanding or using words or phrases related to abstract concepts, idioms, and emotions
    • Trouble determining the central theme or idea of a statement or story
    • Lack of intuitive knowledge regarding the rules of conversation (i.e., taking turns), leading to a tendency to lecture or interrupt
    • Overly literal interpretations, which can make it difficult to get jokes, detect sarcasm, or appreciate metaphors
    • Tendency to parrot things back that they don’t fully understand, creating an impression of intellectual maturity in childhood
    • Often have good rote skills in computers and mathematics

As with NVLD, many have argued that Asperger’s syndrome and SPCD are similar, entirely the same, or on the same continuum. However, it’s possible to have SPCD without the social impairments that typically accompany Asperger’s syndrome (Bishop, 1989).

More Information on Autism and Asperger’s Syndrome

Although this list of conditions appears daunting, with the exception of NVLD and/or SPCD, most of these conditions afflict only 1 in 3 to 1 in 5 of those with AS (or even fewer), which means that the majority of those with AS will not have a given condition. It’s also worth noting that there are a number of positive traits associated with AS.

Note: Asperger’s syndrome has been removed from the DSM as a diagnostic category, and is now considered part of the larger autistic spectrum. However, many people still use and identify with the term, and it has been an area of focus for prior studies, so we continue to use Asperger’s syndrome in this article series. 

For more information on autistic spectrum disorders, visit the main Autism and Asperger’s Syndrome page.

References:

    • Attwood, T. (2007). The Complete Guide to Asperger’s Syndrome. London, UK: Jessica Kingsley Publishers.
    • Barnhill, G. P. (2007). “Outcomes in Adults With Asperger Syndrome.” Focus on Autism & Other Developmental Disabilities, 22(2), 116-126.
    • Bishop, D.V.M. (1989). “Autism, Asperger’s Syndrome and Semantic-Pragmatic Disorder: Where Are the Boundaries?” British Journal of Disorders of Communication, 24, 107-121.
    • Epilepsy Ontario. (n.d.). “Epilepsy/Seizures and Autism.” EpilepsyOntario.org.
    • Gillberg and, C. C., & Billstedt, E. E. (2000). “Autism and Asperger Syndrome: Coexistence with Other Clinical Disorders.” Acta Psychiatrica Scandinavica, 102(5), 321-330.
    • Forrest, B., PhD. (n.d.). “The Boundaries Between Asperger and Nonverbal Learning Disability Syndromes.” NLDLine.com.
    • Goldberg, M.A., PhD, & Berkman, J., PhD. (2011). “Sleep Problems in Children with Asperger Syndrome.” Asperger’s Association of New England, AANE.org.
    • Kopp, S., & Gillberg, C. (1997). “Selective Mutism: A Population Based Study (A Research Note).” Journal of Child psychology and Psychiatry, 38(2), 257-262.
    • Kutscher, M.L., MD. (2006). “Autistic Spectrum Disorders: Sorting It Out.” PediatricNeurology.com.
    • Lawton, S., & Reichenberg-Ullman, J. (2007). Asperger’s Syndrome: Natural Steps Toward a Better Life. Greenwood Publishing Group.
    • National Institute of Neurological Disorders and Stroke. (20 April 2011). “Asperger Syndrome Fact Sheet.” NINDS.NIH.gov.
    • Sharp, W.G.; Sherman, C.; & Gross, A.M. (2007). “Selective Mutism and Anxiety: A Review of the Current Conceptualization of the Disorder.” Journal of Anxiety Disorders, 21(4), 568-579.
    • Wendt, T.; Paavonen, J.E.; Ylisaukko-Oja, T.; Sarenius, S.; Källman, T.; Järvelä, I.; & von Wendt, L. (2005). “Subjective Face Recognition Difficulties, Aberrant Sensibility, Sleeping Disturbances and Aberrant Eating Habits In Families With Asperger Syndrome.” BMC Psychiatry, 5:20.

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