Wednesday, January 27, 2010

What is Aspergers: My Perspective - Part 4 (Co-conditions)

Right at the beginning of this series, I suggested that Asperger's by itself isn't a debilitating condition. I stand by this. It is not simply Asperger's that is the problem but the co-conditions which frequently exist alongside it. Often these co-conditions are called comorbids but it is a word which I have stopped using because there are limitations on what can and cannot be referred to as the a comorbid. I'm not ready to accept those conditions.

It's hard to determine whether or not a co-condition is an entirely separate condition existing at the same time as Asperger's or whether it is simply a facet of the Asperger's itself. Sometimes the conditions seem to start out as part of the aspergers but separate later into fully fledged conditions of their own - sometimes it goes in the opposite direction.

I think that it varies from person to person and from condition to condition.

When a co-condition exists as a part of aspergers, it is never as severe as the condition would be by itself. Many of the lesser symptoms manifest themselves and there are social and functional problems which arise as a result. Although these mini-conditions aren't as severe, there is a good chance that a person with aspergers could display a smattering of mini-conditions all of which combine to make their own lives more difficult.

Some of the most common co-conditions are as follows;

  • OCD Obsessive-Compulsive Disorder
  • SPD Sensory Processing Disorder
  • ADHD Attention-Deficit Hyperactivity Disorder
  • Depression
  • Schizophrenia
  • Anxiety
  • Tourette's syndrome
  • Dyspraxia
  • Seizures
  • Bipolar Disorder
  • Learning Difficulties and Non-Verbal Learning Disabilities
I don't have a lot of room in this post to describe each condition and I'm by no means an expert on any of them. I'll try to highlight what I see as the differences between the condition as part of aspergers versus the condition on it's own but please don't take this a medical advice - it's purely opinion.

OCD Obsessive-Compulsive Disorder
Asperger's already contains some elements of obsessive-compulsive disorder. It is most notable as one of the driving forces behind the need for routine. This, I think is part of "normal aspergers" and I think all aspies have OCD to one degree or another.

Obsessive-compulsive disorder as a co-condition manifests itself in a number of ways with Asperger's. In particular, "lite" OCD can combine with the Asperger's special interests to create compelling and sometimes financially difficult collections. This is the sort of thing which you see on television about Star Wars collectors who have every single figure, spaceship. poster, book - even cutlery. This might not seem to have a great impact on the persons life however you need to think of the social consequences of inviting friends over to a house filled with memorabilia and also the problems of needing to own certain items. Sometimes such OCD desires can actually cause aspies to commit crimes.

Of course, co-condition OCD is nothing compared to its full-fledged counterpart. OCD can cause an individual to continually go through a repetitive set of unnecessary routines. This can make simple things like "leaving the house" become a three-hour job where every appliance, tap, light and lock needs to be checked several times over.

Sensory Processing Disorder
Sensory Processing Disorder is another condition which seems to be part of the core Aspergers condition. In particular, SPD is responsible for the lack of eye contact, the intolerance to loud noises and the difficulty wearing certain clothes. Once again, I believe that most people with Asperger's have this to one degree or another. When SPD is severe enough to be identified as a co-condition with aspergers it moves from simple difficulty with the environment to major levels of intolerance.

People with SPD as a co-condition will often find themselves completely unable to enter a room because of ambience issues. These can be caused by issues with lighting, sound or textures. They have great difficulty wearing certain clothes and may even have difficulty wearing clothes at all. It's obvious how an SPD could turn aspergers from a "passable" condition into something which causes the individual to retreat from society.

Many people with SPD as a co-condition need to wear suppressants such as sunglasses, earphones or gloves when they're out and about.

SPD has a life of it's own as a completely separate condition. In it's severest forms, it can prevent children who are particularly resistant to touch from playing with others, and may even interfere with their relationship to their parents.

Attention-Deficit Hyperactivity Disorder
ADHD and it's sub-condition ADD (the non-hyperactive type) are some of the most frequently misdignosed components of Aspergers. Children with ADHD are extremely distractable by outside influences but tend to "zone out" in close discussion. Sometimes it feels impossible to get their attention. ADHD/ADD can significantly impact learning as children have difficulty paying attention to the right signals and difficulty staying on track.

A child with aspergers and an ADHD comorbid will have a much more difficult academic life than a child with only aspergers.

Most people with aspergers suffer from depression in one form or another. After all, given the the hardship that many people with Asperger's have in their lives, depression is to be expected. Some aspies cope well with depression, showing only a few outward signs of their inner sadness.

When depression takes over a person's life to the extent where they either start to self harm or seriously consider suicide, it stops being a merely irritating co-condition and becomes a fully fledged condition in its own right.

Sometimes however, the aspie isn't actually sad at all. Sometimes it is simply their lack of expression, both facial and tonal, which leads people around them to believe that they are depressed.

One final note on the misdiagnosis of depression, Sometimes self harm is considered to be depression when in fact it is actually a sensory thing. A good example of this is when people cut themselves or when they do things such as biting their nails down to the skin level. Sometimes such actions are about enjoying a feeling because some aspies have such high pain tolerance that they need intense feelings to feel anything much.

This is one of the conditions which has reduced my usage of the word "comorbid". Apparently Schizophrenia and Aspergers are supposed to be mutually exclusive. I do not believe that this is the case. I know people who have shown signs of Aspergers throughout their lives. They've since "developed" schizophrenia. If a diagnosis of schizophrenia starts with the person hearing voices, something that generally isn't present from the early ages, how then does someone separate it from Asperger's which shows up in childhood?

Anxiety is closely related to Asperger's and also to SPD and OCD. Many people with Asperger's are naturally anxious but this does not necessarily mean that they suffer from anxiety. To suffer from anxiety is to have persistent worries on such a frequent basis that it interferes with ones daily life and routines.

Sometimes, anxiety comes on in a wave, called a panic attack which lasts about ten minutes. For many people, these attacks come while doing things that they do every day such as shopping. It may simply be that some environmental conditions such as the number of bystanders or the volume of music has changed.

Unlike most conditions discussed here however, people are not usually born with true anxiety, it tends to be developed over time. The extreme form of anxiety, Post Traumatic Stress Disorder (PTSD), results from violent emotional trauma. Sometimes people with Asperger's can be more open to PTSD because of some of the memory issues associated with the condition or because their naturally anxious conditions exacerbate "normal" trauma.

Tourette's Syndrome
Tourette's syndrome is similar to the ticks and physical and verbal stimming that people with Asperger's tend to do. Once again, while Asperger's itself tends to display some of the characteristics, there is a significant difference between Tourettes as a separate disorder and the co-condition of Tourettes symptoms with Aspergers. In Aspergers generally, facial tics and stimming (Simple Tourettes) may impact social functioning but there is little comparison with the wider issues of complex Tourettes, which involves more complex movements, seizures, utterances and self harm.

There are two major types of Dyspraxia, verbal/oral and motor. Verbal dyspraxia is a condition which it difficult to understand the speech of people. As a co-condition in Asperger's, dyspraxia can be likened to the monotone and speech issues that aspies suffer from. Motor dyspraxia can be likened to many of the coordination issues associated with Asperger's and low muscle tone.

As you would expect, full-fledged dyspraxia has considerably greater impact on the individual.

Bipolar Disorder
Some people with aspergers tend to be a little more polarised in their emotions - either very happy or very sad but usually not "neutral". It doesn't mean that they have bipolar disorder. I sometimes wonder if meltdowns are part bipolar - they're obviously related to some of the other co-conditions too.

What is obvious though is that there is some link between aspergers and bipolar. I'm constantly surprised by how many aspies have both conditions and how many people with purely aspergers talk about having a bipolar parent.

General Learning Difficulties and NVLD
Learning difficulties and Non-Verbal Learning Disabilities (NVLD) are quite common with aspergers. Although children with aspergers often have a great vocabulary, they often have problems reading and writing text. In particular, this comes out when they're called upon to do word-based mathematics problems.

I know that many aspies have difficulty in this regard but the presence of full-fledged NVLD can have such a significant impact on a child's learning abilities that they struggle, even with special education support, for the remainder of their academic lives.


Adelaide Dupont said...

Thank you so much for the list of co-existing conditions.

It is a long list!

I only really started to think about it when Kassiane Sibley talked about being autistic, epileptic and bipolar and in general being "mentally interesting", as go the words on CrazyMeds.

I see that you looked at mostly Axis 1 conditions, unlike the Axis 2 of personality disorders/dysregulations. As well, you included some learning disabilities.

Alexithymia and some of the -thymias are probably ones to look at, especially dysthymia and cyclothymia.

Very glad, too, that you covered anxiety and post-traumatic stress disorder. (The 'violent emotional trauma' as opposed to perhaps the more polarised war [for men]/rape [for women]).

Have got to know a few people with Non-Verbal Learning Disorder.

eaucoin said...

Gavin, you have presented your thinking very clearly here, and I often find your blog a refuge from the bottom-line thinking of the neurotypical world, where a person can't be a little bit disabled, or a little bit mentally ill, anymore than they can be a little bit pregnant. On days when I am coping well, I don't feel disabled and I think, therefore, that I am not. On hard days the different/disabled argument sounds like "which came first: the chicken or the egg?" I would like to see more discussion about how we can teach our Aspie children: when to ask for intervention, how and whom. The problem is that if a person is used to soldiering bravely and emotional numbness is an inherent weakness, how will they know when they need intervention?

eaucoin said...

Another question I would like to put out there: My daughter works in a sports bar-restaurant. Recently one of the regulars who she has pretty good rapport with brought in his three year old son. My daughter told me that she noticed things about the little boy that made her think he may have high-functioning autism. She asked me if I thought she should tell the father of the little boy her concerns (in case the little boy may escape diagnosis longer by her silence) and if so, what's the best approach to keep from offending the man. Any young parents wish to comment on this?

Anonymous said...

This is a great post! A good informative addendum for someone living with, or living with some who has, Asperger's. A lot of things go "untouched" or even "overexamined" and many people are left confused. This is a good starting point. Thanks!

Ann said...

This is a very interesting series of articles. You didn't mention anorexia as a co-condition and I think it should be on your list. Sensory issues can lead to a restricted diet, the motor planning problems of dyspraxia and low muscle tone can lead to difficulties chewing and swallowing, attention issues or talking about a special interest can contribute to forgetting to eat while at the dining table, and detailed long-term memory of bad incidents like gagging on something can lead to permanent avoidance of favorite foods. Out of these difficulties, anorexia can develop. It also seems there may be a genetic link: My son is traveling along this path, he's eight years old.

Adelaide Dupont said...


Here are some interesting links about the autism-anorexia connection.

Cal on his childhood food issues

Cal again on broadening food interest

Cal on Weight, his brother's biggest battle

Vanessa Vega on the question of whether autism and anorexia could be genetically linked

Also there's a really good link about Wendy and her two boys.

Nourishing my son: neither of the young men have Asperger syndrome (as far as we know) but the mother is investigating PANDAS.

Shanti Perez said...

Thank you for this post on co-conditions. I agree that the AS alone does not cause substantial limitations (for the most part). For me it is the depression, anxiety, and sensory disorders which have presented the most challenges for me. Sometimes things are so overwhelming that I shut down. I don't know what to do in these situations. I think this can have a profound effect on the way I make decisions.

Karen at CYB said...

Hi Gavin!

Thank you so much for this fascinating group of articles. There is a lot of food for thought here and I am reminded once again that Aspergers / Autism Spectrum Disorders are complex conditions interwoven with many co-conditions and because they present differently from person to person, asking what is the AS / ASD and what is the co-condition can be incredibly difficult to answer.

One co-condition that I didn't see expanded upon but that I do think may have a correlation is Eating Disorders, especially in women who are on the spectrum.

I have seen some studies that mention Anorexia and Bulimia. I would also like to add from personal experience the possibility of Binge / Compusive Eating Disorder having a potential correlation.

I look forward to continuing to follow your blog.

Thank you for your courage, your candidness and your willingness to share. I am relatively new in the blogosphere but invite you to check out my blog as well.


Anonymous said...

I commented earlier.....and......I am diagnosed with bipolar. I am the one that said that I have often thought I have it and people say I don't. But .....I have wondered for years. Another thing is.....I am also not diagnosed with OCD. I definitely have that or something that causes OCD to happen as a result. I have had two obsessions lately that have drove me into a major depression lately (though I have felt better) OCD isn't typical either. I don't have that clean clean clean stereotypical OCD. I also don't have the numbers thing (but I have done minor things in my head with numbers but nothing of concern lol), I just have the "I think about something every minute along with everything else I think and i can't stop thinking it and I can think of it for a year or more and it haunts me all day long and i can talk about it all day long too". My obsessions can change though....and I usually have 2 to 5 going on at once. I also have ADD...and take adderall. I forget what all you listed but those stuck out to me. Because I always though, how can I have bipolar, OCD, ADD, anxiety, social anxiety, etc as different disorders i mean, it has to be one or two things or just one containing everything with one title. I have fibromyaglgia i'm treated for and I don't know if there is any connection there but I figured i would throw that in too. I hope that it's not a problem that I am not diagnosed because know a lot of people are like that with people that say "I have this" and they thing they are overboard with thinking things. I've seen people do that a lot with bipolar. But this isn't a one day to one month though with me. It's ongoing for years plus I've been not "normal" since at least 4.

oliverthered said...

Schizophrenia can be thought of as a 'selfish' form of Aspergers.

Both typically altruistic, but schizophrenics attach themselves to things and don't like people doing things for them. In a really really really big way. But don't usually in my experience get distressed when someone tries. More it's mine, or I have to do it, or why won't you let me do it.
Than your annoying the hell out of me, leave me alone AS response.

So, exclusivity is
AS don't usually attach themselves to things
Scitzod: Do.

oliverthered said...

both Schizoid and AS people pattern match and often have lots of Anxiety and related synaesthesia (aka hearing voices)

differential is illusion vs delusional.
insite that it's not real (so detachment) vs absolution in it's reality, even when show different, as such self attachment.

AS people can have a 'trained' type of delusion, often caused by their 'wrong-planet' feelings throughout life combined with pattern matching.

Though this usually clears, schizoid conditions are life long.

Anonymous said...

Just a thought...

The schizophrenic symptoms in the Asperger's could have been bipolar mania with psychotic features.

Anonymous said...

The artistic features in schizophrenia could be black and white thinking, anxiety coming through synesthetically with self attachment. Or another way illusions caused by anxiety (well known phononymon) but due to attachment with self and no self belief issues as simple schizophrenics have getting stuck to ones self aka attachment resulting I.true polar is flipping between bring too self consious aka depressions and less consious or concerned about ones actionsand also a inverse relationship to being conscious of other things/people. Or another way showing and hiding ones self.

Anonymous said...

This was an eye-opener - I Googled some of the symptoms/conditions my friend's child has, because doctors can't make up their minds what is wrong. Definitely low muscle tone, mild Tourette's, learning difficulties, eating problems, possible Aspergers...all appear in your article as quite commonly co-existing. Even in a small way, a relief to know there are others out there too. Thank-you.

Anonymous said...

I think putting schizophrenia as co-morbid is INCORRECT, as research has found out that they are caused by OPPOSITE GENES/ Brain components.
Hallucinations are deemed to be caused by excess dopamine, while ASD is characterized by reduced dopemine, serotonine.

Miguel Palacio said...

I believe that what seemsike OCD in ASD is not the same mind of OCD in others. In ASD, some OCD-like traits could simply be coping mechanisms. or a matter of hyper-focus or pattern-latching, for examples. All of which can be mistaken for primary OCD by practicioners who are not fully familiar of not familiar at all with ASDs. And speaking of hyper-focus, this may be one of the reasons why it is often perceived as ADD, yet, instead of the perceived "tuning out", the individual could simply be "tuning in" to something else entirely and concentrating most of one's focus in that particular area instead. So, yes, perhaps it is a form of "zoning out", but only because it is a shift towards "zoning in" to something else, something that is likely more of that person's predilection and interest. Contrary to the ADD trait of not being able to maintain focus, it is more a matter of shifting or gravitating towards and actually maintaining focus on something else. Often times a subject matter or theme from which that individual is very much _not_ distractable and for which that person would most likely have no deficit of attention whatsoever to maintain focus on that chosen subject matter or theme. So, these, IMHO, are the grey areas in which too quick a diagnosis can miss the mark, if the evaluators do not pay sufficient attention themselves. ;-)

Miguel Palacio said...

Funny you should mention fibromyalgia, as I have a recurring pain in my left arm. Sometimes it is gone for days, but when it comes back, I notice that it coincides with most of my other co-conditions peaking. To the point where I have learned to see my pain as an indicator of when I am prone to exhibit just about all my other tendencies such as jerky or spasmodic movements, awkward gait, peculiar speech, excitability, hypersensitivity, stimming, getting stuck on a pattern or theme, hyper-focus, etc. it's like as tho this pain were to be my early warning sign or lithmus test of other things of which I may not be immediately aware. And I've learned to apply coping mechanisms preemptively when I can to mitigate the other tendencies, especially in a situation such as when at the job, etc.

Something that is non-traditional that seems to help a bit is the practice of Reiki. Sometimes quite a bit. It may take some practice, but it can be well worth it!