Dr. Yasir Hameed and Dr. Jaap Hamelijnck present the case of a 32-year-old man with a complex presentation involving mental health and substance abuse issues. He has a long history of psychotic symptoms including auditory hallucinations, anxiety, anger issues, and violence. After various assessments, he was ultimately diagnosed with Asperger's syndrome and attention deficit hyperactivity disorder. Reaching an accurate diagnosis was challenging but important for determining an effective treatment plan. The take-home message is that neurodevelopmental disorders should not be seen as more difficult to diagnose than other psychiatric conditions.

1. Dr Yasir Hameed
Dr Jaap Hamelijnck
Eastern Recovery Team
1 July 2014
THE CURIOUS CASE
OF THE MAN WHO
TALKS TO HIS TEDDY
BEAR

2. Why we chose this case?
ultiple and complex presentation.
arious services supporting him and his mother.
iagnostic and management challenge.

3. Background Information
2 year old white Caucasian male, unemployed, lives alone
in his flat but spends most of his day at his mother’s and
her partner and he is totally dependent on her to organise
his finances, medication and daily activities. No social
contact with others.
eferred to Eastern Recovery Team due to complex mental
health problems in June 2013 and he is also under TADS for
Opioid dependence.

4. History of Present Illness
as been under mental health services since 2008
irst referred by GP in late 2007 due to Opioid (codeine dependence),
together with anxiety, low mood, self harm and chronic insomnia.
ong term anger management problems since an early age, resulting in
severe impairment in his life.
n 2008, he was briefly under the Community Forensic Services due to
concerns about his thoughts of following young women (teenager girls).
lso has long history of being violent to others, especially to his mother and
her partner.

5. Past Psychiatric History
o previous hospitalisation. Not known to service prior to 2008.
pril 2008: Under TADS due to Opioid (codeine) dependence and is on
replacement therapy (Subutex).
ovember 2011: Referred to CRHT due to
• Suicidal thoughts, impulsive acts of two overdoses, and self-harm
(scratching his arms).
• Violent thoughts, actions and concerns about following young women.
• ? Psychotic symptoms: auditory hallucination, believing he has different
personalities (DVD shop owner, Indian Muslim).

6. ? Psychotic symptoms (based on various
psychiatric reviews)
ingle male voice, inside his head, telling him to “do things”. Some
commands are harmless (buying a loaf of bread and leaving it in the
kitchen), some are not (follow young women, scratch cars). He feels
compelled to obey, otherwise “bad things will happen to his family”.
uration: has been hearing this voice for years, but was afraid to talk
about it. Only got worse after his relationship with his partner broke
down.
is mother reported that he “always had imaginary friends”, and she is
used to hear him in ongoing conversations while alone. He still has a
teddy bear (Bradley) whom he talks with and he doesn’t finds that
unusual.

7. n addition, he has certain worries, e.g., that he will be burgled
and lose his possessions, that people are watching him, and
that they might harm him.
e has obsessional traits, in that he prefers to keep everything
tidy and in particular order; he becomes very anxious about
causing harm to his family if he does not do so. He also has
checking and counting rituals.

8. Aggressive thoughts and actions
iolence since the age of 16. Exaggerated by alcohol and amphetamine use
but continued after abstinence.
mateur boxer as a young man.
iolence in his relationships.
e was sacked from various jobs due to his temper. In 2011 he was caught
smearing the toilets at Tesco outlets with faeces.
bsessed with young girls.

9. Forensic History
convictions for ABH and GBH
onviction for section 18 (wounding with intent to cause grievous body
harm).
t the age of 20 he was charged and received a 6 month prison
sentence after assaulting a man in his flat with his friend.
e has also been violent towards his mother in the past and was
arrested by the Police but the charges were later dropped by his
mother (2008-2009)

10. March-April 2012
nder CRHT. Diagnosis of Acute psychotic episode
(F23.0). Quetiapine started and titrated to a dose of
450 mg nocte (effect?).
ther medications: Venlafaxine 150 mg od, , Lorazepam
1 mg bd, Zopiclone 7.5 mg nocte.

11. Drug and Alcohol History
isused alcohol during teenager years.
mphetamine abuse.
odeine dependence.
annabis briefly.

12. Past Medical History
pileptic fits
ypertension
sthma
czema
astritis

13. Pre-morbid personality
onely man, no friends. Avoid social gatherings. Like to live in his
routines and dislikes changes. Enjoys walking the dogs, playing video
games and watching TV.

14. Family History
o history of diagnosis of mental illness in family.

15. Personal History
orn and brought up in Leicester in 1971. Only child. Normal delivery and
milestones. Parents separated in 1972.
other has a homosexual partner since then.
oved to Skegness with mother. Bullied from age 13-16. Later on he started to
fight back.
ad poor academic achievement and left school without any qualifications.
e was an amateur junior boxer from the age of 17 years to his mid twenties,
engaging in fights and suffering some significant knock-outs.

16. September 2012
eviewed by TADS consultant. Stable. Partial response to Quetiapine,
but definitely much better. Agreed to increase Quetiapine to 600 mg
daily and commence a plan of Subutex reduction.

17. December 2012
e would like to stop medication. He is gaining weight, the voice is
getting more derogatory because of his weight.
eported second and third person auditory hallucination, derogatory.
Ideas of reference.
e also described recurrent absences of consciousness for 30 seconds
– 5 minutes during which he becomes unaware of his surroundings,
inaccessible and discontinues whatever he was doing.
epeated head injury.

18. Plan
educe and stop Venlafaxine.
tart Carbamazepine.
eep a diary of absences and tonic/clonic convulsions.
o change to Quetiapine yet: to be considered at later stage.
o postpone Subutex reduction
ater on..
EG reported as 'Normal with occasional G waves in temporal region”. Not
conclusive but lends to diagnosis of temporal lobe epilepsy.
EEG with sleep deprivation reported as 'Normal without epileptic features.

19. ERT assessment (June 2013)
mpression
omplex combination of different types of symptoms.
Obsessions, compulsions and anxiety.
ossibility of organic psychotic illness in relation to his epilepsy as well
as the psychological trauma which occurred following the breakdown
of his relationship.
lan:
witch Quetiapine to Aripiprazole (due to significant weight gain)

20. November 2013
orsening of his anxiety symptoms since the switching. Talking more to
himself, and to objects (tree).
etting very irritable and even confused. Drank a bottle of whisky he bought
as a gift for a relative. He was found wandering in the street by police
afterwards.
lso reporting visual hallucinations (he sees dark shadows, a tiger, a snake in
the shower) and has been having these experiences for the last 3 weeks.
o improvement noted in his obsessions and compulsions.

21. January 2014
xplored the life long nature of his symptoms with his difficulties in in
socialization, communication and repetitive, stereotyped behaviour.
ife long problems with attention, hyperactivity and impulsivity.

22. March 2014
e-referred for forensic community services.
ecommendation on reducing risk:
•Optimise antipsychotic (clozapine)
•Change to valproate
•Increasing his social contact (currently only with mother)

23. March-May 2014
he assessment confirmed the diagnosis of Asperger’s syndrome and
Attention Deficit Hyperactivity Disorder (ADHD).
creening Questionnaire Scores for Asperger’s Syndrome
e used the Autism Spectrum Quotient AQ the Empathy Quotient EQ
and the relative’s questionnaire RQ (ARC, Cambridge University)
• AQ score was 36 out of 50 (any score above 32 is significant)
• EQ score was 13 out of 80(any score below 30 is significant)
• RQ score was 18 out of 31 (any score above 15 is significant)

24. interview for the diagnosis of Adults with Autism Spectrum
Disorder ASD which is (RCPsych)
rea 1 – Reciprocal Social Interaction:
rew up and continued to be lonely.
lways had imaginary friends and used to talk to toys and to himself.
ives in fantasy world and sometimes can not differentiate between
what is real and what is not real.

25. rea 2 – Communication
o language delay but difficulties in pronouncing certain words, like
thirsty or kettle.
iteral Interpretation
o not understand implied meaning and not understand verbal humour

26. rea 3 – Rigidity and Repetitive Interests
ou must do things your own way the same every day and in the same
order and not missing out anything.
ou said you liked to collect DVD’s.
ike watching violent films.

31. ADHD Assessment
urrent symptoms scale- self report form:
/9 Inattentive (IA) 8/9 Hyperactive/Impulsive (HI)
hildhood symptoms scale- self report form:
/9 IA 8/9 HI. All areas. ODD 8/8. CD 4/15.
urrent Symptoms Scale-other:
/9 IA 8/9 HI. All areas were affected.
hildhood Symptoms Scale-other:
/9 IA 8/9 HI. All areas.

32. Clinical Interview (DIVA®)
cored 7 out of 9 on the inattentive symptoms (both as an adult and in
childhood)
cored 9 out of 9 on the hyperactive/impulsive (both as an adult and in
childhood)
ife long pattern of symptoms and limitations in at least 2 domains of
functioning

34. May 2014
witched carbamazepine to valproate
witched Lorazepam to Diazepam
ailed to respond to Methylphenidate. Changed to Atomoxetine.

35. Current Medication (June 2014)
Quetiapine 350mg twice daily
Clomipramine 100mg nocte
Zopiclone 7.5mg nocte
Subutex 16mg once daily, prescribed by NRP/TADS
Diazepam 2mg twice daily for anxiety
Lansoprazole 30mg once daily
Bendroflumethiazide 2.5mg tablets OD
Hydroxyzine 5mg tablet used as advised
Chlorphenamine 4mg tablet TDS
Sodium Valproate 500 mg twice daily

36. Discussion
ifferential Diagnosis of Asperger’s syndrome

37. n 1944 Hans Asperger described a condition he termed autistic
psychopathy, characterised by:
roblems in social integration
on-verbal communication
gocentric preoccupation with unusual and circumscribed interests
ifficulties with empathy and intuition. They were also clumsy (50–90%
had motor coordination problems), found it hard to take part in team
sports and exhibited behavioural difficulties including aggression and
being victims of bullying.

38. Diagnosis and differential diagnosis of Asperger
syndrome
Fitzgerald M and Corvin A. Advances in Psychiatric Treatment (2001)
chizophrenia spectrum disorders vs AS
ajor differences in age at onset, developmental history and mental
state examination. In DSM–IV, PDD is an exclusion condition for
schizophrenia and it should be suspected in atypical or non-
responsive cases.
eople with AS may say they hear voices but refer to actual voices
(auditory hypersensitivity)
eficiencies in concrete thinking and in understanding how other
minds think may cause patients with AS to misinterpret what is said to

39. Schizophrenia vs autism: (cont’d)
ersons with AS sometimes speak their thoughts out loud, which again
can be misinterpreted by a psychiatrist.
anguage abnormalities associated with ASD include substitutions,
literalness, problems with prosody, staccato speech and monotonous
speech that is excessively pedantic and focused on details or
obsessive questions.
tendency to direct the conversation towards obsessions could easily
be mistaken for evidence of associative loosening.

40. Schizophrenia vs autism: (cont’d)
comparison of thought disorder and affective flattening in patients
with autism and with schizophrenia found that they did not differ in
terms of affective flattening, and that adult patients with autism
showed poverty of speech, poverty of content and perseveration
(Ramsey et al, 1986).
he autism group showed significantly less derailment and illogicality,
suggesting that they would be unlikely to meet DSM or ICD criteria
for thought disorder in schizophrenia.

41. Schizophrenia vs autism: (cont’d)
chizophrenia can co-occur in ASD, but the additional diagnosis is
made only if prominent delusions or hallucinations are present for at
least 1 month (less with treatment).
espite an absence of epidemiological studies of psychiatric co
morbidity in ASD, it has been suggested that delusions or auditory
hallucinations may be more common than in the general population,
but the prevalence of schizophrenia (at 0.6 %) is comparable to
general population levels.

43. 4 “A”s
affect’: Inappropriate or flattened affect-emotions in-congruent to
circumstances/situation.
autism’: social withdrawal- preferring to live in a fantasy world rather
than interact with social world appropriately.
ambivalence’ : holding of conflicting attitudes and emotions towards
others and self; lack of motivation and depersonalization.
associations’ : loosening of thought associations leading to word
salad/ flight of ideas/ thought disorder.

44. Schizotypal and Schizoid Personality Disorder
he conditions do differ in at least three important respects.
- An increased rate of development of schizophrenia in schizotypal
personality disorder (not in ASD)
- Schizotypal personality disorder and schizophrenia co-occur in
families and appear genetically related.
- Prospective research of children at high risk of schizophrenia
(Erlenmeyer-Kimling et al, 2000) suggests that some individuals later
diagnosed with schizotypal personality disorder developed without

45. Attention-deficit hyperactivity disorder
illberg & Ehlers (1998) point out that children who meet criteria for
ADHD may also meet the full criteria for Asperger syndrome. They
mention one study, in which 21% of children with severe ADHD met
the full criteria for Asperger syndrome and 36% showed autistic traits.
t is important to consider that impulsivity can interfere with social
relationships, making children appear unempathic.
ndeed, children with ADHD can be so easily distracted that they
appear to be in a world of their own and therefore seem socially
disconnected.

46. Obsessive compulsive disorders
ersons with AS have obsessive interests that are not experienced as
ego-dystonic and, indeed, are often enjoyed.
aron-Cohen (1989) was critical of the use of the term obsession in
persons with autism because the subjective phenomena of resistance
to repetitive activities could not be discerned in autism. He suggested
instead the phrase ‘repetitive activities'.
CD generally has a much later onset and lacks the poor social
emotional reciprocity, empathy problems and social skills difficulties
of people with Asperger syndrome (Szatmari, 1998).

47. Was reaching a diagnosis helpful?
he importance of formulation?
ow do we decide on treatment?
ow do we prescribe?

48. Take home message
eurodevelopmental disorders are not more difficult to diagnose than
any other psychiatric disorder
ife long symptoms trait like behavioural and emotional problems are
big clues
he importance of developmental history and structured assessments

49. Thank you..