by Sandi Mann
Borderline personality disorder, also known as emotionally unstable or emotional regulation personality disorder, affects around 1 per cent of the population, but 75 per cent of those with the diagnosis are women.
Autism spectrum disorder (ASD)
This is a pervasive developmental disorder in that symptoms are present from an early developmental stage (usually within the first two years of life) and cause significant impairment in functioning. Deficits tend to fall within two main areas:
• Social impairment: this includes difficulties with social communication caused by lack of eye contact, ‘flat’ monotone voice, lack of understanding about turn-taking, inability to empathize, narrow range of interests and inability to read social cues.
• Repetitive and stereotyped behaviours: for example, children may repeatedly flap their arms or wave their fingers in front of their faces. These repetitive actions are sometimes called ‘stereotypy’, ‘stereotyped behaviours’ or ‘stims’. They might also be obsessed with certain objects or places.
It should be noted that ASD is a ‘spectrum’, which means that it varies in severity and symptomology. Some children, for example, are very keen to socialize and make friends even though they find it hard to do so, while others are less interested in other people. Sometimes the term Asperger’s Syndrome is used to describe those less severely affected (also referred to as high-functioning); unlike the more severe ‘autism’, people with Asperger’s Syndrome have no significant delay in language development. There is also a unique (and rather rare) form of autism called autistic savantism, where a child can actually display outstanding skills in music, art or numbers, as illustrated so well by the character played by Dustin Hoffman in the 1988 film Rain Man (see the case study below).
‘Savant syndrome is a rare, but extraordinary, condition in which persons with severe mental disabilities, including autistic disorder, have some kind of “islands of genius”.’
Darold Treffert, ‘The Savant Syndrome: An Extraordinary Condition’, Philosophical Transactions of the Royal Society B: Biological Sciences 364(1522): 1351–7
Around one in 100 people has ASD. Around half of people with an ASD also have a learning disability. Boys are more likely to be diagnosed with an ASD than girls. Because there is no specific test for ASD, diagnosing the condition can be difficult and usually involves a mix of observation, questionnaires and interview techniques. One psychological test that helps with diagnosis is called ADOS – the Autism Diagnostic Observation Schedule. This is a semi-structured assessment of communication, social interaction and play (or imaginative use of materials) and consists of four modules containing standardized activities that allow the examiner to observe the occurrence or non-occurrence of behaviours that have been identified as important to the diagnosis of autism.
Case study: Savants
An estimated 10 per cent of the autistic population – and an estimated 1 per cent of the non-autistic population – have savant abilities.
Stephen Wiltshire is one such ‘savant’. Born in London, England, in 1974 to West Indian parents, he was diagnosed as autistic at the age of three. When he was about seven, Stephen became fascinated with sketching landmark London buildings. After being shown a book of photos depicting the devastation wrought by earthquakes, he began to create detailed architectural drawings of imaginary cityscapes. Wiltshire’s amazing skill was that he could look at a subject once and then draw an accurate and detailed picture of it. He frequently draws entire cities from memory, based on brief helicopter rides. For example, he produced a detailed drawing of four square miles of London after a single helicopter ride above that city. His 19-foot (5.8-m)-long drawing of 305 square miles (790 sq. km) of New York City is based on a single 20-minute helicopter ride.
In May 2005 Stephen produced his longest ever panoramic memory drawing of Tokyo on a 32.8-foot (10.0-m)-long canvas within seven days following a helicopter ride over the city. A 2011 project in New York City involved Wiltshire’s creation of a 250-foot (76-m)-long panoramic memory drawing of New York, which is now displayed on a giant billboard at JFK Airport. Wiltshire’s work has been the subject of many TV documentaries. The renowned neurologist Oliver Sacks writes about him in the chapter ‘Prodigies’ in his 2009 book An Anthropologist on Mars.
In 2006 Wiltshire was appointed a Member of the Order of the British Empire (MBE) for services to art. In September 2006 Stephen opened his permanent gallery in the Royal Opera Arcade, Pall Mall, London (http://www.stephenwiltshire.co.uk/).
Daniel Tammet is another autistic savant. Since the age of three when he suffered an epileptic fit, he has been obsessed with counting (as a child he eschewed football in favour of spending his playtimes counting leaves on the trees) and can perform mind-boggling mathematical calculations at breakneck speeds. He achieves this by feeling and seeing shapes rather than actually calculating them – he sees numbers as colours, shapes and textures. He recently broke the European record for recalling pi, the mathematical constant, to the furthest decimal point (which took five hours); to him, pi isn’t an abstract set of numbers but more of a highly visual story.
His incredible abilities can get in the way of everyday life, however: for example, a trip to the supermarket involves high levels of ‘mental stimulus’ as he feels obliged to count, calculate and work out everything from prices to arrangements of fruit and veg (http://www.danieltammet.net/).
Spotlight: Famous people alleged to have had ASD
Isaac Newton, Albert Einstein, George Orwell, H.G. Wells, Beethoven, Mozart, Hans Christian Andersen and Ludwig Wittgenstein are thought to have shown signs of ASD, according to Michael Fitzgerald, Professor of Psychiatry at Trinity College, Dublin. ‘Psychiatric disorders can also have positive dimensions. I’m arguing the genes for autism/Asperger’s and creativity are essentially the same,’ he said in 2008 at a Royal College of Psychiatrists’ Academic Psychiatry conference in London.
There is no clear explanation for what causes ASD. However, family studies have shown that genes play a role; for example, if one identical twin has autism then the other has around a 75-per-cent chance of also having autism. One of the greatest controversies about ASD is centred on whether a link exists between ASD and certain childhood vaccines, particularly the measles–mumps–rubella (MMR) vaccine (see the ‘Spotlight’ below). Despite extensive research, no reliable study has shown a link between ASD and the MMR vaccine.
Spotlight: The MMR vaccine controversy
In 1998 Dr Andrew Wakefield published a research paper in the medical journal The Lancet that lent support to the later discredited claim that colitis and autism spectrum disorders are linked to the combined measles, mumps and rubella (MMR) vaccine. This paper was widely published in the media and directly led to a massive drop in vaccination rates in the UK and Ireland which was followed by a significantly increased incidence of measles and mumps, resulting in deaths and severe and permanent injuries.
Wakefield’s research began to unravel when an investigation by the Sunday Times journalist Brian Deer discovered that Wakefield had multiple undeclared conflicts of interest, had manipulated evidence, and had broken other ethical codes. The Lancet paper was partially retracted in 2004, and fully retracted in 2010, when The Lancet’s editor-in-chief Richard Horton described it as ‘utterly false’ and said that the journal had been ‘deceived’. Wakefield was found guilty by the General Medical Council of serious professional misconduct in May 2010 and was struck off the Medical Register, meaning he could no longer practise as a doctor in the UK.
The scientific consensus today is that, despite many studies across the world since 1988, no evidence links the MMR vaccine to the development of autism, and that this vaccine’s benefits greatly outweigh its risks. A 2011 journal article described the vaccine–autism connection as ‘the most damaging medical hoax of the last 100 years’.
There is no single treatment for autism; treatments generally address behavioural and learning skills. Treatments can include intensive skill-building a
nd educational sessions, known as applied behaviour analysis (ABA).
Attention deficit hyperactivity disorder (ADHD)
ADHD is another developmental condition and was first recognized in 1902 by the British paediatrician George Frederic Still. Since Still’s day, the disorder has been called various things such as hyperkinetic syndrome, attention-deficit disorder (ADD) and now ADHD. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition, the DSM-V (the ‘bible’ for diagnosing all mental health conditions), outlines indicators for ADHD that include:
• Inattention: being easily distracted, missing details, forgetting things, frequently switching from one activity to another, having difficulty maintaining focus on one task, becoming bored with a task after only a few minutes (unless doing something enjoyable), having difficulty focusing attention on completing a task or learning something new, having trouble completing homework assignments, often losing things (e.g. pencils, toys, assignments), not seeming to listen when spoken to, daydreaming, becoming easily confused, and struggling to follow instructions.
• Hyperactivity: fidgets and squirms in their seat, talks nonstop, rushes around, touching or playing with anything and everything in sight, has trouble sitting still, is constantly in motion, has difficulty doing quiet tasks or activities.
• Impulsivity: being very impatient, blurting out inappropriate comments, acting without regard for consequences, having difficulty waiting their turn in games and often interrupting conversations or others’ activities.
Based on the DSM criteria, there are three subtypes of ADHD:
• ADHD, predominantly inattentive
• ADHD, predominantly hyperactive–impulsive
• ADHD, combined type that is a combination of the first two subtypes.
There is no sure-fire way of diagnosing ADHD and the phenomenal rise in children being given this label has led some to believe that it is being diagnosed far too readily. Incidence rates vary according to the diagnostic criteria used but the statistics suggest a massive increase in people with the condition; the Center for Disease Control’s national survey of Children’s Health in the United States reported an 830-per-cent increase in children diagnosed with ADD or ADHD from 1985 to 2011. An article in the New York Times in 2013 reported that, in 24 years, the number of children on medication for ADHD in the United States had soared from 600,000 to 3.5 million. This means that nearly one in five high-school-age boys in the United States and 11 per cent of school-age children overall have received a medical diagnosis of ADHD. The disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma.
As in ASD, there are likely to be a number of factors contributing to the causes of ADHD, including genetic and environmental. Brain imaging studies have revealed that, in young people with ADHD, brain development appears to be delayed, on average, by about three years and this delay is most pronounced in brain regions involved in thinking, paying attention and planning. More recent studies have found that the cortex – the outermost layer of the brain – also shows delayed maturation.
‘The symptoms of ADHD can cause significant suffering in children, families, and schools and significant costs to the health care system, education system, juvenile justice system, and employers through parental work loss.’
Erik Parens and Josephine Johnston, ‘Facts, Values, and Attention-Deficit Hyperactivity Disorder (ADHD): An Update on the Controversies’, Child and Adolescent Psychiatry and Mental Health 3/1 (2009)
There is no cure for ADHD but medication is often used to manage the symptoms when these are severe. Stimulants such as methylphenidate (‘Ritalin’ or ‘Concerta’) and amphetamines (‘Adderall’) are the most common type of medication used; this might seem odd given that hyperactivity is often a major symptom of ADHD but these medications work by stimulating brain circuits that help maintain attention. Non-stimulant medications, such as atomoxetine (‘Strattera’), guanfacine and clonidine are also effective for some.
Oppositional defiant disorder (ODD)
ODD is a developmental behavioural disorder thought to be characterized by uncooperative, defiant, negative, irritable and annoying behaviours towards parents, peers, teachers and other authority figures. The condition is somewhat controversial in that some would argue that most children can be oppositional, even very oppositional, at times – something that used to be simply labelled as naughty. Where ODD differs, however, is that the ‘naughtiness’ persists despite appropriate parenting or other inputs. The condition is defined in the DSM-V, which says that four of the following should be exhibited for at least six months to reach a diagnosis. The child:
• actively refuses to comply with authority figure’s requests or consensus-supported rules
• performs actions deliberately to annoy others
• is angry and resentful of others
• argues often
• blames others for their own mistakes
• frequently loses temper
• is spiteful or seeks revenge
• is touchy or easily annoyed.
Behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Treatment tends to be non-pharmaceutical such as social skills training, training for parents and family therapy.
Dig deeper
Emergence: personality disorder website:
http://www.emergenceplus.org.uk/
Article about Andrew Wakefield:
http://www.nytimes.com/2011/04/24/magazine/mag-24Autism-t.html?pagewanted=all&_r=0
Fact-check
1 Which of the following is not normally a feature of bipolar disorder?
a Excessive happiness or energy
b Decreased need for sleep
c Disorganized speech
d No interest or pleasure in all, or almost all, activities previously enjoyed
2 What might be the causes of bipolar disorder?
a Genetic factors
b Abnormalities in brain structure
c Environmental factors
d All of the above
3 Schizophrenic patients often suffer from delusions. These are:
a Where you hear voices
b Where you believe something totally even there is clear evidence that you are wrong
c Where you see things that are not there
d Where other people don’t believe you
4 Negative symptoms of schizophrenia include:
a Lack of emotional expression
b Lack of interest or enthusiasm
c Social withdrawal
d All of the above
5 Which of the following is an ‘anxious’ personality disorder?
a Avoidant
b Schizoid
c Narcissistic
d Borderline
6 Diagnosis of personality disorder remains controversial because:
a No one knows what it really is
b The rates have increased so much
c There is no real test for it
d It is an insulting term
7 People with autistic spectrum disorder tend to:
a Suffer delusions
b Experience hallucinations
c Hear voices
d Have difficulty in social situations
8 Autistic savantism is:
a What most people with ASD experience
b Where people with ASD have islands of exceptional skill
c When people with ASD are good at maths
d When people with ASD are good at art
9 Which of the following is not a sub-type of ADHD?
a ADHD, predominantly inattentive
b ADHD, predominantly hyperactive–impulsive
c ADHD, combined type that is a combination of the first two subtypes
d ADHD, predominantly autistic
10 People with ADHD are:
a Usually of below average intelligence
b Children – adults grow out of it
c Often psychotic too
d Often easily distracted
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Psychological therapies
Psychological therapies are processes designed by psychologists to modify the feelings or change the behaviours of people who are experiencing difficulties that affect their mental health and well-being. They ‘encompass a range of interventions, based on psychological theory and evidence, which help people to alter their thinking, behaviours and relationships in the present, and process trauma and disturbance from the past, in order to alleviate emotional distress and improve psychosocial functioning’. Such therapies might be provided to adults or children with mental health issues, to those with learning disabilities or to people with physical and neurological disabilities. There is a wide range of therapies available, many of which are discussed in this chapter.
Behaviour therapy
As its name implies, behaviour therapy (or behaviour modification) aims to change human behaviour that is inappropriate or unhelpful in that it is causing problems or difficulties for the patient. Examples of conditions that respond well to behaviour therapy include addictions, anxiety, phobias and obsessive–compulsive disorder (OCD).
The theoretical approach behind behaviour therapy is that maladaptive behaviours are learned and thus can be unlearned by examining the thoughts and feelings that lead to that behaviour occurring or continuing to occur. Unlike some other therapies that focus on the past, behaviour therapy is much more concerned with the present and how behaviour in the future can be changed or modified. (That is not to say that the past is unimportant in this kind of approach, as it can help to explain present problems, but the focus is very much on moving forward rather than delving into the past.) Behaviour therapy usually focuses on some aspect of behaviour that is easily measurable.