Letter to the Editor

ASPERGER’S DISORDER WITH CO-MORBID

SEPARATION ANXIETY DISORDER:

A CASE REPORT

To the Editor: Both DSM-IV TR (APA, 2000) andICD-10 (WHO, 1992) specify that Separation Anxi-ety Disorder (SAD) should not be diagnosed duringthe course of a pervasive developmental disorder(PDD). We describe here the case of a 11.3-year-oldgirl who was diagnosed by us to have SAD as co-morbid disorder in the course of Asperger’s Disorderand our reasons for doing so.

CASE SUMMARY

The parents brought Ms. MB with the com-plaints that she follows her younger sister almosteverywhere.

MB’s IQ was 90 on colored progressive matrices.She fulfilled the DSM-IV TR (APA, 2000) criteria forAsperger’s disorder (A 1–3 & B 1–2).

MB was born by caesarean section. She had nearnormal early motor and speech development and wasindependent in all her daily activities. She wasstudying in class III in a normal school where heracademic performance was average. She had a specialinterest in music. She had once performed on stagewith her father at school. Her parents observed thatMB was shy, introverted and had odd behavior sincechildhood. She never used to initiate conversationand rarely expressed herself. While talking she wouldnot make eye contact. Her facial expression showedlittle variation. She had very limited use of gestureswhile talking (A-1). She did not interact with childrenand never developed any peer relationships (A-2). Shedid not seek enjoyment nor comfort when troubled orill. She never expressed any desire to buy somethingor to go out to play. At the playground, she wouldobserve the other children’s play but would never tryto play with them (A-3). However, she enjoyed aspecial relationship with her younger sister aged six.She was more communicative with her. She would

express concern for her whenever the latter was ill orin discomfort by carressing her forehead and sittingbesides her for prolonged periods. She acted similarlybut less so with her mother.

She had markedly limited interests and activities.She had a specific interest in trains and ships and pre-ferred to have them as toys. She kept one hard toy foryears till she lost it (B-1). She stuck to specific non-functional routines and resisted any change. When atthe dining table, she would sit in a specific chair andplace and would eat everyday in the same plate.Otherwise she would not eat. After coming back fromschool, she would go everyday for cycling despite anyadverse weather conditions (e.g. rain). She would playteacher and student games with the same teddyeveryday in a stereotypedmanner without any change.She would repeat television advertisements in astereotyped manner throughout the day (B-2). Asper-ger’s disorder was the primary diagnosis.

The patient started following her younger sisteralmost everywhere at around 11 years of age. Shedeveloped excessive anxiety and threw tantrums whenseparated from her younger sister (attachmentfigure), which was developmentally inappropriate forher age (A-1). She expressed the fear that the lattermight have an accident or be harmed or kidnappedwhen away. She remained anxious and restless untilher sister returned (A-2). MB was reluctant to stay athome when her sister went to school (A-5) and sherefused to go to sleep without her sister nearby (A-6).She was assessed on Kiddies schedule for AffectiveDisorder and Schizophrenia-Present and Lifetimeversion (KSADS-PL; Kaufman, Birmaher, & Breut,1997) for eliciting psychopathology. As the abovesymptoms were present for the 4 months, MB wasdiagnosed as suffering from SAD as per DSM-IV TR(APA, 2000) criteria (A 1–2; 5–6) even though it oc-curred during the course of a PDD.

MB was given sertraline and its dose was grad-ually escalated up to 150 mg/day. Around 6 monthsfrom the onset of SAD symptoms (about the sametime when dose of sertraline reached 150 mg/day) thepatient was relieved of these symptoms.

1350162-3257/05/0200-0135/0 � 2005 Springer ScienceþBusiness Media, Inc.

Journal of Autism and Developmental Disorders, Vol. 35, No. 1, February 2005 (� 2005)

DISCUSSION

SAD is a disorder with extreme emotionalattachment, while PDD lies at the other pole. Theissue, therefore, is whether persons with PDD arecapable of having extreme emotional attachment.However, PDD patients do not have a total lack ofemotions and empathy. Some go on to developemotional attachments, though they lack the abilityto communicate and express these adequately. Manydevelop social behavior as they grow older. Unusualunemotional attachments in persons with PDD maybe explained by autistic insistence on sameness.However, as described above MB had a specialemotional relationship with her sister even prior tothe onset of symptoms, which was neither odd norexplained by autistic insistence on sameness.

These SAD symptoms appeared only when theyounger sister was away from MB. No anxiety, over-protective behavior or fear was observed in orexpressed by MB when the sister was with her.Moreover, the SAD symptoms disappeared immedi-ately when MB was reunited with her sister. Thisindicates that these symptoms were not obsessions. Inour case, MB having her younger sister as anattachment figure is unusual. Usually, an attachmentfigure is someone elder who is protective, stimulating,loving and caring. But everything else in the clinicalpicture is typical of SAD. Thus, the overall clinicalpicture favors SAD rather than an unemotionalautistic insistence on the younger sister being closeby. In our case, SAD was a major clinical feature,stressful and impairing both for MB and her family,and it ran a course similar to SAD without PDD.Therefore, this case report suggests that SAD may bediagnosed comorbid with PDD.

Thus, though controversies abound, it can besaid that emotional attachments and SAD can existin patients of PDD. Careful clinical examination candifferentiate between SAD and various other autisticsymptoms. Finally, identifying separate co-morbidsymptoms can help us prioritize the patient’s prob-lems and then specific interventions can be plannedand goals of management strategies can be betterdefined. This can translate into better patient care asin this case.

Anupam BhardwajFulbourn Hospital,

Cambridge CB15 EF, UK

Vivek Agarwal, Prabhat Sitholey*Department of Psychiatry

King George’s Medical UniversityLucknow 226003, India

*e-mail:prabhat_sitholay@hotmail.com

REFERENCES

American Psychiatric Association 2000 Asperger’s disorder.Diagnostic and statistical manual of mental disorders (4th ed.,pp. 80–84). Washington, DC American Psychiatric Associa-tion.

Kaufmen, J., Birmaher, B., & Breut, D., (1997). Schedule foraffective disorders and schizophrenia for school age childrenpresent and Lifetime version (K-SADS-PL): Initial reliabilityand validity data. Journal of the American Academy of Childand Adolescent Psychiatry, 36, 83–93.

World Health Organisation 1992 Asperger’s syndrome. TheICD-10 classification of mental and behavioural disorders:Clinical description and guidelines (258–259) Oxford Uni-versity Press.

136 Letter to the Editor