Vignette: Mr B
Mr B is a 25-year-old man, referred to a national neuropsychiatry assessment service by his community mental health team. The referral was at the request of his parents, who wondered if he might have Asperger syndrome.
Mr B was born by normal vaginal delivery at term and his parents described normal motor, language and social communication milestones. He grew up with both parents and three brothers. Throughout primary and secondary mainstream school he made friends easily and excelled at sport to the extent that at age 11 he gained a black belt in karate. Mr B left school after achieving an average performance in state examinations, on a par with his brothers’ achievements. School reports are positive and describe no behavioural or academic problems.
However, at age 15 Mr B began to be more isolated, losing contact with school friends and interacting minimally with his family, eating in his bedroom alone and maintaining poor personal hygiene.
Over the next 10 years Mr B had little contact outside the family home. He attempted several jobs, including labouring and factory work, but despite an initial good impression was asked to leave each position, often after a very short period. Reasons included an inability to conform to safety regulations, lateness and chaotic behaviour. At the time of admission he had not worked at all during the previous year.
Mr B revealed increasing difficulties in planning and making decisions. An example given by his parents was an occasion when he attempted to cut a piece of wood with an electric saw while balancing the wood over banisters. His parents became so concerned both by the dangerousness of this and his aggressive response when they asked him to stop that they called the police. Mr B was reported as being increasingly irritable. If his parents thwarted his actions, episodes of verbal aggression were precipitated.
The deterioration in overall functioning, social behavior and planning ability was gradual and Mr B’s parents sought help after 10 years only because of his low threshold for verbal aggression and his inability to hold down a job. For many years his social withdrawal was attributed by the family to self-consciousness related to his facial acne.
There was no family history of psychiatric disorder, no medical history and up to admission Mr B had lived with his parents.