MEDICINE

REVIEW ARTICLE

Asperger's Syndrome
in Adulthood
Mandy Roy, Wolfgang Dillo, Hinderk M. Emrich, Martin D. Ohlmeier

SUMMARY
Introduction: Asperger´s syndrome is one of the autism A sperger's syndrome is one of the autism
spectrum disorders. Asperger's patients usually
display a distinctive symptom pattern. Because their
spectrum disorders. Affected individuals display
considerably impaired capacity for social interaction, ability to intuitively recognize nonverbal signals in
unusual special interests, and a tendency towards other persons is impaired, patients are considerably
ritualized behavior. limited in their social interactions. Their interest in
other people is often limited; on the other hand,
Methods: The etiology, symptoms, diagnosis, and treatment
Asperger's patients typically have "special interests"
of Asperger´s syndrome in adulthood are outlined on the
that may seem unusual because of their subject matter
basis of a selective literature review via Medline and
or the intensity with which patients pursue them.
information in relevant reference books. Furthermore, the
Asperger's patients are also often fixated on ensuring
authors report their personal experience at a special clinic
for adults. that their external environment and daily routines
remain constant; sudden changes may exceed their
Results: Asperger´s syndrome in adulthood can be coping mechanisms.
diagnosed by thorough anamnesis, heteroanamnesis—
Depending on the severity of their symptoms, Asper-
with emphasis on childhood—and painstaking clinical
ger's patients may either exhibit unusual social behavior
examination. The considerable psychosocial impairments
or be severely impaired in their social and professional
affect the patients' professional, social, and private lives.
life.
The precise etiology is still unknown, but a multifactorial
Although Asperger's syndrome is one of the more
origin with genetic, neurobiological, and psychosocial
common differential diagnoses in child and adolescent
components appears probable. Although no specific,
psychiatry, in adults the disorder has received particular
empirically tested treatment concepts have yet
attention only recently.
been established, psychotherapeutic elements (structuring
and directive interventions) seem to be helpful, together This article provides an overview on the prevalence,
with pharmacotherapy—if indicated—in the presence of diagnostics, and clinical symptoms of Asperger's
comorbidity. syndrome in adults, as well as of current theoretical con-
cepts and possible treatment options.
Conclusions: Asperger´s syndrome should be included in
the differential diagnosis of adults who display the
Methods
corresponding symptoms. The etiopathogenesis and
This article is based on a selective literature search of
treatment of Asperger´s syndrome in adulthood should be
Medline, using the key words "Asperger's syndrome,"
further investigated.
"autism," "prevalence," "diagnostic," "comorbidity,"
Dtsch Arztebl Int 2009; 106(5): 59–64 "pathogenesis," and "brain." We included review ar-
DOI: 10.3238/arztebl.2009.0059 ticles and experimental original articles and reference
Key words: Asperger´s syndrome, diagnosis, books published to May 2008. We also report our own
treatment concept, autism, pediatric disease clinical experiences from a specialist outpatient clinic
for adults with Asperger's syndrome.

Prevalence
The prevalence of Asperger's syndrome in childhood is
estimated at 0.02% to 0.03% (1, 2). Asperger's is far
more common in boys than in girls, with a sex ratio of
8:1 (3). Representative studies of the prevalence in
Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie/Zentrum für adults are currently lacking. However, since the core
Seelische Gesundheit/Medizinische Hochschule Hannover (MHH): Dr. med. Roy, symptoms of Asperger's syndrome persist throughout
Dr. med. Dillo, Prof. Dr. med. Dr. phil. Emrich
Klinik für Psychiatrie und Psychotherapie (Ludwig-Noll-Krankenhaus), Klinikum patients' lifetimes (4), we can assume that Asperger's
Kassel: PD Dr. med. Ohlmeier syndrome is probably not much less common in adults.

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BOX 1

Diagnostic criteria for Asperger's syndrome according to DSM-IV (shortened)

A) Qualitative impairment in social interaction, as manifested by at least two of the following:
1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to eye gaze, facial expression, body postures,
and gestures to regulate social interaction
2. Failure to develop peer relationships appropriate to developmental level
3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
4. Lack of social or emotional reciprocity
B) Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in
intensity or focus
2. Apparently inflexible adherence to specific, nonfunctional routines or rituals
3. Stereotyped and repetitive motor mannerisms
4. Persistent preoccupation with parts of objects
C) The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D) There is no clinically significant general delay in language e.g., single words used by age two years, communicative phrases
used by age three years).
E) There is no clinically significant delay in cognitive development.
F) Criteria are not met for another specific pervasive developmental disorder or schizophrenia.

Diagnosis and symptoms Difficulties in making a diagnosis in adult patients

Somato-organic findings to confirm Asperger's syndrome often arise from gaps in childhood memories. In the
are not known. The diagnosis is a clinical one and is made authors' experience, it is useful in adult patients to also
on the basis of psychopathological findings and a question parents and siblings about particular personality
thorough medical and psychiatric history—including a traits of the patient during childhood. School grade
childhood history. In 1993, Asperger's syndrome was in- papers may be of great help. These may include remarks
cluded as a "pervasive developmental disorder" (F84.5) such as: "... has problems integrating into the class."
in the 10th International Classification of Diseases However, such remarks do not necessarily indicate
(ICD-10), and in 1994 in the Diagnostic and Statistical Asperger's syndrome and can thus only complement the
Manual of Mental Disorders (DSM-IV) of the American diagnostic tools.
Psychiatric Association (box 1). During the clinical examination of adults, typical
Initial symptoms of the disorder can be observed after traits may become noticeable. Initially, patients often do
the third year of life. Because it is often difficult to not pay attention to the doctor's instructions and may
distinguish the syndrome from differential diagnoses, appear clumsy at finding their bearings in the room.
Asperger's syndrome should be diagnosed by a doctor Facial expressions and speech melody are often mono-
specializing in psychiatry and psychotherapy or, in tone and may appear rigid (7). A patient's speaking style
children, by a child and adolescent psychiatrist. may, however, come across as grammatically and lexi-
In addition to the clinical psychiatric examination, cally very honed. Direct visual contact is usually avoided
some questionnaire approaches are available that may (7), the patients often look around themselves in the
be used for diagnostic purposes. The Adult Asperger room during the consultation. Their narrative is typically
Assessment (AAA) is an instrument that was developed extremely detailed and they have problems separating
especially for diagnosing Asperger's syndrome in adults important issues from unimportant ones. Affective
(5). It entails two screening methods, the Autism- modulations on the part of the examiner, such as a smile
Spectrum Quotient (AQ) and the Empathy Quotient or humorous remark, are often not reciprocated.
(EQ), as well as extended DSM-IV criteria (box 2). The authors' own clinical experiences have shown that
The AQ captures 5 symptom areas of Asperger's syn- in adults, typical symptoms of Asperger's syndrome result
drome in 50 items: in particular problems with regard to patients' social and
> Social skills professional lives. Many people with Asperger's syndrome
> Lapses in attention live withdrawn lives and have few "real" social contacts.
> Attention to detail Often, their contacts take place via the internet, in Asperger
> Communication discussion forums. Asperger's patients thus have the
> Fantasy/imagination (threshold value >32 points). opportunity to communicate with people whose thought
The EQ prompts the capacity for empathy, i.e., sharing structures are similar and who use literal language without
and understanding another's "state of mind" or emotion needing to recognize nonverbal signals.
(threshold value <30). Both screening instruments are Difficulties often arise especially in relationships (8).
available in German-language versions (6). Because of their lack of empathy, persons with Asperger's

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CAIXA 1
Critérios de diagnóstico para síndrome de Asperger de acordo
com DSM-IV (abreviado)

A) Comprometimento qualitativo na interação social, manifestado por pelo menos dois dos seguintes:
1. Comprometimento marcante no uso de vários comportamentos não-verbais, como olhar nos olhos,
expressão facial, posturas corporais, e gestos para regular a interação social
2. Falha em desenvolver relacionamentos com pares, adequados ao nível de desenvolvimento
3. Falta de busca espontânea de compartilhar prazer, interesses ou realizações com outras pessoas
4. Falta de reciprocidade social ou emocional
B) Padrões repetitivos e estereotipados restritos de comportamento, interesses e atividades, conforme
manifestado por pelo menos um dos seguintes:
1. Abrangente preocupação com um ou mais padrões de interesse estereotipados e restritos que são
anormais em intensidade ou foco
2. Adesão aparentemente inflexível a rotinas ou rituais específicos e não funcionais
3. Maneirismos motores estereotipados e repetitivos
4. Preocupação persistente com partes de objetos
C) O distúrbio causa prejuízo clinicamente significativo no funcionamento social, ocupacional ou em outras áreas
importantes do funcionamento.
D) Não há atraso geral clinicamente significativo na linguagem, por exemplo, palavras isoladas usadas aos dois
anos de idade, frases comunicativas usadas aos três anos de idade).
E) Não há atraso clinicamente significativo no desenvolvimento cognitivo.
F) Os critérios não são válidos para outro transtorno invasivo do desenvolvimento específico ou esquizofrenia.
 MEDICINE

BOX 2

DSM-IV extensions after Adult Asperger Assessment (AAA) (modified)

Ad A) Difficulties in understanding social situations and other people's thoughts and feelings
Ad B) Tendency to think of issues as being black and white, rather than considering multiple perspectives in a flexible way

Additionally: Qualitative impairments in verbal or nonverbal communication with at least three of the following symptoms:
1. Tendency to turn any conversation back on to self or own topic of interest
2. Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superficial social
contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity.
3. Pedantic style of speaking, inclusion of too much detail
4. Inability to recognize when the listener is interested or bored
5. Frequent tendency to say things without considering the emotional impact on the listener

Additionally: Impairment in at least one of the criteria relating to childhood imagination:

1. Lack of varied, spontaneous make believe play appropriate to developmental level
2. Inability to tell, write or generate spontaneous, unscripted or unplagiarized fiction
3. Either lack of interest in fiction (written, or drama) appropriate to developmental level or interest in fiction is restricted to its
possible basis in fact (e.g. science fiction, history, technical aspects of film)

syndrome may have difficulties to make contact with so-called high functioning autism has been much dis-
potential partners in an appropriate way. In a developing cussed. Compared with patients with early childhood
or existing relationship they may appear selfish or cold. autism, high functioning autists have greater intellectual
The patients often experience the demands that are asso- and better social and communicative abilities, but over-
ciated with relationships—a desire for more intense all their cognitive and speech development is delayed.
communication or mutual sympathy—as a strain. Often, More recent studies have concluded that with regard to
persons with Asperger's syndrome will therefore con- deviant behavior there is no fundamental difference
duct relationships over greater geographical distances, between Asperger's syndrome and high functioning au-
which results in time constrained contacts. This also tism (11).
includes the whole area of sexuality. Some people with Differential diagnostic distinction from schizoid and
Asperger's have a very low need for physical closeness, schizotype personality disorders can be difficult. In both
others even have an aversion to it. Some have great in- disorders, affected persons withdraw from interpersonal
securities regarding sex, although their fundamental relationships; they are usually loners. The schizoid type
need is undiminished (8, 9), since sexual intimacy has a flattened or restricted range of emotions, affective
results from an intense capacity for mutual empathy. distance (a lack of affective rapport), and a diminished
However, some patients manage to build stable rela- capacity for enjoyment/joy. The schizotype personality
tionships and have families. disorder is characterized by odd behavior, often with
With respect to Asperger's patients' professional devel- magical ideas and a mistrustful to paranoid experience
opment, two tendencies are obvious. Some Asperger's of relationships. Neither disorder features the limited
patients are quickly strained by contacts with colleagues special interests that are typical of Asperger's, nor do
and clients. Their direct, seemingly impolite manner they entail a tendency towards stereotypical behavior.
may result in conflict, or they cannot adjust flexibly Schizophrenic psychosis can also be accompanied by
enough to different demands. Some, however, achieve social withdrawal and a lack of empathy. Important
great professional success owing to their special inter- distinctive features include disorganized thinking and
est—for example, in information technology. High delusions, which are characteristic for schizophrenia.
cognitive skills seem to enhance the potential to achieve The symptoms of Asperger's syndrome can be observed
professional and private objectives (clinical example, in early childhood, whereas, for example, the onset of
see box 3). hebephrenic schizophrenia does usually not predate
adolescence. The onset of illness is also important in dif-
Differential diagnosis and comorbidities ferential diagnostic distinction to simple schizophrenia
In early childhood autism according to Kanner, the in- disorder, which does not have productive symptoms.
ability to make contact in a nonverbal manner is often Especially in women, borderline emotional personality
accompanied by incomprehensible or lacking speech. disorders have to be differentiated, because this pathology
Affected children display extensive stereotypical and also features difficulties in empathizing and recognizing
unusual activity patterns (10). The clinical impairment nonverbal signals. However, these disorders are mostly ac-
in Kanner autism is more pronounced than in Asperger companied by severe mood swings, whereas special inte-
autism. The distinction of Asperger's syndrome from the rests and pronounced rational thinking are usually lacking.

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BOX 3 own ideas, thoughts, and emotions, and on the other

hand, the ability to empathize with these. Persons with
Clinical example/case report Asperger's syndrome have substantial deficits in this
respect. Neurophysiologically, the theory of mind appar-
Mr M, age 35 years, has been an "eternal outsider and loner" since childhood.
ently correlates with different areas in the brain, such as
He has never developed any deep friendship. Although he intensely read books
the medial prefrontal cortex (17). In adult patients with
about human social behavior to gain a better understanding of his environment,
Asperger's syndrome, functional imaging has shown
he has always had to "capitulate" when faced with the "riddle“ of interpersonal
that the execution of tasks testing theory of mind was
communication. He could imagine faces only without any movement, like "pass-
port pictures with name inset." He deduced people's emotions in a highly labor accompanied by reduced activity in the left medial pre-
intensive manner, by relating the position of the corners of their mouth to the frontal cortex (18). The amygdala—an important struc-
angle of the eyebrows and lower eyelids. He used and understood speech in the ture in the limbic system that processes and regulates
most literal manner, which often resulted in misunderstandings. He had under- emotions—and the fusiform face area—an area in the
stood only as an adult that his parents, who called him a "Stubenhocker" (couch temporal lobe that is specialized for the perception of
potato) did not mean he was a piece of furniture. He had ended his only relation- human faces—also show reduced activity in Asperger's
ship, a weekend affair, as "the benefits didn't justify all the effort." In spite of this patients or patients with early childhood autism (19, 20).
he expressed a desire to have a life partner. Of particular importance for the ability to empathize
Professionally, he had found his niche. As a child he had spent almost all his and thus for the theory of mind is the mirror neuron
time building "technically complex constructions" from Lego building blocks or system. This neural network becomes active during
learning by heart the titles of several hundred cartoons. As a teenager he had certain activities but is also activated—unconsciously
taught himself computer programming and, although he did not actually and involuntarily—when this activity is being observed
undergo a formal apprenticeship or professional training, he was now very in another person (21). We can assume that the mirror
successful in the computing business. Developing programs gave him "deep neuron system is impaired in persons with Asperger's
satisfaction," whereas the "inevitable social interaction" with colleagues posed a syndrome (22).
substantial strain on him.
Routines were important to him; he disrupted these rarely. Since childhood Central coherence
he had always put his clothes on in a certain sequence. He started his working Central coherence describes the ability to integrate indi-
days always by performing certain actions in the same order. Even minute vidual elements of perception into an overall context of
disruptions to these routines disturbed his day to such an extent that he felt meaning (the "bigger picture") (figure 2). The following
"derailed." Altogether the biggest strain for the patient was participating in life statement could be typical of an Asperger's patient: "I
"outside his own private sphere." see hundreds of individual trees, but I cannot see a
forest." Those who are affected tend to a detail oriented,
selective perception and have great difficulties in
capturing the overall context—their central coherence is
Depression is one of the most important comorbid deficient. The precise neuronal correlate for this clinical
disorders. Its development is also caused by impairments phenomenon is not known.
in patients' personal and professional lives. Differential
diagnosis is hampered by the fact that social withdrawal Executive functions
and impaired nonverbal communication are present in The executive functions comprise skills such as plan-
any case (12, 13). Often, affected persons will also have ning and monitoring one's own actions, inhibiting im-
a compulsive disorder (3) or attention deficit/hyperac- pulses, focusing attention, and flexible searching for
tivity disorder (ADHD) (14). problem solving strategies. In patients with Asperger's
syndrome, the executive functions are often impaired.
Etiology and theoretical concepts The patients are inflexible in their attention and can use
The precise etiology of Asperger's syndrome is not en- newly acquired behaviors only with difficulty. The pre-
tirely clear, but a multifactorial origin is likely. A genetic frontal cortex is a crucial neuromorphological correlate
component is assumed to have a role, especially chromo- of the executive functions (24).
somes 1, 3, and 13 seem to be involved (15). Further, pe- However, it should be emphasized that in spite of
rinatal complications are also likely to contribute to the initial pointers towards a functional impairment of certain
disorder (16). The theoretical disease model of Rem- areas of the brain, as described earlier, no comprehensive
schmidt and Kamp-Becker (7) includes three concepts neurobiological concept for Asperger's syndrome exists.
of abilities that seem to be deficient in autistic disorders
(figure 1): Therapy
> Theory of mind Not every case of Asperger's syndrome has disease status
> Central coherence or requires treatment. If symptoms are pronounced to a
> Executive functions. certain extent, however, and especially in patients with
comorbid disorders, a multimodal therapeutic concept
Theory of mind with symptom oriented pharmacological and psycho-
The neuroscientific term "theory of mind" presents a therapeutic elements seems appropriate. In case of
model of the capacity for empathy. This is the ability to increased impulsiveness, a therapeutic attempt could be
imagine, on the one hand, that other people have their made using atypical neuroleptic drugs or mood stabilizers;

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pronounced symptoms of compulsion or depression can FIGURE 1

be treated with selective serotonin reuptake inhibitors
(SSRIs) if required (7, 10). In comorbid ADHD, the au-
thors have reported positive experiences in one case of
when stimulants were used (14). Medication specifically
to treat Asperger's syndrome, however, does not exist.
Although neither established specific nor empirically
tested therapeutic concepts for the psychotherapeutic
treatment of adult Asperger's syndrome exist, existing
concepts for childhood Asperger's can be used for orien-
tation. Especially behavioral therapeutic approaches A current theoretical disease model is based on the assumption that
such as TEACCH (Treatment and Education of Autistic in Asperger's syndrome the abilities reflected by the three concepts
and related Communication-handicapped Children) and "theory of mind," "central coherence," and "executive functions" are
ABA (Applied Behavior Analysis) are assessed as help- deficient (adapted from [7]).
ful. Such programs promote social and communication
skills by using unequivocally phrased instructions and
partial steps. Adapting the external environment to the FIGURE 2
patient's difficulties is an additional objective (7).
Klin and Volkmar (25) recommend the following
therapeutic principles for patients with Asperger's syn-
drome:
> Practicing and discussing social perceptions
> Stepwise and structured training/coaching in prob-
lem solving skills and life skills
> Practicing behaviors in unfamiliar situations
> Practicing the transfer of certain insights to other
situations
> Promoting a concrete development of identity that
is based on everyday behaviors
> Analyzing situations that trigger frustrations and
analyzing how patients may affect others
> Facilitating further helpful measures, such as ergo-
therapy or physiotherapy.
In sum, structured, directive interventions that discuss Testing central coherence. The patient is given the task to assign one
of the two images at the top to the image at the bottom. People with
situations with the help of concrete, real-life examples,
a holistic perception will assign the beaker to the bottle at the
seem beneficial (8). In all experience, however, psycho- bottom. Detail-oriented perception in poorly developed central
dynamic therapeutic approaches may also be useful, coherence will lead to the decision that the top right object matches
especially with respect to the common problem of low the bottom object as they both consist of squares. The task is taken
self esteem. from a scientific study and not suited for use in routine diagnostics.
From: Müller C: Autismus und Wahrnehmung. Eine Welt aus Farben
Conflict of interest statement und Details. Marburg: Tectum 2007. With permission from Tectum
The authors declare that no conflict of interest exists according to the guidelines of Publishers, Marburg (23)
the International Committee of Medical Journal Editors.

Manuscript received on 21 July 2008, revised version accepted on

30 October 2008.
Key messages
Translated from the original German by Dr Birte Twisselmann.
> The core symptoms of Asperger's syndrome include
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