Having a degree or even a job does not mean that one is an automatic expert at diagnosing or assessing patients, or at treating them. If I think of you as a lesser person than myself, I am not going to diagnose or treat you properly. Same if I don't like you, am bored by you, or judge you. If I'm not interested in observing the way other individuals treat you either in your family or in general, or if I judge your family member to be more worthy or respect-deserving than you, again I am not going to treat or diagnose you properly. If I judge your whole family to be some kind of lesser class of people, there's no way I'll treat or diagnose you properly. If I consider myself a world class expert, I am probably going to overlook my own bias and weakness and fail to diagnose or treat you properly. If I harbor class, race, sex, or age bias, I'm definitely not going to treat you properly. My norm is probably NOT your norm, but if I think it is, if I believe I am the picture of "normalcy", then no, I am not going to diagnose or treat you properly.
Too many difficulties? Too many hurtles? Too bad. That's how it works. Psychology professionals used to have a better grasp on why objectivity and absence of bias is so important, now there are too many who seem to consider themselves superior to their patients, or just superior in general.
The following is an article on comorbidity of AS and Bipolar, but it goes into detail about diagnostic issues and validity. Why is it relevant? Because it's become commonplace for psych. professionals to do very little observation or use objectivity when assessing or treating a patient, because there are no consequences for mistakes for them (only disasterous ones for patients and clients). This article goes into some detail regarding diagnosing and assessment that can and should be applied to any patient.
Introduction
Despite
its increasing popularity as a distinct condition (included in the
ICD-10 in 1993 and in the DSM-IV in 1994), the nosological status of
Asperger's syndrome (AS) and its diagnostic validity remains uncertain.
An astonishing 556% increase in pediatric prevalence of pervasive
developmental disorders (PDD) has been reported between 1991 and 1997 [1].
This jump is probably due to heightened awareness and changing
diagnostic criteria rather than to new environmental influences.
Both
AS and autism persist into adulthood, but their phenotypic expression
varies with age. AS may also be unrecognized in adulthood, although
usually not forever. Some individuals with AS live almost normally and
show good adaptation, while many can hardly cope and need supervision.
Some cases are referred to psychiatric services for adults because of
concurrent mental disorders or behavioral derangement, especially
aggression and self-injury, rather than specific symptoms of AS. In
these circumstances, the AS diagnosis is often overlooked. Since these
cases appear odd and atypical in comparison with patients commonly
observed in the adult psychiatric setting, they often receive several
diagnoses in the course of time. The awareness of the AS diagnosis has
been considered contingent on certain key professionals, who are
interested in the area [2].
However, even when the correct diagnosis of AS or other PDD is made, it
should not be considered necessarily exhaustive. It is of importance
also to recognize comorbid psychiatric disorders, especially if
successfully treatable.
Comorbid psychiatric conditions
are frequent in patients with PDD. Patients with AS often present
eccentricities, emotional lability, impairments in social functioning,
anxiety and obsessive traits, demoralization, suicidal ideation,
tempers, coldness, defiance, motor and phonic tics, repetitive
behaviors, and stereotypies, that can mimic other mental illnesses [3].
The differential diagnosis with true comorbidity of schizophrenia, BD
or anxiety disorders is not always easy. Children with PDD have a
two-to-six-times greater risk of experiencing comorbid psychiatric
conditions than their normal peers [4-6].
Awareness of the problem is increasing but available evidence on the
topic is scanty. Psychiatric comorbidity of AS has been often cited but
not well examined. There are very few systematic studies on psychiatric
comorbidity in PDD [7-10], and only one in AS [11].
Clinicians treating children report a high comorbidity with Attention
deficit hyperactivity disorder (ADHD), Oppositional defiant disorder,
Depressive disorders, and Bipolar disorder [7].
Data on BD and AS comorbidity are inconsistent. McElroy [12]
emphasizes that bipolarity is a marker for comorbidity, and comorbid
disorders, especially multiple conditions occurring when a patient is
young, may be a marker for bipolarity. However, most studies [7-9,11], evidence Unipolar depression as the most common mood disorder in patients with PDD, while only one report by Munesue et al [10] suggests that BD might be the most frequent. Several factors could account for this discrepancy.
First, as discussed by Frazier et al [13],
it is difficult to ascertain the rate of comorbidity between AS and BD
since the diagnosis of AS is currently used rather indiscriminately,
referring to a heterogeneous group [14],
and the actual incidence of pediatric BD is probably underestimated
until the definition of bipolarity in children is more fully agreed
upon. Second, BD often begins in childhood or early adolescence with the
clinical features of unipolar depression, acute psychosis, or comorbid
disorder (e.g., ADHD, obsessive-compulsive disorder (OCD), panic attack,
or eating disorder), while manic symptoms appear later. As a
consequence, the rate of bipolar diagnosis, can increase with the mean
age of studied population. Third, the current classification of mood
disorders has poor reliability and validity. According to DSM-IV-TR, the
differential diagnosis between unipolar depression and BD II should be
based on the lifetime presence of four days of hypomania. Information on
mild symptoms overlapping with manifestations of well-being is subject
to recall bias, unreliable evaluation, misinterpretation, incoherence.
Furthermore, the source of information (patient, relatives, social
institutions) can suggest different conclusions. Widening or narrowing
the criteria for the definition of hypomania modifies substantially the
ratio between unipolar and bipolar II depression [15].
Notwithstanding
such gray area, growing evidence suggests that PDD and BD frequently
co-occur. Unfortunately, most studies do not explicit the number of
cases with AS since they predate DSM-IV [16-18].
In a clinical sample of 727 children, 52 met criteria for PDD, 114 met
criteria for mania, and 14 of 52 children with PDD met criteria also for
BD (2% of all referrals, 12% of children with BD, and 27% of children
with PDD) [19]. In a consecutive series of adult patients referred with a diagnosis of autism spectrum disorder, 7% had BD [20].
Autism spectrum disorder, BD and Tourette syndrome were found to
co-occur at a greater than chance expectation in the study of Kerbeshian
& Burd [21].
Also family data suggest an etiological link between AS and BD. DeLong and Dwyer [22]
found that relatives of probands with PDD had a 4.2% prevalence of BD
and that the prevalence was highest among relatives of probands with AS
(6.1% versus 3.3% for relatives of probands with autism). Gillberg &
Gillberg [23]
found that 4 (17%) of 23 patients with AS and 3 (13%) of 23 patients
with autism had a family history of affective disorder. Comparing
children affected by autistic spectrum disorders with and without
identifiable neurological disorder that could account for their autism,
DeLong and Nohria [24] found that the latter had a higher rate of family history of affective disorder. On the contrary, Piven et al [25]
found that major depression, but not BD, had higher lifetime prevalence
in the parents of autistic probands in comparison with the general
population.
Interestingly, a family history of BD may
influence the phenomenology of patients with PDD. In subjects with
autism spectrum disorder and a family history of BD, many features of
childhood BD have been observed, including affective extremes,
cyclicity, obsessive traits, neuro-vegetative disturbances, special
abilities, and regression after initial normal development. On the other
hand, subjects with autism spectrum disorder and without a family
history of BD showed less florid agitation, fearfulness, and aggression,
and were of lower functioning [26].
