18. Aspergers SpecConsiderations - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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 How Dangerous is this Person? Assessing Danger & Violence Potential Before Tragedy Strikes
Chapter 18: ASPERGERS SYNDROME & SPECIAL CONSIDERATIONS


Chapter 18: ASPERGERS SYNDROME & SPECIAL CONSIDERATIONS
There are special considerations that create nuances and potential ramifications to danger or violence potential.  Substance abuse can be seen as a special important consideration.  As discussed earlier, alcohol abuse does not in of itself increase violence potential, but depends on alcohol's disinhibitory effect and what may be otherwise inhibited.  Stimulant drug use creates an intense high or euphoria that does not necessarily lead to violent behavior.  However, chronic stimulant drug use- that is, abuse can develop personality characteristics that can mimic paranoid personality disorder, which increases violence potential.  Another consideration is psychosis, which varies from individual to individual creating benign to highly dysfunctional consequences. The nature of the psychosis determines the individual's potential for violence.  Other considerations may influence the development of characteristics similar to personality disorders through some identifiable chain of experiences and events.  The therapist, professional, or concerned person may recognize a characterological profile or personality disorder without realizing that it may be the result of other issues having developed over time.  Or, they may identify important issues such as substance use or psychosis and not identify the characterological consequences.  In addition to substance abuse and psychosis, there may be other important considerations to note when assessing for violence potential.

For example, the therapist or professional may find with their extensive experience with young children, pre-teens, and adults with high functioning autism or Asperger’s Syndrome, a developmental progression that can lead in some cases to a paranoid personality disorder.  This is by no means, the normal or only outcome.  With early intervention and skillful education and care, children with Asperger’s Syndrome or other high functioning autism can often be highly successful in all aspects of life.  Dr. Temple Grandin is one example of a highly respected author with autism.   She is an expert on cattle handling, and has written and spoken often from her experiences and insights as an autistic individual, including many television appearances.  Unfortunately with inadequate caregiving and/or highly negative social experiences, there can be extremely problematic outcomes for some individuals.  Autism or Asperger's Syndrome does not cause violence.  In fact, a child within the autistic spectrum may be more prone to being the victim of violence.  One of the major challenges for an individual within the autistic spectrum is the difficulty in reading social cues, especially nonverbal cues.  An individual within the autistic spectrum is also often more sensitive to environmental stimulation.  These combine to make social interactions often extremely challenging for such a child.  In communities such as classrooms or the playground, other children often identify such a child as being different, and subsequently may target him or her for teasing and victimization.  

The childhood history of Seung-Hui Cho reports that he was brutally teased and bullied in school.  Depending on the individual temperament or personality of the child, as well as the environmental and interventions support (or lack of) from caregivers such as teachers, children with these issues respond differently.  It is possible that Cho did not get the appropriate support or intervention, and with his intense personality suffered greatly.  He became ever more resentful.  Another individual with more positive support, with a similar intense personality may become a very attractive passionate individual instead.  Because of the difficulty in understanding social cues, Cho may not have understood how he was perceived, or why others treated him so badly.  His poor Theory of Mind may have exacerbated his growing isolation, emotional trauma, and increasing resentment.  Unable to identify why others were so abusive to him for seemingly no logical reason, hypervigilance and hypersensitivity leading to paranoia may have resulted.  Over the years, a paranoid personality disorder may have developed.  Waeltermann may be interpreted to be alluding to such destructive dynamics, when she says, "This is a wake-up call that stresses the importance of early intervention, research, and appropriate treatment strategies.... research has consistently shown that when children receive the help that they need early on they are more likely to become more adept at social and communication skills" (AutismLink, 2008).  Cho did not apparently receive this intervention or treatment.  It appears that his challenging dynamics (which may have been undiagnosed Asperger's Syndrome or other autistic spectrum issue), while observed were never accurately diagnosed.  Most importantly, they were never treated appropriately.  The consequence to him was his lonely enduring deep dark world of anger and resentment that subsequently erupted to darken the lives of so many others.  In his situation, his anger and resentment was expressed in a massive homicidal attack upon the community of Virginia Tech University.  For another person, it may be expressed in domestic violence with a partner, abuse of children, involvement in gang or criminal aggression and violence, or a violent assault in the workplace.  

Cho may represent a predictable and preventable trail of profound challenges and failed opportunities that culminated in horrific violence.  In his situation, Asperger’s Syndrome may have been the core or a key complicating issue or factor.  The therapist, professional, or concerned person may not encounter this particular set of circumstances involving Asperger’s Syndrome or someone like Cho, but this case may be representative of unanticipated complex demands he or she often faces.  This may be a rare but critical and tragic outcome for some individuals with Asperger's Syndrome who suffer complicating issues.  Adam Lanza, the killer of the Sandy Hook Elementary children and teachers was diagnosed with Aspergers Syndrome.   "...he is only the latest mass murderer whose autism-spectrum status has been speculated about, including Colorado movie shooter James Holmes and Anders Behring Breivik, the Norwegian who killed 77 people in 2011. Even serial killer Jeffrey Dahmer and Unabomber Ted Kaczynski have been retroactively labeled autistic" (Lutz, 2013). The therapist, professional, or concerned person should be alert to the linkages of historical circumstances, cultural and cross-cultural factors, learning issues, social modeling, peer and adult interactions, and other potential influences that interact to cause eventual emotional, psychological, intellectual, social, and spiritual difficulties for the individual.  Analytical, conceptual, psycho-anthropological, investigative journalist, detective, socio-cultural forensic, and other idiosyncratically necessary skills must be combined in each situation to determine how each individual has come to be.   This would be challenging to the therapist or other professional and highly likely to be beyond the capacity of most laypersons.

An additional consideration or diagnosis of Cho in particular is that he may have experienced significant trauma during his formative years.  There were stories of his suffering intense harassment and bullying as a child.  While it has not been documented, there can be speculation that the level of social abuse Cho endured may have caused a post-traumatic stress disorder (PTSD) or developmental trauma disorder (DTD.  DTD had been proposed but not accepted to be included in DSM-5.  van der Kolk and Pynoos (2009, page 1) proposed the diagnosis for "children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems..."  DTD may develop without an identifiable traumatic event, which is a defining criterion in the PTSD diagnosis.  There is not documentation of a specific identifiable traumatic event for Cho.  However, "The traumatic stress field has adopted the term 'Complex Trauma' to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood" (van der Kolk, retrieved 2013). Cho might have endured chronic and prolonged developmentally adverse traumatic events in the form of harassment and bullying.  He might be considered for the DTD diagnosis, which may have contributed to his violent behaviors.  

The therapist, professional, or concerned person, however should know that not everyone who has PTSD or DTD is violent or dangerous to others.  Individuals with post-traumatic stress disorder try to avoid certain activities and environments that remind them of prior traumatic events or experiences.  They are hypervigilant to potential cues of danger despite their unlikely presence and improbability of causing harm.  Terrifying and painful memories can intrude upon them unexpectedly and unpredictably.  Depression is a common symptom. Some individuals also have symptoms of anger, hostility and aggressiveness, which can affect others.  Another common condition for veterans is traumatic brain injury (TBI).  It may or may not be diagnosed and the focus of treatment.  "Headaches, troubled sleep, poor attention and muddled thinking are the hallmarks of mild traumatic brain injury. Impulsive behavior is sometimes seen, too" (Brown, 2012).  If coupled with anger, hostility, and aggressiveness, such PTSD or traumatic brain injury sufferers may become dangerous and violent.  Despite the title of his article, "Link between PTSD and Violence is weak," Brown (2012) states, "Veterans with PTSD are two to three times as likely to be physically abusive of their wives and girlfriends as those without the diagnosis. They’re three times as likely to get into fistfights when they go to college. One study showed they are especially prone to 'impulsive aggression,' but that 'premeditated aggression' ... was far more common in veterans without PTSD than in those with it."  PTSD sufferers are not violent per se, but each person's manifestation of PTSD symptoms may predict internalized distress and self-disruptive behaviors versus externalized behaviors- some of which may be dangerous to others.  The three major sets of symptoms of PTSD (NIMH, 2013) are:

1) Re-experiencing symptoms: flashbacks--reliving the trauma over and over, including physical symptoms like a racing heart or sweating, bad dreams, frightening thoughts.  Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing.
2) Avoidance symptoms: staying away from reminders of the experience, feeling emotionally numb, feeling strong guilt, depression, or worry, losing interests in activities that were enjoyable in the past, and having trouble remembering the dangerous event.  Things that remind an individual of the traumatic event can trigger avoidance symptoms. These symptoms may cause an individual to change his or her personal routine. For example, after a bad car accident, an individual who usually drives may avoid driving or riding in a car.
3) Hyperarousal symptoms: being easily startled, feeling tense or "on edge," having difficulty sleeping, and/or having angry outbursts.  Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the individual feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

These symptoms are relative normal reactions after a dangerous event.  Many people can have significantly distressing symptoms for a while, but they recede over a short time- a few weeks for example.  If confined to between two days and four weeks, the DSM diagnosis is acute stress disorder (APA, 1994). If symptoms last longer and become an ongoing problem, then PTSD may be the appropriate diagnosis. Not all individuals show PTSD symptoms immediately.  The symptoms may not appear or manifest until weeks or months later. The first two sets of symptoms: re-experiencing symptoms and avoidance symptoms would not tend to increase volatility alone, other than a general wearing down of ones psychic and physical energy which can influence reactivity and impulsivity.  However, the third set of symptoms- hyperarousal symptoms may increase the person's volatility.   Individuals primarily suffering re-experiencing and avoidance symptoms may be hypothesized to be more at risk to themselves than to others.  For some individuals, however their composition of PTSD symptoms- in particular significant hyperarousal symptoms can start to mimic or contribute to the development of paranoid personality disorder.  Hypervigilance for potential dangers can potentially become paranoia about other people, groups, or organizations.  The therapist, professional, or concerned person should be aware that PTSD or DTD may be another special consideration when assessing for violence or danger potential.  However, there needs to be great care to note the qualifying distinctions for the individual's expression of PTSD or DTD.  

PTSD is not necessarily a stand-alone diagnosis.  There may be other issues for the individual that need to be considered.  In particular with veterans of war zone service, traumatic brain injury may be an accompanying and complicating issue.  "The effects of traumatic brain injury on future behavior is even more complicated and — on some questions — contradictory.  Head injuries can diminish 'executive function' — self-control — especially when the part of the brain just above the eyes, called the orbitofrontal cortex, takes the hit. Injury there 'increases the chance of violent behavior by about 10 percent,' said David Cifu, director of the VA’s physical medicine and rehabilitation program, citing an analysis of more than 50 studies. TBI can worsen the symptoms of people who already have PTSD or who go on to develop it because of, say, a near-fatal bomb explosion. Curiously, however, PTSD appears to be more severe in soldiers who suffer mild head injuries rather than severe ones. The reason may be that prolonged unconsciousness can blot out the memory of the traumatic event" (Brown, 2012).  Of course, there is also military culture, stoicism (particularly for men), class issues, economic stress, family stress, institutional or other support- or the lack there of, and any number of other relevant influences on the individual that may need to be considered.  The therapist, professional, or concerned person must take all possible issues into consideration.  This is also why it is important to get professional or expert consultation.  While looking at many potential influences, there will be certain issues that will often stand out to the knowledgeable and experienced professional.

One of the special considerations in the case of Cho that should stand out may be Asperger’s Syndrome.  Special considerations may be fairly common in that the therapist or professional often has to incorporate some special consideration of relationship and causation in any given client situation.  It may be a learning disability, a specific historical event, sub-group cultural values, compensations or consequences from a physical disability, an isolated community standard, an ethnic or religious model, and so forth that catalyzes both the substance and style of a presenting issue.  Relatively more common but also complex considerations such as psychodynamic, family-of-origin, affective, cognitive, cognitive behavioral, and other popular theoretical orientations become qualified by such special considerations for accurate assessment and diagnoses about the unique individual, couple, or family.  In the case of Cho, a special consideration was Asperger’s Syndrome and the theoretical orientation was of paranoid personality disorder.  For another individual for example, it may be transgenerational effects from having Holocaust survivor grandparents and cognitive behavioral processes.  There may be any of one or more special considerations: chronic illness, trauma, injuries, sudden disability, domestic violence, child abuse, rape, sexual abuse, and so forth. The therapist or professional must possess conceptual flexibility, as well as a wide expanse of theoretical perspectives to diagnose the etiology for an individual.  And then, he or she can develop an appropriate treatment strategy for each individual.   This is almost certainly outside the experience of the layperson, who should consult with appropriate expert professionals for guidance.


ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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