Academic journal article The Psychoanalytical Study of the Child

The Importance of Mental Organization (or Character Structure) When Diagnosing and Analyzing Asperger’s Patients

Academic journal article The Psychoanalytical Study of the Child

The Importance of Mental Organization (or Character Structure) When Diagnosing and Analyzing Asperger’s Patients

Article excerpt

The tendency to miss the diagnosis of high-functioning Asperger's syndrome

As psychoanalysts embrace a nonlinear dynamic systems model of development (Mayes 2001; Galatzer-Levy 2004; Abrams 2008, 2011; Olesker and Lament 2008; Knight 2011; Lament 2011; Olesker 2011; Harrison 2014), we have expanded our understanding of pathogenesis to include far more than solely drive-defense conflicts or any other single, continuous developmental line, even when treating patients most regard as neurotic. Even more helpful, though, is the way in which this model's consideration and expansion of the array and interaction of etiological factors allows us to better analyze all patients, including those who in the past would have been regarded as not analyzable because they inhabited the farthest reaches of the widening scope. This holds true even with many patients whose mental organization lies on the autistic spectrum, particularly those with high-functioning Asperger's syndrome. Aside from analysts practicing from a Kleinian/Bionian orientation (e.g., Meltzer et al. 1975; Pozzi 2003; Alvarez 2004; Polmear 2004; Rhode and Klauber, 2004), such patients have traditionally been regarded as lying outside the scope of psychoanalysis proper because of the presumed constitutional, organic, and biochemical etiology of their problems with the implicit assumption that one single linear system can automatically make analysis impossible. More recently, child analysts using our more modern understanding of the complexity of development are questioning this assumption (e.g., Olesker 1999; Sherkow 2011; Sugarman 2011; Sherkow and Harrison 2014). These analysts see all pathogenesis, not just that involving patients on the autistic spectrum, as involving some constitutional element. Development and pathogenesis are recast as involving a sequence of both continuities and discontinuities "occurring within a series of progressive differential hierarchical psychological organizations that arise over time" (Abrams 2003, 175). There are psychological, biological, and social contributions that are continuously interwoven through all mental structures and functions (Knight 2011). This interaction between the multiple systems of the mind, including those that might remain persistently linear, results in periodic transformations, and new hierarchically ordered reorganizations, that establish a relative homeostatic equilibrium. As Gilmore and Meersand (2014) said, "This idea of transcending developmental systems obviates the tendency, among developmental thinkers, to assign decisive importance to a singular system, such as genetic endowment, environment, or their interaction, or developmental moment, such as infancy or early childhood" (2). A logical extension of such thinking is that even patients whose genetic endowment or persistent dispositional elements includes Asperger's syndrome might be analyzable, depending on the nature of their mental organization.

Yet it is not uncommon to see such patients misdiagnosed, as the analyst is slow to realize that the symptoms, character traits, defenses, and behavior being addressed in the clinical moment should not formulated reductionistically and solely as the result of inevitable and still active childhood conflicts. One reason for this state of affairs is the continued ambiguity about the parameters or boundaries of the diagnosis of Asperger's syndrome. "In the field of autism and Asperger's syndrome, however, we are still far from having identified all the elements (with the exception of neurological vulnerability (Gillberg 1991), and there are even arguments about the widths of the syndrome itself' (Alvarez 2004, 113). This ambiguity is quite apparent in the elimination of the diagnostic category of Asperger's syndrome and placement of such patients under the rubric of autistic spectrum disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association 2013). …

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