A 26-year-old man comes to the office due to back pain. He hurt his back while lifting a heavy box and now has discomfort while working on his computer. He proceeds to give an overly detailed analysis of the mechanics of his chair in relation to the height of his desk and computer screen. The patient has no medical problems and takes no medication. He lives alone and has a computer data entry job that allows him to work remotely. He prefers working from home because he does not enjoy socializing. The patient says, "I don't really get people's sense of humor, and I think they might be laughing at me. I also prefer to eat at home so I can follow my routines and keep the food separated on my plate." The patient does not use alcohol, tobacco, or illicit drugs. He has no psychiatric history but recalls that his mother once had him evaluated in grade school due to concern about his development.
Physical examination is unremarkable. On mental status examination, the patient makes poor eye contact and appears anxious and uncomfortable. He declines to put on a paper gown because he dislikes the feel of the paper against his skin. He answers questions appropriately in a stilted and monotone voice. He does not feel sad and has no hallucinations or delusions.
Which of the following is the most likely explanation for the patient's behavior?

Question

A 26-year-old man comes to the office due to back pain.  He hurt his back while lifting a heavy box and now has discomfort while working on his computer.  He proceeds to give an overly detailed analysis of the mechanics of his chair in relation to the height of his desk and computer screen.  The patient has no medical problems and takes no medication.  He lives alone and has a computer data entry job that allows him to work remotely.  He prefers working from home because he does not enjoy socializing.  The patient says, "I don't really get people's sense of humor, and I think they might be laughing at me.  I also prefer to eat at home so I can follow my routines and keep the food separated on my plate."  The patient does not use alcohol, tobacco, or illicit drugs.  He has no psychiatric history but recalls that his mother once had him evaluated in grade school due to concern about his development.
Physical examination is unremarkable.  On mental status examination, the patient makes poor eye contact and appears anxious and uncomfortable.  He declines to put on a paper gown because he dislikes the feel of the paper against his skin.  He answers questions appropriately in a stilted and monotone voice.  He does not feel sad and has no hallucinations or delusions.
Which of the following is the most likely explanation for the patient's behavior?

Quizplus · Accepted Answer

11ec193a_98b8_10c4_853d_2faf4206ca8a_MD0002_00 This patient's behavior is most likely explained as features of a mild, high-functioning type of autism spectrum disorder (ASD). Although severe ASD is usually diagnosed by age 5, many individuals with high-functioning ASD are not diagnosed until adulthood as they frequently have normal or near-normal language and intellectual ability. The key features of ASD include deficits in social communication and reciprocal social interactions and restrictive, repetitive interests and stereotyped behaviors. This patient's lack of friends and social isolation, impaired social skills, stilted speech, abnormal sensory sensitivity (eg, disliking the feel of the gown), and desire for routine are all consistent with this syndrome. Patients with ASD can have difficulty interpreting and responding appropriately to nonverbal aspects of communication; abnormal eye contact; intense, perseverative interests and one-sided conversations about specific topics; and difficulty understanding sarcasm, metaphors, or humor. Adults with ASD can benefit from counseling and social skills training to improve their social and occupational functioning. (Choice B) Patients with obsessive-compulsive personality disorder are preoccupied with orderliness and control and frequently exhibit preference for routines and excessive attention to detail. However, they would not exhibit the deficits in social communication seen in this patient. (Choice C) Paranoid personality disorder is characterized by a pervasive and long-standing pattern of suspiciousness and generalized mistrust of others. This patient's preference to be alone and concerns that people are laughing at him are better explained as consequences of his difficulty navigating social interactions, consistent with ASD. (Choice D) Although patients with schizoid personality disorder are socially isolated and disinterested in relationships, this diagnosis would not explain this patient's repetitive patterns, stilted speech, and abnormal sensory sensitivity. Schizoid personality disorder is not diagnosed when ASD is the primary issue. (Choice E) Patients with milder forms of ASD frequently have social anxiety due to their lack of social skills. However, unlike this patient, individuals with social anxiety disorder typically have normal communication skills and interest in socializing. Educational objective: In milder forms of autism spectrum disorder, delayed diagnosis into adulthood is common. Characteristic features of the disorder include impaired social communication and reciprocal social interactions, restricted interests, and behavioral rigidity. __________ References: Autism spectrum disorders - diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/28101829) Differentiating high-functioning autism and social phobia. (http://www.ncbi.nlm.nih.gov/pubmed/22038291) A mixed methods study of barriers to formal diagnosis of autism spectrum disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/28516422)

A 26-Year-Old Man Comes to the Office Due to Back