A 13-year-old boy is brought to the office due to anxiety and behavioral problems at school. Although he has good grades, he frequently feels overwhelmed at school and his mother worries that he is socially awkward and has no friends. The patient often appears anxious and uncomfortable in new social situations. He insists on sitting in the same row and seat in every class and has had several inappropriate outbursts when told by teachers that this was not possible. After school, the patient prefers to spend time at home. His mother observes that he is obsessed with dates and comparing solar and lunar calendars and can discuss this for hours, but has difficulty shifting to other topics of conversation. The patient was born at full term, and developmental milestones were within normal range. Physical examination is unremarkable. Which of the following is the most likely explanation of this patient's behavior?

Question

A 13-year-old boy is brought to the office due to anxiety and behavioral problems at school.  Although he has good grades, he frequently feels overwhelmed at school and his mother worries that he is socially awkward and has no friends.  The patient often appears anxious and uncomfortable in new social situations.  He insists on sitting in the same row and seat in every class and has had several inappropriate outbursts when told by teachers that this was not possible.  After school, the patient prefers to spend time at home.  His mother observes that he is obsessed with dates and comparing solar and lunar calendars and can discuss this for hours, but has difficulty shifting to other topics of conversation.  The patient was born at full term, and developmental milestones were within normal range.  Physical examination is unremarkable.  Which of the following is the most likely explanation of this patient's behavior?

Quizplus · Accepted Answer

11ec160b_3606_8118_9249_cf5fde5ba32a_MD0001_00 This patient's behavior is most consistent with mild, high-functioning autism spectrum disorder (ASD). Patients diagnosed with ASD later in childhood and adolescence frequently have normal or near-normal language and intellectual ability and come to clinical attention when social and academic demands increase, exposing a lack of flexibility and social skill deficits (more severe ASD is usually diagnosed by age 5). Key features of ASD include deficits in social communication and reciprocal social interactions as well as restricted, repetitive interests and stereotyped behaviors. This patient's lack of friends, social isolation, insistence on sameness, intensely fixated interests, and trouble taking turns in conversation are characteristic. Patients with autism have difficulty interpreting and responding appropriately to nonverbal aspects of communication. Abnormal eye contact, stilted, overly formal speech, abnormal sensory sensitivity, and unusual repetitive movements (hand flapping, rocking) are other common findings. (Choice B) Obsessive-compulsive disorder may also present with obsessive interests and insistence on routines. However, this patient lacks the intrusive obsessional thoughts and compulsive rituals performed in response to these thoughts required for this diagnosis (eg, thoughts of contamination leading to cleaning rituals). (Choices C and D) Personality disorders are not diagnosed when the behavior is better explained by another mental disorder and are generally not diagnosed before age 18. Patients with obsessive-compulsive personality disorder are preoccupied with orderliness and control but do not have deficits in social communication. Patients with schizoid personality disorder are socially isolated and disinterested in relationships, but do not exhibit the restricted interests and repetitive patterns seen in ASD. (Choice E) Separation anxiety disorder is characterized by developmentally inappropriate and excessive anxiety related to separation from the primary attachment figure. (Choice F) Patients with social anxiety disorder typically have normal communication skills and an interest in socializing, but they avoid social situations due to fear of being judged. In patients with ASD, social anxiety is related to their lack of social skills. Educational objective: Patients with milder forms of autism spectrum disorder frequently have normal language and cognitive development. Characteristic features include deficits in social communication and reciprocal social interactions, restricted interests, and behavioral rigidity that become more apparent as social and academic demands increase. __________ References: Differentiating high-functioning autism and social phobia. (http://www.ncbi.nlm.nih.gov/pubmed/22038291) A systematic review and meta-analysis of cognitive-behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. (http://www.ncbi.nlm.nih.gov/pubmed/25246292)

A 13-Year-Old Boy Is Brought to the Office Due to Anxiety