History of Asperger syndrome

Asperger syndrome (AS), an autism spectrum disorder (ASD), is a relatively new diagnosis in the field of autism.^[1] It was named in honor of Hans Asperger (1906–80), an Austrian psychiatrist and pediatrician. An English psychiatrist, Lorna Wing, popularized the term "Asperger's syndrome" in a 1981 publication; the first book in English on Asperger syndrome was written by Uta Frith in 1991 and the condition was subsequently recognized in formal diagnostic manuals later in the 1990s.^[1]

Discovery of autistic psychopathy

Asperger was the director of the University Children's Clinic in Vienna, spending most of his professional life in Vienna and publishing largely in German.^[1] As a child, Asperger appeared to have exhibited some features of the very condition named after him, such as social remoteness and talent in language;^[2] photographs taken during his seminal work show that he had a frank and earnest face with an intense gaze.^[3] In 1944, Asperger described in the paper "'Autistic psychopathy' in childhood"^[4] four children in his practice^[5] who had difficulty in integrating themselves socially. Although their intelligence appeared normal, the children lacked nonverbal communication skills, failed to demonstrate empathy with their peers, and were physically clumsy. Their speaking was either disjointed or overly formal, and their all-absorbing interest in a single topic dominated their conversations. Asperger called the condition "autistic psychopathy" and described it as primarily marked by social isolation.^[6] Asperger called his young patients "little professors",^[4] and believed the individuals he described would be capable of exceptional achievement and original thought later in life.^[5] In a society governed by the Nazi eugenics policy of sterilizing and killing social deviants and the mentally handicapped, Asperger's paper passionately defended the value of autistic individuals, writing "We are convinced, then, that autistic people have their place in the organism of the social community. They fulfil their role well, perhaps better than anyone else could, and we are talking of people who as children had the greatest difficulties and caused untold worries to their care-givers."^[4]

A Soviet child psychiatrist, Grunya Efimovna Sukhareva, described a similar syndrome that was published in Russian in 1925, and in German in 1926.^[7]

Relationship to Kanner's work

Two subtypes of autism were described between 1943 and 1944 by two Austrian researchers working independently—Asperger and Austrian-born child psychiatrist Leo Kanner (1894–1981). Kanner emigrated to the United States in 1924;^[1] he described a similar syndrome in 1943, known as "classic autism" or "Kannerian autism", characterized by significant cognitive and communicative deficiencies, including delayed or absent language development.^[8] Kanner's descriptions were influenced by the developmental approach of Arnold Gesell, while Asperger was influenced by accounts of schizophrenia and personality disorders.^[9] Asperger's frame of reference was Eugen Bleuler's typology, which Christopher Gillberg has described as "out of keeping with current diagnostic manuals", adding that Asperger's descriptions are "penetrating but not sufficiently systematic".^[10] Asperger was unaware of Kanner's description published a year before his;^[9] the two researchers were separated by an ocean and a raging war, and Asperger's descriptions were ignored in the United States.^[5] During his lifetime, Asperger's work, in German, remained largely unknown outside the German-speaking world.^[1]

Coinage

According to Ishikawa and Ichihashi in the Japanese Journal of Clinical Medicine, the first author to use the term Asperger's syndrome in the English-language literature was the German physician, Gerhard Bosch.^[11] Between 1951 and 1962, Bosch worked as a psychiatrist at Frankfurt University. In 1962, he published a monograph detailing five case histories of individuals with PDD^[12] that was translated to English eight years later,^[13] becoming one of the first to establish German research on autism, and attracting attention outside the German-speaking world.^[14]

Lorna Wing is credited with widely popularizing the term "Asperger's syndrome" in the English-speaking medical community in her 1981 publication^[15] of a series of case studies of children showing similar symptoms.^[1] Wing also placed AS on the autism spectrum, although Asperger was uncomfortable characterizing his patient on the continuum of autistic spectrum disorders.^[5] She chose "Asperger's syndrome" as a neutral term to avoid the misunderstanding equated by the term autistic psychopathy with sociopathic behavior.^[16] Wing's publication effectively introduced the diagnostic concept into American psychiatry and renamed the condition as Asperger's;^[17] however, her accounts blurred some of the distinctions between Asperger's and Kanner's descriptions because she included some mildly retarded children and some children who presented with language delays early in life.^[9]

Early studies

The first systematic studies appeared in the late 1980s in publications by Tantam (1988) in the UK, Gillberg and Gilbert in Sweden (1989), and Szatmari, Bartolucci and Bremmer (1989) in North America.^[1] The diagnostic criteria for AS were outlined by Gillberg and Gillberg in 1989; Szatmari also proposed criteria in 1989.^[16] Asperger's work became more widely available in English when Uta Frith, an early researcher of Kannerian autism, translated his original paper in 1991.^[1] AS became a distinct diagnosis in 1992, when it was included in the 10th published edition of the World Health Organization’s diagnostic manual, International Classification of Diseases (ICD-10); in 1994, it was added to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as Asperger's Disorder.^[6]

Contemporary

Less than two decades after the widespread introduction of AS to English-speaking audiences, there are hundreds of books, articles and websites describing it; prevalence estimates have increased dramatically for ASD, with AS recognized as an important subgroup.^[1] However, questions remain concerning many aspects of AS; whether it should be a separate condition from high-functioning autism is a fundamental issue requiring further study.^[5] The diagnostic validity of Asperger syndrome is tentative, there is little consensus among clinical researchers about the usage of the term "Asperger's syndrome", and there are questions about the empirical validation of the DSM-IV and ICD-10 criteria.^[9] It is likely that the definition of the condition will change as new studies emerge^[9] and it will eventually be understood as a multifactorial heterogeneous neurodevelopmental disorder involving a catalyst that results in prenatal or perinatal changes in brain structures.^[5]

There is uncertainty regarding the gender gap between males and females with AS. A person with Asperger's is often remarked as possessing masculine traits like emotional distance from the inability to empathize, and far more boys than girls are diagnosed with Asperger's.^[18] Most studies on the syndrome were derived from research on males, neglecting specific attention to females with AS who often go misdiagnosed. For the most part, studies on girls with Asperger's are anecdotal.^[18]

Changes in DSM-5

One of the changes in DSM-5 released in May 2013 eliminated Asperger syndrome as a separate diagnosis, and included it under autism spectrum disorders. ASD is now rated on a scale ranging from severe, through moderate, to mild, based on clinical presentation.^[19]

References