SA vs AS
Ok. I mentioned in a reply to a comment that I'd explain why Asperger Syndrome seems as good a possibility as Social Anxiety Disorder or Social Phobia, and go into some detail about Social Anxiety as well.
Long-term watchers of Santiago's Dead Wasp and the few people who know me may be aware that I already started to consider Social Anxiety as a diagnostic possibility over a year ago after my GP raised it as a possibility. I looked into it at the time, and until recently it was the main explanation I had in mind. I even made contact with the National Phobics Society (NPS) though I didn't really make much use of their services, partly because I was so stressed and ill.
Social Anxiety
This is a useful starting resource from NPS, that I'll refer to in what follows. Drawing from the obviously simplified account of what Social Anxiety is there are aspects which clearly match my behaviours and thoughts and aspects which are clearly different.
"[T]his disorder ... is often expressed as a fear of being the centre of attention..."
That is certainly not the case with me. I'm happy to be the centre of attention, and can be happy well away from any attention. What I find difficult are the more fluid and normal situations where you're a member of a group, sometimes contributing and sometimes not. I'll return to my being happy at the centre of attention later.
"...or of others noticing the sufferer's anxious behaviour."
I do worry about what people will think, but never that they'll notice my anxious behaviour. It's something I simply don't care about.
I also don't display what are described as "[t]he physical manifestations of this phobia ... blushing, shaking and sweating etc."
The "self diagnosis" checklist, which obviously is only an indication of probability and not a replacement for a diagnosis carried out by a qualified professional, produces a more positive result.
I do worry about embarrassing myself in front of others, about what they may think of me, I do get anxious in social situations, and I do avoid parties and other social gatherings (if I have to go there alone) because they make me feel anxious. On the other hand, I don't worry about behaving anxiously in any situation, and have no problems whatsoever with public speaking, eating/drinking in front of others, or writing in front of others. Indeed when I can, I enjoy performing my poetry in public. In performance situations, and in work and other similar contexts where there are clear rules governing relationships and conduct, then I'm well able to cope.
Asperger Syndrome
This is the resource from the National Austisic Society (NAS) that I'll refer to. Again the emphasis is on ensuring that you get a qualified diagnosis. The process here in the UK is that you ask your GP for a referral to a psychiatrist or clinical psychologist. This is what I did, though it can take some time, as you'll see.
Initially I presented in September 2004 with stress, anxiety, panic attacks etc. The GP gave me some information on Social Anxiety and referred me to psychiatric services who were able to see me in December the same year. That appointment felt rather like a box-ticking exercise, and although I emphasised my social difficulties was told the symptoms might indicate 'Adjustment Disorder'. There was no indication given as to what this meant, or how it could be dealt with, just a mention that I would now be referred to the clinical psychologist. Over the coming months it became clear that no referral was forthcoming, so I started to try and find out what happened. Eventually toward the end of 2005 I was told that I was required to approach my GP for a referral, and finally went to my GP again in January this year (2006), who referred me to the clinical psychologist, but warned that it may take around nine months to be seen. Last month I filled out and returned a form confirming that I wanted an appointment, and started waiting (again). Even at that point my major thought was Social Anxiety.
But over the years some friends have suggested, often quite convincingly, that Asperger Syndrome or some form of Autistic Spectrum Disorder (ASD) might be present. I'd even done some cursory research myself and filed the idea away as possible, though I had no clue how you might go about getting a diagnosis, not realising it was the GP/psychiatrist/clinical psychologist route.
Anyway I didn't give it much further thought until the week before a counselling session through my work occupational health. I then checked out the NAS site for information, and printed off the leaflet linked to above. Then in the counselling session, without previously raising the subject, the possibility of Asperger was raised. Hence the recent references on the blog and the decision to raise it with the clinical pyschologist.
Triad of Impairments
The NAS resource refers to the "triad of impairments" which are characteristic of people with AS, who "will be affected in some way by each". The three areas are in social communication, social understanding, and imagination, which are explained as follows:
Social Communication
Examples of problems in this area are in:
1. "the social aspects of communication", "difficulty understanding gestures, body language and facial expressions"
2. "[unawareness] of what is socially appropriate ... difficulty choosing topics to talk about"
and
3. "[lack of social motivation] ... find[ing] communication difficult ... not many friends [and] not choos[ing] to socialise very much".
These may be presented in the following ways:
1. "difficulty making eye contact"
I certainly have great difficulty making or maintaining eye contact even with people I feel comfortable and safe with. I look away or avoid eye contact frequently.
2. "repetitive speech"
This doesn't seem to be any more present than with anyone else I know.
3. "difficulties expressing themselves especially when talking about emotions"
This is definitely true, though whether it's any more pronounced than with other men I couldn't say. There is a noticeable lag in consciously understanding what I've been told and thinking of the appropriate thing to say. Although when things that are concerning me are expressed in a fictional (poetic or other) form, then they show a level of understanding beyond anything I'd be able to summon in conversation.
4. "anxiety in social situations"
Along with the inability to make eye contact this is the clearest manifestation of problems. Although I do attempt from time to time to put myself in social situations it's exceptionally difficult. On occasion I will even avoid passing people in the street,simply because it feels like an intrusion on personal space.
Social Understanding
The areas of difficulty identified by NAS here include:
"difficulties in group situations"
Group situations are a major challenge, even with a relatively small group of people that I know well. Larger groups and groups with people I don't really know are extremely problematic. There's the difficulty of knowing what to talk about, the difficulty of knowing how to pitch myself, and the difficulty of simply finding a point to break into the conversation. I am aware that these last are all challenges experienced by most people.
"finding small talk and chatting very difficult"
Small talk and chat is fine one to one with people I'm familiar with, in groups and with people I don't know it's a problem. One strategy I adopted quite early on was to plan what I wanted to say so that it would fit, and so I wouldn't stand out too much or say something inappropriate. The drawback is that it inhibits my joining a conversation, and I frequently find that what I've planned to say isn't relevant by the time I'm ready to say it.
"problems understanding double meanings [eg] teasing"
Even with friends and family it can be very difficult to know when someone is teasing by not being entirely sincere.
"not choosing appropriate topics"
I don't generally have any problems in choosing appropriate topics, although I may start talking in a roundabout way or confine myself to a limited range of subjects I feel comfortable with.
"talking what people say very literally"
While I don't have any particular problems with figurative language, for instance "Hold your horses" wouldn't confuse me, I do tend to take people literally. I understand (in a quite conscious way) that "five minutes" doesn't mean exactly that, but if someone says they'll call tomorrow then I expect that they will. Likewise if someone expresses an opinion and it's not clear that they're joking or that it's a thow-away remark, then I will take that as their position on the subject. I will be quite baffled or even upset if it subsequently emerges that this is not the case.
Imagination
And for imagination, the third of the triad of impairments, NAS provide the following examples:
"obsession with rigid routines and severe distress if ... disrupted"
I am certainly at my most productive and happy when I'm imposing timetables on myself, and their disruption can throw me out of balance for a long time. I'm also aware from what friends say that I like tasks to be done in a certain order and become agitated if I have to put them aside. I also flourish socially and personally best in situations where the 'rules' are clear-cut, such as in work or in my volunteer capacity. Performance is something I also find easy, whereas approaching the person organising an open-mic night to ask for a slot is all but impossible.
"problems with making plans ... difficulty organising your life"
You might think that needing to stick with rigid routine would mean someone was easily able to make plans and organise their life. It's not the case. Some of the time I find myself not doing things on the pretext that someone might want to get in touch with me and have something better to do. Otherwise my timetables centre around absolutely mundane tasks. Longer-term planning and the organisation to make more complex plans come about is usually beyond me, unless I make a particular effort to break down the task into tiny bits. This difficulty combined with an inabilty to network significantly inhibits, for instance, my ability to promote my poetry.
"problems with sequencing tasks ... can't always remember what to take with you"
I don't think this is a particular problem.
Secondary traits
"obsessive compulsive behaviours"
Behaviours like this have always been a potential problem rather than an actual one. Mainly because I've consciously managed my behaviour when I've been aware that it might be becoming compulsive or ritualistic.
"phobias"
In my case probably not diagnostic. I do have a long standing fear of heights. I also have a fear of social situations, which of course is where we came in.
"acute anxiety, which can lead to panic attacks and [rigid routines]"
Panic attacks are rare, though acute anxiety is present a lot of the time, most strongly in social situations. I've been tense and anxious for most of my life so far as I remember. When I'm at my lowest anxiety is more present, and if I'm under personal stress then the chances are there will be panic attacks. I've also had regular panic attacks throughout my life since about the age of five centering on my fear of death. They're less frequent now, but I'd still expect around three or four a year.
"depression and social isolation"
I've never been diagnosed with depression, and my symptoms never match the classic profile of depression. However, I do get extremely low and demotivated, and friends have suggested at times that I suffer fom depression. In essence my behaviours and thought patterns often seem to indicate depression, but a more detailed look usually says stress and anxiety. On balance I'd have to say I don't seem to experience depression, but I certainly experience social isolation. I have friends, mainly outside of Manchester, but I see them and speak to them less frequently than I would like. The majority of my time is spent inside my own head.
"clumsiness often linked to ... dyspraxia"
Another tricky one. I can be quite clumsy, or more properly physically unaware, especially when I'm intoxicated or getting carried away. The rest of the time I am physically controlled, often elegant. Many of the ways in which I move and hold myself have been consciously adopted either from photographs or descriptions, though almost never from film or seeing other people. I was certainly a clumsy child, although I've never been diagnosed as dyspraxic.
Conclusion
So there you go. I'm not sure whether this indicates one diagnosis over another or discounts both. It is of course written without the benefit of an outside perspective, and is based on simplified descriptions. I'll let you know what the clinical psychologist thinks when I eventually get to see them.
Long-term watchers of Santiago's Dead Wasp and the few people who know me may be aware that I already started to consider Social Anxiety as a diagnostic possibility over a year ago after my GP raised it as a possibility. I looked into it at the time, and until recently it was the main explanation I had in mind. I even made contact with the National Phobics Society (NPS) though I didn't really make much use of their services, partly because I was so stressed and ill.
Social Anxiety
This is a useful starting resource from NPS, that I'll refer to in what follows. Drawing from the obviously simplified account of what Social Anxiety is there are aspects which clearly match my behaviours and thoughts and aspects which are clearly different.
"[T]his disorder ... is often expressed as a fear of being the centre of attention..."
That is certainly not the case with me. I'm happy to be the centre of attention, and can be happy well away from any attention. What I find difficult are the more fluid and normal situations where you're a member of a group, sometimes contributing and sometimes not. I'll return to my being happy at the centre of attention later.
"...or of others noticing the sufferer's anxious behaviour."
I do worry about what people will think, but never that they'll notice my anxious behaviour. It's something I simply don't care about.
I also don't display what are described as "[t]he physical manifestations of this phobia ... blushing, shaking and sweating etc."
The "self diagnosis" checklist, which obviously is only an indication of probability and not a replacement for a diagnosis carried out by a qualified professional, produces a more positive result.
I do worry about embarrassing myself in front of others, about what they may think of me, I do get anxious in social situations, and I do avoid parties and other social gatherings (if I have to go there alone) because they make me feel anxious. On the other hand, I don't worry about behaving anxiously in any situation, and have no problems whatsoever with public speaking, eating/drinking in front of others, or writing in front of others. Indeed when I can, I enjoy performing my poetry in public. In performance situations, and in work and other similar contexts where there are clear rules governing relationships and conduct, then I'm well able to cope.
Asperger Syndrome
This is the resource from the National Austisic Society (NAS) that I'll refer to. Again the emphasis is on ensuring that you get a qualified diagnosis. The process here in the UK is that you ask your GP for a referral to a psychiatrist or clinical psychologist. This is what I did, though it can take some time, as you'll see.
Initially I presented in September 2004 with stress, anxiety, panic attacks etc. The GP gave me some information on Social Anxiety and referred me to psychiatric services who were able to see me in December the same year. That appointment felt rather like a box-ticking exercise, and although I emphasised my social difficulties was told the symptoms might indicate 'Adjustment Disorder'. There was no indication given as to what this meant, or how it could be dealt with, just a mention that I would now be referred to the clinical psychologist. Over the coming months it became clear that no referral was forthcoming, so I started to try and find out what happened. Eventually toward the end of 2005 I was told that I was required to approach my GP for a referral, and finally went to my GP again in January this year (2006), who referred me to the clinical psychologist, but warned that it may take around nine months to be seen. Last month I filled out and returned a form confirming that I wanted an appointment, and started waiting (again). Even at that point my major thought was Social Anxiety.
But over the years some friends have suggested, often quite convincingly, that Asperger Syndrome or some form of Autistic Spectrum Disorder (ASD) might be present. I'd even done some cursory research myself and filed the idea away as possible, though I had no clue how you might go about getting a diagnosis, not realising it was the GP/psychiatrist/clinical psychologist route.
Anyway I didn't give it much further thought until the week before a counselling session through my work occupational health. I then checked out the NAS site for information, and printed off the leaflet linked to above. Then in the counselling session, without previously raising the subject, the possibility of Asperger was raised. Hence the recent references on the blog and the decision to raise it with the clinical pyschologist.
Triad of Impairments
The NAS resource refers to the "triad of impairments" which are characteristic of people with AS, who "will be affected in some way by each". The three areas are in social communication, social understanding, and imagination, which are explained as follows:
Social Communication
Examples of problems in this area are in:
1. "the social aspects of communication", "difficulty understanding gestures, body language and facial expressions"
2. "[unawareness] of what is socially appropriate ... difficulty choosing topics to talk about"
and
3. "[lack of social motivation] ... find[ing] communication difficult ... not many friends [and] not choos[ing] to socialise very much".
These may be presented in the following ways:
1. "difficulty making eye contact"
I certainly have great difficulty making or maintaining eye contact even with people I feel comfortable and safe with. I look away or avoid eye contact frequently.
2. "repetitive speech"
This doesn't seem to be any more present than with anyone else I know.
3. "difficulties expressing themselves especially when talking about emotions"
This is definitely true, though whether it's any more pronounced than with other men I couldn't say. There is a noticeable lag in consciously understanding what I've been told and thinking of the appropriate thing to say. Although when things that are concerning me are expressed in a fictional (poetic or other) form, then they show a level of understanding beyond anything I'd be able to summon in conversation.
4. "anxiety in social situations"
Along with the inability to make eye contact this is the clearest manifestation of problems. Although I do attempt from time to time to put myself in social situations it's exceptionally difficult. On occasion I will even avoid passing people in the street,simply because it feels like an intrusion on personal space.
Social Understanding
The areas of difficulty identified by NAS here include:
"difficulties in group situations"
Group situations are a major challenge, even with a relatively small group of people that I know well. Larger groups and groups with people I don't really know are extremely problematic. There's the difficulty of knowing what to talk about, the difficulty of knowing how to pitch myself, and the difficulty of simply finding a point to break into the conversation. I am aware that these last are all challenges experienced by most people.
"finding small talk and chatting very difficult"
Small talk and chat is fine one to one with people I'm familiar with, in groups and with people I don't know it's a problem. One strategy I adopted quite early on was to plan what I wanted to say so that it would fit, and so I wouldn't stand out too much or say something inappropriate. The drawback is that it inhibits my joining a conversation, and I frequently find that what I've planned to say isn't relevant by the time I'm ready to say it.
"problems understanding double meanings [eg] teasing"
Even with friends and family it can be very difficult to know when someone is teasing by not being entirely sincere.
"not choosing appropriate topics"
I don't generally have any problems in choosing appropriate topics, although I may start talking in a roundabout way or confine myself to a limited range of subjects I feel comfortable with.
"talking what people say very literally"
While I don't have any particular problems with figurative language, for instance "Hold your horses" wouldn't confuse me, I do tend to take people literally. I understand (in a quite conscious way) that "five minutes" doesn't mean exactly that, but if someone says they'll call tomorrow then I expect that they will. Likewise if someone expresses an opinion and it's not clear that they're joking or that it's a thow-away remark, then I will take that as their position on the subject. I will be quite baffled or even upset if it subsequently emerges that this is not the case.
Imagination
And for imagination, the third of the triad of impairments, NAS provide the following examples:
"obsession with rigid routines and severe distress if ... disrupted"
I am certainly at my most productive and happy when I'm imposing timetables on myself, and their disruption can throw me out of balance for a long time. I'm also aware from what friends say that I like tasks to be done in a certain order and become agitated if I have to put them aside. I also flourish socially and personally best in situations where the 'rules' are clear-cut, such as in work or in my volunteer capacity. Performance is something I also find easy, whereas approaching the person organising an open-mic night to ask for a slot is all but impossible.
"problems with making plans ... difficulty organising your life"
You might think that needing to stick with rigid routine would mean someone was easily able to make plans and organise their life. It's not the case. Some of the time I find myself not doing things on the pretext that someone might want to get in touch with me and have something better to do. Otherwise my timetables centre around absolutely mundane tasks. Longer-term planning and the organisation to make more complex plans come about is usually beyond me, unless I make a particular effort to break down the task into tiny bits. This difficulty combined with an inabilty to network significantly inhibits, for instance, my ability to promote my poetry.
"problems with sequencing tasks ... can't always remember what to take with you"
I don't think this is a particular problem.
Secondary traits
"obsessive compulsive behaviours"
Behaviours like this have always been a potential problem rather than an actual one. Mainly because I've consciously managed my behaviour when I've been aware that it might be becoming compulsive or ritualistic.
"obsessive interests in just one topic"
Again I think on the whole I probably fall short of this, although my interest in writing and its potential power (particularly with poetry), and in film some pretty close. As conversational subjects they definitely dominate."phobias"
In my case probably not diagnostic. I do have a long standing fear of heights. I also have a fear of social situations, which of course is where we came in.
"acute anxiety, which can lead to panic attacks and [rigid routines]"
Panic attacks are rare, though acute anxiety is present a lot of the time, most strongly in social situations. I've been tense and anxious for most of my life so far as I remember. When I'm at my lowest anxiety is more present, and if I'm under personal stress then the chances are there will be panic attacks. I've also had regular panic attacks throughout my life since about the age of five centering on my fear of death. They're less frequent now, but I'd still expect around three or four a year.
"depression and social isolation"
I've never been diagnosed with depression, and my symptoms never match the classic profile of depression. However, I do get extremely low and demotivated, and friends have suggested at times that I suffer fom depression. In essence my behaviours and thought patterns often seem to indicate depression, but a more detailed look usually says stress and anxiety. On balance I'd have to say I don't seem to experience depression, but I certainly experience social isolation. I have friends, mainly outside of Manchester, but I see them and speak to them less frequently than I would like. The majority of my time is spent inside my own head.
"clumsiness often linked to ... dyspraxia"
Another tricky one. I can be quite clumsy, or more properly physically unaware, especially when I'm intoxicated or getting carried away. The rest of the time I am physically controlled, often elegant. Many of the ways in which I move and hold myself have been consciously adopted either from photographs or descriptions, though almost never from film or seeing other people. I was certainly a clumsy child, although I've never been diagnosed as dyspraxic.
Conclusion
So there you go. I'm not sure whether this indicates one diagnosis over another or discounts both. It is of course written without the benefit of an outside perspective, and is based on simplified descriptions. I'll let you know what the clinical psychologist thinks when I eventually get to see them.
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