Another difficult week

This last week was another tough one for Jeff. Like most of his rough periods, this was brought on by Jeff's perceptual misperception of conversations taking place around him and his very egocentric assumptions of what he has heard.

I had come down to our Adult Program just to visit and was quickly alerted by Sue, the Program Director, that Jeff was very upset because he thought his group home was going to the snow on the weekend. Jeff thought that meant he would have to ski and he doesn't know how. This idea terrified him. Apparently no one at his group home had said anything about skiing; they were merely contemplating a trip to the snow. However, another client in our program had been talking to everyone about her ski trip the previous weekend. Jeff very likely overheard her conversations and made the erroneous connection that going to the snow was synonymous with skiing - and he was petrified. Unable to tease out what was real and what was not, Jeff was swearing and threatening to hit anyone who mentioned snow or skiing. While Sue tried to reassure him and called the group home to get the actual story, Jeff relaxed a bit and I was able to talk with him and explain that these two different activities could be mutually exclusive. I could tell Jeff was trying to understand and at times, it seemed he did get it. But his anxiety over feeling compelled to do something so scary as skiing simply overwhelmed any logical conclusions he could hope to come to and about every 15 - 20 minutes, he would become upset again, requiring constant assurances that there would be no skiing.

Later in the day, Jeff was still distressed about the possible trip, so when I came down to visit, I wrote out on a piece of paper " I do not have to ski - ever!" this despite his staff offering many the same information throughout the day. I had Jeff read the sentence, cut it out, and told him to put it in his jacket pocket. Anytime he started to think about it, I reminded him, just take it out and read it. Seeing it in print seemed to make more of an impression on Jeff and he folded it carefully and stuffed it into his pocket. Then, Jeff came down to my office to listen to some music and with a few reminders, seemed calmer. It was St. Patrick's day as well and throughout the day, we were able to distract Jeff by talking of corned beef and cabbage and singing Irish songs that none of us could remember all the words to. By the time he left the program for the day, Jeff had calmed down considerably.

The following morning, the staff had their usual morning staff meeting and talked about Jeff's anxiety and the group home's plans. Unfortunately, one staff member was late due to traffic and missed the part of the discussion about how the trip was not even going to happen, not skiing, not snow, nothing. As the clients came in, this staff person casually asked Jeff how the plans were going for the snow trip. Big mistake! Jeff went off like Mt. Vesuvius, yelling and shouting and threatening to hit the staff who asked. Jeff had been told by his group home that the snow trip was off, but this question made it all come to life again as if it were imminent. He was still nervous and again needed assurances throughout the day that skiing was not on his agenda for the weekend. But the fragility of his understanding kept the staff on their toes all day and no one talked about snow unless it was to remind Jeff that he wasn't going.

And so this morning, when I came down to visit, Jeff instantly called out " I had a great weekend and I never worry anymore! And my dad made me corned beef and cabbage when I stayed with him on Saturday!" So, we're back to normal, or at least what is a state of equilibrium for Jeff. With his worries behind him, there we will stay until the next misunderstanding happens.

Anxiety and Autism

Several days a week, around 1:30 or 2 in the afternoon, I get a phone call from one of our adult clients, Jeff. He will ask if its okay to come down to my office and chat and, he hopes, listen to some music on my laptop. If I don't have a meeting, I invite Jeff down. Jeff arrives with pronouncements about whatever is on his mind. His conversations tend to be one sided, and I've learned over the years that you really have to listen to Jeff to understand what he is trying to tell you.

Jeff can be quite entertaining in an innocent, yet amazing way. He delights in talking about nationalities, and how he is Swedish or German or Italian or whatever nationality is on his mind - or whatever is the ethnicity of the latest person he has met. He has a very convoluted view of how people get to be who they are, and makes most unusual combinations of ethnic groups. For instance, a person from England who happens to be Jewish may become a "Yiddish British" or an Australian may morph into a Tasmanian Mexican, depending on their origin, according to Jeff's own understanding of geography. When he's focused on nationalities, we are pretty certain, all is right in Jeff's world.

But this last week Jeff came down as usual, and immediately announced definitively that he no longer worries. We've all ascertained that such a statement, offered in such a way, usually means something quite different. So, I began to explore. First, I acknowledge that of course, he doesn't have to worry, because he has nothing to worry about.

"That's right!" he exudes exuberantly, "I'm all done with that!"

Then, I wait to see what follows, and I never have to wait long, for Jeff is as garrulous as anyone I know and can out talk the most chatty of persons.

"I'm really healthy now," Jeff states, and then we begin to get to the core of his anxiety. His health is always a concern to him, and indeed he has some health concerns. But Jeff worries about anything related to doctors - every year he frets about getting a flu shot, and typically the month before he is to get it, he begins to speak constantly of flu shots, telling us how he is not afraid of that, no sir, not one bit!

"The doctor said everything is fine and I don't have to go back for another year!" Jeff says enthusiastically.

Jeff is 41 years old, has high blood pressure, sleep apnea, and recently has lost over 60 pounds, though he is still overweight. When he was at his heaviest, he had trouble with breathlessness, and was very anxious he was going to have a heart attack. He is aware of common ailments having gained just enough information from TV shows to make him nervous. And, because of his egocentricity, he is a bit of a hypochondriac. If he hears someone is sick, he assumes he must be, too. Our recent restriction at the school and adult program on peanuts because some students have severe allergies, created hours of discussion for Jeff. After much talking, he finally came to understand he does not have this problem.

During the time when he was his heaviest, Jeff visited a new doctor who asked him innocently some questions routine for a new patient intake. Unfortunately for that doctor, one question was "are you depressed?" which to Jeff meant "you are depressed." Jeff became extremely upset. He began swearing and was very distraught, and even the next day when he came down to my office, he was still ranting about "that *#~$#!&* doctor!!" each time he thought of him. So, in addition to our Adult Program Director talking with him extensively, I also spent some time reassuring him that the doctor was simply asking a question and it didn't mean Jeff was depressed.

This seeing the world from the perspective of self is always an issue for Jeff and many of our students and clients. As they perceive the world always from their own point of view, they typically misunderstand most events and conversations around them. Any reference to subjects they are anxious about instantly (from their viewpoint) becomes about them. So we have to listen constantly to their conversations, observe their interactions and help them interpret what we can only guess they may be internalizing. We may not hear about it for weeks or months or we may see the person immediately demonstrate anxiety or absolute fear that something they heard, an offhand remark, is an imminent danger to them.

Jeff's remark that he has no worries can't be taken at face value. It means instead he has been worried and probably significantly. Because he was talking about the visit to the doctor, it was pretty evident that Jeff was concerned about his health and afraid some doctor would ask him something to make him believe he has some new disease. The doctor who asked if he was depressed is long gone, as Jeff couldn't even tolerate the idea of ever going back to him. He gets upset at the very mention of his name. So, when he came to my office, I once again reassured him that he needn't be concerned, he has nothing to worry about and that all is right with his world. Jeff happily accepts my reassurances and we listen to a favorite song of his. But I know we are not done with his concerns and we will have many more conversations to clarify his always confusing environment.