A, a 25-year-old man with alcohol use disorder, presented with a chief complaint of feeling "lonely and frustrated." His father was his sober support person.
Birth was reported difficult with more than 12 h of labor and use of opioids for analgesia. Past psychiatric history was significant for ADHD, and "anxiety, and depression," his pediatrician had diagnosed when he was 16. He described family as "disconnected" since his parents' divorce. He felt "trapped" while living with his mother. Therefore he relocated and has lived with his father, "Since some time just after [high school] graduation." He described distant sibling relationships "because they all hate my dad for some reason. Because I'm the only one giving him a chance they don't talk to me."
A described a long history of poor communication and difficulty socializing. Throughout his education he was in "special classes" that he feels were stigmatizing and responsible for "making it really difficult to have friends at school. Everyone looked at us like we were weird and didn't want to be seen with us." After high school, A worked as a custodian for a few months at a college until, for unclear reasons, he was terminated and barred from the campus. A stated, "I just decided that being alone all the time, at work and at home, wasn't good for me and never went back." This was his only significant work in the seven years since high school graduation.
He spent much of his time indulging in alcohol, tobacco, and cannabis and avoiding social interactions. Alcohol consumption had been responsible for a hospital admission for withdrawal, an inpatient rehab followed by six months in a half-way house, and a drinking dream, suggestive of alcohol changing his ventral tegmental dopaminergic SEEKING system to produce alcohol craving (Johnson,).
During the initial interview he described feeling nauseous and agitated as we discussed his relationship with addicting substances. His mental exam was remarkable for tense posture, marked fidgeting, and gaze avoidance. His thought process was illogical regarding emotions and relationships. Affect was remarkable for dysphoria and irritability. His mood was described as "confused." Insight and judgment were poor.
Hamilton Rating Scale for Depression was 21, severe. A's SCID-2 screen for Borderline Personality was positive with 8/15 items checked. DSM5 criteria were ADHD positive for six inattentive and four hyperactive symptoms. Expired carbon monoxide was 8 part per million reflecting current cigarette use. Cognitive function was perfect. Diagnoses were Major Depressive Disorder, ADHD, Inattentive Type, Tobacco, Cannabis, and Alcohol Use Disorder.
We gave A and his father rating scales. The SRS-2 is validated for adults (Chan et al.,). The patient self-rates with a score above 75 indicating severe autism. The SCQ is observer rated; a score of 23.08 is the standardized mean for a diagnosis of autism (Rutter et al.,). A scored 79 on the SRS-2. The father rated 27 on the SCQ with a threshold for diagnosis of ASD being 15.
On day 8 cold pressor time (CPT), an ice water bath measuring pain tolerance by timing duration of forearm submersion, was 190 s. Our control average using support persons is 113 s. The withdrawal at 190 s seemed more from annoyance at feeling confined and controlled by remaining stationary rather than intolerable pain. A trial of naltrexone at 25 mg (0.39 mg/kg) was discussed.
A was reluctant to begin naltrexone but provided no reason for his objection. On day 21, A reported improvement in ADHD and depression with twice a week transference focused psychotherapy and bupropion 450 mg/day. After showing these signs of clinical improvement a trial of naltrexone was revisited.
A was apprehensive. He demonstrated an odd rationale about how naltrexone might injure him. We find autistic patients express pride at being autistic, as A did. They speak as if among many frustrations of their life they possess one outstanding quality:being autistic. We clarified his concerns and interpreted rationalizations regarding avoiding treatment. A agreed to begin naltrexone.
On day 28 A started 25 mg naltrexone with improvement in relatedness and odd thinking by day 35. We felt the therapeutic effects of naltrexone 25 mg had plateaued. We increased the dose to 50 mg. A felt significantly better with improved relatedness and clearer thinking.
His CPT was 28 s on 50 mg of naltrexone with a repeat CPT of 39 s a week later. CPT falling from 190 s to 28 or 39 s is thought to represent decreased central nervous system opioid tone, moving A toward the top of the inverse parabolic function in Figure 1. Closeness caused pleasure rather than pain. But A could also feel the pain of emotional responses to relationship problems.
On day 55, A lost his naltrexone prescription. We did not hear about this until inquiring about worsening gaze avoidance, confused thinking, and deterioration of relatedness. At his psychotherapy hour he smelled foul as if self-care had deteriorated.
One evening soon after he cut his left palm with a knife so deeply that the wound required 11 sutures. It was as if A had decided, "I needed to feel pain." This may have been an attempt to upregulate pain drivers to balance high opioid tone. Again there was reluctance to take medication as his odd thinking prevented appreciation of naltrexone's benefits. His father came to his psychotherapy hour and it was agreed A would restart naltrexone.
On day 65, A returned with vast improvement in mental status on 50 mg of naltrexone. On day 74, A decided to increase naltrexone to 75 mg (1.17 mg/kg). Initially, he felt better. However, after a few days, with no discussion in psychotherapy, he returned to 50 mg. A stated, "At 75 mg I didn't feel like I was on anything." This is consistent with 75 mg pushing A out of the 2-4 range of Figure 1, and into the 0-1 range of opioid tone where pain is identical to the 5-6 autistic range of opioid tone.
Overall, A felt marked improvement at naltrexone 50 mg. He said, "I can watch a basketball game now with my father without losing interest or wanting drugs or alcohol." He stopped alcohol, tobacco, and cannabis. Although we attributed the cessation of drug use to his psychotherapy, it may be that naltrexone also made a contribution. Naltrexone is an approved drug for Alcohol Use Disorder. On day 85, A's father rated him a 9 on the SCQ:not consistent with autism. A rated himself 54 on the SRS-2, considered normal.
On day 98, A was hired for a job loading trucks, full time at $14 per hour, and had purchased a new car. He reported positive interactions with coworkers. Soon after he terminated psychotherapy.
On day 166, A had again stopped his naltrexone. He got drunk, crashed his car, and lost his driver's license for a year. A has re-engaged in psychotherapy. Its focus has become negotiating painful relationships including the relational difficulties he encounters with his therapist.
Two years into his psychotherapy A has been working full-time since day 98. He talks mostly about his work relationships. Like other patients with major mental illness, sharing drugs becomes a way of engaging with others. He has resumed inhaling tobacco. He described with great pleasure asking a supervisor for a cigarette. "We walked the whole length of the warehouse to his office. He said, 'I wouldn't do this for any deadbeat but you work hard so I'll happily give you one of mine.'" Coworkers who inhale tobacco with him on breaks are characterized as, "Good, social people with a lot going on."
Figures of external authority, such as law enforcement and physicians who, "Always have such a serious look on their face," are associated with projected judgment and feeling inadequate, evoking guilt and shame. "Court is the worst because everyone is serious. Everyone looks at you like there's something wrong with you." A's reflective accounts of school are often externalizations he experiences as pondering other people's thoughts of him. He questions whether people past and present were/are honest about their perceptions. This identity question is part of A's transference and a focus of his continuing psychotherapy.
The paranoid thinking about external judgments and malevolence has consistently been examined in the transference, "Are we judging you?" By two years into treatment the paranoia is gone. A is working on developing relationships that he now desires.