‘Time slip’ phenomenon in adolescents and adults with autism spectrum disorders: Case series
Shinnichi Tochimoto, MD, Department of Neuropsychiatry, Ishikawa Prefectural Takamatsu Hospital, Ya-36, Uchitakamatsu, Kahoku, Ishikawa 929-1293, Japan. Email: firstname.lastname@example.org
In recent years, it has been noticed that adolescent and adult patients with autism spectrum disorder (ASD) sometimes visit psychiatric medical institutions. In some cases, these patients commit an act of violence and are dealt with by psychiatric emergency and forensic psychiatric services. In this report, we present two cases with ASD who visited a psychiatric emergency service because of the ‘time slip’ phenomenon, and discuss the clinical significance of this phenomenon.
DR SUGIYAMA, A pediatric psychiatrist in Japan, examined a specific recollection phenomenon seen in patients with high-functioning autism spectrum disorder (HFASD), naming it the ‘time slip’ phenomenon (TS) and reported it in the Japanese medical literature in 1994.1 This phenomenon is characterized by the clear recall of trivial events, which occurred many years earlier, and the re-experience of the events, including the feelings that were experienced, as if they were occurring in the present. Sugiyama claimed that this phenomenon is a characteristic symptom of autism spectrum disorder.
In this report, we present two typical patients who visited a psychiatric emergency service because of the TS, and discuss the clinical significance of TS. Informed consent to publish the details of these two cases was obtained from the patients and their parents.
Case 1, a male patient, was 16 years old at the time of his first visit to our hospital. He had not shown any delay in language development but had been isolated and unable to make friends since his infancy. In addition, he was extremely clumsy. He was extremely afraid of developing liver dysfunction. He had been bullied by a classmate when he was in the 8th grade; thereafter he refused to go to school and began to stay indoors. One day, he clearly recalled the bullying incident that had occurred a few years earlier and re-experienced the feelings of fear and frustration as if he were once again experiencing that event. Thereafter, he often had similar experiences, even though he did not purposely intend to recall the event, and he became strongly distressed. He and his family stated that the recalled content was always the same. He thought that the distress could only be relieved by obtaining revenge on the boy who had bullied him, and he visited the boy's house with a knife. He was subsequently admitted to the emergency ward of our hospital.
Our hospital collected detailed information on his developmental history from his parents. The patient's ‘Maternal and Child Health Handbook’ and report cards for elementary and junior high school were used as major information sources. We confirmed the presence of autistic features since his infancy using the Pervasive Developmental Disorder-Autism Society Japan Rating Scale (PARS),2 developed by Japanese investigators as a semi-structured screening method for ASD. The Japanese version of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) revealed an IQ of 77 (verbal: 88; performance: 66). Blood tests and brain computed tomography (CT) and electroencephalogram (EEG) examination did not reveal any abnormal findings. He was diagnosed as having Asperger's disorder based on the DSM-IV criteria3 after being examined by two psychiatrists.
The patient continued to experience the TS even after he was hospitalized. If he saw any man with an appearance similar to that of the boy who had bullied him, he recalled the same experience of being bullied and became violent. The patient's doctor and the ward staff observed that the patient made no effort to avoid the recall stimuli but instead tended to approach the stimuli. He was treated with selective serotonin reuptake inhibitors (SSRI) and second-generation antipsychotics (SGA), combined with individual psychotherapy. Following treatment, he continued to recall the bullying episode, but the strength of his feelings of fear and frustration during the recollection weakened. Also, he stopped displaying violent behavior. Four years after hospitalization, he was discharged to a group home for the mentally disabled.
Case 2, a male patient, was 27 years old at the time of his first visit. He had shown no marked clinical signs of delayed language development. However, since an early age, he had exhibited disturbed reciprocal sociality and did not have any close friendships. His interest was limited to collecting figures of comic characters. He began to be bullied during junior high school. He entered senior high school but quit during the second year. Thereafter, he tended to seclude himself at home. One day, he watched his neighbor discarding a cigarette butt in front of his home. Thereafter, he began to be annoyed by that memory. Almost every time he heard the voice of that neighbor or saw that man, he would leave his home and curse at the neighbor. His behavior became more violent and he eventually threatened the neighbor with a wooden sword. Because of this event, his family brought him to our hospital as an emergency patient.
The patient was examined on an outpatient basis over a period of several months, and detailed information was gathered from his parents, similar to Case 1. No episodes of epilepsy, delusions, or hallucinations were reported. Laboratory data and brain CT and EEG examinations did not reveal any abnormal findings. Autistic features since his infancy were confirmed using the PARS.2 WAIS-R revealed an IQ of 88 (verbal: 84; performance: 95). After being examined by two psychiatrists, he was diagnosed as having a pervasive developmental disorder not otherwise specified (PDDNOS) based on the DSM-IV definition.3
In this case, an acoustic or visual stimulus (the voice or appearance of the neighbor) provoked the TS resulting in the recollection of the same visual scene accompanied by the vivid emotions that he had experienced at the actual time. He took no measures to avoid remembering the event and tended to advance closer towards the neighbor.
Despite continuous intervention, including individual psychotherapy and pharmacotherapy with SSRI, the TS continued for several years. Five years later, he was admitted to our hospital because of violent behavior toward the same neighbor caused by the TS. Cognitive-behavioral interventions and pharmacotherapy consisting of SGA and a mood-stabilizing agent alleviated the TS, and he was discharged after 3 months. Thereafter, he continued to experience the TS, but his distress during the recollection had attenuated.
Among the patients who visited the emergency department of our hospital between 1998 and 2006, TS was confirmed in four of seven cases with HFASD. Based on the DSM-IV,3 two patients were diagnosed as having Asperger's disorder, and the remaining two were diagnosed as having PDDNOS. Three of the patients were male. The recalled content consisted of bullying experiences that had occurred while the patient was at school in two of the patients and unpleasant experiences involving neighbors in the remaining two patients. The recalled content always reappeared without any variation in all the cases. Although the TS was a remarkably unpleasant experience for the patients, none of them avoided stimuli that provoked the TS. In all the cases, the patients visited the emergency department of our hospital because they had committed an act of violence resulting from their experiences of the TS. Two patients had attempted to take revenge against the persons on whom they had a grudge, and the other two used violence against their family as a substitute to acting against the perceived oppressor.
Based on our limited experience, the contents of the TS were persecutive, and the TS seemed to be the cause of the violent behavior. However, our patients represent a small number of cases encountered during the special field of psychiatric emergencies, and not the entire population of subjects diagnosed as having ASD. Therefore, caution is needed when attempting to apply our experiences to the whole ASD population. Accordingly, clinical reports on TS should be collected from a larger number of cases and a larger number of institutions in the future.