This is an 18 year old female patient, diagnosed (DSM-IV-TR) with social phobia and dependent personality disorder, referred from the Child and Adolescent Mental Health Service (CSMIJ) for follow-up in the adult service, who comes accompanied by her mother.
She is the eldest of two sisters. Parents separated. Lives with her mother and sister. During her childhood she shows attention deficit and poor academic performance without repeating a grade. She is currently studying a higher module and is working in the family business. Medical history of interest: isolated growth retardation that required treatment with growth hormone (GH) from the age of 12 to 17 years. Fructose intolerance associated with digestive bleeding and lactose intolerance. In childhood, genetic examination was carried out, and no genetic alteration, neither numerical nor structural, was observed. She denies the use of toxic substances. Among the family psychiatric antecedents, the mother refers to long-standing anxious symptoms. The father is described as a solitary, introverted and "unemotional" person, characteristics that are present in several relatives in the paternal line. From the psychiatric point of view, the patient came into contact with the CSMIJ at the age of 14, with a diagnosis of Social Phobia. At the age of 17 she was admitted to the Day Hospital for 2 months due to difficulties in socialising, truancy and great dependence on the family environment. The diagnostic orientation was Social Phobia and Dependent Personality Disorder (according to evolution) which, after discharge, evolved towards partial improvement. Among the pre-morbid personality traits, she has a high degree of introversion. Her mother describes her as an isolated child, "different", with little social interest.
Initial examination revealed distant contact, unspontaneous language with no formal alterations. Moderate psychophysical anxiety, obsessive hypochondriacal ideas, onychophagia and nocturnal bruxism. No symptoms of the affective or psychotic sphere were observed. No alterations in the course or content of thought. No alterations of sensory perception. Partial consciousness disorder.
The picture is classified as a Cluster C Personality Disorder (phobic, obsessive and dependent traits). Pharmacological treatment is maintained as prescribed by CSMIJ (Sertraline, 100 mg), and she is referred to psychology to work on social difficulties. She made few visits with poor compliance with the proposed strategies (cognitive-behavioural model), and disengaged due to incompatibility with studies.

Second contact after two years
The patient re-engages after almost two years (20 years) of no follow-up. Social difficulties persist. Exploratory visits are made by psychiatry and psychology, including a visit with the mother. They express the decision to abandon SSRI medication. They do not accept pharmacological treatment, although they do accept psychological treatment. During the assessment, the patient impresses a "peculiar" contact rather than the usual phobic-anxious contact. There is a strange - albeit subtle - alteration in eye contact. Language remains unspontaneous. In addition to social difficulties and little interest in the environment, obsessive hypochondriacal ideas and an absolute rejection of physical and sexual contact stand out. In order to assess the patient's difficulties/skills at the interpersonal level, simple social exposure exercises are proposed outside the consultation room. The patient does not carry out any of the proposed exercises/strategies. Nor does she show any concern for resolving these difficulties. On the contrary, she appears to be somewhat indifferent to them. In view of this, doubts begin to arise regarding social avoidance (uncomfortable vs. anxious?), and regarding the desire to socialise (learned social discourse?). Given these doubts, the suspicion arises that these symptoms could be explained by other diagnoses: schizoid traits? autistic spectrum traits? and so a new evaluation of the patient is proposed.

Assessment protocol and results:
- Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II):
- Criteria Schizoid Personality Disorder: 4/5. Close to cut-off point.
- Criteria Avoidant Personality Disorder: 5/5. Meets cut-off point.
- Theory of Mind Tests (TOM):
- "Happé Stories Test": shows adequate ability to infer mental states in others, understand metaphors and double meanings.
- "Mind's Eye Reading Test": Is able to attribute to the majority of items (23/36) the appropriate feeling or emotion shown in the photograph.
- Screw-Up Test: Correctly identifies "screw-up" stories but shows difficulty in attributing emotional states and intentionality to characters.
- Wechsler Adult Intelligence Scale (WAIS-III): IQ Verbal= 99 IQ Manipulative= 94 IQ Total= 97 Range: Medium
- Autism Diagnostic Interview-Revised (ADI-R): Disturbances in reciprocal social interaction are identified. Limited range of facial expressions to communicate and regulate social interaction. Inability to develop relationships with peers. A lack of socio-emotional reciprocity, inadequate social responses and a deficit in seeking to share pleasure with others are observed. In retrospect, qualitative alterations in communication are identified, such as a lack of spontaneous and varied symbolic play.
Some restricted behaviour patterns are also identified.
- Magnetic Resonance Imaging (MRI): Cranial examination within normality.

Global assessment:
Throughout the examination the patient is cooperative although not very motivated. The information obtained shows signs of an autistic spectrum disorder (ASD) with low social interest, inappropriate expressions and behaviours, difficulties in establishing social relationships with peers, restricted facial expressions and affectivity, and limited interests/activities. The cognitive profile and performance in the 'TOM' domains (number of non-significant errors, although difficulty in attributing emotional states and intentionality to characters in the 'Meteduras de Pata' test) are consistent with the profile observed in high-functioning ASD patients (1).