I read with interest the letter by Darryl Watts ‘Malignant alienation – a concept that has not yet arrived’ (Psychiatric Bulletin, December 2004, 28, 459). I also read the earlier editorial on malignant alienation by Watts & Morgan (Reference Watts and Morgan1994). It would appear to me that the term ‘malignant alienation’ does describe a group of patients who according to Watts and Morgan are ‘hard to like’. I believe that quite a number of these patients overlap with persons who would now be diagnosed with Asperger syndrome. The major problems in relationships with others, and the loss of sympathy from staff who perceive their behaviour as being unreasonable, would fit with Asperger syndrome. It is hardly surprising if this continues that there could be a suicidal outcome. I would suggest that patients with this description ‘malignant alienation’ be assessed for Asperger syndrome.