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Psychosisand AutismSpectrumDisorderPETERCARPENTERWITH THANKS TO DHEERA J RA I
Picture:JamesEdwards
Planofworkshop◦ Whyisthisimportant◦ Theoriginsandevolutionofaconfusingdebate◦ Possiblereasonsbehindanoverlap◦ Somecaseexamples◦ Howdowediagnoseandtreat?
Planofworkshop◦ Whyisthisimportant◦ Theoriginsandevolutionofaconfusingdebate◦ Possiblereasonsbehindanoverlap◦ Somecaseexamples◦ Howdowediagnoseandtreat?
Majorincreaseinautismdiagnoses
Nowpeopleaskinginadult‘isthisschizophreniaand/orASD?’◦ HowASDaffecttreatmentofPsychosisandviceversa
Verylittleknownabout◦ howASDfarelaterinlifeatthepopulationlevel◦ Commonfeaturesleadingtomisdiagnosis ofcomorbidityormisdiagnosisofASD.◦ Howfartreatingco-morbiditiesleadstobetteroutcomes.◦ HowASDaffectstreatmentofcomorbidities
ResearchonmentalhealthinASDanditstreatmentnowseenasresearchpriority.
Planofworkshop◦ Whyisthisimportant◦ Theoriginsandevolutionofaconfusingdebate◦ Possiblereasonsbehindanoverlap◦ Somecaseexamples◦ Howdowediagnoseandtreat?
Nosology intertwinedinhistory...Bleuler (1905)- ‘autism’wasoneofthefourcardinalfeatures(the4A’s)ofSchizophrenia
Earlyattemptsatseparation(Kanner 1943)
Normaldevelopmentfollowedbydeclinevs ‘extremealoneness’fromthebeginning
Steppingoutofaworldafterbeingapartofit,vs gradualcompromisetoextendcautiousfeelersintoaworldtheyhavebeenstrangersto(potentialforprogressandimprovement)
It’sallcalledschizophrenia...Creak’s(1961)‘ninepoints’forSchizophrenicSyndromeinChildren
1968DSM2– 295Schizophrenia.0Schizophrenia,simpletype8Schizophrenia,childhoodtype
1970’sthestartofautismasneurodevelopmentaldisorder
ICD91977separatesoutAutismbutstillhashascurrentorresidualstateAutism
ICD10(researchcriteria)ChildhoodAutism:theconditionisnotattributabletoschizophreniaofunusuallyearlyonset.
Aspergers– theconditionisnotattributabletosimpleschizophrenia,orschizo-typal personalitydisorder.
Chapterstrump– schizophreniatrumpsautism[butinthehereandnow– ifASDaschildthendevelopSchizophreniadoyouloseASD?]
AutismSpectrumDisorderDSM5Persistentdeficitsinsocialcommunicationandsocialinteractionacrossmultiplecontexts,asmanifestedbythefollowing,currentlyorbyhistoryof:
◦ Deficitsinsocial-emotionalreciprocity,...rangingfromabnormalsocialapproachandfailureofnormalback-and-forthconversation,toreducedsharingofinterests,emotionsoraffect,tofailuretoinitiateorrespondtosocialinteractions.
◦ Deficitsinnon-verbalcommunicativebehaviorsusedforsocialinteractioneg poorlyintegratedverbalandnon-verbalcommunicationtoabnormalitiesineyecontactandbodylanguageoritsunderstanding
◦ Deficitsindeveloping,maintainingandunderstandingrelationships.egadjustingbehaviortosuitvarioussocialcontexts,difficultysharingimaginativeplay.
AutismSpectrumDisorderDSM5Restrictedrepetitivepatternsofbehavior,interestsoractivities.Atleast2of:(currentorinhistory)
◦ Stereotypedorrepetitivemotormovements,useofobjectsorspeech.
◦ Insistenceonsameness,inflexibleadherencetoroutinesorritualised patternsofverbalornon-verbalbehavior.
◦ Highlyrestricted,fixatedintereststhatareabnormalinintensityorfocus.
◦ Hyperorhyporeactivitytosensoryinputorunusualinterestinsensoryaspectsoftheenvironment.
DSM5differentialdiagnosisechoesDSM4
Schizophreniawithchildhoodonsetusuallydevelopsafteraperiodofnormalornearnormaldevelopment.Aprodromal statehasbeendescribedinwhichsocialimpairmentandatypicalinterestsandbeliefsoccur.
Hallucinationsanddelusionswhicharedefiningfeaturesofschizophreniaarenotfeaturesofautismspectrumdisorder.◦ [Butneedtoseparatehallucinationfromeideticimagery,imaginaryfriendsetc.Anddelusionsfrombizarremisinterpretationsorovervaluedideas]
Planofworkshop◦ Whyisthisimportant◦ Theoriginsandevolutionofaconfusingdebate◦ Possiblereasonsbehindanoverlap◦ Somecaseexamples◦ Howdowediagnoseandtreat?
Possible reasons behind an overlap
ASDandPsychosesareonthesamespectrumwithacommonorigin
ASDisariskfactorforSchizophrenia
Diagnosticconfusionbecausedefinitionsorsymptomsoverlap
Commonorigins?ChildrenwithASDmorelikelytohaveafamilyhistoryofpsychoticdisorders(egSullivan2012).
Sharedriskfactors– e.g.paternalage,obstetriccomplications,fetalgrowth
Istherealinkthroughpersonalitydiagnosis?ASDsaidbysometoincludeSchizoidPersonalityDisorderandSchizotypal PersonalityDisorder
Schizoidpersonalitydisorder[3timesmorecommonthanASD?]isassociatedwithafamilyhistoryofSchizophrenia.
Schizotypal personalitydisorderpredisposestoschizophrenia.
ASDariskfactor?Populationstudies
StockholmYouthCohortASD(n=9072)andmatchedcontrols(10:1)diagnosedbeforeage16
AdjustedOddsRatioforNonAffectivePsychoticDisorderbyage27◦ 3.9(2.8-5.6)◦ 1.8(1.2-2.8)forfullnonASDsiblingsofthosewithASD
ForBipolarDisorder◦ 4.0(2.8-5.8)◦ 1.7(1.1-2.6)forfullnonASDsiblingsofthosewithASD
J-PSelten etal2015JAMAPsychiatry
ASDariskfactor?Populationstudies
ALSPACbirthcohort,Bristol(c14,000)
86childrendiagnosedformallywithASDbyage11(0.6%prevalence)◦ Inadditionvariousdimensionalmeasuresofautistictraitsmeasured[n=5359]
Interviewedforpsychoticexperiencesatage12
ThosewithASDhadOddsRatioof2.81[1.07– 7.34]for‘psychotic’symptoms.◦ Similarresultsforautistictraitmeasures,includingtraitslesslikelytobeconfusedwithpsychosisi.e.repetitivebehaviours
ASDasariskfactorforpsychoses129ASDadultsreferredtochildneuropsychiatricclinicinSweden(Ståhlberg etal2004)◦ 7%hadbipolardisorderwithpsychoticfeatures◦ 7.8%hadschizophreniaoranotherpsychoticdisorder◦ Lackofcontrolsalimitation
Of89childrendiagnosedwithatypicalautism,inlongtermfollow-up31developedaschizophreniformillness(Mouridsen 2007)◦ ButisthislackofaccuratediagnosisofAutism?
AnoverlapclinicallyAdultswithASD:Selfreporthallucinationswhenwell[eg,whenbored]Oftenreporthearingvoices‘intheirheads’‘Delusional’beliefisfairlyhigh- usuallygrandioseorpersecutoryMotorCatatoniacanoccur
AdultswithSchizophrenia:PerformbadlyonToM testsandonVisualToM Jokes- notlinkedtoseverityofdelusionorhallucinations.MajorityofadultswithChildOnsetSchizophreniameetoneormorecriteriaforPDD
FeaturesofpsychosisinAutismAnalysisof116adultswithASDandhistoryofpsychosisvsgroupofASDonlyvsgroupoffirstepisodePsychosisonly[fromAESOP]
ASDwithPsychosishadsignificantlyfewerlifetimerepetitiveorrestrictiveinterestsorbehavioursthanthosewithASDonly
LarsonetalBJPsych 2017
Somecasestudies
Planofworkshop◦ Whyisthisimportant◦ Theoriginsandevolutionofaconfusingdebate◦ Possiblereasonsbehindanoverlap◦ Somecaseexamples◦ Howdowediagnoseandtreat?
CanoneseparateASDfromSchiz orfromASD+Schiz?Hereandnowbehaviour diagnosticassessmentssuchasADOSalgorithmwillnotseparateASDfromSchizophreniawell.ButthequalityoftherapportandinteractionmayfeeldifferentAndRRBIisfeatureofASD.
Historywill◦ Howautisticbeforeage10◦ Wasthereafirstillness– ifsowhatlikebeforeandwhathappened?
CommentsofRaja2009◦ Motorclumsinessisnotfrequentlyobservedinschizophrenia.◦ Specificskillsandunusualandrestrictedinterestsarenotdescribedinschizophrenia.
◦ ViolenceinASDmoreoftentargetedatrelatives,unlikeinschizophrenia.
MistakingASDforpsychosisThoughtsexpressedsimplyandconcretelybysomeonewhohasdifficultyindescribinginternalsymptomscansoundverylikehallucinations.
Occasionally,averyvividaccountofeventsisheldconsistentlybutisplainlyfalse;theseperceptionsdonotseemtotroubletheindividualortobeassociatedwithanyfunctionalchange.Thereisthesensethattheindividualislivingina‘videoworld’,onlydetectableandcomprehensibleiftheinterviewerhasalsoseenthevideo.
Higharousalinadevelopmentaldisordercanproduceanacuteandtransientpsychoticstatewithhallucinationsandthoughtdisorder.
Incompleteanswerscansoundlikepsychoticsymptoms.Forexample,abaldreport,withoutelaborationorcontext,ofeverydayteasingcansoundlikepersecutorydelusions.
◦ TomBerney 2004
MistakingASDforpsychosisApragmaticdifficultyinappreciatingtheextentorlimitationsofsomeoneelse’sknowledgeofatopic,coupledwithatendencytoobsessionality,canresultinover-inclusive,irrelevantspeechthatmimicsthoughtdisorder.
Impassivityandalackofawarenessoftheemotionalclimatecanlooklikeinappropriateorbluntedaffect.
Thecatatonicsymptoms(e.g.oddmannerismsandpostures,freezingordifficultyininitiatingmovement)thatoccurinavarietyofneurologicalconditions,includingschizophrenia,canalsooccurinASD(Wing&Shah,2000).
Theslowandreluctantresponseofpatientsaskedtoperformataskthathasnomeaningforthemresemblesthenegativesymptomsofschizophrenia.
ASDscanshowimprovementwithneuroleptics (Campbelletal,1996).◦ TomBerney 2004
Thoughtdisorder?Mycollegeapplication+Irepeatedthefullfirstyeartwicehavingfailedthecoursework.+Wehaveinherenthighcapability,thereislittleyoucannotachieve,withtherelevantpermissions.+Ihaveneverrecoveredfromthelossoftheplaceatcollege,assuchmakingupforthedeficits,thatIattributedtoitsloss,growingintellectandevenwithinamentalinstitution.IfeltIhaveprovenmyselftomyselfandmypeergroupinthatenvironment,gainedconfidence,equality,learn't practicality.Thisequality- overcomeinferioritycomplex.Ihavelearnttoworkingroups,withthegroups-deficitforanAsperger.+ThisiswhatIneedtogetmylifebackontrack,takingtheharderpath,theonlythingthatabsorbsme,sharpeningmebackasatool,tomyformerself- mentalagility.ThemoreenergyIgettodirectthemorestableIam.
Whenisitadelusioninautism(orID)?Pointers◦ [Clearconsciousness]◦ HeldwithCertainty[arearemostbeliefsofpersonwithautism]◦ Fixed– absolutecertainty[mostpeoplewithautismwilldiscusstheirbeliefs]◦ Bizarre– [ifnon-bizarremightbeadelusionaldisorder][butchecknotlogicalforthepersonwithautism,giventheirunderstanding]
◦ Dominatingbehaviour adversely[makeyouwanttotreatit]
Butconsideralsoifitis:◦ Fantasy◦ Recall◦ Magicalthinking
Emotionalcommitmenttoitdoesnotseparateout.
TreatmentofPsychosisinASDConventionalneuroleptics.◦ Careofsideeffectintolerance◦ Aripiprazolefashionableduetolackofbloodtestsetc.[ifitworks]◦ Clozapinecanworkwell– powerfulanxiolytic.◦ ItmaybeCatatoniaandnotNMS
Practicalstructureandsupportworks◦ Theymayhaveproblemsseeingfutureplan◦ Dealwithlossofconfidence.
Nidotherapy isgoodforbothSchizophreniaandASD
Doconsiderreducingtheneuroleptics.◦ ButIrecognisethatverylowdoseneurolepticscanreducestressandbeprotective.
ConclusionIncreasingevidenceshowingadultswithASDmayhaveincreasedliabilityforpsychosis.◦ ThesearecommonlytransientstatesbutmaylastlongenoughtobelabelledSchizophrenia.
But...adultswithASDcanpresentfeaturesthatcanbemistakenforPsychosis(andviceversa).
Arewenotrecognising psychosisinASDenoughorarewetreatingitbutnotlabelingitasschizophrenia?
DoesthisaffecthowwedesignservicesforASD?OrforEarlyinterventionservices?