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PSYCHIATRIC CO-OCCURRENCE IN ADOLESCENTS & ADULTS WITH AUTISM

Derek Ott M.D., M.S.Associate Clinical Professor of PsychiatryDirector, Pediatric Neuropsychiatry ClinicUCLA David Geffen School of MedicineDivision of Child & Adolescent Psychiatry

Disclosures• Will be discussing “off-label” use of medications• Speaker Bureau-current

• Neos (Cotempla/Adzenys), Tris (Dyanavel), Shire (Vyvanse/Mydayis)• Lundbeck/Takeda) (Trintellex)• Allergan (Vraylar)• Genecept (Genomind)

• Advisory Board• Neos (Cotempla/Adzenys), Tris (Dyanavel/Quillivant), Shire (Vyvanse/Mydayis)

• Speaker Bureau-Past• Arbor (Aptensio), Novartis (Focalin XR/Ritalin LA/Focalin), Rhodes (Evekeo), Shire

(Intuniv), Shionogi (Kapvay)• Astra Zeneca (Seroquel), Bristol Meyers Squibb (Abilify), Janssen (Risperidone),

Novartis (Fanapt), Pfizer (Zoloft/Geodon) • Vaya (Vayarin/Vayacog)• Assure Rx

About me• Worked with individuals with developmental

disabilities/autism for almost 25 years• Variety of settings

• Private office, community office, hospital, group homes, residential facilities, locked facilities, locked forensic facilities

• UCLA Pediatric Neuropsychiatry Clinic• UCLA Westside Regional Center clinic• Lanterman Regional Center clinic• Consultant for other regional centers

• Clinical staffing at Westside regional center• Private practice-psychopharmacology

Objectives• Will discuss “behavior” in individuals with autism• Will discuss co-occurring psychiatric conditions including

important aspects of diagnostic assessment • Diagnoses will include ADHD, anxiety, OCD,

trauma/PTSD, mood disorders & psychosis.• Will also provide diagnostic assessment insights and

clinical pearls for treatment.

Credit: Keith Negley for Spectrum

Behavior

• Often used in many ways in the context of individuals with developmental issues

• Used by a parent, behaviorist, clinician• Need to understand what that term actually means by

the person using it• “that’s just a behavior”

What is behavior?• Per Merriam Webster

• The way in which one acts or behaves• The way something moves, functions, or reacts

• Ultimately behavior is communication

Causes of behaviors• Behavioral issues

• Acute vs chronic• Adaptive dysfunction

• Adjustment Disorder?, Anxiety• Symptoms of a comorbid psychiatric condition• Medical issues

• Medication side effects (new, chronic)

✳Often multiple causes/triggers

What is behavior?• Ultimately Behavior IS communication

• Chronic/learned/conditioned response• Chronic self-injurious behavior (SIB) as sensory

seeking/soothing• Adaptation to new environment or circumstance

• New onset SIB as a coping mechanism• Symptoms of a psychiatric issue

• New onset SIB as anxiety disorder/OCD• Medication side effects

• New onset SIB related to confusion, cognitive issues, etc.• Symptoms of medical issues

• New onset SIB related to gastrointestinal/pain issues

Medical causes of challenging behaviors• Medication issues

• Drug interactions• Side effects• Generics vs Brand

• Medical issues• General-allergies, cardiac• Gastrointestinal (GI)- reflux, pica, constipation• Pain• Hormonal• Sleep-insomnia, apnea• Neurologic-HA, seizures

• Often multiple causes

What is our target?• To date, there is no commonly used treatment shown to

specifically target “core symptoms” of ASD• Impairment in reciprocal social communication

• language• Restrictive repetitive patterns of behavior• Self-stimulatory behavior

• Need to identify and understand co-occurring symptoms• Evaluate for possible co-occurring psychiatric disorders

What is the target?

From McCracken and Gandal, Psychopharmacology of ASD, Oxford Press

Psychiatric comorbidity in intellectual /developmental disability(IDD)-diagnostic difficulties

• DSM relies primarily on self-report• Communication impairment /nonverbal

• Approximately 50% of individuals with autism are functionally nonverbal• Impairment of theory of mind + abstraction + executive functioning

• “cloak of competence” (Edgerton 1967)

• Tendency not to be forthcoming with descriptions of symptoms• “acquiescence bias”

• Trying to please the evaluator by answering falsely or in a manner that is inaccurate

• Symptoms of psychiatric disorders are often expressed differently (Sovner 1986)

• Baseline exaggeration, intellectual distortion, psychosocial masking, cognitive disintegration

“Diagnostic overshadowing”• =tendency to assess comorbid psychopathology in

persons with intellectual/developmental disability less accurately than persons without (Rice, Leviton + Szyszko (1982))

• Cognitive deficits/developmental presentation negatively impact clinician judgments about psychopathology

• May impact • Severity-Unusual/severe behavior considered artifact of IDD

• Severe SIB• Category-

• Withdrawn/asocial person with profound IDD >depressed• Severely impulsive/aggressive/violent person >psychotic

• Treatment-• Treatments, services and support are often tied directly to diagnoses

especially in community health systems(Jopp, Keys, diagnostic overshadowing reviewed and reconsidered, Am J MR, 2001)

Psychiatric issues in intellectual/development disability (IDD)

• Subjective assessment of the level of behavioral issues in the context of the overall biological, psychological, developmental and social profile.

• Critical to understand baseline functioning-behavior, skills, language, communication, daily living skills, overall functioning

• If these behaviors are of significant intensity and duration and associated with distress/impairment, the diagnosis of a psychiatric disorder may be warranted.• Based upon the diagnostic and statistical manual for mental disorders,

5th edition (DSM-5)• Difficulties extrapolating to those with intellectual

disability/neurologic issues• 2016 Diagnostic Manual-Intellectual Disability (DM-ID)

• Allows for the facilitated diagnosis of a full standard DSM psychopathology in individuals with IDD

Higher rates of psychiatric comorbidity in IDD

• ID• 4-7X more likely (Dykens 2000, Einfeld, Ellis, Emerson 2011, Emerson and Hatton 2007)

• Youth-10-39% (Borthwick-Duffy, 1994)

• 55% people with ID (13,466) have co-occurring psychiatric illness in the United States (National Core Indicators 2016)

• ASD• Youth-average 6.4 comorbid psychiatric diagnoses (Joshi et. al., 2010)

• Youth-10-44%-depression + anxiety (Leyfer, et. al., 2006)

• Adult- 6 comorbid lifetime psychiatric diagnoses (vs 3.5 psychiatric clinic sample), 3-current (vs 1.5) (Joshi et. al., 2013)

• Adult-structured clinical interview-60-70% depression + anxiety (Joshi et. al., 2013)

ADHD & Autism-diagnosis• With prior DSM’s, diagnosis of ADHD not permitted

• Concern that lack of response/awareness/attetion related to core ASD issues-deficits in language/communication/abstraction

• Previously the only psychiatric disorder which was excluded• Many clinicians with experience aware that it was possible/relevant

• With DSM-5, comorbid ADHD now allowed• Features

• Common in individuals with higher functioning autism/HFA• Can be present in those that are nonverbal• Often “forgotten” in individuals as they get older

• Perception that this is a childhood disorder• Often leads to excessive medication to address impulse control

ADHD & Autism-features• Some with autism can attend almost indefinitely to

thing/activities they find interesting/perseveration• Not just highly novel or sensory rich items (e.g. videogames)

• Other aspects of attention are also relevant for many• Not just “deficit”(e.g. can attend to things that are highly interesting

or novel (video games)• Distractibility, difficulty returning to previous topic/activity, difficulty

shifting attention, hyperfocusing• Inattention mostly apparent when requested to engage in

nonpreferred activities (i.e. school, homework, etc.)

ADHD & Autism-Rates• Neurotypical rates?

• Children/Adolescents• School-age kids-3-8%• Ages 4-17yo-9.5% (Pastor et. al., 2015) or 11% or 6.4 million US (parent

report) (Visser et. Al., 2014)

• >fairly common disorder• Adults

• 4.4%/10.5 million US (Howden, et. Al., 2010)

• >fairly common disorder• ASD

• Children• 29-73% (children)

• Adults• Current-42%/lifetime-68% (ASD specialty clinic) (Joshi, et. al., 2013)

• Suggest persistent of childhood onset disorder into adulthood (Joshi et. al., 2010)

ADHD & Autism-treatment• Treatment with appropriate medication can be quite

profound in terms of benefits with improvement of typical ADHD symptoms (inattention, hyperactivity, impulsivity) as well as anxiety, mood and other behavior.• Impulsivity and related mood reactivity/irritability are common

ADHD symptoms and frequent reason for psychiatric evaluation• Treatment of impulsivity can be greatly beneficial• ADHD treatments (stimulants, alpha agonist (guanfacine,

clonidine)) readily effective and fewer side

• Caution-psychostimulants can worsen anxiety and associated behaviors (repetitive behaviors, compulsions/ rituals, self stimulatory behaviors) in some

ADHD & Autism-treatment• Alpha agonists (guanfacine, clonidine)

• Address impulsivity/irritability, hyperactivity/restlessness> attention?• May also address anxiety in some/also don’t worsen• Clonidine for sleep, PTSD• Generally well tolerated-sedation possible

• Stimulants• Effects are rapid and readily apparent• Address attention more intensely vs Alpha’s• Side effects can be problematic

• Anxiety>increased self stimulatory behavior• Mood effects-irritability, depression• Appetite and weight effects

• Concern about abuse + diversion• Many without training/experience may not be comfortable

Anxiety & autism

• Anxiety/distress associated with ASD characteristics vary widely• Some experience debilitating fears/worries related to any change in

routine while others can be fairly flexible• Distress, worry and loneliness related to successful social interactions

while others are socially indifferent• Restricted interest & behaviors have positive significance for many but

others have a pressured and distressed quality• Repetitive behaviors/self-stimulatory/sensory seeking behaviors

• May occur at “baseline” (i.e. even when calm)• Can occur when bored, under duress, severely stressed, happy or excited• Change in frequency or intensity as marker for increased anxiety?

Anxiety & autism• Various types of anxiety are considered common

• Vary with age, autism severity, ID, verbal ability, comorbid conditions,

• Communication deficits/difficulties as frequent contributor• Conceptualization

• Universal consequence of ASD vs • comorbid anxiety disorder vs • unique manifestation of anxiety altered by co-occurrence

with ASD (Wood, Gadow 2010)

Anxiety & autism-rates• General-Child

• Reported rates-17-84% (Rumsey, Rapoport & Sceery, 1985)

• Child-39.6% > 1 DSM-IV Anxiety DO (Met analysis 31) (van Steensel et. al., 2011)

• Youth- 41.9%- 3 mo prevalence-any anxiety DO (Simonoff et. al., 2008)

• vs 1-12%-Neurotypical population estimated(Kessler et. al., 2012)

• General-Adult• Anxiety DO-current 27%, lifetime 42% (Hollocks et. al., 2017)

• Higher rates of lifetime >2 anxiety DO (ASD vs psychiatric clinic) (Joshi, et. al., 2013)

• Anxiety DO-62% w/ASD vs 38% w/o ASD (hospital inpts w/ MDD (Charcot et. al., 2008)

• Caution-Antipsychotic treatment- 80% w/ASD, 49% w/o ASD

Anxiety & autism-clinical insights• Often may manifest as somatic or physical symptoms

• Difficult for individuals with autism to understand internal states and experiences

• Poor understanding of internal states/sensations and relationship to environment/circumstances

• Headache, stomach ache, other body sensation/pains as main presenting symptom

• Many individuals not aware of the anxiety until it is severe• As a consequence anxiety can build up and then be quite intense

with associated behavioral consequences • > agitation, property destruction, aggression, SIB• Particularly relevant in nonverbal individuals where you have no

history or description

Anxiety & autism-specific diagnoses• Specific phobia

• Child-29% (van Steensel et. al., 2011), 8-63% (Rumsey, Rapoport & Sceery, 1985)

• Loud noises-10% (Leyfer, 2008) Not common in typical children

• Generalized anxiety disorder• Child-2-35% (Rumsey, Rapoport & Sceery, 1985)

• May not consistent with anxiety typical in ASD• More often a trait rather than state related /not vary over time

• Social anxiety/social phobia• Adult-current-40%, lifetime-56% (ASD vs psych clinic )(Joshi, et. al., 2013)

• Child-6-37% (Rumsey, Rapoport & Sceery, 1985)

• Less variability of common symptoms (e.g. social withdraw, preference for being alone, not speaking in social situations, gaze avoidance, staring, lack of emotional expression) in ASD

• Lack of interest in engagement in social situations and ASD

Obsessive-compulsive disorder & autism• Child-6-37% (Rumsey, Rapoport & Sceery, 1985), 17.4% (van Steensel et. al., 2011)

• Adult- 1.5-81% ID (Ghaziuddin et. al., 1992, Le Couteur, et. al., 1989, Muris, et. al., 1998)

• Overlapping symptoms/phenomenology as well as brain circuits• Difficult to distinguish perseverations + repetitive behaviors versus

obsessions + compulsions• Diagnosis

• Chronic vs new onset obsessions/perseverations, rituals/compulsions• Fixation with organization/symmetry, picking up small specks/debris

• Assessment of interests/fixations/obsessions & rituals/compulsions• Difficulty assessing in nonverbal or limited verbal individuals

• Need to rely observation of others• Obsessions-significant change/increase -rigidity, concern with

organization/symmetry, germs• Compulsions-touching, tapping, handwashing

Anxiety & autism-treatment• SSRIs

• Fluoxetine/Prozac, paroxetine/Paxil, sertraline/Zoloft, citalopram/Celexa, escitalopram/Lexapro, fluvoxamine/Luvox

• Buspirone/BuSpar• Benzodiazepines

• Lorazepam/Ativan, clonazepam/Klonopin, diazepam/Valium• Beta-blockers

• Propranolol/Inderal• Gabapentin/Neurontin• Atypical antipsychotics

• Risperidone/Risperdal, aripiprazole/Abilify, olanzapine/Zyprexa, quetiapine/Seroquel, ziprasidone/Geodon

Anxiety & autism-treatment• SSRIs


• Used to treatment depression, anxiety (generalized, panic, social anxiety, social phobia), OCD, PTSD (for associated anxiety + depression)

• Preferred treatment vs benzodiazepines

• Side effects• generally well tolerated• Common-transient-GI upset/changes + mild sleep change• Can cause activation >increased anxiety• Suicidality concerns in those <20 yo

Anxiety & autism-treatment• BuSpar

• Treatment for anxiety ONLY/no mood benefits• Lacks SSRI concerns- SI, potential for activation

• Benzodiazepines• Lorazepam/Ativan, clonazepam/Klonopin, diazepam/Valium• Work for acute treatment of anxiety• Concern about dependence, sedation, negative cognitive side

effects (i.e., slowing, memory issues,) abuse• Beta-blockers

• Propranolol/Inderal• Block the peripheral reaction to acute stress (i.e. increased heart

rate, palpitations, sweating, etc.)• Work well for performance /situational anxiety including social• Tolerability usually good other than very mild sedation

Anxiety & autism-treatment• Anticonvulsants

• Gabapentin/Neurontin-Limited data/Also help with sleep• Oxcarbazepine/Trileptal-limited data

• Atypical antipsychotics• Risperidone/Risperdal, aripiprazole/Abilify, olanzapine/ Zyprexa,

quetiapine/Seroquel, ziprasidone/Geodon• Some preferable (risperidone, quetiapine) -> anti-anxiety benefits• Akathisia (i.e. restlessness) >increased anxiety-aripiprazole

• Other antipsychotics• Chlorpromazine/Thorazine, Thioridazine/mellaril• Reduced potential for neurological side effects• Can work well for anxiety + agitation• Higher sedation for some

Trauma & autism• Trauma/traumatic events

• Event (series) that are experienced as threatening and that have immediate and/or lasting adverse effects on the individual’s function• Trauma for one person may not be for another depending upon the

individual’s understanding and reactions to the event• Psychological injury that harms or damages the individual• Acute versus chronic, mild versus major

• Posttraumatic stress disorder =PTSD• Specific set of traumatic symptoms (e.g. flashbacks, nightmares,

avoidance, memory lapses, emotional numbing) that persist for > 1 month after trauma

Trauma & autism• Youth ID/DD-1.5-3X maltreated (Hibbard and Desch, 2007, Reiter et. al., 2007)

• Poor social skills and understanding, communication issues • Numerous financial, psychological,other stressors associated with care

• Rates in ASD?• Believed to be higher vs neurotypical• 26%-some form of trauma (Youth Opt ASD clinic Istanbul) (Mehtar, Mukaddes, 2011)

• 67% exposed to traumatic events • 2x general pop > symptoms of posttraumatic stress

• PTSD often not included in studies of psychiatric comorbidity• 0-3% in one study of ASD youth (de Bruin et al., 2007, Storch et al., 2013)

Trauma & autism• Complex interaction between trauma + individual w/ ASD

• How is the situation understood (or not)?• Abstract thinking, theory of mind issues

• What is appraised as harmful or threatening?• Prior history of trauma?

• Symptoms may not be apparent in many at first• Nonverbal-behavior as communication• Chronic behavior not recognized as trauma related• Difficulty obtaining complete history including trauma

• Significant behavioral responses/reactions w/ triggers• Environments/situations/homes• People as triggers/reminders-family, staff, students, etc

• Shower example

Depression & autism-general• People with ID can be diagnosed w/ depression, present with many

of same symptoms (more literature vs ASD) (Tsiouris, Mann, et. al., 2003)

• Adults with ID features of depression similar typically developing children (Angold, 1988; Charlot, 2005)

• Aggressive/disruptive behavior manifestation of depression (Charlot et al., 1993)

• Common symptoms of depression (changes in sleep, concentration, facial expression, intonation, etc.) could be masked by pre-existing symptoms of ASD (Stewart et. al., 2006)

• Feelings of worthlessness or guilt may not be endorsed in ASD perhaps related to difficulties with self-report.

• Typical depressive symptoms in ASD have been observed including sadness, tearfulness, apathy, anhedonia

Depression & autism-general

• More specific or common depressive symptoms in ASD? • increased irritability/agitation, social withdraw, compulsive

behavior or change of obsessions (more morbid tone)• Suggested that symptoms of anhedonia, crying spells,

weight loss and poor sleep might be accompanied by aggressive behavior in individuals with depression in ASD

• For lower functioning individuals-increased self injury + regression of adaptive skills (Magnuson & Constantino, 2011)

• Characteristic ritualistic and repetitive behaviors may intensify with the onset of acute mood episode (Ghzaiuddin et. al., 2002)

Depression & autism-general

• Depression likely substantially underdiagnosed in individuals with autism (Lainhart & Folstein, 1994) especially with comorbid ID (Sovner & Hurley, 1983)

• BUT likely fairly common/most common psychiatric DO• 30-40%-clinically referred adolescents/adults w/ ASD (Ghzaiuddin et. al., 2002)

• 20-35%-clinical studies treatment seeking adults (Mazefsky et. al., 2008, Gotham et. al, 2015)

• 31% current-31%, 77%-lifetime-ASD adult clinic (Joshi et. al., 2013)

• 4X rate-meta-analysis-children, adolescents, adults-(Hudson, et. al., 2018)

• Higher rates with higher IQ individuals (Hudson, et. al., 2018)

• 10%-MDD, 13.8%-sub syndromal depression-NIH child study (Leyfer, et. al, 2006)

• Elevated risk for depression among first-degree relatives of probands with ASD suggest possible genetic link (Bolton, Pickles, Murphy, Rutter 1998)

Depression & autism-treatment• SSRI’s


• SNRI’s• Venlafaxine/Effexor (ER), Desvenlafaxine/Pristiq,

Duloxetine/Cymbalta (pain), levomilnacipran/Fetzima• Other antidepressants

• Bupropion/Welbutrin (XL/SR) (attention/addiction), nefazodone/Serzone, vortioxetine/Trintellex, mirtazapine/Remeron (sleep + appetite), Deseryl/trazodone (sleep)

• Other/alternative• Omega-3’s-relevant for milder depression/very few side effects

Depression & autism-treatment• SSRI’s


• Used to treatment depression, anxiety (generalized, panic, social anxiety, social phobia), OCD, PTSD (for associated anxiety + depression)• May treat more than one disorder simultaneously

• Generally first choice because of improved tolerability• Some can be more activating >anxiety + agitation

• More problematic in lower functioning individuals (not report)• SNRI’s

• More complicated pharmacologically (i.e. impact more than one neurotransmitter at a time)

• Effect on norepinephrine + dopamine >activation potential

Autism & bipolar• Bipolar disorder-state-dependent illness

• Distinct episodes of depression & mania/hypomania• Not just consistent with rapid changes of mood (“mood swings”)

• Emotions of individuals with autism tend to be quite reactive, poorly modulated and change minute to minute with what is happening in their environment

• May be difficult to distinguish symptoms in context of ASD• Inappropriate affect, laughter• Excitability versus elated or elevated mood• Chronic sexual behavior versus hypersexual• Chronic sleep disturbance versus sleeplessness

Autism & bipolar-treatment-mood stabilizers• Mood stabilizers

• Treat acute mania/hypomania & prevent further episodes• May also prevent further episodes of depression• Also many work well for impulse control

• Traditional mood stabilizers• Lithium/Lithobid• Divalproex/Depakote • Carbamazepine/Tegretol• Oxcarbazepine/Trileptal• Lamotrigine/Lamictal

• Other mood stabilizers-Atypical antipsychotics

Autism & bipolar-treatment-mood stabilizers• Lithium-blood work required

• Tremor, cognitive side effects• Toxicity risk-higher-nausea, vomiting, ataxia• Long-term-kidney/renal, thyroid

• Divalproex/Depakote-blood work required• Tremor, weight gain• Concern-liver function, pancreatitis

• Carbamazepine/Tegretol-blood work required• Tremor-milder• Concern-sodium alterations

• Oxcarbazepine/Trileptal• Tremor-milder

• Lamotrigine/Lamictal• Generally very well-tolerated/no blood work

Psychosis & autism-history• ASD & Schizophrenia (spectrum disorders (SSD))

• Bleuler (1950) viewed autism as central feature of schizophrenia while others viewed it as the childhood onset of the disorder (Bender 1947)

• Autism used interchangeably with schizophrenia until the 1970s when proposed as distinct disorders (Rutter 1972, Kolvin 1971).

• Conceptualized as separate illnesses with DSM-5• SSD-typical adolescent onset with prominent psychotic

symptoms• ASD deficits in social interaction, communication behavior

noted in early childhood

Psychosis & autism-features-similarities• Despite this clear diagnostic distinction, many

similarities/overlap-features/symptoms, impairments, neuroanatomy, & genetics

• Both conceptualized as spectrum (phenotypic continua)

• Similar deficits for both in• Social interaction & communication• Theory of mind & mentalization• Neurocognitive + social cognitive functioning • Lack of emotional reciprocity in ASD similar to blunted

affect in SSD• Delay/lack of speech development in ASD similar to

poverty of speech in SSD•

Psychosis & autism-features• Positive psychotic experience not included in diagnostic

criteria for ASD for BUT Evidence that these experiences occur at elevated rates in ASD populations (Barneveld et. al., 2011, Bevan Jones et. al., 2012)

• 35% in one ASD sample >1 positive symptom (Konstantareas, Hewitt, 2011)

• Core features such as circumscribed interest, resistance to change, abnormal response to stimuli are not included in diagnostic criteria for SSD but are often present

• Severe or unusual or bizarre or impulsive or violent behavior IS NOT necessarily psychosis or psychotic• Lack of understanding of ASD can lead to diagnosis of psychosis

when not warranted

Psychosis & autism-rates• Genetic & neuroanatomical overlap (Carroll& Owen 2009, Cheung et. al 2010)

• Both ASD + SSD-1% of the population (Brugha et. al., 2011, CDC 2012, Van Oset. al., 2001)

• In ASD ->comorbid SSD-0-34.8%• Mean incidence of 12.8% in larger studies (Billsedt et. al., 2005, Davidson et. al., 2014,

Hofvander et. al., 2009)

• In SSD->comorbid ASD-3.6-60%• SSD < 18 yo-18-56%• Childhood onset schizophrenia-comorbid ASD-30-50% (Rappaport et. al, 2009)

• Mean incidence of 3.6% in larger study (Davidson et. al., 2014)

Psychosis & autism-diagnosis• Critical to understand baseline functioning

• Level of functioning-cognitive, social, language, skills• Self-stimulatory behavior (form, frequency, intensity)• Self talk• Other common behaviors

• With complete understanding a baseline functioning can distinguish what is new or different • New symptoms may represent onset of new psychotic

disorder/psychosis• Reality testing for many with ASD may be impaired

• Associated difficulties with abstract logical and social thinking• “interpersonal paranoia”=that person is being mean to me or

doing things to get me in trouble • Preoccupation with certain things/topics not based in reality

• Ghosts, spirits, monsters, other creatures, aliens

Psychosis & autism-diagnosis• Self talk

• Common for many with ASD/IDD• Form of echolalia• Related to perseverations/scripting• Recall of past events/difficulties/trauma• help “talk through things”

• Difficult tasks, social activities• Way to organize or soothe self especially when anxious

•

Psychosis & autism-diagnosis• Triggers > impact reality testing

• Medications-stimulants, benzodiazepines, anticonvulsants, etc.

• Medical issues-illness, sleep deprivation seizures, head injury

• Significant stress, duress, trauma• (micro) psychotic episodes

• Ability to accurately determine reality can shift especially in the context of significant stress/duress

• Such episodes can be relatively brief or temporary and decreased when stress trigger is reduced/eliminated

Psychosis & autism-diagnosis• Frequent/intense impairment of reality testing >psychosis

• Typical psychotic symptoms• disorganized/illogical thinking/speech• delusions including paranoia• hallucinations (auditory + visual).

• Loss of skills or regression or changes in behavior• Social withdrawal• Symptoms similar to depression-lack of enjoyment or interest in activities

• Inability to complete typical daily activities• Lower functioning individuals-enuresis, catatonia

Psychosis & autism-diagnosis• Individuals who are lower functioning may lack insight • Need to elicit information/feedback from family/care

provider/staff.• Patients appear as if responding to something (i.e.

hallucinations or internal stimuli) • Appear internally preoccupied• Appears more like a conversation

• Especially if loud or anger with cursing• Inappropriate or spontaneous laughter• Slow or no response• Turning around as if hearing things or grabbing things

from the air

Psychosis & autism-clinical perspectivesIn verbal individuals-progression to psychosis• Fixation with cartoons >intense scripting of cartoon content

>seduction by cartoon world (hallucinations + delusions)• Fixation with cartoon character >reciting of

dialogue>pretending as if character or responding to character verbally or behaviorally (hallucinations+ delusions)

• Fixation with celebrity >desire to develop a relationship with this person >belief that they do have a relationship (delusions)

• Fixation with eating a certain way >concerned that food is poisoned (delusions)

• Difficulty with one particular person >difficulty with anyone (delusion/paranoia)

• Sudden appearance of monsters, animals, etc.(hallucinations)

Psychosis & autism-treatment• Reducing anxiety may help psychotic symptoms

• SSRI-Prozac, Paxil, Zoloft, etc.• Benzodiazepines-lorazepam, clonazepam, alprazolam• Other interventions-behavioral therapy, individual

therapy, changing the environment (e.g. residence, day program, school, etc.)

• Direct treatment of psychosis-antipsychotic• Carefully considered given potential side effects• Duration of treatment-limited information and research

available

Psychosis & autism-treatment• Atypical antipsychotics

• Risperidone/Risperdal(ODT/IM-Consta), aripiprazole/Abilify(IM/ODT), olanzapine/ Zyprexa(ODT/IM), quetiapine/Seroquel, ziprasidone/Geodon, paliperidone/Invega (Sustenna+ Trinza)

• Dopamine Partial agonists- aripiprazole/Abilify, brexripiprazole/ rexulti, cariprazine/Vraylar

• Clozapine/Clozaril• Iloperidone/fanapt, asenapine/Saphris(SL)

• Typical antipsychotics• Haloperidol/Haldol (IM)• chlorpromazine/Thorazine, Thioridazine/mellaril

Psychosis & autism-antipsychotics-side effects• Antipsychotics very effective for many symptoms/conditions

• Psychosis-schizophrenia, schizoaffective disorder• Mood stabilization/acute treatment of mania• Major depression-augmentation-abilify, Seroquel• Treatment of depression in Bipolar disorder• Anxiety, agitation, violence, impulse control

• Benefits may be somewhat nonspecific• Many may continue to receive these medications for years

with no clear indication or previous symptom/condition no longer relevant

Psychosis & autism-antipsychotics-side effects• Side effects need to be monitored and understood• Metabolic-

• weight gain-can be significant-5-40 pounds• Changes in lipids + cholesterol• Create additional metabolic problems in susceptible individuals

• Neurologic side effects• Especially problematic for those who are nonverbal• Akathisia= restlessness which can be quite intense

• Can create anxiety, agitation• Dystonia= muscle stiffness• Tremor• Tardive dyskinesia= slow development of abnormal movements

• Related to drug, dose, duration of treatment• Often occur in the mouth/face but also in limbs• May be irreversible, further stigmatizing

•

Autism & Psychopathology-Summary• ”Behavior” as communication• Individuals with ASD are susceptible to behavioral

changes related to many factors including medical issues, medication issues, adaptive dysfunction, and psychiatric issues/disorders.

• Rates of psychiatric disorders in general and specific psychiatric disorders are higher for several psychiatric disorders as compared to neurotypical populations.

Autism & Psychopathology-Summary• Although the process is different and sometimes

complicated, diagnosis of psychiatric disorders in individuals with ASD is possible.• Presentation may be somewhat atypical• Lack of verbal reporting• Regression of behavior as initial presenting feature

• Common psychiatric disorders in neurotypical individuals remain common in those with ASD• Anxiety disorders +Depression+ ADHD>>OCD, BAD, Psychosis

Autism & Psychopathology-Summary• Treatment of psychiatric symptoms/disorders should be

carefully considered• Treatment algorithms should be hypothesis based and re-

evaluated periodically• Go slow with medication treatment but go

Thank you

Maladaptive behavior in autism

• As many as 40% of individuals with developmental disability may experience a period of disturbed behavior/function at some point in their lives

• Sudden change in behavior/functioning should prompt medical or clinical evaluation to identified any treatable medical causes

• Need to understand prior baseline behavior• Need to coordinate with other providers such as neurologist,

internist, pediatrician, behaviorist, therapist, etc.

Adaptive dysfunction

• Mismatch between needs, abilities, goals of individual and environment/circumstances/expectations• Parents/care providers/staff make assumptions about the

abilities of the individual which creates stress/duress/anxiety

• Can occur in home, other residents, school, day program• Often occurs with changes in parents/care providers,

health-illness/pregnancy/death of care providers, other people around the individual (i.e. staff, students, residents, etc.), schedule (i.e. home, school, day program, residents), etc.

• Anniversary reactions-death of family members or other people that were close, holidays

Determining psychiatric comorbidity in IDD• Inherent difficulties/variable results in literature of psychiatric

comorbidity• Who is in the sample?• What tools are used to assess for ID/ASD?• How are psychiatric disorders defined and classified?• Who is included or excluded?

• “challenging behavior”• biomedical conditions as potential contributing/ideological factors

• What is the training and expertise of those who were conducting the evaluations?

• Despite all of this issues, studies have indicated that rates of psychiatric disorders are higher for those with ASD as compared to neurotypical populations

Difficulties in Diagnosing Comorbidity• Diagnostic concordance/agreement

• Mental health clinician report vs “adapted-for-ASD” version of the Mini-International Neuropsychiatric Interview (MINI)(parent version) for children with ASD (Stadnick et. al., 2016).

• 26% vs 78% for ADHD• 17% vs 57% for disruptive behavior disorders,• 23% vs 57% for anxiety disorders• 11% vs 31% for mood disorders

• Diagnostic concordance/confusion• Semi-structured interview of youth with ASD (Mazefsky et. al., 2012)

• Approximately 60% of prior psychiatric diagnoses were not supported using Autism Comorbidity Interview

• Lowest diagnostic concordance was for prior BAD+OCD• While 51% of children met ACI criteria for at least 1 psychiatric disorder,

rates of prior diagnoses were much higher• 77% having at least 1 prior psychiatric diagnosis and 60% >2

Comorbid psychiatric disorders in children with autism: interview development & rates of disorders, Leyfer, 2006Children-5-17 (109) with autism-ADI + ADOS + DSM-IV-TR/verbal or IQ >65Autism comorbidity interview-present & lifetime version/Modified Kiddie Schedule for Affective Disorders & Schizophrenia (KSADS)

Lifetime prevalence of psychiatric disorders in children with autism

Comorbid psychiatric disorders in children with autism: interview development & rates of disorders, Leyfer, 2006Children-5-17 (109) with autism-ADI + ADOS + DSM-IV-TR/verbal or IQ >65Autism comorbidity interview-present & lifetime version(ACI)/Modified Kiddie Schedule for Affective Disorders & Schizophrenia (KSADS)

Lifetime prevalence of psychiatric disorders in children with autism

ASD, a Psychiatric Disorder, or Both? Psychiatric Diagnoses inAdolescents with High-Functioning ASD, Mazefsky, J Clin Child Adolesc Psychol 2012(35 verbal 10-17-year-old, confirmed ASD without ID)

Psychiatric Diagnoses in Adolescents w High functioning Autism–Autism Comorbidity Interview (ACI) vs Prior Diagnosis History

Psychiatric comorbidities in psychiatrically referred adults w/ & w/o ASD

Psychiatric Comorbidity and Functioning in a Clinically ReferredPopulation of Adults with Autism Spectrum Disorders: A Comparative Study, Joshi, et. al., J Aut Dev Disord, 2013/ Adults referred to a special ambulatory program for ASD (63)vs referrals to a psychopharmacology program at academic center/structured clinical interview (DSM-IV) + KSADS



