psychosis and autism spectrum disorder

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?