mental illness in adults with autism spectrum disorder martyn matthews preliminary results of a...
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Mental Illness in Adults with Autism Spectrum Disorder
Martyn Matthews
Preliminary results of a study of comorbidity
What we know so far
Around 90% of ASD research is about children
Most adult ASD research is about problem behaviour
A few studies have identified that adult outcomes are negatively influenced by mental health problems (Howlin 2009)
Very little research has looked at the mental health of adults with ASD
Confusion Conflict
What are core features of ASD vs. comorbid disorders?
How can we make a clear assessment or diagnosis (tools & knowledge)
whether the usual treatment/intervention work for people with ASD
Who should Who should provide or pay for provide or pay for servicesservices
Getting access to Getting access to inpatient mental inpatient mental health services health services (getting past the (getting past the gatekeeper)gatekeeper)
Behaviour of Behaviour of people with ASD in people with ASD in mental health mental health settingssettings
So what does the evidence tell us?
Anxiety Disorders• Anxiety seems to be a key feature
of ASD, but we don’t have strong research evidence for this notion
• But, case study evidence suggests a 100% prevalence!
However,
Only one well designed prevalence study has been done by Szatmari et al (2000).
• 13.6% ( 8 out of a group of 59 teenagers with AS or HFA) had anxiety at a level that met DSM IV diagnostic criteria.
• Rates for general population are 3-5%
DSM IV Generalised Anxiety Disorder
A. At least 6 months of "excessive anxiety and worry" about a variety of events and situations. Generally, "excessive" can be interpreted as more than would be expected for a particular situation or event. Most people become anxious over certain things, but the intensity of the anxiety typically corresponds to the situation.
B. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met.
C. The presence for most days over the previous six months of 3 or more (only 1 for children) of the following symptoms: 1. Feeling wound-up, tense, or restless2. Easily becoming fatigued or worn-out3. Concentration problems4. Irritability5. Significant tension in muscles6. Difficulty with sleep
D. The symptoms are not part of another mental disorder.
E. The symptoms cause "clinically significant distress" or problems functioning in daily life. "Clinically significant" is the part that relies on the perspective of the treatment provider. Some people can have many of the aforementioned symptoms and cope with them well enough to maintain a high level of functioning.
F. The condition is not due to a substance or medical issue
Possible implications
It is extremely hard to differentiate between ASD symptoms and an anxiety disorder
Low level, generalised anxiety may be a key feature of ASD (85-90%), though this may not be ‘anxiety’ as we currently understand it
In some individuals it is a diagnosable comorbid disorder (10-15%)
More able people with ASD have higher levels of anxiety (may just be ability to report symptoms)
Mood Disorders
DepressionCase study and clinic population studies indicate that adults with ASD are much more likely to experience depression than the general population:
• Sterling et al (2007), 20/46 (43%) of adults with Sterling et al (2007), 20/46 (43%) of adults with ASD had symptoms that would meet DSM IV ASD had symptoms that would meet DSM IV criteria for depressioncriteria for depression
• Wing (1984), 10/34 (29%) of young adults with Wing (1984), 10/34 (29%) of young adults with AS had diagnosable depressionAS had diagnosable depression
Rates for general population are 6.8% (NCS-R, 2001)
Depression & co-existing disorders
Q. In the general population, depression is frequently comorbid with an additional disorder, so is this also true for people with ASD?
A. It looks likely, case study descriptions suggest that:As depression worsens, stereotypic or ritualistic As depression worsens, stereotypic or ritualistic behaviour increase to meet OCD diagnostic behaviour increase to meet OCD diagnostic criteriacriteria
OrRestlessness and hyperactivity increase to Restlessness and hyperactivity increase to meet ADHD diagnostic criteriameet ADHD diagnostic criteria
Gahaziudin M, Gahaziudin N, Greden J (2002)Gahaziudin M, Gahaziudin N, Greden J (2002)
Psychosis
Catatonia has highest prevalence rates of psychotic disorders in adults with ASD.
• Billstedt & Gilberg (2005) 12%(10 of 120)
• Wing & Shah (2000) 17%(86 of 506)
Psychosis
Psychotic disorders are rare in people with ASD, despite the fact that autism used to be classified as a psychotic disorder
Schizophrenia is very rarely diagnosed.• Billstedt & Gillberg (2005) identified 1 individual from a sample of 120 Billstedt & Gillberg (2005) identified 1 individual from a sample of 120
adults with ASD adults with ASD • Volkmar & Cohen (1991) identified 1 adult from a sample of 163 Volkmar & Cohen (1991) identified 1 adult from a sample of 163
adolescents & adults with ASDadolescents & adults with ASD
Prevalence rate is the same as general population (0.4-0.6%)
Psychosis
Catatonia DSM IV criteria motor immobility as evidenced by catalepsy
(including waxy flexibility) or stupor; excessive motor activity (purposeless, not influenced
by external stimuli); extreme negativism (motiveless resistance to all
instructions or maintenance of a rigid posture against attempts to be moved) or mutism;
peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
echolalia or echopraxia
What we know about mental illness in people with ASD, is still “not a lot”
What we do know relates mostly to people who are usually described as high functioning
Almost nothing about the ‘inner world’ of people with ASD and severe intellectual disability
SoSo what do we really know?
Some Solutions
More research! Use screening tools to identify
undiagnosed disorders Train support workers to observe for
and record information relating directly to mental health of the individual
Provide training to mental health services around ASD
Otago Study
Based in Department of Psychological Medicine, University of Otago.
ResearchersMartyn MatthewsDr Kumari FernandoDr Brigit Mirfin-Veitch
Aims of study
To identify the range of psychiatric disorders experienced by a sample of people with ASD
Examine similarities/differences in types of disorder experienced by ID vs Non-ID adults with ASD
To compare range and rate of disorders with ID only and general population studies
Identify effective treatments & support strategies Identify service gaps & future needs
Method
Review of service provider & DHB files for individual clinical/diagnostic data
Completion of screening tool with key support agent for ID and ID/ASD groups
Questionnaire to clinicians gathering data on ASD/no ID group and treatment issues
Qualitative interviews re experiences of treatment & support services
Psychiatric Screening Process & Tools
The REISS Screen for Maladaptive Behaviour (Reiss S, 1988, revised 2009)
The ASD-A (Autism Spectrum Disorder Battery-Adult Version), (Matson, J,Terlonge, C & Gonzalez M, 2006)
Characteristics
10 adults with ID & ASD
80% male All have 24 hr support 90% take one or more psychoactive medication 7 people have severe or profound intellectual
disability 3 have mild to moderate intellectual disability 9 have formal diagnosis of Autistic Disorder 1 has no formal diagnosis, but meets DSM IV
criteria for Pervasive Developmental Disorder-Not Otherwise Specified
Results
70% of the group had clinically significant scores for anxiety
60% displayed self injurious behaviour
50% had Conduct Problems 40% showed symptoms of
depression 30% had clinically significant
impulsivity or hyperactivity
Overall ASD-CA Scores
ASD-CA Comorbidity Scores
0123456789
Anxi
ety
Con
duct
Prob
lem
s
Beha
viou
ral
Exce
ss/Ir
ritab
ilit
y
Hyp
erac
tivity
Dep
ress
ion
Shaun
Garth
Kenny
Bede
Natalie
Brian
Vince
Rachel
Wilf
Dan
MeanScores(Otago)Clinical Cut-off
Mean Scores on ASD-A
ASD-A Mean Scores for ASD/ID Group
0
1
2
3
4
5
6
Anxiety
Conduct Problems
Behavioural Excess/Irritability
Hyperactivity
Depression
Mean Scores(Otago)
Mean Scores(Louisiana)
Clinical Cut-off
Mean Scores on REISS Screen
REISS Comorbidity Mean Scores: ASD/ID group
0
1
2
3
4
5
6
Aggre
ssive
Beh
avio
ur
Psych
osis
Paran
oia
Depre
ssio
n (B
eh)
Depre
ssio
n (p
hys)
PD Dep
ende
nt
PD Avo
idan
t
Mean Scores(Otago)
Mean Scores(Chicago)
Clinical Cutoff
RachelASD-CA comorbidity: Rachel
01234
56789
Anxiet
y
Condu
ct P
roble
ms
Behav
iour
al Exc
ess/
Irrita
bility
Hyper
activ
ity
Depre
ssion
Mean Scores
Rachel
Clinical Cut-off
REISS Comorbidity scores: Rachel
0123456789
Mean Scores(Otago)
Rachel
Clinical Cutoff
BrianASD-CA comorbidity: Brian
0
1
2
3
4
5
6
7
Anxiet
y
Conduc
t Pro
blems
Behav
iour
al Exc
ess/I
rrita
bility
Hyper
activ
ity
Depre
ssion
Brian
Mean Scores (Otago)
Clinical Cut-off
Reiss Comorbidity Scores: Brian
0
1
2
3
4
5
6
7
8
Aggre
ssive
Beh
aviou
r
Psych
osis
Paran
oia
Depre
ssion
(Beh
)
Depre
ssion
(phy
s)
PD Dep
ende
nt
PD Avo
idan
t
Brian
Mean Scores (Otago)
Clinical Cutoff
Discussion
70% had clinically significant scores for one or more additional disorder
High rates of anxiety and depression found across both screening tools.
Severe challenging behaviours were also highly prevalent in the group (60%).
Results indicate that additional psychiatric problems may have a major influence on the behaviour of adults with ASD
Screening Tools:
Both screening tools are straightforward to use
Results are useful in identifying the need for targeted psychiatric treatment.
The ASD-A Screen shows particular promise in the assessment of anxiety, depression and behavioural disorders.