BRAIN & MINDRESEARCHINSTITUTE

On being socially aware: Implications for adolescents with mental health problems

ASSOCIATE PROFESSOR ADAM GUASTELLA Autism Clinic for Translational Research (ACTr) | Brain & Mind Research Institute

adam.guastella@sydney.edu.au

Benefits of social relationships

• resilience to the negative effects of life stressors

• greater career achievement, and fewer financial problems

• higher self-ratings of health and well-being,

• lower rates of diagnosed psychological disorder

• fewer diagnosable health problems

• Improved immune response

• improved coping with major illnesses

• greater life expectancy

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Social Development

Attachment and Social Synchrony in Early Life

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Feldman, 2015, Developmental Psychopathology

Rilling and Young, 2014, Science

› Communication style, physiological synchrony, and empathy predicts romantic relationship stability (Gottmans work; Feldman, 2014)

› Growing evidence that responsivity and awareness of others (e.g., emotional intelligence) predicts a range of functional outcomes in adulthood

› Ability to understand more complex emotions and social situations improves at least into late puberty (Lawrence, Campbell and Skuse, 2015)

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Excessive stress and arousal Social anxiety typically emerges in adolescents and young adulthood-primarily driven by stress and misinterpretation of social valence

NeurodevelopmentalPsychosis and social withdrawal emerges in adolescents and young adulthood-

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Adolescents

Social Anxiety

Persistent fear of one or more social situations

Fear of negative evaluation: embarrassment, humiliation

Fear is excessive and causes impairment

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Adolescents

› Youth onset disorder (usually between 12 and 25)

- Timing from childhood to adolescence may have more to do with role changes

› 1 in 20 young Australians in any 12-month period

› Many more report social disability

› Persistence greater than any other anxiety disorder

Trajectory

› Social anxiety / initial shyness

› Difficulty at school and social settings

› Gradual increase of withdrawal and stress

› Later onset of depression, substance misuse, deviant behaviour, and other anxiety problems

Social Anxiety in Youth

Social withdrawal presents as a significant risk factor for progression to other mental health problems

Increases the risks of future mood disorder from 40% to 85% (Duffy et al., 2010)

10% of mood disorders could be prevented by the early intervention of SAD (Beesdo et al., 2007).

60% of substance misuse could be prevented by earlier treatment of common mental health problems, including SAD (Kendell et al., 2002).

The Critical Transition: 16-25

› Poorer educational and work outcomes

- Unemployment and disability

- Progression

› Lower rates of satisfaction with peers/ relationships

› Self-esteem

› Burden of Social Anxiety >= Schizophrenia

› Anxiety- Disables flexible goal directed and controlled / reflective thinking

- Decisions rely more on habits and reflexes. (escape, immediate reward)

Two separable decision making processes

• one mediating controlling flexible goal-directed behaviour (R-O)

• one mediating habitual actions (S-R)

• Reliance on habitual modes of action characteristic of anxious states(Alvares, Bellaine, & Guastella, 2014, Plos One, 2015 Autism Research)

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The fear circuits

› Anxiety- Reduction in goal directed behaviour (Alvares, Bellaine, & Guastella, 2014, Plos One, 2015

Autism Research)

- Attention biases to threat and reductions in automatic processing of positive cues (Chen et al., 2,013 2104, 2015)

- When intervene to manipulate these circuits the ability to shift on experimental tasks predicts symptoms and CBT response.

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The fear circuits

Fear Circuitry Disorders

Pre-existing Sensitivity(gene + environment)

Learning of Fear

Consolidation of FearHours – days following event

Expression of FearMemories, Nightmares, FlashbacksAvoidance, Sympathetic Response, Startle

ExtinctionDiminished response to cuesOver time

GeneralizationRecruitment of Non-associatedcues

ASensitizationIncreased FearWith repeatedexposure

DiscriminationFear is limited to specifictrauma cue

Social anxietyPanic PTSD

+ - recovery

Brain development

Prefrontal cortex maturation

extends into the third decade impulse controlplanningemotional regulation

› Youth typically have much greater number of systems (schools, families, peers, social groups and potential for mentoring)

› Greater control to manipulate the environment

› Brains are developing

› Peer groups are abundent

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But there are many advantages

› Difficulty mentalising, completing complex tasks

› Engaging in more independent and less structured social situations

› Neurodevelopmental pathways to social de-synchrony

- Autism and Psychosis

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Vulnerability emerges in Neurodevelopment

Autism: A disorder of social dysfunction

Qualitative impairment in social interaction

(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

(b) failure to develop peer relationships appropriate to developmental level(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other peo(d) lack of social or emotional reciprocity

Qualitative impairments in communication

(a) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

Various snesory sensitivities; repitive behjaviour`

Autism Spectrum Disorders (ASD) Diagnostic Criteria

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Qualitative impairment in social interaction and social

communication

Restricted, repetitive and stereotypic patterns of behaviour

Executive Function deficits• impairment in cognitive flexibility• planning• Initiating, shifting and monitoring• fluid reasoning• behavioural regulation• emotional control• vigilance

Demetriou et al., 2015

Rationale for this Study

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Aim

Review the evidence for executive dysfunction in

Autism Spectrum Disorders (ASD)

Objectives• Assess overall effect of

executive dysfunction• Identify executive dysfunction

domains that differentiate between ASD and control groups

Executive Function Domains

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Executive Functions

Cognitive Flexibility

Set Shifting

Working MemoryPlanning

Response Inhibition

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Methodology

PsychInfo

Assessed for eligibility880

Included for qualitative analysis

261

Did not meet inclusion criteria

619

Included for quantitative analysis

152 studies

Excluded due to insufficient data

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• Systematic literature review using search terms related to autism and executive function domains

• Period from 1980 until December 2014

Embase/Medline

Statistical Analysis

EF Domain Number ofStudies

Effect SizeHedges’s g

I2 P

OverallAnalysis

151 Moderate(0.59)

72.90% <0.001

Cognitive Flexibility

60 Large(0.78)

82.96% <0.001

Planning 43 Large(0.64)

66.84% <0.001

Response Inhibition

66 Moderate(0.56)

68.22% <0.001

Set Shifting 64 Large(0.67)

79.58% <0.001

Working Memory

47 Moderate(0.49)

76.82% <0.001

Random Effects Model

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Statistical Analysis

Moderator No of Studies

Effect SizeHedges’s g

Pbetween Comment

AgeChildren<14

Youth>14<18

Adults>18

78

9

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Moderate to Large (0.63)

(p<0.001)

Large (1.14)

(p<0.001)

Moderate (0.47)

(p<0.001)

0.05 Significant differences in effect size between age groups

Most pronounced effect size observed in Youth group suggesting a critical period for executive function?

GenderMixed

Females

Males

117

3

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Large (0.61)

p<0.001)

Small(0.38),

(p=0.06)

Moderate(0.56)

( 0 001)

0.52 Gender differences in effect sizes approached significance, small number of studies with females.

Moderator Analysis

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› 1423 significant (psychosis spectrum) and 898 limited (psychosis limited).

› They had no comorbid medical conditions.

› Compared with

- 981 participants endorsing significant other psychiatric symptoms

- 1963 typically developing children with no psychiatric or medical disorders.

- Age 8 - 21

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Neuro-psychological tests

› executive (abstraction and mental flexibility, attention, working memory)

› episodic memory (words, faces, shapes),› complex cognition (verbal reasoning, nonverbal reasoning, spatial processing),

› social cognition (emotion identification and intensity differentiation, age differentiation),

› sensorimotor speed (motor, sensorimotor).

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Results

› Psychotic illness was associated with general decline in functioning.

› Average of one year behind peers

› Complex cognition and social cognition lags most pronounced

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Social Cognition

The mental operations that underlie social interactions, including perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviours of others

(NIMH workgroup).

We constantly make judgments about ourselves and other people. We want to know the reasons why people do things, we want to know what other people are like, we want to know what we are like.

Social Cognition

Social Cognition

John walks quickly into his bedroom. He scans the top of his dresser. He pulls out his dresser drawers and rummages around inside. He crinkles his brow and scratches his head. He looks around the rest of his room. He shakes his head from side to side. He

pats his trouser pockets. He reaches inside his trouser pockets and pulls his hands out empty. He shakes his head from side to side again. He puts his hands on his hips

and sighs. He stomps out of the room and rushes down the stairs.

Social Cognition

John was looking for something he wanted to find (perhaps his keys). He was puzzled. He thought he had left what he wanted in his bedroom. He doesn’t know where to find what he wants. He

is frustrated.

Social cognition deficits predicts social disabilityAddington et al., 2008; Losh et al., Archives of General Psychiatry ; Couture et al., 2010

› 115 patients were consecutively recruited for the study (between 15 and 30 years old).

› Three primary diagnostic groups based on primary presenting symptoms:

› Depression (Major Depressive Disorder or Dysthymia; n = 52),

› Bipolar (Bipolar Affective Disorder; n = 40)

› Psychosis (Schizophrenia, First Episode of Psychosis or Schizoaffective Disorder; n = 23).

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Assessments

› Predicted IQ (WTAR/ WRAT-4)

› Trail-Making Test — Part A (TMT A) and Part B (TMT B)

› Rapid Visual Processing (RVP)

› The Rey Auditory Verbal Learning Test (RAVLT)

› Spatial Span Test (SSP)

› The RMET (Baron-Cohen et al., 2001) assessed ability to infer mental states from the eyes of others.

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Social Cognitive Performance as a marker of neurodevelopmental aberration

› 83 people diagnosed with Social Anxiety

› 38 people diagnosed with Autism

› 52 people diagnosis with Early Psychosis

› 40 people not diagnosed with mental illness

› Assessed on the RMET and Movie Stills

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Social Cognitive Performance as a marker of neurodevelopmental aberration

› 83 people diagnosed with Social Anxiety

› 38 people diagnosed with Autism

› 52 people diagnosis with Early Psychosis

› 40 people not diagnosed with mental illness

› Assessed on the RMET and Movie Stills

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Structure

› Safe environment to practice interaction

› To develop skill and confidence

› To see how others interact and to replicate

› To be mentored

› Reduced stimulation

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What works?

Treatment for social dysfunction in autism and schizophrenia

Anti-depressents

Anti-psychotics

Herbal Remedies

CBT

Hyperbaric Chambers

Family Therapy

Electric Shock

Dolphin Therapy

Social Cognitive Training

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X

XX

X

?X

X

Intranasal Administration

Oxytocin enhances social cognition and behaviour

› Oxytocin enhances trust- Kosfeld et al 2005, Nature

› Oxytocin enhances eye-gaze- Guastella, Mitchell, & Dadds, 2008, Biol Psychiatry

› Oxytocin enhances Theory of Mind- Domes et al., 2007, Biol Psychiatry

› Oxytocin improves recall of positive social memories- Guastella, Mitchell, & Matthews, 2008, Biol Psychiatry

› Oxytocin improves emotion recognition in 381 participants- Sharhestani, Kemp, & Guastella., 2013, Neuropsychopharmacology

Oxytocin enhances social cognition in psychiatric disorders

› Oxytocin enhances eye gaze in ASD adults- Andari et al., 2010, PNAS

› Oxytocin enhances theory of mind in ASD youth- Guastella et al., 2010, Biological Psychiatry

› Oxytocin enhances social cognition in Schizophrenia- Guastella et al., 2015, Schizohrenia Research

Early Psychosis TrialCacciotti, Langdon, Ward, Hickie, Naismith, Redoblado-Hodge, & Guastella, 2014

› 52 randomised (27 OT, 25 PL)

- Twice daily 24 IU spray, plus one additional prior to each group session

› Males and females

› Current or past diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and within the first three years of treatment for psychosis

› Both groups received social cognition training

- 6 weeks, 2 one hour sessions

› 9 drop-outs over the course of the trial

› Baseline, post-treatment, and three-month follow-up assessments

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Social Cognition: Treatment Targets

Four key domains comprising social cognition:

• Emotional processing

• Theory of mind

• Social perception/knowledge

• Attribution bias

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Social Cognition Training Program

Week 1 & 2: Emotion Recognition • Facial expressions; Vocal cues; Body gesture

Week 3 & 4: Theory of Mind/Social Knowledge•Mental state recognition, Intention inference, Pragmatic language (e.g., faux pas, sarcasm)

Social Cognition Training Program

Attributions•Attribution bias, jumping to conclusions, distinguishing facts from guesses

Film – ‘Pretty Woman’

Role Play - multiple attributions“You are always given gifts for your birthday but this year your family and friends each

decided to give you money”

Additional: Homework; Generalisation of skill

Weeks 5 & 6: Attributions

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Jumping to conclusions

Moritz & Woodward (2007)

Distinguishing facts from guesses –‘Social Detective’

Penn et al. (2005)

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Demayo, Lagopoulos and Guastella, in prep.

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Summary

› Social deficit and subsequent withdrawal in mental health are typically driven by

- Anxiety and arousal

- Neurodevelopmental difficulties that cause problems in flexibility (responding to habits) and mentalising(knowing how)

› Focus of intervention and support needs to be on modyfing behaviour, altering circuits and acknowledging that persistence is very important

› Adolescents typically have unique opportunities for systems of intervention

› In contrast to the previous 20 years there is now great hope we can improve social development for people with neurodevelopmental difficulties

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Organizational Support