Mental Illness in Adults with Autism Spectrum Disorder

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Mental Illness in Adults with Autism Spectrum
Disorder
Preliminary results of a study of comorbidity

• Martyn Matthews

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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

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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 provide or pay for services
• Getting access to inpatient mental health
  services (getting past the gatekeeper)
• Behaviour of people with ASD in mental health
  settings

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So what does the evidence tell us?

• Anxiety Disorders
• Anxiety seems to be a key feature of ASD, but we
  dont have strong research evidence for this
  notion
• But, case study evidence suggests a 100
  prevalence!

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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

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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

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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)

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Mood Disorders

• Depression
• Case 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
  ASD had symptoms that would meet DSM IV criteria
  for depression
• Wing (1984), 10/34 (29) of young adults with AS
  had diagnosable depression
• Rates for general population are 6.8 (NCS-R,
  2001)

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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?
• It looks likely, case study descriptions suggest
  that
• As depression worsens, stereotypic or
  ritualistic behaviour increase to meet OCD
  diagnostic criteria
• Or
• Restlessness and hyperactivity increase to meet
  ADHD diagnostic criteria
• Gahaziudin M, Gahaziudin N, Greden J (2002)

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Bipolar Disorder

• We know very little
• Some case reports
• Lots of internet forum discussions
• Little data

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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)

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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 adults with ASD
• Volkmar Cohen (1991) identified 1 adult from a
  sample of 163 adolescents adults with ASD
• Prevalence rate is the same as general
  population (0.4-0.6)

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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

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So what do we really know?

• 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

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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

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Otago Study

• Based in Department of Psychological Medicine,
  University of Otago.
• Researchers
• Martyn Matthews
• Dr Kumari Fernando
• Dr Brigit Mirfin-Veitch

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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

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Method
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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

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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)

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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

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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

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Overall ASD-CA Scores
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Mean Scores on ASD-A
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Mean Scores on REISS Screen
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Rachel
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Brian
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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

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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.

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ASD-D-A diagnostic screen

• Scores of 19 indicate ASD
• For autistic disorder score of 11 Social
  behaviour and 8 on repetitive behaviour/
  restricted interests