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Mental Illness in Adults with Autism Spectrum Disorder

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Title: Mental Illness in Adults with Autism Spectrum Disorder


1
Mental Illness in Adults with Autism Spectrum
Disorder
Preliminary results of a study of comorbidity
  • Martyn Matthews

2
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

3
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

4
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!

5
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

6
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

7
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)

8
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)

9
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)

10
Bipolar Disorder
  • We know very little
  • Some case reports
  • Lots of internet forum discussions
  • Little data

11
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)

12
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)

13
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

14
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

15
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

16
Otago Study
  • Based in Department of Psychological Medicine,
    University of Otago.
  • Researchers
  • Martyn Matthews
  • Dr Kumari Fernando
  • Dr Brigit Mirfin-Veitch

17
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

18
Method
19
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

20
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)

21
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

22
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

23
Overall ASD-CA Scores
24
Mean Scores on ASD-A
25
Mean Scores on REISS Screen
26
Rachel
27
Brian
28
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

29
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.

30
(No Transcript)
31
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
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