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)

Bipolar Disorder

We know very little:Some case reportsLots of internet forum discussionsLittle data

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

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.

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