Transcript PSYCHIATRIC CO-MORBIDITY IN AUTISM – T

PSYCHIATRIC COMORBITY
IN AUTISM
Teresita M. Amay, M.D.
Diplomate
American Board of Psychiatry and
Neurology
PSYCHIATRIC COMORBIDITY IN AUTISM
ANXIETY
DEPRESSION
BIPOLAR MOOD DISORDER
ANXIETY
University of Amsterdam Study
40% of children with ASD had at least 1
comorbid anxiety disorder
Observed Rates of Anxiety Disorders among
Persons with ASD
Specific Phobia
30%
Obsessive Compulsive DO
17%
Social Anxiety DO
17%
Generalized Anxiety DO
17%
Separation Anxiety DO
9%
Panic DO
2%
DSM IV TR: Generalized Anxiety Disorder
Excessive anxiety and worry (apprehensive expectation)
Person finds it difficult to control worry.
The anxiety and worry are associated with 3 (or more) of the
following six symptoms:
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep or
restless unsatisfying sleep)
Obsessive Compulsive Disorder symptoms are similar
to repetitive and stereotyped behaviors seen in
ASD.
Symptoms more severe in ASD than non-ASD
TREATMENT:
For higher functioning individual Cognitive
Behavior Therapy (CBT)
For severe symptoms: medication + CBT
For lower functioning individual: medication
DEPRESSION
Symptoms of depression seen in general
population and ASD
-sadness
-apathy
-anhedonia
-loss of interest
-decrease self care
-psychomotor retardation
In general clinicians rely on patients’ selfreport; this makes it difficult to assess
depression in the ASD population
Symptoms of depression can be
manifested in poor sleep, ability to
concentrate, and in communication
through facial expression or intonation.
These are easily masked by symptoms of
autism.
Symptoms that may be present but not
frequently seen:
- Feeling of worthlessness
- Guilt
Other possible depressive symptoms more
specific to or common in ASD
- Irritability
- Agitation
- Increase social withdrawal
- Change in character or obsession
- Increase in compulsive behavior
For Individuals with co-morbid cognitive
disability, depression can be manifested
through:
- Increase in self injury
- Regression of adaptive skills
Presentation of depression
Depends on age, level of intelligence and verbal skills.
TREATMENT
For mild to moderate symptoms and higher functioning
- Cognitive Behavior Treatment (CBT)
For severe symptoms - CBT + Medications
For ASD patient with co-morbid cognitive disability
– Medications
BIPOLAR MOOD DISORDER
Prevalence of Bipolar Disorder (BD) in adults with
ASD ranges from 6% to 27%
Usual onset in adolescence
Characterized by atypical presentation, making
identification difficult.
Family history of affective disorder very important
Clinical features often diagnosed as Schizophrenia
because of the atypical presentation.
One key factor in differentiating bipolar disorder is to
look carefully at when the symptoms appear and how
long they last.
Manic episodes in adult ASD are characterized
by mixed features such as irritability, unstable
and dysphoric mood, hostility, restlessness,
anxiety, perplexity, aggression, violent behavior
and insomnia.
Uncommon are euphoric mood, elation and
jocularity.
Psychotic symptoms may be so prominent that
other manic symptoms remain unrecognized.
Bizarre thought contents vs. odd thinking,
bizarre ideas and idiosyncratic views are
common among ASD individuals.
Important in making the diagnosis is an
accurate clinical interview, and use of
assessment instruments for mood symptoms.
The presence of a family history of BD in first
degree relatives, special abilities, anxiety and
or multiple psychiatric co-morbidities and comorbid Tourette’s Syndrome are other
important indicators of bipolarity.
TREATMENT: Mood stabilizers
Lithium: Predictors of favorable response are -
Family history of BD
Severe hyperactivity unresponsive to stimulants
Cyclical pattern of behavioral changes
Irritability
Enduring outbursts of laughter
Subjective dizziness
Presence of at least some BD diagnostic criteria
Valproate
Several reports suggests efficacy in symptoms of
irritability, dysphoria and anxiety.
Favorable effects in ASD patients with Mental
Retardation, typical and atypical BD including
rapid cycling.
Oxcarbazepine + low dose second generation
antipsychotic
ATYPICAL ANTIPSYCHOTIC OR SECOND
GENERATION ANTIPSYCHOTIC MEDICATIONS
Risperidone
Effective in reducing repetitive, aggressive
and impulsive behaviors and improving some
aspects of sociality
Side effects: Extrapyramidal symptoms,
Tardive Dyskinesia, weight gain, drowsiness
and elevated prolactin level.
Aripiprazole
Effective in reducing irritability, self-injury
and temper tantrums.
Well tolerated
Side Effects: weight gain, elevated
prolactin, dose-dependent sedation and
drooling/increased salivation. EPS and
Tardive Dyskinesia are not negligible.
References:
NADD Bulletin Volume X Number 6 Article 1
Bipolar Spectrum Disorder with Comorbid Spectrum Disorders
Jay A Salpekar, MD, Peter Daniolos, MD, The George Washington University
School of Medicine
Journal of Affective Disorders
Bipolar Disorder in Adults with Asperger’s Syndrome
A Systematic Review
Giulia Vannucchi, Gabriele Masi, Cristina Toni, Dell’Osso
Andreas Erfurth, Giulio Perugi
The National Autistic Society
Depression and its measurement in the verbal adolescents and adults
with autism spectrum disorder
Katherine Gotham, Kathryn Unruth and Catherine Lord
References:
DSM IV TR
APA Publishing
Indiana Resource for Autism
Anxiety and Autism Spectrum Disorders
Ann Merrill
Thank you.
Questions and Comments
Email address [email protected]