Mental Health & Autism

Mental Health Problems
in Autism

Travis Thompson, PhD, LP

Most people with autism encounter difficulties with anxiety, especially social anxiety. This fearfulness can lead to a mental health diagnosis of Agoraphobia (intense fear of being away from a safe setting, usually home) of Generalized Anxiety Disorder. In addition, most people with ASDs experience the feeling that activities must be done in a very particular way or that physical objects in their environment must be arranged in a uniquely idiosyncratic way. Many children and youth with autism have attention problems, i.e. focusing on instructional or work materials specified by a parent, teacher or supervisor. Social anxiety, ritual behaviour and attention difficulties are inherent parts of autism, though in extreme cases psychologists or psychiatrists may assign a separate secondary diagnostic label to the additional condition, e.g. Obsessive Compulsive Disorder, ADHD, Social Phobia, which can lead to a more specific treatment for that condition, much as others without autism might receive.

CONTINUE READING HERE …. Other mental health disorders that are not generally part of autism may co-occur more often than would be expected by chance. Earlier research (1991) by Volkmar and colleagues at Yale University suggested schizophrenia was about as common among individuals with autism as among the general population. However, using later diagnostic methods Judith Rapport and colleagues (2009) found a greater degree of association. In two large studies that have examined this systematically, Childhood Onset Schizophrenia is preceded by and comorbid with Pervasive Developmental Disorder in 30%-50% of cases. Epidemiologic and family studies find association between the disorders. Both disorders have evidence of accelerated trajectories of anatomic brain development at ages near disorder onset. A growing number of risk genes and/or rare small chromosomal variants (micro-deletions or duplications) are shared by schizophrenia and autism. A study more recently published by Raja (2011), indicates suicidality in young adults with autism is associated with co-morbid schizophrenia (15 of 25 cases of suicide attempts or thoughts of hospitalized individuals). In that study, the remaining autism cases in which suicidality was a concern involved Mood Disorder alone or in combination with substance abuse. All of these individuals were seen in a mental health clinic because they had suicide risk, they were not a random sample of people with autism.

Another mental health disorder category sometimes associated with autism in childhood and adolescence is Oppositional Defiant Disorder. ODD can be very difficult to distinguished from exaggerated typical behavior of an adolescent with autism. In ODD one sees a pattern of negativistic, hostile, and defiant behavior, that is clearly interfering with their ability to function at home, school and work and is not due to a mood disorders, such as Bipolar Disorder. Knowingly harming animals, attempting to set fires and apparent pleasure at causing others to experience pain are usually indications of this condition.

It is very difficult to differentially diagnose these conditions, because at times many people with ASDs may display symptoms of other conditions without actually having that condition, but may do so only infrequently and sporadically. Since most mental health diagnoses depend on the person’s emotional expressions (sadness), comments about their own mental state (confused, forgetful), both of which are impaired in autism, the clinician is left to infer from indirect information and interviews with caregivers.
It is risky for a clinician who has never seen an individual before to arrive at a diagnosis based on the current presentation alone. Without baseline information about that person, for example grandiosity, that may inadvertently lead to a Bipolar Disorder diagnosis, while in fact the person frequently says unrealistic things in their day to day life. Symptoms of depression are especially difficult to differentiate from those of autism, and unless one has an idea of the person’s behavior and appearance six months or a year earlier, there is no way to know whether his/her current status is different from baseline (e.g. lack of talkativeness, withdrawn, lack of positive emotion, loss of interest in favorite activities). Clinicians experienced with other disability populations, such as intellectual disabilities, are often more aware of these problems.

Intervention protocols for individuals with combined conditions must take each diagnosis into consideration. Parents are understandably wary of over prescribing psychotropic medications. While this is understandable, it is important that they are made aware that some medications used judiciously can be very beneficial to their adolescent child, such as Selective Serotonin Reuptake Inhibitors (Proazac) for phobias and severe OCD rituals. Few experienced professionals would contend medication alone will solve the person’s problems, but in some cases, e.g. Bipolar Disorder, or Atypical Antipsychotic for a person with schizophrenia and autism, it can be critical. Treatment teams need to carefully think through each of the person’s diagnoses, e.g. Panic Attack Disorder and Autism (High Functioning), and tailor make a treatment plan for each that is integrated across the two diagnoses. This is a realm in which well trained behavior analysts working closely with prescribing physicians and their nursing staff can play an important role in monitoring medication effects and reporting back on results (both favorable and side effects).

Bibliography

Guttman-Steinmetz, S. et.al J Autism Dev Disord. 2009 Jul;39(7):976-85.

Raja, M. et.al. Clin Pract Epidemiol Ment Health. 2011; 7: 97–105.
Published online 2011 March 30.

Tsai, L and Mesibov, GB (2001) Taking the mystery out of medications in Autism/Asperger syndromes. Future Horizons, Inc.

Volkmar, FR and Cohen, DJ, (1991) The American Journal of Psychiatry 148(12):1705-1707

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