Comorbid Disorder in Autism Tom Berney Northgate & Prudhoe NHS Trust Fleming Nuffield Child & Family...

Comorbid Disorder in Comorbid Disorder in AutismAutism

Tom BerneyNorthgate & Prudhoe NHS Trust

Fleming Nuffield Child & Family Psychiatry UnitEuropean Services for People with Autism (ESPA)

Athens University visitAthens University visit

ConceptsConcepts Autism Symptoms, syndrome & disorder Developmental disabilities

Attention deficit & hyperactivity Tics Obsessions & compulsions


Comorbid conditionsComorbid conditions Epilepsy Schizophrenia Arousal (anxiety / aggression)

Autism as asyndrome2o to amedicaldisorder

Limited imagination / creativityLimited imagination / creativityRepetitive/stereotyped movementsRepetitive/stereotyped movements

OCDOCDCircumscribed interestsCircumscribed interests

Social responsivenessSocial responsiveness CommunicationCommunication

AutismAutism What is ‘autism’

symptomssymptoms

symptoms

SyndromeSyndrome

Autism as a1o disorder

Disordergeneticcause

Primary Primary Genetic disorder - interaction of 3+ sitesGenetic disorder - interaction of 3+ sites

Secondary Secondary to any disorder that causes LDto any disorder that causes LD tuberous sclerosistuberous sclerosis fragile X fragile X

disorder

syndrome

What is ‘autism’AutismAutism

Limited imagination / creativityLimited imagination / creativityRepetitive/stereotyped movementsRepetitive/stereotyped movements

OCDOCDCircumscribed interestsCircumscribed interests

Social responsivenessSocial responsiveness

Theory of MindTheory of Mind

EmpathyEmpathy

CommunicationCommunication

Executive FunctionExecutive Function

VoluntaryVoluntary AutomaticAutomatic

AutismAutism Diagnostic domains

Theory of MindTheory of Mind

Social responsiveness

EmpathyEmpathy

CommunicationCommunication

Executive FunctionExecutive Function

VoluntaryVoluntary AutomaticAutomatic

Repetitive/stereotyped movementsRepetitive/stereotyped movements

OCDCircumscribed interestsCircumscribed interests

Motor abnormalityMotor abnormality

ToneTone

Co-ordination Co-ordination Central coherenceCentral coherence

PerceptionPerception

DepressionDepression

EpilepsyEpilepsy

ImmunologyImmunologyBowel dysfunctionBowel dysfunction

SocialSocial responsivenessresponsiveness

AutismAutism Pervasive & complex disorder

AdministrativeAdministrative

ClinicalClinical

ResearchResearch

Threshold of diagnosisAutismAutism

The purpose of the diagnosisThe purpose of the diagnosis

A syndromal (> a laboratory) diagnosisA syndromal (> a laboratory) diagnosis

A continuum, A continuum, the diagnostic threshold depending on:the diagnostic threshold depending on: the autism - how severe / fragilethe autism - how severe / fragile sympathy of the settingsympathy of the setting


Autism Asperger’s Broader Autism Asperger’s Broader phenotypephenotype

ASD Neurotypical

A syndromal (> a laboratory) diagnosisA syndromal (> a laboratory) diagnosis

A continuum, A continuum, the diagnostic threshold depending on:the diagnostic threshold depending on: the autism - how severe / fragilethe autism - how severe / fragile sympathy of the settingsympathy of the setting


Subtypes – depend on:Subtypes – depend on: level of cognitive abilitylevel of cognitive ability change with agechange with age

Aloof Passive Active-but-odd

DevelopmentalDevelopmentaldisordersdisorders

Disorders that are:Disorders that are: innate (genetic)innate (genetic) change with developmentchange with development

(i.e. brought out at different ages)(i.e. brought out at different ages)

DevelopmentalDevelopmentaltrajectoriestrajectories

OCD

ADHD

ASD

Tics

Age(yrs)0 5 10 15 20

DevelopmentalDevelopmentaldisordersdisorders

SymptomsSymptomsSpecific developmental disabilitiesSpecific developmental disabilities

Specific developmental disabilitiesSpecific developmental disabilities

Obsessions &Obsessions &CompulsionsCompulsions

ImpulsivityImpulsivity

TicsTics

DyscalculiaDyscalculia

DyslexiaDyslexiaSocialSocial

impairmentimpairment

RepetitiveRepetitiveself stimnself stimn

ADAD

CatatonicCatatonicsymptomssymptoms

StereotypyStereotypy

LanguageLanguageproblemsproblems

DyspraxiaDyspraxia

HyperactivityHyperactivity

Obsessions &Obsessions &CompulsionsCompulsions

ImpulsivityImpulsivity

TicsTics

DyscalculiaDyscalculia

DyslexiaDyslexiaSocialSocial

impairmentimpairment

RepetitiveRepetitiveself stimnself stimn

ADAD

Developmental syndromesDevelopmental syndromes

CatatonicCatatonicsymptomssymptoms

StereotypyStereotypy

languagelanguageproblemsproblems

DyspraxiaDyspraxia

HyperactivityHyperactivity

Developmental disordersDevelopmental disorders

Autism

ADHD

Comorbiddisorders

Hybriddisorder

(Autism-ADHD)

Symptoms

SyndromesSyndromes

Disorders

ConceptsConcepts

arousal(anxiety / aggression )

inattentiondepressionobsessionstics

ADHDADHDOCDOCDTouretteTourette

22oo autism autism

1o autism EpilepsySchizophreniaCyclical disorders

ASD in epilepsySelected populationsDisability - more severe / multipleCause of autism - 10 & 20

Diagnosis - how narrow / broad

Regression (probably) unrelated to epilepsy

Bimodal onset - childhood & adolescence

Epilepsy (seizures) in ASD (5-30%)Depends on degree & nature of disability

About 5-10% in childhood Asperger Up to 70% in disintegrative disorder

EpilepsyEpilepsyComorbid disorderComorbid disorder

Socialimpairment

Repetitive &stereotypedbehaviours

Communicationabnormality

Comorbid disorderComorbid disorder

Socialimpairment



Epilepsy can amplify the symptoms of autism

EpilepsyEpilepsy

Comorbid disorderComorbid disorder

Socialimpairment



Can epilepsy mimic the symptoms of autism?

EpilepsyEpilepsy

Comorbid disorderComorbid disorder SchizophreniaSchizophrenia

Positive SymptomsDelusionsHallucinationsThought disorderAbnormal movement

• catatonia• stereotypies

Negative SymptomsWithdrawal (autism)Emotional change

• inappropriate• blunted / apathy

Psychosis

Schizoid PD Schizoid PD SchizophreniaSchizophrenia

Autism Asperger’s Broader Autism Asperger’s Broader phenotypephenotype

Unitary psychosis

Age

Birth 16 yrs.

Schizophrenia

Autism

Autism

1971

- SD -


AgeBirth 16 yrs.

SchizophreniaAutism

Developmental trajectoriesDevelopmental trajectories


AgeBirth 16 yrs.

SchizophreniaAutism

Asperger

Developmental trajectoriesDevelopmental trajectories


High arousalhallucinationsthought disorder

Difficulty in expressing thoughts & feelings

Reality ≈ observed fictionPragmatic difficulty – irrelevant detail

Thoughts & Perceptions

Motor Catatonic symptomatologyImpassivity

• negativism• initiation• mutism

Performance & Skills Maintained in anxiety statesDevelopmental trajectory

Why the confusion?Why the confusion?


Does Autism predispose to Does Autism predispose to schizophrenia?schizophrenia?

Autism does not protect against Autism does not protect against schizophreniaschizophrenia

Similar underlying abnormalities

How do we define schizophrenia• presenting symptomatology?• course & prognosis?

Not supported by outcome studies


What is the relationship?What is the relationship?

events control

Anxiety

Uncertainty

Symptoms Emotional arousal

ObsessionsCompulsions

Anxiety PanicFear

ObsessionsCompulsions

Anger Sexual arousal

Symptoms Emotional arousal

verbal

people

property

selfothers

self-injury (SIB) self-stimulation

form function

predatory / instrumental

defensive / reactive

frustration

communicative

cause

emotional arousal

pain

organic states

drugs

unusual perception

alcohol / stimulants / AEDs

brain injury epilepsy

Symptoms Aggression

SIB

High pain threshold

Compulsion

Social reinforcement

self-stimulation

Symptoms SIB

Maladaptive response

Comorbid symptoms

Autismsymptoms

Interaction Interaction → → complex presentationcomplex presentation

Comorbid Disorder in Autism Tom Berney Northgate & Prudhoe NHS Trust Fleming Nuffield Child & Family...

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