1. Case Series – Management of Autism and Psychiatric Comorbidities
Dr Jennifer Spencer and Dr Anton Canagasabey
South Essex Partnership University NHS Foundation Trust (SEPT)
Aims
There is growing recognition that psychiatric co-morbidities
occur regularly in people with Autistic Spectrum Disorders
(ASD). Symptoms such as obsessive, repetitive behaviours,
hyperactivity and anxiety are “shared” between ASD and
common psychiatric disorders such as Depression, Obsessive
Compulsive Disorder and Anxiety Disorders. In people with
ASD, “shared” symptoms may not be severe enough to lead
to formal co-morbid diagnoses. Recently released guidelines
propose that treatments which work well in psychiatric
disorders with “shared” symptoms are also effective in ASD
even if “shared” symptoms are present at sub-syndromal
levels. (Taylor 2009)
DSM-5 proposes semi-quantitative, ordinal scales be used in
ASD to “provide quantitative measures of important clinical
areas that will be relevant beyond any set of syndromal
criteria” and to “assist the clinician in assessment, treatment
planning, and treatment monitoring.” (http: //www.dsm5.org/
ProposedRevisions/Pages/Cross-
CuttingDimensionalAssessmentinDSM-5.aspx)
Methods
From 1995- 2010, patients with learning disabilities and ASD
were offered medical and/or psychosocial intervention for
symptoms suggestive of co-morbidity during AC’s routine
outpatient clinics. Carers subjectively rated symptom severity
on a 0 – 10 scale, with 10 being the most severe, before and
during treatment. Patients were followed in outpatient clinic for
1-5 years with symptom severity recorded at each follow-up
visit.
All cases were reviewed. Symptom severity, medication dose
and psychosocial interventions were graphically depicted over
time. Many benefitted from such treatment; three examples
are presented here.
References
First MB. Psychopathology 2005 Jul-Aug;38(4):206-10. Mutually exclusive versus co-
occurring diagnostic categories: the challenge of diagnostic comorbidity.
O’Brien G. JIDR 2002 May;46(Supp1):21-30. Dual diagnosis in offenders with intellectual
disability: setting research priorities: a review of research findings concerning psychiatric
disorder (excluding personality disorder) among offenders with intellectual disability.
Reaven J. JSPN 2009 July:4(3):192-199. Children with High-Functioning autism Spectrum
Disorders and Co-occurring Anxiety symptoms: Implications for Assessment and Treatment.
Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines 10th ed. September 2010.
Pp 270-275.
West L, Brunssen S, Waldrop J. JSPN 2009 July:14(3):183-191. Review of the Evidence for
treatment of Children with Autism with Selective Serotonin Reuptake Inhibitors.
http: //www.dsm5.org/ProposedRevisions/Pages/Cross-
CuttingDimensionalAssessmentinDSM-5.aspx)
Case study 2 Behavioural disorder and Hyperactivity
Presentation
18 yo man with classical autism and moderate LD.
Returned home from residential placement 6/12 earlier.
Hyperactivity and destructive, repetitive behaviour
quickly led to disrepair of family residence
Autistic
features
Social interaction – No reciprocity
Communication – No verbal or nonverbal from <3 yoa
Severely restricted, repetitive behaviour
Personal Hx
Normal pregnancy and delivery. Normal milestones til
2yoa. Loss of skills from 2-3 yoa. Residential school 8 -
18 yoa. Constant hyperactive, repetitive, destructive
behaviour.
Ψ Hx
Classical childhood autism
Probable ADHD (no formal diagnosis made)
Medical Hx Nil significant
Family Hx Nil significant
Meds Hx Concerta XL from 13 – 18 yoa. No improvement.
Treatment
and Progress
Parents had tried many holistic therapies but had not
been keen on standard treatments. They reluctantly
agreed to try Risperidone 1 mg/day initially and later to
add Fluoxetine 10 – 20 mg/day.
Within a few months significant improvement was seen
in socialization and communication, along with a
significant decrease in hyperactivity and some decrease
in agitiation. Additionally, the patient became more
affectionate and began to use sign language. His
parents were very happy.
Discussion
Hyperactivity is an associated feature of ASD.
Symptoms are frequently severe enough to meet ADHD
diagnostic criteria and can lead to behavioural problems.
Maudsley Guidelines 10th ed (Taylor 2009) recommends
Methylphenidate for “ADHD-like” symptoms, (but warns
of highly variable responses), SSRIs for “Restricted
Repetitive Behaviours and Interests” (with increased
agitation in some patients), Atypical antipsychotics for
agitation/ irritability/ aggression (Risperidone is licensed
for ASD with irritability)
Small case series report a combination of SSRI and
Risperidone can give the best results. (West 2009)
SEP
T
0
2
4
6
8
10
Date Jun-05 Jun-06 Jun-07 Jun-08 Jun-09
0
5
10
Lamotrigine
0
25
50
75
100
Communication
Sertraline
0
2
4
6
8
10
Obsessive/Repetitivebehaviour
Agitation
0
5
10
SocialInteraction
0
1
2
0
2
4
6
8
10
Date Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10
0
5
10
0
5
10
15
20
Lamotrigine
0
10
20
Risperidone
Communication
Fluoxetine
0
2
4
6
8
10
0
2
4
6
8
10
Obsessive/Repetitivebehaviour
Hyperactivity
Agitation
ConcertaXL
0
5
10
Social Interaction
Case Study 1 Behavioural disorder and Core symptoms
Presentation
21 yo man with Severe learning disability
Referred for clarification of diagnosis
Autistic
features
Social interaction – Refused hugging as a child. Now
ok.
Communication – Single word and nonverbal
communication of his needs.
Repetitive behaviour – Ritualistic toileting behaviour
(3 hours in morning)
Personal Hx
Normal pregnancy. Obstructed labour with hypoxia and
emergency C- section. Resusc required. LBW 2.7 kg.
All milestones delayed. Moved to UK w/family 15 yoa.
Ψ Hx
Diagnosed with Atypical autism during this assessment
Severe learning disability
Intermittent sleep disturbance
Behavioural disorder NOS (F19.9) with episodes of
agitation and hand biting
Social Hx
24 hour supported residential accommodation for 2
years. Required assistance with all ADLs. Enjoyed
sensory room, music, swimming, gardening, computers.
Medical Hx
Perinatal hypoxia
Genetic disorders excluded (Fragile X, others)
Family Hx Mother had had depression
Meds Hx
Paroxetine and a “major tranquillizer” tried in the past.
“Had not suited him” per parents.
Treatment and
Progress
Parents initially refused meds aside from PRN
lorazepam.
1 year post referral his behavioural disorder escalated.
• Increased frequency of self harm (hand biting)
• Attacking care staff
Parents agreed to trial of Sertraline init 25mg later
75mg
Significant improvement in behaviour and also in core
functioning. Parents very happy.
Discussion
Rigid, repetitive & obsessive traits are core symptoms
of ASD. Symptoms are frequently severe enough to
meet OCD diagnostic criteria and can lead to
behavioural problems. Maudsley Guidelines 10th ed
(Taylor 2009) recommends SSRIs for “Restricted
Repetitive Behaviours and Interests”. Theoretically no
medication has been shown to improve Sociality and
Communication, however, small case series have
reported effects similar to the ones seen here. (West
2009)
Case study 3 Rigidity, Depression and Oppositional traits
Presentation
18 yo with Asperger’s syndrome, depression and
obsessive ruminations about harm to others.
Autistic
features
Social interaction - Inappropriate, stereotyped.
Communication – Normal speech with specific language
impairment (semantic/pragmatic use of words)
Restricted interests (sports), perfectionistic schoolwork.
Personal Hx
Normal pregnancy & delivery. Normal milestones.
Mainstream school, bullying in childhood.
Verbal IQ = 117, Performance IQ = 78
Refused to attend after being streamed into lower class.
New school refused again after 6/12
Family Hx
Aunt had agoraphobia and anxiety.
Father had Stills disease.
Medical Hx Nil significant
Ψ Hx
In childhood diagnosed with oppositional behaviour,
anxiety, and school refusal (14 and 15 yoa). Thought to
have ADD then OCD (14 and 15 yoa).
Asperger’s syndrome diagnosed 16 yoa
Depression diagnosed 17 yoa
• Ongoing symptoms 17 – 22 yoa
• Initial suicidal ideation
• Anger and resentment over past experiences
• Obsessive, persecutory ruminations, initially with
thoughts of harm to others. Responded to CBT.
Behavioural disorder diagnosed 22 yoa in the form of
occasional aggression to parents.
Treatment
Hx
Methylphenidate 14 yoa 2/52 (stopped due to
hyperactivity).
Fluoxetine 15 yoa 3/52 (stopped due to
ineffectiveness).
CBT 18 yoa 10 sessions over 6/12 – (Partial response).
Sertraline 18 yoa 2-3/52 (stopped due to agitation)
Treatment
and progress
Depressive symptoms had worsened over 3-4 months,
with aggression towards parents and suicidal ideation.
He was prescribed Risperidone 0.5 mg/day, increased
to 1mg after 4/12 Sertraline 50mg initiated due to
persistent low mood (stopped after 3/12 – refused)
Risperidone increaed to 1.5 after 6/12. Referred for
further CBT, but the therapist felt his beliefs were to rigid
to respond to treatment. He did not take this rejection
well. A second private therapist refused due to concerns
about his own safety. Strength and rigidity of beliefs
were an obstacle to engagement. He stopped taking
Risperidone after reading about its side effects.
Discussion
Cumulative effect
Rigid, repetitive & obsessive traits are core symptoms of
ASD that can worsen with depression. In extreme cases
can increase the risk of antisocial behaviour. Treatment
of overlying depression can mitigate these effects.
Cognitive rigidities can interfere with therapeutic
engagement.
Aggression/offending in patien ts with autism
Causes of aggression and/or offending behaviour in
patients with autism can be due to social naiveté,
impulsive anger secondary to disruption of routine/
misinterpretation of social cues, or can arise from
obsession. Offending arising from rigidities and
obsession is of greatest concern (O’Brien et al 2002).
Psychotherapy for patients with autism
Modified CBT has proven to be an effective treatment
for core symptoms, anxiety, OCD and depression in
small case series. Modified psychodynamic therapy has
proven to be effective in selected (cognitively high
functioning) cases. Recommended modifications to
improve efficacy include:
• Written worksheets with multiple choice lists for new
concepts
• Focus on strengths and areas of interests
• Emphasis on drawing, photography and creative
outlets
• Use of video activities to enhance generalization
• Multiple opportunities for repetition and practice
• Involvement of parents/carers in treatment provision
(Reaven et al 2009)
Lamotrigine
0
25
50
0
1
2
Risperidone
Restrictedinterests,rigidopinions
Socialinteraction- awkwardconversationalattempts
Sertraline
Aggression
Thoughtsofself harm
Date 2001 2002 2003 2004 2005
CBT
GeneralMoodSymptoms
Anger
Beliefhe hadbeen wronged
Thoughtsofintentionalharmto others
Avoidingcontactw family
Activitieslimitedtohome
Isolative/Reversedsleeppattern
Language- difficultieswithgradedsemantics,nonverbalcommunication
Diagnostic
threshold
Depressive
Symptoms
Autistic features
“Comorbidity in psychiatry does not imply
the presence of multiple disease or dysfunctions
but rather reflects our current inability to apply Occam’s razor.”
-- Michael B. First (2005)
Conclusion
Limited data exists with respect to treatment of co-morbidities
for patients with learning disabilities and ASD. However,
positive results have been reported in several small case
series such as this one, suggesting these treatments and
symptom monitoring strategies warrant further exploration.