Autism and gender, by Dr Patricia JM Van Wijngaarden cremers

2,127 views

Published on

Autism and gender, by Dr Patricia JM Van Wijngaarden cremers

Published in: Health & Medicine
  • Be the first to comment

Autism and gender, by Dr Patricia JM Van Wijngaarden cremers

  1. 1. Autism in girls & women a scientific approach to everyday pratice Patricia J.M. van Wijngaarden-Cremers DIMENCE GGz Addiction & Developmental Disorders Zwolle UMCN St. Radboud KARAKTER K&J Psychiatrie Nijmegen
  2. 2. Disclosures <ul><li>Patricia van Wijngaarden-Cremers </li></ul><ul><li>Speakerslist: </li></ul><ul><li>Eli Lilly – Janssen Cilag - Eurocept </li></ul>
  3. 3. Overview <ul><li>Autism a male condition? </li></ul><ul><li>What do we learn form Evolution? </li></ul><ul><li>What does genetics tell us? </li></ul><ul><li>From the literature </li></ul><ul><li>Research data </li></ul><ul><li>Clinical practice </li></ul><ul><li>Conclusions and recommendations </li></ul>
  4. 4. Autism a Male Condition? <ul><li>Autism is always characterized by: </li></ul><ul><ul><li>Impaired development of Social Reciprocity </li></ul></ul><ul><ul><li>Impaired verbal and non-verbal communication </li></ul></ul><ul><ul><li>Rigid and Restricted patterns of behaviour & interests </li></ul></ul><ul><li>Autism a disorder or </li></ul><ul><li>the extreme end of “male” (brain) condition ??? </li></ul>
  5. 5. Autism a Male Condition? <ul><li>Classic autism – Autistic Disorder and PDD-NOS </li></ul><ul><ul><li>Man- Woman ratio: 4 to 1 </li></ul></ul><ul><ul><li>Under an IQ of 50 ratio’s are equal with more severe symptoms, epilepsy and “self-harm” </li></ul></ul><ul><li>In Asperger’s </li></ul><ul><ul><li>Ratio Man-Woman: 9-10 to 1 </li></ul></ul>
  6. 6. Evolutionary Perspective <ul><li>In prehistoric societies: </li></ul><ul><ul><li>♀ : responsible for social cohesion in the group </li></ul></ul><ul><ul><li>- attractive women: </li></ul></ul><ul><ul><li>know how to relate and pacify </li></ul></ul><ul><ul><li>strong social and communicative skills </li></ul></ul><ul><ul><li>♂ : responsible for acquisition of nurture </li></ul></ul><ul><ul><li>- appealing men: </li></ul></ul><ul><ul><li>are detail geared hunters </li></ul></ul><ul><ul><li>do not interfere with the social life in the group </li></ul></ul>
  7. 7. Evolutionary Perspective <ul><li>Women are characterized by : </li></ul><ul><ul><li>Social skills and qualities </li></ul></ul><ul><ul><li>Strong verbal capacities </li></ul></ul><ul><ul><li>an Analog way of thinking: </li></ul></ul><ul><ul><ul><li>sensitive to and </li></ul></ul></ul><ul><ul><ul><li>able to integrate emotional aspects… </li></ul></ul></ul>
  8. 8. Evolutionary Perspective <ul><li>Men are characterized by </li></ul><ul><ul><li>Strong emphasis on details </li></ul></ul><ul><ul><li>Logic reasoning (mathematic precision) </li></ul></ul><ul><ul><li>One-sided perseverance on a particular theme (scientist: e.g computer technology) </li></ul></ul><ul><ul><li>More digital (binary: black and white) way of thinking </li></ul></ul>
  9. 9. Evolution <ul><li>No clear-cut boundaries between women and men </li></ul><ul><li>A normal distibution along Gauss curves </li></ul><ul><li>Extreme “male thinking” </li></ul><ul><li>But many women are more “male thinkers”than many men… </li></ul>
  10. 10. Evolution <ul><li>“ male” and “female” characteristics evole under influence of chromosomes and hormones </li></ul><ul><li>Testosteron is active in women too! </li></ul><ul><li>In Transsexuals: the way of thinking changes under influence of the hormons they receive in order to change gender features </li></ul>
  11. 11. What do genetics tell us? <ul><li>In 10-15% ASD due to a known medical condition </li></ul><ul><li>85% of the variance explained by heritability </li></ul><ul><li>In interaction with environmental factors: </li></ul><ul><ul><li>Drugs/Medication? </li></ul></ul><ul><ul><li>(Prenatal) infections? </li></ul></ul><ul><ul><li>Exposure to hormones e.g. testosterone??? </li></ul></ul>
  12. 12. What do genetics tell us? <ul><li>To date genes have been identified on as many as 17 chromosomes </li></ul><ul><li>Especially on chromosomes 7 and 15 </li></ul><ul><li>BUT also on the X- chromosome </li></ul>
  13. 13. What do genetics tell us? <ul><li>David Skuse (London 2006) </li></ul><ul><li>In Turner (X-O) patients high prevalence of </li></ul><ul><li>autism </li></ul><ul><li>Turner girls with ASD have an X-chrom. </li></ul><ul><li>from their mothers (Silent Copy’s) </li></ul>
  14. 14. What do genetics tell us? <ul><li>David Skuse concluded : </li></ul><ul><li>that theoretically “Autistic” fathers could pass on ASD </li></ul><ul><li>Mothers can be carriers </li></ul><ul><li>‘ autistic traits can be located on the X chromosome without expressing themselves (recessive characteristic) </li></ul><ul><li>Chromosomes are passed through daughters who will only develop autistic traits if they inherit two affected X-chromosomes </li></ul>
  15. 15. Recent Studies <ul><li>From the group of Simon Baron-Cohen </li></ul><ul><li>Chakrabarti B, Dudbridge F, Kent L, Wheelwright S, Hill-Cawthorne G, Allison </li></ul><ul><li>C, Banerjee-Basu S, Baron-Cohen S. (2009) Genes related to sex steroids, neural growth, </li></ul><ul><li>and social-emotional behavior are associated with autistic traits, empathy, and </li></ul><ul><li>Asperger syndrome. Autism Res. 2(3):157-77. </li></ul><ul><li>84 candidate genes where screened in relation to </li></ul><ul><ul><li>a) promoting attachment and socialization </li></ul></ul><ul><ul><li>b) involved in planning and organizing behaviour </li></ul></ul><ul><ul><li>c) rigid patterns of reacting to social situations </li></ul></ul>
  16. 16. the Chakrabarti & Baron-Cohen Study 2009 <ul><li>“ normal” controls from a general population where ordered from ‘no autistic traits” to ‘pronounced autistic traits’ and compared to men and women diagnoses with ASD </li></ul><ul><li>From the 84 genes 5 emerged as characteristic </li></ul><ul><li>TWO of which (socialization and detail perception versus global processing) are located on the X-chromosome! </li></ul>
  17. 17. What does literature tell us about Sex Differences in ASD ?
  18. 18. Asperger’s & Girls Tony Attwood 2006 <ul><li>♂ : more often referred ( extern./aggressive behavior) </li></ul><ul><li>♀ : - passive personalities </li></ul><ul><li>- more often mothered by other ♀ ♀ </li></ul><ul><li>- well motivated at school </li></ul><ul><li>- eager to attend drama classes </li></ul><ul><li>- more often involved in imaginary friends </li></ul><ul><li>- preoccupied with animals and classic literature </li></ul><ul><li>- problems increase in adolescence </li></ul>
  19. 19. Recent Studies M. Holtmann 2007 <ul><li>Study in high functioning individuals ♀ en ♂ with ASD: </li></ul><ul><li>No differences in symptoms on the TRIAS </li></ul><ul><li>- Parents of ♀ report more often </li></ul><ul><li>- social problems </li></ul><ul><li>- attention problems </li></ul><ul><li>- thought disorders </li></ul>Holtmann M, Bölte S, Poustka F. (2007) Autism spectrum disorders: sex differences in autistic behaviour domains and coexisting psychopathology. Dev Med Child Neurol. 49(5):361-6.
  20. 20. literature <ul><li>T.Pilowsky e.a. 1998 </li></ul><ul><li>ADI-R en CARS 85,7% overlap </li></ul><ul><li>no differences between genders </li></ul><ul><li>S. Baron-Cohen 2005 </li></ul><ul><li>empathy: no differences between genders </li></ul>
  21. 21. What does literature tell us about Sex Differences in ASD ? <ul><li>Boys tend to have higher IQ’s </li></ul><ul><li>Boys have more restricted play </li></ul><ul><li>Girls have stronger communication skills </li></ul><ul><li>Sex-related difficulties emerge over time </li></ul><ul><li>Boys are more easily distracted </li></ul><ul><li>Disruptive behavior is different </li></ul><ul><ul><li>♂ to gain objects </li></ul></ul><ul><ul><li>♀ to acquire care-givers attention </li></ul></ul>
  22. 22. What does literature tell us about Sex Differences in ASD ? <ul><li>Girls skills may be underestimated (higher expectancies regard to communication and social skills) </li></ul><ul><li>Girls may be overlooked and not included in intervention programs </li></ul><ul><li>On screening instruments girls tend to receive lower total scores with respect to diagnosis (more PDD-NOS diagnosis than autism) </li></ul>
  23. 23. researchdata
  24. 24. Tentative Conclusions Gender in ASD in very young children <ul><li>Gender distribution in line with what could be expected </li></ul><ul><li>Girls have indeed lower IQ’s </li></ul><ul><li>girls more severely affected </li></ul><ul><li>less communicative skills than expected </li></ul><ul><li>more pretend play, social interactions skills and </li></ul><ul><li>far less externalizing comorbidity </li></ul>
  25. 25. Sex Differences in Children and Adolescents with ASD <ul><li>IQ’s for both sexes in line </li></ul><ul><li>Girls indeed “overestimated” >> PDD-NOS </li></ul><ul><li>Very different patterns of Co-morbidity: girls more relation problems and affective problems </li></ul><ul><li>more environmental stress in girls especially in adolescents </li></ul>
  26. 26. Data from our Adult Cohort UMCN + Dimence 2007-2009 <ul><li>UMCN ASD clinic </li></ul><ul><li>31 women </li></ul><ul><li>131 men, </li></ul><ul><li>(1:4) </li></ul><ul><li>Dimence </li></ul><ul><li>Addiction + Dev. clinic </li></ul><ul><li>18 women </li></ul><ul><li>98 men, </li></ul><ul><li>(1:5) </li></ul><ul><li>Total Population </li></ul><ul><li>278 cases </li></ul><ul><li>49 women </li></ul><ul><li>229 men </li></ul><ul><li>(1:4.5) </li></ul>
  27. 27. Mean age <ul><li>All: 36y </li></ul><ul><li>Women: 34,7y </li></ul><ul><li>Men: 36,6y </li></ul><ul><li>p =0,4 </li></ul>
  28. 28. Age distribution
  29. 29. Diagnoses <ul><li>Autistic Disorder: 37% </li></ul><ul><li>PDD-NOS: 43% </li></ul><ul><li>Asperger: 30% </li></ul>
  30. 30. Gender differences ASD criteria (PDD-NOS, Asperger,Autism)
  31. 31. Gender differences ASD criteria <ul><li>All diagnoses considered in one analysis </li></ul><ul><li>Significant differences </li></ul><ul><ul><li>Restricted pattern of interest greater in men: p=0.001 </li></ul></ul><ul><ul><li>Persistent preoccupation greater in women: p=0.047 </li></ul></ul>
  32. 32. Gender differences ASD criteria (PDD-NOS, Asperger, Autism) <ul><li>PDD-NOS, Asperger, Autism in one analysis </li></ul><ul><li>Sum of diagnostic criteria </li></ul><ul><li>No significant difference </li></ul>
  33. 33. Gender differences autism criteria <ul><li>Sum of diagnostic criteria </li></ul><ul><li>Interpretation: </li></ul><ul><ul><li>Women need more criteria to be diagnosed </li></ul></ul><ul><ul><li>Social expectations are higher for women </li></ul></ul>
  34. 34. Co-morbidity in ASD
  35. 35. Comorbidity Autism PDD-NOS and Asperger <ul><li>Psychotic disorders are more frequently seen in PDD-NOS p=0.03 </li></ul><ul><li>Psychosis is seen in PDD-NOS 4x more often than in the general population </li></ul>
  36. 36. Gender differences co-morbidity Psychotic disorders more frequent in women p=0.06
  37. 37. Gender differences co-morbidity Life Events <ul><li>Life events more frequent in women </li></ul>
  38. 38. Autism in adolescents and women
  39. 39. Women with ASD manifest themselves!
  40. 40. Temple Grandin : <ul><li>Well-known from </li></ul><ul><li>the chapter an Anthropologist on Mars by Oliver Sachs </li></ul><ul><li>the Squeeze machine </li></ul><ul><li>Extraordinary visual spatial capacities (e.g. in cattle farms ) </li></ul>
  41. 41. Donna Williams
  42. 42. Gunilla Gerland
  43. 43. In Clinical Practice <ul><li>Case M </li></ul><ul><li>- 23 years of age </li></ul><ul><li>- addicted to cocaine and cannabis </li></ul><ul><li>- misuse all other drugs except heroine </li></ul><ul><li>- 6x unsuccessful treatments in different clinics </li></ul><ul><li>- victim of sexual and physical abuse </li></ul><ul><li>- diagnosed as borderline personality </li></ul>
  44. 44. In Clinical Practice 2 <ul><li>After detox: </li></ul><ul><li>High levels of Anxiety </li></ul><ul><li>Chaotic </li></ul><ul><li>Clumsy </li></ul><ul><li>Severe attention problems / ADHD </li></ul><ul><li>Compulsive </li></ul><ul><li>Problems with social relations </li></ul><ul><ul><li>In contrast with the past or… “active but odd”??? </li></ul></ul><ul><ul><li>After two years ASD is diagnosed and a real guidance program can start </li></ul></ul>
  45. 45. Women with ASD: symptoms and additional problems <ul><li>Girls with clear-cut Kanner-autism and low IQ’s are not missed in screening programs </li></ul><ul><li>In Girls with high IQ and mild ASD traits the symptoms go unnoticed behind </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Learning difficulties </li></ul></ul><ul><ul><li>Mood swings </li></ul></ul>
  46. 46. Women with ASD: symptoms and additional problems <ul><li>Good language skills and some social empathy blur the clinical picture </li></ul><ul><li>Girls/Women with ASD tend to be overanxious and fuss (on to getting depressive) whereas boys/men with ASD do not seem to feel awkward or guilty. </li></ul><ul><li>Girls/Women can show “compensatory” obsessive-compulsive behaviour’s (eating disorders and addiction) </li></ul>
  47. 47. Relationships and Sexuality <ul><li>Sexuality in ASD is still often a taboo subject!!! </li></ul><ul><li>ASD is a cognitive disorder without biological deviances </li></ul><ul><li>Women with ASD have great problems and many questions with regards to sexuality </li></ul><ul><li>But mostly they can easily become victims of sexual abuse (eager as they are to get contact with others… but at what price !!!) </li></ul>
  48. 48. General Conclusions & Discussion <ul><li>More AD in young girls </li></ul><ul><li>More PDD-NOS in women </li></ul><ul><li>Comorbidity </li></ul><ul><ul><li>Affective comorbidity in females at all ages </li></ul></ul><ul><ul><li>In boys more externalizing problems </li></ul></ul><ul><ul><li>Psychosis occurs in 1/20 adults with PDD-NOS </li></ul></ul><ul><li>Caveat: this is a series of cross-sectional studies and will need to be confirmed in a longitudinal design </li></ul>
  49. 49. Conclusions Women <ul><li>Diagnosing ASD in women is difficult especially in milder cases </li></ul><ul><li>High levels of Co-morbidity </li></ul><ul><ul><li>clinical impression is that it plays a blurring role but this has to be confirmed </li></ul></ul><ul><li>Be aware of signs of abuse and misuse </li></ul><ul><li>( ♀ with ASD suffer a great deal because they cannot </li></ul><ul><li>or dare not to express themselves) </li></ul>
  50. 50. Thanks to <ul><li>Maartje de Kanter </li></ul><ul><li>Wouter Groen </li></ul><ul><li>Iris </li></ul><ul><li>Servatius-Oosterling </li></ul><ul><li>Patricia </li></ul><ul><li>Van Deurzen </li></ul>
  51. 51. <ul><li>and of course to you for your kind attention! </li></ul><ul><li>Questions? Comments? </li></ul>

×