Autism spectrum disorder and
mental health
Autism spectrum disorder: a lifespan perspective
To be published, Jessica Kings...
9.30 Introduction
9.45 to 10.15 where I work, what I am looking for from the day
10.15 to 10.45 common mental health probl...
Disorder	
  (Seedat	
  et	
  al,	
  2009)	
       %affected	
  (95%	
  confidence	
  

                                     ...
Mini-SPIN (Connor et al, 2001)
    •  ‘‘Fear of embarrassment causes me
       to avoid doing things or speaking to
      ...
WHO screening questions for ADHD
•  How often does he/she have trouble finishing a task or project once the
   challenging...
%	
  people	
  with	
  ASD	
  	
                                                                   Hofvande
and	
  with	
 ...
OCD

•  Obsession: recurrent, intrusive thought. Not
   simply worry. anxiety
•  Compulsion: Action. anxiety
•  Person rea...
OCD: Course

•    75% have both obsessions and compulsions
•    Sudden onset after stress
•    1/3 worsen; 1/3 improve; 1/...
PTSD

•    Must experience extreme trauma
•    Re-experience trauma
•    Avoid reminders
•    Numbing
•    Persistent hype...
Psychosis: illness features
•  Positive symptoms"
  •    Hallucinations"
  •    Disorganized thinking"
  •    Delusions"
 ...
Psychosis: the affected person may: "

•  Talk to himself "
•  See things"
•  Gesture to himself "
Psychosis: the affected person may: "

•    Become confused in their speaking"
•    Appear muddled"
•    Dress in layers i...
Psychosis: the affected person may: "

•    May even believe he is God "
•    See things"
•    Feel people are out to get ...
Psychosis: the affected person may: "

•  May become restless and over-active for no
   reason"
•  Become slowed, and some...
Psychosis: the affected person may: "

•    Be unable to work "
•    Stop talking or greatly reduce conversation "
•    Ap...
•  Are voices always hallucinations?
•  Are weird ideas always delusions?
•  Is incoherent speech always thought
   disord...
•  physical agitation and/or anger
•  expressed intent to kill or take revenge
•  identification of specific victim(s)
•  ...
•  living under circumstances of violence
•  environmental access to guns or other lethal
   weapons
•  membership of viol...
Number of children

                                          Ratio of improved       trying this treatment (% of

Type of...
Ratio of improved to        Number of children trying this

Type of intervention	
                no effect or worse	
    ...
What are the real drug effects?
•  Reducing severe depression:
      Antidepressants
•  Reducing positive symptoms:
  •  A...
Choose a drug with least side
effects
Psychological treatments

•  Some specific anxiety reduction with
   cognitive methods
•  Some specific improvement of moo...
Parental or informal carer
involvement
•  Reduces depression, and therefore critical
   comments, and hostility
•  Reduces...
• Impaired nonverbal communication (expression and
interpretation) is the sine qua non
• There is a low bandwidth ‘interbr...
Enmeshment

•  Anxious attachment
•  Caused by threat
•  Identity threat to family system and work with
   it, and not aga...
The power of power

•  The rage that conceals impotence, or
   incapacity is inversely proportional to
   popularity and ‘...
From The autistic spectrum OpenLearn LabSpace




                           Sacar, Bradford 22 Oct 09
Sacar, Bradford 22 Oct 09
Features of nonverbal inexpressiveness



    •  Reduction of expression or occasionally
       idiosyncratic expressions ...
Feature of nonverbal
         inexpressiveness

•  Reduction of expression or occasionally
   idiosyncratic expressions su...
Atypical Asperger syndrome: a disorder of
       nonverbal interpretation

•  Primary abnormality is lack of
   empathy, p...
Knowing about the world using non-verbal
cues

                                      Who is being
                        ...
Is Asperger syndrome the future?
Owen Thor Walker apointed to TelstraClear, who previously wrote code enabling
a hacker gr...
Psychological disorder in people with Autism Spectrum Disorders
Psychological disorder in people with Autism Spectrum Disorders
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Psychological disorder in people with Autism Spectrum Disorders

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An overview of the mental health problems of people with Asperger syndrome: a workshop originally given to senior staff of the National Autistic Society

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Psychological disorder in people with Autism Spectrum Disorders

  1. 1. Autism spectrum disorder and mental health Autism spectrum disorder: a lifespan perspective To be published, Jessica Kingsley, 2010 Can the world afford autistic spectrum disorder? Published Jessica Kingsley, 2009 www. dilemmas.org Digby Tantam, Universities of Cambridge and Sheffield Dilemma Consultancy
  2. 2. 9.30 Introduction 9.45 to 10.15 where I work, what I am looking for from the day 10.15 to 10.45 common mental health problems in ASD/ how to recognize them/ risks 10.45-11 break 11.00 common emotional and externalizing problems in ASD/ how to recognize them/ psychological/ medical treatments 12.30-1.15 Lunch. 1.15-1.45 work in small groups, select one challenging case where there was never an additional diagnosis, what mental health diagnosis or category might have been applicable, consider how this would have changed management (if at all) 1.45-3 How do these mental health problems link with ASD 3-3.15 break. 3.15-4.15 answer questions and feedback
  3. 3. Disorder  (Seedat  et  al,  2009)   %affected  (95%  confidence   interval)   Social  anxiety   29.2%  (13.2%  to  45.1%)   ADHD   28.2%  (13.3%  to  43%)   Opposi>onal  defiant  disorder   28.1%  (13.9%  to  42.2%)   Tic  disorder,  tricho>llomania,   enuresis,  encopresis  
  4. 4. Mini-SPIN (Connor et al, 2001) •  ‘‘Fear of embarrassment causes me to avoid doing things or speaking to people,’’ •  ‘‘I avoid activities in which I am the center of attention,’’ •  ‘‘Being embarrassed or looking stupid are among my worst fears.’’ Not at all Extremely 0 1 2 3 4 5
  5. 5. WHO screening questions for ADHD •  How often does he/she have trouble finishing a task or project once the challenging parts have been done? •  How often does he/she have difficulty getting things in order when he/ she has to do a task requiring organisation? •  How often does he/she have problems remembering appointments or obligations? •  When he/she has a task that requires a lot of thought, how often does he/she avoid or delay getting started? •  How often does he/she fidget or squirm with his/her hands or feet when sitting down for a long time? •  How often does he/she seem to be overly active and compelled to do things, like he/she was being driven by a motor? 1. Rarely 2. Occasionally 3. Frequently as a child 4. Frequently as a child •  as a child but has now stopped and still persists
  6. 6. %  people  with  ASD     Hofvande and  with  this   Hu5on  et   My  clinic   Balfe  et  al   r  et  al   Weighted   disorder   al  N=135   sample  N=490   N=78   N=122   mean  %   ADHD   43   43.00   Anxiety   16   42   47   50   39.40   Depression   25   30   17.68   Obsessive-­‐ compulsive  disorder   4   14   8.97   Substance  misuse   4   16   4.74   Somatoform   disorder   41   5   4.62   Bipolar  disorder   1   3.2   8   3.25   Panic  disorder   30   2.84   Brief  psychosis   3.4   2   2.32   Schizophrenia   3   3   2.23   EaSng  disorder   5   0.74   Catatonia   1   0.59   Delusional  disorder   1   0.15  
  7. 7. OCD •  Obsession: recurrent, intrusive thought. Not simply worry. anxiety •  Compulsion: Action. anxiety •  Person realizes irrationality. Ego-dystonic experience. Attempt at thought supression •  Lifetime prevalence: 2.5% in all cultures
  8. 8. OCD: Course •  75% have both obsessions and compulsions •  Sudden onset after stress •  1/3 worsen; 1/3 improve; 1/3 stay ill •  1/3 have Major Depression •  Suicide risk
  9. 9. PTSD •  Must experience extreme trauma •  Re-experience trauma •  Avoid reminders •  Numbing •  Persistent hyper-arousal •  Dissociation
  10. 10. Psychosis: illness features •  Positive symptoms" •  Hallucinations" •  Disorganized thinking" •  Delusions" •  Movement disorder" •  Negative symptoms in schizophrenia" •  Decline in social and occupational functioning " •  Reduction of nonverbal expression (ʻflattening of affectʼ)" •  Partial mutism (poverty of speech)"
  11. 11. Psychosis: the affected person may: " •  Talk to himself " •  See things" •  Gesture to himself "
  12. 12. Psychosis: the affected person may: " •  Become confused in their speaking" •  Appear muddled" •  Dress in layers in any weather " •  Fail to bathe and get a haircut " •  Gain an odd interest in ordinary things (like religion) "
  13. 13. Psychosis: the affected person may: " •  May even believe he is God " •  See things" •  Feel people are out to get them " •  Believe in all sorts of conspiracies " •  Have ideas that no amount of evidence to the contrary can dislodge 

  14. 14. Psychosis: the affected person may: " •  May become restless and over-active for no reason" •  Become slowed, and sometimes immobile for long periods with long pauses in speaking" •  Limbs may seem as if made of soft bendable metal

  15. 15. Psychosis: the affected person may: " •  Be unable to work " •  Stop talking or greatly reduce conversation " •  Appear lazy, unmotivated and uninterested " •  May look like he has dementia " •  Lose the ability to get and keep friends " •  Be tense 

  16. 16. •  Are voices always hallucinations? •  Are weird ideas always delusions? •  Is incoherent speech always thought disorder? •  When is thought insertion, rumination?
  17. 17. •  physical agitation and/or anger •  expressed intent to kill or take revenge •  identification of specific victim(s) •  psychotic symptoms, especially 2nd person command hallucinations to commit violence •  persecutory delusions •  disinhibition caused by traumatic brain injuries and other central nervous system dysfunctions •  current use of alcohol or other drug
  18. 18. •  living under circumstances of violence •  environmental access to guns or other lethal weapons •  membership of violent peer group •  poor impulse control; risk taking or reckless behaviour •  statements to others of intent to inflict harm •  History of violence or antisocial acts
  19. 19. Number of children Ratio of improved trying this treatment (% of Type of medication   to no effect or worse   sample)   Miscellaneous GI medication   4.00   10 (2%)   Miscellaneous herbal medication   3.33   13 (2.7%)   Atypical antipsychotics   2.08   80 (16.7%)   Anxiolytics   2.00   12 (2.5%)   Stimulants   1.80   172 (35.9%)   Mood stabilizers   1.80   70 (14.6%)   Chelation   1.60   32 (6.7%)   GF and/or CF dietb 1.52 155 (32.4%)   Antidepressants   1.31   136 (28.4%)   Other dietc   1.19   54 (11.3%)   Miscellaneous other medication   1.17   13 (2.7%)  
  20. 20. Ratio of improved to Number of children trying this Type of intervention   no effect or worse   treatment (% of sample)   Applied behavior analysis (ABA)   3.76   225 (47.0%)   Social skills training   3.05   244 (50.9%)   Picture exchange system (PECS)   2.88   231 (48.2%)   TEACCH   2.86   88 (18.4%)   Positive behavioral support   2.82   233 (48.6%)   Sensory Integration   2.79   255 (53.2%)   Occupational therapy   2.77   361 (75.4%)   Physical therapy   2.68   146 (30.5%)   Speech therapy   2.53   403 (84.1%)   Early intervention services   2.39   331 (69.1%)   Social stories   2.33   197 (41.1%)   Floor time   2.10   129 (26.9%)  
  21. 21. What are the real drug effects? •  Reducing severe depression: Antidepressants •  Reducing positive symptoms: •  Antipsychotics •  Reducing anxiety •  ?SSRIs •  Reducing over-activity and increasing response control: •  Stimulants •  Reducing mood fluctuations •  Lithium and anticonvulsants
  22. 22. Choose a drug with least side effects
  23. 23. Psychological treatments •  Some specific anxiety reduction with cognitive methods •  Some specific improvement of mood with behavioural activation •  Otherwise there is no difference in modalities except •  Flavour and values •  Main outcome determinant is focus
  24. 24. Parental or informal carer involvement •  Reduces depression, and therefore critical comments, and hostility •  Reduces externalizing behaviour in client •  ‘oppositional behaviour’ •  Conduct disorder •  Bloody mindedness
  25. 25. • Impaired nonverbal communication (expression and interpretation) is the sine qua non • There is a low bandwidth ‘interbrain connection’ • Often associated with other learning difficulties and disconnection problems • People with AS are more susceptible to bullying, to emotional disorder, and therefore have worse quality of life than others with ASD • Understanding the experience of having ASD is key to more successful coping strategies WHAT IS ASD?
  26. 26. Enmeshment •  Anxious attachment •  Caused by threat •  Identity threat to family system and work with it, and not against it •  Define hostility as frustration •  Rage and anger as fear
  27. 27. The power of power •  The rage that conceals impotence, or incapacity is inversely proportional to popularity and ‘social influencing power’ •  Outrage conceals this •  In men, anger often conceals shame
  28. 28. From The autistic spectrum OpenLearn LabSpace Sacar, Bradford 22 Oct 09
  29. 29. Sacar, Bradford 22 Oct 09
  30. 30. Features of nonverbal inexpressiveness •  Reduction of expression or occasionally idiosyncratic expressions such as unusual prosody, facial mannerisms •  Affects all channels •  Voluntary signals e.g. social smiles unaffected •  Is not the commonest cause of gaze avoidance, in fact may result in staring Sacar, Bradford 22 Oct 09
  31. 31. Feature of nonverbal inexpressiveness •  Reduction of expression or occasionally idiosyncratic expressions such as unusual prosody, facial mannerisms •  Affects all channels •  Voluntary signals e.g. social smiles unaffected Sacar, Bradford 22 Oct 09
  32. 32. Atypical Asperger syndrome: a disorder of nonverbal interpretation •  Primary abnormality is lack of empathy, partly due to failure of non-verbal interpretation (‘face blindness’) •  Ability to make relationships but not to keep them •  Lack of empathy may lead to antisocial behaviour, but greater problem is lack of persuasiveness and ‘social influencing power’ Picture from the film, “Ripley’s game” starring Matt Damon as Ripley Sacar, Bradford 22 Oct 09
  33. 33. Knowing about the world using non-verbal cues Who is being shot? Terrorists or partisans? Sacar, Bradford 22 Oct 09
  34. 34. Is Asperger syndrome the future? Owen Thor Walker apointed to TelstraClear, who previously wrote code enabling a hacker group to steal £13.9M from bank accounts Bram Cohen, founder BitTorrent, and self diagnosed Aspie

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