Mental Illness in Adults with
Autism Spectrum Disorder
Preliminary results of a study of comorbidity
Martyn Matthews
What we know so far
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Around 90% of ASD research is about
children
Most adult ASD research is about problem
behaviour
A few studies have identified that adult
outcomes are negatively influenced by
mental health problems (Howlin 2009)
Very little research has looked at the
mental health of adults with ASD
Confusion
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What are core features
of ASD vs. comorbid
disorders?
How can we make a
clear assessment or
diagnosis (tools &
knowledge)
whether the usual
treatment/intervention
work for people with
ASD
Conflict

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Who should
provide or pay for
services
Getting access to
inpatient mental
health services
(getting past the
gatekeeper)
Behaviour of
people with ASD in
mental health
settings
So what does the evidence tell
us?
Anxiety Disorders
• Anxiety seems to be a key feature
of ASD, but we don’t have strong
research evidence for this notion
• But, case study evidence suggests a
100% prevalence!
However,
Only one well designed prevalence
study has been done by Szatmari et
al (2000).
• 13.6% ( 8 out of a group of 59
teenagers with AS or HFA) had
anxiety at a level that met DSM IV
diagnostic criteria.
• Rates for general population are 35%
DSM IV Generalised Anxiety
Disorder
A. At least 6 months of "excessive anxiety and worry" about a variety of events and situations.
Generally, "excessive" can be interpreted as more than would be expected for a particular situation
or event. Most people become anxious over certain things, but the intensity of the anxiety typically
corresponds to the situation.
B. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult
struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met.
C. The presence for most days over the previous six months of 3 or more (only 1 for children) of
the following symptoms:
1. Feeling wound-up, tense, or restless
2. Easily becoming fatigued or worn-out
3. Concentration problems
4. Irritability
5. Significant tension in muscles
6. Difficulty with sleep
D. The symptoms are not part of another mental disorder.
E. The symptoms cause "clinically significant distress" or problems functioning in daily life.
"Clinically significant" is the part that relies on the perspective of the treatment provider. Some
people can have many of the aforementioned symptoms and cope with them well enough to
maintain a high level of functioning.
F. The condition is not due to a substance or medical issue
Possible implications
It is extremely hard to differentiate between ASD symptoms
and an anxiety disorder
Low level, generalised anxiety may be a key feature of ASD
(85-90%), though this may not be ‘anxiety’ as we
currently understand it
In some individuals it is a diagnosable comorbid disorder
(10-15%)
More able people with ASD have higher levels of anxiety
(may just be ability to report symptoms)
Mood Disorders
Depression
Case study and clinic population studies
indicate that adults with ASD are much
more likely to experience depression than
the general population:
•
•
Sterling et al (2007), 20/46 (43%) of adults with
ASD had symptoms that would meet DSM IV
criteria for depression
Wing (1984), 10/34 (29%) of young adults with
AS had diagnosable depression
Rates for general population are 6.8% (NCS-R, 2001)
Depression & co-existing
disorders
Q. In the general population, depression is
frequently comorbid with an additional
disorder, so is this also true for people
with ASD?
A.
It looks likely, case study descriptions
suggest that:
As depression worsens, stereotypic or
ritualistic behaviour increase to meet OCD
diagnostic criteria
Or
Restlessness and hyperactivity increase to
meet ADHD diagnostic criteria
Gahaziudin M, Gahaziudin N, Greden J (2002)
Bipolar Disorder
We know very little:
Some case reports
Lots of internet forum discussions
Little data
Psychosis
Catatonia has highest prevalence
rates of psychotic disorders in
adults with ASD.
•
•
Billstedt & Gilberg (2005)
12%
(10 of 120)
Wing & Shah (2000)
17%
(86 of 506)
Psychosis
Psychotic disorders are rare in people
with ASD, despite the fact that
autism used to be classified as a
psychotic disorder
Schizophrenia is very rarely diagnosed.
•
•
Billstedt & Gillberg (2005) identified 1 individual from a sample of
120 adults with ASD
Volkmar & Cohen (1991) identified 1 adult from a sample of 163
adolescents & adults with ASD
Prevalence rate is the same as
general population (0.4-0.6%)
Psychosis
Catatonia
DSM IV criteria
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motor immobility as evidenced by catalepsy
(including waxy flexibility) or stupor;
excessive motor activity (purposeless, not influenced
by external stimuli);
extreme negativism (motiveless resistance to all
instructions or maintenance of a rigid posture
against attempts to be moved) or mutism;
peculiarities of voluntary movement as evidenced by
posturing, stereotyped movements, prominent
mannerisms, or prominent grimacing
echolalia or echopraxia
So what do we really know?
What we know about mental illness
in people with ASD, is still “not a lot”
What we do know relates mostly to
people who are usually described as
high functioning
Almost nothing about the ‘inner
world’ of people with ASD and severe
intellectual disability
Some Solutions
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More research!
Use screening tools to identify
undiagnosed disorders
Train support workers to observe
for and record information relating
directly to mental health of the
individual
Provide training to mental health
services around ASD
Otago Study
Based in Department of
Psychological Medicine, University
of Otago.
Researchers
Martyn Matthews
Dr Kumari Fernando
Dr Brigit Mirfin-Veitch
Aims of study
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To identify the range of psychiatric disorders
experienced by a sample of people with ASD
Examine similarities/differences in types of disorder
experienced by ID vs Non-ID adults with ASD
To compare range and rate of disorders with ID only
and general population studies
Identify effective treatments & support strategies
Identify service gaps & future needs
Method
120 individuals
40 with both ID
and ASD
40 ASD, no ID
40 ID/No ASD
Method
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Review of service provider & DHB
files for individual clinical/diagnostic
data
Completion of screening tool with key
support agent for ID and ID/ASD
groups
Questionnaire to clinicians gathering
data on ASD/no ID group and
treatment issues
Qualitative interviews re experiences
of treatment & support services
Psychiatric Screening Process & Tools
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The REISS Screen for Maladaptive
Behaviour (Reiss S, 1988, revised
2009)
The ASD-A (Autism Spectrum
Disorder Battery-Adult Version),
(Matson, J,Terlonge, C & Gonzalez
M, 2006)
Characteristics
10 adults with ID & ASD
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80% male
All have 24 hr support
90% take one or more psychoactive medication
7 people have severe or profound intellectual
disability
3 have mild to moderate intellectual disability
9 have formal diagnosis of Autistic Disorder
1 has no formal diagnosis, but meets DSM IV
criteria for Pervasive Developmental Disorder-Not
Otherwise Specified
Results
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70% of the group had clinically
significant scores for anxiety
60% displayed self injurious
behaviour
50% had Conduct Problems
40% showed symptoms of
depression
30% had clinically significant
impulsivity or hyperactivity
Overall ASD-CA Scores
ASD-CA Comorbidity Scores
Shaun
Garth
9
8
7
6
5
4
3
2
1
0
Kenny
Bede
Natalie
Depression
Hyperactivity
Behavioural
Excess/Irritabilit
y
Conduct
Problems
Anxiety
Brian
Vince
Rachel
Wilf
Dan
Mean
Scores
(Otago)
Clinical Cutoff
Mean Scores on ASD-A
ASD-A Mean Scores for ASD/ID Group
6
5
4
3
2
1
0
Mean Scores
(Otago)
Mean Scores
(Louisiana)
Clinical Cut-off
An
xie
ty
Co
nd
Be
uc
tP
rob
Hy
ha
v
i ou
lem
s
pe
r
ral
ac
Ex
ce
ss
De
pr
/ Ir
tiv
ity
rita
b
ilit
y
es
sio
n
Mean Scores on REISS Screen
REISS Comorbidity Mean Scores: ASD/ID group
6
5
Mean Scores
(Otago)
4
Mean Scores
(Chicago)
3
2
Clinical Cutoff
1
Ag
gr
e
ss
iv
e
Ps
Be
ha
vi
o
ur
yc
ho
s
Pa is
D
ep
ra
re
no
ss
ia
D
io
ep
n
(B
re
ss
eh
io
)
n
(
PD
ph
y
D
ep s )
en
de
PD
nt
Av
oi
da
nt
0
Be
ha
vi
ou
Ps
r
yc
ho
sis
Pa
De
r
pr
an
e
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a
De ssio
n
pr
(
es
Be
sio
h)
n
(p
PD
hy
D
s)
ep
en
de
PD
Av nt
oi
da
nt
e
iv
ha
v
io
ur
al
ep
r
y
sio
n
ity
bi
lit
tiv
ac
es
yp
er
D
H
ty
le
m
s
xie
rit
a
ro
b
/Ir
tP
uc
ce
ss
Ex
on
d
An
9
8
7
6
5
4
3
2
1
0
Ag
gr
es
s
Be
C
Rachel
ASD-CA comorbidity: Rachel
Mean Scores
Rachel
Clinical Cut-off
REISS Comorbidity scores: Rachel
9
8
7
6
5
4
3
2
1
0
Mean Scores
(Otago)
Rachel
Clinical Cutoff
D
id
nt
an
t
de
s)
)
oi
a
(p
hy
Av
o
r
s
(B
eh
en
n
De
p
PD
PD
sio
ra
n
n
Pa
sio
es
es
ep
r
ep
r
D
io
u
yc
ho
si
Ps
Clinical Cut-off
av
2
Be
h
Mean Scores (Otago)
ive
ep
re
ss
io
n
3
ss
lity
ity
yp
er
ac
tiv
D
H
em
s
et
y
/Ir
rit
ab
i
es
s
xc
Pr
ob
l
An
xi
Brian
gr
e
ur
al
E
on
du
ct
4
Ag
Be
ha
vi
o
C
Brian
ASD-CA comorbidity: Brian
7
6
5
1
0
Reiss Comorbidity Scores: Brian
8
7
6
5
4
Brian
Mean Scores (Otago)
3
Clinical Cutoff
2
1
0
Discussion
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70% had clinically significant scores for
one or more additional disorder
High rates of anxiety and depression
found across both screening tools.
Severe challenging behaviours were also
highly prevalent in the group (60%).
Results indicate that additional psychiatric
problems may have a major influence on
the behaviour of adults with ASD
Screening Tools:
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Both screening tools are
straightforward to use
Results are useful in identifying the
need for targeted psychiatric
treatment.
The ASD-A Screen shows particular
promise in the assessment of
anxiety, depression and behavioural
disorders.
ASD-A Diagnostic Scores
35
Kenny
30
25
Bede
Natalie
Bob
20
15
Vince
Rachel
Wilf
10
5
Dan
Mary
Kevin
0
ASD-D-A diagnostic screen
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Scores of 19+ indicate ASD
For autistic disorder score of 11+
Social behaviour and 8+ on
repetitive behaviour/ restricted
interests