Thursday, 7 July 2011

PTSD and autism

'When I'm asleep, dreaming and lulled and warm, they come, the homeless ones, the noiseless dead'. The opening line from the poem 'Sick Leave' by the World War I poet Siegfried Sassoon. Sassoon, alongside other poets of the time, famously depicted the true horror of the trenches of the Great War in his various writings after himself being hospitalised for 'shell shock'.

In modern times, the term 'shell shock' and it's various presentations such as the thousand yard stare, whilst not forgotten, has been superseded by quite a few other descriptions; most notably that of post-traumatic stress disorder (PTSD), reflecting the increasing interest of psychology and psychiatry in the topic. Whilst still primarily associated with war and conflict, PTSD has found its way into the various diagnostic texts of the ICD and DSM, including proposals for a revised PTSD diagnosis in preschool children in the upcoming DSM V revisions. The core notion being that witnessing an act or threat of an act of violence leads to a 'replaying' of said event and the onward effects of heightened arousal as a consequence. The DSM V proposals also seek to include a sexual element to the trigger factors, mindful of the effects that such experiences under certain circumstances can have.

Down the years there has been some discussion about PTSD co-morbid to autism. Given that the world still witnesses war and conflict, it is perhaps implied that during such actions, people with autism will invariably be caught up either as civilians or even military personnel during such occasions. Although perhaps slightly going off at a tangent, autism and the military has been discussed at some length from various points of view; be it parents serving in the military or even controversy regarding the suggestion that the military might be a possible career path for those towards the more able end of the autism spectrum. Whether during conflict or during the course of day-to-day life such as the recent devastation in the States, people with autism are therefore at similar risk as everyone else to witness events that might have profound influence on their health and well-being.

The literature on co-occurence of PTSD in cases of autism is currently quite sparce. Most comes from either personal case reports or more speculative literature on a possible association, with individual study following response to natural disasters added. I was drawn to this article which speculated on the potential effects that the use of certain restraint procedures and/or aversives might produce in cases of autism. Reading through it, my mind also drifted towards the recent actions uncovered in a residential setting here in the UK which was home to some adults with autism. The reporter describes how he was 'haunted' by the scenes he witnessed - what about the people who experienced such acts?

This abstract from the IMFAR 2009 conference potentially ties into the same issue. Although only an abstract, it details how a young child with an autism spectrum disorder also presented with PTSD as a result of multiple treatment for retinoblastoma. The study highlights the difficulties in disentangling what is autism and what is PTSD and also perhaps highlights how, with a little attention, the 'layers' of autism can be peeled away diagnostically to reveal other co-morbidities, in this case PTSD.

In my continuing quest to demonstrate how autism as a diagnosis does not seem to be protective of other conditions and complaints, I do think we have to be very careful when proceeding down the PTSD diagnostic path. PTSD, like many diagnoses, share certain characteristics with autism irrespective of any co-morbidity being present or not. Indeed, coupled with the presence of problems with communication seen in many cases, we do need to ensure that we don't start to enter the rather shaky ground made from other judgements.

I finish with a link to a poem by Wilfred Owen on the War to end all Wars.