Sunday, 7 April 2013

Asperger syndrome in first-episode psychosis

There are some key 'go-to' peer-reviewed texts which I've found to be useful when talking about the various conditions on the autism spectrum. On the topic of Asperger syndrome, I've always tended to come back to the paper by Tom Berney* (open-access) charting the progression of the condition through childhood into adulthood.
The whisper of the Muse @ Wikipedia 

Despite being published nearly 10 years ago, the paper by Dr Berney weathers well and covers many of the discussions which have come to the forefront in recent years including education and employment prospects, the potential for overlap with the schizophrenia spectrum and the difficult issue of offending behaviour.

Indeed the first place I went looking after reading the paper by Conor Davidson and colleagues** highlighting the prevalence of Asperger syndrome (AS) in cases of first-episode psychosis (3.6%), was the Berney paper to see if this was something new, a rehash of what is already known about or just a chance event. Turns out there was a pearl of wisdom in there as per his observations on 'mistaking Asperger syndrome for psychosis' and in particular "high arousal in a developmental disorder can produce an acute and transient psychotic state with hallucinations and thought disorder".

I'm sorry that I can't post a link to the full-text of Dr Davidson's paper but take my word for it that it is an interesting piece of research, well thought out and well executed. Without wishing to plagiarise the work, there is an interesting case study nestled among the data, describing the experiences of one participant and his lifelong features of AS which were seemingly not picked up by any agency. In particular the description demonstrates how following the transition from home environment to University, the new social demands contributed to him "eschewing all human contact" and after a period of issues with eating and sleeping he developed grandiose delusions with a theme of absolute control over others: "I'm studying neuroscience to take over people's minds... take over the world... become immortal and invincible". Apparently Tony Attwood has previously described this 'God mode'.

OK, let's back up here a little and put this in context. I've said it many times before on this blog, how a diagnosis within the autism spectrum is seemingly protective of nothing when it comes to comorbidity. That people diagnosed and living with an autism spectrum condition might also be more prone to various other psychiatric comorbidity particularly into young adulthood is no big secret (see this paper by Lugnegård and colleagues*** for example) and has been raised before on this blog.

Yes, one could look to that recent Lancet study**** as being evidence that there may be a genetic 'fragility' towards common ground between autism and other conditions but let's not get too ahead of ourselves when it comes to all things genetic. The important caveats being that such psychiatric comorbidity is by no means a universal phenomenon to everyone with autism, and realising the potentially important effects that a person's environment for example, has on the presentation or protection against said comorbidity (social circles and support, living conditions, employment, finances, etc.). Oh and the possible involvement of a few more biological factors too...

Still I find myself intrigued by the Davidson findings and their suggestions about clinicians being "alert to the possibility of Asperger syndrome when assessing patients" presenting with psychosis. Not least because of the implications for the appropriate detection and assessment of Asperger syndrome; only in this study becoming apparent to health care professionals when the individual was presenting with first-episode psychosis.

Questions, questions, questions: why were these young adults not initially 'picked-up' for an autism spectrum conditions when younger, as per the Berney statement, was Asperger syndrome to 'blame' for their psychosis presentation, and what are the longer-term implications of Asperger syndrome for example related to other future episodes of psychosis and their management?

Added into the mix too are papers like this one from James MacCabe and colleagues***** which suggested that a decline in cognitive performance and verbal ability during the adolescent years might translate into an increased risk for psychosis in adulthood. If so, could this be a potential way of differentiating Asperger syndrome + psychosis from psychosis as a result of Asperger syndrome and that 'high arousal' quoted by Berney? Indeed on the back of the paper by Sönmez and colleagues****** (open-access) is there also a tie-up between first-episode psychosis, depression and Asperger syndrome too?

I haven't got any specific answers to these questions by the way, aside from reaffirming my line about a diagnosis of an autism spectrum condition being seemingly protective of nothing when it comes to somatic or psychiatric comorbidity. Oh and the need for appropriate services and support to identify and if possible, mitigate such comorbidity as and when it does present.


* Berney TP. Asperger syndrome from childhood into adulthood. Adv Psychiatr Treat. 2004; 10: 341-351.

** Davidson C. et al. Prevalence of Asperger syndrome among patients of an Early Intervention in Psychosis team. Early Interv Psychiatry. March 2013.

*** Lugnegård T. et al. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Res Dev Disabil. 2011; 32: 1910-1917.

**** Cross-Disorder Group of the Psychiatric Genomics Consortium. Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet. February 2013.

***** MacCabe JH. et al. Decline in cognitive performance between ages 13 and 18 years and the risk for psychosis in adulthood. JAMA Psychiatry. 2013; 70: 261-270.

****** Sönmez N. et al. Depressive symptoms in first episode psychosis: a one-year follow-up study. BMC Psychiatry 2013; 13: 106.

---------- Davidson C, Greenwood N, Stansfield A, & Wright S (2013). Prevalence of Asperger syndrome among patients of an Early Intervention in Psychosis team. Early intervention in psychiatry PMID: 23472601