On treating psychosis in the context of autism

"This report describes the successful improvement in symptoms and quality of life in a young man with psychosis and ASD [autism spectrum disorder], who had previously tried numerous medical interventions."

So said the findings published by Victoria Bell and colleagues [1] (open-access available here) providing some discussion not only about how a diagnosis of autism is seemingly not protective against the development of something like psychosis (see here) but also how psychosis in this context can be successfully managed with a little bit of [clinical] thought. I'll also draw your attention to some other quite recent research that has conversely talked about how difficult it can be to treat psychosis when an autism diagnosis is also in the frame (see here).

Bell et al discuss a case report of a young man (HP) who came to clinical attention in his mid-teens. School examinations seemed to be a possible trigger for episodes of vomiting after eating, leading to hospitalisation. Other symptoms also appeared - "a lowering of mood and poor sleep, and weight loss" - leading to more clinical contact. Bullying was also a feature; as we are told that: "a group of boys had made videos of him, including him being flash mobbed, which had been placed on YouTube; they had also made a persecutory Facebook page." I can think of a few choice words to describe such boys and their antics but won't.

As time progressed, he had "an in-patient admission to a Child and Adolescent Mental Health Services ward, for over a year" where a diagnosis of Asperger syndrome was made alongside "dissociative disorder, and a severe depressive episode with psychotic features." Lots more followed including him becoming "increasingly non-communicative and episodically aggressive toward his parents" culminating in him returning to an in-patient setting.

What is rather refreshing to see is the clinical work-up that this young man received. So: "magnetic resonance imaging (MRI) scans, electroencephalograms (EEGs), anti-NMDA antibodies, as well as B12, folate and thyroid function tests were repeatedly normal." Some critical thinking eventually led clinicians to discount the idea that his symptoms 'were just part of his autism' - "differentiating between psychotic catatonia and autism-related catatonia" - and instead look to a comorbid diagnosis of psychosis. Further: "this was adopted as our working diagnosis for treatment."

Treatment came in the form of various pharmacotherapy and some 'psychological input' bearing in mind "HP remained selectively mute throughout his admission." His clinical management wasn't exactly helped by the fact that another 'very disruptive patient' was admitted at the same time as HP and, on more than one occasion, physically attacked him. But eventually the 'number of days out' increased and symptoms such as vomiting, incontinence and aggression decreased as the "symptom-based approach" adopted seemed to work.

What lessons can be learned from this case report? Well, several. Not least that as well as not existing in some sort of diagnostic vacuum (see here), a diagnosis of autism can and does raise the risk of various psychiatric comorbidity potentially appearing. And sometimes it's hard to see where autism ends and said comorbidity starts (see here for example); assuming that is, that you see comorbidity as comorbidity and not something rather more core.

There is also a positive message from the Bell findings in relation to the 'treatability' of various comorbidity over-represented alongside autism. Yes, it takes time and resources to diagnose and rule things in or out, but quality of life can be improved for the person and those around them. Indeed the authors add: "The level of violence upon admission concerned our team and his parents... if psychotic symptoms were ignored, violence may have continued and led to long-term placements in a more secure environment." Indeed.

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[1] Bell V. et al. A symptom-based approach to treatment of psychosis in autism spectrum disorder in October 2017. BJPsych Open. 2018 Jan;4(1):1-4.

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Catatonic symptoms and autism

"Catatonic symptoms are more prevalent in young people with autism than previously thought" said the article recently published by Breen and Hare [1]. Continuing a research theme of at least one of the authors [2], the idea that catatonic symptoms - primarily manifesting as stupor, unresponsiveness to light, noise or touch, mutism, etc - might be over-represented when it comes to autism is not a new one by any means.

Breen & Hare set about looking for "the presence and nature of such attenuated behaviours in children and adolescents with autism" based on something called the Attenuated Behaviour Questionnaire. This was delivered to parents/caregivers online alongside looking at information from other measures based on the presence of repetitive behaviour and depression.

"Attenuated behaviour indicative of catatonia was relatively common in young people with autism with up to 20.2% having an existing diagnosis of catatonia and evidence of a relationship between attenuated behaviours and measures of depression and repetitive and restricted behaviours." Such findings as I said, are by no means novel but once again highlight how a diagnosis of autism or autism spectrum disorder (ASD) is seemingly protective of nothing when it comes to comorbidity. To quote another author on this topic: "an unabashed drumroll for increased recognition and treatment of catatonia in autism spectrum disorders (ASD)" [3] is needed.

Catatonia appearing alongside [some] autism leads into a number of areas in relation to the 'closeness' of any relationship (some people have talked about 'autistic catatonia') and the management strategies that may be subsequently indicated. On the issue of management, guidance is available [4] albeit including a strategy - electroconvulsive therapy (ECT) - that is probably not going to win any awards in terms of popularity given its historical basis. Accepting that still today ECT as an 'intervention' option when it comes to autism still courts heated discussion (see here), there is the requirement for much greater study of catatonic symptoms in relation to autism and whether there may be several presentations ripe for more novel intervention [5] (in light of a growing area of research interest). Said intervention might also take into account the plurality of autism too (see here)...

To close, yet another song for my brood and a very proud father who saw some real talent in the karate competition yesterday (those first place trophies are proof that team kata and team kumite are definitely the way forward)...

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[1] Breen J. & Hare DJ. The nature and prevalence of catatonic symptoms in young people with autism. J Intellect Disabil Res. 2017 Feb 1.

[2] Hare DJ. & Malone C. Catatonia and Autistic Spectrum Disorders. Autism. 2004; 8: 183-195.

[3] Dhossche DM. Decalogue of Catatonia in Autism Spectrum Disorders. Frontiers in Psychiatry. 2014;5:157.

[4] Mazzone L. et al. Catatonia in patients with autism: prevalence and management. CNS Drugs. 2014 Mar;28(3):205-15.

[5] Kiani R. et al. Anti-NMDA-receptor encephalitis presenting with catatonia and neuroleptic malignant syndrome in patients with intellectual disability and autism. BJPsych Bull. 2015 Feb;39(1):32-5.

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Breen J, & Hare DJ (2017). The nature and prevalence of catatonic symptoms in young people with autism. Journal of intellectual disability research : JIDR PMID: 28150394