Big data Taiwan on risk of "major psychiatric disorders" in kindreds of those with schizophrenia

'Big data' Taiwan listed in the title of this post refers to the wide range of findings emerging from the resource known as the National Health Insurance Research Database (NHIRD) based in Taiwan. Seriously people, this is population-wide science at it's very, very best (see here)...

Today I present yet another example of how the NHIRD is being put to good use and, as reported by Cheng and colleagues [1], how NHIRD derived data supports "the familial dose-dependent co-aggregation of schizophrenia, bipolar disorder, major depressive disorder, ASD [autism spectrum disorder] and ADHD [attention-deficit hyperactivity disorder]." In other words, how lots of seemingly individual and specific behavioural and psychiatric labels may well 'club' around each other in affected families.

So, the starting point: "A previous genetic study has suggested that schizophrenia, bipolar disorder, major depressive disorder, autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) share common disease-associated genes." Yes, several studies have talked about possible genetic 'relationships' between these labels (see here); accepting that structural genetics may only be a part of the story. Researchers specifically examined "whether individuals with first-degree relatives (FDRs) with schizophrenia have a higher risk of these major psychiatric disorders" and the extent of any enhanced risk.

The NHIRD harboured details for some 150,000 people diagnosed with schizophrenia and some 225,000 people with FDRs diagnosed with schizophrenia. Authors crunched the data to come up with relative risks (RRs) statistics using schizophrenia as the diagnostic starting point.

Results: "The individuals with FDRs with schizophrenia exhibited higher RRs (95% confidence interval) of major psychiatric disorders, namely schizophrenia (4.76, 4.65-4.88), bipolar disorder (3.23, 3.12-3.35), major depressive disorder (2.05, 2.00-2.10), ASD (2.55, 2.35-2.77) and ADHD (1.31, 1.25-1.37) than were found in the total population." You'll notice the sliding scale of RRs, where an index case of schizophrenia most significantly raises the RR of schizophrenia being diagnosed in first-degree relatives, down to a slightly lower RR in relation to something like ADHD among FDRs. It's probably to be expected that a diagnosis of schizophrenia might raise the risk of schizophrenia in FDRs too. Indeed, this is precisely what other NHIRD derived data has previously suggested (see here).

The range (and risks) of other diagnoses present in FDRs of someone diagnosed with schizophrenia is probably of little surprise to anyone who's surveyed the peer-reviewed literature in this area (see here) or indeed works in psychiatric circles. Although contemporary psychiatric science goes to some lengths to 'compartmentalise' specific diagnoses/labels, there's always been a strong undercurrent that labels are likely to be linked or at the very least, overlap. I've talked quite a lot for example, about the links between autism and schizophrenia on this blog (see here and see here). How, minus the [important] societal implications and politics, people such as Mildred Creak and colleagues [2] probably reached a closer 'definition' of some modern-day autism than we have now with their inclusion of "distortion in motility patterns" and "acute, excessive and seemingly illogical anxiety." Yes, they headed it "schizophrenic syndrome in childhood" and autism has been moved away from this description. But with all the emphasis on gait and motility patterns coming back into fashion together with increasing recognition of the truly disabling effect that anxiety can have in the context of autism, I think they were closer that many people thought to hitting the diagnostic mark.

Other implications from the Cheng results? Screening, enhanced screening. So when schizophrenia is diagnosed in the family, greater resources are put into preferential screening of first-degree relatives also for schizophrenia and the range of other labels mentioned in the current study. I'd also add that given the ever-growing relationship between the behavioural/psychiatric and the somatic, a greater consideration of some other health-related conditions (see here and see here for examples) might also be useful...

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[1] Cheng CM. et al. Co-aggregation of major psychiatric disorders in individuals with first-degree relatives with schizophrenia: a nationwide population-based study. Mol Psychiatry. 2017 Nov 7.

[2] Evans B. How autism became autism: The radical transformation of a central concept of child development in Britain. History of the human sciences. 2013;26(3):3-31.

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Self-reported sexual attraction and autism continued

"Attention to gender identity and sexual diversity in education and clinical work with people with ASD [autism spectrum disorder] is advised."

So said the findings reported by Jeroen Dewinter and colleagues [1] (open-access) adding to something of an important theme in autism research circles in recent times (see here). Drawing on self-reported responses for some 675 people diagnosed (self-reported diagnosis) with an autism spectrum disorder (ASD) compared with over 8000 not-autism (self-reported?) controls on 9 questions, some interesting trends were observed. Those questions asked about information in relation to "assigned gender at birth, gender identity, sexual orientation (sexual attraction and sex of the partner), relationship status and evaluation of relationship status, duration of the relationship, living situation, and whether the partner has (or is suspected of having) ASD."

I mentioned that participants "self-reported a diagnosis on the autism spectrum" but to be fair, authors did also employ the Autism Spectrum Quotient—Short Version (AQ) "to assess autistic traits" of their ASD group. I've been a little critical of the AQ on other occasions on this blog (see here) but am willing to concede that as a rough-and-ready measure, it's about as good as we have at the moment.

Results: "Most men and women in the ASD group identified conforming their assigned gender at birth." Bearing in mind data on gender identity were not actually available for the control group, authors did note that about a quarter of women with ASD in their cohort and just short of 10% of men "reported some gender non-conforming feelings."

In terms of sexual orientation, researchers noted that: "Sexual orientation was more varied in ASD compared to controls in both men... and women." So: "Compared to general population peers, more people with ASD, especially women, reported sexual attraction to both same- and opposite-sex partners."

Relationship status was also something asked about during the study. Fewer participants with ASD reported being in a relationship at the time of inquiry compared with controls (50% vs. 70%) but for those in a relationship, most were living with their partner and most were pretty satisfied with their relationship. Yet also: "Of the singles, 29% regretted their relationship status" so one has to careful about sweeping generalisations.

There is quite a bit of important information included in this article but there are also caveats. Aside from the self-report angle to autism diagnoses, the question in my mind is: how representative is this sample in terms of the very heterogeneous autism spectrum? Y'know, self-report typically implies insight from the more 'able' end of the autism spectrum, or at least those able to self-report, and onward whether sweeping generalisations are necessarily warranted to covering the entire autism spectrum (see here). Bearing in mind also the gaps in some of the responses for the control group, I also wonder whether honesty could be a key variable when it comes to comparisons with the ASD group. I say this on the basis that very personal information about sexual identity and/or thoughts and feelings might be more honestly described by those with autism than those without autism. As the authors put it: "autistic participants being less influenced by societal views or stereotypes on attraction and gender." Such a suggestion could accord with other work looking at context effects in relation to autism [2].

The specific point about more women with ASD in the Dewinter study reporting greater levels of "sexual attraction to both same- and opposite-sex partners" and more "gender non-conforming feelings" adds to other independent findings in the peer-reviewed domain (see here). Again, such observations highlight how sex education in the context of autism (as indeed, in the context of the general population) needs to be inclusive of the spectrum of sexuality.

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[1] Dewinter J. et al. Sexual Orientation, Gender Identity, and Romantic Relationships in Adolescents and Adults with Autism Spectrum Disorder. J Autism Dev Disord. 2017. June 9.

[2] Farmer GD. et al. People With Autism Spectrum Conditions Make More Consistent Decisions. Psychol Sci. 2017 Jun 1:956797617694867.

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A (bleedin' obvious) guide to happiness

Happy New Year!

Welcome back to Questioning Answers in 2017. While we wait to see just what this year will offer in [autism research] blogging terms, I open proceedings with the answer to happiness. Yes, you heard me right, I can officially unveil the Questioning Answers guide to happiness...

Drum roll please... and "Mental health and relationships 'key to happiness'."

As I unclutch my hands from my face and those opening 'bleedin' obvious' words included in the title of this post resonate once more alongside the question: 'how much did this research cost?' I direct you to some further discussion about the Origins of Happiness study (see here) from where results were derived.

Taken from: http://voxeu.org/article/origins-happiness

"So in short. If your suffering from depression your not very happy. Dontcha just love the intellectual elite" and "So in a nutshell, have the report's authors found that people not suffering with depression are generally happier than those that are suffering with it? How much are these geniuses paid?" are just two of the comments following that BBC coverage of the study results. With all due respect to the study authors and their introduction of new watchwords like 'wellbeing creation' over wealth creation, I am kinda reeling from the idea that we actually needed a study/report like this given the lack of surprising outcomes noted.

As per Figure 1 and the 'determinants of adult life satisfaction' is anyone really that surprised that having an education, a job, an income, being in rude health, having a special someone or even special 'some people', not being incarcerated or exposed to criminality and not suffering from depression and/or anxiety actually makes people more satisfied with their lives? No, and neither should you be.

I've little more to say on this topic aside from mentioning that (a) happiness is perhaps a relative term and something that includes both short-term and long-term elements to it and (b) the focus on treating mental health issues such as depression and anxiety with 'psychological therapies' (made by the author(s)) should not necessarily be to the exclusion of other well-validated treatment measures. Indeed, I might advance the position of a greater 'correlation' between physical health and mental health in light of other research findings (see here).

So: Be Happy! (I promise that my blogging this year will get better).

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Interest in romantic relationships is high in autism

It's official: "the vast majority of high-functioning adults with ASD [autism spectrum disorder] are interested in romantic relationships." Yes, the scientific findings reported by Sandra Strunz and colleagues [1] have said as much.

Sorry to be so sarcastic about them but coming from a place where the words 'the bleedin' obvious' are commonly used, I couldn't believe that in 2016 anyone would genuinely believe otherwise. Yes, I know the autism awareness et al message still has some distance to go, but underneath every diagnostic label including autism there are people: people with hopes, dreams, wants, needs and yes, even desires...

With all due respect to the authors and the work they put into doing this study - "total sample comprised 229 high-functioning adults with ASD (40% males, average age: 35 years)" - there is an interesting detail included in their paper such that: "7% had no desire to be in a romantic relationship." What this perhaps tells us is that when it comes to reporting on issues like quality of life and long-term outcome (see here) with autism in mind, people should be wary of making sweeping generalisations. But 7% means that 93% did have a desire for romance in their lives...

Insofar as where next with this area of research, well, there are a few avenues to suggest. Intimacy as one part of a 'romantic relationship' is something still in need of a lot more discussion as and when autism is included in the mix, in terms of education and aspects like safety and sexual health for example (see here). As difficult as it might be for some to acknowledge, people are generally 'designed' for relationships with others, and even those who might present with sometimes extreme disability as a result of their autism or related issues should not necessarily be seen as asexual in terms of their wants and needs. I know this issue has crossed into the legal domain in past times and intersects with other important areas such as competence and vulnerability. There are no easy answers.

Perhaps another important area for further research concerns how romantic relationships might affect the presentation of autism or other important (over-represented) comorbidities. Y'know, in the context of how relationships might be protective against certain things and how these manifest when it comes to the autism spectrum particularly where issues like depression and anxiety are over-represented (see here). That also the 'products' of some romantic relationships (yes, the brood) can also impact on health and wellbeing is another important area requiring quite a bit more investigation with autism in mind particularly in the context of parenting experiences.

But let's not complicate matters too much and turn the wants and desires of people into something that needs to be continually scrutinised and experimentally analysed. People generally want to be close to other people and autism should not necessarily be seen as a barrier to this...

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[1] Strunz S. et al. Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. J Clin Psychol. 2016 May 16.

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Strunz S, Schermuck C, Ballerstein S, Ahlers CJ, Dziobek I, & Roepke S (2016). Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. Journal of clinical psychology PMID: 27196958