The quote titling this post - "Ruminative thinking is the autistic dimension more strongly associated with suicidality" - comes from the findings published by Liliana Dell'Osso and colleagues [1] and provides something of an extension of previous work from authors on this paper (see here).
The important topic under investigation by Dell'Osso et al was suicidality; something that crops up time and time again in connection to the autism spectrum (see here). No, such a topic doesn't make for great PR 'about autism'. But if you want to talk about research/clinical priorities when it comes to the autism spectrum, I can't think of many topics that would be more pressing...
The hypothesis: those with subthreshold autistic traits (AT) and autism spectrum disorder (ASD) "will both show a higher prevalence of suicidal ideation and behaviors" when compared with asymptomatic controls. Further: "to clarify if AT do actually imply a risk factor for suicidality similar to full-blown ASD, hypothesizing that suicidal thoughts and behaviors will not differ between subjects with subthreshold autism and full-blown ASD." Similar sentiments have been previously expressed in other research results (see here and see here and see here).
I won't bore you with all the details of the hows-and-whys of Dell'Osso study (it is open-access) but do want to focus in on a few important observations made. First authors reported that they "found no differences in suicidality scores between ASD and AT groups, while both showed a higher score than HC [healthy controls]." I might add that 'HC' is a term used by the authors and wouldn't be my choice for describing a control group. This finding is important not just for autism but potentially for lots of other labels that manifest autistic traits (see here and see here) on the basis that autistic traits are not necessarily exclusive to a diagnosis of autism.
Second: "the ASD group reported significantly higher MOODS-SR total score and MOODS-SR depressive component score than the AT group, and the AT group in turn scored significantly higher than the HC." I don't think anyone should be really surprised by the finding that the symptoms of mood disorders such as depression seem to be 'over-represented' alongside a diagnosis of autism given other data on this issue (see here). Indeed, one might even say that depression could, for some autistic people, be considered a core issue over and above just being described as a comorbidity (see here).
Finally I head back to the title of this post, and how something like ruminative thinking - "a pattern of repetitive thinking, usually associated to and exacerbating anxiety and depression, often affecting problem-solving and the processing of negative feelings and leading to social isolation" - might be a particular dimension *associated* with suicidality in the context of autism or the presentation of subthreshold autistic traits. I've talked a few times about rumination in the context of autism on this blog (see here and see here). Rumination has also been talked about in the context of autism and suicide before too (see here). If research continues to point to rumination as something important, one might potentially envisage the development of interventions that could ameliorate such an issue and possibly onward *affect* the risk of something like suicidality?
I don't want anyone to get the impression that the Dell'Osso findings have *solved* the issue of suicidality in the context of autism because they haven't. As I've said many times before on this blog, suicide is a very, very complicated and deeply personal issue (see here) with no one-size-fits-all answer to the questions it raises. As part of a larger picture however, the Dell'Osso results are however important. If their application in a clinical context saves even one life, I would consider that to be infinitely worthwhile.
If anyone needs someone to talk to, there are people who will listen (see here and see here)...
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[1] Dell'Osso L. et al. Mood symptoms and suicidality across the autism spectrum. Comprehensive Psychiatry. 2019. April 3.
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Showing posts with label rumination. Show all posts
Showing posts with label rumination. Show all posts
Tuesday, 14 May 2019
Monday, 28 August 2017
Post-traumatic stress disorder (PTSD) and autism (minus the psychobabble)
Quite a few years back, I talked about the idea that a diagnosis of autism or autism spectrum disorder (ASD) is seemingly not protective of other conditions/labels appearing alongside in the context of post-traumatic stress disorder (PTSD) (see here). Described as an 'anxiety disorder', PTSD is a complicated condition typically encompassing several key features: experiencing one or more traumatic events (natural disaster, victim of crime, experiencing various forms of abuse, etc) and subsequent re-experiencing of said events (flashbacks, nightmares, anxiety, etc) significantly impacting on day-to-day life.
The paper by Haruvi-Lamdan and colleagues [1] provides some further, welcomed, research interest in the relationship between PTSD and autism in the context that a "potentially unique perception of traumatic events, particularly from the social sphere" might predispose those diagnosed with autism to be more vulnerable to PTSD than other groups.
I've titled this post 'minus the psychobabble' because, unfortunately, there is still a body of thinking out there that tries to explain concepts like PTSD in terms of schools of thought such as the psychoanalytical for example. I don't want to get into the nitty-gritty of whether your 'ego balances the id' or whatnot (and how one would actually evidence such concepts), but I do want to keep autism away from psychoanalysis. I say all that in the context that Haruvi-Lamdan et al note: "While autism and trauma were often linked in psychoanalytic theory..." but go on to provide some slightly more evidence-based discussions.
Three important points are made by the authors as to how PTSD (and trauma in general) might be linked to autism.
"First, autism spectrum disorder (ASD) may serve as a vulnerability marker for posttraumatic stress disorder (PTSD), specifically by increasing the risk for exposure to traumatic events." Although not easy to say, a diagnosis of autism or the presence of clinically-relevant autistic traits does seemingly put someone at far greater risk for experiencing various traumatic events [2]. I speak of peer-reviewed research talking about being a victim of bullying in the context of autism (see here) for example; noting that bullying is not always 'just playground shenanigans'. I would also refer you to some other factors that don't make for great dinner-table conversation in the context of autism (see here). And if you think that such factors are typically present only in childhood, think again. This all on top of the more usual likelihood of experiencing trauma that we all face.
"Second, PTSD, once it has appeared, may exacerbate certain ASD symptoms, for example, through maladaptive coping strategies and reduced help-seeking." I'm not in total agreement with the idea of 'maladaptive coping strategies' in the context of autism because science/practice does not really know enough about coping strategies (and concepts such as resilience) either in general or in the specific context of autism. I don't doubt that individuals with and without autism might have their own way of 'coping' but there is no evidence of some 'one-size-fits-all' across the entire diagnosis or population. I do agree that there may be aspects of autism that can lead to 'reduced help-seeking' as per the issue of communication and/or language use for example, and also the strength of social circles, but that's about as far as we can reliably say at this point.
"Third, there may be shared underlying mechanisms for PTSD and ASD, including neurological abnormalities associated with both disorders, as well as cognitive and behavioral mechanisms, such as increased rumination, cognitive rigidity, avoidance, anger, and aggression." Again there are some quite sweeping generalisations included in the authors writings here - 'neurological abnormalities'? - but they do raise some important points. Rumination - a deep or considered thought about something - coupled to perseveration is something that I've covered before in the context of autism (see here). It boils down to a potential heightened risk of 'not letting go' of a topic and how, in the context of trauma and PTSD, this could be something over-represented in the context of autism or the presence of autistic traits. Added to other issues such as an intolerance of uncertainty (see here) and you can perhaps see how autism and PTSD might not necessarily be miles apart. I probably didn't need to say it but will anyway, anxiety in the context of autism seems to be both rife and in many cases, is absolutely disabling (see here).
Although there may be several inter-connecting variables that potentially unite autism and PTSD, I don't want to lose sight of the heterogeneity that is present alongside both labels. Even in the context of experiencing some truly awful acts, there are disparities in whether PTSD is diagnosed in the context of autism [3] similar to the not-autism population. Diagnosis of autism and/or clinically relevant autistic features are likely to be only part of the picture here. That being said, there does seem to be grounds for quite a bit more investigation in this area, and onward, whether screening for PTSD in the context of autism should be more widespread and also examination of how effective the intervention(s) currently in place for PTSD are in the context of autism + PTSD...
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[1] Haruvi-Lamdan N. et al. PTSD and Autism Spectrum Disorder: Co-morbidity, Gaps in Research, and Potential Shared Mechanisms. Psychol Trauma. 2017 Jul 20.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 Jul;45:135-42.
[3] Brenner J. et al. Behavioral Symptoms of Reported Abuse in Children and Adolescents with Autism Spectrum Disorder in Inpatient Settings. J Autism Dev Disord. 2017 Jun 7.
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The paper by Haruvi-Lamdan and colleagues [1] provides some further, welcomed, research interest in the relationship between PTSD and autism in the context that a "potentially unique perception of traumatic events, particularly from the social sphere" might predispose those diagnosed with autism to be more vulnerable to PTSD than other groups.
I've titled this post 'minus the psychobabble' because, unfortunately, there is still a body of thinking out there that tries to explain concepts like PTSD in terms of schools of thought such as the psychoanalytical for example. I don't want to get into the nitty-gritty of whether your 'ego balances the id' or whatnot (and how one would actually evidence such concepts), but I do want to keep autism away from psychoanalysis. I say all that in the context that Haruvi-Lamdan et al note: "While autism and trauma were often linked in psychoanalytic theory..." but go on to provide some slightly more evidence-based discussions.
Three important points are made by the authors as to how PTSD (and trauma in general) might be linked to autism.
"First, autism spectrum disorder (ASD) may serve as a vulnerability marker for posttraumatic stress disorder (PTSD), specifically by increasing the risk for exposure to traumatic events." Although not easy to say, a diagnosis of autism or the presence of clinically-relevant autistic traits does seemingly put someone at far greater risk for experiencing various traumatic events [2]. I speak of peer-reviewed research talking about being a victim of bullying in the context of autism (see here) for example; noting that bullying is not always 'just playground shenanigans'. I would also refer you to some other factors that don't make for great dinner-table conversation in the context of autism (see here). And if you think that such factors are typically present only in childhood, think again. This all on top of the more usual likelihood of experiencing trauma that we all face.
"Second, PTSD, once it has appeared, may exacerbate certain ASD symptoms, for example, through maladaptive coping strategies and reduced help-seeking." I'm not in total agreement with the idea of 'maladaptive coping strategies' in the context of autism because science/practice does not really know enough about coping strategies (and concepts such as resilience) either in general or in the specific context of autism. I don't doubt that individuals with and without autism might have their own way of 'coping' but there is no evidence of some 'one-size-fits-all' across the entire diagnosis or population. I do agree that there may be aspects of autism that can lead to 'reduced help-seeking' as per the issue of communication and/or language use for example, and also the strength of social circles, but that's about as far as we can reliably say at this point.
"Third, there may be shared underlying mechanisms for PTSD and ASD, including neurological abnormalities associated with both disorders, as well as cognitive and behavioral mechanisms, such as increased rumination, cognitive rigidity, avoidance, anger, and aggression." Again there are some quite sweeping generalisations included in the authors writings here - 'neurological abnormalities'? - but they do raise some important points. Rumination - a deep or considered thought about something - coupled to perseveration is something that I've covered before in the context of autism (see here). It boils down to a potential heightened risk of 'not letting go' of a topic and how, in the context of trauma and PTSD, this could be something over-represented in the context of autism or the presence of autistic traits. Added to other issues such as an intolerance of uncertainty (see here) and you can perhaps see how autism and PTSD might not necessarily be miles apart. I probably didn't need to say it but will anyway, anxiety in the context of autism seems to be both rife and in many cases, is absolutely disabling (see here).
Although there may be several inter-connecting variables that potentially unite autism and PTSD, I don't want to lose sight of the heterogeneity that is present alongside both labels. Even in the context of experiencing some truly awful acts, there are disparities in whether PTSD is diagnosed in the context of autism [3] similar to the not-autism population. Diagnosis of autism and/or clinically relevant autistic features are likely to be only part of the picture here. That being said, there does seem to be grounds for quite a bit more investigation in this area, and onward, whether screening for PTSD in the context of autism should be more widespread and also examination of how effective the intervention(s) currently in place for PTSD are in the context of autism + PTSD...
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[1] Haruvi-Lamdan N. et al. PTSD and Autism Spectrum Disorder: Co-morbidity, Gaps in Research, and Potential Shared Mechanisms. Psychol Trauma. 2017 Jul 20.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 Jul;45:135-42.
[3] Brenner J. et al. Behavioral Symptoms of Reported Abuse in Children and Adolescents with Autism Spectrum Disorder in Inpatient Settings. J Autism Dev Disord. 2017 Jun 7.
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Monday, 11 April 2016
Levels of paranoia are higher in autism: systematic review
Paranoia, defined as the unfounded or exaggerated idea that something or someone is deliberately trying to psychologically, physically or financially harm you, is not an uncommon transient sentiment among the general population at one time or another. On a more pathological level, paranoid schizophrenia perhaps represents the archetypal label where paranoia assumes an altogether more persistent and 'life-changing' effect; also potentially escalating into more extreme behaviour/s.The idea that levels of paranoia might also be elevated as and when a diagnosis of autism spectrum disorder (ASD) is received is discussed in a recent review paper by Debbie Spain and colleagues [1]. Looking at the available peer-reviewed literature on the topic, researchers reported that those with ASD "were consistently found to have higher levels of paranoia compared to non-clinical controls, and lower levels than individuals with current psychotic experiences manifesting in the context of schizophrenia." They further speculated that: "core ASD characteristics and associated neurocognitive impairments also serve to precipitate and perpetuate paranoia."
Accepting that cultural views of paranoia or paranoid behaviour are not generally all that 'positive' and how this may have potentially the same impact on autism as it has had on the perception of schizophrenia, the Spain paper is an important addition to the research literature. I say this not solely because of how issues such as perseveration and rumination potentially linked to the perpetuation of paranoia are not uncommon in cases of autism [2] but also because of the still evolving story around how autism and schizophrenia might, on occasion [3], overlap (see here). The idea that social anxiety and depression might be something else important to the clinical regions of paranoid thought [4] also ties in with evidence on the over-representation of these labels/behaviours alongside some autism (see here).
Appropriate clinical screening is, once more, implied as and when any suspicions about the presence of chronic paranoid thinking occur when autism is diagnosed; not least because of the potential for progression into the clinical realms of schizophrenia (with caveats) and related labels. That paranoia combined with ruminative thinking and/or worry [5] for example, can in some circumstances be absolutely disabling for a person is also a good reason why intervention should be very, very seriously considered...
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[1] Spain D. et al. Conceptualising paranoia in ASD: A systematic review and development of a theoretical framework. Research in Autism Spectrum Disorders. 2016; 25: 97-111.
[2] Pugliese CE. et al. The role of anger rumination and autism spectrum disorder-linked perseveration in the experience of aggression in the general population. Autism. 2015 Aug;19(6):704-12.
[3] Woodbury-Smith MR. et al. Autism spectrum disorders, schizophrenia and diagnostic confusion. Journal of Psychiatry & Neuroscience : JPN. 2010;35(5):360.
[4] Carroll A. Are you looking at me? Understanding and managing paranoid personality disorder. Advances in Psychiatric Treatment. 2009; 15: 40-48.
[5] Startup H. et al. Worry processes in patients with persecutory delusions. Br J Clin Psychol. 2016 Mar 20.
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Spain, D., Sin, J., & Freeman, D. (2016). Conceptualising paranoia in ASD: A systematic review and development of a theoretical framework Research in Autism Spectrum Disorders, 25, 97-111 DOI: 10.1016/j.rasd.2016.02.002
Friday, 5 October 2012
Teeth, dentists and autism
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I have, in passing, mentioned teeth and autism in previous posts; most notably in this post on self-injurious behaviour (SIB) and the potentially wide variety of reasons to account for instances of SIB in autism outside of just impulsivity and stereotypy (see here).
Anyone who has experienced the discomfort of toothache or those so-called wisdom teeth making a slow and protracted appearance might understand the feelings involved. Imagine if you will what potentially might happen were you not able to communicate such discomfort or get the required medical attention that you might need?
There is however so much more to this area.
Oral hygiene and trips to the dentist are often not an easy thing for many children and adults, whether diagnosed with autism (or anything else) or not. Brushing, flossing and mouth-washing have been instilled as an integral part of the daily routine across many parts of the world in order to keep our pearly whites, pearly white and reduce the instance of tooth decay (caries) and beyond. Aside from poor adherence to a good oral health regime, including watching what you eat, there are however a multitude of reasons why people in general still have issues with their teeth (see here).
The collected literature on autism and dental health is quite extensive both in topic and findings but with a few common points raised:
- Health inequality. For whatever reason, children (and adults) with autism, as in several other conditions, often have high rates of unmet dental needs as per studies like this one from Nelson and colleagues** and this one from Brickhouse and colleagues***. There are several possible reasons for this health inequality including: cost, locality and the availability of professional skills and experience of dentistry in cases of autism. I might add that such inequalities seem also to extend to other areas of healthcare too.
- Autism and anxiety. I don't think I need to say too much more about the relationship between autism, stress and anxiety that hasn't already been said before. Anxiety can happen for lots of different reasons outside of the more classical 'out of routine' line which is pretty extensively described. Doctors appointments have been mentioned as a potential source of anxiety (see here) and one has no reason to doubt that a visit to the dentist (white coats, bright lights, funny sounds and smells) might also bring about similar feelings for some, particularly if previous visits have not been altogether unadventurous. Not surprisingly papers like this one from Loo and colleagues**** add to the Wang paper and their talk about dental patients with autism as being more likely "uncooperative and required dental treatment to take place under general anesthesia". The anaesthetic bit automatically implies that the risks are heightened for some people with autism, even for what should be routine dental work.
- Dental health. There is still a degree of discussion about whether the presence of autism correlates with an increased risk of dental caries or not. The paper from Loo et al said not, as did Namal and colleagues*****. Other results say there is, as per this paper by Jaber******. There are potentially many factors influencing tooth decay so I will perhaps reserve judgement on what the main suggestion is in this area.
- Dental injuries. I've kinda touched upon this area previously in a post discussing the issue of pica and autism (the eating of non-food materials). Suffice to say that not every instance of pica will be over something soft like dirt or paper as per the bezoars and other items that have been reported in cases of autism. Rocks, coins and related hard matter are generally not good news for teeth. Allied to this area are reported instances of rumination (eat, regurgitate, re-eat) in cases of autism******* (full-text) which given the acidity of such contents is likely to be as detrimental to oral health as repeated vomiting. Finally, there is the potential effects of bruxism (gnashing of teeth) in cases of autism. I can't readily find any reliable figures about the overlap between bruxism and autism but certainly it is relationship that has been noted as per this article by Orellana and colleagues******** and when chronically present will most certainly impact on oral health.
There are other areas which I could have talked about such as the oral effects of certain medicines, dietary patterns and habits in cases of autism and the whole sensory side of things in relation to oral health. I'm going to stop round about here though save you all getting too bored.
If there is any conclusion from the analysis of this area it is that oral health and wellbeing is an important part of healthcare in relation to autism. Understanding the issues which can follow autism is central to maintaining good oral health; not least in the provision of trained, professional dental care sensitive to those issues.
To close, the music chatter at the moment is all about Adele and the latest Bond theme tune. I have to say that out of all Daniel Craig's outings as 007, the Casino Royale theme tune was pretty good...
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* Wang YI. et al. Dental anesthesia for patients with special needs. Acta Anaesthesiol Taiwan. 2012; 50: 122-125.
** Nelson LP. et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatric Dentistry. 2011; 33: 29-36.
*** Brickhouse TH. et al. Barriers to dental care for children in Virginia with autism spectrum disorders. Journal of Dentistry for Children. 2009; 76: 188-193.
**** Loo CY. et al. The caries experience and behavior of dental patients with autism spectrum disorder. Journal of the American Dental Association. 2008; 139: 1518-1524.
***** Namal N. et al. Do autistic children have higher levels of caries? A cross-sectional study in Turkish children. Journal of the Indian Society of Pedodontics & Preventive Dentistry. 2007; 25: 97-102.
****** Jaber MA. Dental caries experience, oral health status and treatment needs of dental patients with autism. Journal of Applied Oral Science. 2011; 19: 212-217.
******* Rhine D. & Tarbox J. Chewing gum as a treatment for rumination in a child with autism. JABA. 2009; 42: 381-385.
******** Orellana LM. et al. Oral manifestations in a group of adults with autism spectrum disorder. Medicina Oral, Patalogia Oral Y Cirugia Bucal. 2012; 17: e415-e419.
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Wang YC, Lin IH, Huang CH, & Fan SZ (2012). Dental anesthesia for patients with special needs. Acta anaesthesiologica Taiwanica : official journal of the Taiwan Society of Anesthesiologists, 50 (3), 122-5 PMID: 23026171
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