Mental Health and Asperger Syndrome

People with autism or Asperger syndrome are particularly vulnerable to mental health problems such as anxiety and depression, especially in late adolescence and early adult life (Tantam & Prestwood, 1999). Ghaziuddin et al (1998) found that 65 per cent of their sample of patients with Asperger syndrome presented with symptoms of psychiatric disorder.
However, as mentioned by Howlin (1997), "the inability of people with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders". Similarly, because of their impairment in non-verbal expression, they may not appear to be depressed (Tantam, 1991). This can mean that it is not until the illness is well developed that it is recognised, with possible consequences such as total withdrawal; increased obsessional behaviour; refusal to leave the home, go to work or college etc; and threatened, attempted or actual suicide. Aggression, paranoia or alcoholism may also occur.
In treating mental illness in the patient with autism or Asperger syndrome, it is important that the psychiatrist or other health professional has knowledge of the individual with autism being assessed. As Howlin (1997) says, "it is crucial that the physician involved is fully informed about the individuals usual style of communication, both verbal and non-verbal". In particular it is recommended, if possible, that they speak to the parents or carers to ensure that the information received is reliable, eg any recent changes from the normal pattern of behaviour, whilst at the same time respecting the right of the person with autism to be treated as an individual.
Wing (1996) asserts that psychiatrists should be aware of autism spectrum disorders as they appear in adolescents and adults, especially those who are more able, if diagnostic errors are to be avoided. Attwood (1998) also stresses the importance of the psychiatrist being knowledgeable in Asperger syndrome. Tantam and Prestwood (1999), however, state that treatments for anxiety and depression that are also effective for people without autism are effective for people with autism. They go on to say that practitioners and psychiatrists with no special knowledge of autism or Asperger syndrome can be of considerable assistance in treating these conditions. Typically, however, it is of great advantage if the psychiatrist has experience of autism/Asperger syndrome.
Here, we concentrate on mental health in people with high-functioning autism or Asperger syndrome although references will be made to autism per se where appropriate. Emphasis will be on depression, anxiety and obsessive compulsive disorder, but it is important to realise that people with Asperger syndrome also experience other problems, such as impulsive behaviour and mood swings. To date there has been little research in this area but, as Carpenter (2001) has found, these can sometimes be incapacitating. Treatment can include conventional mood stabilising drugs, but helping the person to improve their self-awareness is also important.

Depression

Depression is common in individuals with Asperger syndrome with about 1 in 15 people with Asperger syndrome experiencing such symptoms (Tantam, 1991). People with Asperger syndrome leaving home and going to college frequently report feelings of depression as demonstrated by the personal accounts that can be found at www.users.dircon.co.uk/~cns/index.html
As one young person says, "I also had to deal with anger, frustration, and depression that I had been keeping inside since high school". A study by Kim et al (2000) also found depression to be more common in children aged 10-12 years with high-functioning autism/Asperger syndrome than in the general population of children of the same age.
Depression in people with Asperger syndrome may be related to a growing awareness of their disability or a sense of being different from their peer group and/or an inability to form relationships or take part in social activities successfully. Personal accounts by young people with Asperger syndrome frequently refer to attempts to make friends but "I just did not know the rules of what you were or were not supposed to do." www.users.dircon.co.uk/~cns/jeanpaul.html
Indeed, some people have even been accused of harassment in their attempts to socialise, something that can only add to their depression and anxiety; "I also did not know how to approach girls and ask them to go out with me. I would just walk up and talk to them, whether they wanted to talk to me or not. Some accused me of harassment, but I thought that was the way everybody did that." www.users.dircon.co.uk/~cns/jeanpaul.html
The difficulties people with Asperger syndrome have with personal space can compound this sort of problem. For example, they may stand too close or too far from the person to whom they are speaking.
Other precipitating factors are also seen in many people without autism who are depressed and include loneliness, bereavement or other form of loss, sexual frustration, a constant feeling of failure, extreme anxiety levels etc.
Childhood experiences such as bullying or abuse may also result in depression, as can a history of misdiagnosis. Another possibility is that the person is biologically predisposed to depression (Attwood, 1998). However, there are, of course, many other factors that may trigger the depression and this list should not be taken as exhaustive.
Tantam and Prestwood (1999) describe the depression of someone with Asperger syndrome as taking the same form as in people without the condition, although the content of the illness may be different. For example, the depression might show itself through an individuals particular preoccupations and obsessions and care must be taken to ensure that the depression is not diagnosed as schizophrenia or some other psychotic disorder or just put down to autism. It is important to assess the individuals depression in the context of their autism, ie their social disabilities, and any gradual or sudden changes in behaviour, sleep patterns, anger or withdrawal should always be taken seriously.
Symptoms of depression can be psychological (poor concentration/memory, thoughts of death or suicide, tearfulness); physical (slowing down or agitation, tiredness/lack of energy, sleep problems, disturbed appetite (weight loss or gain)); or affects of mood and motivation (eg low mood, loss of interest or pleasure, hopelessness, helplessness, worthlessness, withdrawal or bizarre beliefs etc.) People with depression can also experience periods of mania.
Lainhart and Folstein (1994) cite three approaches that need to be made in diagnosing depression in a person with autism. The first concerns a deterioration in cognition, language, behaviour or activity. The complaint is rarely couched in terms of mood. Secondly, it is important to take the patients history to establish their baseline, patterns of activity and interests. It is this pattern with which the presenting patterns can be compared. Thirdly, an attempt should be made to assess the patients mental state, both directly and through the parent or carer, if present. Examples would include reports of crying, difficulties in separating from their parent/carer for an interview, increased/decreased activity, agitation or aggression. There may be evidence of new or increased self-injury or worsening autistic features, such as increased proportion of echolalia or the reappearance of hand-flapping.
Attwood (1998) also refers to the inability that some people with Asperger syndrome have in expressing appropriate and subtle emotions. They may, for example, laugh or giggle in circumstances where other people would show embarrassment, discomfort, pain or sadness. He stresses that this unusual reaction, for example after a bereavement, does not mean the person is being callous or is mentally ill. They need understanding and tolerance of their idiosyncratic way of expressing their grief.
In treating depression, medications used in general practice may be prescribed (Carpenter, 1999). It is important to realise, however, that such agents do not make an impact on the primary social impairments that underlie autism. See Gringras (2000) for a discussion on the use of psychopharmacological prescribing for children with autism or Santosh and Baird (1999) for a analysis of psychopharmacotherapy in children and adults with intellectual disability (including autism).
As with any treatment for depression, adjustments may have to be made to find the appropriate drug and dosage for that particular person. Side effects should also be monitored and effort made to ensure the benefits of the treatment outweigh the penalties (Carpenter, 1999). It is also important to identify the cause for the depression and this may involve counselling (see below), social skills training, or meeting up with people with similar interests and values.

Anxiety

Anxiety is a common problem in people with autism and Asperger syndrome. Grandin (2000) writes that, at puberty, fear was her main emotion. Any change in her school schedule caused intense anxiety and the fear of a panic attack. Anxiety attacks started shortly after her first menstrual period.
Muris et al (1998) found that 84.1% of children with pervasive developmental disorder met the full criteria of at least one anxiety disorder (phobia, panic disorder, separation anxiety disorder, avoidant disorder, overanxious disorder, obsessive compulsive disorder). This does not necessarily go away as the child grows older.
Attwood (1998) states that many young adults with Asperger syndrome report intense feelings of anxiety, an anxiety that may reach a level where treatment is required. For some people, it is the treatment of their anxiety disorder that leads to a diagnosis of Asperger syndrome.
People with Asperger syndrome are particularly prone to anxiety disorders as a consequence of the social demands made upon them. As Attwood (1998) explains, any social contact can generate anxiety as to how to start, maintain and end the activity and conversation. Changes to daily routine can exacerbate the anxiety, as can certain sensory experiences.
One way of coping with their anxiety levels is for persons with Asperger syndrome to retreat into their particular interest. Their level of preoccupation can be used a measure of their degree of anxiety. The more anxious the person, the more intense the interest (Attwood, 1998). Anxiety can also increase the rigidity in thought processes and insistence upon routines. Thus, the more anxious the person, the greater the expression of Asperger syndrome. When happy and relaxed, it may not be anything like as apparent.
One potentially good way of managing anxiety is to use behavioural techniques. For children, this may involve teachers or parents looking out for recognised symptoms, such as rocking or hand-flapping, as an indication that the child is anxious. Adults and older children can be taught to recognise these symptoms themselves, although some might need prompting. Specific events may also be known to trigger anxiety eg a stranger entering the room. When certain events (internal or external) are recognised as a sign of imminent or increasing anxiety, action can be taken for example, relaxation, distraction or physical activity.
The choice of relaxation method depends very much on the individual and many of the relaxation products available commercially can be adapted for use for people with autism/Asperger syndrome. Young children may respond to watching their favourite video. Older children and adults may prefer to listen to calming music. There is much music on the market, both from specialist outfits and regular music stores, that is written specifically to bring about a feeling of tranquillity. It is important the person does not have social demands, however slight, made upon them if they are to benefit. It is also important that they have access to a quiet room.
Other techniques include massage (this should be administered carefully to avoid sensory defensiveness), aromatherapy, deep breathing and using positive thoughts. Howlin (1997) suggests the use of photographs, postcards or pictures of a pleasant or familiar scene. These need to be small enough to be carried about and should be laminated in order to protect them. Howlin also stresses the need to practice whichever method of relaxation is chosen at frequent and regular intervals in order for it to be of any practical use when anxieties actually arise.
An alternative option, particularly if the person is very agitated, is to undertake a physical activity (Attwood, 1998). Activities may include using the swing or trampoline, going for a long walk perhaps with the dog, or doing physical chores around the home.
Drug treatment may be effective for anxiety. Individuals may respond to buspirone, propranilol or clonazepam (Santosh and Baird, 1999) although Carpenter (2001) finds St. Johns Wort, benzodiazepines and selective serotonin reuptake inhibitors (SSRI) antidepressants to be more effective. As with all drug treatments it may take time to find the correct drug and dosage for any particular person. Such treatment must only be conducted through a qualified medical practitioner.
Whatever method is chosen to reduce anxiety, it is crucial to identify the cause of the anxiety. This should be done by careful monitoring of the precedents to an increase in anxiety and the source of the anxiety tackled.

Obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is described as a condition characterised by recurring, obsessive thoughts (obsessions) or compulsive actions (compulsions) (Thomsen, 1999). Thomsen goes on to say that obsessive thoughts are ideas, pictures of thoughts or impulses, which repeatedly enter the mind, whereas compulsive actions and rituals are behaviours which are repeated over and over again.
Baron-Cohen (1989) argues that the stereotypic obsessive action seen in children with autism differs from the child with OCD. As Thomsen (1999) explains, the child with autism does not have the ability to put things into perspective. Although terminology implies that certain behaviours in autism are similar to those seen in OCD, these behaviours fail to meet the definition of either obsessions or compulsions. They are not invasive, undesired or annoying, a prerequisite for a diagnosis of OCD. The reason for this is that people with (severe) autism are unable to contemplate or talk about their own mental states. However, OCD does appear often to coincide with Asperger syndrome, although there is very little literature examining the relationship between the two (Thomsen, 1999).
Szatmari et al (1989) studied a group of 24 children. He discovered that 8% of the children with Asperger syndrome and 10% of the children with high-functioning autism were diagnosed with OCD. This compared to 5 per cent of the control group of children without autism but with social problems. Thomsen el at (1994) found that in the children he studied, the OCD continued into adulthood.
People with Asperger syndrome can sometimes respond to conventional behavioural treatment to help reduce the symptoms of OCD. However, as with anyone, this will only be effective if the person wants to stop their obsessions. An alternative is use medication to reduce the anxiety around the obsessions, thus enabling the person to tolerate the frustration of not carrying out their obsession (Carpenter, 2001).

Schizophrenia

There is no evidence that people with autism spectrum conditions are any more likely than anyone else to develop schizophrenia (Wing, 1996).
It is also important to realise that people have been diagnosed as having schizophrenia when, in fact, they have Asperger syndrome. This is because their 'odd' behaviour or speech pattern, or the person's strange accounts or interpretations of life, are seen as a sign of mental illness, such as schizophrenia. Obsessional thoughts can become quite bizarre during mood swings and these can be seen as evidence of schizophrenia rather than the mood disorder that actually are. However, should someone with Asperger syndrome experience hallucinations or delusions that they find distressing, conventional antipsychotic medications can be prescribed. However, it is recommended that only the newer atypical antipsychotics are used, as people with Asperger syndrome often have mild movement disorders (Carpenter, 2001). Cognitive behaviour therapy and other psychological management methods may be effective.

Psychological treatments

A primary psychological treatment for mood disorders is cognitive behavioural therapy as it is effective in changing the way a person thinks and responds to feelings such as anxiety, sadness and anger, addressing any deficits and distortions in thinking (Attwood, 1999).
Hare and Paine (1997) list ways in which the therapy can be adapted for use with people with Asperger syndrome: having a clear structure eg protocols of turn-taking; adapting the length of sessions therapy might have to be very brief eg 10-15 minutes long; the therapy must be non-interpretative; the therapy must not be anxiety provoking as any arousal of emotion during therapy may be very counterproductive; group therapy should not be used. It is also important that the therapist has a working knowledge and understanding of Asperger syndrome in a counselling setting ie the difficulty people have dealing things emotionally, finding it best to deal with things intellectually. The therapist and client can work towards explicit operational goals, the focus being on concrete and specific symptoms.
Attwood (1999) gives a succinct overview of the components of the counselling process. Hare and Paine (1997) stress that such therapy is not a treatment or even an amelioration of the characteristics of Asperger syndrome itself. It merely opens the psychotherapeutic door for people with such a diagnosis.

Catatonia

Catatonia is a complex disorder covering a range of abnormalities of posture, movement, speech and behaviour associated with over- as well as under-activity (Rogers, 1992; Bush et al, 1996; Lishman, 1998).
There is increasing research and clinical evidence that some individuals with autism spectrum disorders, including Asperger syndrome, develop a complication characterised by catatonic and Parkinsonian features (Shah and Wing, 2006; Wing and Shah, 2000; Realmuto and August, 1991).
In individuals with autism spectrum disorders, catatonia is shown by the onset of any of the following features:

• increased slowness affecting movements and/or verbal responses;
• difficulty in initiating completing and inhibiting actions;
• increased reliance on physical or verbal prompting by others;
• increased passivity and apparent lack of motivation.

Other manifestations and associated behaviours include Parkinsonian features including freezing, excitement and agitation, and a marked increase in repetitive and ritualistic behaviour.
Behavioural and functional deterioration in adolescence is common among individuals with autism spectrum disorders (Gillberg and Steffenburg, 1987). When there is deterioration or an onset of new behaviours, it is important to consider the possibility of catatonia as an underlying cause. Early recognition of problems and accurate diagnosis are important as it is easiest to manage and reverse the condition in the early stages. The condition of catatonia is distressing for the individual concerned and likely to exacerbate the difficulties with voluntary movement and cause additional behavioural disturbances.
There is little information on the cause or effective treatment of catatonia. In a study of referrals to Elliot House who had autism spectrum disorders, it was found that 17% of all those aged 15 and over, when seen, had catatonic and Parkinsonian features of sufficient degree to severely limit their mobility, use of speech and carrying out daily activities. It was more common in those with mild or severe learning disabilities (mental retardation), but did occur in some who were high functioning. The development of catatonia, in some cases, seemed to relate to stresses arising from inappropriate environments and methods of care and management. The majority of the cases had also been on various psychotropic drugs.
There is very little evidence about effective treatment and management of catatonia. No medical treatment was found to help those seen at Elliot House (Wing and Shah, 2000). There are isolated reports of individuals treated with anti-depressive medication and electro-convulsive therapy (ECT) (Realmuto and August, 1991; Zaw et al, 1999).
Given the scarcity of information in the literature and possible adverse side effects of medical treatments, it is important to recognise and diagnose catatonia as early as possible and apply environmental, cognitive and behavioural methods of the management of symptoms and underlying causes. Detailed psychological assessment of the individuals, their environment, lifestyle, circumstances, pattern of deterioration and catatonia are needed to design an individual programme of management. General management methods on which to base an individual treatment programme are discussed in Shah and Wing (2001).

Conclusion

People with Asperger syndrome can experience a variety of mental heath problems, notably anxiety and depression, but also impulsiveness and mood swings. They may be misdiagnosed as having a psychotic disorder and it is therefore important psychiatrists treating them are knowledgeable about autism and Asperger syndrome. Conventional drug treatment can be used to treat depression, anxiety and other disorders. Behavioural treatments and therapies can also be effective. However, any treatment must be careful tailored to suit an individual and overseen by a qualified practitioner. However, any psychotropic medicine should be used with extreme caution and strictly monitored with people with autism due to their susceptibility to movement disorders, including catatonia.

References

Attwood, T. (1998). Asperger's syndrome: a guide for parents and professionals. London: Jessica Kingsley
Attwood, T. (1999). Modifications to cognitive behaviour therapy to accommodate the unusual cognitive profile of people with Asperger's syndrome. Paper presented at autism99 internet conference
Baron-Cohen, S. (1989). 'Do autistic children have obsessions and compulsions?' in British Journal of Clinical Psychology, 28(99), pp193-200
Bush, G. et al (1996). 'Catatonia. I. Rating scale and standardising examination'. Acta Psychiatrica Scandinavica, 93, pp129-136
Carpenter, P. (1999). The use of medication to treat mental illness in adults with autism spectrum disorders. Paper presented at autism99 internet conference
Carpenter, P. (2001). Personal correspondence
Ghaziuddin, E., Weidmer-Mikhail, E. and Ghaziuddin, N. (1998). 'Comorbidity of Asperger syndrome: a preliminary report' in Journal of Intellectual Disability Research, 42(4), pp279-283
Gillberg, C. and Steffenburg, S. (1987). 'Outcome and prognostic factors in infantile autism and similar conditions: a population based study of 46 cases followed through puberty' in Journal of Autism and Developmental Disorders, 17(2), pp273-287
Hare, D.J. and Paine, C. (1997). 'Developing cognitive behavioural treatments for people with Asperger's syndrome' in Clinical Psychology Forum, 110, pp5-8
Howlin, P. (1997). Autism: preparing for adulthood. London: Routledge
Kim, J. et al (2000). 'The prevalence of anxiety and mood problems amongst children with autism and Asperger syndrome' in Autism, 4(2), pp117-132
Lainhart, J.E. and Folstein, S.E. (1994). 'Affective disorders in people with autism: a review of published cases' in Journal of Autism and Developmental Disorders, 24(5), pp587-601
Lishman, W. A. (1998). Organic psychiatry: the psychological consequences of cerebral disorder, pp349-356. Oxford: Blackwell
Muris, P. et al. (1998). 'Comorbid anxiety symptoms in children with pervasive developmental disorders' in Journal of Anxiety Disorders, 12(4), pp387-393
Realmuto, G. and August, G. (1991). 'Catatonia in autistic disorder; a sign of comorbidity or variable expressions?' in Journal of Autism and Developmental Disorders, 21(4), pp517-528
Rogers, D. (1992). Motor disorder in psychiatry: towards a neurological psychiatry. Chichester: Wiley
Santosh, P.J. and Baird, G. (1999). 'Psychopharmacotherapy in children and adults with intellectual disability' in The Lancet, Vol 354, July 17, pp233-242
Szatmari, P., Bartoluci, G. and Bremner, R. (1989). 'Asperger's syndrome and autism: comparison of early history and outcome' in Developmental Medicine and Child Neurology, 31, pp709-720
Tantam, D. (1991). 'Asperger syndrome in adulthood' In U. Frith (ed.) Autism and Asperger Syndrome, Cambridge University Press, pp147-183
Tantam, D. and Prestwood, S. (1999). A mind of one's own: a guide to the special difficulties and needs of the more able person with autism or Asperger syndrome. 3rd ed. London: National Autistic Society
Thomsen, P.H. (1994). 'Obsessive-compulsive disorder in children and adolescents. A 6-22 year follow-up study. Clinical descriptions of the course and continuity of obsessive-compulsive symptomatology' in European Child and Adolescent Psychiatry, 3, pp82-86
Thomsen, P.H. (1999). From thoughts to obsessions: obsessive compulsive disorder in children and adolescents. London: Jessica Kingsley
Wing, L. (2002). The autistic spectrum: a guide for parents and professionals. London: Constable and Robinson
Wing, L. and Shah, A. (2000). 'Catatonia in autistic spectrum disorders' in British Journal of Psychiatry, 176, pp357-362
Zaw, F. K. et al (1999). 'Catatonia, autism and ECT' in Developmental Medicine and Child Neurology, 41, pp 843-845

Further reading

Andrews, D.N. (2006). 'Mental health issues surrounding diagnosis, disclosure and self-confidence in the context of Asperger syndrome' in  Murray D. Coming out Asperger. London: Jessica Kingsley, pp94-107
Attwood T. (2006). 'Psychotherapy' in Attwood T. The complete guide to Asperger syndrome. London: Jessica Kingsley, pp316-326
Berney, T. (2006). Psychiatry and Asperger syndrome. In: Murray D. ed. Coming out Asperger. London: Jessica Kingsley, pp67-87
Berney, T. (2007). 'Mental health needs of children and adolescents with autism spectrum disorders' in Advances in Mental Health and Learning Disabilities, Vol. 1(4), pp10-14
Carpenter, B. et al. (2007). 'Identifying and responding to the needs of young people with ASD and mental health problems: implications for organisation, research and practice' in Carpenter B. and Egerton J. eds. New horizons in special education: evidence-based practice in autism. Clent: Sunfield Publications, pp77-88
Carpenter, P. (2007). 'Mental illness in adults with autism spectrum disorders' in Advances in Mental Health and Learning Disabilities, 1(4), pp3-9
de Bruin, E.I. et al. (2007). 'High rates of psychiatric co-morbidity in PDD-NOS' in Journal of Autism and Developmental Disorders, 37(5), pp877-886
de Bruin, E.I. et al. (2007). 'Behaviour management problems as predictors of psychotropic medication and use of psychiatric services in adults with autism' in Journal of Autism and Developmental Disorders, 37(6), pp1080-1085
Dhossche, D.M. et al eds. (2006). Catatonia in autism spectrum disorders. London: Jessica Kingsley
Dhossche, D.M., Shah, A. and Wing, L. (2006). 'Blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders' in Dhossche D.M. et al eds. Catatonia in autism spectrum disorders. London: Academic Press, pp267-284
Farrugia, S. and Hudson, J. (2006). 'Anxiety in adolescents with Asperger syndrome: negative thoughts, behavioral problems and life interference' in Focus on Autism and Other Developmental Disabilities, 21(1), pp25-35
Ghaziuddin, M. (2005). Mental health aspects of autism and Asperger syndrome. London: Jessica Kingsley
Grandin, T. (2006). 'Stopping the constant stress: a personal account' in Baron M.G. et al eds. Stress and coping in autism, New York: Oxford University Press, pp71-81
Hutton, J. et al (2008). 'New-onset psychiatric disorders in individuals with autism' in Autism, 12(4), pp373-390
Konstantareas, M.M. (2005). 'Anxiety and depression in children and adolescents with Asperger syndrome' in Stoddart K.P. ed. Children, youth and adults with Asperger syndrome: integrating multiple perspectives. London: Jessica Kingsley, pp47-59
Lemkuhl, H.D. et al. (2008). 'Brief report: Exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism' in Journal of Autism and Developmental Disorders, 38(5), pp977-981
Leyfer, O.T. et al. (2006). 'Comorbid psychiatric disorders in children with autism: interview development and rates of disorders' in Journal of Autism and Developmental Disorders, 36(7), pp849-861
Posey, D.J. et al. (2007). 'Treatment of autism with antipsychotics' in Hollander E.L. and Anagnostu E. eds. Clinical manual for the treatment of autism. Washington: American Psychiatric Publishing, pp99-120
Royal College of Psychiatrists. (2006). Psychiatric services for adolescents and adults with Asperger syndrome and other autistic-spectrum disorders. London: Royal College of Psychiatrists
Download from: www.rcpsych.ac.uk
Scahill, L. and Martin, A. (2005). 'Psychopharmacology' in Volkmar F.R. et al (eds.) Handbook of autism and pervasive developmental disorders, Vol. 2, 3rd ed., New Jersey: John Wiley & Sons, pp1102-1117
Shah, A. and Wing, L. (2006). 'Psychological approaches to chronic catatonia-like deterioration in autism spectrum disorders' in Dhossche D.M. et al eds. Catatonia in autism spectrum disorders. London: Academic Press, pp245-264
Sterling, L. et al. (2008). 'Characteristics associated with presence of depressive symptoms in adults with autism spectrum disorder' in Journal of Autism and Developmental Disorders, 38(6), pp1010-1018
Stewart, M.E. et al. (2006). 'Presentation of depression in autism and Asperger syndrome: a review' in Autism, Vol. 10(1), pp103-116
Tsai, L.Y. (2006). 'Diagnosis and treatment of anxiety disorders in individuals with autism spectrum disorder' in Baron M.G. et al eds. Stress and coping in autism. New York: Oxford University Press, pp388-440
Ward, A. and Russell, A. (2007). 'Mental health services for adults with autism spectrum disorders' in Advances in Mental Health and Learning Disabilities, 1(4), pp23-28
Wing, L. and Shah, A. (2006). 'A systematic examination of catatonia-like clinical pictures in autism spectrum disorders' in Dhossche D.D. et al eds. Catatonia in autism spectrum disorders. London: Academic Press, pp21-39
Xenitidis, K. et al. (2007). 'Assessment of mental health problems in people with autism' in Advances in Mental Health and Learning Disabilities, 1(4), pp15-22

Catatonia section by Dr Amitta Shah

Read Books for Depression: A Way To Get Out Of The Eternal Darkness

By Anuradha Malhotra

"The Sun stopped shining for me is all. The whole story is: I am sad. I am sad all the time and the sadness is so heavy that I can't get away from it. Not ever." -Nina LaCour
Depression is like a termite feeding on your soul, eating it slowly till it becomes all empty, hollow, and lifeless. Those who are living with it know how it feels: as if someone has extinguished a light inside you and there is no way out of that eternal darkness. In that case, books for depression can be a ray of hope. We know about antidepressants, medications, and other therapies. They are effective but only as long as you are having them. But, in no way, they can change your way of thinking; they may increase the level of serotonin in brain, but cannot stop from having negative thoughts. The depression books, on other hand, can bring about a change in how you perceive the things around you.
How can a Book Help When you are Feeling Low?

1. Can Improve your Quality of Life:
   You are feeling down in dumps, have locked yourself in a room, and are crying incessantly. You are not willing to listen to what consoling words others are saying to you, as you think that they have no idea of how are you feeling. And this is your daily routine. Then what to do? How to deal with the melancholy that comes from nowhere and makes your life hell?
   
   Grab a depression book, read it thoroughly, and see what the author recommends to do. Try to do the same, one step at a time. It would, of course, seem superficial at the first go but as you practice on daily basis, things would start changing. So, when that sorrow returns, you would be able to handle it better rather than bursting into tears.


2. Help you Get Rid of the Suicidal Thoughts:
   If your hopelessness has gone out of control and you are resorting to self-destruction or killing yourself, in addition to counselling, a book for depression can help you from taking such an extreme step. Read what others did when they were in your shoes; how they stopped themselves when they too thought that they could no longer take it. Reading about their close calls with depression will help you understand that you are not the only one dealing with this saddening disease and that there are many ways to get out of it.


3. Let you Help Others:
   The books for depression are not exclusively for melancholic persons. If you know someone who is hanging in this situation and is unable to assist himself, you can play the role of healer for him. Let them realize that they too can come out of their present situation and lead a quality life once again. Meliorate his life by taking him under your wing.


4. Keep you Engaged:
   Waiting for your brain's chemicals to return to the normal level can be a nightmare. Certain effort is, indeed, required on your part too. Why not keep a depression book by your side and read it? This will keep you engaged, on one hand and help you to deal with your situation, on the other. Such a book helps in making a go of your ailment: what to do and how to do... So, when next time you are in the grip of the hollow feeling, try to get out of it by following author's advice. Read again if you feel the need. When you nothing worthwhile to do, read such books; this will kill your time and divert your mind from negative thoughts.

The following list of books for depression books may prove therapeutic to you and your loved ones:

• How to Break the Grip of Depression: Read How Robert Declared War On Depression... And Beat it! (by John McArthur)
• The Mindfulness and Acceptance Workbook for Depression: Using Acceptance and Commitment Therapy to Move Through... (by Patricia Robinson and Kirk D. Strosahi)
• The Pillar of Strength- How to Free Your Loved One from Depression (by Felix Freeman)
• Depression: Breaking Free from its Grip (by Krystal Kuehn)
• Killing the Black Dog: A Memoir of Depression (by Les A. Murray)
• From Dawn to Dusk to Daylight: A Journey Through Depression's Solitude (by Bruce Ross)

LSNet ( http://www.lsnet.in ) is a book portal that sells books from different genres at discount prices. The books are made available to users right at their doorstep and that too without any shipping charges. The members of LSNet.in can also get to share books for a limited period and free of cost. They can also sell their personal collections via online bidding process

Schizophrenia and Evolution of Complex Linguistic Abilities in Homo Sapiens

By Stan Flannery

The following is an article on schizophrenia and its relationship to natural human evolution. I am writing this from more of a personal, subjective level than one of scientific authenticity, and I am basing allot of my conclusions off of inferences into my own psychological experiences. One of the most prominent features of the schizophrenic spectrum of disorders is that of abnormal linguistic dysfunction displayed by individuals suffering from the disorder. Interestingly, during the development of modern man, that is, the addition of the neomammillian cortex and the movement of linguistic dominance from the right hemisphere of the brain to the left, the mind of homo sapiens started to exceed its metabolic capabilities, which led to some humans acquiring the cognitive disorders associated with schizophrenia. It can then be said that having schizophrenia is a natural bi product of essential positive selection. I would like to shed some light on this subject through some of my research on the subject, and my personal experience of having a schizophrenic illness.
First of all, I would like to introduce myself as someone who has had a schizophrenic illness for the past fourteen years. When I was eighteen, I fell into a paranoid manic psychosis. I was a freshman in college at the time, and I started to feel remarkably "different," but this feeling was not entirely unpleasant as some may believe, in fact it was quite pleasurable. I had been suffering from depression for a year prior to the psychotic episode, and the elation of being manic gave me a feeling that I was somehow alive for the first time. It was felt that I was on the verge of cosmic epiphany, and I no longer needed to sleep; instead, all that I wanted to do was stay up all night and talk. For a while, people didn't notice that I was becoming psychotic, rather they thought I was simply in a good mood, and doing well for the first time in a few years. The insomnia persisted, and I started to talk in "loose associations," that is, my ideas were strung together by weak relationships between ideas; however, I felt that I was making perfect sense. Then language itself took on another dimension: everything that came out of people's mouths took on symbolic significance that I interpreted as something I was just beginning to understand. For instance, a simple statement always meant something deeper, profound, and often related to religious and celestial subjects. I felt God put special significance on my existence, and I was on Earth for some specific messianic mission, which, being born on December 25, gave me the delusional hypothesis that I was in fact Jesus Christ, Son of God here to save people's souls. Soon, however, I was obviously unable to work, and was hospitalized, where I was medicated with anti-psychotic medication. I was diagnosed with "acute psychosis," and the psychiatrist was not definite if I was going to develop schizophrenia, but I was still convinced, for the length of my three week visit to the psychiatric ward of the hospital, that I was a divine messenger, of some sort. The word "schizophrenia," however, when he said it gave me the sobering realization that I may in fact be ill. This was strange to me since I felt so well, so alive, and enlightened.
When I was released from the hospital, I was treated with just anti-psychotic medication, and soon became very depressed. For a year, I went from psychiatrist to psychiatrist trying to figure out exactly what I was suffering from. I spent some more time in another psychiatric hospital where I was diagnosed with paranoid schizophrenia. At this time, I was quite certain that I was not a divine messenger, or Jesus Christ, but I was still having a hard time processing language, and I was paranoid. Finally, after going to the hospital again for my depression, they diagnosed me (I feel correctly) with schizoaffective disorder bi polar type one. Schizoaffective disorder is a rare illness that affects about.05 percent of the population, and includes the symptoms of schizophrenia and an affective illness. In this case, my affective ailment was bi polar one disorder, which was indicated by my mood congruent psychotic episode. Yet, I did not just have bi polar disorder, because my delusions were so bizarre, and I was still having cognitive symptoms associated with schizophrenia when I was not manic; therefore, I am said to have schizoaffective, which unfortunately has a worse prognosis than does that of bi polar disorder, but fortunately a better overall outcome than does having schizophrenia.
In any case, I finished college with a bachelor's degree in English and a minor in psychology. I earned a 3.7 in my major of study. This, I find to be unusual, given my deteriorated linguistic abilities during my psychosis; however, I found that, when normalized, I am endowed in language abilities, and I love to read and especially take great enjoyment in writing. I am a naturally curious person, and having schizoaffective disorder provided a catalyst for my interest in abnormal psychology, especially schizophrenic illnesses. Lately, I have become fascinated with the theory that schizophrenia and human evolution are intimately related, that is, schizophrenia may be a result of positive natural selection.
I always suspected, even before beginning my research on the subject, the schizophrenic spectrum of illnesses are partly disorders of language. Human beings think and communicate, primarily with language, but in schizophrenia, this ability is hindered. Schizophrenics tend to have difficulty expressing themselves effectively using linguistic means, sometimes they are completely mute, or at other times speak in gibberish-and I'm sure that my speech was nonsensical to other people during my ride through the realm of psychosis, but I thought it made complete sense. During evolution of the homo sapien mind, we developed complex language usage through the development of the neo mammalian cortex, growing from the reptilian base of the brain, which enabled us to reserve more brain power for executive functioning, which takes place in the frontal cortex. However, metabolically, the human mind was required to use more energy, and this caused some cognitive dysfunction in many individuals, manifesting in schizophrenia and psychosis.
I have always been creative, from the time I was very little. My imagination has always been wild, which may very well have led to some of the bizarre delusional ideas that I developed so easily during my psychotic break from reality. There have been many famous people who had schizotypal personalities (not full-blown schizophrenia per se, but displayed indications of having symptomatic characteristics of the disorder), and these people were often times had schizophrenia inherent in their family genealogy, although these individuals usually never succumbed to having a complete loss of reality. It can be said that the slightly different perceptual outlook on the world that these individuals had led to some very breakthrough thinking in the arts and sciences. I can only think of a few people with full-blown schizophrenia who were considered "geniuses," John Forbes Nash being one of them. He is a mathematician, who happens to still be alive today, and will be remembered, for his groundbreaking work in economics and game theory. The movie "A Beautiful Mind" was based on his life, although the depictions of his schizophrenia are inaccurate, it is still a good film that displays the suffering of John Nash and shows how his unique perceptions led to highly original mathematical ideas. In the movie it depicts him having visual hallucinations, and this is an erroneous depiction, because he, as well as the majority of schizophrenics, have auditory hallucinations, or "voices." I saw John Nash speak at Penn State. He gave a lecture entitled, "An Interesting Equation In Relation to Space Time and Gravitational Waves," and although I understood next to nothing (I have no background in mathematics), I still enjoyed the opportunity to get to see him speak. He appeared to be relatively stable, which is amazing, given he recovered without the use of anti-psychotic medications. However, I noticed, that his mind would make random associations that made no sense to me, and when I asked a person who was also there at the lecture, a student of mathematics who knew some about quantum mechanics, about whether or not he was making sense, the student said that he was, but his logic was very loose. I made the conclusion that he was still suffering from the disease, but had he taken the anti-psychotics, he may not have been able to penetrate into deepest of mathematical complexities as easily, or at all. I'm tentative to take mine on a regular basis, but I generally do comply to the psychiatrists recommendations, although, I must admit, there are times when I don't take my medication, just so I can feel the rush of creativity associated with the manic state. However, unlike someone suffering from bi polar disorder, I experience a much more severe mania-one of which is accompanied by schizophrenic thought disturbances, and paranoid delusions. I often times feel the police are following me, and eye contact frightens me because I feel that people are reading my mind and inserting thoughts into my brain. This, of course, only happens when I am experiencing mania, and upon having these symptoms of the schizophrenia, I generally take my medication-unfortunately, my medication is very sedating, and I tend to sleep for an entire day following an episode, and upon awakening, I feel very sluggish, and miserable. I suppose, being creative, I am also curious as to the internal workings of the human mind, and I was given a very unique opportunity to see the world from an altered perspective, not from doing drugs either, but rather, just from not taking my medication. I'm not sure why, but my control of language is still intact no matter if I'm severely manic, whereas during my psychosis, my speech was often derailed, and my linguistic cognitive abilities suffered, especially in my brains capacity to process language. I can still remember this vividly, even though it was over fourteen years ago to this day, and I have allot of empathy for people suffering from linguistic disabilities of schizophrenia.
Based on my own self-evaluation and my grades in college, I can confidently say that I have a high degree of verbal intelligence, and perhaps my psychosis was simply my brain's language ability working overtime, which led to the discordant trends in my cognition and interpretation of the world around me. This is very possible, that my brain, like the rest of the schizophrenic population, was just not suited for functioning with higher metabolic energy, and essentially "cracked" due to neurological overload. But, now, having been treated successfully for many years, my mind is now able to function using a great deal of energy, however, if I would have been able to harness the abnormal mental energy consumption during my psychosis, and use this extra brain power for creative means, I don't know what great things I could have accomplished, but that is just fantastical ideation that may not really have any objective basis in reality at all, after all I am crazy.
They say that James Joyce was the only one who could understand his schizophrenic sister when she was speaking in psychotic tongues during her illness, and looking at "Ulysses," one can clearly see Joyce's innate access into the world of schizophrenic thought, which is unique, and may very well stand as a testament to his evolved genius, which was derived from this insight into the language of inwardness. There are many similarities between the speech of schizophrenics and modern and postmodern poetry as well, both are rich in metaphor, deep in symbolism-and at times, seem extraordinarily cryptic to the interpreter or reader, who must use essentially more cognitive energy to extract meaning which may be difficult to ascertain. Still, the one difference between schizophrenic speech, and the poems of a post modern writer, is that the schizophrenic's intent of conveying meaning, although seemingly meaningful to them personally, is often impossible to harness by the healthy individual, whereas the intentions of the author can be successfully extracted through logical literary means of interpretation. The poem "The Wasteland," by T.S. Eliot, is one of the most difficult pieces of poetry in modern English, but its intentions, and the meanings are explicable by literary scholars, who have put a tremendous amount of work in its interpretation; however, the schizophrenic, who often times uses "word salad," or a mish-mash of gibberish, and "neologisms," or made up words, is usually disregarded as being irrelevant and incommunicative-therefore, the schizophrenic's linguistic abnormalities in their cognitive functioning are discounted, but maybe we should pay more attention to what they are saying, and will find, like Joyce may have very well found in pay attention to his sister, a deeper significance in the complexities of the human language. Just like the Shamans of ancient cultures, who were no doubt schizophrenic or schizotypal, the mentally ill may-if humans become less ignorant and more accepting of our differences-provide needed enlightenment that may boost the cultural and scientific powers of mankind. Even the most chronic of the mentally ill, may very well one day become great contributors to mankind, but at the present time, these individuals are sometimes confined to institutions, when in a more advanced society, we will be holding them in great esteem, because they may hold the answers to the mystery of human evolution.
For now, it cannot be concluded that schizophrenia is not advantageous in existing in civilized society, but in time, the keys to life's most confounding evolutionary mysteries may be revealed through careful examination of the internal processing of individuals that are "suffering" from schizophrenia. It may come into the light, that, just as it is known now that having relatives with schizophrenia may lead to one's own creative ingenious, having the illness itself, if science can figure out how to help those with the disorder harness the energy of their mind's possible advanced cognitive processes, may lead to future evolution in the way in which we communicate. This sounds a bit outlandish and fantastical, but in all reality we are only beginning to understand neurological functions of the human mind, so this speculation is not a product of me alone; the interest in the schizophrenias has boomed in scientific community, who are well aware too that there are some significant answers available concerning, not only a possible "cure" to the disease, but also strong evidence of the evolutionary development of language and the human race in its entirety.
Interestingly, schizophrenics tend to not be as capable of reproduction as the rest of the healthy population, but even so, there is increasing growth in the rate of incidences of people developing schizophrenia. If healthy people are reproducing more so than those affected with the disorder, then why is the prevalence of schizophrenia increasing rather than decreasing? Wouldn't the disorder be eventually eradicated through negative selection, or is the occurrence of the disorders frequency a sign that we are still in a state of evolution, that schizophrenia serves a natural human developmental purpose? Although this remains as mind boggling as the disorder itself, the truth in these objective, measurable facts will one day serve to add elucidation for the scientific community as to schizophrenia's probable imperative function of existing in the psychology of modern man. In my opinion, schizophrenia serves a purpose to society that deserves an even closer observation.
I am certain, after having been through the mysterious psychological experience of psychosis that having a schizophrenic illness was a mixed blessing, which gave me empirical insight towards the nature of the disorder-and because I was so fortunate enough to be able to recover to a degree that I can function effectively in society, I am driven to communicate through my unlikely written aptitude to those who are interested in learning about an essential component of human history, which happens to be found in the study of the perplexing nature of the schizophrenic syndrome. All too often schizophrenia is misunderstood as being an illness reserved for violent or delinquent individuals who cannot function in society and are in constant need of added assistance, but I am proof that this is a fallacious assumption of the mentally ill. Whether a person have an affective disorder such as bi polar, schizophrenia, or a personality disorder, he or she is most likely completely able to live outside of an institution, and most likely the reader of this article met someone, or encountered a person with a schizophrenic illness this week, but wasn't even aware-this is due to the effectiveness of the newer psychiatric medications. One more thing, before I conclude this article, I really need to emphasis that schizophrenia is not having a "split-personality" or "multiple personality," actually when a person exhibits two or more individual personas, he or she is suffering from multiple personality disorder. This is a rare personality disorder that has nothing to do with schizophrenia. "Schizo" actually has German origins, and means "split," but this splitting has nothing to do with having two personalities, but rather, denotes the individual's divorce or splitting of emotional capacity from cognitive mental functions. The schizophrenic may seem to be withdrawn from the world, emotionally divorced, which is labeled "the flattened effect," named this for the essentially lack of, or "flat" emotions the schizophrenic often time displays. The individual may appear cold or lifeless, and not be able to experience pleasure as would a healthy individual; however, with the newer medications and the advent of the atypical anti-psychotics, these negative symptoms are more easily controlled so that the sufferer can live a more fulfilling life. Society needs to be aware that the stigma attached to schizophrenia must be removed in order to better cope with understanding this enigmatic disorder's perplexing nature, which is in fact the root of this stigmatization, because people tend to be afraid of what they don't understand, and over-generalize complexities in order to simplify things that are too difficult to explain without a significant amount of acquired knowledge. I learned a good deal about the schizophrenic family of illnesses before I actually acquired schizoaffective disorder, this is because my mother had schizophrenia and was institutionalized for twenty years, but people who have no direct close contact with someone suffering from schizophrenia may never feel the need to learn about the disorder; and, I feel that it is imperative for every person to be more aware of mental illnesses. We are now finally becoming more comfortable with talking about the affective disorders, and bi polar disorder is finding a more common place in everyday conversation because we are now aware of the disorders prevalence, although, personally, I think there are too many people being diagnosed with bi polar disorder, and actually just have mood swings, but I'm not a psychiatrist. One of the less impressive things about public awareness of bi polar is its tendency to now be glamorized as a disorder of "geniuses," however, being labeled a creative illness this is not a far cry from the truth that many great artists, writers, and especially poets suffered from manic depression, however, these individuals would tell you, that they would have most likely have accomplished more if they didn't have to go through the hell of the illness.
Schizophrenia and schizoaffective disorder are not at this present time being thought of as being desirable to be diagnoses with, that is, at least what I gather, and for a long time I was embarrassed to say that I had schizoaffective disorder, instead I would-if I had to confess, for whatever reason of having a disability-that I had bi polar disorder, but now, after learning about the unique situation I have in life, and my privileged vantage point into the internal world of schizophrenia, I am not ashamed at conveying to others what I am diagnosed with, and am usually pleasantly surprised to find that people actually listen to me when I talk about my illness. Although I can't speak of my illness with medical authority, because I am no doctor or scientist, I can however, discuss it in from a more personal level, which I have tried to do so here in this article. I hope that after having read this and my other writings on the subject of schizophrenic disorders, you will become more respectful to the psychological differences between people in society, and aware that, although understanding mental illness is difficult and at times, and often emotionally taxing because we may watch our loved ones going through the distresses of mental disorders, it is not in our best interest to try to hide behind our irrational fears of the unexplainable phenomena of psychotic disorders, but instead we should try to find enough humility in our hearts and become more educated in the subject before we judge what we don't understand.
We should never make the quick assumptions that people with schizophrenia are "intellectually inferior" to us, because individuals with schizophrenia, in all likelihood, are intelligent and usually creative, but unable to access much of their cognitive abilities because their brains in many occasions have structural abnormalities that lead to neurological dysfunctions in linguistic comprehension, language production, emotional withdraw, and other thought disturbances. But, it should be highlighted that the schizophrenic's disadvantageous predicament could very easily be the result of natural human evolution, only the development of the schizophrenic mind was affected by the colossal increase in metabolic consumption, and in turn, the system essentially "crashed." I testified of my own experience of having a schizophrenic psychosis where I experienced this complete thought fragmentation, which focused primarily on my language abilities. To this day, I am uncertain of how I am able to write as effectively as I am able to do given my state of linguistic decline that lasted for over a year during the beginning stages of my illness, but having recovered, and having obsessive curiosity to the origin of the schizophrenic spectrum of disorders, I discovered through some simple research, these interesting ideas about the disorder and its relation to human evolution. I hope you enjoyed reading this, and have become more aware of the importance of scientific research into the nature of schizophrenia. I also would like to think that, if you haven't done so already, have dismissed some of the previous dogmatic stigmatization associated with societies limited comprehension of schizophrenia, and realize that those who have schizophrenic disorders should be respected and admired for the unique and difficult journey they take in life every day. Thank you, and I hope that if you have a mental disorder and have just read this article, know that I wish you the best, and to always keep hope alive; one day, soon I have a feeling, there are going to be even more effective treatment of schizophrenic illnesses, so don't ever give up the fight. Remember, you are unique in that you have an original perspective on the world around you that should be considered a gift, although it usually seems like a curse. I know how this feels, but if you keep it in your mind that because you have been to hell and back, you are stronger than the average person, who should listen to your story, and I bet if you start to talk about your experiences with having a mental illness, others will listen. It is your job to help teach the world that the mentally ill have a far greater significance to mankind than ever, and as society slowly wakes up from its deep sleep, people are just starting to become aware that schizophrenia and severe mental illness are distinct features of mankind that exhibit human's evolved intellectual superiority over the rest of the animal kingdom.