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.
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Berney, T. (2006). Psychiatry and Asperger syndrome. In: Murray
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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
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Catatonia in autism spectrum
disorders. London: Academic Press, pp267-284
Farrugia, S. and Hudson, J. (2006). 'Anxiety in adolescents with
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interference' in
Focus on Autism and Other Developmental
Disabilities, 21(1), pp25-35
Ghaziuddin, M. (2005).
Mental health aspects of autism and
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Grandin, T. (2006). 'Stopping the constant stress: a personal
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Catatonia section by Dr Amitta Shah
