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Psychiatric Disorders in Autism:

Diagnosis and treatment

Susan E. Folstein MD

Professor of Psychiatry

University of Miami

Miller School of Medicine

What parents complain of

• Can’t sit still

• Aggression when “doesn’t get his way”

• Self-abuse

• Can’t take him to shops

• Won’t pay attention to homework

• Gets upset with certain noises

• “Meltdowns”

• Paces around

Interpretation of these complaints

• As individual symptoms

• As ADHD

• As “behavioral” (translation: use behavior

modification or discipline)

• As components of a psychiatric syndrome

– It groups the symptoms into a syndrome

– It takes into account the natural history

– Particular diagnoses suggest particular treatments

Psychiatric Perspectives

• Disease Perspective:

– Mood and anxiety disorders

– ADHD

– Catatonia

– Schizophrenia

• Dimensional Perspective:

– Intelligence

– Personality and temperament

– Language ability

• Behavior Perspective

– Tantrums

– Phobias, fears

– Aggression to self or others

• Life Story Perspective

– Change in school

– Moving house

– Onset of household

disruption

– Abuse or neglect

Variation in time?

• Is the symptom always present or does it wax

and wane over months, weeks or days?

– Anxiety in autism is more a trait than a state

– It waxes and wanes according to the situation

• Worse at school

• Worse with homework

• Worse when need to change sets

• Worse in socially taxing situations

• Worse when “desires” [requirements] are thwarted

• Worse in any novel situation

• May be accompanied by self-abuse

Variation in time?

• Is the symptom always present or does it wax

and wane over months, weeks or days?

– ADHD is almost always present,

• Child does not look anxious or depressed

• Child does not have symptoms of anxiety or depression

• Can often sit still if engaged in preferred activity

• Improves briefly if child is fearful

• Sleep is not usually disturbed except initial insomnia if

too wound up.

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Anxiety vs. ADHD in autism

Anxiety

• Worse in new or cognitively

taxing situations

• Activity is likely pacing,

jumping, hand wringing

• More self-abuse

• Often sleep poorly: fall asleep

but waken in night in fearful

state, want to sleep with

parent, afraid of dark

ADHD

• May be better in new

situations

• Activity is usually moving

from one activity or point of

interest to another

• Not associated with self-

abuse

• Usually sleep well

ADHD and anxiety may co-occur.

Treat the anxiety first!

Case example: anxiety

• 14 year old boy with Asperger syndrome, tics, a flat voice, poor eye contact.

• He has considerable artistic talent and is interested in musical comedy. When acting or

singing, his voice has a normal lilt.

• He never has had much interest in friends, because he has a lot of interests that take up his

time and that he feels somewhat compelled to do: making animated cartoons, tending his

plants. He has a hard time completing homework without someone sitting with him to keep

him focused. Medications for ADHD helped a little but he stopped eating.

• His parents brought him to see me in anticipation of difficulties as he started high school.

The first few months were touch and go: his father sat with him for homework, he missed

the bus often, usually forgot to write down his homework, and often ate lunch alone.

• Finally, I convinced them to start sertraline. Within 2 weeks, he was a different person:

happy, alert, having conversations with peers:

– His dad did not have to sit with him while he does his homework

– He became more sociable

– He remembered more often to take down his homework assignments

– He got his H/W done in less time

– H/W didn’t seem as overwhelming

– He moved from a C to a B in English

Case example:

Anxiety with self-abuse

• 15 year old deaf boy with severe mental retardation and

deafness

• He destroyed the office and constantly hit himself in the head.

His father had to keep him on a leash to prevent his running

away.

• We first started him on an atypical antipsychotic and a mood

stabilizer which helped a little but he was still unmanageable.

• I asked his father if he thought he was anxious, he replied yes,

with enthusiasm. We started him on Prozac, increasing the dose

until self-abuse stopped. Now he sits in a chair and examines

the toys. He does not run away and sleeps well. He occasionally

bites his wrist.

Aggression to self or others

Table 1. Demographics of patients with ASD treated for aggression at the DDC at JMH between 2010 and 2012.

SIBN (%)

Aggression to othersN (%)

All aggressionN (%)

N 33 26 43

Age (y) 14 ±5.8 13 ± 5.4 14 ±6

> 18 11 22 11

Gender (m) 23 (69%) 19 (73%) 31 (72%)

Ethnicity

White 6 (18.1%) 4 (15.4%) 7 (16.3%)

African American 13 (39.4%) 11(42.3%) 16 (37.2%)

Hispanic 14 (42.4%) 11 (42.3%) 20 (46.5%)

Treatment of Aggression

Medications used to treat aggression in ASD at theDDC at JMH between 2010-2012.

Drug NAntipsychotic

Risperidone 14Aripiprazol 9Quetiapine 3Olanzapine 2Haloperidol 1

Mood StabilizersValproic Acid 7Topiramate 1Oxcarbazepine 1Lithium Carbonate 1

α-2 agonistClonidine 5Guanfacine 1

StimulantsAmphetamine 3Methylphenidate 2

SSRIsFluoxetine 22Sertraline 5Citalopram 3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

worsen no

improvement

transient

improvement

improvement remission

Self injurious behavior

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

worsen no

improvement

transient

improvement

improvement remission

All aggression

B

A

C

%

%

%

Figure 1. Clinical response to treatment of aggression with SSRIs and non SSRIs

medications in patients with ASD seen at the JMH DDC between 2010-2012. Bars

represent percentage of cases receiving SSRIs (green) or non SSRIs (white).

Response to treatment of Self Injurious Behavior (A), aggression to others (B) and

all types of aggression (C).

Non SSRIs

SSRIs

0.0

10.0

20.0

30.0

40.0

50.0

60.0

worsen no improvement improvement remission

Aggression to others

0 5 10 15

All aggression

Self Injurious

Behavior

p=0.0008

p=0.0004

Figure 2. Treatment of Self Injurious Behavior (SIB) and overall aggression with SSRIs had five times the

odds of being effective than that with non SSRIs medications. Chi square test of clinical response in SIB

(A) and overall aggression (B). Representation of odds ratio and confidence intervals of the effect of SSRIs

on treatment of aggression in ASD patients.

No SSRIs SSRIs

Negative response 31 6

Positive response 20 22

Self Injurious Behavior All aggression

No SSRIs SSRIs

Negative response 31 6

Positive response 20 22

BA

C

X2= 11.2, p= 0.0008 X2= 12.4, p= 0.0004

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Diagnosis of Anxiety in Autism

• We developed a new questionnaire for

parents

• Focused on the unusual manifestations of

anxiety

• Focused on the situations that upset people

with autism

Situations that often provoke anxiety

Wanting to obtain object related to special interest

Misplaced valuable object

Excessive noise

Noisy environments

Children screaming

Loud talk with high emotional content such as parents arguing

Change in plans

Awaiting a future event

Doctor or dentist visit

Treatment for Anxiety

• SSRIs: Fluoxetine, sertraline, citalopram

• Begin with low doses and increase the dose

until the symptoms are relieved

• Sometimes they have to be given in the

evening because of sedation.

Is it Anxiety or Depression?

Variation over time• Crying

• Even worse sleep than usual

• Usually intermittent, with a clear onset and offset, while

anxiety in autism is more like a situation-dependent trait

• More aggression when forced to interact or do something difficult

• More self-abuse

• Pessimistic talk: “I can’t do it, I will never be able to do it.”

• Less willing to speak or engage in activities

• More time on preferred, often repetitive activities (repetitive behavior, listening to CDs, computer activities)

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Documenting an unstable mood

• “Sometimes he wakes up in a stormy mood” and I know that the day will not go well.

• Mother may say, “he is always miserable”, but upon questioning, there are good days also.

• Learn to distinguish between

– Irritable confident and irritable miserable

– Sleepless and energetic, vs., middle-of-of night sleepless with anxiety and fear.

– Overbearing and talkative vs., anxious and talkative with many repeated questions.

• Take a family history! If there are bipolar family members, be careful with SSRIs.

• After puberty bipolar swings are common.

Case example of depression

• 9 year old echolalic boy who is generally happy and likes school; only his

brother can engage him in simple play. Marked insistence on sameness.

• 2 years ago he slept poorly for 5 months, waking at 3-4 in the morning

every night. It subsided spontaneously.

• In December he became fussy, whining and tearful, some nighttime

awakening, decreased appetite.

• One day, he took off his shoes in the car on the way to school, the next he

took off his shirt on the way to school. This progressed to refusing to wear

any clothes, including his pull-up Pampers. If his mother tried to dress him,

he screamed, hit himself in the head and banged his head on anything

hard. (silver lining: he urinated and defecated in the toilet for the first time

ever).

• Prozac was started, starting at 2.5 mg. Gradually he started to be more

cheerful.

Treatment of depression

• Same as anxiety: fluoxetine or sertraline

• Sometimes need to augment with a little

Welbutrin.

• As in all children, it is made worse by being in

a difficult situation at home, or most

commonly, in a school where the work is too

difficult.

Recognizing unstable moods

Normal to depressed

• Irritable

• Aggression

• Poor sleep; intermittent

waking, gets into parents’ bed

• Stormy expression

• Not confident

• Doesn’t want to talk

• Onset or increased self-injury

• Says, “I will never learn it.”

• Says, “Nobody loves me.”

• More repetitive behavior

Depressed to normal to high

• Irritable

• Aggression

• Decreased sleep; wakes up

“ready to start the day”

• Cheerful expression

• Super confident

• May talk more, even chat

• No self injury when “up”

• Says, “I can do it!”

• Says, “I’m a good kid!”

• Says, “Do what I say!”

Treatment of bipolar mood instability

• First stabilize the mood– Atypical antipsychotics

– Depakote or Lamotrigine

– Lithium carbonate

• This will take a little time; often the first medication is unsatisfactory for one reason or another.

• Once the mood is stable, assess for anxiety, depression OCD and ADHD; treat it if necessary (it is often necessary)

• Failure to first stabilize the mood is the main reason that autistic children get “wild” from SSRIs or Strattera.

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Catatonia

• Onset: adolescence or adult life

• Symptoms:

– Trouble initiating movements

– Waxy flexibility

– Catatonic stupor

– Catatonic Excitement (less common)

• Occurrence in autism

– Adolescence

– May be seen with bipolar disorder or depression

• Treatment: Ativan, ECT, lithium

Catatonia: Case Example

20 yo man with autism & little language but a cheerful demeanor and a love of

music who was easy to manage

In May 2009, there was a profound change in his behavior.

• He did not want to be touched, he did not sleep or eat.

• If his mother got close to him, he pushed her away.

• He could not stay still and destroyed the ER when she took him there.

• He did the same thing over and over – he imitated his father’s movements all

day long.

• He was hospitalized for 20 days after he became rigid and could not open his

mouth and was fed with an NG tube. He was given haldol and possibly ativan

and on the 10th day he finally slept after trying all the different sedatives. He

did not return to baseline, but finally regained a little speech.

Catatonia, continued

In July 2010, a similar thing happened.

• He was not sleeping and was admitted.

• They gave him risperidone in the ER and he slept and went home

• 3 days later he returned because again his jaw locked and he needed an

NG tube.

• I recommended IV Ativan, but they were afraid and gave it to him via his

NG tube. Two days later his jaw unlocked on 1 mg BID.

• He gradually improved as Ativan was titrated up to 16 mg per day.

• Recently he became obviously manic, although his catatonic symptoms are

almost all gone and he is eating again without having to stop/start.

• Medications: Ativan 14 mg/da and Lithium 450 mg bid

Dimensions

(distributed on a continuum and measurable)

• Personality/temperament (Chess and Thomas)

– Activity, attention

– Mood

– Approach/withdrawal

– Persistence

– Sensitivity to criticism

– Intensity of reactions

– Regularity

• Intelligence

Abnormal Behaviors

• A 14 year old autistic child with limited speech, presented

with anxiety in many situations. He was particularly anxious

about a young girl in his class who had a high-pitched scream.

This gradually generalized to even the sight of small girls. He

would become panic stricken and do whatever was necessary

to escape the situation, including physical aggression to

caregivers.

• Treatment with Sertraline decreased his anxiety overall, but

had no impact on this phobia of young girls.

• Behavioral methods were instituted to try to extinguish his

responses to the sights and sounds of little girls and to teach

him ways to calm down when in their presence. He can now

go to the park and other places without untoward effects.

Life Story

• Change of schools

• Abuse at school (hard to detect)

• Abuse at home

• Change in the household composition

– New people (aunt shared room, sib returns)

– Parent leaves

– Sib leaves for college

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Life story: persons with autism are highly

sensitive to changes in environment

• A 19 year old autistic boy with bipolar disorder and anxiety

was stable on depakote and fluoxetine for several months.

• His sister and her husband moved in with him and his parents.

He enjoyed their attention and affection. However, he could

not settle at night until they were both home from work, and

began to worry about their whereabouts at other times.

• His anxiety increased to the point that he cut his arm enough

to need stitches and was admitted to the hospital.

• The family has now settled down into a predictable routine

and there have been no more difficulties.

Psychiatric problems in relation to age

AGE

2-5: mostly behaviors that need modifying

5+: anxiety in school depression increases with ageADHD becomes problematical

Puberty: Depression and bipolar disorderSeizures that can look like odd behaviors

Later adolescence: bipolar disorder, catatonia, schizophrenia life story

Later life: ???

Summary

• Children and adults with autism have many

co-morbid psychiatric symptoms

• It is useful to think about these from several

different perspectives:

– some are “diseases”

– some are related to personal attributes

– some are behaviors that need to be stopped

– some are related to what is happening in life

Summary, continued

• Anxiety is probably the most common psychiatric

disorder seen in autism before puberty, and it can

have unusual manifestations

• Bipolar disorder starts at puberty and is often missed

• Catatonia is not common can have very serious

consequences

• People with ASD are very sensitive to changes in

seemingly trivial the environment.