Individuals with autism or Aspergers 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 Aspergers presented with symptoms of psychiatric disorder. However, as mentioned by Howlin (1997), "the inability of individuals 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 recognized, with possible consequences such as total withdrawal; increased obsessional behavior; 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 Aspergers, 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 care-givers to ensure that the information received is reliable, e.g., any recent changes from the normal pattern of behavior, 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 autistic 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 Aspergers. Tantam and Prestwood (1999), however, state that treatments for anxiety and depression that are also effective for individuals without autism are effective for individuals with autism. They go on to say that practitioners and psychiatrists with no special knowledge of autism or Aspergers can be of considerable assistance in treating these conditions. Typically, however, it is of great advantage if the psychiatrist has experience of autism/Aspergers.
This post will concentrate on mental health in individuals with high-functioning autism or Aspergers 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 realize that individuals with Aspergers also experience other problems, such as impulsive behavior 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 stabilizing drugs, but helping the person to improve their self-awareness is also important.
Depression—
Depression is common in individuals with Aspergers with about 1 in 15 individuals with Aspergers experiencing such symptoms (Tantam, 1991). Individuals with Aspergers 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/Aspergers than in the general population of children of the same age.
Depression in individuals with Aspergers 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 individuals with Aspergers 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 individuals have even been accused of harassment in their attempts to socialize, 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 individuals with Aspergers 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 individuals 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 Aspergers as taking the same form as in individuals without the condition, although the content of the illness may be different. For example, the depression might show itself through an individual’s 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 individual’s depression in the context of their autism, i.e. their social disabilities, and any gradual or sudden changes in behavior, 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 (e.g., low mood, loss of interest or pleasure, hopelessness, helplessness, worthlessness, withdrawal or bizarre beliefs etc.) Individuals 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, behavior 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 patient’s mental state, both directly and through the parent or care-giver, if present. Examples would include reports of crying, difficulties in separating from their parent/care-giver 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 individuals with Aspergers have in expressing appropriate and subtle emotions. They may, for example, laugh or giggle in circumstances where other individuals 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 realize, 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 psycho pharmacotherapy 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 counseling (see below), social skills training, or meeting up with individuals with similar interests and values.
Anxiety—
Anxiety is a common problem in individuals with autism and Aspergers. 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, and obsessive compulsive disorder). This does not necessarily go away as the child grows older. Attwood (1998) states that many young adults with Aspergers report intense feelings of anxiety, an anxiety that may reach a level where treatment is required. For some individuals, it is the treatment of their anxiety disorder that leads to a diagnosis of Aspergers.
Individuals with Aspergers 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 Aspergers 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 Aspergers. When happy and relaxed, it may not be anything like as apparent.
One potentially good way of managing anxiety is to use behavioral techniques. For children, this may involve teachers or parents looking out for recognized symptoms, such as rocking or hand-flapping, as an indication that the child is anxious. Adults and older children can be taught to recognize these symptoms themselves, although some might need prompting. Specific events may also be known to trigger anxiety e.g., a stranger entering the room. When certain events (internal or external) are recognized 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 individuals with autism/Aspergers. Young children may respond to watching their favorite 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 tranquility. 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 characterized 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 behaviors 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 behaviors in autism are similar to those seen in OCD, these behaviors 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 individuals with (severe) autism are unable to contemplate or talk about their own mental states. However, OCD does appear often to coincide with Aspergers, 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 Aspergers 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.
Individuals with Aspergers can sometimes respond to conventional behavioral 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 individuals with autistic conditions are any more likely than anyone else to develop schizophrenia (Wing, 1996).
It is also important to realize that individuals have been diagnosed as having schizophrenia when, in fact, they have Aspergers. This is because their odd behavior or speech pattern, or the persons 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 Aspergers 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 individuals with Aspergers often have mild movement disorders (Carpenter, 2001). Cognitive behavior therapy and other psychological management methods may be effective.
Psychological Treatments—
A primary psychological treatment for mood disorders is cognitive behavioral 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 individuals with Aspergers: having a clear structure e.g., protocols of turn-taking; adapting the length of sessions therapy might have to be very brief e.g., 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 Aspergers in a counseling setting i.e., the difficulty individuals 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 counseling process. Hare and Paine (1997) stress that such therapy is not a treatment or even an amelioration of the characteristics of Aspergers itself. It merely opens the psychotherapeutic door for individuals with such a diagnosis.
Catatonia—
Catatonia is a complex disorder covering a range of abnormalities of posture, movement, speech and behavior 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 Aspergers, develop a complication characterized by catatonic and Parkinsonian features (Wing and Shah, 2000; Shah and Wing, 2001; Realmuto and August, 1991).
In individuals with autistic spectrum disorders, catatonia is shown by the onset of any of the following features:
a. difficulty in initiating completing and inhibiting actions
b. increased passivity and apparent lack of motivation
c. increased reliance on physical or verbal prompting by others
d. increased slowness affecting movements and/or verbal responses
Other manifestations and associated behaviors include Parkinsonian features including freezing, excitement and agitation, and a marked increase in repetitive and ritualistic behavior.
Behavioral and functional deterioration in adolescence is common among individuals with autistic spectrum disorders (Gillberg and Steffenburg, 1987). When there is deterioration or an onset of new behaviors, 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 behavioral disturbances.
There is little information on the cause or effective treatment of catatonia. In a study of referrals to Elliot House who had autistic 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 recognize and diagnose catatonia as early as possible and apply environmental, cognitive and behavioral 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 program of management. General management methods on which to base an individual treatment program are discussed in Shah and Wing (2001).
Conclusion—
Individuals with Aspergers can experience a variety of mental health 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 Aspergers. Conventional drug treatment can be used to treat depression, anxiety and other disorders. Behavioral 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 individuals with autism due to their susceptibility to movement disorders, including catatonia.
References—
• Attwood T. (1998) Aspergers 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 Aspergers syndrome. Paper presented at autism99 internet conference ( http://www.autismconnect.org ).
• Baron-Cohen S. (1989 ) Do autistic children have obsessions and compulsions? British Journal of Clinical Psychology, Vol. 28 (99), 193-200.
• Bush G. et al (1996) Catatonia. I. Rating scale and standardising examination. Acta Psychiatrica Scandinavica, Vol. 93 , pp. 129-136
• Carpenter P. (1999) The use of medication to treat mental illness in adults with autism spectrum disorders . Paper presented at autism99 internet conference ( http://autismconnect.org ).
• Ghaziuddin E., Weidmer-Mikhail E. and Ghaziuddin N. (1998) Comorbidity of Asperger syndrome: a preliminary report. Journal of Intellectual Disability Research Vol. 42 (4), pp. 279-283.
• 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. Journal of Autism and Developmental Disorders, Vol. 17 (2), pp. 273-287.
• Hare D.J. and Paine C. (1997) Developing cognitive behavioural treatments for people with Aspergers syndrome. Clinical Psychology Forum, no. 110, pp. 5-8.
• 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. Autism, Vol. 4(2), pp. 117-132.
• Lainhart J.E. and Folstein S.E. (1994) Affective disorders in people with autism: a review of published cases. Journal of Autism and Developmental Disorders, Vol. 24 (5), pp. 587-601.
• Lishman W. A. (1998) Organic psychiatry: the psychological consequences of cerebral disorder pp. 349-356. Oxford: Blackwell.
• Muris P. et al (1998) Comorbid anxiety symptoms in children with pervasive developmental disorders. Journal of Anxiety Disorders, Vol. 12 (4), pp. 387-393.
• Realmuto G. and August G. (1991) Catatonia in autistic disorder; a sign of comorbidity or variable expressions? Journal of Autism and Developmental Disorders, Vol. 21 (4), pp. 517-528.
• Rogers D. (1992) Motor disorder in psychiatry: t owards a neurological psychiatry. Chichester: Wiley.
• Santosh P.J. and Baird G. (1999) Psychopharmacotherapy in children and adults with intellectual disability . The Lancet, Vol 354 , July 17, pp.233-242.
• Shah A. and Wing L. (2001) Understanding and managing catatonia in autism. A clinical perspective. To be published.
• Szatmari P., Bartoluci G. and Bremner R. (1989) Aspergers syndrome and autism: comparison of early history and outcome . Developmental Medicine and Child Neurology, Vol. 31 , pp. 709-720.
• Tantam D. (1991) Asperger syndrome in adulthood . In U. Frith (ed.) Autism and Asperger Syndrome, pp. 147-183 Cambridge University Press.
• 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.
• 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 . European Child and Adolescent Psychiatry, Vol. 3 , pp. 82-86.
• Thomsen P.H. (1999) From thoughts to obsessions: obsessive compulsive disorder in children and adolescents. London: Jessica Kingsley.
• Wing L. (1996) The autistic spectrum: a guide for parents and professionals. London: Constable.
• Wing L. and Shah A. (2000) Catatonia in autistic spectrum disorders. British Journal of Psychiatry, Vol. 176 , pp. 357-362.
• Zaw F. K. et al (1999) Catatonia, autism and ECT . Developmental Medicine and Child Neurology, Vol. 41 , pp. 843-845.
