Determination of psychosis-related clinical profiles in children with autism spectrum disorders using latent class analysis
Marinos Kyriakopoulos
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Argyris Stringaris
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Sofia Manolesou
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Maja Drobnic Radobuljac
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Brian Jacobs
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Avi Reichenberg
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Daniel Stahl
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Emily Simonoff
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Sophia Frangou
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M. Kyriakopoulos A. Reichenberg S. Frangou Icahn School of Medicine at Mount Sinai
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New York, USA
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M. Kyriakopoulos (&) A. Stringaris B. Jacobs A. Reichenberg D. Stahl E. Simonoff Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King's College London
, P066, De Crespigny Park, London SE5 8AF,
UK
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M. Kyriakopoulos B. Jacobs E. Simonoff Child and Adolescent Mental Health Clinical Academic Group, South London and the Maudsley NHS Foundation Trust
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London, UK
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M. D. Radobuljac University Psychiatric Hospital
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Ljubljana, Slovenia
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S. Manolesou Central and North West London NHS Foundation Trust
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London, UK
In children with autism spectrum disorders (ASD), high rates of idiosyncratic fears and anxiety reactions and thought disorder are thought to increase the risk of psychosis. The critical next step is to identify whether combinations of these symptoms can be used to categorise individual patients into ASD subclasses, and to test their relevance to psychosis. All patients with ASD (n = 84) admitted to a specialist national inpatient unit from 2003 to 2012 were rated for the presence or absence of impairment in affective regulation and anxiety (peculiar phobias, panic episodes, explosive reactions to anxiety), social deficits (social disinterest, avoidance or withdrawal and abnormal attachment) and thought disorder (disorganised or illogical thinking, bizarre fantasies, overvalued or delusional ideas). Latent class analysis of individual symptoms was conducted to identify ASD classes. External validation of these classes was performed using as a criterion the presence of hallucinations. Latent class analysis identified two distinct classes. Bizarre fears and anxiety reactions and thought disorder symptoms differentiated ASD patients into those with psychotic features (ASD-P: 51 %) and those without (ASD-NonP: 49 %). Hallucinations were present in 26 % of the ASD-P class but only 2.4 % of the ASD-NonP. Both the ASD-P and the ASD-NonP class benefited from inpatient treatment although inpatient stay was prolonged in the ASD-P class. This study provides the first empirically derived classification of ASD in relation to psychosis based on three underlying symptom dimensions, anxiety, social deficits and thought disorder. These results can be further developed by testing the reproducibility and prognostic value of the identified classes.
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Autistic and psychotic disorders have historically been
considered as related diagnostic entities. In the late 1970s,
autism spectrum disorders (ASD) and schizophrenia (SZ)
were split into two different diagnostic categories
(DSMIII). The boundaries between the two disorders, however,
continue to be debated. ASD and SZ share common
neurobiological processes [1, 2] and genetic risk factors [3
5]. In addition, the presence of autistic traits in early
childhood increases the risk of psychotic experiences in
adolecence [6] and of SZ and SZ spectrum disorders in
adulthood [7]. Conversely, a significant proportion of
adults with SZ also fulfils criteria of childhood ASD [8].
Better characterisation of psychosis-related symptom
profiles in children with ASD is likely to advance our
understanding of these overlaps.
A potentially fruitful approach is to improve the clinical
charaterisation of children with ASD that present with
psychotic experiences. There is some evidence that
affective symptoms in children with ASD may mediate the
emergence of psychotic symptoms. In particular, formal
thought disorder in ASD has been found to be induced by
anxiety and stress [9]. This concept is also supported by
reports of higher rates of psychotic symptoms in ASD
children with significant symptoms of anxiety and throught
disorder. It has been suggested that these children may
represent a particular subgroup of ASD refered to as
multiple complex developmental disorder (MCDD) [10
12]. The criteria for MCDD are shown in Table 1 and
highlight the importance of peculiar and idiosyncratic
fears, panic episodes and explosive emotional behaviours
[10]. Although anxiety symptoms were noted in the
original description of classic autism [13] they do not feature as
core symptoms of autism in more recent operational
descriptions of the disorder. However, large-scale
epidemiological studies (e.g. [14] ) and a recent meta-analysis
[15] estimated that approximately 40 % of ASD children
have a comorbid anxiety disorder. A comprehensive review
by White and colleagues [16] also reported that ASD
children experiencing anxiety are more likely to show
explosive behaviours in response to their fears and phobias.
Weisbrot and colleagues [17] examined the relationship
between specific types of anxiety and psychotic
experiences in 483 children with ASD. (...truncated)