Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders

BMC Psychiatry Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders Bjrn Hofvander*1, Richard Delorme2,7, Pauline Chaste2,7, Agneta Nydn3, Elisabet Wentz3,4, Ola Sthlberg5, Evelyn Herbrecht2,6,7, Astrid Stopin2, Henrik Anckarster 1 2 5 Christopher Gillberg 0 Maria Rstam 8 Marion Leboyer 1 3 4 7 0 Child and Adolescent Psychiatry, Institute of Neuroscience and Physiology, University of Gothenburg , Gothenburg , Sweden 1 INSERM, U 995, dept of Genetics, Institut Mondor de Recherche Biomedicale , Psychiatry Genetics, Creteil , France 2 Forensic Psychiatry, Department of Clinical Sciences, Malmo, Lund University , Lund , Sweden 3 Fondation FondaMental , Creteil , France 4 Assistance Publique-Hopitaux de Paris, Henri Mondor-Albert Chenevier Hospitals, Department of Psychiatry , Creteil , France 5 Forensic Psychiatry, Institute of Neuroscience and Physiology, University of Gothenburg , Gothenburg , Sweden 6 Vardal Institute, Swedish Institute for Health Sciences , Lund , Sweden 7 University Paris 12, Faculty of Medicine, IFR10 , Creteil , France 8 Department of Clinical Sciences, Lund, Child and Adolescent Psychiatry, Lund University , Lund , Sweden Background: Individuals with autism spectrum disorders (ASDs) often display symptoms from other diagnostic categories. Studies of clinical and psychosocial outcome in adult patients with ASDs without concomitant intellectual disability are few. The objective of this paper is to describe the clinical psychiatric presentation and important outcome measures of a large group of normalintelligence adult patients with ASDs. Methods: Autistic symptomatology according to the DSM-IV-criteria and the Gillberg & Gillberg research criteria, patterns of comorbid psychopathology and psychosocial outcome were assessed in 122 consecutively referred adults with normal intelligence ASDs. The subjects consisted of 5 patients with autistic disorder (AD), 67 with Asperger's disorder (AS) and 50 with pervasive developmental disorder not otherwise specified (PDD NOS). This study group consists of subjects pooled from two studies with highly similar protocols, all seen on an outpatient basis by one of three clinicians. Results: Core autistic symptoms were highly prevalent in all ASD subgroups. Though AD subjects had the most pervasive problems, restrictions in non-verbal communication were common across all three subgroups and, contrary to current DSM criteria, so were verbal communication deficits. Lifetime psychiatric axis I comorbidity was very common, most notably mood and anxiety disorders, but also ADHD and psychotic disorders. The frequency of these diagnoses did not differ between the ASD subgroups or between males and females. Antisocial personality disorder and - substance abuse were more common in the PDD NOS group. Of all subjects, few led an independent life and very few had ever had a long-term relationship. Female subjects more often reported having been bullied at school than male subjects. Conclusion: ASDs are clinical syndromes characterized by impaired social interaction and nonverbal communication in adulthood as well as in childhood. They also carry a high risk for coexisting mental health problems from a broad spectrum of disorders and for unfavourable psychosocial life circumstances. For the next revision of DSM, our findings especially stress the importance of careful examination of the exclusion criterion for adult patients with ASDs. Background Autism spectrum disorders (ASDs) (or pervasive developmental disorders (PDDs), in the DSM-IV) are impairing developmental disorders characterized by aberrations in the domains of social interaction, communication and stereotyped or repetitive behavior patterns, estimated to affect about 1% of the general population [1]. The DSMIV includes the following ASDs: autistic disorder (AD) (pervasive problems/deficits in all three domains), Asperger's disorder (AS) (pervasive deficits in social interaction and in behaviours in the presence of a normal verbal development) and pervasive developmental disorder not otherwise specified (PDD NOS). Research criteria for AS by Gillberg & Gillberg (G & G) [2] include the same triad of restrictions but also verbal peculiarities and abnormal motor development. "High-functioning autism" (HFA) is a disputed term sometimes used to describe individuals with AD without concomitant mental retardation [3]. Community-based studies show highly skewed male>female ratios for ASDs [4]. Possible sex differences in the clinical phenotypes have been insufficiently studied [5], and instruments and criteria have been developed and validated mostly on male subjects, which also might have affected the estimated sex ratio. Further, ASDs have mainly been diagnosed among children and adolescents, but increasing attention is directed to their prevalence and clinical presentation among adults. A few long-term prospective follow-up studies have so far shown high diagnostic stability [6,7]. Data on psychosocial life circumstances and psychiatric comorbidity in normal-intelligence adult patients with ASDs are scarce but suggest reduced social functioning, and a substantially better outcome in AS than in autism, probably attributable to better intellectual abilities [7]. Estimated rates of co-existing psychiatric disorders in subjects with normal intelligence ASDs have varied substantially, from 9% to 89% [8]. Attention deficits and hyperactivity have been shown to be common in children with ASDs [4], but studies of the co-occurrence of ADHD and ASDs in adults are few [9,10]. A high rate of chronic tic disorders has been reported in ASD patients [11]. Mood disorders, together with anxiety disorders, have been described as important complications of ASDs in a range of studies [8,12,13]. Autism was until the 1970's conceptualized as the earliest manifestation of schizophrenia [14]. Kolvin [15], among others, provided evidence of a bimodal distribution of onset in "childhood psychosis", which was thought to separate the two conditions. It was even suggested that at least the childhood-onset subtype of schizophrenia was less common in autism than in the general population [16]. Today, autism and schizophrenia are referred to as early and late onset neurodevelopmental disorders [17]. Psychotic symptoms in ASD patients have often come to be regarded as misattributions of autistic phenomena [18]. However, "schizophrenic-type illnesses" represent around one-tenth of all psychiatric comorbid diagnoses in a review by Howlin [8]. Additionally, a number of clinical case reports have described psychotic symptomatology, including auditory hallucinations, paranoid ideas, or delusional thoughts in subjects with ASDs. It seems probable that ASD is one possible vulnerability factor for the development of psychotic symptoms and schizophrenia [19]. A more definitive picture of the life-time prevalences of ASD, psychotic disorders and their over (...truncated)