1. Comorbid Disorder in Autism Tom Berney Northgate & Prudhoe NHS Trust Fleming Nuffield Child & Family Psychiatry Unit European Services for People with Autism (ESPA) Athens University visit

2. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

3. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

4. Autism as a syndrome 2 o to a medical disorder Limited imagination / creativity Repetitive/stereotyped movements OCD Circumscribed interests Social responsiveness Communication AutismWhat is ‘autism’ symptoms Syndrome Autism as a 1 o disorder Disorder genetic cause

5. Primary Genetic disorder - interaction of 3+ sites Secondary to any disorder that causes LD  tuberous sclerosis  fragile X disorder syndrome What is ‘autism’Autism

6. Limited imagination / creativity Repetitive/stereotyped movements OCD Circumscribed interests Social responsiveness Theory of Mind Empathy Communication Executive Function VoluntaryAutomatic AutismDiagnostic domains

7. Theory of Mind Social responsiveness Empathy Communication Executive Function VoluntaryAutomatic Repetitive/stereotyped movements OCD Circumscribed interests Motor abnormality Tone Co-ordination Central coherence Perception Depression Epilepsy Immunology Bowel dysfunction Socialresponsiveness Social responsiveness AutismPervasive & complex disorder

8. Administrative Clinical Research Threshold of diagnosis Autism The purpose of the diagnosis

9. A syndromal (> a laboratory) diagnosis A continuum, the diagnostic threshold depending on:  the autism - how severe / fragile  sympathy of the setting Threshold of diagnosis Autism Autism Asperger’s Broader phenotype ASDNeurotypical

10. A syndromal (> a laboratory) diagnosis A continuum, the diagnostic threshold depending on:  the autism - how severe / fragile  sympathy of the setting Threshold of diagnosis Autism Subtypes – depend on:  level of cognitive ability  change with age  Aloof  Passive  Active-but-odd

11. Developmentaldisorders Disorders that are:  innate (genetic)  change with development (i.e. brought out at different ages)

12. Developmentaltrajectories OCD ADHD ASD Tics Age (yrs) 05101520 Developmentaldisorders

13. Symptoms Specific developmental disabilities

14. Obsessions & Compulsions Impulsivity Tics Dyscalculia Dyslexia Socialimpairment Repetitive self stimn AD Catatonicsymptoms Stereotypy Languageproblems Dyspraxia Hyperactivity

15. Obsessions & Compulsions Impulsivity Tics Dyscalculia Dyslexia Socialimpairment Repetitive self stimn AD Developmental syndromes Catatonicsymptoms Stereotypy languageproblems Dyspraxia Hyperactivity

16. Developmental disorders Autism ADHD Comorbid disorders Hybrid disorder (Autism-ADHD)

17. Symptoms Syndromes Disorders Concepts arousal (anxiety / aggression ) inattention depression obsessions tics ADHDOCDTourette 2 o autism 1 o autism Epilepsy Schizophrenia Cyclical disorders

18. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

19. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

20. ASD in epilepsy Selected populations Disability - more severe / multiple Cause of autism - 1 0 & 2 0 Diagnosis - how narrow / broad Regression (probably) unrelated to epilepsy Bimodal onset - childhood & adolescence Epilepsy (seizures) in ASD (5-30%) Depends on degree & nature of disability  About 5-10% in childhood Asperger  Up to 70% in disintegrative disorder Epilepsy Comorbid disorder

21. Social impairment Repetitive & stereotyped behaviours Communication abnormality Comorbid disorder Social impairment Repetitive & stereotyped behaviours Communication abnormality Epilepsy can amplify the symptoms of autismEpilepsy

22. Comorbid disorder Social impairment Repetitive & stereotyped behaviours Communication abnormality Can epilepsy mimic the symptoms of autism? Epilepsy

23. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

24. Comorbid disorder Schizophrenia Positive Symptoms  Delusions  Hallucinations  Thought disorder  Abnormal movement catatonia stereotypies Negative Symptoms  Withdrawal (autism)  Emotional change inappropriate blunted / apathy Psychosis

25. Schizoid PD Schizophrenia Autism Asperger’s Broader phenotype Unitary psychosis Age Birth16 yrs. SchizophreniaAutism 1971 - SD - Comorbid disorder Schizophrenia

26. Age Birth16 yrs. SchizophreniaAutism Developmental trajectories Comorbid disorder Schizophrenia

27. Age Birth16 yrs. SchizophreniaAutism Asperger Developmental trajectories Comorbid disorder Schizophrenia

28. High arousal hallucinations thought disorder Difficulty in expressing thoughts & feelings Reality ≈ observed fiction Pragmatic difficulty – irrelevant detail Thoughts & Perceptions Motor Catatonic symptomatology Impassivity negativism initiation mutism Performance & SkillsMaintained in anxiety states Developmental trajectory Why the confusion? Comorbid disorder Schizophrenia

29. Does Autism predispose to schizophrenia? Autism does not protect against schizophrenia Similar underlying abnormalities How do we define schizophrenia presenting symptomatology? course & prognosis? Not supported by outcome studies Comorbid disorder Schizophrenia What is the relationship?

30. Concepts  Autism  Symptoms, syndrome & disorder  Developmental disabilities  Attention deficit & hyperactivity  Tics  Obsessions & compulsions Comorbid Disorder in Autism Comorbid conditions  Epilepsy  Schizophrenia  Arousal (anxiety / aggression)

31. eventscontrol Anxiety Uncertainty Symptoms Emotional arousal Obsessions Compulsions

32. Anxiety PanicFear Obsessions Compulsions AngerSexual arousal Symptoms Emotional arousal

33. verbal people property selfothers self-injury (SIB) self-stimulation formfunction predatory / instrumental defensive / reactive frustration communicative cause emotional arousal pain organic states drugs unusual perception alcohol / stimulants / AEDs brain injury epilepsy Symptoms Aggression

34. SIB High pain threshold Compulsion Social reinforcement self-stimulation Symptoms SIB

35. Maladaptive response Comorbid symptoms Autism symptoms Interaction → complex presentation