An overview of the mental health problems of people with Asperger syndrome: a workshop originally given to senior staff of the National Autistic Society

1. Autism spectrum disorder and
mental health
Autism spectrum disorder: a lifespan perspective
To be published, Jessica Kingsley, 2010
Can the world afford autistic spectrum disorder?
Published Jessica Kingsley, 2009
www. dilemmas.org
Digby Tantam,
Universities of Cambridge and Sheffield
Dilemma Consultancy

2. 9.30 Introduction
9.45 to 10.15 where I work, what I am looking for from the day
10.15 to 10.45 common mental health problems in ASD/ how to
recognize them/ risks
10.45-11 break
11.00 common emotional and externalizing problems in ASD/ how
to recognize them/ psychological/ medical treatments
12.30-1.15 Lunch.
1.15-1.45 work in small groups, select one challenging case where
there was never an additional diagnosis, what mental health
diagnosis or category might have been applicable, consider how
this would have changed management (if at all)
1.45-3 How do these mental health problems link with ASD
3-3.15 break.
3.15-4.15 answer questions and feedback

3. Disorder
(Seedat
et
al,
2009)
%affected
(95%
confidence
interval)
Social
anxiety
29.2%
(13.2%
to
45.1%)
ADHD
28.2%
(13.3%
to
43%)
Opposi>onal
defiant
disorder
28.1%
(13.9%
to
42.2%)
Tic
disorder,
tricho>llomania,
enuresis,
encopresis

4. Mini-SPIN (Connor et al, 2001)
• ‘‘Fear of embarrassment causes me
to avoid doing things or speaking to
people,’’
• ‘‘I avoid activities in which I am the
center of attention,’’
• ‘‘Being embarrassed or looking
stupid are among my worst fears.’’
Not at all Extremely
0 1 2 3 4 5

5. WHO screening questions for ADHD
• How often does he/she have trouble finishing a task or project once the
challenging parts have been done?
• How often does he/she have difficulty getting things in order when he/
she has to do a task requiring organisation?
• How often does he/she have problems remembering appointments or
obligations?
• When he/she has a task that requires a lot of thought, how often does
he/she avoid or delay getting started?
• How often does he/she fidget or squirm with his/her hands or feet when
sitting down for a long time?
• How often does he/she seem to be overly active and compelled to do
things, like he/she was being driven by a motor?
1. Rarely 2. Occasionally 3. Frequently as a child 4. Frequently as a child
• as a child but has now stopped and still persists

6. %
people
with
ASD
Hofvande
and
with
this
Hu5on
et
My
clinic
Balfe
et
al
r
et
al
Weighted
disorder
al
N=135
sample
N=490
N=78
N=122
mean
%
ADHD
43
43.00
Anxiety
16
42
47
50
39.40
Depression
25
30
17.68
Obsessive-­‐
compulsive
disorder
4
14
8.97
Substance
misuse
4
16
4.74
Somatoform
disorder
41
5
4.62
Bipolar
disorder
1
3.2
8
3.25
Panic
disorder
30
2.84
Brief
psychosis
3.4
2
2.32
Schizophrenia
3
3
2.23
EaSng
disorder
5
0.74
Catatonia
1
0.59
Delusional
disorder
1
0.15

9. OCD
• Obsession: recurrent, intrusive thought. Not
simply worry. anxiety
• Compulsion: Action. anxiety
• Person realizes irrationality. Ego-dystonic
experience. Attempt at thought supression
• Lifetime prevalence: 2.5% in all cultures

10. OCD: Course
• 75% have both obsessions and compulsions
• Sudden onset after stress
• 1/3 worsen; 1/3 improve; 1/3 stay ill
• 1/3 have Major Depression
• Suicide risk

11. PTSD
• Must experience extreme trauma
• Re-experience trauma
• Avoid reminders
• Numbing
• Persistent hyper-arousal
• Dissociation

12. Psychosis: illness features
• Positive symptoms"
• Hallucinations"
• Disorganized thinking"
• Delusions"
• Movement disorder"
• Negative symptoms in schizophrenia"
• Decline in social and occupational functioning "
• Reduction of nonverbal expression (ʻflattening of
affectʼ)"
• Partial mutism (poverty of speech)"

13. Psychosis: the affected person may: "
• Talk to himself "
• See things"
• Gesture to himself "

14. Psychosis: the affected person may: "
• Become confused in their speaking"
• Appear muddled"
• Dress in layers in any weather "
• Fail to bathe and get a haircut "
• Gain an odd interest in ordinary things (like
religion) "

15. Psychosis: the affected person may: "
• May even believe he is God "
• See things"
• Feel people are out to get them "
• Believe in all sorts of conspiracies "
• Have ideas that no amount of evidence to
the contrary can dislodge

16. Psychosis: the affected person may: "
• May become restless and over-active for no
reason"
• Become slowed, and sometimes immobile
for long periods with long pauses in speaking"
• Limbs may seem as if made of soft bendable
metal

17. Psychosis: the affected person may: "
• Be unable to work "
• Stop talking or greatly reduce conversation "
• Appear lazy, unmotivated and uninterested "
• May look like he has dementia "
• Lose the ability to get and keep friends "
• Be tense

18. • Are voices always hallucinations?
• Are weird ideas always delusions?
• Is incoherent speech always thought
disorder?
• When is thought insertion, rumination?

19. • physical agitation and/or anger
• expressed intent to kill or take revenge
• identification of specific victim(s)
• psychotic symptoms, especially 2nd person
command hallucinations to commit violence
• persecutory delusions
• disinhibition caused by traumatic brain injuries
and other central nervous system dysfunctions
• current use of alcohol or other drug

20. • living under circumstances of violence
• environmental access to guns or other lethal
weapons
• membership of violent peer group
• poor impulse control; risk taking or reckless
behaviour
• statements to others of intent to inflict harm
• History of violence or antisocial acts

21. Number of children
Ratio of improved trying this treatment (% of
Type of medication
to no effect or worse
sample)
Miscellaneous GI medication
4.00
10 (2%)
Miscellaneous herbal medication
3.33
13 (2.7%)
Atypical antipsychotics
2.08
80 (16.7%)
Anxiolytics
2.00
12 (2.5%)
Stimulants
1.80
172 (35.9%)
Mood stabilizers
1.80
70 (14.6%)
Chelation
1.60
32 (6.7%)
GF and/or CF dietb 1.52 155 (32.4%)
Antidepressants
1.31
136 (28.4%)
Other dietc
1.19
54 (11.3%)
Miscellaneous other medication
1.17
13 (2.7%)

22. Ratio of improved to Number of children trying this
Type of intervention
no effect or worse
treatment (% of sample)
Applied behavior analysis (ABA)
3.76
225 (47.0%)
Social skills training
3.05
244 (50.9%)
Picture exchange system (PECS)
2.88
231 (48.2%)
TEACCH
2.86
88 (18.4%)
Positive behavioral support
2.82
233 (48.6%)
Sensory Integration
2.79
255 (53.2%)
Occupational therapy
2.77
361 (75.4%)
Physical therapy
2.68
146 (30.5%)
Speech therapy
2.53
403 (84.1%)
Early intervention services
2.39
331 (69.1%)
Social stories
2.33
197 (41.1%)
Floor time
2.10
129 (26.9%)

23. What are the real drug effects?
• Reducing severe depression:
Antidepressants
• Reducing positive symptoms:
• Antipsychotics
• Reducing anxiety
• ?SSRIs
• Reducing over-activity and increasing response
control:
• Stimulants
• Reducing mood fluctuations
• Lithium and anticonvulsants

24. Choose a drug with least side
effects

25. Psychological treatments
• Some specific anxiety reduction with
cognitive methods
• Some specific improvement of mood with
behavioural activation
• Otherwise there is no difference in modalities
except
• Flavour and values
• Main outcome determinant is focus

26. Parental or informal carer
involvement
• Reduces depression, and therefore critical
comments, and hostility
• Reduces externalizing behaviour in client
• ‘oppositional behaviour’
• Conduct disorder
• Bloody mindedness

27. • Impaired nonverbal communication (expression and
interpretation) is the sine qua non
• There is a low bandwidth ‘interbrain connection’
• Often associated with other learning difficulties and
disconnection problems
• People with AS are more susceptible to bullying, to
emotional disorder, and therefore have worse quality of
life than others with ASD
• Understanding the experience of having ASD is key to
more successful coping strategies
WHAT IS ASD?

28. Enmeshment
• Anxious attachment
• Caused by threat
• Identity threat to family system and work with
it, and not against it
• Define hostility as frustration
• Rage and anger as fear

29. The power of power
• The rage that conceals impotence, or
incapacity is inversely proportional to
popularity and ‘social influencing power’
• Outrage conceals this
• In men, anger often conceals shame

30. From The autistic spectrum OpenLearn LabSpace
Sacar, Bradford 22 Oct 09

31. Sacar, Bradford 22 Oct 09

32. Features of nonverbal inexpressiveness
• Reduction of expression or occasionally
idiosyncratic expressions such as unusual
prosody, facial mannerisms
• Affects all channels
• Voluntary signals e.g. social smiles
unaffected
• Is not the commonest cause of gaze
avoidance, in fact may result in staring
Sacar, Bradford 22 Oct 09

33. Feature of nonverbal
inexpressiveness
• Reduction of expression or occasionally
idiosyncratic expressions such as unusual
prosody, facial mannerisms
• Affects all channels
• Voluntary signals e.g. social smiles
unaffected
Sacar, Bradford 22 Oct 09

34. Atypical Asperger syndrome: a disorder of
nonverbal interpretation
• Primary abnormality is lack of
empathy, partly due to failure
of non-verbal interpretation
(‘face blindness’)
• Ability to make relationships
but not to keep them
• Lack of empathy may lead to
antisocial behaviour, but
greater problem is lack of
persuasiveness and ‘social
influencing power’
Picture from the film, “Ripley’s game” starring Matt
Damon as Ripley
Sacar, Bradford 22 Oct 09

35. Knowing about the world using non-verbal
cues
Who is being
shot?
Terrorists or
partisans?
Sacar, Bradford 22 Oct 09

36. Is Asperger syndrome the future?
Owen Thor Walker apointed to TelstraClear, who previously wrote code enabling
a hacker group to steal £13.9M from bank accounts
Bram Cohen, founder BitTorrent, and
self diagnosed Aspie