President of MSSA Prof. Dr. Vladimir Trajkovski presented this topic "Mental Health Issues in Autism Spectrum Disorders" at the mini simposyum in Voerandaal, Holland, organized by ReAttach Academy at May 10th 2019.

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Mental Health Issues in AutismMental Health Issues in Autism
Spectrum DisordersSpectrum Disorders
Prof. Dr. med. VladimirProf. Dr. med. Vladimir TrajkovskiTrajkovski
Voerendaal, May 10th 2019
UniversityUniversity ““St. Cyril and MethodiusSt. Cyril and Methodius””
Faculty of PhilosophyFaculty of Philosophy
Institute of Special Education and RehabilitationInstitute of Special Education and Rehabilitation
Macedonian Scientific Society for AutismMacedonian Scientific Society for Autism

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““Disconnection SyndromeDisconnection Syndrome””

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Normal FunctionsNormal Functions
Left HemisphereLeft Hemisphere
Verbal communication, reading, mathematicalVerbal communication, reading, mathematical
calculation, musical abilitycalculation, musical ability
Approach behavior, which is really about desire. It is theApproach behavior, which is really about desire. It is the
motivation to do things. Social motivationmotivation to do things. Social motivation
Inductive reasoning (inferences)Inductive reasoning (inferences)
Details and facts (Local Coherence)Details and facts (Local Coherence)
Pattern Recognition skillsPattern Recognition skills
SamenessSameness
Immune activationImmune activation
Fine motor skillsFine motor skills
Near visionNear vision
High frequency sound and lightHigh frequency sound and light

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Left Hemisphere Under ActivationLeft Hemisphere Under Activation
Can result in the followingCan result in the following
–– Poor ReadingPoor Reading
–– Delayed speechDelayed speech
–– Poor auditory processingPoor auditory processing
–– Poor object identificationPoor object identification
–– Poor verbal communication skillsPoor verbal communication skills
–– DepressionDepression
–– Poor math operationsPoor math operations
–– GraphomotorGraphomotor problemsproblems
–– Cross lateralityCross laterality
–– Autonomic nerve systemAutonomic nerve system dysregulationdysregulation
–– Decreased Immune responseDecreased Immune response
–– Miss small detailsMiss small details
–– Poor motivationPoor motivation
Learning disabilities, processing disorders, dyslexia,Learning disabilities, processing disorders, dyslexia, dyscalculadyscalcula,,
dysgraphiadysgraphia

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Normal FunctionsNormal Functions
Right HemisphereRight Hemisphere
Nonverbal communication, math reasoning, readingNonverbal communication, math reasoning, reading
comprehension, spatial, attention, control impulsivecomprehension, spatial, attention, control impulsive
behavior, feeling your own body,behavior, feeling your own body, proprioceptionproprioception
Deductive reasoningDeductive reasoning
Seeing the big picture (Global Coherence)Seeing the big picture (Global Coherence)
Distance visionDistance vision
Facial recognitionFacial recognition
Social skillsSocial skills
Withdrawal behavior, stopping any activity, may also controWithdrawal behavior, stopping any activity, may also contro
fear and anxietyfear and anxiety
Novel (new) things are right brainNovel (new) things are right brain
Immune suppressionImmune suppression
Low frequency sound and lightLow frequency sound and light
Gross motor, eyes, posture , big muscles, rhythmGross motor, eyes, posture , big muscles, rhythm

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Right Hemisphere Under ActivationRight Hemisphere Under Activation
Can result in the followingCan result in the following
–– Poor spatial orientationPoor spatial orientation
–– Inappropriate social behaviorInappropriate social behavior
–– Miss big pictureMiss big picture
–– Cannot reflect on own mental processesCannot reflect on own mental processes
–– Poor nonverbal communication skillsPoor nonverbal communication skills
–– Poor attentionPoor attention
–– ImpulsivityImpulsivity
–– Repetitive behavior and movementsRepetitive behavior and movements
–– Poor reading comprehension and pragmatic skillsPoor reading comprehension and pragmatic skills
–– Overactive immune response (allergies,Overactive immune response (allergies,
hypersensitivities, autohypersensitivities, auto--immune)immune)
–– Poor gross motor skills and developmentPoor gross motor skills and development
–– Poor math reasoningPoor math reasoning
–– AnxietyAnxiety
ADHD,ADHD, AspergerAsperger’’ss, PDD, OCD, Tics, Autism, PDD, OCD, Tics, Autism

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OverviewOverview (1)(1)
Epidemiological studies suggest that between 54 andEpidemiological studies suggest that between 54 and
70% of people with autism also have one or more other70% of people with autism also have one or more other
mental health conditions (Romero, 2016).mental health conditions (Romero, 2016).
Like autism, ADHD, schizophrenia and bipolar disorderLike autism, ADHD, schizophrenia and bipolar disorder
areare neurodevelopmentalneurodevelopmental conditions that appear to haveconditions that appear to have
roots in early brain development.roots in early brain development.
Among people with autism, anxiety and depression mayAmong people with autism, anxiety and depression may
stem, at least in part, from autismstem, at least in part, from autism--related impairmentsrelated impairments
that increase daily stress and social isolation andthat increase daily stress and social isolation and
decrease overall quality of life (decrease overall quality of life (VasaVasa et al., 2016).et al., 2016).
Untreated mental health conditions can profoundlyUntreated mental health conditions can profoundly
worsen autismworsen autism’’s behavioral challenges.s behavioral challenges.

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OverviewOverview (2)(2)
But because of overlapping symptoms, they can beBut because of overlapping symptoms, they can be
particularly difficult to identify in someone who has autismparticularly difficult to identify in someone who has autism
((SikoraSikora et al., 2012).et al., 2012).
The social withdrawal associated with depression orThe social withdrawal associated with depression or
schizophrenia, for example, can be difficult to distinguishschizophrenia, for example, can be difficult to distinguish
from autismfrom autism--related social impairments.related social impairments.
Many people with autism have difficulty identifying andMany people with autism have difficulty identifying and
expressing emotions and other internal feelings.expressing emotions and other internal feelings.
Autism specialists have developed guidelines forAutism specialists have developed guidelines for
diagnosing and treating some of the most commondiagnosing and treating some of the most common
mental health conditions affecting children, and adultsmental health conditions affecting children, and adults
who have autism.who have autism.

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OverviewOverview (3)(3)
GhaziuddinGhaziuddin et al. (1998) found that 65% ofet al. (1998) found that 65% of
adults with autism presented with mental healthadults with autism presented with mental health
conditions.conditions.
These included: depression, anxiety, OCD,These included: depression, anxiety, OCD,
eating disorders.eating disorders.

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Common Psychiatric
Comorbidities seen with ASD
ADHD
Aggression
Self injurious behaviors 24 – 43%,
Anxiety Disorders
Depressive Disorders 9 – 44%
Obsessive Compulsive Behaviors >40%
Sleep disturbances
Sexualized behaviors
Psychosis
Tics

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Autism and ADHD
Over the last decade, studies have suggested that
between 30-61% of people with autism also have
symptoms of ADHD (Romero, 2016).
Symptoms of ADHD include a persistent pattern of
inattention, hyperactivity and/or impulsivity that interferes
with daily life, social development and learning.
People with ADHD often fail to pay close attention to
details and make careless mistakes at school or work.
Often, they don’t appear to listen when spoken to, have
trouble organizing tasks and fail to follow through on
instructions and assignments, especially those that require
sustained attention.

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ADHD symptoms in ASD
In early childhood
hyperactivity
stereotyped behaviors
irritability and temper tantrums
Later
aggressiveness/self injurious behavior
stereotypic behaviors
In adolescence and adulthood:
esp. in higher functioning individuals depression or
OCD may develop and interfere with functioning

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Autism and anxiety disorders (1)
Between 11 and 42% of people with autism struggle with
one or more anxiety disorder (Vasa et al., 2016).
These disorders include separation anxiety, panic disorder
and phobias (extreme fear of certain noises, places).
Most research on anxiety in autism has focused on
children and adults who are verbal and have normal to
high intelligence.
Experts agree on the need for more studies involving the
1/3 of people with autism who are nonverbal or minimally
verbal and/or have intellectual disability.

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Autism and anxiety disorders (2)
Anxiety can trigger strong internal sensations of tension
that include a racing heart, muscle tightness and stomach
ache.
In someone with autism, these feelings can prompt an
increase in self-soothing, repetitive behaviours (flapping,
rocking, spinning, etc.) and/or destructive or self-harming
behaviours (shredding, clothing, head banging, etc.).
Anxiety can be the underlying cause of new resistance to
what had been an enjoyed activity (e.g. a trip to the beach,
a birthday party, school, etc.) (Autism Speaks, 2017).

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Impact of Anxiety on
functioning in ASD
Exacerbates ASD symptoms;
Interferes with treatments of ASD;Interferes with treatments of ASD;
Can result in irritability,Can result in irritability, agressionagression, and self, and self--injury;injury;
Led to depression andLed to depression and sucicidalitysucicidality;;
Increase family stress;Increase family stress;
Risk forRisk for longtermlongterm psychopatologypsychopatology;;
Influences developmental transitions (e.g. into elementaryInfluences developmental transitions (e.g. into elementary
school, adulthood).school, adulthood).

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Treating anxiety disorders
It is important to try to break this vicious cycle, and this is
why cognitive (to do with thoughts) and behavioural
psychological treatments are often as important in
treatment as medication.
Treatments involve forming a working relationship with a
therapist, building up any necessary skills, and deciding to
work through a set of challenges (involving exposure to an
aspect of the feared situation) one step at a time that are
anxiety-provoking but not intolerable.
This way both the mind and the body learn that the feared
situation isn't as dreadful as was thought, and this leads to
a gradual reduction in anxiety.

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Autism and OCD
OCD is an anxiety disorder. If someone has OCD, it means that
they experience repetitive thoughts and behaviours that are
upsetting to them.
OCD occurs in about 2-3% of people who are not autistic and is
more common in people who are autistic.
It is thought that our genes (DNA) and our psychological
predisposition can make us vulnerable to developing OCD,
which can run in families.
OCD can be distressing, exhausting and can get in the way of
everyday life for the person who has it and their families.
However, it is treatable.
There are two main parts to OCD: obsessions (thoughts) and
compulsions (behaviours). OCD can be overlooked in people
on the autism spectrum as it may be mistaken for repetitive
behaviour.
It is still under-recognised and therefore under-treated.

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Treating OCD
Two recommended treatments for OCD: Cognitive Behavioural
Therapy (CBT) and medication.
CBT gives you tools to help you change the way you think and
act. As the most researched psychological treatment for OCD,
there is now evidence that specialized CBT is effective for
treating OCD.
Medication can be used either alone or in combination with
CBT.
Drugs are SSRIs: Fluoxetine and Paroxetine.
Some autistic people can be vulnerable to side-effects from
medication and so it’s best to start with a low dose, which you
and your doctor can increase slowly over time if needed,
monitoring your symptoms with an OCD monitoring scale.
Information about autism and OCD (psychoeducation) and
social skills work can also form part of a helpful package of
individualised care for people on the autism spectrum and
OCD.

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Autism and depression (1)
Depression affects an estimated 7% children and 26% of
adults with autism (Croen, 2015).
This compares to 2% of children and close to 7% of adults
in the general U.S. population. A recent report in the
journal Pediatrics found that the rate of depression among
children with autism rose dramatically with age, from just
under 5% in grade-schoolers to just over 20% in
teenagers.
It likewise rose with intellectual ability (IQ), as well as the
presence of one or more of the medical conditions that
commonly accompany autism – particularly seizures and
gastrointestinal issues.

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Autism and depression (2)
That depression rates rise with age and intellectual ability
suggests a painful awareness of autism’s social challenges
and isolation, the researchers propose.
Authors called on healthcare professionals to consider
screening for depression as a routine part of care for teens
and adults who have autism – particularly those with normal
to high IQ and those with additional medical issues.
Signs and symptoms of depression include chronic feelings
of sadness, hopelessness, worthlessness, emptiness and/or
irritability. Also common: social isolation, moving or talking
slowly, feeling restless, and having trouble sitting still or
concentrating. At its most serious, depression can include
frequent thoughts about death and/or suicide (Autism
Speaks, 2017).

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Treating depression
Treatments for depression can be psychological
or medical, regardless of whether a person is
autistic.
The most important step to getting help is for the
autistic person to tell someone they trust, such as
a family member, a close friend, their GP or
another professional.
Some people need a referral to a specialist
service, either because they would benefit from
psychological therapy adapted for autistic people,
or due to a more complex set of problems.

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Video presentationVideo presentation

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Autism and schizophrenia
Autism and schizophrenia both involve impairments in
processing language and understanding other people’s
thoughts and feelings.
Clear differences include schizophrenia’s hallmark psychosis,
which often involves hallucinations.
Autism’s core symptoms typically emerge between ages 1 and
3 years; schizophrenia’s in early adulthood. Many clinicians
have reported identifying autism at high rates in adults already
diagnosed with schizophrenia and vice versa. Investigations
looking at how commonly these two conditions occur together
vary widely in their findings. Taken together, the studies found
schizophrenia in 4 to 35% of adults who have autism and found
autism in 4 to 60% of those who have schizophrenia. Many of
the same gene changes known to increase risk of autism also
increase the risk of schizophrenia (Autism Speaks, 2017).

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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 & Skills Maintained in anxiety states
Developmental trajectory
Why the confusion?Why the confusion?
Comorbid disorderComorbid disorder SchizophreniaSchizophrenia

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

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Comorbid disorderComorbid disorder SchizophreniaSchizophrenia
Positive Symptoms
Delusions
Hallucinations
Thought disorder
Abnormal movement
• catatonia
• stereotypies
Negative Symptoms
Withdrawal (autism)
Emotional change
• inappropriate
• blunted / apathy
Psychosis

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Autism and bipolar disorder (1)
Bipolar disorder is a mood disorder also known as “manic
depression”. People with bipolar disorder tend to alternate
between a frenzied state known as mania and episodes of
depression.
While some people experience only the manic episodes,
most alternate between these two states and can show
extreme irritability.
Research shows that children and adults with autism are
at increased risk for bipolar disorder.
Studies vary widely in estimating the prevalence of bipolar
disorder among people with autism, ranging from 6 to
27%.

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Autism and bipolar disorder (2)
Bipolar disorder affects around 4% of the general
population. Some leading experts propose that bipolar
disorder may be over-diagnosed in those who have
autism, due to overlapping symptoms such as
hyperactivity, irritability and disturbed sleep.
They caution mental health providers to tease apart the
symptoms of true bipolar disorder from those of autism by
looking at when the symptoms appeared and how long
they lasted.
The antipsychotics risperidone and aripiprazole can treat
irritability in children with autism, though both tend to
produce significant weight gain and diabetes risk (Autism
Speaks, 2017).

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Learning Disabilities
Some children with autism have diagnosable
learning disabilities such as dyslexia, while
others have unusual abilities such as
hyperlexia (the ability to read at an extremely
young age).
Some have a very tough time gaining basic
math skills; others are mathematical
"savants,“ achieving far beyond their grade
level.

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Serious Emotional Disturbances
It can also be tough to distinguish
between mood disorders and bipolar
disorder, schizophrenia, and autistic
behaviors.
It is not unusual for a person with autism
to also have a mental health diagnosis of
bipolar disorder, clinical depression,
obsessive compulsive disorder or
schizophrenia.

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Anxiety PanicFear
Obsessions
Compulsions
Anger Sexual arousal
Symptoms Emotional arousal

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Behavioral Issues
Common reason for presentation to
mental health services
20% with severe mental retardation have
some form of severe behavioral disorder
Problem behaviors: self harm/aggression
to others
Significantly disabling/ not responding to
other measures

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ConclusionsConclusions (1)(1)
Autism is frequently accompanied by mental healthAutism is frequently accompanied by mental health
conditions including anxiety, depression, and ADHD.conditions including anxiety, depression, and ADHD.
AutismAutism--associated health problems extend across the lifeassociated health problems extend across the life
spanspan –– from young children to senior citizens.from young children to senior citizens.
A better understanding of the possible mechanismsA better understanding of the possible mechanisms
leading to poorer health status will enable improvedleading to poorer health status will enable improved
patient care and ultimately enhance the quality of life forpatient care and ultimately enhance the quality of life for
people with autism spectrum disorders.people with autism spectrum disorders.
Despite the prevalence of these health conditions, moreDespite the prevalence of these health conditions, more
systematic research is needed to understand theirsystematic research is needed to understand their
manifestation in people with ASD and the best practicesmanifestation in people with ASD and the best practices
for identifying and treating them.for identifying and treating them.

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ConclusionsConclusions (2)(2)
Specialists at autism care centers are workingSpecialists at autism care centers are working
with patients and their families to improve thewith patients and their families to improve the
health and quality of life of all those with ASD byhealth and quality of life of all those with ASD by
developing and disseminating evaluation anddeveloping and disseminating evaluation and
treatment guidelines for healthcare providers.treatment guidelines for healthcare providers.
DonDon’’t feel afraid to ask about the healtht feel afraid to ask about the health
professionals experience of autism.professionals experience of autism.
Follow the evidence based medicine!Follow the evidence based medicine!

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THANK YOU!THANK YOU!
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vladotra@fzf.ukim.edu.mkvladotra@fzf.ukim.edu.mk
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Prof. Dr. VladimirProf. Dr. Vladimir TrajkovskiTrajkovski
@@vladotravladotra
ttp://www.linkedin.com/profile/ttp://www.linkedin.com/profile/VladimirTrajkovskiVladimirTrajkovski