Autism spectrum disorder (ASD) and psychosis are distinct but closely related psychiatric conditions. In the twentieth century, Swiss psychiatrist Eugen Bleuler identified autism, which he defined as withdrawal from the world, as a core, pathognomonic symptom of schizophrenia. Since the 1970s and the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), ASD and psychosis have become recognized as separate diagnoses, but they remain highly comorbid. Up to 34.8% of those with ASD exhibit psychosis and 3.6-60% of those with schizophrenia present with autistic traits. Individuals with ASD are 3.5x more likely to develop psychosis than the general population. Both conditions share risk factors including advanced paternal age, pregnancy and birth complications, migration status, specific genetic pathways, abnormalities in brain development, neuroanatomical markers, and social cognition deficits. It is thought that the impairments in information processing seen in ASD may confer a risk for later psychosis.

Identifying psychosis in individuals with ASD can be challenging. First, patients with ASD may have difficulty communicating psychotic experiences, such as delusions and hallucinations due to the social communication impairments inherent to ASD and/or insufficient cognitive ability if they have comorbid intellectual disability. Additionally, overlapping symptoms in both conditions may create complications. For example, hallucinations may be misinterpreted as the anomalous perceptual experiences reported in ASD, or negative symptoms of psychosis, such as flat affect and social withdrawal, may be confused for difficulties with socio-emotional reciprocity seen in ASD.

Considering the overall course of illness can be helpful in distinguishing psychosis from ASD. While the onset of ASD is typically in early childhood, as early as 12-24 months of age, the onset of primary psychotic disorders is typically between late adolescence and the mid-thirties (there are exceptions to this pattern; for example, childhood-onset schizophrenia can be diagnosed before 13 years old). Furthermore, negative symptoms of psychosis typically worsen over time if untreated while autistic traits remain more stable.

There are also key differences between these two disorders that can aid in diagnosis. ASD is generally associated with an impairment in understanding the rules of common social interactions, greater impairment in theory of mind (the ability to understand and predict the mental states of others) and difficulty in distinguishing between one’s subjective perceptions and reality. On the other hand, individuals with psychosis tend to have a greater tendency towards external attributions for negative events and internal attributions for positive events. They are also more likely to demonstrate hostility bias, or the tendency to interpret the ambiguous behaviors of others as hostile.

Distinguishing ASD from psychosis is important, as it can allow for early intervention and treatment. Medications for these diagnoses can overlap; for instance, the second-generation antipsychotics aripiprazole and risperidone are used for both irritability associated with ASD and for psychosis. However, higher doses of such medications may be required in primary psychotic disorders compared to ASD. Additionally, diagnostic clarification can help guide therapy. While Applied Behavior Analysis may be most appropriate for an individual with ASD, Cognitive Behavioral Therapy for Psychosis might be recommended for individuals with psychosis. Understanding the differences and shared features of ASD and psychosis is crucial for accurate diagnosis and effective intervention, ultimately leading to improved outcomes for affected individuals.

Back to the Case: Patient was diagnosed with unspecified psychosis in addition to his existing diagnosis of autism spectrum disorder. He was started on aripiprazole, which was gradually titrated to 20mg daily. He and his mother reported improvement in his aggression, hallucinations, and paranoia on this medication. He was referred to the San Diego Regional Center for interventions related to his autism spectrum disorder and to a psychosis specialty clinic for interventions related to his psychosis.

AUTHOR:

Dr. Kristen Kim, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

Particularly for those more significantly affected, the issue of agitated and aggressive outbursts is often a major concern, though even in those with less significant symptom profiles, affectively charged outbursts may occur. Helping families and caregivers better understand both the causes of these incidents and the course of such outbursts can aid in reducing and preventing aggressive behaviors and may lead to helpful intervention strategies when they do occur.

Most aggressive and agitated episodes in the ASD population are best conceptualized as “meltdowns” which are a typically a reaction to either an overwhelming intense sensory experience or an unanticipated external frustration.   While sometimes compared to and described as “tantrums”, these meltdown outbursts are typically not goal-directed as most tantrums are in non-affected individuals.

For those with ASD, it is always important to consider what may be causing a meltdown—- parents and caregivers can and should be tasked with being “detectives” in figuring out possible causal factors. This can be a very powerful tool in addressing and reducing meltdowns over the long term.

Things to consider include:

• Is this a medical problem—is the individual in pain or other distress?
• Does the individual not have ability to communicate their wants or needs?
• Are cognitive or social demands too high or too low?
• Sensory dysregulation: Is there too much or too little stimulus?
• Has there been reinforcement of the behavior in the past?
• Is there a co-occurring mental health condition that might explain the problem(s)?
• Are there family/school dynamics such as bullying, moving to a new home/school, caregiver burnout?

Once (and if) a causal factor(s) for the meltdowns has been identified, it will often be feasible for parents and caretakers to intervene, either to address or to minimize their frequency and/or intensity.

An understanding of the concept of the “Rage Cycle” can also be a helpful framework for parents and caretakers in managing meltdown outbursts more effectively. The following graphic of the cycle of rage is very useful for understanding when and how a caretaker can intervene. Although referenced here in the context of individuals with ASD, the concepts can also be applied to other individuals with similar issues of reactivity, impulse control and affect management.

Most importantly, it is important to know that once the cycle of a meltdown has begun, ,,,this is NOT the time to attempt teaching what to do or introducing a new task or skill.

Early recognition of the precursors to a meltdown –when a person begins to “rumble”– can sometimes be helpful and if seen, early intervention may arrest the cycle from becoming a full meltdown. For example, rumbling may present with heightened physical activity such as jumping or pacing about, yelling, fidgeting, rapid movements or making noises. If the individual’s level of agitation is not too advanced, parents and caregivers can utilize simple strategies that may be used during the “rumbling phase” such as:

• Acknowledge the difficulty and coach simply and calmly
• Attempt gentle redirection or refocussing
• Intervene without challenging or raising the temperature
• Keep verbal input simple:   Just “walk”, don’t “talk”
• Move the individual away from the ‘offending’ environment, if feasible.
• Use proximity control– stay with the person, be present and calm
• Refer to a schedule and highlight positive future activities, if available
• Go to a predetermined “home base” or “calming place”

If the meltdown reaches the rage stage, aggressive behaviors are more likely occur and appropriate caution is important. In this phase, the profile may include disinhibition, impulsivity, emotional lability, explosive behavior, property destruction, self-injurious behavior, yelling, biting, hitting or crying. During this time, it is of utmost importance to keep the individual and those around them safe. Interventions during a meltdown may include:

• Protect the individual and others
• Disengage emotionally, this is not about you—getting agitated or loud won’t help.
• Use few words, remain calm and quiet.
• Be flexible—extra tolerance and a bit of slack may help defuse the rage state.
• Have a plan and follow it— e.g., siblings go to their rooms, only certain people will interact with individual, have pre-identified the safe places to go, etc.
• Attempt to move the individual to a “safe place” or “home base”
• Obtain assistance if needed.
• Do not discipline– this is not the “teachable phase” and retribution does no good.

Once the meltdown has begun to pass, the individual with ASD (or any other predisposing condition) will enter a “recovery” phase.   Keep in mind that they have just gone through an intense sensory and emotional overwhelm— often we will see someone needing to sleep, cry, withdraw or appear exhausted. During this time, allowing the person time to sleep, rest or engage in a preferred activity may be needed.

Again, this is not the time to teach a new skill or place demands on the person as they are in cool down mode, not learning mode.

Helping families and caregivers understand meltdowns and the rage cycle is rarely simple, but sustained efforts can provide effective, long term tools for addressing agitation and aggressive outbursts. Consultation with mental health providers and behavioral experts can be an important asset and should be part of the clinical team helping the ASD individual.

Some services provided by the San Diego Regional Center for families struggling with aggression include:

1. Consultation with a behavioral psychologist
2. Safety Alert, Inc. ( https://www.safetyalert.net/ )
3. START program  https://www.exodusrecovery.com/vista-start/.
4.  Fred Finch Specialized Wraparound https://www.fredfinch.org/specialized-wraparound
5. Advance CIRT (Crisis Intervention Response Team) Advance North (760) 294-1188 Advance San Diego (619) 756-4095

   All programs require a referral from the SDRC. Families may request these services through their Regional Center service coordinator.

   Reference:

Myles, B.S., and Southwick, J. (1999) Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns. Shawnee Mission, KS: Autism Asperger Publishing Company.

https://www.cdc.gov/ncbddd/autism/data.html