Recognition and treatment of Asperger syndrome in the community

Morita Therapy as a Treatment Approach for Adolescent Autism Spectrum Disorder: A Five-Year Case Report Incorporating Inpatient and Diary Therapy

In 1919, Shoma Morita established Morita therapy, and this method of psychotherapy is widely used in Japan and across the world. With time, the medical indications of Morita therapy have expanded to include not only neurosis and anxiety disorders but other conditions as well. In modern times, Morita therapy has been used to treat adolescentneurodevelopmental disorders; however, it has not been widely covered in the English-language literature. In this report, a five-year course of treatment for a female patient with autism spectrum disorder (ASD) is presented. The patient exhibited dissociation, auditory hallucinations, overmedication, and wrist cutting, leading to multiple admissions to an adolescent ward. Over the treatment course, the symptoms of dissociation, self-harm, and auditory hallucinations disappear. Further, the patient was able to find a way to relate to society that was appropriate for her.

Asperger Syndrome (AS): A Review Article

A variant of autism spectrum disorder (ASD) known as Asperger syndrome (AS) is characterized by severe issues with interpersonal, verbal, and nonverbal communication as well as restricted and repetitive patterns of behavior and activities. Although there is no known cause for ASD, various genetic as well as non-genetic risk factors that may act either alone or in combination to induce ASD have been identified. The occurrence of ASD has been increasing worldwide. Co-occurring neuropsychological diseases are frequently present as well. The premise for diagnosis is the observation of abnormal conduct, with diagnostic criteria emphasizing limitations in social interaction and communication as well as constrained, repetitive behavioral patterns, activities, or hobbies. The degree of the illness and the presence of intellectual impairment have a significant impact on the prognosis. Like autism, Asperger's can neither be prevented nor treated. There is no specific medical therapy that can effectively cure all of the symptoms of autism. However, medications may be used as adjuvant therapy for maladaptive behaviors and co-occurring mental problems. The treatment aims to reduce core impairments, increase functional ability, and reduce harmful behaviors that could limit functional skills. It is crucial to provide proper care, establish supportive networks for individuals who are affected and their families, and use effective therapies to enhance functioning and results.

Pharmacotherapy for bipolar disorder in adults with high-functioning autism

INTRODUCTION

The association between high-functioning autism (HFA) and bipolar disorder (BD) in adult subjects has been confirmed by a growing number of studies. However, identifying and treating BD in this population is a clinical challenge and requires careful assessment and adequate knowledge of both disorders.

AREAS COVERED

This review aims to provide a clinical presentation of mood episodes in HFA individuals, and an update on the pharmacotherapy of BD in these individuals, sharing with the reader expert opinion on the current state of the art and future perspectives.

EXPERT OPINION

BD has an atypical clinical presentation in HFA subjects with the possibility of diagnostic and therapeutic mistakes. Despite the absence of controlled studies, the available evidence indicates mood stabilizers, especially lithium, as the first treatment option. HFA subjects are particularly vulnerable to pharmacological side effects, such as extrapyramidal and catatonic symptoms with antipsychotics, or activation syndrome with antidepressants. Accordingly, initial titration of these drugs should be slow and their use should be limited in time. Among antipsychotics, dopamine receptor antagonists with combined serotonergic activity are preferable. Further research is needed to improve the diagnostic process and to delineate the effectiveness of different drugs for BD in HFA subjects.

Assessing Youth with Psychotic Experiences: A Phenomenological Approach

Psychotic experiences may be part of normal development or indicate a wide range of mental disorders. This article shows how a systematic, domain-based, phenomenological approach to assessing psychotic symptoms in youth facilitates the gathering of the nuanced clinical information necessary to understand a child's specific experience. Mapping this information onto a narrative timeline, while understanding the evolution and developmental context of psychotic experiences, is essential in making an accurate diagnostic formulation and appropriate treatment plan for youth presenting with psychotic experiences.

Personalized and precision medicine as informants for treatment management of bipolar disorder

DSM-5 diagnostic categories, defined by a set of psychopathological symptoms are heterogeneous conditions that may include different biological entities, with distinct etiopathogenesis, different courses and requiring different treatment management. For bipolar disorder the major evidences for this lack of validity are the long paths before a proper diagnosis, the inconsistence of treatment guidelines, the long phases of pharmacological adjustment and the low average of long-term treatment response rates. Personalized medicine for mental disorders aims to couple established clinical-pathological indexes with new molecular profiling to create diagnostic, prognostic and therapeutic strategies precisely tailored to each patient. Regarding bipolar disorder, the clinical history and presentation are still the most reliable markers in stratifying patients and guiding therapeutic management, despite the research goes to great lengths to develop new neuropsychological or biological markers that can reliably predict individual therapy effectiveness. We provide an overview of the advancements in personalized medicine in bipolar disorder, with particular attention to how psychopathology, age at onset, comorbidity, course and staging, genetic and epigenetic, imaging and biomarkers can influence treatment management and provide an integration to the conventional treatment guidelines. This approach may offer a new and rational path for the development of treatments for targeted subgroups of patients with bipolar disorder.

Behavioral, Cognitive and Neural Markers of Asperger Syndrome

Asperger syndrome (AS) is a subtype of Autism Spectrum Disorder (ASD) characterized by major problems in social and nonverbal communication, together with limited and repetitive forms of behavior and interests. The linguistic and cognitive development in AS is preserved which help us to differentiate it from other subtypes of ASD. However, significant effects of AS on cognitive abilities and brain functions still need to be researched. Although a clear cut pathology for Asperger has not been identified yet, recent studies have largely focused on brain imaging techniques to investigate AS. In this regard, we carried out a systematic review on behavioral, cognitive, and neural markers (specifically using MRI and fMRI) studies on AS. In this paper, behavior, motor skills and language capabilities of individuals with Asperger are compared to those in healthy controls. In addition, common findings across MRI and fMRI based studies associated with behavior and cognitive disabilities are highlighted.

From Asperger's Autistischen Psychopathen to DSM-5 Autism Spectrum Disorder and Beyond: A Subthreshold Autism Spectrum Model

Growing interest has recently been devoted to partial forms of autism, lying at the diagnostic boundaries of those conditions previously diagnosed as Asperger's Disorder. This latter includes an important retrieval of the European classical psychopathological concepts of adult autism to which Hans Asperger referred in his work. Based on the review of Asperger's Autistische Psychopathie, from first descriptions through the DSM-IV Asperger's Disorder and up to the recent DSM-5 Autism Spectrum Disorder, the paper aims to propose a Subthreshold Autism Spectrum Model that encompasses not only threshold-level manifestations but also mild/atypical symptoms, gender-specific features, behavioral manifestations and personality traits associated with Autism Spectrum Disorder. This model includes, but is not limited to, the so-called broad autism phenotype spanning across the general population that does not fully meet Autism Spectrum Disorder criteria. From this perspective, we propose a subthreshold autism as a unique psychological/behavioral model for research that could help to understand the neurodevelopmental trajectories leading from autistic traits to a broad range of mental disorders.

Bipolar disorder in adults with Asperger׳s Syndrome: a systematic review

BACKGROUND

Asperger׳s Syndrome (AS) is a neurodevelopmental disorder included in the Autism Spectrum (ASD). The current literature shows growing evidence of a high rate of comorbidity between AS and other psychiatric disorders, particularly Bipolar Disorder (BD). We reviewed available epidemiological and clinical data on BD-AS comorbidity and its diagnostic and therapeutic implications

METHODS

A systematic review of the literature was conducted through PubMed, Scopus and Psych-Info using combinations of the following search terms: Asperger׳s Syndrome, Bipolar Disorder, depression, mood disorder, psychiatric comorbidity, treatment, mood stabilizers, anticonvulsants, antipsychotics, and antidepressants.

RESULTS

BD prevalence in adults with AS ranges from 6% to 21.4% of the cases. Relatives of patients with AS showed a doubled risk of being affected by BD and a BD prevalence near to 10%. When comorbid with AS, BD assumes peculiar features which might shape its under-recognition or misdiagnosis (especially schizophrenia when psychotic symptoms are prominent). Although controlled data on pharmacological treatments in BD-AS comorbidity are substantially lacking, information is derived by open observations, case series and chart reviews. Mood stabilizers should be considered the first choice, and antipsychotics, especially second generation drugs (SGA) with 5-HT2a antagonism, have been shown useful in controlling psychotic and behavioral symptoms and improving social withdrawal. Some evidence of efficacy for the treatment of anxiety, obsessive-compulsive symptoms and depression is reported for SSRI antidepressants. The use of these drugs should be carefully monitored, because activation with hypomanic or manic switches is reported up to 54% of the treated subjects.

CONCLUSION

BD in AS patients is frequent, usually it onsets during adolescence and is often characterized by atypical presentation, making its correct identification particularly difficult. A correct diagnosis of BD in AS individuals has relevant implications on the choice of adequate psychopharmacological, psycho-social and rehabilitative treatments.

Comparison between a Mandarin Chinese version of the Childhood Autism Spectrum Test and the Clancy Autism Behaviour Scale in mainland China

A Mandarin Chinese version of the Childhood Autism Spectrum Test (CAST) and Clancy Autism Behaviour Scale (CABS) were applied to 150 children aged 4-11 years old from clinical settings and mainstream schools in Beijing. All the children were further assessed using the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R). The validity of two instruments on screening of ASC was examined and compared using receiver operating characteristic (ROC) curve analysis. The validity of CAST (sensitivity: 89%, specificity: 80%, PPV: 70%) was better than the CABS (sensitivity: 58%, specificity: 84%, PPV: 65%). The area under the curve (AUC) of the CAST (AUC=0.90) was significantly higher than the CABS (AUC=0.79, p=0.0002). The Mandarin CAST demonstrated a better validity in distinguishing children with ASC from children without ASC. It is an acceptable candidate as a screening instrument for ASC in large epidemiological study in Chinese population.

Prevalence of Asperger syndrome among patients of an Early Intervention in Psychosis team

BACKGROUND

There is a lack of systematic studies into comorbidity of Asperger syndrome and psychosis.

AIM

To determine the prevalence of Asperger syndrome among patients of an early intervention in psychosis service.

METHODS

This study was a cross-sectional survey consisting of three phases: screening, case note review and diagnostic interviews. All patients on caseload (n = 197) were screened using the Autism Spectrum Disorder in Adults Screening Questionnaire. The case notes of patients screened positive were then reviewed for information relevant to Asperger syndrome. Those suspected of having Asperger syndrome were invited for a diagnostic interview.

RESULTS

Thirty patients were screened positive. Three of them already had a diagnosis of Asperger syndrome made by child and adolescent mental health services. After case note review, 13 patients were invited to interview. Four did not take part, so nine were interviewed. At interview, four were diagnosed with Asperger syndrome. In total, seven patients had Asperger syndrome. Thus, the prevalence rate in this population is at least 3.6%.

CONCLUSIONS

The results suggest that the prevalence of Asperger syndrome in first-episode psychosis is considerably higher than that in the general population. Clinicians working in early intervention teams need to be alert to the possibility of Asperger syndrome when assessing patients.

Clinical features, developmental course, and psychiatric comorbidity of adult autism spectrum disorders

Autism spectrum disorders (ASDs) include a heterogeneous group of neurodevelopmental disorders with early onset in childhood. ASDs should be considered lifelong clinical entities, although there is a certain variability in developmental trajectories, and therefore should be considered of great interest also for adulthood psychiatrists. A few studies have been carried out to explore the clinical picture and course development of these disorders during adulthood, or their relationship with other mental disorders. Indeed, ASDs often share overlapping features with other disorders, such as schizophrenia and obsessive-compulsive, mood, and personality disorders, and as a result misdiagnoses often occur. The aim of this review is to summarize the available literature on ASDs in adulthood with a specific focus on the clinical picture, course, and psychiatric comorbidity. It is proposed that a careful diagnostic screening for ASDs in adults would contribute to clarifying the relationship with comorbid psychiatric disorders, while improving the possibility of treatment and outcome of such conditions.

Effect of a Motor-Based Role-Play Intervention on the Social Behaviors of Adolescents With High-Functioning Autism: Multiple-Baseline Single-Subject Design

OBJECTIVE. We examined the effect of a motor-based role-play intervention on the social skills of adolescents with high-functioning autism.

METHOD. An ABA multiple-baseline design with three 3-mo phases occurring over 12 mo was used with 7 participants. Frequency of targeted verbal and nonverbal behaviors was tallied in each phase. Frequency data were analyzed using repeated-measures analyses of variance with post hoc comparisons to examine differences in targeted behaviors over the three phases.

RESULTS. Three participants completed all three study phases, 2 completed Phase 2, and 2 completed Phase 1. All participants (N = 7) demonstrated improved social skill use in Phase 1. Participants completing Phase 2 (n = 5) further improved social skill use. Additional improvements were observed among participants (n = 3) who completed Phase 3.

CONCLUSION. The intervention helped participants improve targeted social skill use. Further testing with larger samples and intervention modifications is warranted.

The neural bases of social intention understanding: the role of interaction goals

Decoding others' intentions is a crucial aspect of social cognition. Neuroimaging studies suggest that inferring immediate goals engages the neural system for action understanding (i.e. mirror system), while the decoding of long-term intentions requires the system subserving the attribution of mental states (i.e. mentalizing). A controversial issue, stimulated by recent inconsistent results, concerns whether the two systems are concurrently vs. exclusively involved in intention understanding. This issue is particularly relevant in the case of social interactions, whose processing has been mostly, but not uncontroversially, associated with the mentalizing system. We tested the alternative hypothesis that the relative contribution of the two systems in intention understanding may also depend on the shared goal of interacting agents. To this purpose, 27 participants observed social interactions differing in their cooperative vs. affective shared goal during functional-Magnetic-Resonance-Imaging. The processing of both types of interactions activated the right temporo-parietal junction involved in mentalizing on action goals. Additionally, whole-brain and regions-of-interest analyses showed that the action understanding system (inferior prefrontal-parietal cortex) was more strongly activated by cooperative interactions, while the mentalizing-proper system (medial prefrontal cortex) was more strongly engaged by affective interactions. These differences were modulated by individual differences in empathizing. Both systems can thus be involved in understanding social intentions, with a relative weighting depending on the specific shared goal of the interaction.

Genetic and functional abnormalities of the melatonin biosynthesis pathway in patients with bipolar disorder

Patients affected by bipolar disorder (BD) frequently report abnormalities in sleep/wake cycles. In addition, they showed abnormal oscillating melatonin secretion, a key regulator of circadian rhythms and sleep patterns. The acetylserotonin O-methyltransferase (ASMT) is a key enzyme of the melatonin biosynthesis and has recently been associated with psychiatric disorders such as autism spectrum disorders and depression. In this paper, we analysed rare and common variants of ASMT in patients with BD and unaffected control subjects and performed functional analysis of these variants by assaying the ASMT activity in their B-lymphoblastoid cell lines. We sequenced the coding and the regulatory regions of the gene in a discovery sample of 345 patients with BD and 220 controls. We performed an association study on this discovery sample using common variants located in the promoter region and showed that rs4446909 was significantly associated with BD (P= 0.01) and associated with a lower mRNA level (P< 10(-4)) and a lower enzymatic activity (P< 0.05) of ASMT. A replication study and a meta-analysis using 480 independent patients with BD and 672 controls confirmed the significant association between rs4446909 and BD (P= 0.002). These results correlate with the general lower ASMT enzymatic activity observed in patients with BD (P= 0.001) compared with controls. Finally, several deleterious ASMT mutations identified in patients were associated with low ASMT activity (P= 0.01). In this study, we determined how rare and common variations in ASMT might play a role in BD vulnerability and suggest a general role of melatonin as susceptibility factor for BD.

A descriptive social and health profile of a community sample of adults and adolescents with Asperger syndrome

Background

Little is known about the health and social profile of adolescents and adults with Asperger syndrome (AS) living in the community. We conducted a study to describe the living, employment and psycho-social situation of a community sample of forty two adults and adolescents with AS, and to describe these indivdiuals' experiences of accessing health services and taking medication.

Findings

Most respondents (including those over eighteen years of age) lived at home with their parents. Most had trouble reading and responding to other people's feelings, and coping with unexpected changes. Difficulties with life skills, such as cleaning, washing and hygiene were prevalent. The majority of respondents were socially isolated and a large minority had been sexually or financially exploited. Almost all respondents had been bullied. Mental health problems such as anxiety or depression were common. 30% of respondents said that they regularly became violent and hit other people and 15% had attempted suicide. More positively, the majority of respondents felt that they could access health services if they had a health problem.

Conclusions

The results of this study suggest a relatively poor social and health profile for many people with Asperger syndrome living in the community, with high levels of social problems and social exclusion, and difficulties managing day to day tasks such as washing and cleaning; these findings support the results of other studies that have examined psycho-social functioning in this group.

Health-related quality of life in adolescents and young adults with high functioning autism-spectrum disorder

AIM

Over the last years, health-related quality of life (HRQOL) has emerged as an important measure not only in somatic medicine but also in psychiatry. To date, there are only few reports on HRQOL in patients with autism-spectrum disorder (ASD). This study aimed at studying HRQOL in ASD patients with an IQ >70, using a self-report HRQOL questionnaire with cross-cultural validity.

METHODS

In this cross-sectional study, twenty-six male adolescents and young adults with the diagnosis of Asperger Syndrome, high functioning autism and atypical autism were evaluated, using the German version of the WHOQOL-BREF HRQOL questionnaire.

RESULTS

Mean WHOQOL-BREF global scores were 60.6 (SD ±26.1), mean WHOQOL-BREF subscale scores were 70.1 (SD ±19.1) for the domain "physical health", 61.5 (SD ±21.9) for the domain "psychological health", 53.8 (SD ±23.5) for the domain "social relationships" and 67.9 (SD ±17.4) for the domain "environment". Compared to a reference population of healthy controls, our sample scored significantly lower in three of four WHOQOL-BREF domains. In comparison to a reference sample of individuals with schizophrenia spectrum disorder (SSD), HRQOL of our sample was significantly better in all domains except for the "social relations" domain. There was a significant association between HRQOL and the Vineland Adaptive Behavior Scales domain "daily living skills", but not with age, IQ, or ADOS-G summary scores.

CONCLUSION

Overall self-reported HRQOL in patients with high functioning ASD seems to be lower than in healthy individuals, but better than in patients with SSD. Also, higher HRQOL was associated with better daily living skills. This interrelationship should especially be accounted for in the design and application of treatment programmes for individuals with ASD, as it is of importance for the level of self-perceived HRQOL.

The effect of a motor-based, social skills intervention for adolescents with high-functioning autism: two single-subject design cases

The purpose of this study was to assess the effect of a motor-based, social skills intervention for two adolescents with high-functioning autism (HFA) using single-subject design. A description of the intervention is provided as a first step in the manualization process. The intervention was provided as a 7-week after-school program, once weekly to the paired participants. Intervention consisted of role-play methods in which motor behaviours were linked with their cognitive and emotional meanings. Baseline, intervention and 3-month probe data collection periods were carried out and then compared using visual inspection of graphed data, paired t-tests and a three-standard-deviation-band approach. Both participants displayed a statistically significant increase in targeted social skills behaviours from baseline to intervention and maintained this level at a 3-month post-intervention probe. These single-subject design cases illustrate that motor-based, social skills interventions may be effective for adolescents with HFA and warrant further testing.