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Distinct features and diagnostic challenges of psychosis in autism
Although there is a considerable overlap in symptoms, it is important to recognize that autism and psychosis are distinct conditions. Nevertheless, it is not uncommon for these two conditions to co-occur, and their comorbidity rates are significantly higher compared to the general adult population. Intriguingly, significant associations were found between autistic traits and probable psychosis and psychotic experiences (with the exception of mania) in general population (Martinez et al. 2020).
Psychosis in autism
There are several distinct features that characterise the manifestation of psychosis in autism:
- The onset and progression of psychosis in autism differ from typical psychosis
Psychosis in autism often occurs earlier in life, and the progression may be slower and more gradual due to the differences in social development and cognitive functioning. Some studies have suggested that early intervention and treatment for psychosis in autism can help prevent long-term negative effects.
- Atypical psychosis
In their 2016 study, Larson et al. explored the unique characteristics of individuals with both ASD and psychosis, comparing them to those affected by either condition alone. The researchers discovered that individuals with comorbid ASD and psychosis were more likely to be diagnosed with atypical psychosis rather than schizophrenia, unlike those with psychosis only. The results of the study also provide further support for previous research indicating that psychosis in individuals with ASD is often atypical, particularly regarding affective disturbance.
Furthermore, individuals with ASD and psychosis exhibited fewer stereotyped interests and behaviours compared to those with ASD but without psychosis. These findings suggest the existence of a specific subtype of ASD that is closely associated with comorbid psychosis.
- Vulnerable groups
ASD individuals without intellectual impairment (DSM-V) or Asperger’s (DSM-IV) are often particularly vulnerable to mental health problems such as anxiety disorders including social phobia and generalised anxiety disorder, depressive disorders and psychosis. Moreover, autistic adults without intellectual impairment experience higher rates of physical and psychiatric morbidity. They also exhibit a poorer ability to engage with treatment and have a lower chance of recovery compared with the general population. It is important to recognize the unique challenges faced by these individuals when it comes to mental health. Unfortunately, adults with suspected ASD without intellectual impairment and co-morbid mental health problems are often not best supported through adult mental health services (Crowley, O'Connell, Gervin 2022). Addressing the mental health needs of this specific group requires specialized attention and support.
- Specific P300 brain activity
E.g., in another recent study, researchers focused on the P300 brain response. This P300 is usually different in people with schizophrenia and it can also predict if someone with Clinical High Risk (CHR) for psychosis will actually develop psychosis.
The researchers looked at a group of people who had both CHR and ASD, and they compared them to a group of people who only had CHR. They found that in the group with both CHR and ASD, the P300 was actually stronger when they were paying attention to things, instead of being weaker like in the other group. This was true for both visual and auditory stimuli. These findings are pretty surprising because they show that people with both CHR and ASD who go on to develop psychosis have a different brain response compared to others. Usually, a weaker P300 is a sign of developing psychosis, but in this group, it was actually stronger (Foss-Feig et al. 2021).
- Another characteristic of psychosis in autism is the comorbidity with anxiety disorders.
Since autistic individuals are more prone to anxiety, it is not surprising that psychosis in autism can be coupled with anxiety disorders. However, studies have shown that anxiety is more prevalent in individuals with psychosis without autism than in those who have both conditions.
- Psychosis in autism is different from psychosis in schizophrenia
While the experience of psychosis may be similar in both autism and schizophrenia, the underlying causes and symptoms differ. Individuals with schizophrenia often experience more severe and long-lasting psychotic episodes, whereas autistic individuals tend to have milder and briefer episodes.
Psychosis can significantly impact an individual's behaviour and functioning.
They may find it hard to navigate daily tasks and social interactions, struggle with self-care, become more withdrawn or disruptive and experience difficulty with focus and attention.
Early detection and intervention for psychosis in autism are critical for improving outcomes and reducing the impact of psychosis on individuals with autism and their families. Early intervention can help reduce the severity of symptoms, improve cognitive and social skills, and reduce the risk of long-term emotional and psychological impacts of psychosis.
Challenges in diagnosing psychosis in autism
Diagnosing psychosis in autism can be complicated due to the overlap of symptoms between the two conditions.
In autism, psychosis can manifest as hallucinations, delusions, or disordered thinking. It is often difficult to diagnose because communication problems in autism can make it difficult for individuals to report symptoms accurately, leading to potential misdiagnosis or delayed diagnosis. Additionally, healthcare providers may not always be familiar with the unique experiences of individuals with autism, further complicating the diagnostic process.
Moreover, ASD frequently co-occurs with ADHD due to shared etiological mechanisms and genetic susceptibility. The presence of psychosis in these clinical scenarios adds an additional layer of complexity (Scarselli et al. 2022).
Understanding the differential diagnosis between two or more conditions, and comprehending their interplay is very important. It will help to effectively develop appropriate strategies, treatment and support, improving the overall well-being and quality of life for those affected and their families.