Lecture 8: Comorbidity Part One

Depression Symptom Presentation

- May not complain - Miserable/fed up - Suicidal thoughts - Lack of enjoyment - Poor concentration - Fatigue - Somatic complaints

Depression: Verbal Signs

- Negative cognitions - Low -self-esteem - Hopelessness - Self-Blame - Slowed thought processes - Poor concentration.

Depression: Nonverbal Signs

- Self-isolation - Anhedonia (inability to experience pleasure) - Irritable/aggressive - Decreased psychomotor activity - Increased stereotyped behavior - Diurnal variation (variation of mood during day.) - Sleep - Appetite - Weight

Untreated Anxiety has Far-Reaching Effects

Anxiety can exacerbate autism features. Has the potential to significantly interfere with many aspects of day-to-day functioning: □ Autism treatment □ Social development/peer relationships □ Daily life skills/independence □ Learning/academic achievement □ Family relationships/functioning

Diagnostic Overshadowing

Anxiety symptoms can be incorrectly attributed to ASD This "diagnostic overshadowing" is a significant barrier to accessing treatment for anxiety. The problem isn't the autism, it is the anxiety that isn't being dealt with.

Empirically Supported Treatments

Applied Behavior Analysis □ Applications for ritualistic behaviors, ordering/arranging, etc. □ Cognitive Behavior Therapy (CBT) □ Exposure-Response Prevention (ERP) □ Medications Fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa).

Anxiety symptoms that can be incorrectly attributed to ASD:

Avoidance Tantrums Crying Fear of object/situation

Anxiety and IQ

Correlated with anxiety + with social anxiety; the higher the IQ, the higher the social anxiety if you have autism - with separation anxiety - the higher the IQ, the lesser the likelihood of having separation anxiety.

Differential Diagnosis

In distinguishing between typical OCD features and more typical ASD features need to take into account: □ Emotional valence of the thoughts and compulsions. □ Content of the obsessions and compulsions. □ Function of the obsessive-compulsive behaviors and patterns of restrictive and repetitive behaviors.

Depression/ASD incidence rates

Incidence rates for ASD upto 30% compared to 3.5% in typical populations Confound: Alexithymia (i.e. incapability to identify, describe, and interpret emotional states)...looks like depression but they're just emotionally "flat" Risk Factors: □ Gender: no relationship □ Age: Positive Correlation; more women than men but no gender difference in autism □ IQ: with ASD - the higher the IQ and milder the symptom presentation = higher rates of depression □ Social Comparison: higher rates of social comparison lead to high rates of depressed mood. □ Life events (e.g., death, moving, abuse, loss of relationship): Bullying: e.g., 44-77% of ASD reporting bullying in the last month (only 10-20% in typical children). □ Suicide: underestimated, not well studied.

ASD and Comorbidity

Likelihood of finding an individual with ASD and no co-occurring conditions...very unlikely. Recent study Lundstrom et. Al. (2014) in a study of 19,130 twins in Sweden found an Asd incidence rate of 1.4% (approximately 1/68) □ Percentage of children with ASD with no co-occurring conditions = 4% □ Approximately 30% of the ASD sample had 4 or more comorbid conditions.

Sub-Classifications of Depression - DSM-V:

Major depressive disorder Persistent Depressive Disorder Disruptive Mood Dysregulation Disorder Substance/Medication induced Depressive Disorder Premenstrual Dysphoric Disorder

Comorbidity

Official definition: The simultaneous presence of two (or more) chronic or acute diseases or conditions within one person. AKA Co-occurring. Relationship between the conditions may be direct related, associated or other. In mental health, the impact of comorbidity considered to lead to more problematic outcomesmorbidity

Suicide ASD and Depression

Poorly studied in ASD (only one study) Mayes et. Al. (2014) found that suicidal ideation and attempts were: - 28 times more frequent in children (up to 16 years old) with ASD than in typical children - But 3 times less frequent than in children that were depressed. Contributing Factors: - Impulsivity - Higher cognitive/social insight - Abuse/bullying - Poor social support/social isolation

OCD/ASD Symptom Overlap/Separation

Problem is that OCD and ASD can look extremely similar. Significant overlap of symptoms with OCD and ASD. Restricted and repetitive patterns of behavior, interests, or activates may include: - Stereotyped or repetitive motor movements, use of objects, or speech - Insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior. - Restricted, fixated interests - Reactivity to sensory input

Anxiety and Age

Separation Anxiety & OCD (younger) - starts younger w/ individuals on the spectrum Generalized Anxiety Disorder (older) - starts as people start to age.

ASD Specific Factors of Depression

Social isolation and rejection Perception of developmental differences Educational failure Low self-esteem Other co-morbid disorder Negative life events

Compulsions

actions and/or thoughts that are meant to clear or reduce the anxiety associated with the obsession - May or may not be visible to others. - Often done in patterns (e.g., even or odd) - Often includes physical and thought patterns

Disruptive Mood Dysregulation Disorder

aka someone who tantrums a lot. High degree of irritability .

Premenstrual Dysphoric Disorder

for women who have significant emotional depressive-like states

Persistent Depressive Disorder (Dysthymia)

long-term minor depression (persistent for more than 2 years.)

Anxiety Disorders - DSM-V

one of the most prevalent mental health conditions One of the most prevalent co-occurring mental health conditions with ASD. Estimates of anxiety disorders in ASD ranges from 22-84% (compared to 2-20% in 'typical samples') Meta-analyses report found 39.6% of individuals with ASD had at least one form of anxiety disorder. In BC: 25% of school age children with ASD have at least one anxiety disorder.

Obsessions

uninvited, unwanted thoughts, urges, images that do not remit - Obsessions must be distressing and create significant anxiety. - Not 'typical' worries - The person attempts to ignore/suppress/neutralize the thoughts: - Irrational and the person knows it.

Major depressive disorder

□ Single episode - the likelihood of having a second episode is very high □ Recurrent episode