What are spectrum disorders?
Autism and spectrum disorders are neurodevelopmental disorders characterized by difficulties with communication, social interaction and repetitive behaviours or interests. The disorders that fall on the autism spectrum are autism, Asperger syndrome and atypical autism. People with these symptoms are said to be ‘on the spectrum’ because autism is of many types and the severity of symptoms varies from person to person. Although it can be diagnosed at any age, autism is a neurodevelopmental disorder because symptoms usually become visible in the first years of life. There are exceptions, as some people with more subtle forms of the disorder disguise their symptoms to better adapt to situations and avoid social rejection. This is more common in women with an above-average IQ and delays the process of receiving a diagnosis. Thus, the disorder can remain unidentified until adulthood, when it manifests together with other mental illnesses, such as depression, anxiety or ADHD. In any case, the symptoms associated with autism need to be managed throughout life and can have a detrimental impact on adult life [1]. For this reason, early and correct diagnosis of autism spectrum disorders is essential.
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How common are they in young people and adults?
The prevalence of autism is approximately 1% in adults, which means it is more common than conditions such as diabetes. However, many adults face difficulties in accessing diagnostic and treatment services [2]. Spectrum disorders are associated with financial and emotional difficulties for both affected individuals and their families and society. Additionally, other mental health disorders are also found alongside spectrum disorders: approximately 70-80% of adults with autism also experience other conditions, such as depression, anxiety, ADHD or psychotic disorders [3]. It is, therefore, important to raise awareness of the autism spectrum and the mental health disorders often associated with it.
The autism spectrum and depression
While in Romania it is estimated that between 3 and 5% of people suffer from depression at some point in their lives [4, 5], approximately three or four times more adults with spectrum disorders also experience depressive symptoms [6].
A meta-analysis of 7857 articles published in English reported that depression in people on the spectrum is more commonly diagnosed among Caucasians with an above-average intellect [6]. Possible explanations are that people with autism with an above-average intellect are more aware of autistic symptoms and their negative impact on their lives [7]. Regarding the high prevalence among Caucasians, this may also be due to the fact that depression diagnostic methods are not adapted to other cultures and ethnicities or that, in developing countries, people cannot easily access psychology or psychiatry services.
We must also consider that diagnosing depression involves good collaboration between the clinician (psychologist and/or psychiatrist) and the patient, so that the clinician can understand the concerns of the person in question. In the case of people on the spectrum, communication of depressive symptoms is hindered by communication deficits (verbal and non-verbal) and a lack of self-reflection. Additionally, depressive symptoms in those on the spectrum are often atypical, presenting as increased aggression, irritability and agitation, as well as fluctuating moods. Young people experiencing this set of symptoms are simultaneously more prone to exacerbated compulsive states and more pronounced stereotypical behaviour [8].
The autism spectrum and psychotic disorders
Spectrum disorders and psychotic disorders often overlap, with psychoses being found in more than 3 out of 100 people with a spectrum disorder [9]. For context, psychoses are found in one person out of 100 in the general population.
Both categories of disorders are considered neurodevelopmental and spectrum problems. Both are characterised by difficulties in social interaction, such as a lack of emotional reciprocity in autism and a lack of natural reactions to emotional stimuli in psychoses. Similarly, delayed or absent language in spectrum disorders is similar to poverty of speech in psychotic disorders, and deficits in executive functioning (attention, information processing) are similar for both groups. While paranoia and an omnipresent sense of threat are symptoms of the psychotic spectrum, those on the autism spectrum hesitate to interact with or trust other people. Overall, the two groups of disorders appear to exist at different ends of a continuum [10].
Autism and psychotic disorders have an interesting history. Before autism spectrum disorders emerged as a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, they were seen as psychotic disorders that developed in childhood. Although we now know that they can occur simultaneously, it is still very difficult to differentiate certain symptoms, and research on this topic is in its early stages. However, people who present with both autism spectrum disorders and psychotic disorders simultaneously appear to differ from those diagnosed only with a psychotic disorder – namely, they are more likely to receive a diagnosis of unspecified psychotic disorder, precisely because their clinical presentations are atypical. Due to the nature of autistic symptoms, this may also be because people on the spectrum appear less disturbed by the presence of hallucinations or delusions and, therefore, these are more difficult to identify.
© Pep Boatella
The autism spectrum and ADHD
Spectrum disorders and Attention Deficit Hyperactivity Disorder (ADHD) often overlap, with approximately 28-44% of adults diagnosed with autism also meeting the criteria for an ADHD diagnosis [11]. Although the American Psychiatric Association denied until 2013 that autism and ADHD could be diagnosed simultaneously in the same person, the new Diagnostic and Statistical Manual of Mental Disorders was adapted to support that the two can coexist. This psychiatric comorbidity (when two mental conditions occur in the same person) can be partially explained by the existence of common genetic risk factors.
Both are neurodevelopmental disorders that affect executive functioning (for example, attention, concentration and decision-making). Although the neurobiological mechanisms are not clear, the increased interest and attention that people on the spectrum give to certain activities are similar to the phenomenon of ‘hyperfocus’ in ADHD, when a person is so concentrated on an activity or a subject that they become fixated on the smallest details. People who present with both sets of symptoms face increased problems with social integration and organisation, but these can be managed through treatment.
Accessible resources about autism
Book recommendation in English: Explaining Humans, by Camilla Pang – The Experiences of a Young Scientist with Autism and ADHD
Film recommendation: The Accountant:
https://www.imdb.com/title/tt2140479/
TEDTalk recommendation: Autism and addictions:
https://www.youtube.com/watch?v=FU5nUEfCDdI
TEDTalk recommendation: What do children with autism do when they become adults?
https://www.youtube.com/watch?v=WtgGzKRHT-Y
Resource recommendation about autism in Romanian:
https://autismvoice.ro/exista-mai-multe-tipuri-de-autism/
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Scientific resources
[1] https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
[2] Murphy, C. M., Wilson, C. E., Robertson, D. M., Ecker, C., Daly, E. M., Hammond, N., … & McAlonan, G. M. (2016). Autism spectrum disorder in adults: diagnosis, management, and health services development. Neuropsychiatric Disease and Treatment, 12, 1669-1686.
[3] Lever, A.G., Geurts, H.M. (2016) Psychiatric co-occurring symptoms and disorders in young, middle-aged, and older adults with autism spectrum disorder. Journal of Autism and Developmental Disorders 46(6): 1916–1930.
[4] Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J., … & Whiteford, H. A. (2013). Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS medicine, 10(11).
[5] Florescu, S., Ciutan, M., Popovici, G., Gălăon, M., Ladea, M., Petukhova, M. & Hoffnagle, A. (2009) The Romanian Mental Health Study: main aspects of lifetime prevalence and service use of DSM-IV disorders. Management in Health 13, 22-29.
[6] Hudson, C. C., Hall, L., & Harkness, K. L. (2019). Prevalence of depressive disorders in individuals with autism spectrum disorder: A meta-analysis. Journal of Abnormal Child Psychology, 47(1), 165-175.
[7] Chandrasekhar, T., & Sikich, L. (2015). Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan. Dialogues in Clinical Neuroscience, 17(2), 219–227.
[8] Magnuson, K. M., & Constantino, J. N. (2011). Characterization of depression in children with autism spectrum disorders. Journal of developmental and behavioral pediatrics, 32(4), 332.
[9] Zheng, Z., Zheng, P., & Zou, X. (2018). Association between schizophrenia and autism spectrum disorder: A systematic review and meta‐analysis. Autism Research, 11(8), 1110-1119.
[10] Ciaramidaro, A., Bölte, S., Schlitt, S., Hainz, D., Poustka, F., Weber, B., … & Walter, H. (2015). Schizophrenia and autism as contrasting minds: neural evidence for the hypo-hyper-intentionality hypothesis. Schizophrenia bulletin, 41(1), 171-179.
[11] Lai, M.C., Lombrado, M.V., & Baron-Cohen, S. (2014). Autism. Lancet, 383(9920):896-910.
