“Bipolar Disorder and ASD”, 2019-09-25 ():
Background: Bipolar disorder (BD) co-occurs with autism spectrum disorder (ASD) in adults in the 10–30% of the cases, and the prevalence rates are similar in high-functioning autism (HFA) & low-functioning autism (LFA). Familial studies also showed a link between the two conditions, especially for HFA forms, suggesting a possible common genetic liability.
In clinical practice HFA and LFA may present different diagnostic issues. In HFA adults, autistic symptoms may have been misinterpreted as “character” or “personality”. [emphasis added] When mood symptoms co-occur, the peculiar clinical picture may easily be misdiagnosed with important implications for the management.
In LFA the restricted repertoire of communication and behavior brings to atypical presentations of mood symptoms, which are often not recognized and attributed to the underlying neurodevelopmental condition. Controlled data on pharmacological treatments in BD-ASD comorbidity are virtually absent, and the information derives from open observations, case series, and chart reviews.
Mood stabilizers should be considered the first choice, and antipsychotics with 5-HT2a antagonism have been shown useful in controlling psychotic and behavioral symptoms. 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 hypomanic or manic switches have been observed in up to 54% of the treated subjects.
…7.3 Clinical Features of Bipolar Disorder in Autism Spectrum Disorder: Manic episodes in adult with ASD seem to be frequently characterized by irritable, unstable, and dysphoric mood and hostility more than classic euphoric mood, elation, and jocularity. Other important symptoms are restlessness, anxiety, perplexity, aggression, violent behavior, and insomnia5, 6, 11, 14, 44, 45. To our knowledge, frequencies of mixed versus classic manic features were not systematically studied in adults with ASD.
Psychotic symptoms may be an important feature of the manic: in many cases, hallucinations, psychotic interpretations, and delusional ideas (mostly with persecutory, reference and grandiose content) may be prominent and dominate the clinical presentation5, 6, 44, 45. Bizarre thought contents are not rare but they have to be distinguished from odd thinking, bizarre ideas, and idiosyncratic views or feelings, which are really common among ASD subjects also during euthymia19, 45, 46, 47.
It has been suggested that during manic episodes the peculiar way of thinking of ASD subjects becomes more prominent or that they become more prone to share their thoughts with others6, 46. Making a differential diagnosis should be considered a crucial point. Indeed, persons without [intellectual disability] ID and language impairment and with good adaptive skills may remain undiagnosed until a comorbidity onset. The differentiation of bizarre, “different”, and concrete thinking and perceptual anomalies of autistic persons by psychotic symptoms is based on comprehending whether those symptoms are autistic core features or reactive behaviors with understandable link to the experience and specific cognitive deficits of these persons48.
For example, there are clear differences in the peculiar pedantic and accurate language of some HFA persons from the formal disturbances in thought and language found in schizophrenic patients with prominently negative symptoms, mostly incoherence, vagueness, and circumstantiality49. Similarly, paranoid ideas might be dragged by difficulty in the theory of mind and social reciprocity associated with repeated negative social experiences. Concretism may also lead to misinterpretation of medical questions during the psychiatric exam.
The presence of other behavioral features typical for ASD such as rigid adherence to routines, sensory issues, and early-onset stereotypies can support the diagnostic process. As a rule, although odd thinking may become more intense during acute affective phases, it is stable and long-lasting, and in the majority of the cases, it is present since childhood without the classical rift of thinking and functioning as they are described in other psychotic conditions. In addition, “psychotic” thoughts are less interfering with daily functioning and less emotionally engrossing in ASD than in schizophrenia46, 50. In ASD patients with ID and language impairment, the excitatory phase may be described more appropriately by the disruption of neurovegetative patterns such as appetite, sleep, sexual activity, and the variation of psychomotricity.
…In individuals with ASD, depression may be barely recognizable, because it is frequently characterized by mild severity and long-lasting, often chronic, course. Depressive symptoms have to be specifically investigated as a clear-cut variation in personal, adaptive, and social functioning in comparison with a baseline reference point: some of the core autistic dimensions, such as blunt affect and social withdrawal, can be simply amplified during depression, and the depressive dimension remains neglected6. Moreover, difficulties in social communication and introspection, idiosyncratic thinking, and feelings might add difficulties in investigating or correctly interpreting the “inner” dimension of depression6, 12. Non-verbal typical expressions of depression may also lack4.
To improve the capacity of detecting depression in clinical settings, the systematic usage of specific assessment instruments, both self & hetero-administered rating scales (eg. MADRS, BDI), could be useful. As in the case of mania and hypomania, variations in psychomotricity and neurovegetative functioning are the best depressive diagnostic parameters (from hypersomnia to insomnia, loss of appetite)12, 55, 60, 61. The loss of energy may reflect in the reduction of the number and involvement in usual interests and activities. Anhedonia, apathy, feelings of worthlessness or guilt, low self-esteem, recurrent thought of death, diminished concentration, and indecisiveness are common as in other depressive patients7, 53, 55, 56. Stressful events preceding the onset of depression are not uncommon, especially in higher functioning subjects with problems in social adjustment but high social motivation with decrease of self-esteem and experience of personal failure62. Mood instability, atypical, violent and sudden affective changes, from lability to irritability, aggression, self-injuring, and agitation are not uncommon7, 63,64,65.
It has to be considered that such behavioral features of depression are particularly common in persons with co-occurring ID in which psychopathology may manifest itself via challenging behaviors and the increase of core symptoms of the basic neurodevelopmental disorder, for example, stereotypies. In LFA a deterioration in cognitive performance, behavior, or activities with cyclic pattern (“alternation of good and bad times”), even in the absence of other clear mood symptoms, may be indicative of the co-occurrence of bipolarity11.
Suicidality in ASD is not infrequent becoming a primary challenge. Any suicidal behavior including suicidal ideation, planning, suicide attempt, and completed suicide ranged 11%–50% in different populations, much higher than suicidal rates in schizophrenic patients (7–10%)66, 67. In such a case, the implications of a misdiagnosis might be severe. Suicidal ideation may be facilitated by some cognitive peculiarities of HFA such as the impairment of the capacity to understand mental and emotional states, difficulties in realizing what suicide means for their relatives, reduced flexibility, and dichotomous thinking: suicidal thoughts may become an obsession, and the person may spend lot of time searching information and planning4.
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