People who experience psychosis experience a disconnect from reality. They may experience hallucinations, disorganized speech, grossly disorganized or catatonic behaviors and diminished emotional expression. Psychosis is commonly associated with schizophrenia spectrum disorders and bipolar and related disorders.
In 2003, a research team from the Department of Child and Adolescent Psychiatry at Goteborg University in Sweden wrote, “Adult subjects with AD/HD and ASD sometimes display bizarre ideas, disorganized speech/cognitive processes (especially under stress), and significant mood swings (Stahlberg et al., 2003, p 892),” all symptoms associated with psychotic disorders.
They also stated that the then “diagnostic criteria ha[d] to be revised to acknowledge the comorbidity of bipolar and/or psychotic disorders in AD/HD and ASD.” They didn’t feel as if the diagnostic criteria in the DSM of the time (DSM-IV-TR) were sufficient.
In psychology terms, comorbidity means that two or more disorders occur in the same individual at the same time. Stahlberg and colleagues found that many (but not all!) people who have ASD also experience psychosis and that many (and again… not all) who have a psychotic disorder also have autism. They also found comorbidity with ADHD.
Much more is known about autism today than was known in 2003 when Stahlberg and colleagues published their findings. Of especial note is the sheer prevalence of autism. Today’s mental health community is still coming to grips with the fact that autism affects somewhere around 1 in 68 children.
Children with autism grow into adults with autism. Autism is a developmental disorder. It doesn’t go away with age.
High-functioning autism, formerly known as Asperger’s, went almost unrecognized in children until it was included in DSM-IV in 1994. Children diagnosed wth Asperger’s in the 1990s and early 2000s have now grown into today’s young adults bringing about the current nascent awareness of the high-functioning autism that has likely always been with us in our adult communities.
Many adults with high-functioning autism remain unrecognized, unacknowledged and undiagnosed. These unrecognized adults with ASD have developed highly effective compensatory strategies that mask the most obvious signs of the disorder. As a result, many mental health professionals do not know how to recognize or diagnose high-functioning autism in adults and many may adults with autism may be in treatment for the commonly comorbid anxiety or depression without any awareness that they also have ASD.
It is also possible that some intelligent adults experiencing psychosis also have and underlying undiagnosed autism spectrum disorder.
It is known that many people with autism are more likely than the general population to develop a comorbid psychotic disorder. One study found that up to 28% of people with ASD experience psychosis (Mouridsen, Rich, & Isager, 2008 as seen in Larsen et al, 2017)! Another population based study found that the probablity of people with autism developing psychosis to be between 5.6 and 5.8 (Stetson et. al, 2015 as seen in Larsen et al., 2017).
That said, in DSM-V it states, “Hallucinations and delusions, which are defining features of schizophrenia, are not features of autism spectrum disorder” (American Psychiatric Association, 2013, p. 58). And they are not. Many people with autism do not experience psychosis.
At the same time, in 2017, Felicity Larsen and her colleagues found evidence for a distinct subtype of autism that includes psychosis and published their results in the British Journal of Psychiatry. They called this subtype of autism “ASD-P” or “autism spectrum disorder – psychosis.”
Larsen and her team investigated whether or not there were any differences between individuals with ASD who do qualify for a diagnosis of a psychotic disorder and those who do not. They found that people with ASD who develop a psychotic disorder show “significantly fewer lifetime stereotyped repetitive or restrictive interests/behaviors” than people with ASD who do not develop psychosis (Larsen et al., 2017).
As repetitive and restrictive behaviors are often considered a major indication of autism, it’s possible that adults who belong to the ASD-P subtype may be even more difficult for mental health professionals to recognize or diagnose.
Yet early understanding and diagnosis is critical to patient (and family!) outcome.
In an interview with the University of Cambridge Department of Psychiatry, Larsen said,
For me, the most important thing about this research is that it focuses attention on something that impacts the lives of many autistic people and their families, but that is under-researched and poorly understood. Autistic people can not only struggle due to having to fit into a “neurotypical” world that often increases their stress and vulnerability to mental illness, but additionally when they suffer from mental health problems, are often seen in services that feel ill-prepared to help them due to a lack of understanding. There is a need to build more and better understanding, at a research and clinical level, about mental health problems in autistic people, and to work out what approaches work best to support them. I’m pleased to be able to carry on my work in this area by focusing on emotional regulation difficulties in autistic people, as this is a possible factor in the development of psychosis that could be successfully treated before the onset of more serious mental health problems.
Clearly, we are still in the beginning stages of understanding autism in adults and the ways it affects the individuals on the spectrum, and their spouses, families and children. High-functioning autism in adults, being much more difficult to recognize and diagnose than other forms of autism, adds another layer of complexity to mental health providers’ efforts to help those on the spectrum and their families.
More research on high-functioning autism and psychosis in adults is necessary. I personally wonder if theory of mind deficits in intelligent adults with autism could eventually lead to psychotic beliefs, especially during times of extreme duress.
Anne Janai, M.L.A.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5 TM. Washington, D.C: American Psychiatric Publishing.
Larsen, F., Wagner, A. P., Jones, P. B., Tantam, D., Lai, M., Baron-Cohen, S., and Holland, A. J. (2017). Psychosis in autism: comparison of the features of both conditions in a dually affected cohort. British Journal of Psychiatry, 210(4): 269-275.
Mouridsen, S. E., Rich B, Isager, T. (2008). Psychiatric disorders in adults diagnosed as children with atypical autism. A case control study. Journal of Neural Transmission, 115: 135–8.
Selten JP, Lundberg M, Rai D, Magnusson C. (2015). Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: a population-based study. JAMA Psychiatry, 72(5):483-9.
Stahlberg, O., Soderstrom, H., Rastum, M., and Gillberg, C. (2003). Bipolar disorder, schizphrenia, and other psychotic disorders in adults with childhood onset AD/HD and/or autism spectrum disorders. Journal of Neural Transmission, 111: 891-902.