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Overlap Between Autism Spectrum Disorder and Bipolar Affective Disorder

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CORE Metadata, citation and similar papers at core.ac.uk Provided by University of Regensburg Publication Server Review Psychopathology 2015;48:209–216 Received: November 24, 2014 DOI: 10.1159/000435787 Accepted after revision: May 23, 2015 Published online: August 8, 2015 Overlap between Autism Spectrum Disorder and Bipolar Affective Disorder a, c b–d Norbert Skokauskas Thomas Frodl a Centre of Child and Adolescent Mental Health and Child Protection, Department of Neuroscience, Norges b Teknisk-Naturvitenskapelige Universitet, Trondheim , Norway; Department of Psychiatry, University of Regensburg, c d Regensburg , Germany; Department of Psychiatry, and Institute of Neuroscience, University of Dublin, Trinity College Dublin, Dublin , Ireland Key Words Introduction Autism spectrum disorder · Bipolar affective disorder · Co-occurrence · Prevalence Autism spectrum disorder (ASD) is a lifelong neuro- developmental disorder previously characterized as a tri- ad of symptoms [1] and now as a dyad, comprising social Abstract communication difficulties and repetitive, stereotyped Background: At present there is a substantial uncertainty re- behavior [2] . A recent review of global prevalence of ASD garding the extent and nature of autism spectrum disorder reported a median of 62 cases per 10,000 and did not sup- (ASD) and bipolar affective disorder (BPAD) co-occurrence port differences in prevalence by geographic region or of due to disparate findings in previous studies. This paper a strong impact of ethnic/cultural or socioeconomic fac- aimed to find and review original studies on co-occurrence tors [3] . rates of ASD with BPAD, assess them, synthesize the findings In the past there was a tendency to attribute almost all in a systematic way, present an overview and make recom- psychiatric and behavioral problems in persons with ASD mendations for future research. Methods: Systematic litera- to ASD itself [4] . Possible reasons were that the diagnosis ture searches were performed using several databases. Se- of ASD encompasses such a severe and comprehensive lected articles had to describe an original study that provid- label that secondary, tertiary or subsequently appearing ed prevalence and/or incidence analysis on ASD co-occurring psychiatric problems were not viewed as pivotal [5] . together with BPAD. Results and Conclusion: A significant However, more recently an increasing number of studies minority of patients (7%) with ASD suffers from BPAD. An ac- have argued for accepting behaviors and symptoms that curate detection of co-occurring ASD and BPAD can lead to had been considered additional or associated features of a more targeted treatment and improve the patients’ func- ASD as potentially warranting additional diagnosis [6] . tioning and quality of life. © 2015 S. Karger AG, Basel For example, Simonoff et al. [7] found in a population- based sample of 10- to 14-year-old children that 71% of children with ASD met criteria for at least 1 current psy- chiatric disorder, 41% had 2 or more and 24% had 3 or © 2015 S. Karger AG, Basel Prof. Norbert Skokauskas 0254–4962/15/0484–0209$39.50/0 Norges Teknisk-Naturvitenskapelige Universitet, Faculty of Medicine RKBU, PO Box 8905, MTFS E-Mail [email protected] NO–7491 Trondheim (Norway) www.karger.com/psp E-Mail Norbert.Skokauskas @ ntnu.no Downloaded by: Universitätsbibliothek, Regensburg 132.199.199.230 - 8/28/2018 2:24:54 PM more diagnoses. However, this unique ASD population Comorbid mood disorders in ASD were noticed early: study did not assess several important co-occurring psy- Kanner [16] noted in his original series that at least 1 per- chiatric disorders, including bipolar affective disorder son showed a tendency to lapse into a ‘momentary fit of (BPAD). In fact, much of the literature devoted to exam- depression’, and a few children described by Asperger ining the extent of co-occurring psychiatric disorders in [17] had depressive features. The association between ASD has not assessed the presence of BPAD [8] . ASD and BPAD has only relatively recently received a BPAD is a familial illness characterized by recurrent larger attention despite the fact that case reports of severe episodes of mania and depression, which may have their periodic mood disturbances highly suggestive of BPAD onset in childhood. Both depressive disorders and BPAD have been described in children and adults with ASD for can be specified with mixed features [2] . The current or a period of time [18–23] . 12-month prevalence rates of mania, hypomania and bi- At present, however, there is a substantial uncertain- polar disorder in population-based studies of youth range ty regarding the extent and nature of ASD and BPAD from 0 to 0.9% in children aged 14–18. Lifetime preva- co-occurrence due to disparate findings in previous lence rates for BPAD among youth range from 0 to 2.1%, studies. Co-occurring conditions, especially BPAD, and the lifetime prevalence rate for hypomania ranges be- may more severely impair individuals with already lim- tween 0 and 0.4% [9–11] . BPAD in children is associated ited cognitive functioning and social skills and may lead with significant functional impairment in several do- to increased psychological and psychosocial impair- mains including increased risks for psychiatric hospital- ment and higher rates of hospitalization. It may also ization, antisocial behaviors, addictions and suicidal ide- have important implications for behavioral and phar- ation [12, 13] . macological treatment, given that treatment interven- Mood disorders are one of the most common psychi- tions for BPAD and ASD differ: while there is no estab- atric comorbidities reported in individuals with ASD [6] . lished pharmacological treatment for ASD per se, there And this is despite the fact that mood changes can go eas- are well-known evidence-based pharmacotherapies for ily unnoticed in many individuals with autism partly be- adult BPAD [8, 24] . A consensus still needs to be reached cause some of them do not have sufficient language skills regarding pharmacological treatment strategies for chil- to express their feelings, describe changes in mood or dren with BPAD. comment on the presence of biological symptoms of de- pression. Even verbal individuals with ASD may be im- paired in the reporting of these symptoms, given the pres- Aims ence of deficits in socioemotional communication. More- over, some of the symptoms that are characteristic of This paper aims to review original studies on the co- ASD, e.g. social withdrawal, limited facial expression and occurrence between ASD and BPAD and to provide di- flattened affect, are also features of depression. Typical rections for the future research to improve the diagnosis hypomanic behaviors like overspending, gambling or ex- and treatment of patients with these two conditions. cessive shopping are rarely seen in individuals with ASD. Behavior problems can manifest in other forms, i.e. verbal aggression, increased social intrusiveness, restlessness, Methods etc. Frazier et al. [14] suggested that BPAD should be en- PubMed, EMBASE, Science Direct, PsychINFO and Ovid On- tertained as a possible co-occurring diagnosis in ASD line were searched from database inception through July 2014 us- when there is deterioration in cognition, language, be- ing the following key words: autism, ASD, Asperger’s syndrome, havior or activity, when there is a clear pattern of fluctua- bipolar affective disorder, BD and BPAD. Two independent un- tion or cyclicity in activity, behavior and interests (with blinded reviewers (N.S. and T.F.) assessed the study eligibility by screening the titles and abstracts in a standardized manner. Then ‘good times’ and ‘bad times’) and when observed behav- full texts were reviewed in more detail by the first author. Addi- iors indicate mood problems. A special attention should tional scientific papers were identified by checking the reference be paid at pragmatic, distracted or odd language seen in lists. The search was confined to English language articles. Selected children who have language disorders as part of ASD ver- articles, as a criterion for inclusion, had to describe an original sus the flight of ideas/thought disorder of mania [15] . study that investigated the co-occurrence of ASD and BPAD. Giv- en the preliminary stage of research in the area, only minimal ex- Sometimes, however, bipolar symptoms are more notable clusion criteria were used and no limits were placed on the demo- and disruptive, and the intensity of the presentation of graphics, e.g. geographical, gender, age or size of the study popula- mood dysregulation masks the ASD [8] . tions (however, case reports were excluded). 210 Psychopathology 2015;48:209–216 Skokauskas/Frodl DOI: 10.1159/000435787 Downloaded by: Universitätsbibliothek, Regensburg 132.199.199.230 - 8/28/2018 2:24:54 PM Results the Autism Comorbidity Interview (ACI), a modified version of the Kiddie Schedule for Affective Disorders Using the criteria described above, we identified and and Schizophrenia [34] . According to Leyfer et al., the reviewed 20 original studies conducted in North Ameri- ACI provides a more accurate measure of the behavioral ca, Europe and Asia. More than a half of them [12] were manifestation of psychiatric comorbidity by gathering in- published over the past 5 years reflecting the growing formation on symptoms that cluster together in time, are interest in the topic. Most studies [14] investigated chil- significantly impairing, and, when acute, represent a dren, and 3 studies focused on children with high-func- change from the child’s baseline emotional state, behav- tioning autism (HFA) [25–27] . All studies but one [28] ior and functioning [34, 35] . Mazefsky et al. [36] admin- employed clinical samples. Most studies [18] investigat- istered the ACI to 35 children with ASD and compared ed the presence of BPAD in subjects with ASD (n = the findings to their history of prior diagnoses to help 6,128), and 431 (7%) also met criteria for BPAD. Only 3 clarify the level of concordance. Approximately 60% of studies investigated ASD diagnosis in persons with prior psychiatric diagnoses were not supported on the BPAD (n = 530).
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