Is it autism or psychosis or both? Autistic traits and psychotic symptoms can look a lot alike. How common is psychosis in autism? And how can we differentiate co-occurring autistic traits from psychotic symptoms? Dr. Kristin Cadenhead gives us an approach for sorting through the history and addressing these problems separately.
Published On: 8/21/2023
Duration: 16 minutes, 04 seconds
Dr. Feder: Psychosis can co-occur with autism more often than it does in the general population. In a meta-analysis from 2022 of 53 studies on kids and teens, about 9% of those with autism also had psychosis, and 7.5% had bipolar disorder. It can be challenging to differentiate co-occurring autistic traits from psychotic symptoms. In this episode, we will discuss how to recognize and treat psychosis in autistic children.
Dr. Kristin Cadenhead joins us today to help us unpack this topic. She is a professor of psychiatry and director of Cognitive Assessment and Risk Evaluation (CARE) Early Psychosis Treatment and Research Program at the University of California, San Diego.
Welcome to The Carlat Psychiatry Podcast.
This is another episode from the child psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
Dr. Feder, you mentioned earlier how the co-occurrence of autism and psychosis is higher than the occurrence of psychosis alone within the general population. How severe are psychotic symptoms in autistic vs non-autistic kids?
Dr. Feder: The severity of psychotic symptoms seems to be similar between both conditions. One study found the severity of psychotic symptoms was about equal in people with schizophrenia spectrum and patients who are autistic and have psychotic symptoms.
Mara: Do the conditions share common risk factors?
Dr. Feder: There are certain factors that increase the risk of developing both psychosis and autism, such as obstetrical complications and urban living. Additionally, being a first-generation immigrant, the child of an immigrant, or belonging to a minority group within an immigrant population can also be a risk factor for both conditions. Although you might not find puberty recognized as a risk factor for psychosis in autism according to existing literature, some autistic teens misinterpret the intentions of others and may mistakenly believe that someone likes them, which could resemble an erotomanic delusion. Hormonal changes during puberty could potentially contribute to this misinterpretation.
Mara: It is also important to mention that autistic children who use cannabis are at a higher risk for developing psychosis. While autism can increase their susceptibility to cannabis-induced psychosis, it may also lead to reduced substance use behavior in some cases. According to the Varcin meta-analysis, one study found that the co-occurrence of autism and psychosis was linked to less substance use and higher employment rates compared to non-autistic children.
Dr. Feder: Both autism and psychosis share symptoms such as unusual affect, social isolation, misperceiving social interactions, and suspicious thinking. Dr. Cadenhead, are there specific questions that we can ask to help us differentiate whether a patient is experiencing autism, psychosis, or both?
Dr. Cadenhead: Well, you can look at it from the perspective of an early psychosis clinic and then also from the perspective of a clinic that treats autistic children or adults. So, I know that for me, when I’m seeing somebody that I think might have kind of autism as well as psychotic symptoms, I want to first of all establish whether there’s been a developmental disorder all these years and so, I get a really careful developmental history to find out if there was anything in earlier childhood. Because I usually see them once they’re teenagers, and so I want to know if there have been indications. Have they been referred for testing or to the regional center? That kind of thing, so I get an indication of whether there might have been a pre-existing autism that’s kind of flavoring what I’m seeing with what appears to be a first psychotic break.
But I think that the other way around, like from somebody who’s treating people with autism more regularly, you want to look for a change in behavior compared to their baseline symptoms. You know, they may have always had kind of idiosyncratic interests or something like that. Or they may have had trouble reading other people, and their social interactions could be off. But when it changes and like you said, to the point where there’s a belief that the FBI is monitoring things or it kind of moves into something that is not characteristic of that individual.
Mara: Are there tests or other tools to differentiate psychotic symptoms from autistic ones?
Dr. Cadenhead: No. I’ve looked over this pretty carefully and I think that still, it’s really by history, clinical symptoms. Things like family psychiatric history. You can see ASD and schizophrenia, spectrum disorders in the family histories of both. It’s really sort of hard to determine, other than with the clinical. There are some neuropsych, neurocognitive type tests that are done and there’s evidence of difficulty with theory of mind and being able to read other people.
But again, it comes down to historical because typically, people with schizophrenia would have had intact theory of mind and reading social cues and those kinds of things prior to the onset of their illness. Whereas, with autism you would expect that to have been there from very early on when the autism began.
Same thing, neuroimaging. You know, it’s schizophrenia. We don’t have a diagnostic neuroimaging test that can tell us, this is schizophrenia, or this isn’t. There are patterns that you can see the population level and there’s actually overlap with some of the brain areas involved, like cortical thickness and various areas that are involved in both autism and psychotic disorders. But again, they also have differing areas that have been shown in studies. So, we don’t have that.
There is evidence of some genetic differences in both patients with schizophrenia and autism. There’s some overlap with certain loci, but it may be that they’re just both associated with something like 22q deletion syndrome, but it doesn’t seem that it’s the same diagnosis. It may be that you see different manifestations of psychopathology in each condition. But they’re both associated with the 22q or different loci or different copy number variants. So, again, there’s no specific test and I still think that it comes down to a very careful history and a history from the family, history from any kind of medical records to be able to put the story together to help tease it out.
Mara: Is there a general timing to the onset of psychotic symptoms for schizophrenia, bipolar disorder, and schizoaffective disorder in autism that can help us to sort out the nature of the psychotic symptoms?
Dr. Feder: From clinical experience, the age at which psychotic disorders show up in autistic individuals is similar to what you'd see in non-autistic people. Affective disorders tend to pop up at a younger age than schizophrenia though. Schizophrenia is usually rare before the age of 15, so if I spot signs of psychosis in a young adolescent, I'm more likely to think it's an affective psychosis. There are other clues to look out for too. Sometimes young patients can become psychotic after they start taking antidepressants. This might mean that they're predisposed to bipolar disorder or schizoaffective disorder, rather than schizophrenia.
Mara: Sometimes, prodromal schizophrenia can look a lot like autism. The symptoms can stick around for anywhere from a few weeks to a few years and can include things like neuromotor deficits and learning disabilities. The thing is, you can't officially call it prodromal until the patient becomes psychotic. To identify people who are at a higher risk of developing psychosis, we keep an eye out for subsyndromal positive symptoms. These could be things like changes in perception, where the person thinks they see or hear things that aren't really there. They still have some insight though and can acknowledge that it's a bit strange. For example, they might say "I know it sounds weird, but I think I hear a voice talking to me." They haven't lost touch with reality yet. Delusions can be present too, but the person still has some insight into them. They might say something like "Yeah, I get a bit paranoid sometimes and self-conscious, so I think people are talking about me." Negative symptoms, like social isolation, can also be present in young people at high risk for psychosis.
Dr. Feder, are there other risk factors that can predict which prodromal kids will become psychotic?
Dr. Feder: Just based on clinical criteria, we can usually predict who's going to develop psychosis about 25% of the time. But researchers have actually gone a step further and developed something called a "psychosis risk calculator." This calculator takes into account other factors, like neurocognition, to give us an even better prediction. To use the calculator, we need to get the results of a few different assessments, like the Structured Interview for Prodromal Syndromes (SIPS), neurocognitive tests, and some other specialized scales.
Mara: Is there an advantage to looking for a diagnosis other than psychosis to explain the symptoms?
Dr. Feder: It's definitely possible that there are other conditions that might respond better to treatment than what's being observed. For example, many non-autistic kids might have ADHD, anxiety, or depression that needs to be addressed. When it comes to young autistic people, if they start experiencing psychotic symptoms, I tend to look for signs of bipolar disorder. The prognosis for affective psychoses is usually better than it is for schizophreniform psychosis since they tend to be episodic rather than persistent.
Mara: When discussing psychosis and autism with families, it is important to address psychotic symptoms and work closely with clinicians who specialize in autism. Although these cases can be complex, many patients prioritize relationships, independence, and educational or vocational pursuits once their symptoms subside. Young adults may also express frustration about living with their parents, and it is essential to establish goals and ask about the necessary steps to achieve functional autonomy. Ask questions such as "What do you want to be able to do? Live independently? Attend school or training? Work? What kinds of fun things do want to be able to do?" and "What specific actions will you need to take to reach these goals?"
Dr. Feder: In certain populations, cultural factors can complicate the process of distinguishing between psychosis and autism. These challenges can vary depending on the family and cultural background. For example, some children may not receive early diagnoses of neurodevelopmental disorders due to limited access to healthcare. Additionally, certain communities may stigmatize mental health care and avoid seeking help. Some families may struggle to accept their child's mental health issues due to high expectations, while others may not disclose that their child is autistic. Understanding this historical context is crucial for making an accurate diagnosis of a psychotic spectrum disorder versus autism.
Mara: Dr. Feder how does treatment differ in the use of antipsychotics with kids who have a single diagnosis of autism vs psychosis?
Dr. Feder: What first comes to my mind is one study that found that people who have both autism and psychosis may not respond as well to antipsychotic medication. It's tough for autistic kids because they experience extra stress from sensory, motor, and communication disabilities, which can make their psychotic symptoms worse. But there are ways to help, like individual therapy or social skills training to reduce stress levels. Oh, and I always check if there's any bipolarity or severe depression with psychotic features because sometimes mood stabilizers work better than antipsychotics. Of course, if the delusional beliefs or hallucinations are really persistent, then antipsychotics might be necessary.
Mara: When it comes to choosing an antipsychotic medication, there are a few things to keep in mind. First, it's a good idea to start with a second-generation antipsychotic that won't cause too much weight gain, like lurasidone or ziprasidone, or one that has a long-acting depot form, such as risperidone, paliperidone, or aripiprazole. If the first antipsychotic doesn't seem to be working, it's worth trying a medication that has different pharmacologic properties. Some are more focused on dopamine D2 receptors, while others target multiple receptors like serotonin. It's also important to pay attention to the potential side effects of each medication. For example, if sleep disturbances are an issue, olanzapine may be helpful. Keep in mind that not all insurance plans cover newer antipsychotics, so it may be best to start with medications that are typically covered under most plans.
Dr. Feder: Let's chat for a moment about seizures because it's something to keep in mind with autistic children who are at a higher risk for them. You might also see this with kids who have a psychotic illness, even if you give them a second-generation antipsychotic, it could lower their seizure threshold and make things more challenging. Dr. Cadenhead, have you noticed this happening often, especially with clozapine, or maybe not so much?
Dr. Cadenhead: Right. You know, I really have not seen it that much and I just saw somebody the other day who had had a seizure, but it turned out he had some sort of lesion in his brain that was causing the seizure and I was realizing he had been – neurology had seen him and put him on Lamotrigine, but I continued to treat him with antipsychotics. He had also been on Wellbutrin which can lower the seizure threshold, too, and so I had taken him off the bupropion because of that. I think it – at least, my understanding is that it is...you know, you would want to follow somebody in conjunction with a neurologist and I’m not certain if there are worse offenders. Clozapine may be, for sure, but I’m not sure which ones have a higher risk of seizures.
Mara: What do you do if patients are not responding to antipsychotics?
Dr. Cadenhead: I know that within the early psychosis field, we usually try to move to something like clozapine early if it looks like somebody is failing at least two atypical antipsychotics. We often try to move to a long-acting injectable medication. And that’s often just in case compliance is the problem with non-response. So, that’s another way to go.
I have moved toward – sometimes when somebody’s not responding, getting levels of antipsychotics, because it could be that there’s a rare case of a really fast metabolizer who just doesn’t have an adequate blood level of an antipsychotic, so it might make sense to just check, to make sure. And then, you never know if there are illicit drugs involved, you know, they’re using things and you just don’t know and that’s the reason they haven’t responded.
Mara: Do you use pharmacogenetic testing?
Dr. Cadenhead: I don’t. I don’t typically use it because at least my read of what’s available is that it’s not that those tests don’t really tell you about efficacy of the agent for a particular person, more about how they metabolize the drug.
Dr. Feder: When it comes to treating bipolarity, there are a variety of mood stabilizers to choose from. Lithium is a great option because it can help with both mania and depression. Lamotrigine is another option, but there isn't as much evidence for its effectiveness in treating mania. It's typically used more for BD II where depression is the main issue. You can also use atypical antipsychotics like lurasidone or aripiprazole to stabilize mood. And for a depressive component, you can use agents that are approved for bipolar depression, such as aripiprazole, quetiapine, or lurasidone.
Mara: How difficult might it be to treat schizoaffective disorder with autism?
Dr. Feder: Treating schizoaffective disorder is much like treating affective disorders and schizophrenia. In my experience, I use similar pharmacological strategies as I do for non-autistic kids. However, I usually recommend a therapist who is well-versed in social skills training, family therapy, and other therapies that are more tailored to the needs of autistic individuals.
Mara: What about the use of stimulants when we are concerned about psychosis?
Dr. Cadenhead: I’ve always been really cautious with things like stimulants. I don’t like to use them in anybody who’s been psychotic. But again, when I talk to people who do a lot of bipolar treatment, they feel comfortable – and you may [00:35:00] speak to this, too, because in children there are many people who feel comfortable that if they’re on a mood stabilizer that you can safely use a stimulant without inducing a psychotic episode. I always proceed with caution and try to treat, for example, the bipolar disorder first before I even consider something to help.
But if there’s a propensity to abuse substances, I’m again very cautious.
Mara: Some people hope to avoid medications or use unstudied herbal treatments. We recommend evidence-based psychotherapies like cognitive behavioral therapy for psychosis and social skills training. Potential alternative interventions include omega-3, cannabidiol (CBD), anti-inflammatory interventions related to diet, and mindfulness meditations, but more research is needed to confirm their effectiveness. At present, there are ongoing clinical trials involving CBD, anti-inflammatory diets, and family-focused therapy.
Dr. Cadenhead, do you have any last thoughts about prognosis for these patients?
Dr. Cadenhead: I think there’s probably more of a stigma with something like psychotic disorders, because I think that a lot of the public worry that they’re dangerous or that kind of thing. Who knows? That could explain why there are more jobs in the comorbid autism group. I don’t know. But I think just again, anecdotally, and just off the top of my head my assumption is that if somebody has both it’s more difficult to treat and there are so many more issues coming up. And at least the group who I see that are comorbid, they do tend to be a bit lower functioning and they tend to need more resources. But again, that’s just the small handful who are in my clinic who seem to have both.
I think that the main thing is that we need more research in this area to better characterize these co-occurring illnesses. I think there’s a lot of interest in figuring out – you know, there are clues that there is some overlap. You know, genetically, in terms of the brain structure. So, there are clues that there’s some overlap, but it’s really not very well-understood what might explain that.
You know, they’re both neurodevelopmental disorders. It’s not as though everybody with autism will develop schizophrenia. So, it’s not really clear kind of why we see this, but I think that there is a lot of overlap with many mental health disorders and it’s part of the reason it’s exciting to be in this field because there’s so much more to learn about it.
Dr. Feder: This podcast is based on an edited interview with Dr. Josh Feder and Dr. Kristen Cadenhead. The clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
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Mara: As always, thanks for listening and have a great day!