Mood symptoms and suicidality across the autism spectrum

Factors mediating pre-existing autism diagnosis and later suicidal thoughts and behaviors: A follow-up cohort study

LAY ABSTRACT

Autistic people are more likely to experience suicidal thoughts and behaviors. The underlying relationships between potential risk factors and suicidal thoughts and behaviors in autistic individuals remain unclear. To understand this, we investigated whether specific factors in childhood/youth explain the effects of pre-existing autism spectrum disorder (ASD) diagnoses on later suicidal thoughts and behaviors in adolescence/adulthood. We assessed internalizing and externalizing problems, bullying experiences, and executive functions (including cognitive flexibility, sustained attention, and spatial working memory) at an average baseline age of 13.4 years and suicidal thoughts and behaviors at an average follow-up age of 19.2 years among 129 autistic and 121 typically developing (TD) individuals. During the follow-up period in adolescence/adulthood, autistic individuals were more likely to report suicidal thoughts than TD individuals. Being bullied partially accounted for the relationship between a pre-existing ASD diagnosis and later-reported higher suicidal thoughts. Contrary to our hypothesis, higher (instead of lower) cognitive flexibility in some autistic young people appeared to partially explain their higher rates of suicidal thoughts compared with typically developing young people. The findings imply that school bullying prevention and tailored intervention programs for autistic people, especially those with higher cognitive flexibility, are warranted to reduce their risks of experiencing suicidal thoughts.

Suicide risk in transition-aged autistic youth: The link among executive function, depression, and autistic traits

LAY ABSTRACT

Autistic people are more likely to consider suicide than non-autistic people, with transition-aged youth (ages 16-21 years) at potentially the highest risk. Research has also shown that difficulties with executive functioning (e.g., difficulties with organization, sequencing, and decision-making) may heighten suicide risk among non-autistic people, but it is not clear whether this is also true for autistic people. This study explored this question by asking 183 transition-aged autistic youth about their experience with suicidal behavior and examining the relationship between their responses and additional measures of depression, autistic traits, and executive function skills. About one-third of autistic transition-aged youth (33.3%) said that they had experienced thoughts of hurting themselves with the intent to end their lives (i.e., suicidal ideation). Both depression and executive function challenges predicted suicide risk (i.e., participants who experienced depression were more likely to have had suicidal thoughts than those who had not, and participants who had more difficulty with executive function skills were more likely to have had suicidal thoughts than those who had less difficulty). These findings suggest that executive functioning, a common area of difficulty among autistic people, is an important indicator of suicide risk in this population.

Major Depressive Disorder with Catatonia: A Phenotype Related to Autistic Traits and High Suicidality

Background: Major Depressive Disorder (MDD) represents a significant global health concern, often complicated by comorbidities such as catatonia and autism spectrum disorder (ASD). Recognizing the interplay among these conditions and their impact on suicidal tendencies is crucial for effective clinical management. Methods: A total sample of 147 subjects with MDD was divided into Significant Catatonia (SC) and Non-Significant Catatonia (NSC) groups based on Catatonia Spectrum (CS) scores. Participants were evaluated through the Structured Clinical Interview for DSM-5, Research Version (SCID-5-RV), the Adult Autism Subtreshold Spectrum (AdAS Spectrum), and the Mood Spectrum-Self Report questionnaires. Statistical analyses included Mann-Whitney U test, Chi-square test, logistic regression analyses, and a decision tree model. Results: The SC group exhibited higher CS, AdAS Spectrum, and MOODS-SR total and domain scores compared to the NSC group. Individuals with significant autistic traits were over-represented in the SC group, as well as participants with higher suicidality, suicidal ideation, and a history of suicide attempts. The total AdAS Spectrum and MOOD-SR score, the AdAS domain "Hyper-hypo reactivity to sensory input", and the "Cognitive depressive" MOOD-SR domain were predictive of belonging to the SC group. Suicidality levels appeared to be higher in clinically significant ASD, intermediate in subjects with autistic traits (AT), and low in the absence of AT. Conclusions: the study suggests the existence of a specific phenotype of MDD associated with catatonia, characterized by elevated autistic traits and suicide risk.

It is More Anxiousness than Role-playing: Social Camouflaging Conceptualization Among Adults on the Autism Spectrum Compared to Persons with Social Anxiety Disorder

PURPOSE

Autistic individuals consider social camouflaging, e.g., masking autistic traits or social skills compensation, as exhausting and effortful, often leading to diminished well-being or burnout, as well as adaptive for satisfying social interactions. Developing camouflaging may result in isolation, social avoidance, increased self-stigmatization, and misdiagnosis, including social anxiety disorder. The study's objective was to explore and conceptualize social camouflaging, with a particular focus on social anxiety symptoms, autistic burnout, and public stigma, among autistic individuals, with two comparative samples: with social anxiety disorder (SAD) and dual diagnoses (SAD + ASD).

METHODS

254 individuals participated in the study (including 186 females, 148 with ASD diagnosis). CAT-Q, AQ-10, AASPIRE's Autistic Burnout Scale, LSAS-SR, The Perceived Public Stigma Scale were used.

RESULTS

The findings suggest differences in the interrelation dynamics between the samples studied, with autistic burnout and social anxiety symptoms of essential significance in camouflaging strategies, and autistic traits being of secondary importance. Structural equation models showed that the proposed conceptualization, with camouflaging and autistic burnout as the outcome variables, exhibited acceptable fit, implying that this strategy is costly and may result in exhaustion.

CONCLUSION

The total score of camouflaging did not differ between the groups studied, suggesting that a tendency to camouflage is rather transdiagnostic, deriving from anxiousness and negative self-perception, not being autistic per se.

A qualitative exploration of an autism-specific self-compassion program: The ASPAA

LAY ABSTRACT

Autistic people often struggle to find the right support for their mental health. We wanted to change that by trying a new approach to help autistic adults with their emotions and well-being. We focused on something called "self-compassion," which is a way of being kind and understanding toward ourselves. This approach has worked well for many people, but we didn't know if it would work for autistic individuals. We invited 39 autistic adults to join an online program that taught them about self-compassion. The program lasted 5 weeks and included educational materials, meditation exercises, and self-reflection activities. We asked the participants for feedback each week and at the end of the program. From their responses, we discovered four important things. First, self-compassion had a big positive impact on the well-being of autistic adults. Second, they faced some challenges during the program. Third, they saw self-compassion as a journey that takes time and practice. Finally, they described how they valued changes to help autistic people engage with the program. Our findings show that self-compassion can really help autistic adults. We learned about the benefits they experienced and the difficulties they faced. Most importantly, we found that personalized support is crucial for autistic individuals. By creating programs that consider their specific needs, we can improve their mental health and make their lives better.

Adapting suicide safety plans for youth with intellectual and developmental disabilities

INTRODUCTION

Although risk for suicide appears elevated in individuals with intellectual and developmental disorders (I/DD), few interventions or tools addressing suicide prevention have been adapted for this population. Among evidence-based interventions for preventing suicide, safety planning interventions are an effective and commonly employed intervention for reducing suicide-related risk.

METHODS

By drawing on Special Education praxis for supporting the learning needs of individuals with I/DD, we provide recommendations for adapting suicide safety planning interventions for youth with I/DD.

RESULTS

Specific visual, content, teaching, and communication components of the safety plan intervention can be adapted to better meet the needs of youth with I/DD.

DISCUSSION

Although future research is needed to evaluate these recommendations, these modifications may support clinicians serving youth with I/DD and suicide-related risk.

Potential Mechanisms Underlying Suicidality in Autistic People with Attention Deficit/Hyperactivity Disorder: Testing Hypotheses from the Interpersonal Theory of Suicide

Background

Autistic people with co-occurring attention deficit/hyperactivity disorder (ADHD) appear to be at heightened risk of suicide. To understand why, we explored two explanatory mechanisms from the interpersonal theory of suicide: first, that co-occurring ADHD might be associated with greater risk through greater thwarted belongingness and perceived burdensomeness and, secondly, that hyperactive/impulsive features might incur additional risk through their association with painful and provocative events, which are suggested to create "capability" for suicide.

Methods

Autistic adults (n = 314) completed an online survey including measures of thwarted belongingness, perceived burdensomeness, painful and provocative events, acquired capability for suicide, and ADHD features. Creating an overall index of likely ADHD, we examined associations between likely ADHD, suicide ideation, and lifetime suicide attempts through the parallel mediators of thwarted belongingness, perceived burdensomeness, anxiety, and depression. In several models, we then examined hyperactive, impulsive, and inattentive features as predictors of exposure to painful and provocative events and subsequent capability for suicide, and examined whether these two variables, sequentially or individually, mediated an association with lifetime suicide attempts.

Results

Likely ADHD was associated with past-year suicide ideation through greater depression and perceived burdensomeness, which also mediated its association with more suicide attempts. Hyperactive and impulsive features were associated with exposure to painful and provocative events and through this acquired suicide capability. Both features were associated with more numerous suicide attempts through these two mediators sequentially, and through exposure to painful and provocative events alone.

Conclusions

These data suggest that suicidality in autistic people with ADHD may be partially related to perceived burdensomeness and to acquired suicide capability after exposure to painful and provocative events. However, as we observed a pathway to suicidality associated with painful and provocative events alone, it is likely that there are also other explanatory mechanisms for the influence of traumatic events on suicide risk.

May Female Autism Spectrum Be Masked by Eating Disorders, Borderline Personality Disorder, or Complex PTSD Symptoms? A Case Series

Introduction: The prevalence of Autism Spectrum Disorder (ASD) is four times higher in males than females; however, females are significantly more likely to go undiagnosed due to the existence of a "female autistic phenotype", a manifestation unique to females that conflicts with conventional, masculine conceptualizations of ASD. Furthermore, subthreshold autistic traits, which exert a significantly negative impact on quality of life and represent a vulnerability factor for the development of other psychopathological conditions, may remain even more under-recognized. Subsequently, many women with ASD may never receive a diagnosis or any resulting care, with serious consequences for their health. Aims: We aimed to describe two brief cases in order to confirm the diagnostic difficulties that ASD female undergo during their clinical evaluation and the possible alternative phenotype that they can manifest. Methods: We reported the cases of two young women on the autism spectrum that came to clinical attention only after the development of severe symptomatology attributed to other mental disorders, overlooking the presence of underlying autism spectrum features and a brief résumé of the literature on this topic. Results: These cases confirm the need for a timely and proper identification of females on the autism spectrum in order to prevent complications and improve the outcome. Conclusions: Research on gender differences could lead to a reexamination of the sex ratio in the prevalence of ASD and provide a better understanding of several psychiatric conditions that are frequently diagnosed in women, supporting the neurodevelopmental approach to psychopathology.

The biosocial correlates and predictors of emotion dysregulation in autistic adults compared to borderline personality disorder and nonclinical controls

BACKGROUND

Emotion dysregulation (ED) is a core symptom of borderline personality disorder (BPD), whose aetiology has been attributed to biosocial factors. In autism spectrum condition (ASC), although ED is prevalent and is associated with decreased well-being (e.g. self-harm, suicidality), it has been understudied, especially in adults. It is therefore crucial to further understand ED in autistic adults to improve its treatment. Our study investigates ED, its behavioural correlates (e.g. self-harm, suicidality) and biosocial predictors in autistic adults relative to BPD and nonclinical controls (NC).

METHODS

A total of 724 participants (ASC = 154; BPD = 111; NC = 459) completed 11 self-reported questionnaires assessing ED, ASC and BPD traits, co-occurring disorders, alexithymia, emotional vulnerability and invalidating experiences (e.g. bullying, autistic camouflaging). The occurrence of ED behavioural correlates (i.e. self-harm, history of suicide attempts, and psychiatric hospitalizations) was collected. In addition, between-groups analyses, linear regressions and machine learning (ML) models were used to identify ED predictors in each group.

RESULTS

ED and its behavioural correlates were higher in ASC compared to NC, but milder than in BPD. While gender did not predict ED scores, autistic women had increased risk factors to ED, including sexual abuse and camouflaging. Interestingly, BPD traits, emotional vulnerability and alexithymia strongly predicted ED scores across the groups. Using ML models, sensory sensitivity and autistic camouflaging were associated with ED in ASC, and ADHD symptoms with ED in BPD.

LIMITATIONS

ASC and BPD diagnoses were self-reported, which did not allow us to check their accuracy. Additionally, we did not explore the transactional and the moderating/mediating relationships between the different variables. Moreover, our research is cross-sectional and cannot draw conclusions regarding the direction and causality of relationships between ED and other clinical dimensions.

CONCLUSIONS

ED and its behavioural correlates are heightened in BPD compared to ASC and nonclinical controls. In the ASC group, there were no gender differences in ED, despite the heightened exposure of autistic women to ED risk factors. BPD traits, emotional vulnerability, and alexithymia are core to ED regardless of diagnosis. Although less central, sensory sensitivity and autistic camouflaging seem to be specific predictors of ED in autistic adults.

Factor analysis of the autism spectrum screening questionnaire in a population-based child sample

PURPOSE

The aim of this study was to investigate several possible factor structures of the Autism Spectrum Screening Questionnaire (ASSQ).

MATERIALS AND METHODS

We used the 27-item screening tool for school-aged children in a general population of 8-year-old children (n = 3,538) and compared the occurring solutions to previously published factor models.

RESULTS

A one-factor solution and a four-factor solution were identified in Exploratory Factor Analysis (EFA) and confirmed with Confirmatory Factor Analysis (CFA), while two-, three-, five- and six-factor solutions were rejected. In CFA, our four-factor solution showed the best goodness-of-fit indexes when compared with factor models previously presented by Posserud et al. and Ehlers et al.

CONCLUSIONS

The results indicate a strong underlying connection between all ASSQ items which is elicited by the one-factor solution. Although as a screening tool, ASSQ is functioning with the unifactorial solution, the four factors can help to identify certain clusters of autism spectrum traits.

IL-6, homocysteine, and autism spectrum phenotypes: an investigation among adults with autism spectrum disorder and their first-degree relatives

BACKGROUND

The importance of recognizing different kinds of autism spectrum presentations among adults, including subthreshold forms and the broad autism phenotype (BAP), has been increasingly highlighted in recent studies. Meanwhile, the possible involvement of immune system deregulation and altered methylation/trans-sulfuration processes in autism spectrum disorder (ASD) is gaining growing attention, but studies in this field are mainly focused on children. In this framework, the aim of this study was to compare plasmatic concentrations of IL-6 and homocysteine (HCY) among adults with ASD, their first-degree relatives, and healthy controls (CTLs), investigating also possible correlations with specific autism symptoms.

METHODS

Plasma concentrations of IL-6 and HCY were measured in a group of adult subjects with ASD, their first-degree relatives (BAP group), and healthy controls (CTL). All participants were also evaluated with psychometric instruments.

RESULTS

IL-6 and HCY concentrations were significantly higher in the ASD group than in CTLs, while BAP subjects reported intermediate results. Significant correlations were reported between biochemical parameters and psychometric scales, particularly for the dimension of ruminative thinking.

CONCLUSIONS

These findings support the hypothesis of a key involvement of HCY-related metabolism and immune system alteration in autism spectrum pathophysiology. HCY and IL-6 seem to show different associations with specific autism dimensions.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

The Inter-Relationship of Emotion Regulation, Self-Compassion, and Mental Health in Autistic Adults

Background

Emotion regulation is one of the key factors that influence mental health outcomes in autistic and nonautistic populations. Recent research has also identified self-compassion as a negative correlate of depression and positive correlate of psychological well-being in autistic adults. Empirical evidence from the general population supports the notion that being kind and compassionate toward oneself during stressful and difficult moments can help with one's ability to regulate negative emotions, which then has flow-on effects on mental health outcomes. However, the inter-relationship between self-compassion, emotion regulation, and mental health has not been examined in autistic samples. Therefore, the aim of this study was to determine if emotion regulation mediates the relationship between self-compassion and anxiety or depression in a sample of autistic adults.

Methods

Participants were 153 adults (meanage = 35.70, standard deviationage = 12.62) who had either self-reported a clinical diagnosis of autism spectrum disorder or self-identified as autistic. They completed an online survey capturing self-compassion, emotion regulation, anxiety, and depression. We hypothesized that emotion regulation would mediate the relationship between self-compassion and anxiety or depression, and self-compassion would not mediate the relationship between emotion regulation and anxiety or depression.

Results

As predicted, only emotion regulation mediated the relationship between self-compassion and mental health outcomes. Self-compassion did not mediate the relationship between emotion regulation and mental health outcomes.

Conclusion

This study provides preliminary evidence for the role that self-compassion plays in improving emotion regulation and mental health in autistic adults. If this mechanism of emotion regulation mediating the relationship between self-compassion and mental health is consistently found in future studies, then it would be helpful for future research to examine the clinical benefits of including a self-compassion component in emotion regulation interventions to improve mental health outcomes of autistic adults.

Autism Spectrum, Hikikomori Syndrome and Internet Gaming Disorder: Is There a Link?

The aim of this study is to review the available literature investigating the relationship between hikikomori, a pathological condition characterized by severe social withdrawal or isolation, autism spectrum disorder (ASD) and Internet gaming disorder (IGD). Studies on the relationship between ASD and IGD have found significant positive correlations between these two conditions. Individuals with ASD would appear to be at risk of developing a problematic use of the Internet, which, to the right extent, would represent a useful tool for social interaction and cognitive development. Even subjects with hikikomori, in whom rarefied interpersonal relationships and social isolation could be balanced by the use of online connections, appear to be at high risk of developing IGD. On the other hand, the finding of significant autistic traits in populations with hikikomori could lead to considering this psychopathological condition as a particular presentation of autism spectrum, a hypothesis that requires further investigation.

Unlocking the Secrets: Exploring the Biochemical Correlates of Suicidal Thoughts and Behaviors in Adults with Autism Spectrum Conditions

Involving 1 million people a year, suicide represents one of the major topics of psychiatric research. Despite the focus in recent years on neurobiological underpinnings, understanding and predicting suicide remains a challenge. Many sociodemographical risk factors and prognostic markers have been proposed but they have poor predictive accuracy. Biomarkers can provide essential information acting as predictive indicators, providing proof of treatment response and proposing potential targets while offering more assurance than psychological measures. In this framework, the aim of this study is to open the way in this field and evaluate the correlation between blood levels of serotonin, brain derived neurotrophic factor, tryptophan and its metabolites, IL-6 and homocysteine levels and suicidality. Blood samples were taken from 24 adults with autism, their first-degree relatives, and 24 controls. Biochemical parameters were measured with enzyme-linked immunosorbent assays. Suicidality was measured through selected items of the MOODS-SR. Here we confirm the link between suicidality and autism and provide more evidence regarding the association of suicidality with increased homocysteine (0.278) and IL-6 (0.487) levels and decreased tryptophan (-0.132) and kynurenic acid (-0.253) ones. Our results suggest a possible transnosographic association between these biochemical parameters and increased suicide risk.

Autistic traits distribution in different psychiatric conditions: A cluster analysis on the basis of the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire

Increasing interest is being paid on full-threshold and sub-threshold autism spectrum conditions among adults. Sub-threshold autistic traits (AT) seem to be distributed in a continuum from the clinical to the general population, being particularly higher among subjects with other psychiatric disorders. The aim of the present study was to evaluate the distribution of AT in a sample of subjects with different psychiatric conditions by means of a cluster analysis on the basis of the score reported to the AdAS Spectrum instrument. A total of 738 subjects recruited by seven Italian Universities were divided in 5 groups depending on the clinical diagnosis: Autism spectrum disorder (ASD), subthreshold ASD symptoms (partial ASD), Bipolar disorder (BD), Feeding and eating disorders (FED), and controls (CTLs). All subjects were assessed with the AdAS Spectrum. The cluster analysis identified 3 clusters: the high, medium and low autism clusters. The Restricted interests and rumination domain reported the highest influence in forming the clusters. The high, medium and low autism clusters were respectively more represented in the ASD, partial ASD and CTL groups. The clusters were represented intermediately in the FED and BD groups, confirming the presence of intermediate levels of AT in these clinical populations.

Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art

Despite the relationship between Autism spectrum disorder (ASD) and personality disorders (PD) still being scarcely understood, recent investigations increased awareness about significant overlaps between some PD and autism spectrum conditions. In this framework, several studies suggested the presence of similarities between BPD and ASD symptoms and traits, based on the recent literature that increasingly reported increased comorbidity rates and significant symptomatologic overlaps between the two conditions. The aim of this review is to describe the available studies about the prevalence of the association between different forms of autism spectrum (full-fledged clinical conditions as well as subthreshold autistic traits) and BPD. Despite some controversial results and lack of homogeneity in the methods used for the diagnostic assessment, the reviewed literature highlighted how subjects with BPD reported higher scores on tests evaluating the presence of AT compared to a non-clinical population and hypothesized the presence of unrecognized ASD in some BPD patients or vice versa, while also describing a shared vulnerability towards traumatic events, and a greater risk of suicidality in BPD subjects with high autistic traits. However, the specific measure and nature of this association remain to be explored in more depth.

Autism Spectrum Disorder in a Patient with Bipolar Disorder and Its Relationship with Catatonia Spectrum: A Case Study

According to several studies, the prevalence of Autism Spectrum Disorder (ASD) ranges from 2.4 to 9.9 percent among adult mental inpatients. However, subjects with forms of ASD that fit in the high functioning spectrum may remain undiagnosed during childhood and adolescence without reaching clinical attention until they develop in adult life other psychiatric disorders, often characterized by treatment resistance and poor outcomes. The aim of this case report was to evaluate the role of an undiagnosed ASD in the mental illness trajectory and discuss the diagnostic and therapeutic implications. We reported a case of a young man with an undiagnosed ASD that came to clinical attention only after the development of a severe manic episode with mixed and psychotic features and with catatonia in adulthood, despite meeting DSM-5-TR (APA, 2022) diagnostic criteria for ASD since early childhood. This case confirms the need of a timely identification of ASD in order to prevent the development of a mental illness trajectory and to improve the prognosis and the outcome. Moreover, on the heuristic level, this case seems to support the presence of a continuum between ASD and catatonia. In this framework, the use of a questionnaire based on a spectrum model, such as the AdAS Spectrum, could be useful in early diagnosis of ASD without intellectual or language impairment as well as in early detection of subthreshold conditions (broad autism spectrum phenotype or autistic traits), which represents a vulnerability factor for the development of various mental disorders.

A comprehensive perspective of autistic traits and catatonic symptoms in a patient with Fronto-Temporal Dementia and Bipolar Disorder: a case report

BACKGROUND

Fronto-Temporal Dementia (FTD) is a neurodegenerative disorder featuring frontotemporal lobe atrophy which leads to profound changes in behavior and cognition in the affected subjects. Considering that the onset of this type of dementia is typically characterized by the development of affective symptoms, differential diagnosis between FTD and Bipolar Disorder (BD) is particularly difficult. An important overlapping feature between BD and FTD is the presence of catatonic symptoms: Catatonia is extremely frequent in FTD, and, on the other hand, BD is the psychiatric disease with the highest frequency of association with catatonic states. In this framework, it should be noted that also Autism Spectrum conditions have been reported to show high rates of comorbidity and overlapping features with BD. In addition, subjects with autistic traits were reported to show an increased vulnerability towards the development of mood and anxiety disorders, as well as increase the risk of mood episodes with mixed features, suicidal thoughts and catatonic symptoms.

CASE PRESENTATION

We reported the case of a patient with a diagnosis of both BD and FTD who showed catatonic symptoms.

OBJECTIVES

The aim of this case report is to evaluate the possible role of autistic traits in the illness trajectory of BD and FTD.

CONCLUSION

This case confirms the presence of a continuum between psychiatric and neurological conditions, which should be considered as expressions of a same neurobiological system and further investigated in light of an integrative model.

A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability

BACKGROUND

Suicidality is highly prevalent in autistic people without co-occurring intellectual disabilities, and high autistic traits are found in adults who have attempted suicide. However, prevalence rates for both autistic and possibly autistic people have not been synthesised meta-analytically.

AIMS

To (1) calculate pooled prevalence estimates of suicidality in autistic people and possibly autistic people without co-occurring intellectual disability; (2) evaluate the influence of participant and study level characteristics on heterogeneity; and (3) determine the quality of evidence.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PsycINFO, Embase, MEDLINE and Web of Science were systematically searched from 1992 to January 25, 2022. Empirical quantitative studies reporting prevalence of suicidal ideation, suicide plans, or suicide attempts and behaviours were considered for inclusion. Random effects models were used to estimate pooled prevalence of each suicidality outcome with 95% confidence intervals. Heterogeneity was explored using sensitivity and moderator analyses.

RESULTS

Data from 48,186 autistic and possibly autistic participants in 36 primary studies were meta-analysed. Pooled prevalence of suicidal ideation was 34.2% (95% CI 27.9-40.5), suicide plans 21.9% (13.4-30.4), and suicidal attempts and behaviours 24.3% (18.9-29.6). High levels of heterogeneity (I² > 75) were observed in all three analyses. Estimates did not differ between autistic or possibly autistic samples. Geographical location (p = 0.005), transgender or gender non-conforming samples (p < 0.001) and type of report (p < 0.001) significantly moderated suicidal ideation, whereas age group (p = 0.001) and measure of suicidality (p = 0.001) significantly moderated suicide plans. There was a significant association between the proportion of male participants and prevalence of suicide plans, with a decrease in the proportion of males for every unit change of suicide plan prevalence (p = 0.013). No variables were found to moderate estimates of suicide attempts and behaviours.

CONCLUSIONS

The results confirm suicidality is highly prevalent in both autistic and possibly autistic people without co-occurring intellectual disability and highlights potential moderators. Possibly autistic individuals require more attention in clinical and research considerations going forward to further understand and prevent suicide in both groups.

Measuring Social Camouflaging in Individuals with High Functioning Autism: A Literature Review

In the recent years, growing attention has been paid to the use of camouflaging strategies by adult populations suffering from autism spectrum disorder (ASD) with milder manifestations and without intellectual impairment, which may lead to a delay in diagnosis or even a misdiagnosis. In fact, high-functioning ASD individuals were reported to be more aware of their communication difficulties and were more likely make considerable efforts to adjust their behavior to conventional rules of non-autistic individuals, learning to imitate other non-ASD individuals. Moreover, females reported a higher frequency of camouflaging strategies, suggesting a role of camouflaging in the gender gap of the ASD diagnosis. Although camouflaging strategies can sometimes grant a better level of adjustment, even resulting in a hyper-adaptive behavior, they are also often correlated with negative mental health consequences due to the long-term stress associated with continuous attempts to adapt in day-to-day life. In this framework, the aim of the present work was to review the available studies that assessed the presence and correlates of camouflaging strategies in individuals with ASD. Although the literature available on the topic is still scarce, some interesting correlations between camouflaging and anxious and depressive symptoms, as well as suicidality, were highlighted. In particular, the controversial and sometime opposite thoughts and results about camouflaging may be clarified and integrated in light of a dimensional approach to psychopathology.

"Self-compassion changed my life": The self-compassion experiences of autistic and non-autistic adults and its relationship with mental health and psychological wellbeing

Self-compassion is a gentle way of relating to oneself, linked to a host of mental health benefits in non-autistic people. Although many autistic individuals report high anxiety and depression symptoms, no research to-date has examined the self-compassion experiences of autistic individuals and determined if self-compassion is associated with psychopathology. Therefore, the purpose of the current study was to address this research gap. The participants (153 autistic and 93 non-autistic adults) completed on online survey and 11 autistic participants were also interviewed. Autistic participants reported significantly lower self-compassion than non-autistic adults, and in both groups, those with higher self-compassion reported higher psychological wellbeing and lower depression symptoms. Demographic predictors of self-compassion were identified. These findings have both clinical and research implications.

A systematic review of predictors of suicidal thoughts and behaviors among autistic adults: Making the case for the role of social connection as a protective factor

Autistic adults are a high-risk population for suicidal thoughts and behaviors (STBs). Accordingly, this systematic review aims to review the prevalence of STBs among autistic adults, review the risk and protective factors for STBs in autistic adults, and formulate a disorder-specific conceptualization of risk in this population. We systematically searched PsycINFO and Google Scholar for all studies published prior to March 28th, 2022. We included empirical articles focused on autistic adults, ages 18 years and older, reporting on suicide-related outcomes. In total, 45 peer-reviewed empirical articles were included in the current systematic review. The most frequently studied factors in relation to suicide risk among autistic adults were interpersonal constructs (42.4% of total studies looking at risk/protective factors) and depressive symptoms (36.4% of total studies looking at risk/protective factors). We conclude by summarize two key content areas: exploring social and interpersonal constructs and better understanding the role of depressive symptoms in autism. As researchers continue to explore STBs among autistic adults, it will be necessary to addressing the overreliance on autistic symptoms instead of autism diagnoses, measurement issues of STBs, and a need for treatment adaptations.

Social communication problems, social anxiety, and mood problems: kindergarten and primary school teachers' perspective among students with autism spectrum disorder

This study examined the level of social communication problems (SCP), social anxiety (SA), and mood problems (MP) among children with ASD (age 4-13 years) enrolled in special classes (n = 74) and regular classes (n = 73) and grade level (kindergarten, 1st-3rd, 4th-6th) from teachers' perspective in schools of Palestinian Arabs in Israel. Teachers responded to three questionnaires about (1) SCP, (2) SA and (3) MP; the teachers' responses to the questionnaires were used to answer the research questions. Results: SCP, SA and MP were of medium rates for students with ASD enrolled in regular and special classes. No significant differences in the level of SCP could be attributed to class type (Regular, Special) or the grade level (kindergarten, 1st-3rd, 4th-6th). There were significant differences in SA levels that could be attributed to grade level in favor of the 4th-6th grades but there were no significant differences according to class type (Regular, Special). There were statistically significant differences in MP levels that could be attributed to the class type in favor of special classes, and the effect of grade level was not significant. There was a direct significant relationship between SCP, SA, and MP. Conclusion: SCP may be an important risk factor for the development of SA and MP among students with ASD, which lead us to incorporating social skills interventions by educational staff to alleviate or even prevent symptoms of SA and MP among students with ASD, which supports the view of inclusion.

Autistic traits and camouflaging behaviors: a cross-sectional investigation in a University student population

BACKGROUND

Increasing research is stressing the importance of identifying autistic traits (ATs) in clinical and general populations. University students may be a group at higher risk for the presence of ATs. Recently, specific attention has been paid to camouflaging strategies used by subjects in the autism spectrum in order to cope with the social environment. The aim of this work was to evaluate the prevalence of ATs and camouflaging behaviors in a population of University students.

METHODS

Subjects were requested to anonymously fill out through an online form the Adult Autism Subthreshold Spectrum and the Camouflaging AT Questionnaire.

RESULTS

ATs were more represented among males and among students of specific fields of study. Camouflaging behaviors were significantly more frequent among subjects with more severe autism spectrum symptoms, without differences depending from sex.

CONCLUSIONS

Our study confirms the strong association between ATs and camouflaging behaviors and the relationship between ATs, sex, and specific fields of study.

An attempted "suicide pact" in Covid-19 era - psychiatric perspectives

BACKGROUND

A "suicide pact" is a joint and actively induced death of two individuals with the essential and unavoidable characteristic of a mutual consent. One of the partners (dominant in the relationship, commonly male) usually induces the action and in most cases, it is the one who actively carries it out. Undiagnosed psychopathological dimension or pathological subthreshold traits are found in those who enter into suicide agreements, the presence of cluster B personality traits such as narcissistic or borderline is of particular relevance in the dominant partner, while in the submissive one dependent personality traits are more frequent. As in the case of other similar health emergencies, COVID-19 pandemic seems to lead to greater suicidality, including the "suicide pacts" of couples whose motivation varies including firstly financial problems, strictly followed by fear of infection and not being able to return home from abroad.

CASE PRESENTATION

We reported a case of a couple who entered a suicide agreement consequently to the economic difficulties caused by COVID-19 pandemic, hospitalized in our department. Both partners were assessed with Adult Autism Subthreshold Spectrum (AdAS Spectrum) and both crossed the threshold for clinically relevant autistic traits (M = 67; F = 49).

CONCLUSION

This case further confirms the link between COVID-19 pandemics and suicidality. The role of autism spectrum traits as a vulnerability factor towards the development of severe psychopathological consequences after traumatic events is also stressed.

A Scoping Review of Autism and the Way It Changes the Presentation of Suicidal Thoughts and Behavior Compared to the General Population

Autism spectrum conditions are a group of neurodevelopmental conditions that carries an array of co-occurring diagnoses, including a heightened risk of suicide attempts and suicide. This scoping review examined primary research focusing on autism and suicidality, to understand what is currently known on the topic, including how autism changes the presentation of suicidal thoughts and behavior; and to assess the suicide awareness and prevention education programs currently available for autistic people, their families, and health professionals and support workers. A comprehensive search (November 2021) across Scopus, PubMed and CINAHL identified 39 articles from 38 studies. Three themes emerged, with five subthemes. 1. The prevalence of suicidality in autistic people; 2. The presentation of suicidality in autistic people, including (a) risk of suicidality; (b) gender, age, employment and education; (c) co-occurring psychiatric conditions; (d) autism traits and social communication; (e) intellectual disability; and 3. Autism-specific approaches to suicidal thoughts, behavior and prevention. Findings were mixed, including conflicting evidence on the risk of autism and suicidality, and limited evidence of resources related to autism-specific suicide awareness or information, and education or prevention programs.

Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study

Self-harm and suicidal behaviors are prevalent among autistic adults without intellectual disability (ID). Emotion dysregulation (ED), the difficulty in modulating emotions, has been identified as an important risk factor. Dialectical behavior therapy (DBT) has been proved effective to treat ED in disorders other than autism spectrum disorder. Our study aimed at assessing the feasibility, acceptability and preliminary efficacy of DBT in seven autistic adults without ID exhibiting self-harm and/or suicidal behaviors linked to severe ED. Our results suggest that DBT is feasible and highly acceptable to autistic adults without ID. Additionally, mean scores on the Difficulties in Emotion Regulation Scale decreased significantly post-treatment and at 4-month follow-up, suggesting that DBT might be efficacious in reducing ED in this population.

Investigating the relationship between orthorexia nervosa and autistic traits in a university population

BACKGROUND

Orthorexia nervosa (ON) is an emerging condition featuring restrictive eating behaviors on the basis of subjective beliefs about food healthiness. Many authors have stressed the similarities between ON and anorexia nervosa (AN) in both cognitive and behavioral patterns. Despite that, while the link between AN and female autism presentations is well known in the literature, no study has yet investigated the relationship between ON and autism spectrum. This work aims to investigate the relationship between ON and autistic traits in a university population.

METHODS

An e-mail invitation was sent to all the students and University workers of University of Pisa. Subjects were asked to fulfill the ORTO-15 and the Adult Autism Subthreshold spectrum (AdAS spectrum) questionnaires.

RESULTS

A total of 2426 subjects joined the survey: 623 subjects (26.3%) reported a score associated with significant orthorexic symptoms according to ORTO-15 (ON group), while 1789 subjects (73.7%) did not report ON symptomatology and were considered as healthy controls (HC). The ON group scored significantly higher on almost all AdAS spectrum domains. Moreover, being female and scoring higher on AdAS spectrum were statistically predictive factors for the presence of ON symptomatology. Among AdAS spectrum domains, higher scores on AdAS spectrum inflexibility and adherence to routine and restricted interests and rumination domains, as well as lower scores on verbal communication domain, were statistically predictive of orthorexic symptoms.

CONCLUSIONS

Our findings highlight an overlap between ON and autism spectrum psychopathology. Further studies are needed to clarify the relationship between restrictive eating disorders and female autism phenotypes.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood: A systematic review

Introduction

Emotional dysregulation (ED) is characterized by inappropriate emotional reactions related to environmental or cognitive stimuli. In most recent years, increasing interest has been devoted to its definition and detection across mental disorders for its detrimental role progressively highlighted in both neurodevelopment and adult mental disorders, with implications on the severity of clinical manifestations. The aim of this systematic review was to evaluate and gather the scientific evidence about ED in adult psychiatric population to elucidate the concept of ED as trans-nosographic entity.

Methods

The electronics databases PubMed, Scopus and Web of Science was reviewed to identify studies in accordance with the PRISMA guidelines; at the end of the selection process a total of 29 studies (N = 709; N = 658; N = 1,425) was included. All studies included assessed the presence of ED symptoms, by means of a validate scale in adult (>18 years of age), in clinically diagnosed patients as well as healthy control participants.

Results

Our results suggest ED as a trans-diagnostic factor across multiple mental disorders, such as bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, personality disorders; a better definition of this concept could be helpful to interpret and clarify many clinical cases and improve their diagnostic and therapeutic management.

Parent-Reported Suicidal Ideation in Three Population-Based Samples of School-Aged Korean Children With Autism Spectrum Disorder and Autism Spectrum Screening Questionnaire Screen Positivity

OBJECTIVES

Higher prevalence of suicidality has been reported in individuals with ASD. This study aimed to (1) Estimate the prevalence of suicidal ideation (SI) in epidemiologically-ascertained, population-based, samples of children with ASD or Autism Spectrum Screening Questionnaire (ASSQ) Screen Positivity (ASP); (2) Determine whether ASD/ASP is an independent risk factor for SI, controlling for known SI risk factors; and, (3) Develop an explanatory model for SI in children with ASD/ASP.

METHODS

Participants came from three epidemiologically-ascertained samples of school-aged Korean children (n = 14,423; 3,702; 4,837). ASSQ ≥ 14 was the cutoff for ASP. A subsample (n = 86) was confirmed to have ASD. SI was based on parents' endorsement of items on the Behavioral Assessment System for Children-2-Parent Report Scale-Children. Logistic regressions were used to assess associations between SI and ASD/ASP, controlling for demographics, peer victimization, behavior problems, and depression. To develop an explanatory model for SI within ASD/ASP, the associations between SI and child characteristics (comorbid conditions, ASD symptoms, IQ, adaptive function) were tested.

RESULTS

SI was higher in children with ASD (14%) and ASP (16.6-27.4%) than ASSQ Screen Negative (ASN) peers (3.4-6.9%). ASD/ASP was strongly predictive of SI (ORs: 2.87-5.67), after controlling for known SI risk factors compared to ASN. Within the ASD and ASP groups, anxiety was the strongest predictor of SI.

CONCLUSIONS

SI prevalence was higher in non-clinical samples of children with ASD and ASP, relative to ASN peers. These results underscore the need for routine screening for SI in children with ASD and social difficulties, particularly those with high anxiety. HighlightsPopulation-based, epidemiologically-ascertained, school-aged childrenASD and ASP are independent risk factors for SI in school-aged childrenAnxiety is an independent risk factor for SI in children with ASD or ASP.

Eating disorders and autism spectrum: links and risks

In the last decades, increasing attention has been provided to socio-cultural and neurobiological factors involved in the psychopathology of feeding and eating disorders (FED), encouraging a multifactorial approach. In this framework, several authors stressed an association between FED and other kinds of psychiatric disorders from both a psychopathological and a neurobiological point of view. In particular, many promising contributions are focusing on the possible link between FED and autism spectrum disorder (ASD). Growing interest about this association rose from the frequently reported evidence of ASD-like traits amongst FED patients and abnormal eating behaviors amongst patients with ASD. This narrative review overview aims to summarize the most relevant findings about the overlap between different kinds of FED and the autism spectrum, taking into account the most recent hypotheses about the psychopathology of both these conditions. While most of the studies focused on anorexia nervosa, both ASD and autistic traits seem to be detectable also in other kinds of FED. In addition, the recently increased interest toward a dimensional approach to psychopathology led to progressively broadening the concept of ASD, focusing on its subthreshold and gender-specific manifestations and on its link with other psychiatric conditions, including FED. Globally the studies summarized here provide further support to theoretical models featuring a neurodevelopmental approach for mental disorders. In particular, FED have been conceptualized as a possible psychopathological trajectory of a neurodevelopmental alteration, toward which female gender would act as one of many predisposing factors.

Brief Report: Risk and Protective Factors Associated with Depressive Symptoms among Autistic Adults

Autistic individuals are at risk for developing depression though the risk and protective factors for co-occurring depression in autistic individuals are not yet fully characterized. In this retrospective medical chart review study, we explored factors associated with self-reported depressive symptoms (Patient Health Questionnaire-9) in autistic adults (N = 58). For autistic adults, engagement in one or more activities (recreational, educational and/or vocational) was associated with less severe depressive symptoms (Mann-Whitney U test, p = 0.006); and reported family history of depression/anxiety was associated with increased likelihood of suicidal ideation (Chi-square test, p = 0.027). Promotion of community-based activities and family support systems may be an integral part of creating effective treatment plans for depressive symptoms in autistic adults.

Kynurenine pathway and autism spectrum phenotypes: an investigation among adults with autism spectrum disorder and their first-degree relatives

BACKGROUND

Increasing literature highlighted alterations of tryptophan (TRP) metabolism and kynurenine (KYN) pathway in children with autism spectrum disorder (ASD). However, no study specifically focused on adult samples. Meanwhile, several authors stressed the relevance of investigating neurobiological correlates of adult forms of ASD and of those subthreshold ASD manifestations frequently found in relatives of ASD probands, known as broad autism phenotype (BAP). This work aimed to evaluate circulating levels of TRP and metabolites of KYN pathway in a sample of ASD adults, their first-degree relatives and controls (CTLs), investigating also the correlations between biochemical variables' levels and ASD symptoms.

METHODS

A sample of ASD adults, together with a group of first-degree relatives (BAP group) and unrelated CTLs were assessed by means of psychometric scales. Circulating levels of TRP, KYN, quinolinic acid (QA), and kynurenic acid (KYNA) were assessed in all subjects.

RESULTS

ASD patients reported significantly higher total scores than the other groups on all psychometric scales. BAP subjects scored significantly higher than CTLs. ASD patients reported significantly lower TRP levels than BAP and CTL groups. Moreover, significantly lower levels of KYNA were reported in both ASD and BAP groups than in CTLs. Specific patterns of associations were found between autism symptoms and biochemical variables.

CONCLUSIONS

Our findings confirm in adult samples the presence of altered TRP metabolism through KYN pathway. The intermediate alterations reported among relatives of ASD patients further stress the presence of a continuum between subthreshold and full-threshold ASD phenotypes also from a biochemical perspective.

Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics

OBJECTIVE

The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings.

METHODS

A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews.

RESULTS

During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment.

CONCLUSION

Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

The Autism Spectrum Quotient in a sample of Brazilian adults: analyses of normative data and performance

Autism spectrum disorder (ASD) is characterized by difficulties in social interaction and inflexible behaviors/interests. To quantify ASD traits in adults with preserved intelligence, the Autism Spectrum Quotient (AQ) was developed, which is a self-report instrument and one of the most used and recommended tools.

Do Autistic Traits Correlate with Post-Traumatic Stress and Mood Spectrum Symptoms among Workers Complaining of Occupational Stress?

The adult autism subthreshold spectrum model appears to be a useful tool for detecting possible vulnerability factors in order to develop mental disorders in the contest of work-related stress. The aim of the present study is to analyze the relationship between autism, mood, and post-traumatic spectrum in a cohort of subjects complaining of work-related stress before the COVID-19 pandemic. The authors carried out a retrospective investigation of both medical records and self-assessment tools of a sample of subjects evaluated at the Occupational Health Department of a University hospital in central Italy. Data showed significant correlations between the AdAS spectrum, TALS-SR, and MOODS total and domain scores. A multiple linear regression evidenced that both the AdAS spectrum and TAL-SR significantly predict the MOODS scores. In particular, mediation analysis showed both a direct and indirect, mediated by TALS-SR, effect of the AdAS Spectrum on the MOODS-SR. These results corroborate the role of autistic traits in influencing the traumatic impact of work-related stress and the development of mood spectrum symptoms.

Validation of the Italian version of the Camouflaging Autistic Traits Questionnaire (CAT-Q) in a University population

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is an instrument recently developed and validated in English for measuring social camouflaging. While increasing research is focusing on camouflaging behaviours often used for masking autistic traits in social contexts, the CAT-Q remains the only self-report instrument in this field. We aimed to validate the Italian version of the CAT-Q, further testing its validity and reliability in a large Italian University population (N = 2439). We employed the Adult Autism Subthreshold Spectrum (AdAS Spectrum) for assessing autism spectrum conditions. The CAT-Q demonstrated excellent internal consistency and test-retest reliability, as well as strong correlations with the AdAS Spectrum. Our results confirm that the CAT-Q is a valuable instrument for evaluating social camouflaging.

Investigating Orthorexia Nervosa With the ORTO-R in a Sample of University Students With or Without Subthreshold Autism Spectrum: Focus on Dietary Habits and Gender Differences

BACKGROUND

The aim of the present study was to investigate the presence of Orthorexia (ON) symptoms in a sample of University students with or without autistic traits (AT), specifically focusing on evaluating the role of gender and of dietary habits in the association between ON and autism spectrum.

METHODS

Subjects were requested to anonymously fill out the questionnaires through an online form.

RESULTS

Two thousand one hundred forty students participated in the study. Subjects with significant AT, measured by means of the Adult Autism Sub-threshold spectrum (AdAS Spectrum) reported significantly higher ON symptoms, as measured by ORTO-R scores, than subjects with low AT. Females and subjects following a vegetarian/vegan diet reported significantly higher ORTO-R scores than males and than subjects following an omnivorous diet, respectively. Significant positive correlations were found between ORTO-R and AdAS Spectrum scores. A decision tree model, with gender, type of diet and presence of high AT as independent variables and ORTO-R score as dependent variable, showed in the first step the presence of significantly higher ORTO-R scores among females than among males, and in the second step showed in both genders the presence of higher ORTO-R scores among subjects with high AT than in those with low AT. A significant interaction of gender and presence/absence of high AT was reported on ORTO-R score, with a higher increasing trend of ORTO-R score with the increase of AdAS Spectrum score among females than among males.

CONCLUSIONS

Our results further highlighted the association between AT and ON, in particular among females.

Camouflaging: psychopathological meanings and clinical relevance in autism spectrum conditions

In the last decade, increasing literature focused on camouflaging as a strategy adopted to cope with social environment by patients with autism spectrum disorder (ASD). A better understanding of this phenomenon may shed more light on cognitive mechanisms and coping strategies of patients in the autism continuum, eventually leading to reconsider some previous "dogmas" in this field, such as the gender discrepancy in ASD diagnosis. Moreover, shared features can be observed in the camouflaging strategies adopted among the general population, among patients of the autism spectrum, and among patients with different kinds of psychiatric disorders, further challenging our perspectives. Camouflaging behaviors might be considered as a transdiagnostic element, closely associated with the continuous distribution of the autism spectrum among the general and the clinical population.

Risk of Self-harm in Children and Adults With Autism Spectrum Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

Multiple studies have reported that people with autism spectrum disorder (ASD) are at a higher risk for self-injurious behavior and suicide. However, the magnitude of this association varies between studies.

OBJECTIVE

To appraise the available epidemiologic studies on the risk of self-injurious behavior and suicidality among children and adults with ASD.

DATA SOURCES

PubMed, Embase, CINAHL, PsycINFO, and Web of Science were systematically searched for epidemiologic studies on the association between ASD and self-injurious behavior and suicidality. Databases were searched from year of inception to April through June 2020. No language, age, or date restrictions were applied.

STUDY SELECTION

This systematic review and meta-analysis included studies with an observational design and compared self-injurious behavior (defined as nonaccidental behavior resulting in self-inflicted physical injury but without intent of suicide or sexual arousal) and/or suicidality (defined as suicidal ideation, suicide attempt, or suicide) in children (aged <20 years) or adults (aged ≥20 years) with ASD.

DATA EXTRACTION AND SYNTHESIS

Information on study design, study population, ASD and self-harm definitions, and outcomes were extracted by independent investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Overall summary odds ratios (ORs) and 95% CIs were estimated using DerSimonian-Laird random-effects models.

MAIN OUTCOMES AND MEASURES

The ORs for the associations of ASD with self-injurious behavior and suicidality were calculated. Analyses were stratified by study setting and age groups as planned a priori.

RESULTS

The search identified 31 eligible studies, which were of moderate to high quality. Of these studies, 16 (52%) were conducted in children, 13 (42%) in adults, and 2 (6%) in both children and adults. Seventeen studies assessed the association between ASD and self-injurious behavior and reported ORs that ranged from 1.21 to 18.76, resulting in a pooled OR of 3.18 (95% CI, 2.45-4.12). Sixteen studies assessed the association between ASD and suicidality and reported ORs that ranged from 0.86 to 11.10, resulting in a pooled OR of 3.32 (95% CI, 2.60-4.24). In stratified analyses, results were consistent between clinical and nonclinical settings and between children and adults.

CONCLUSIONS AND RELEVANCE

This study found that ASD was associated with a substantial increase in odds of self-injurious behavior and suicidality in children and adults. Further research is needed to examine the role of primary care screenings, increased access to preventive mental health services, and lethal means counseling in reducing self-harm in this population.

Cultivating Self-Compassion to Improve Mental Health in Autistic Adults

Many autistic adults experience poor mental health. Research has consistently shown that cultivating self-compassion is a promising approach to strengthening resilience in nonautistic adults. Self-compassion is a trainable skill that is associated with several mental health benefits, such as higher levels of happiness and well-being as well as lower symptoms of depression and anxiety. However, no studies to date have explored self-compassion in autistic individuals. We suggest that self-compassion may be a relevant target in mental health interventions for autistic adults without severe or profound intellectual disability. Self-compassion may improve mental health in autistic adults through directly modifying emotions (as an emotion regulation strategy) or its interactions with emotion regulation processes. Existing approaches to cultivating self-compassion include identifying and practicing self-compassionate behaviors, using self-compassionate thought records, and practicing self-compassion meditations. Before self-compassion approaches are implemented by autistic adults, it will be necessary to evaluate their role and effectiveness in mental health through carefully designed studies. We suggest that researchers should first study the relationship between self-compassion and mental health outcomes in autistic adults. Once researchers have established the connection, we can then begin to study self-compassion-based interventions for autistic adults. Relevant clinical considerations include identifying the autistic groups that self-compassion practices are suitable for, determining how autistic adults with and without mental health conditions can effectively practice self-compassion (on their own and with the support of clinicians), and evaluating existing self-compassion tools or designing new tools. It is also relevant for future research to identify the enablers and barriers to using self-compassion in autistic adults.

Lay summary

What is self-compassion?: Self-compassion is when we: are friendly toward ourselves (kindness)are aware of our feelings and thoughts (mindful awareness)realize that everyone feels pain and makes mistakes (common humanity)What is the purpose of this article?: We think that practicing self-compassion is important for autistic adults. No research has studied self-compassion in autistic individuals. We provide examples of how to improve self-compassion. We make recommendations for future research on self-compassion for autistic adults.What perspectives do the authors bring to this subject?: We bring together different and unique perspectives in this article. One author is a researcher whose research has focused on emotion regulation and mental health in autistic youth and adults. The other author is a self-compassion researcher who is also a private practice clinical psychologist. We have practiced self-compassion and personally experienced the benefits of developing our self-compassion skills. We think that cultivating self-compassion has helped to improve our mental health and enriched our lives.Why is self-compassion important?: Self-compassion is associated with a lot of positive aspects of life in nonautistic individuals. These positive aspects include greater happiness and well-being, and lower levels of depression and anxiety symptoms.How is self-compassion relevant to autistic adults?: We know that as a group, autistic adults have poorer mental health when compared with nonautistic adults. That is, autistic adults experience higher rates of anxiety and depression. Research shows that practicing self-compassion in nonautistic people can improve their mental health. We think that cultivating self-compassion can also be helpful to autistic adults.What do the authors recommend?: We suggest that cultivating self-compassion may improve the mental health of autistic adults. There are several ways to improve self-compassion. Self-compassion can be improved by identifying and practicing self-compassionate behaviors. For example, we can take a walk outside. Another way to improve self-compassion is to record our thoughts. This can be performed by keeping a log of self-critical thoughts. We can also practice self-compassion by meditating. It is too early to tell how self-compassion should be practiced by autistic adults. Research is needed to observe if self-compassion is helpful to autistic adults. We made a series of recommendations for researchers and clinicians. Researchers should first check if there is a relationship between self-compassion and mental health in autistic adults. If more self-compassion is associated with better mental health, then researchers and clinicians can try and find out how we can improve autistic people's self-compassion.How will these recommendations help autistic adults now or in the future?: We hope that our recommendations will start a conversation on the relevance of self-compassion for autistic adults and lead to the development of self-compassion-related research programs that involve autistic adults. The ultimate goal is to improve the mental health and psychological well-being of autistic adults in the future.

Gender Differences in Misdiagnosis and Delayed Diagnosis among Adults with Autism Spectrum Disorder with No Language or Intellectual Disability

Autism Spectrum Disorder (ASD) is often unrecognized, especially in mild forms and in women. Studies evaluating features associated with missed/misdiagnosis in men and women with ASD are warranted. 61 subjects (22 females, 39 males, age 28.5 ± 10.8 years) with ASD with no language/intellectual deficit were enrolled in the service for the treatment of psychiatric comorbidities in adults with ASD of the ASST Fatebenefratelli-Sacco in Milan (Italy). A detailed clinical history was gathered, and two self-report questionnaires (Autism Spectrum Quotient-AQ and Adult Autism Subthreshold Spectrum-AdAS Spectrum) were administered. 75.4% received their ASD diagnosis average eight years later than the first evaluation by mental health services. Compared to males, females showed a significantly greater delay in referral to mental health services and a significantly higher age at diagnosis of ASD. Among men, diagnostic delay inversely correlated with scores on the AdAS Spectrum total, Verbal communication, Empathy and Inflexibility and adherence to routine domains. Among women, diagnostic delay positively correlated with the Attention to detail score while the age at diagnosis of ASD positively correlated with the AdAS Spectrum Verbal communication and Restricted interests and rumination domain scores. Females were less likely to be correctly diagnosed and more likely to be misdiagnosed at first evaluation than men. Females reported significantly higher scores than men in the Hyper/Hyporeactivity to sensory input domain only among subjects who were misdiagnosed. Our findings provide gender-specific information about ASD patients seeking help for comorbid conditions and might be a primary ground for future research.

Self-harm and Mental Health Characteristics of Prisoners with elevated rates of autistic traits

BACKGROUND

Prevalence studies among prisoners have found rates of 1-4% for autism spectrum disorder (ASD) or autistic traits. However, little is known about those prisoners with high levels of autistic traits.

AIM

This aim of this study was to compare the mental health characteristics of prisoners with autistic traits with neurotypical prisoners not screening positive for neurodevelopmental disorders.

METHOD

The study recruited 240 male prisoners from a London prison and screened for autism spectrum disorder using the Autism Quotient (AQ) 20 and 10, and Autism Diagnostic Observation Schedule (ADOS). The Mini International Neuropsychiatric Interview was used to assess for depression, anxiety, self-harm behavior and suicide.

RESULTS

Screening using the AQ identified 46 prisoners with significant autistic traits, with 12 meeting the diagnostic threshold for ASD using the ADOS. Those screening positive with autistic traits were significantly more likely to have thought about self-harm and suicide in the past month than neurotypical prisoners and have a comorbid mental disorder. They were also significantly more likely to report having attempted suicide during their lifetime compared to neurotypical peers at a rate of 64.9 % compared to 11.6 % for the neurotypical prisoners.

CONCLUSION

Prisoners with elevated levels of autistic traits were more likely to report self-harm, suicidal thoughts and were more vulnerable to a range of mental disorders than neurotypical prisoners. There is a need for more evidence on the experience of autistic prisoners to inform how pathways should work to improve health outcomes through increased awareness and access to screening and subsequent diagnosis which currently prisons are currently not set up for.

Autism - A Comprehensive Array of Prominent Signs and Symptoms

BACKGROUND

Autism Spectrum Disorder (ASD) is a multifaceted neurodevelopmental condition characterized by multiple psychological and physiological impairments in young children. According to the recent reports, 1 out of every 58 newly-born children is suffering from autism. The aetiology of the disorder is complex and poorly understood, hindering the adaptation of targeted and effective therapies. There are no well- established diagnostic biomarkers for autism. Hence the analysis of symptoms by the pediatricians plays a critical role in the early intervention.

METHODS

In the present report, we have emphasized 24 behavioral, psychological and clinical symptoms of autism.

RESULTS

Impaired social interaction, restrictive and narrow interests, anxiety, depression; aggressive, repetitive, rigid and self-injurious behavior, lack of consistency, short attention span, fear, shyness and phobias, hypersensitivity and rapid mood alterations, high level of food and toy selectivity; inability to establish friendships or follow the instructions; fascination by round spinning objects and eating non-food materials are common psychological characteristics of autism. Speech or hearing impairments, poor cognitive function, gastrointestinal problems, weak immunity, disturbed sleep and circadian rhythms, weak motor neuromuscular interaction, lower level of serotonin and neurotransmitters, headache and body pain are common physiological symptoms.

CONCLUSION

A variable qualitative and quantitative impact of this wide range of symptoms is perceived in each autistic individual, making him/her distinct, incomparable and exceptional. Selection and application of highly personalized medical and psychological therapies are therefore recommended for the management and treatment of autism.

Prevalence and profile of depressive mixed state in patients with autism spectrum disorder

PURPOSE

The present study aimed to clarify prevalence and profile of depressive mixed state (DMX) in depressed individuals with autism spectrum disorder (ASD).

PATIENTS AND METHODS

The Quick Inventory of Depressive Symptomatology Self-Report Japanese version (QIDS-SR-J) and global assessment of functioning (GAF) were administered to 182 consecutive patients (36 ASD and 146 non-ASD subjects) with a major depressive episode (MDE). DMX was categorically diagnosed according to the criteria for mixed depression (MD) by Benazzi and mixed features (MF) specifier by DSM-5. Severity of DMX was assessed by the self-administered 12-item questionnaire for DMX (DMX-12). Clinical backgrounds and incidence/severity of DMX were compared between the ASD and non-ASD groups.

RESULTS

ASD patients showed higher prevalence of MD than non-ASD patients (36.1% versus 18.5%). Mood lability, distractibility, impulsivity, aggression, irritability, dysphoria and risk-taking behavior as mixed symptoms were more prevalent in ASD patients than those in non-ASD patients, together with higher scores of total DMX-12 and its disruptive emotion/behavior cluster. Multiple regression analysis revealed significant contribution of ASD to the disruptive emotion/behavior symptoms.

CONCLUSION

Careful monitoring and management of potential DMX are warranted in depressed ASD individuals.

Investigating the Relationship between Autistic Traits, Ruminative Thinking, and Suicidality in a Clinical Sample of Subjects with Bipolar Disorder and Borderline Personality Disorder

(1) Background: Previous literature reported in both subjects with Borderline personality disorder (BPD) and Bipolar disorder (BD) higher levels of autistic traits, linked to a greater suicidality risk. The aim of this study was to evaluate and compare the presence of autistic traits in a sample of individuals with BD or BPD, with a specific focus on suicidality. (2) Methods: We recruited two clinical samples of subjects (BPD and BD) and a control group without a diagnosis according to DSM-5 (CTL). Subjects were assessed with the AdAS Spectrum, the RRS and, for evaluating suicidality, the MOODS-SR. (3) Results: The CTL group showed significantly lower scores of both BD and BPD on AdAS Spectrum, RRS, and suicidality scores. BPD subjects showed significantly lower scores than BD ones in most of AdAS Spectrum domain scores. Correlation and regression analyses highlighted specific patterns of association among AdAS Spectrum domains, RRS, and suicidality in each clinical group. (4) Conclusions: Both BPD and BD individuals show greater levels of autistic traits, which seem to be distributed in a continuum featuring the highest levels among BD subjects. In both disorders, higher autistic traits were linked to suicidal tendencies, although with different patterns of association between BD and BPD subjects.

Autistic Traits Moderate Reappraisal Success for Depression and Anxiety Symptoms

Cognitive reappraisal is associated with reduced emotional distress; however, little is known about the nature of this relationship in autism. This study tested whether autistic traits moderate reappraisal success (i.e., the negative correlation between reappraisal use and emotional symptom severity). Emotional symptoms were assessed using measures of depression, anxiety, and stress. It was hypothesized that more severe autistic traits would be associated with weaker reappraisal success across all scales. Data were collected from 377 adults using an on-line survey. Structural equation models found moderation effects for depression and anxiety, but not stress. Contrary to hypotheses, more severe autistic traits were associated with stronger reappraisal success. These preliminary results support including reappraisal in emotion regulation treatments for individuals with autistic traits.

Autism spectrum in patients with schizophrenia: correlations with real-life functioning, resilience, and coping styles

BACKGROUND

Previous researches highlighted among patients with schizophrenia spectrum disorders (SSD) a significant presence of autistic traits, which seem to influence clinical and functional outcomes. The aim of this study was to further deepen the investigation, evaluating how patients with SSD with or without autistic traits may differ with respect to levels of functioning, self-esteem, resilience, and coping profiles.

METHODS

As part of the add-on autism spectrum study of the Italian Network for Research on Psychoses, 164 outpatients with schizophrenia (SCZ) were recruited at eight Italian University psychiatric clinics. Subjects were grouped depending on the presence of significant autistic traits according to the Adult Autism Subthreshold Spectrum (AdAS Spectrum) instrument ("AT group" vs "No AT group"). Other instruments employed were: Autism Spectrum Quotient (AQ), Specific Levels of Functioning (SLOF), Self-Esteem Rating scale (SERS), Resilience Scale for Adults (RSA), and brief-COPE.

RESULTS

The "AT group" reported significantly higher scores than the "No AT group" on SLOF activities of community living but significantly lower scores on work skills subscale. The same group scored significantly lower also on SERS total score and RSA perception of the self subscale. Higher scores were reported on COPE self-blame, use of emotional support and humor domains in the AT group. Several correlations were found between specific dimensions of the instruments.

CONCLUSION

Our findings suggest the presence of specific patterns of functioning, resilience, and coping abilities among SSD patients with autistic traits.

Suicidality: An Evolutionary Concept Analysis

Suicide is a preventable health problem. Multiple definitions and inconsistent use of the term suicidality can result in failure to properly recognize suicide risk and behavior and confuses suicide research. Clarification of the suicidality concept is needed to facilitate the care for individuals at risk for suicide. Using Rodgers' evolutionary concept analysis method, this analysis describes the breadth and scope of the suicidality concept. Findings indicate suicidality covers a spectrum of suicidal risk and levels of emotional suffering and intent. The analysis does not draw definite conclusions, but outlines a direction for further research.