Prevalence of Schizophrenia Spectrum Disorders in Average-IQ Adults with Autism Spectrum Disorders: A Meta-analysis

Autism-spectrum quotient mediates the relationship between clinical symptoms and quality of life in schizophrenia

BACKGROUND

Social dysfunctions can affect the quality of life (QOL) of patients with schizophrenia. The autism-spectrum quotient (AQ) is a widely used measure of innate autistic traits. However, in patients with schizophrenia, the score may represent the severity of autism-like social dysfunctions as a consequence of symptoms. We tested the hypothesis that AQ would mediate the relationship between clinical symptoms and QOL in patients with schizophrenia, based on the assumption that the AQ measures autism-like social dysfunctions rather than autistic traits in this population.

METHODS

We analyzed data from 108 outpatients with schizophrenia. The relationships among the scores on the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Quality of Life Scale (SQLS), and the AQ were examined using structural equation modeling (SEM).

RESULTS

Path analyses of the total scale scores revealed partial mediation, but not full mediation or independent effects. However, both the AQ and PANSS scores could be mediators. SEM including the three domain scores of PANSS, the two factors of the AQ, and the three subscale scores of the SQLS showed a good fit of the AQ mediation model, but not the symptom mediation model, supporting our hypothesis. In this final model, the relationship between negative symptoms and QOL was mediated by autism-like social dysfunctions, whereas positive symptoms directly affected QOL.

CONCLUSIONS

Our findings advance our understanding of what the AQ measures when applied to patients with schizophrenia and suggest that autism-like social dysfunctions are important treatment targets for improving QOL in this population.

Perceived changes in mental health and social engagement attributed to a single psychedelic experience in autistic adults: results from an online survey

RATIONALE

Anecdotal reports suggest that psychedelic drugs can improve psychological wellbeing and social engagement in autistic people. However, there are few contemporary studies on this topic.

OBJECTIVES

To examine autistic participants' experiences with psychedelic drugs and the extent to which they attributed changes in mental health and social engagement to their most 'impactful' psychedelic experience. We also explored associations between these changes and mechanistically important variables (e.g., aspects of the acute psychedelic experience and changes in 'psychological flexibility').

METHODS

Self-selecting autistic participants (n = 233) with high autism quotient scores completed an online survey relating to their most impactful psychedelic experience. Questionnaires assessed the acute psychedelic experience and perceived psychedelic-induced changes in distress, social engagement and psychological flexibility, among other relevant variables.

RESULTS

The majority of participants attributed reductions in psychological distress (82%) and social anxiety (78%) and increases in social engagement (70%) to their most 'impactful' psychedelic experience. A substantial minority (20%) also reported undesirable effects such as increases in anxiety with some describing their psychedelic experience as among the most negatively impactful experiences of their lives. The only substantial predictor of reductions in psychological distress was increased psychological flexibility.

CONCLUSION

Autistic people attributed changes in mental health and social engagement to a single highly impactful psychedelic experience. The results and their implications are discussed with caution considering the use of a non-experimental design and biased sampling.

Prenatal environmental risk factors for autism spectrum disorder and their potential mechanisms

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is globally increasing in prevalence. The rise of ASD can be partially attributed to diagnostic expansion and advocacy efforts; however, the interplay between genetic predisposition and modern environmental exposures is likely driving a true increase in incidence. A range of evidence indicates that prenatal exposures are critical. Infection during pregnancy, gestational diabetes, and maternal obesity are established risk factors for ASD. Emerging areas of research include the effects of maternal use of selective serotonin reuptake inhibitors, antibiotics, and exposure to toxicants during pregnancy on brain development and subsequent ASD. The underlying pathways of these risk factors remain uncertain, with varying levels of evidence implicating immune dysregulation, mitochondrial dysfunction, oxidative stress, gut microbiome alterations, and hormonal disruptions. This narrative review assesses the evidence of contributing prenatal environmental factors for ASD and associated mechanisms as potential targets for novel prevention strategies.

A general principle governing neuronal evolution reveals a human-accelerated neuron type potentially underlying the high prevalence of autism in humans

The remarkable ability of a single genome sequence to encode a diverse collection of distinct cell types, including the thousands of cell types found in the mammalian brain, is a key characteristic of multicellular life. While it has been observed that some cell types are far more evolutionarily conserved than others, the factors driving these differences in evolutionary rate remain unknown. Here, we hypothesized that highly abundant neuronal cell types may be under greater selective constraint than rarer neuronal types, leading to variation in their rates of evolution. To test this, we leveraged recently published cross-species single-nucleus RNA-sequencing datasets from three distinct regions of the mammalian neocortex. We found a strikingly consistent relationship where more abundant neuronal subtypes show greater gene expression conservation between species, which replicated across three independent datasets covering >106 neurons from six species. Based on this principle, we discovered that the most abundant type of neocortical neurons-layer 2/3 intratelencephalic excitatory neurons-has evolved exceptionally quickly in the human lineage compared to other apes. Surprisingly, this accelerated evolution was accompanied by the dramatic down-regulation of autism-associated genes, which was likely driven by polygenic positive selection specific to the human lineage. In sum, we introduce a general principle governing neuronal evolution and suggest that the exceptionally high prevalence of autism in humans may be a direct result of natural selection for lower expression of a suite of genes that conferred a fitness benefit to our ancestors while also rendering an abundant class of neurons more sensitive to perturbation.

An alpha 5-GABAA receptor positive allosteric modulator attenuates social and cognitive deficits without changing dopamine system hyperactivity in rats exposed to valproic acid in utero

Autism spectrum disorders (ASDs) are characterized by core behavioral symptoms in the domains of sociability, language/communication, and repetitive or stereotyped behaviors. Deficits in the prefrontal and hippocampal excitatory/inhibitory balance due to a functional loss of GABAergic interneurons are proposed to underlie these symptoms. Increasing the postsynaptic effects of GABA with compounds that selectively modulate GABAergic receptors could be a potential target for treating ASD symptoms. In addition, deficits in GABAergic interneurons have been linked to dopamine (DA) system dysregulation, and, despite conflicting evidence, abnormalities in the DA system activity may underly some ASD symptoms. Here, we investigated whether the positive allosteric modulator of α5-containing GABAA receptors (α5-GABAARs) SH-053-2'F-R-CH3 (10 mg/kg) attenuates behavioral abnormalities in rats exposed to valproic acid (VPA) in utero, an established risk factor for autism. We also evaluated if animals exposed to VPA in utero present changes in the ventral tegmental area (VTA) DA system activity using in vivo electrophysiology and if SH-053-2'F-R-CH3 could attenuate these changes. SH-053-2'F-R-CH3 was administered intraperitoneally 30 min before each behavioral test and electrophysiology. In utero VPA exposure caused male and female rats to present increased repetitive behavior (self-grooming) in early adolescence and deficits in social interaction in adulthood. Male, but not female VPA rats, also presented deficits in recognition memory as adults. SH-053-2'F-R-CH3 attenuated the impairments in sociability and cognitive function in male VPA-exposed rats without attenuating the decreased social interaction in females. Adult male and female VPA-exposed rats also showed an increased VTA DA neuron population activity, which was not changed by SH-053-2'F-R-CH3. Despite sex differences, our findings indicate that α5-GABAARs positive allosteric modulators may effectively attenuate some core ASD symptoms.

Beyond imagination: Sorting out and treating psychosis in the context of autism spectrum disorder

In the last decades, growing caseness for Autism Spectrum Disorder (ASD) has been observed, owing to the diagnostic accretion of low-impairment forms, over and above other possible causes. Unrecognized ASD is likely to be mislabeled as a psychotic disorder (PD), as people in the spectrum may show 'pseudopsychotic' symptoms, resembling both negative and positive symptoms. On the other hand, PDs are likely to be overlooked when they arise in people with ASD, due to the 'diagnostic overshadowing' of new-onset conditions by lifelong core autistic symptoms. The three available metanalyses on the occurrence of psychosis in adults with ASD convergently reported a rate of PDs that is at least ten times higher than in the general population. Therefore, the lack of literature addressing risk factors, outcomes, and treatment options for psychosis in the context of ASD is utterly concerning. The present review aims to summarize up-to-date knowledge of PDs with comorbid ASD in terms of clinical features, course, and treatment.

Schizophrenia in Autistic People with Intellectual Disabilities. Treatment and Interventions

Autistic people with intellectual disabilities appear to be at increased risk of schizophrenia. While current recommendations emphasize adapting interventions used for people with schizophrenia in general, few studies to date have investigated treatment of co-occurring schizophrenia in this specific population. To explore what interventions are provided to autistic people with intellectual disabilities and co-occurring schizophrenia in specialized mental health services, and to investigate whether changes in mental health symptoms and challenging behavior occurred during treatment. Using data from a longitudinal, national multicenter study, interventions provided to 26 autistic individuals with intellectual disabilities and co-occurring schizophrenia were explored. Symptoms were measured using the Psychopathology in Autism Checklist (PAC) and the Aberrant Behavior Checklist ABC) at referral (T1), at the end of treatment (T2), and at follow-up 12 months after T2 (T3). A broad range of interventions were provided to the participants, including inpatient admission, psychopharmacological treatment, various psychosocial interventions, and supportive interventions. Scores on the PAC and ABC were significantly lower at T2 than T1 for most scales, and no significant change was found from T2 to T3.Treatment of co-occurring schizophrenia appears feasible and effective in autistic people with intellectual disabilities.

Schizophrenia in autistic people with intellectual disabilities: Symptom manifestations and identification

BACKGROUND

The assessment of schizophrenia in autistic people with intellectual disabilities is challenging. This study aimed to explore the identification of schizophrenia in this population.

METHODS

Using data from a clinical multi-centre study, reported symptoms in 26 autistic individuals with intellectual disabilities diagnosed with co-occurring schizophrenia were explored. Scores on two checklists (Psychopathology in Autism Checklist [PAC], Aberrant Behaviour Checklist [ABC]) were compared with two comparison groups: autistic individuals with intellectual disabilities and other mental disorders (94), or no mental disorder (63).

RESULTS

Reported symptoms of schizophrenia in this population met the formal diagnostic criteria. For PAC/ABC scales, only PAC psychosis differed for the schizophrenia group. Among participants with schizophrenia, two were diagnosed with additional mental disorders. Elevated scores for anxiety and depression were common.

CONCLUSIONS

Emphasising core symptoms seems necessary when assessing co-occurring schizophrenia in autistic people with intellectual disabilities. The PAC may serve as a helpful screening tool.

An alpha 5-GABAa receptor positive allosteric modulator attenuates social and cognitive deficits without changing dopamine system hyperactivity in an animal model for autism

Autism Spectrum Disorders (ASD) are characterized by core behavioral symptoms in the domains of sociability, language/communication, and repetitive or stereotyped behaviors. Deficits in the prefrontal and hippocampal excitatory/inhibitory balance due to a functional loss of GABAergic interneurons are proposed to underlie these symptoms. Increasing the postsynaptic effects of GABA with compounds that selectively modulate GABAergic receptors could be a potential target for treating ASD symptoms. In addition, deficits in GABAergic interneurons have been linked to dopamine (DA) system dysregulation, and, despite conflicting evidence, abnormalities in the DA system activity may underly some ASD symptoms. Here, we investigated whether the positive allosteric modulator of α5-containing GABA A receptors (α5-GABA A Rs) SH-053-2'F-R-CH3 (10 mg/kg) attenuates behavioral abnormalities in a rat model for autism based on in utero VPA exposure. We also evaluated if animals exposed to VPA in utero present changes in the ventral tegmental area (VTA) DA system activity using in vivo electrophysiology and if SH-053-2'F-R-CH3 could attenuate these changes. In utero VPA exposure caused male and female rats to present increased repetitive behavior (self-grooming) in early adolescence and deficits in social interaction in adulthood. Male, but not female VPA rats, also presented deficits in recognition memory as adults. SH-053-2'F-R-CH3 attenuated the impairments in sociability and cognitive function in male VPA-exposed rats without attenuating the decreased social interaction in females. Male and female adult VPA-exposed rats also showed an increased VTA DA neuron population activity, which was not changed by SH-053-2'F-R-CH3. Despite sex differences, our findings indicate α5-GABA A Rs positive allosteric modulators may effectively attenuate some core ASD symptoms.

Methodological issues in social cognition research in autism spectrum disorder and schizophrenia spectrum disorder: a systematic review

Recent systematic reviews and meta-analyses conclude that similar social cognitive impairments are found in autism spectrum disorder (ASD) and schizophrenia spectrum disorder (SSD). While methodological issues have been mentioned as a limitation, no study has yet explored the magnitude of methodological heterogeneity across these studies and its potential impact for their conclusion. The purpose of this study was to systematically review studies comparing social cognitive impairments in ASD and SSD with a focus on methodology. Following the PRISMA guidelines, we searched all publications on PubMed, PsycINFO, and Embase. Of the 765 studies identified in our data base searches, 21 cross-sectional studies were included in the review. We found significant methodological heterogeneity across the studies. In the 21 studies, a total of 37 different measures of social cognition were used, 25 of which were only used in 1 study. Across studies, the same measure was often said to be assessing different constructs of social cognition - a confusion that seems to reflect the ambiguous definitions of what these measures test in the studies that introduced them. Moreover, inadequate differential diagnostic assessment of ASD samples was found in 81% of the studies, and sample characteristics were markedly varied. The ASD and SSD groups were also often unmatched in terms of medication usage and substance use disorder history. Future studies must address these methodological issues before a definite conclusion can be drawn about the potential similarity of social cognitive impairments in ASD and SSD.

The Autism Spectrum: Behavioral, Psychiatric and Genetic Associations

Autism spectrum disorder (ASD) consists of a group of heterogeneous genetic neurobehavioral disorders associated with developmental impairments in social communication skills and stereotypic, rigid or repetitive behaviors. We review common behavioral, psychiatric and genetic associations related to ASD. Autism affects about 2% of children with 4:1 male-to-female ratio and a heritability estimate between 70 and 90%. The etiology of ASD involves a complex interplay between inheritance and environmental factors influenced by epigenetics. Over 800 genes and dozens of genetic syndromes are associated with ASD. Novel gene–protein interactions with pathway and molecular function analyses have identified at least three functional pathways including chromatin modeling, Wnt, Notch and other signaling pathways and metabolic disturbances involving neuronal growth and dendritic spine profiles. An estimated 50% of individuals with ASD are diagnosed with chromosome deletions or duplications (e.g., 15q11.2, BP1-BP2, 16p11.2 and 15q13.3), identified syndromes (e.g., Williams, Phelan-McDermid and Shprintzen velocardiofacial) or single gene disorders. Behavioral and psychiatric conditions in autism impacted by genetics influence clinical evaluations, counseling, diagnoses, therapeutic interventions and treatment approaches. Pharmacogenetics testing is now possible to help guide the selection of psychotropic medications to treat challenging behaviors or co-occurring psychiatric conditions commonly seen in ASD. In this review of the autism spectrum disorder, behavioral, psychiatric and genetic observations and associations relevant to the evaluation and treatment of individuals with ASD are discussed.

Differences in daily life executive functioning between people with autism and people with schizophrenia

This is a comparative analysis of everyday executive functioning between individuals with Autism Spectrum Disorder (ASD), Schizophrenia Spectrum Disorders (SSD) and controls using Dysexecutive Questionnaire-Spanish (DEX-Sp), to identify patterns of difficulties. Also we assessed the relationship between EF and adaptive behavior as measured by the Vineland Adaptive Behavioral Scale-II. Common areas of everyday executive functions were established as problematic in individuals with ASD and SSD related to Disinhibition and Apathy, while Disorganization and Impulsivity was gravely affected in ASD group only. The degree of Dysexecutive Syndrome was predictive of adaptive behavior in ASD group only. These suggest that DEX-Sp could be a useful tool in differentiating areas of strength and weaknesses in clinical groups such as ASD and SDD.

Autism spectrum disorder and schizophrenia: An updated conceptual review

Autism spectrum disorder (ASD) and schizophrenia (SCZ) are separate disorders, with distinct clinical profiles and natural histories. ASD, typically diagnosed in childhood, is characterized by restricted or repetitive interests or behaviors and impaired social communication, and it tends to have a stable course. SCZ, typically diagnosed in adolescence or adulthood, is characterized by hallucinations and delusions, and tends to be associated with declining function. However, youth with ASD are three to six times more likely to develop SCZ than their neurotypical counterparts, and increasingly, research has shown that ASD and SCZ converge at several levels. We conducted a systematic review of studies since 2013 relevant to understanding this convergence, and present here a narrative synthesis of key findings, which we have organized into four broad categories: symptoms and behavior, perception and cognition, biomarkers, and genetic and environmental risk. We then discuss opportunities for future research into the phenomenology and neurobiology of overlap between ASD and SCZ. Understanding this overlap will allow for researchers, and eventually clinicians, to understand the factors that may make a child with ASD vulnerable to developing SCZ. LAY SUMMARY: Autism spectrum disorder and schizophrenia are distinct diagnoses, but people with autism and people with schizophrena share several characteristics. We review recent studies that have examined these areas of overlap, and discuss the kinds of studies we will need to better understand how these disorders are related. Understanding this will be important to help us identify which autistic children are at risk of developing schizophrenia.

Population-Based Psychiatric Comorbidity in Children and Adolescents With Autism Spectrum Disorder: A Meta-Analysis

Psychiatric comorbidity in autism spectrum disorder (ASD) is a subject of critical scientific importance, affecting the quality of life, prognosis, and functional outcomes. The prevalence of psychiatric disorders vary considerably according to variables such as index subject characteristics, study setting, sampling frame, diagnostic methods used, as well as country of geographic origin. To date, most studies comprise clinical or treatment referral samples in tertiary care or subjects enrolled in clinical trials and genetic cohort collections. Such samples carry the potential for overestimation of both the frequency and severity of psychiatric comorbidity. A systematic literature search was performed using PubMed and Web of Science databases restricted to population-based study publications in the English between May 1, 2015, and May 31, 2020. A comprehensive keyword list was generated to investigate co-occurrence of psychiatric disorders in children and adolescents with ASD. A wide range of DSM-5 based disorders such as anxiety, mood, ADHD, intellectual disability/intellectual developmental disorder, eating/feeding, gender dysphoria and sleep-wake disorders were assessed. Initial search revealed a total of 1674 articles after removal of duplicates. Two independent researchers conducted a parallel-blinded screening process to identify the eligible studies based on titles and abstracts; 39 studies were analyzed in the current review. The main findings show prevalence estimates of 22.9% (95% CI: 17.7- 29.2) for intellectual disability; 26.2% (22-31) for attention-deficit hyperactivity disorder; 11.1% (8.6-14.1) for anxiety disorders; 19.7% (11.9-30.7) for sleep disorders; 7% (5.2- 9.3) for disruptive disorders; 2% (1.3- 3.1) for bipolar disorders; 2.7% (1.8- 4.2) for depression; 1.8% (0.4-8.7) for obsessive-compulsive disorder; and 0.6% (0.3-1.1) for psychosis. Psychiatric comorbidity in population-based studies is lower than in clinical and referred samples. However, our results also indicate that the frequency of psychiatric comorbidity in children and adolescents with ASD in the population context is considerable, without the influence of referral bias implicit in clinical and treatment samples. There is a need for better targeted diagnostic tools to detect psychiatric comorbidity in children and youth in future population-based studies, as an essential component in providing care as well as new insights into the nature and mechanisms of its underlying associations.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234464].

Predictive waves in the autism-schizophrenia continuum: A novel biobehavioral model

The brain is a predictive machine. Converging data suggests a diametric predictive strategy from autism spectrum disorders (ASD) to schizophrenic spectrum disorders (SSD). Whereas perceptual inference in ASD is rigidly shaped by incoming sensory information, the SSD population is prone to overestimate the precision of their priors' models. Growing evidence considers brain oscillations pivotal biomarkers to understand how top-down predictions integrate bottom-up input. Starting from the conceptualization of ASD and SSD as oscillopathies, we introduce an integrated perspective that ascribes the maladjustments of the predictive mechanism to dysregulation of neural synchronization. According to this proposal, disturbances in the oscillatory profile do not allow the appropriate trade-off between descending predictive signal, overweighted in SSD, and ascending prediction errors, overweighted in ASD. These opposing imbalances both result in an ill-adapted reaction to external challenges. This approach offers a neuro-computational model capable of linking predictive coding theories with electrophysiological findings, aiming to increase knowledge on the neuronal foundations of the two spectra features and stimulate hypothesis-driven rehabilitation/research perspectives.

Behavioural equivalents of schizophrenia in people with intellectual disability and autism spectrum disorder. A selective review

Assessment of schizophrenia (SCZ) in people with autism spectrum disorder (ASD) is complicated due to confounding symptoms between ASD and SCZ. These confounding factors are aggravated when the patient has sparse verbal skills. A selective review was conducted to identify behavioural equivalents when assessing SCZ in individuals with ASD with sparse verbal skills, from 16 years of age. Only clinical papers were reviewed. Eight relevant articles were analysed for the use of behavioural equivalents in clinical settings. The results showed that especially disorganized speech and behaviour and negative symptoms can be observed in patients with SCZ and ASD who speak sparsely. It is not possible to observe delusions, but they may be reported by the patients when treated adequately for some time, usually months. Hallucinations cannot be observed directly, but 'hallucinatory behaviour' may be interpreted as hallucinations when observed concurrently with other SCZ symptoms. Additionally, age of onset and marked impaired global functioning compared to habitual functioning may constitute a diagnosis of SCZ in ASD. ASD is considered a lifelong condition and may be identified within the first 3-4 years, while SCZ onset is usually in adolescence or early adulthood.

Obstacles to diagnostic investigation of a child with comorbid psychiatric conditions

Presented here is the unique case of diagnostic investigation for a 16 year old male presenting in an acute state of apparent psychosis. The patient had a long history of previous specialist work-ups, tentative diagnoses, multiple emergency department admissions, and medication trials, all of which failed to produce significant lasting relief. While initial encounters diagnostically centered on autoimmune encephalitis, comprehensive work-ups always drove the differential towards a likely psychiatric disorder. Despite this consistent professional opinion, tentative diagnosis of schizophrenia with underlying Autism Spectrum Disorder was delayed for many years, due to a variety of complicating factors. Overall, this case highlights many different considerations that might assist in avoiding a protracted road to diagnosis, including navigating the obstacles that parental interaction with a complex healthcare system can pose during diagnostic evaluation and recommended treatment as well as, the role of re-interpreting past test results within the context of new literature, and the complexities of diagnosing comorbid psychiatric conditions.

The co-occurrence of autistic spectrum disorder and schizophrenia: A nationwide population-based study

Although the co-occurrence of autistic spectrum disorder (ASD) and schizophrenia have been previously reported, the scope and magnitude of this comorbidity across large samples have not been sufficiently established. This study was aimed to assess the co-occurrence between schizophrenia and ASD in a large dataset, and to examine its predominance across different age and sex groups. Schizophrenia patients and age and sex frequency controls (n = 49,334) were assessed for the prevalence of autism spectrum disorder. The sample was stratified by age and sex, and co-occurrence was assessed using univariate and multivariate logistic regressions. Results indicated that schizophrenia was associated with ASD (OR = 7.01, 95%CI 2.98-16.43, p < .0001) across all age groups aside from 50 to 70 years. This association was significant among male participants (OR = 11.69, 95%CI 3.59-38.01, p < .0001) but not among female participants (OR = 2.33, 95%CI 0.60-9.03, p = .21). These findings indicate a large overlap between schizophrenia and ASD, and point to the need to expand the understanding of the potential mediating mechanisms of this co-occurrence.

Subclinical schizotypal vs. autistic traits show overlapping and diametrically opposed facets in a non-clinical population

BACKGROUND

The overlap of autism spectrum disorder (ASD) and psychosis or schizophrenia spectrum disorders (SSD) has exposed problems central to conceptualising and understanding co-morbidity in psychiatric disorders.

METHODS

In the present study, we demonstrate that a deep phenotyping approach aids clarification of both overlapping and diametrically opposed features of ASD and SSD on the level of trait facets.

RESULTS

We first show overlap of negative and disorganised (but not positive) features of schizotypy with autistic traits in a sample of n = 376 German non-clinical subjects using multiple psychometric measures of schizotypy (MSS multidimensional schizotypy scale, OLIFE Oxford-Liverpool Inventory of Feelings and Experiences, and SPQ-B schizotypal personality questionnaire - brief) and the AQ autism spectrum quotient, with control measures for affective spectrum pathology (BDI). Findings were then replicated in a French-Swiss sample (n = 264) using MSS, OLIFE, AQ, and in addition the Community Assessment of Psychic Experiences (CAPE). Additional principal component analysis confirmed our finding of the co-existence of both overlapping (loss of function, social communication deficit, and negative schizotypy) as well as diametrically opposed features (AQ attention to detail, positive schizotypy) across the two spectra. Results were validated with Horn's parallel analyses, affirming two component solutions, and PCA using sample-specific, factor-analysis-derived schizotypy scores.

CONCLUSIONS

Providing a framework for multi-dimensional transdiagnostic characterisation of ASD vs. SSD phenotypes we point out overlapping vs. discriminating facets. In addition to the use of novel multidimensional schizotypy scales, it also shows transcultural consistency of findings, and highlights a particular role for the attention to detail AQ subscale.

Autism Spectrum Disorder in Early Intervention in Psychosis Services: Implementation and Findings of a 3-step Screening and Diagnostic Protocol

Evidence indicates that autism spectrum disorder (ASD) is underidentified in populations with psychosis, but that clinical presentations of comorbid ASD and psychosis (ASD-P) and specific treatment needs that may relate to this group are not well understood. In fact, recent studies of ASD in first-episode psychosis suggest that there may be a specific clinical presentation of ASD-P. In response, the Cambridgeshire and Peterborough Early Intervention in Psychosis (EIP) service in the UK implemented and evaluated a 3-step ASD screening and diagnostic protocol, using the Autism Spectrum Disorder in Adults Screening Questionnaire (ASDASQ), case note review, and the Autism Diagnostic Observation Schedule (ADOS-2) and the Childhood Autism Spectrum Test (CAST). As a quality improvement project, the evaluation aimed to (1) establish the prevalence of patients with ASD-P, (2) describe characteristics of the clinical presentation of ASD-P and compare them to those of patients suffering from psychosis but no ASD, and (3) determine any differences in treatment between psychosis patients with and without ASD. Notably, at least 9% of the EIP service caseload met the criteria for a diagnosis of ASD-P, with half identified via the implementation of this protocol. The patients with ASD-P had specific clinical presentations and treatment needs that differed from those of patients with psychosis but no ASD. Thus, the findings from this study supported existing evidence concerning the underdetection of ASD in EIP populations. Our findings also added to emerging evidence for a clinical presentation of ASD-P with specific treatment needs. Our protocol has now been established as routine practice, and its implementation has improved the detection and treatment of patients with ASD-P within our EIP service.

Suicidal Ideation and Suicidal Attempts in Referred Adolescents with High Functioning Autism Spectrum Disorder and Comorbid Bipolar Disorder: A Pilot Study

Suicidal ideation and attempts in adolescents are closely associated to bipolar disorders (BD). Growing evidence also suggests that high functioning autism spectrum disorders (HF-ASD) are at increased risk for suicidal ideation and behaviors. Although BD and HF-ASD are frequently comorbid, no studies explored suicidality in these individuals. This exploratory study addressed this issue in a clinical group of inpatient adolescents referred to a psychiatric emergency unit. Seventeen adolescents with BD and HF-ASD and severe suicidal ideation or attempts (BD-ASD-S), were compared to 17 adolescents with BD and HF-ASD without suicidal ideation or attempts (BD-ASD-noS), and to 18 adolescents with BD and suicidal ideation or attempts without ASD (BD-noASD-S), using a structured assessment methodology. Individuals with BD-ASD-S had a higher intelligence quotient, more severe clinical impairment, more lethality in suicide attempts, more internalizing symptoms, less impulsiveness, and lower social competence. Severity of ASD traits in individuals and parents did not correlate with suicidal risk. Some dimensions of resilience were protective in terms of repulsion by life and attraction to death. Main limitations are the small sample size, the lack of a control group of typically developing adolescents. However, a better understanding of the specificities of bipolar HF-ASD individuals with suicidality may improve prevention and treatment strategies.

Neuroimaging Heterogeneity in Psychosis: Neurobiological Underpinnings and Opportunities for Prognostic and Therapeutic Innovation

Heterogeneity in symptom presentation, outcomes, and treatment response has long been problematic for researchers aiming to identify biological markers of schizophrenia or psychosis. However, there is increasing recognition that there may likely be no such general illness markers, which is consistent with the notion of a group of schizophrenia(s) that may have both shared and unique neurobiological pathways. Instead, strategies aiming to capitalize on or leverage such heterogeneity may help uncover neurobiological pathways that may then be used to stratify groups of patients for prognostic purposes or for therapeutic trials. A shift toward larger sample sizes with adequate statistical power to overcome small effect sizes and disentangle the shared variance among different brain-imaging or behavioral variables has become a priority for the field. In addition, recognition that two individuals with the same clinical diagnosis may be more different from each other (at brain, genetic, and behavioral levels) than from another individual in a different disorder or nonclinical control group-coupled with computational advances-has catapulted data-driven efforts forward. Emerging challenges for this new approach include longitudinal stability of new subgroups, demonstration of validity, and replicability. The "litmus test" will be whether computational approaches that are successfully identifying groups of patients who share features in common, more than current DSM diagnostic constructs, also provide better prognostic accuracy over time and in addition lead to enhancements in treatment response and outcomes. These are the factors that matter most to patients, families, providers, and payers.

Self-Reported Autistic Traits Using the AQ: A Comparison between Individuals with ASD, Psychosis, and Non-Clinical Controls

The term "autism" was originally coined by Eugen Bleuler to describe one of the core symptoms of schizophrenia. Even if autism spectrum disorder (ASD) and schizophrenia spectrum disorders (SSD) are now considered two distinct conditions, they share some clinical features. The present study aimed to investigate self-reported autistic traits in individuals with ASD, SSD, and non-clinical controls (NCC), using the Autism-Spectrum Quotient (AQ), a 50-item questionnaire. The study was conducted in the Psychiatry Unit of Policlinico "G. Rodolico", Catania, Italy. The AQ was administered to 35 adults with ASD, 64 with SSD, and 198 NCC. Overall, our data showed that the ASD sample scored significantly higher than NCC. However, no significant differences were detected between individuals with ASD and SSD. Notably, the three groups scored similarly in the subscale "attention to detail". AQ showed good accuracy in differentiating ASD from NCC (AUC = 0.84), while discriminant ability was poor in the clinical sample (AUC = 0.63). Finally, AQ did not correlate with clinician-rated ADOS-2 scores in the ASD sample. Our study confirms that symptoms are partially overlapping in adults with ASD and psychosis. Moreover, they raise concerns regarding the usefulness of AQ as a screening tool in clinical populations.

Prevalence of comorbid psychiatric disorders among people with autism spectrum disorder: An umbrella review of systematic reviews and meta-analyses

With ever-increasing prevalence of various mental disorders worldwide, a comprehensive evaluation of the prevalence of co-occurring psychiatric disorders among individuals with autism spectrum disorder (ASD) is needed to strengthen the knowledge base. This umbrella review aims to summarize the current evidence on the prevalence of comorbid psychiatric disorders among people with ASD. A systematic search of 12 major databases and additional sources was conducted. Any systematically conducted narrative, qualitative, or meta-analytic review reporting the prevalence of psychiatric disorders among people with ASD with no age or geographical restriction were included. From a total of 2755 records, 26 articles representing 14 systematic reviews and 12 meta-analyses met the criteria of this review. The synthesized findings reveal a high burden of comorbid psychiatric disorders among people with ASD, including anxiety disorders, depressive disorders, bipolar and mood disorders, schizophrenia spectrum, suicidal behavior disorders, attention-deficit/hyperactivity disorder, disruptive, impulse-control and conduct disorders amongst diverse age groups, with a majority in younger participants. Most studies were conducted in developed nations, with limited evidence from low and middle-income countries. These synthesized findings provide high-quality evidence for clinical and policy-level decision-making from a global overview of the status of comorbid psychiatric disorders among people with ASD.

Prevalence and outcomes of young people with concurrent autism spectrum disorder and first episode of psychosis

BACKGROUND

The intersect and blurring of boundaries between schizophrenia spectrum disorders and autism spectrum disorder (ASD) has long been an area of confusion, in both nosology and clinical practice. Individuals with a comorbid presentation of the two spectra can present with a distinct phenomenological profile to those with psychosis or ASD alone.

AIMS

To examine the prevalence rates of ASD in a cohort of young people presenting with a first episode of psychosis (FEP) and compare the demographic and clinical characteristics and functional outcomes between individuals with concurrent FEP and ASD, and individuals with FEP only.

METHODS

Young people aged 15 to 24 who presented with FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1st January 2011 and 31st December 2013 were included in the study.

RESULTS

Of the 544 individuals presenting with a FEP, 3.7% (N = 20) had a diagnosis of ASD. Individuals with a concurrent diagnosis of FEP and ASD were more likely to be male and less likely to have comorbid substance use issues. There was no difference found in the severity of psychotic symptoms or diagnoses between groups. Those with FEP and ASD were more likely to experience impairments in interpersonal skills and be more likely to be engaged in employment or education at time of discharge from service.

CONCLUSIONS

Individuals with concurrent FEP and ASD can present with distinct clinical characteristics that require specialised assessment and treatment. Further large-scale studies with control groups could help to better understand the phenomenological specificity of this subgroup.

Machine Learning for Differential Diagnosis Between Clinical Conditions With Social Difficulty: Autism Spectrum Disorder, Early Psychosis, and Social Anxiety Disorder

Differential diagnosis in adult cohorts with social difficulty is confounded by comorbid mental health conditions, common etiologies, and shared phenotypes. Identifying shared and discriminating profiles can facilitate intervention and remediation strategies. The objective of the study was to identify salient features of a composite test battery of cognitive and mood measures using a machine learning paradigm in clinical cohorts with social interaction difficulties. We recruited clinical participants who met standardized diagnostic criteria for autism spectrum disorder (ASD: n = 62), early psychosis (EP: n = 48), or social anxiety disorder (SAD: N = 83) and compared them with a neurotypical comparison group (TYP: N = 43). Using five machine-learning algorithms and repeated cross-validation, we trained and tested classification models using measures of cognitive and executive function, lower- and higher-order social cognition and mood severity. Performance metrics were the area under the curve (AUC) and Brier Scores. Sixteen features successfully differentiated between the groups. The control versus social impairment cohorts (ASD, EP, SAD) were differentiated by social cognition, visuospatial memory and mood measures. Importantly, a distinct profile cluster drawn from social cognition, visual learning, executive function and mood, distinguished the neurodevelopmental cohort (EP and ASD) from the SAD group. The mean AUC range was between 0.891 and 0.916 for social impairment versus control cohorts and, 0.729 to 0.781 for SAD vs neurodevelopmental cohorts. This is the first study that compares an extensive battery of neuropsychological and self-report measures using a machine learning protocol in clinical and neurodevelopmental cohorts characterized by social impairment. Findings are relevant for diagnostic, intervention and remediation strategies for these groups.

Lifetime and Momentary Psychotic Experiences in Adult Males and Females With an Autism Spectrum Disorder

BACKGROUND

Existing research shows that adults with an autism spectrum disorder (ASD) are more vulnerable to develop overt psychosis. However, studies investigating (subclinical) psychotic experiences (PE) in ASD are scarce, and it is unknown if PE are accompanied with more distress in adults with ASD compared to the general population. This study examined lifetime PE and accompanying distress, momentary PE levels, and the impact of daily life stress and negative affect (NA) on momentary PE in males and females with ASD compared to controls.

METHODS

In 50 adults with ASD (males N= 26, females N= 24) and 51 adults without ASD (males N= 26, females N= 25), the Community Assessment of Psychic Experiences (CAPE) was used to analyze group differences in frequency and distress of lifetime subclinical positive, negative, and depressive symptoms. The Experience Sampling Method (ESM) was used to measure momentary PE, NA, and stress (activity-related, event-related, and social stress) for 10 days. Multilevel analyses were conducted to test whether stress and NA were associated with momentary PE and whether these associations were modified by group or sex.

RESULTS

Adults with ASD reported more lifetime CAPE negative and depressive symptoms, but similar levels of PE, than controls. Higher levels of accompanying distress were found in participants with ASD for each subscale. With respect to ESM momentary PE, higher levels were reported by adults with ASD and a stronger association between event-related stress and momentary PE was found compared to controls. This was not the case for NA, activity-related, and social stress. Overall, no significant differences between male and female outcomes were found.

CONCLUSION

Adults with ASD are more prone to encounter lifetime subclinical negative and depressive symptoms and accompanying distress compared to adults without ASD. Similar levels of lifetime PE in both groups were still accompanied with more distress in the ASD group. Furthermore, higher levels of ESM momentary PE were found in participants with ASD. Additionally, event-related stress may act as a risk factor for PE in both females and males with ASD, with a stronger risk-increasing effect than in their control counterparts.

Two Sides of the Same Coin: A Case Report of First-Episode Catatonic Syndrome in a High-Functioning Autism Patient

Background: Catatonic phenomena such as stupor, mutism, stereotypy, echolalia, echopraxia, affective flattening, psychomotor deficits, and social withdrawal are characteristic symptoms of both schizophrenia and autism spectrum disorders (ASD), suggesting overlapping pathophysiological similarities such as altered glutamatergic and dopaminergic synaptic transmission and common genetic mutations. In daily clinical practice, ASD can be masked by manifest catatonic or psychotic symptoms and represent a diagnostic challenge, especially in patients with unknown or empty medical history. Unclear diagnosis is one of the main factors for delayed treatment. However, we are still missing diagnostic recommendations when dealing with ASD patients suffering from catatonic syndrome. Case presentation: A 31-year-old male patient without history of psychiatric disease presented with a severe catatonic syndrome and was admitted to our closed psychiatric ward. After the treatment with high-dose lorazepam and intramuscular olanzapine, catatonic symptoms largely remitted, but autistic traits persisted. Following a detailed anamnesis and a thorough neuropsychological testing, we diagnosed the patient with high-functioning autism and catatonic schizophrenia. The patient was discharged in a remitted state with long-acting injectable olanzapine. Conclusion: This case represents an example of diagnostic and therapeutic challenges of catatonic schizophrenia in high-functioning autism due to clinical and neurobiological overlaps of these conditions. We discuss clinical features together with pathophysiological concepts of both conditions. Furthermore, we tackle social and legal hurdles in Germany that naturally arise in these patients. Finally, we present diagnostic "red flags" that can be used to rationally select and conduct current recommended diagnostic assessments if there is a suspicion of ASD in patients with catatonic syndrome in order to provide them with the most appropriate treatment.