Innovations In Clinical Neuroscience

MAR-APR 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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34 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 C A S E R E P O R T play with other children, and would make gestures to return back home. There were no symptoms suggestive of separation anxiety at home or at social situations. In school, he would not interact with teachers or classmates, he would sit alone, and he would not play with other children or show any interest in making friends. He would not share with his teachers or parents any positive experiences, nor would he report any negative experiences, even if he got injured. The teachers frequently reported communication problems they encountered with him, and he refused to participate in oral exams. At home, he preferred to play alone, preferring activities that required the least participation from others (e.g., he would play with puzzles or blocks). If his parents offered something new or special to his elder sister, he would not show any anger, emotional distress, or jealousy, seeming unconcerned. His eating, sleeping, and playing times were regular, and any deviation from his daily schedule would make him irritable. His school performance was below average. Continuing in this pattern, one year prior to presentation, without any apparent reason, the Patient A became disinterested school and began watching cartoons and or other programs with magical themes more frequently. The patient would become irritated if anyone tried to sit near him while he was watching television, preferring to watch alone, which was unlike his previous behavior. He would also lie in bed with his head covered under a blanket in the evening hours, offering no explanation. Additionally, he appeared self-absorbed and was often seen smiling to himself and doing odd gestures in the air. At times, he would go outside and make similar hand gestures pointing toward the sky, and when inside, would jump from one chair to other, saying he had great magic power, without any further elaboration. His irritability began to last throughout the day and he would become angry without provocation, destroying household articles. These symptoms continued to worsen, leading to the necessity of removing him from school. His self-care and appetite reduced. He would not sleep at night, seeming fearful, and would scream without any apparent reason. Additionally, he displayed signs of suspiciousness and fear when anyone would come into the home, and he would physically try to make them leave. At times, he appeared fearful and would cry without any apparent reason and be difficult to console. He would not allow his mother to leave him even for few minutes, even when going to the toilet, which was unlike his previous behavior. His interaction with his parents deteriorated. There was no history of seizures, fever, and head trauma. On a mental state examination, the patient did not initiate eye contact and was irritable. He was admitted to our child ward for observation. Hematological and routine biochemical, thyroid function, and serum calcium tests, as well as electroencephalogram and magnetic resonance imaging assessments, were normal. Urine examination for any abnormal metabolites was negative. Following admission, a diagnosis of atypical autism with unspecified psychosis as per International Classification of Diseases-10 (ICD-10) 8 was considered. He was treated with risperidone tablet 2.5mg/day, and his symptoms of fearfulness, suspiciousness, and irritability significantly improved within three weeks of inpatient stay. After he was stablized, nonpharmacologically applied behavior analysis (ABA) was performed in a systemic manner, and social skills training to improve communication and social interaction, speech therapy, and activity scheduling was initiated. Three attempts were made to assess intelligence quota (IQ) but were unsuccessful due to uncooperativeness of the patient. At Day 45, Patient A was discharged from our facility in a clinically stable state. He continued a regimen of risperidone 2.5mg/day and social skills training on an outpatient basis and eventually was able to return to school. He was still symptomatically stable at the 1.5-year follow-up visit, though he continued to struggle academically. DISCUSSION ASD is often difficult to diagnose unless a careful early childhood and developmental history is taken. In the case presented here, a diagnosis of atypical autism was given, despite our patient's signs of early developmental impairment that is often apparent in typical cases of autism. Unlike childhood autism, in our patient, there was insufficient demonstrable abnormalities in all three areas of psychopathology that are required for the diagnosis of autism (i.e., dysfunctional social interaction and communication skills [verbal and nonverbal] and restrictive, stereotyped, repetitive behavior), despite characteristic abnormalities in other areas, according to the ICD-10. 8 For example, our patient was able to communicate his needs to his parents and did not have any repetitive or stereotyped behavior. Psychosis in a child with symptoms of autism is difficult to diagnose because such individuals might not be able to report psychopathology. We also considered a differential diagnosis of childhood onset schizophrenia (COS). Presence of positive symptoms is a critical component of COS diagnosis. 9 There was no clear evidence of hallucinations in our patient, but there was evidence of delusions (as suggested by patient's report of magical powers), symptoms of fearfulness and suspiciousness, and episodes of excessive, unexplained irritability, screaming, and agitation. Studies have reported that about 27 percent of patients with COS often meet the criteria of ASD prior to the onset of psychosis, 10,11 and these children present with symptoms of brief and transient psychosis; episodes of emotional liability disproportionate to the stimuli; a lack interpersonal skills; cognitive deficits in processing information; and with no clear evidence of formal thought disorders. 12 Our case met many of the criteria for COS present, making this a possible differential diagnosis. The increased risk of association between psychosis and autism has been hypothesized in many ways. First, long-term avoidance of gaze and eye contact in children with autism can lead to lack of social development, 13 which can lead to underdevelopment of theory of mind. 14 These social cognition deficits can lead the individual to inaccurate inferences of mental states when aware of being looked at by others, which subsequently can lead to symptoms of paranoia and/or psychosis. 15 Second, neurobiological studies have found that amygdala has a significant role in mediating theory of mind skills in autism. 16–18 Similarly functional neuroimaging studies in schizophrenia have also demonstrated under-activation of amygdala compared to controls, in recognizing facial expression and emotions. 19–23 The under-activation of amygdala suggests reduced cognitive capability in individuals with ASD or schizophrenia. 24 Third, there is good evidence

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