Innovations In Clinical Neuroscience

MAR-APR 2018

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

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35 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 C A S E R E P O R T regarding the hypo-activation in the mirror neuron systems in ASD, which is usually associated with mentalistic cognition and identification of cognitive and emotional resonance during social interactions. 25 Recent studies on the mirror-neuron system underlying facial perception and emotional resonance in schizophrenia have also demonstrated dysregulation in the context of emotion inappropriate to social context and flat affect. 26–28 These findings suggest that deficits in the mirror neuron system in ASD could progress to develop psychotic symptoms. A recent review article documented evidence from several retrospective studies (conducted on patients with schizophrenia) and from longitudinal studies of children with ASD and onset of psychosis later in life and suggested that is a link between ASD and the psychosis spectrum disorders". 29 This further broadens the concept that psychosis can develop in individuals with ASD, from both biological and clinical perspectives. With regard to symptom overlap between ASD and schizophrenia, the negative symptoms of schizophrenia, such as affective flattening, alogia, avolition, apathy, anhedonia, and poor communication, are observed as components of social interaction impairments in individuals with ASD, more particularly among those with high functioning ASD (previously referred to as Asperger's syndrome). 3 These symptoms are assessed thoroughly in adolescence, but it is often too difficult to assess the symptoms in late childhood—as in our case. Obtaining a clear history of early development and overall longitudinal course of illness, including recent changes in symptom characteristics, are needed before making a diagnosis. 30 Accurate and prompt identification of psychosis in ASD is important to ensure proper treatment. Brief reactive psychosis or acute and transient psychosis should be part of the differential diagnostic exercise as there is evidence of these in individuals with ASD in the context of increased stress and anxiety. Psychosis might be diagnosed in individuals with ASD if certain problematic behaviors occur in response to a disrupted routine, but these usually resolve without the need for medication and with the introduction of a structured routine. 31 In our case, the psychotic symptoms were not brief, they did not resolve quickly, and they did not appear to be related to a disrupted routine. The symptoms resolved with antipsychotic medication (risperidone) after three weeks. Risperidone was chosen because it is one of the FDA-approved medications for disruption and irritability in children with ASD. The only other FDA- approved antipsychotic medication for children with autism is aripiprazole. 32,33 IQ testing should be attempted in all children with ASD once they become cooperative or should be attempted once psychosis has stabilized. In our case, working with the parents, particularly the mother, on how to properly use behavioral interventions helped the patient long term. CONCLUSION In cases of childhood psychosis, the clinician should maintain a high suspicion of COS. In cases of ASD, a careful and detailed history of early development and course of illness should be obtained to identify or rule out any symptoms of psychosis, as there is a strong link between schizophrenia and ASD. Distinguishing symptoms of psychosis from other symptoms of ASD is critical for optimal treatment in this challenging group of pediatric patients. REFERENCES 1. Kraepelin E. Psychiatrie. 8 Auflage Leipzig, Austria: Barth; 1909. English translation and adaptation by Barclay RM, Robertson GM. Dementia Praecox and Paraphrenia. Huntington, NY: Krieger Publishing; 1971. 2. Bleuler E. Lehrbuch der Psychiatrie. Berlin, Germany: Springer Verlag; 1920. English translation: Textbook of Psychiatry. New York, NY: Arno Press;1976. 3. Raja M, Azzoni A. Autistic spectrum disorders and schizophrenia in the adult psychiatric setting: diagnosis and comorbidity. Psychiatr Danub. 2010;22:514–21. 4. Cashin A. Autism spectrum disorder and psychosis: a case study. J Child Adolesc Psychiatr Nurs. 2016;29:72–8. 5. Crespi B, Badcock C. Psychosis and autism as diametrical disorders of the social brain. Behav Brain Sci. 2008;31:241–61. 6. Kyriakopoulos M, Stringaris A, Manolesou S, et al. Determination of psychosis-related clinical profiles in children with autism spectrum disorders using latent class analysis. Eur Child Adolesc Psychiatry. 2015;24:301–7. 7. Bevan Jones R, Thapar A, Lewis G, Zammit S. The association between early autistic traits and psychotic experiences in adolescence. Schizophr Res. 2012;135:164–9. 8. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992. 9. Starling J, Williams LM, Hainsworth C, Harris AW. The presentation of early-onset psychotic disorders. Aust N Z J Psychiatry. 2013;47(1):43– 50. 10. Rapoport J, Chavez A, Greenstein D, et al. Autism spectrum disorders and childhood- onset schizophrenia: clinical and biological contributions to a relation revisited. J Am Acad Child Adolesc Psychiatry. 2009;48:10–8. 11. King BH, Lord C. Is schizophrenia on the autism spectrum? Brain Res. 2011;1380:34–41. 12. Driver DI, Gogtay N, Rapoport JL. Childhood onset schizophrenia and early onset schizophrenia spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2013;22:539–55. 13. Barak B, Feng G. Neurobiology of social behavior abnormalities in autism and Williams syndrome. Nat Neurosci. 2016;19:647–55. 14. Baron-Cohen S. The extreme male brain theory of autism. Trends Cogn Sci. 2002;6:248–54. 15. Rijn S van, Swaab H, Aleman A. Psychosis and autism as two developmental windows on a disordered social brain. Behav Brain Sci. 2008;31:280–1. 16. Castelli F, Happé F, Frith U,et al. Movement and mind: a functional imaging study of perception and interpretation of complex intentional movement patterns. Neuroimage. 2000;12(3):314–25. 17. Nacewicz BM, Dalton KM, Johnstone T, et al. Amygdala volume and nonverbal social impairment in adolescent and adult males with autism. Arch Gen Psychiatry. 2006;63(12): 1417–1428. 18. Castelli F, Frith C, Happé F, et al. Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain. 2002;125(Pt 8):1839–1849. 19. Ashwin C, Baron-Cohen S, Wheelwright S, et al. Differential activation of the amygdala and the "social brain" during fearful face-processing in Asperger syndrome. Neuropsychologia. 2007;45(1):2–14. 20. Baron-Cohen S, Ring HA, Wheelwright S, et al. Social intelligence in the normal and autistic brain: an fMRI study. Eur J Neurosci.

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