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.

The effects of lockdown of work and activities for adults with multiple, complex needs including sensory impairments during the pandemic in 2020.

Sheltered work and leisure activities were locked down in at the Signo centre in March 2020 because of the COVID-19 pandemic. The Signo centre is a Norwegian national centre for adults with multiple, complex needs, including severe sensory loss/impairments. Tension and uncertainty rapidly spread among relatives and workers. To explore the impacts of the pandemic on residents, 24 adults living in Signo Vivo answered a semi-structured interview together with their primary worker. Additionally, reports on staff injuries and PRN medication between April and Aug of 2020 were compared to the period before the lockdown. The reports from the interviews included fewer stressful events for the participants, more rest and sleep, more time spent in their own apartments, and more time with smaller groups of workers. The reports on staff injuries and PRN medication showed decreased occurrence.

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.

Case study: identification of anxiety and subsequent intervention in an adolescent male with autism, severe intellectual disability and self-injurious behaviour.

Introduction: Anxiety disorders are highly prevalent in individuals with autism spectrum disorder (ASD), but knowledge is limited regarding identification and treatment of these disorders in individuals with ASD and more severe levels of intellectual disability (ID). The current case study aims to explore and describe the inpatient, psychiatric assessment in an adolescent male with ASD, severe ID and self-injurious behaviour (SIB) who was diagnosed with a co-occurring anxiety disorder. The study further aims to explore the implications of this diagnosis for subsequent intervention and care, including management of SIB. Materials and methods: Case study including multimodal, psychiatric assessment and subsequent intervention. Results: Following changes in care strategies attempting to incorporate the understanding of anxiety/trauma as contributing to SIB, a reduction of SIB was observed, and this reduced frequency was maintained when the patient was discharged from the inpatient setting. Conclusions: Though no causal inferences are possible, these experiences indicate that further research is needed regarding possible associations between SIB and anxiety in individuals with ASD, including implications for treatment. Experiences from the current case further indicate that it is possible to recognize and diagnose anxiety disorder in complex cases involving ASD, severe ID, limited verbal language skills, and severe SIB.

Experiences of ward atmosphere in inpatients with intellectual disability and mental illness: clinical implications for mental health nursing.

Background: Patients with intellectual disability in psychiatric services are rarely asked about their experiences when admitted to inpatient units. Aim: To enhance the understanding of ward atmosphere for inpatients with co-occurring intellectual disabilities (ID) and mental illness by exploring patients' experiences from a specialised mental health inpatient unit. Methods: A selected sample of 10 adults with comorbid mental illness and ID were recruited for a qualitative interview study based on Gunderson's conceptualisation of therapeutic components in mental health wards. The patients were interviewed by two experienced clinicians and interviews were analysed using directed content analysis. Results: Patients' experience of their relationships with ward staff seemed central to their experiences of several aspects of mental health nursing. Feeling safe, contained, and validated, were further important aspects. However, the patients seemed to have little influence on treatment choices and did not report participating in shared decision-making. Conclusions: The patients' answers in this study are in line with previous research on ward atmosphere for patients in the general population. However, more research is necessary to inform future mental health nursing for patients with ID, both in inpatient and ambulatory services.

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.

Psychosocial treatment of major depression in people with intellectual disabilities. Improvements within the last four decades: points of view.

Abstract Psychosocial treatments like psychotherapy and group therapy are common for the treatment of depression in the general population. Depression in people with intellectual disability presents challenges, because people with intellectual disability often cannot consent to various treatments, clinicians and family members must be involved and use their best judgment. A selected review was conducted to highlight the progress in psychosocial treatment of depression within the last four decades. The main search terms were intellectual disability (ID), depression, and treatment. Nine articles were chosen; and included cognitive behaviour therapy (CBT), computer-assisted CBT, mindfulness-based cognitive therapy (MBCT), exercise therapy, behaviour activation, self-help intervention, dialectal behaviour therapy (DBT), and psychodynamic/psychoanalytical therapy. There were no articles on mental health nursing. Adaptions included smaller groups (in group intervention), visual material, simplifying of concepts, longer duration/more sessions, more practical help, more repetitions when learning new skills, more guiding, professional caregiver/family involvement, and individual support within group interventions.

"If we do not look for it, we do not see it": Clinicians' experiences and understanding of identifying post-traumatic stress disorder in adults with autism and intellectual disability.

BACKGROUND: Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) are at increased risk of potentially traumatic events and may be at increased risk of post-traumatic stress disorder (PTSD). However, knowledge regarding identification of PTSD in this population is limited. The aim of this study was to investigate clinical experience regarding PTSD and trauma assessment in individuals with co-occurring ASD and ID. METHOD: Interpretative phenomenological analysis was used to explore experiences of identifying PTSD in this population among 18 mental health clinicians working with ASD and ID. RESULTS: Informants viewed PTSD in individuals with ASD and ID as equivalent to PTSD in the general population, but with causes and expressions potentially differing. Several factors were described to contribute to challenges in identification. CONCLUSIONS: Trauma may have severe impact in individuals with ASD and ID. Multidimensional, individualized assessment strategies seem necessary to recognize PTSD or trauma-related symptoms in this population.

A 22q13.33 duplication harbouring the SHANK3 gene: does it cause neuropsychiatric disorders?

A young man with neuropsychiatric problems has a small 22q13.33 duplication. We suggest this causes his condition. His disorder may represent a 22q13.33 behavioural phenotype. In childhood, he was diagnosed with mild intellectual disability. He was later diagnosed with Tourette syndrome, atypical autism spectrum disorder and bipolar disorder. Lithium seems effective in treating his affective symptoms. He has mild dysmorphic features, full lips and protruding ears. An array comparative genomic hybridisation showed a 300 kb duplication. The duplication harbours several genes, notably SH3 and multiple ankyrin repeat domain 3 (SHANK 3). The small size helps focus on a critical region for a 22q13.33 duplication syndrome. Mutations, deletions and duplications should be kept in mind as causes of neuropsychiatric disorders, especially in a patient with dysmorphic traits.

Specialized psychiatric services: patient characteristics, referral practice and length of stay in a representative clinical sample 2010-2016.

BACKGROUND: Mental health services for patients intellectual disabilities (ID) and additional mental illnesses are only sparsely studied. OBJECTIVE: The objective was to describe a representative sample of patients with ID in a specialized psychiatric department. METHODS: Data were collected from case files in a 7-year period. Of 143 invited patients, 133 participated. RESULTS: More than 60% were admitted involuntarily. Schizophrenia was found in 30.1%, mood disorder in 25.6%, and anxiety disorders in 15.8%, Obsessive Compulsive Disorder (OCD) in 8.4% and Post Traumatic Stress Disorder (PSTD) in 12.9%, PD in 14.3%, and ADHD in 12%. Average waiting time was 6.1 months. Length of stay was 9.1 months for the inpatients. CONCLUSION: Services for patients with ID appear to still be reliant on inpatient units for at least a proportion of their patients. More research is needed to find out why this is. The results raise questions about referring, compliance between psychiatric diagnosis, and interventions.

The Use of Validation in Mental Health Nursing for Adults with Intellectual Disabilities and Mental Illness: A Descriptive Study.

Mental health nursing for adults with intellectual disabilities and mental illness is understudied. The aim of this study was to investigate the use of validation in mental health nursing for patients with intellectual disabilities and additional mental illness in a specialised psychiatric inpatient setting. Ten nurses/social educators and four individual therapists described the use of validation; each provided three vignettes with clinical examples. The clinical examples support the view that interventions developed for patients in the general population are feasible also for patients with intellectual disabilities. Clinical implications relate to the use of validation as an important factor in mental health nursing for adults with intellectual disabilities. Skills required include being capable of interpreting behavioural equivalents of mental illness symptoms, responding adequately to unusual utterances, and occasionally communicating in a predominantly non-verbal way.

Patients', Family Members', and Professional Carers' Experiences of Psychoeducational Multifamily Groups for Participants with Intellectual Disabilities and Mental Illness.

There is a dearth of articles addressing psychoeducational multifamily groups for adults with intellectual disabilities. The objective of this study is to investigate the participants' experiences of being part of a group like this. The group intervention had been slightly modified due to the participants' intellectual disabilities. Four patients, their close relatives, and community professional caregivers were interviewed using a semi-structured scheme. The four patients had participated in different groups. Three of them had autism spectrum disorder in addition to intellectual disabilities and mental illness. None of the patients were in the most acute phase during the group intervention. Topics discussed in the group sessions encompassed friendship, personal economy, hygiene, understanding of mental illness, and the need for help. A basic meal was served at every group meeting. The experiences were favorable.

Metyrosine treatment in a woman with chromosome 22q11.2 deletion syndrome and psychosis: a case study.

Background: People with 22q11.2 deletion syndrome (DS) are assumed to be especially vulnerable to developing mental illness such as psychosis. Aim: The study was established to contribute to knowledge about metyrosine medication in patients with 22q11.2 DS and psychosis. Methods: A case study was established including a woman with intellectual disability, 22q11.2 DS, and psychosis. Metyrosine medication was implemented, as conventional anti-psychotic medication was unsuccessful. Results: Effect of metyrosine medication included both psychotic symptom relief with decreased aggressive behaviour. Adjunctive milieu therapy contributed to complience. Conclusion: For patients with 22q11.2 DS and psychosis, metyrosine medication may prove effective. However, there are significant ethical dilemmas related to metyrosine medication for psychotic symptoms.

Mental Health Nursing of Adults With Intellectual Disabilities and Mental Illness: A Review of Empirical Studies 1994-2013.

Mental health nursing for adults with intellectual disabilities and mental illness is underresearched. The aim of this review is to summarize empirical mental health nursing studies including adults with intellectual disabilities and additional mental illness. Out of 137 hits, 16 articles were reviewed in full text. Thirteen of the articles presented modified nursing interventions. Three articles discussed training and education. The main finding is that mental health nursing interventions in patients with intellectual disabilities and additional mental illness are in line with mental health nursing for the general population. There are still not many publications on empirical studies concerning mental health nursing for adults with intellectual disabilities. Clinical implications are primarily related to the need for facilitated nurse-patient communication adjusted to the patients' cognitive levels. Insights drawn from this review illuminate the importance of mental health nursing interventions adjusting to the particular patients' symptoms, instead of targeting behavior change. The findings underpin factors found to have a positive impact on patients with mental illness in the general population as relevant topics for future research.