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Running head: PRESENTATION OF DEPRESSION AND ANXIETY

Presentation of Depression and Anxiety Disorders in Autism and Asperger Syndrome and their Diagnostic Difficulties David G. Flynn Old Dominion University Literature Review Abstract The sometimes subtle presentation of depression and various anxiety disorders in persons with Asperger Syndrome (AS) and autism makes diagnosis more difficult and presents the clinician with diagnostic challenges. The typicalities of presentation of those on the autistic spectrum can commonly mask the traditional symptoms of depression and anxiety. The mask of the unemotional, the lack of reciprocal interaction and repetitive motion used to sooth the spectrum self or exert control over ones environment all contribute to diagnostic difficulties. The somewhat sparse evidence seems to support the notion that depression and anxiety disorders are more prevalent in patients with Asperger’s Syndrome and autism than the general population. The need for a diagnostic tool specifically designed for these individuals should be developed. A key aspect of this tool should place emphasis on the AS and autistic view of self when compared to others. Readily available resources could be modify to accommodate the AS and autistic patient Keywords: autism, Asperger’s, depression, anxiety, disorder Presentation of Depression and Anxiety Disorders in Autism and Asperger Syndrome and their Diagnostic Difficulties

Depression and anxiety disorders are common in people with Asperger’s Syndrome and autism. Depression and anxiety disorders are common psychiatric illness with a lifetime prevalence of about 17% (Angst, 1988) in the general population. With the increasing attention to, and diagnosis of, these disorders few diagnosis tools are available to the clinicians to assist in the diagnosis of these related emotional problems. Some research has shown that the presentation of depression and anxiety disorders can be different for patients with Asperger’s or autism. Their typical characteristic behaviors and lack of outwardly expressed emotional displays means that these individual can suffer a lifetime without ever being properly diagnosed as anxious or depressed (Kabot et al., 2003).

Characteristics of AS and Anxiety Disorders Autistic spectrum disorders present with significant impairment of their social skills and communications with others. Behaviors, activities, and interests can become restricted. The onset of this spectrum of disorders is usually in early childhood. Asperger’s disorder is similar, in some ways, to autism in its presentation, but without the delay in language and other characteristics of autism. Additionally, the symptoms of AS vary in their intensity when compared to truly autistic individuals.

The DSM-IV-TR lists 9 specific symptoms for depression. These symptoms include: feelings of sadness, lost of interest in pleasurable activities, weight loss of five percent or more, insomnia or hypersomnia, retardation of psychomotor agitation, fatigue or loss of energy, feelings of worthlessness or guilt, inability to think clearly or to make decisions, and reoccurring thoughts of death such as suicidal idealization (American Psychiatric Association, 2000). Further, the DSM-IV-TR lists restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances as symptoms for Generalized Anxiety Disorder (GAD) (American Psychiatric Association, 2000).

Symptom Overlap and AS/Autistic Nuances At times it can be more difficult to diagnosis these patients as their symptoms are often masked as their normal behavior. Repetitive motions, the mask of the unemotional and desire to seek solitude may be normal behavior for these patients. These typical behaviors for the AS or Autistic person can mimic depression and anxiety in the general population and at the same time hide emotional problems. The anxiety disorder Obsessive Compulsive Disorder (OCD) can become morbid in nature with reoccurring thoughts or disturbing imagery. An increasing in stereotypic behavior such as repetitive motion, like rocking, may occur in lower functioning persons. Early data suggest that hyperactivity, impulsivity, and distractibility can rise to a level meeting the criteria for ADHD (Ghaziuddin et al., 2002).

The diagnosis of depression depends primarily on verbal and communication skills. Those on the higher levels of functioning have fewer problems conveying their feelings than those on the lower side of functioning. The clinician should look for changes in character or the autistic’s preoccupations. Rituals changes commonly associated with OCD but used by the AS and autistic person to attempt to control and assuage their environments (Ghaziuddin et al., 2002).

Possible Explanation for an Increase in Depression and Anxiety Most cases presented of depression in autism are of adolescents or young adults. Ghaziuddin et al., (2002) suggest that this rate should increase with age, but lack specific data. Gender studies have not specifically been conducted but general population data suggest that autistic females may run a higher risk of depression than their male autistic counter parts.

Meyers et al., (2006) while acknowledging that depression and anxiety was poorly understood on the autistic spectrum, suspect that social information processing played a key role. She noted that the 1944 original case of AS described pervasive deficits in the understanding that children have in social interaction, awareness of their social difficulties and the toll these emotional symptoms took on them (Wing, 1981).

Even though, like most others, many individuals with AS desire reciprocal relationships with others, they lack the skills to do so (Barnard et al., 2000; Green et al., 2000; Sigman and Ruskin, 1999). It is thought that limitations with interactivity in others may be the root cause for depression and anxiety disorders in these individuals (Bauminger and Kasari, 200; Frith, 1996; 2004; Klin and Volmar, 2003; Tantum, 2000; 2003). It is these failed attempts at social interaction that can further drive the AS and autistic patient into deeper social withdrawal (Hedley and Young, 2006).

One researcher conducted an experiment to see if “comorbid psychological adjustment difficulties found in children with Asperger syndrome would be associated with disturbances in information processing related to social attributions” (Meyer et al., p. 386, 2006). Participants were recruited through a clinical database (n-31, 26 boys). The research was conducted via extensive clinical diagnosis interviews of the parents. The researchers found marked abnormalities in reciprocal in their social interaction and also their non-verbal communications. Also these participants had restricted behavior and interests without any significant delays in cognitive or language abilities (Meyer et al., 2006).

Development of Diagnostic Tools One recent study used several diagnostic questionnaires to test children with Pervasive Development Disorder (PDD) and other language impairment disorders to detect the prevalence of anxiety and mood disorders (Kim et al., 2000). The three tools used were: Arthur Adaptation of the Leiter Performance Scales; Standford-Binet Intelligence Scale, forth edition and; the revised Ontario Child Health Study. The results showed at “clinically relevant” levels on several scales that AS and autistic did have higher risks for depression and anxiety disorders. While the conclusion illustrated the increased risk for depression and mood disorders, the difficulties in obtaining this conclusion illustrated the need for a refinement in the above tests to adapt to people with AS and Autism.

Depression and anxiety disorders are common psychiatric illness with a general population lifetime prevalence of about 17% (Angst, 1999). The data there is on the AS and autistic person suggest that this rate would be even higher. The difficulties in diagnosis can be overcome in most instances with the development of new or perhaps refinement of existing psychological tests. The method for conducting the tests and interpreting the responses present the most challenge for the clinician. The questionnaires should place a greater emphasis on the patient’s cognitive view of his own placement when measured against others, a measure of perceived differences or deviance from others (Hedley & Young, 2006). It is this comparison of self to others that could be the defining measure for mood disorders on the autistic spectrum. References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edition). Washington, DC: American Psychiatric Association. Angst, J. (1988). Clinical course of affective disorders. Helgason & R. J. Daly (Edz.) Depressive illness: Prediction of course and outcome (pp. 1-44). Berlin: Springer-Verlag. Retrieved from http://www.psy-journal.com/article/S0165-1781(00)00233-X/abstract Barnhill G. & Smith M. B. (2001). Attributional Style and Depression in Adolescents with Asperger Syndrome Journal of Positive Behavior Interventions, 175-182, doi:10.1177/109830070100300305 Bauminger, N. & Kasari, C. (2000) ‘Loneliness and Friendship in High-Functioning Children with Autism’, Child Development 71: 447–56. Retrieved from http://web.ebscohost.com.proxy.lib.odu.edu/ehost/detail?vid=2&hid=106&sid=cd823ba8-48fb-4500-a3c1-683961214637%40sessionmgr113&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=3168454 Frith, U. (1996) ‘Social Communication and Its Disorder in Autism and Asperger Syndrome’, Journal of Psychopharmacology 10: 48–53. Retrieved from http://jop.sagepub.com/cgi/pdf_extract/10/1/48 Frith, U. (2004) ‘Emanuel Miller Lecture: Confusions and Controversies about Asperger Syndrome’, Journal of Child Psychology and Psychiatry 45: 672–86. http://web.ebscohost.com.proxy.lib.odu.edu/ehost/detail?vid=3&hid=106&sid=0d49a499-8dc5-468c-b4b7-930fcf881ce2%40sessionmgr112&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=12661187 Ghaziuddin, M., Ghaziuddin, N., & Greden, J. (2002). Depression in Persons with Autism: Implications for Research and Clinical Care. Journal of Autism & Developmental Disorders, 32(4), 299-306. Retrieved from http://web.ebscohost.com.proxy.lib.odu.edu/ehost/detail?vid=2&hid=106&sid=89f69f8f-4fcf-48ab-a28d-e15054be0c8d%40sessionmgr114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=11305694 Hedley, D., & Young, R. (2006). Social comparison processes and depressive symptoms in children and adolescents with Asperger syndrome. Autism: The International Journal of Research & Practice, 10(2), 139-153. doi:10.1177/1362361306062020. Kabot, S; Masi, W; Segal, M (2003) Advances in the Diagnosis and Treatment of Autism Spectrum Disorders. Professional Psychology - Research & Practice. 34(1):26-33, February 2003. Retrieved from http://web.ebscohost.com.proxy.lib.odu.edu/ehost/pdfviewer/pdfviewer?vid=4&hid=110&sid=7eb35a46-1c8b-4cb9-9c82-28d702ce8830%40sessionmgr114 Klin, A. & Volkmar, F.R. (2003) ‘Asperger Syndrome: Diagnosis and External Validity’, Child and Adolescent Psychiatric Clinics of North America 12: 1–13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12512395 Meyer, J., Mundy, P., Vaughan van Hecke, A., & Durocher, J. (2006). Social attribution processes and comorbid psychiatric symptoms in children with Asperger syndrome. Autism: The International Journal of Research & Practice, 10(4), 383-402. doi:10.1177/1362361306064435. Tantam, D. (2000) ‘Psychological Disorder in Adolescents and Adults with Asperger Syndrome’, Autism 4: 47–62. Retrieved from http://web.ebscohost.com.proxy.lib.odu.edu/ehost/detail?vid=2&hid=106&sid=335d9147-f675-4288-94e4-70c498058573%40sessionmgr112&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=5435532 Tantam, D. (2003) ‘The Challenge of Adolescents and Adults with Asperger Syndrome’, Child and Adolescent Psychiatric Clinics of North America 12: 143–64. Retrieved from http://web.ebscohost.com.proxy.lib.odu.edu/ehost/detail?vid=2&hid=106&sid=9b972f3c-ef18-4169-b976-c28332a4ab3e%40sessionmgr114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=5435532 Wing L (1981). "Asperger's syndrome: a clinical account". Psychol Med 11 (1): 115–29. doi:10.1017/S0033291700053332