DEVELOPMENTAL DISORDER,
AUTISM SPECTRUM DISORDER,
PERSONALITY DISORDER
Richmond Foundation Malta
22/23rd October 2012
Dolmen Resort Hotel
12.20pm/12.55pm
www.professormichaelfitzgerald.com
www.professormichaelfitzgerald.eu
www.pressurepointsonirishfamilies.com
Pervasive Developmental Disorders
299.00 Autistic Disorder.
A.
A total of six (or more) items from (1), (2), and (3), with at least two from (1),
and one each from (2) and (3):
(1) Qualitative impairment in social interaction, as manifested by at least two of
the following:
a)
Marked impairment in the use of multiple non-verbal behaviours such as eye-toeye gaze, facial expression, body postures, and gestures to regulate social
interaction.
Pervasive Developmental Disorders
b)
Failure to develop peer relationships appropriate to developmental level.
c)
A lack of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g. by a lack of showing, bringing, or pointing out objects of
interest).
d)
Lack of social or emotional reciprocity.
Lack of Social or Emotional Reciprocity
(2) Qualitative impairments in communication as manifested by at least one of
the following:
a)
Delay in, or total lack of, the development of spoken language (not accompanied
by an attempt to compensate through alternative modes of communication such
as gesture or mime).
b)
In individuals with adequate speech, marked impairment in the ability to initiate
or sustain a conversation with others.
c)
Stereotyped and repetitive use of language or idiosyncratic language.
d)
Lack of varied, spontaneous make-believe play or social imitative play
appropriate to developmental level.
Lack of Social or Emotional Reciprocity
(3) Restricted repetitive and stereotyped patterns of behaviour, interests, and
activities, as manifested by at least one of the following:
a)
Encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus.
b)
Apparently inflexible adherence to specific, nonfunctional routines or rituals.
c)
Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or
twisting, or complex whole-body movements).
d)
Persistent preoccupation with parts of objects.
Lack of Social or Emotional Reciprocity
B.
Delays or abnormal functioning in at least one of the following areas, with onset
prior to age 3 years: (1) social interaction, (2) language as used in social
communication, or (3) symbolic or imaginative play.
C.
The disturbance is not better accounted for by Rett's Disorder or Childhood
Disintegrative Disorder.
SYNONYMS
Autistic Psychopathy
Autistic Personality Disorder
High Functioning Autism
Asperger’s Syndrome
Some forms of Schizoid Personality Disorder (Sula Woolf)
7
Sub typing of ASD has been unsuccessful and will have to
wait for genotyping or biological makers.
Current sub types including:1. Low functioning ASD
2. High functioning ASD
3. ADI-R Autism
4. Criminal Autistic Psychopathy (Fitzgerald 2010)
5. Combined ASD and ADHD
6. Combined ASD and Bipolar Disorder
7. Combined ASD and Schizophrenia
8
Classification in Psychiatry
ICD and DSM are mythology? Sigmund Freud regarded
Their metapsychology as mythology.
For homosapiens mythologies are the first hypothesis.
They are the first stage in development.
9
DSM/ICD MYTHOLOGY
1. Do we need to start classification or nosology again?
2. Do we need to go back before Kraeplin?
3. Have we divided up most psychiatric disorders at wrong division
points?
4. Do we need to go back and identify the core gestalts conditions
before the current tick box classifications of DSM IV/V.
10
DSM/ICD MYTHOLOGY
5. How much of ICD10/DSM IV should we retain? 30%
6. No difference between AXII clinical conditions and AXI
personality disorders.
7. Every psychiatric condition does not overlap with every other
but you could be forgiven for thinking it does.
11
Massive Hetrogeneity and Overlap with other disorders
12
FORME FRUSTE
‘Crude, unfinished’
PDDNOS
13
FORM PLEIN
Full criteria Autism
14
DEVELOPMENTAL DISORDERS
1. Begin any time during development up to
22 years of age and usually last a lifetime
(CDC 2012).
2. Characterised by problems of language or
mobility, self help and independent living
(CDC 2012)
15
DEVELOPMENTAL DISORDERRS
1. ASD
2. Intellectual Disability
3. ADHD
4. Schizophrenia
5. Bipolar Disorder
16
NEURODEVELOPMENTAL DISORDERS
Owen et al (2011) states “overlapping syndromes to which
neurodevelopmental abnormalities contribute”
Partly as consequence of events occurring early in
development.
“Combination of genetic and environmental effects on
brain development”.
17
Continuum of Nature/Nurture induced
neurodevelopmental causality
OWEN 2012 points out that “there are shared
genetic as well as environmental risk between
Intellectual Disability and Neurodevelopmental
conditions such as Autism, ADHD, Schizophrenia,
Epilepsy”. “These can be conceived as lying along a
continuum of genetically and environmentally
induced neurodevelopmental causality”.
18
NEURODEVELOPMENTAL DISORDERS
Undermines categorical diagnosis
Genetic data suggest continuum between child and
adult psychiatric disorders.
Owen et al (2011)
19
ASD PREVALENCE
McCarthy Smith Fitzgerald 1984 4 per 10,000 Ireland
Prevalence 1/88 CDC 2012
1. Last twelve years prevalence of Autism increasing by
289.5% (CDC 2012)
1 female/five males
Personality Disorders 4% Great Britain (Coid et al
2006)(2011) 2.6% American Journal of Psychiatry (KIM)
20
PERSONALITY DISORDERS AND DEVELOPMENTAL
DISORDERS
A. Some personality disorders are probably
developmental disorders e.g. Schizod, schizotypal,
borderline, OCPD, paranoid, sadistic, paranoid, sadistic PD
(DSM IIIR)
21
ADULT OFFENDERS, PERSONALITY
DISORDER AND ASD
(1) Adult Offenders (Hill 2002) 50-80%
Antisoc Per. Dis.
(2) Adult Offenders 15-30% Psychopathy
(3) Adult Offenders – 27% have ASD
(Sipponma 2000)
(4) Sex Difference
Psychopathy 1F/5M
Autism 1F/5M
Female more deadly than the male
22
DIAGNOSIS ADMISSIONS TO A SPECIAL PSYCHIATRIC
HOSPITAL
(Murphy 2003) showed that half of a group (N=13) of
offenders admitted to special hospital, had previously been
diagnosed with personality disorder and other mental illness
and now has ASD (Asperger’s Syndrome)
23
ASD CRIMINALITY
Arson
Stalking
Sex offences
Strange repetitive crimes
24
ASD/WHISTLEBLOWERS
Whistleblowers who are rejected by the
whole system, often have ASD
25
MYTHS OF ASD
The first myth is that ASD and personality
disorder/psychopathy are completely different.
The myth is that Autism and Asperger’s have little
or no relation with criminality, serious aggression
and murder.
There is “little if any significant association
between Autism and criminal offending” (Howlin
1997)
26
(Lorna Wing 1981) used the term Asperger
Syndrome to get rid of psychopathy from Hans
Asperger’s Autistic Psychopathy.
Lorna Wing was particularly sensitive to parents of
Autistic children being herself a parent and wanted
to remove the negative connotations of
psychopathy from Autism.
27
I have resurrected the term Autism Psychopathy used
by Hans Asperger to deal with ASD persons who get
involved with the criminal code. I have called this
Criminal Autistic Psychopathy.
(Sipponma 2000) points out that 27% of adult
offenders in her study met the criteria for ASD.
28
PERSONALITY DISORDER ICD10 DSM IV is “enduring
characteristics from early childhood inflexible and
pervasive.
Similar clinical features of ASD
29
1. Personalities Disorders (ADSHEAD and SARKAR 2012) are
“developmental in nature”.
Personality regulates:(a) ‘Social relationships’
(b) Arousal, impulsivity and emotions’
(c) Self directedness and self soothing’
(d) Verbal and non verbal communication’
(ADSHEAD and SARKAR 2012)
All these are also abnormal in ASD
30
PERSONALITY DISORDER AND ASD
(1) Personality Disorder can improve like ASD with time;
(2) Personality Disorder and ASD can bring contact with the
law;
(3) Interfere with occupational functioning;
(4) Have significant communication problems;
(5) Cause significant personal distress.
31
CLUSTERS OF PERSONALITY DISORDERS (ADSHEAD
and SARKAR 2012)
Cluster (a)
Odd, eccentric behaviour (schizoid paranoid schizoid
type) overlaps with ASD
Cluster (b)
Anti-social borderline and narcissistic overlap with
criminal autistic psychopathy
Cluster (c)
Fearful and anxious behaviour (avoidant, dependent
and obsessive compulsive) can also overlap with ASD.
32
OVERLAP FEATURES PERSONALITY DISORDER
(ADSHEAD and SARKAR 2010) and ASD
1. “Emotional indifference”
2. Anger, suspicion, fearfulness”
3. “Fears others attacking and threatening
them”
4. “Brief psychotic episodes”
33
OVERLAP FEATURES PERSONALITY DISORDER
(ADSHEAD and SARKAR 2010) and ASD
5. “Odd beliefs”
6. “Magical thinking”
7. “Pre-occupation and ruminations”
8. “Identity diffusion”
34
OVERLAP FEATURES PERSONALITY DISORDER (ADSHEAD and
SARKAR 2010) and ASD
9. “Empathy problems”
10. “Major problems in inpatient units”
11. “Failure to conform to social norms”
12. “Social relationship problems”
35
OVERLAP FEATURES PERSONALITY DISORDER (ADSHEAD
and SARKAR 2010) and ASD
13. “Social reciprocity problems”
14. “Impulsivity”
15. “Irrationality”
16. “Disregard safety of self and others”
36
OVERLAP FEATURES PERSONALITY DISORDER
(ADSHEAD and SARKAR 2010) and ASD
17. “Reduced reaction to upset in other people”
18. “Pre-occupation with one or more stereotyped
patterns of behaviour”
19. “Problems emotional processing”
20. “Emotional detection problems”
37
OVERLAP FEATURES PERSONALITY DISORDER
(ADSHEAD and SARKAR 2010) and ASD
21. “Reduced observing self”
22. “Reduced self awareness and capacity to decentre
the self”
23. “Egocentricity”
24. “Low affiliation and arm avoidance”.
38
ASD AND PD
(1) The Autism spectrum is very wide and indeed single or
minor traits occur in the general population. It is the
accumulation of features and difficulties in the
personal and social impairment that gives the
diagnosis of ASD.
(2) Similarly Personality Disorder.
39
(1) The notion of a singular concept of Autism is
a myth. There is not one Autism but a huge
number of varieties of Autism (ASD)
(2) The idea that the ADI-R gives you the true
Autism is not accurate, it’s like searching for
the Holy Grail.
(3) ADI-R Autism is very narrow 1940’s Kanners
Autism Wing (1976)points out that 10% of
children with ASD met Kanner’s Autism
40
CO-MORBIDITY ASD AND PERSONALITY DISORDER
Anxiety, depression, suicidal behaviour, rigidity and
compulsive behaviour
41
DIFFERENTIAL DIAGNOSIS ASPD and PSYCHOPATHY
(1) Psychopathy at the end of PD spectrum as criminal
autistic psychopathy is at the end of the ASD spectrum.
(De River 1949/1956) describes some sexual criminals
as “autistic personality”.
(2) Callous and unemotional traits overlap ASD and
Psychopathy
(3) ASD lack “instinctive grasp of the social contract/the
rules that govern obligations that other people have”
(Economist 2010); same psychopathy.
42
TREATMENT CALLOUS AND UNEMOTIONAL TRAITS
(Dadds 2006) showed that helping children with
psychopathic traits (callous and unemotional) improved
recognition of faces and fear on faces if they were trained
to look at eyes.
Overlap of treatment of ASD/PD
43
LYING AND AUTISM
A second myth is that persons with Autism don’t lie.
Persons with Autism by and large are extremely truthful,
naive and honest. However I do see a small proportion of
ASD persons who make serious false accusations about their
parents. They get their parents into serious trouble with
the law.
44
LYING ASD/SCHIZOID PERSONALITY DISORDER
(Woolf 1990) in her group of schizoid disorder
overlapping with Asperger’s Syndrome found:(a) “Fraudulent behaviour and pathological lying”.
(b) She also found that five out of thirteen had “falsely
reported their parents of being cruel to them”.
(c) “Had used aliases”.
(d) The serial killer Ted Bundy who had ASD lied a great
deal.
(e) Christopher Gillberg also noticed that on occasion
persons with ASD could persecute people with false
accusations.
45
OVERLAP BIOLOGY ASD AND PSYCHOPATHY
1. Frontal lobe/temporal lobe/amygdala.
2. Cortical thinning temporal cortex in Autism and
psychopathy (Blair 2012) (Wallace et al 2010)
3. Possible impaired social cognitive functions reliant
on the superior temporal cortex and temporal role
in Autism and psychopathy (Blair 2012)
4. Psychopathy problems structural integrity (Blair
2012).
46
SELECTIVE LIST OF CRIMINAL AUTISTIC
PSYCHOPATHY SERIAL KILLERS
(Young, Violent and Dangerous to Know Fitzgerald
2010)
1. Harold Shipman
2. Fred West
3. Timothy McVeigh
4. Ted Bundy
5. Graham Young
47
PSYCHOSIS IN AUTISM
Overlap of genetic susceptibility; across categories of
Schizophrenia, Autism and Neurodevelopmental Disorders
(Craddock et al 2010)
48
AUTISM/PSYCHOSIS/PERSONALITY DISORDER
The 3rd Autistic myth is that Autism and Schizophrenia
are completely separate as stated by (Michael Rutter).
We are aware of the considerable overlap clinically
and genetically between Autism and Schizophrenia.
Indeed one can have the dual diagnosis of Autism and
Schizophrenia.
49
AUTISM/PSYCHOSIS/PERSONALITY DISORDER
In adult psychiatry many people with high functioning
Autism/Asperger’s Syndrome are misdiagnosed with
Schizophrenia and put on depot medications. I have
seen persons on these for 40 years come to see me and
to have their diagnosis re-classified as HFA.
Psychotic episodes can occur in ASD and Personality
Disorder.
50
CREATIVITY AND REDUCED BRAIN
CONNECTIVITY (ASD/PD)
Reduced connectivity leads to increased
performance in Autism (Savants) and
Psychopathy (Stroope Tess) (Blair 2012)
Psychopathy
51
IMAGINATION AND CREATIVITY
(1) The fourth myth is that persons with
Autism and Asperger’s Syndrome have
no capacity for imagination. (L. Wing).
Indeed the opposite is true. The
greatest persons with ASD e.g. The
scientist Albert Einstein, Poet W.B.
Yeats, Writer George Orwell,
Mathematician Isaac Newton.
(Fitzgerald 2004)
(2) Donald Treffert maintains true
creativity is not possible with ASD.
(3) Autistic creativity is particularly
associated with science fiction writers.
E.g. H.G. Wells who had Asperger’s
Syndrome
52
IMAGINATION AND CREATIVITY
(1) Persons with high functioning Autism have an
imagination that reaches beyond what most people
are capable of. Their social imagination is different
but not absent. Their social imagination is often
paranoid and fantastic.
(2) In the literature these are often described as
Personality Disorders or Asperger’s Syndrome.
(3) Low functioning autistic savants are not creative.
53
ADI-R
Myth 5 is that the semi structured diagnostic
instrument Autism Diagnostic Instrument revised
(ADI-R) is the Gold Standard Autism Diagnostic
Instrument. It is not as it only recognises a
narrow spectrum of Autism and excludes a great
number of persons with ASD with the
consequent deprivation of services for these
persons such as even more serious consequence.
Many researchers in developing countries find
the cost of this instrument prohibitive.
54
The proposed 2013 American Psychiatric classification
DSM V appears to be using this narrow concept of
Autism which will mean that many persons with Autism
meeting the broader Autism phenotype classification will
lose their services which will be catastrophic. It may take
the Autism field 20 years to recover from these narrow
and inappropriate classifications and diagnostic tool
(ADI-R)
All scientific and clinical evidence points to the idea that
the broad ASD what is called the broader Autism
phenotype is the core and correct diagnostic profile.
55
The 6th Myth
Applied Behaviour Analysis
Is that Applied Behavioural Analysis (ABA) is the only
proper treatment for persons with ASD. The ABA is
useful when used as part of a multi model intervention
for a person on the Autism Spectrum.
When the treatment was first used by Lovass he used
cattle prods as part of his interventions. These have now
been discarded.
56
APPLIED BEHAVIOUR ANALYSIS
The number of hours required for ABA even at it’s
maximum is probably 17 hours per week if it’s used
excessively I have seen some of the children develop
Post Traumatic Stress Disorder.
Some practitioners have expressed faith in this approach
and believe that it can cure Autism. Indeed this was
asserted initially.
57
APPLIED BEHAVIOUR ANALYSIS
There are major problems with generalisation of ABA
from gains in the classroom to the supermarket etc. It is
a rather robotic form of training. Nevertheless I have
often seen it to bring benefits and there is scientific
evidence for it’s benefits.
Indeed elements of ABA are always recommended but to
include speech and language therapy, occupational
therapy, therapist focusing on visual approaches.
58
MIND READING
Some of the new mind reading therapies are also
useful and certainly give parents a valuable way of
thinking about their child’s problems.
59
CLASSICAL PSYCHOANALYSIS
Was also used in the 20th Century. It has no place now in the
treatment of ASD.
60
There is no specific treatment for ASD and parents
have to be trained insofar as they are to be cotherapists.
There is no place for gurus or miracle treatments.
61
The 10th Autism myth that all persons with ASD have
poor eye contact.
Rutter had this as one of his key features. I see many
people with ASD who don’t have poor eye contact but
meet all the other criteria.
62
The 8th myth is that pronominal reversal is a key
feature of Autism.
It was a key feature in Rutter’s criteria.
It does occur clinically but of course many cases
have no language and indeed I see it fairly rarely in
my cases.
63
The 9th myth is that ASD and ADHD can’t be diagnosed
together. In DSM IV if you make a diagnosis of ASD then
you are prohibited from making a diagnosis of ADHD.
In reality both have to be made and both have to be
treated even though as usual there is some genetic
overlap.
64
OVERLAP
INSULA MALFUNCTIONING IN BOTH ASD AND
PSYCHOPATHY
DIFFERENCES
Serotonin up in Autism and down in Psychopathy
Biological overlap is partial at best.
Biological overlap is more forced and on weaker
ground here in relation to PD and ASD than clinical
symptoms.
65
PHRASES ASSOCIATED WITH PERSONALITY DISORDER
COULD BE ASSOCIATED WITH ASD
1. Schizoid personality “you can knock, but nobody’s
home”. (Millon 2000)
2. Schizotypal personality. “I am eccentric, different,
strange”. (Millon 2000)
3. Paranoid personality. “You can’t trust anybody”.
(Millon 2000)
4. Borderline Personality “I will be very angry, if y ou try
to leave me”.
66
PHRASES ASSOCIATED WITH PERSONALITY DISORDER
COULD BE ASSOCIATED WITH ASD
5. The sadistic personality (DSM IIIR) “I will savour your
suffering”. (Millon 2000)
6. Narcissistic personality “my command is your wish”.
(Millon 2000)
7. Asperger’s are dominating and controlling and have
difficulty recognising other people’s needs as the same
happens with narcissistic personality.
67
OCD PERSONALITY
“I just don’t want to make a mistake” (Millon 2000)
68
DEVELOPMENTAL DISORDER,
AUTISM SPECTRUM DISORDER,
PERSONALITY DISORDER
Richmond Foundation Malta
22/23rd October 2012
Dolmen Resort Hotel
12.20pm/12.55pm
www.professormichaelfitzgerald.com
www.professormichaelfitzgerald.eu
www.pressurepointsonirishfamilies.com