T1 L23. Autism (LQ).pptx

Autism L23 Dr Lisa Quadt (she/her) Research Fellow in Psychiatry Department of Neuroscience Overview & Learning Outcomes • Autism in the medical model vs autism as a neurodivergence • Neural, affective and sensory patterns in autistic people • Strengths and challenges of autistic people • Autism s...

Autism L23 Dr Lisa Quadt (she/her) Research Fellow in Psychiatry Department of Neuroscience Overview & Learning Outcomes • Autism in the medical model vs autism as a neurodivergence • Neural, affective and sensory patterns in autistic people • Strengths and challenges of autistic people • Autism specific healthcare  Recognise that autistic people present on a spectrum  Give examples of autistic-specific healthcare needs and barriers  Describe neural differences and their potential impact  Describe how autism may present itself Autism in the medical model vs autism as a neurodivergence Medical Model of Autism DSM-5 [1] A. Persistent deficits in social communication and social interaction across multiple contexts, e.g.: i. Abnormal social approach/failure of normal back-and-forth conversation ii. Deficits in nonverbal communicative behaviours iii. Deficits in developing, maintaining and understanding relationships B. Restricted, repetitive patterns of behaviour, interest, or activities, e.g.: i. ii. Stereotyped or repetitive motor movement Insistence on sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behaviour iii. Highly restricted, fixated interests that are abnormal in intensity and/or focus iv. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (Medical) Myths about Autism • Autistic people are either genius or severely intellectually disabled “It is recognised now that most autistic people are adult, do not have an intellectual disability and are likely to be undiagnosed.” (RCPsych, CR228, [2]) (Medical) Myths about Autism • Autism is more common in males (assigned at birth) than females (assigned at birth) “Systematizing” • Maths skills • Attention to detail • Map reading • Constructional abilities • Toy choices (vehicles, weapons, building blocks) “Empathizing” • Sharing and turntaking • Empathic response to distress • Theory of mind • Values in relationships • Cooperative, reciprocal language use • Talk about [3] emotions (Medical) Myths about Autism • Autism is more common in males (assigned at birth) than females (assigned at birth) [4] (Medical) Myths about Autism • Autistic people (who are mostly men/have an extreme male brain) do not have empathy [5 ] (Medical) Myths about Autism • Autistic people are not motivated to have meaningful social relationships [6 ] Autism as a Neurodivergence Neurodiversity Neurodivergence Autism as a Neurodivergence Neurodevelopmental origin, like ADHD, Tourette syndrome, dyslexia, dyspraxia… Overlap between behavioura cognitive and emotional patterns across neurodivergent conditions Differences in cognitive, emotional, and sensory processing High co-occurrence of physical & mental health conditions, e.g., chronic pain Language Survey in 2015: 61% of autistic adults preferred “identity-first” vs “person-first” language [7] Autistic person/people  Autistic identity is named first: “Identity-first” Person/people with autism  Person is named first: “Person-first” [8] Neural, affective and sensory patterns in autistic people DORSAL ANTERIOR / ROSTRAL MID CINGULATE Anxiety (apathy) Psychophysiological arousal & affect control Salience, DORSALexecutive STRIATUM networks (head of caudate) Disgust (compulsiveness OCD, stress provocation) Motivational drive (motoric) Salience network SUBGENUAL CINGULATE Sadness (depression) Psychophysiological relaxation reward signaling Default mode network ORBITOMEDIAL Pleasure, regret (rumination, acquired psychopathy, disinhibition) Processing of relative value Extinction learning Default mode network VENTRAL STRIATUM Happiness & pleasure (anhedonia, addiction) BRAIN REGION Specific emotional role General role in affective processes Associated functional network THALAMUS Fear & threat Salience interoception Salience network ROSTRAL PONS Interoception, autonomics & ascending neuromodulators Salience network HIPPOCAMPUS (anxiety, stress, PTSD) Emotional & context memory, learning Default mode PARIETAL CORTICES (agnosias, neglect) Visuospatial attention, self representation Salience, default mode & executive networks SUPERIOR TEMPORAL SULCAL CORTEX Emotional cue detection Visuosensory network INFERIOR TEMPORAL SULCAL CORTEX Visual identity detection (including fusiform face & body areas) Visuosensory network INSULAR CORTEX Disgust (anxiety, alexithymia) Interoception, emotional feeling states, autonomic arousal Salience network AMYGDALA Fear & threat (anxiety PTSD) Emotional arousal & memory Salience network • Brain regions work locally for a specific function (e.g., fear processing in amygdala, emotion processing in insula) • And brain regions work globally in networks (e.g., salience network) • In autism, it is believed that local processing takes precedent over global processing Theories Theories about neural, affective and sensory differences • Underconnectivity hypothesis: Long-range underconnectivity between frontal and posterior regions in the brain underlies autistic phenotype [9] • Intense world hypothesis: Increased local neural connectivity and plasticity lead to hyperperception and –attention in autistic people [10] • Weak central coeherence: Autism is characterized by difficulties in processing information in its context, leading to a locally focused processing style [11] • Monotropism: Autistic characteristics emanate from atypical attention allocation. In autism, attention allocation supports few synchronous interests, each highly aroused, compared to typical attention allocation supporting multiple interests, that are less highly aroused [12] [13] [14] • So many autistic people experience sensory differences it has now been added as part of the diagnostic criteria. • Autistic people can be hyper or hypo sensitive in any of these areas – External senses hearing sight smell taste touch Not all senses will be affected the same way! Internal senses interoception (knowing if I’m hungry/ thirsty / sad / angry) proprioception (knowing where my body is in space) vestibular sense (balance) Sensory sensitivities are not just for signals from the outside… …but also from inside the body! Knowing when hungry/thirsty/full Emotional processing Temperature regulation Anxiety Intuitive decision making/gut feelings Strengths and challenges of autistic people • Important to acknowledge individual strengths and challenges • There is just as much variance as in nonautistic people • High-functioning vs low-functioning unhelpful categories Autism specific healthcare [15] • Autism-specific communication skills training is the biggest training need for primary healthcare providers • Phone communication especially difficult • Feeling misunderstood, dismissed, invalidated • Lack of clear, unambiguous language • Sensory issues interfere with References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 ed. Washington; 2013. 2. Royal College of Psychiatrists. The psychiatric management of autism in adults (CR228). 2020. https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2020-college-reports/c r228 (accessed 21.03.2021 2021). 3. Baron-Cohen S. The extreme male brain theory of autism. Trends in Cognitive Sciences 2002; 6(6): 248-54. 4. Burrows CA, Grzadzinski RL, Donovan K, et al. A Data-Driven Approach in an Unbiased Sample Reveals Equivalent Sex Ratio of Autism Spectrum Disorder–Associated Impairment in Early Childhood. Biological Psychiatry 2022. 5. Gu X, Eilam‐Stock T, Zhou T, et al. Autonomic and brain responses associated with empathy deficits in autism spectrum disorder. Human brain mapping 2015; 36(9): 3323-38. 6. Quadt L, Williams GL, Mulcahy JS, et al. "I'm trying to reach out, I'm trying to find my people": Loneliness and loneliness distress in autistic adults. PsyArXiv 2021. 7. Kenny L, Hattersley C, Molins B, Buckley C, Povey C, Pellicano E. Which terms should be used to describe autism? Perspectives from the UK autism community. Autism 2015; 20(4): 442-62. 8. Ferenc K, Płatos M, Byrka K, Król ME. Looking through rainbow-rimmed glasses: Taking neurodiversity perspective is related to subjective wellbeing of autistic adults. Autism; 0(0): 13623613221135818. 9. Just MA, Cherkassky VL, Keller TA, Minshew NJ. Cortical activation and synchronization during sentence comprehension in high-functioning autism: evidence of underconnectivity. Brain 2004; 127(8): 1811-21. 10. Markram H, Rinaldi T, Markram K. The intense world syndrome - an alternative hypothesis for autism. Frontiers in Neuroscience 2007; 1. 11. Happé F, Frith U. The Weak Coherence Account: Detail-focused Cognitive Style in Autism Spectrum Disorders. Journal of Autism and Developmental Disorders 2006; 36(1): 5-25. 12. Murray D, Lesser M, Lawson W. Attention, monotropism and the diagnostic criteria for autism. Autism 2005; 9(2): 13956. 13. Ebisch SJ, Gallese V, Willems RM, et al. Altered intrinsic functional connectivity of anterior and posterior insula regions in high-functioning participants with autism spectrum disorder. Human brain mapping 2011; 32(7): 1013-28. 14. Silani G, Bird G, Brindley R, Singer T, Frith C, Frith U. Levels of emotional awareness and autism: an fMRI study. Soc