An Autistic Child With Psychotic Symptoms

Although autism has long been recognized as a separate diagnostic entity from schizophrenia, both disorders share clinical features. Childhood-onset schizophrenia (COS), considered a rare and severe form of schizophrenia, frequently presents with premorbid developmental abnormalities. This prepsychotic developmental disorder includes deficits in communication, social relatedness, and motor development, similar to those seen in autism spectrum disorders (ASD). The following illustrates the presentation and management of ASD and schizophrenia, originally described in "Autism and Schizophrenia," on which this case is adapted.

Question to consider when reading the case
What are the similarities and differences in clinical presentations of COS and ASD in this patient?

Case Vignette
George is a 14-year-old boy who first presented to Dr Frazier at age 8 with a diagnosis of ASD. Initially, the diagnosis was made when George was 27 months old and had been reconfirmed by numerous well-regarded autism experts over the years. George had received the usual autism-specific services, and although he made gains, he continued to present with atypical behaviors. George was referred to Dr Frazier because of an increase in the intensity and frequency of unusual and disturbing preoccupations that often had a morbid theme. Those who worked with him had difficulty in getting him off of these disturbing topics.

George also had unusual behaviors and mood-regulation difficulties. When he first presented to the clinic, he was disinhibited, emotionally unstable, and talked at length about his “other world.” His thoughts were loosely connected and he spoke about the friends in his other world who were talking to him. Initially, these friends were humming to him or saying hello. Because of a history of at least 1 depressive episode and what appeared to be more of a chronic euphoric state with affective lability, George was given a provisional comorbid diagnosis of bipolar disorder with psychotic features. Over the ensuing years, despite a number of medication trials including atypical antipsychotics and mood stabilizers, he became tortured by more persistent auditory hallucinations. “She” was particularly disturbing to him and he wanted her to go away.

George’s affective instability continued, but his thought disorder and psychosis have been the most enduring symptoms, even in the absence of mood dysregulation. His comorbid diagnosis was changed to schizoaffective disorder and, more recently, to schizophrenia. He is currently taking a typical antipsychotic. His thoughts are more linear, he rarely talks about “she,” and he is much more able to engage in his schoolwork.

Outcome
Although George’s psychotic symptoms are well controlled by the medication, symptoms of ASD persist. These include poor eye contact, ongoing failure to develop appropriate peer relationships, inability to sustain a conversation with others, a preoccupation with restricted patterns of interest, and stereotypies (patterned repetitive movements, postures, and utterances). Present since early childhood, these symptoms predated his symptoms of psychosis and continue to require the support of autism-specific services.

Clinical implications
Autism and schizophrenia may present as 2 separate disorders that need to be differentiated, or treated as comorbid conditions. It is important to remember that some individuals may have both COS and ASD, which has implications when designing appropriate biopsychosocial interventions. Adult psychiatrists may benefit from additional training in the diagnosis of ASD in adults, whereas child psychiatrists may benefit from increased comfort with identifying primary psychotic symptoms in autistic youth.

Discussion
For the discussion on the biological and clinical links between COS and ASD disorders, please click here.