ReviewBipolar disorder in adults with Asperger׳s Syndrome: A systematic review
Introduction
Asperger׳s Syndrome (AS), formerly recognized as a specific diagnostic entity in DSM-IV-TR, has been recently included by DSM-5 in the Autism Spectrum Disorders (ASD), together with other Pervasive Developmental Disorders. ASD currently lump together different heterogeneous clinical subtypes such as AS and severe autism, based on a dimensional perspective. This DSM-5 spectrum view permit to include on the broad autistic spectrum not only AS but also many other ASD-variants labeled “high functioning autisms” (HFA) till now. In this perspective new severity “specifiers” permit to distinguish different ASD phenotypes. Indeed, high functioning autisms might be better indicated as ASD with “less marked general impairment” only “requiring support” (level 1), while classical “low functioning “autisms (e.g. with intellectual and language impairment) as “requiring very substantial support” (level 3).
Although it is true that diagnostic criteria are flawed and difficult to implement in clinical practice, patients with AS usually show some peculiar features and a less marked general impairment compared with other autistic phenotypes. Although intelligence and language abilities are always preserved, they usually present atypical features. Cognitive profile can be uneven, with high verbal abilities compared with poor non-verbal skills, visuo-spatial problem solving, and motor performances (included uncoordinated motion, clumsiness, and illegible handwriting). Furthermore, language is formally adequate and often precocious (particularly in lexicon), but usually pedantic, monotonous and poorly communicative. Typically, their ability to recognize non-verbal signals and social-emotional reciprocity are variously impaired. Moreover, AS subjects tend to show highly restricted and fixated interests that are abnormal in intensity or focus, associated with inflexible adherence to routines and hard and fast rules.
Considered a relatively common diagnosis in childhood and adolescence, AS has only recently gained some attention in adults. The data relative to AS prevalence are variable especially in reason of the dispute concerning the distinction from HFA. When not only AS is included in HFA but also many other high functioning ASD-variants the prevalence is likely to be much higher. Moreover, major psychiatric comorbidities, especially with mood disorders and psychoses, may contribute to the underestimation of AS. Indeed, reliable data on the actual AS prevalence among adults are not available. In childhood, the prevalence is estimated to be between 0.02% and 12.27% (Baird et al., 2000, Fombonne and Tidmarsh, 2003, Mattila et al., 2007). Similarly to other ASD forms, AS is considered a “life-long” disorder (Shattuck et al., 2007); as a result, its prevalence in adulthood could be comparable to that seen in childhood (Tantam and Girgis, 2009). Nonetheless, its phenotypic expression may vary in relation to age (Roy et al., 2009) and gender (Lai et al., 2011). Different outcomes can be observed on the basis of the severity of the symptoms: some individuals reach a functioning comparable to that of the general population, showing high levels of adaptation. On the contrary, other subjects present psychopathological manifestations and unusual behaviors, up to suffer from serious functional deficits.
In adults, psychiatric intervention is usually required for the presence of comorbid mental disorders, including both anxiety and mood disorders and disruptive disorders, with impulsivity and aggression. Attention deficit hyperactivity disorder (ADHD) is also often comorbid with both AS and affective disorders. In such contexts, the diagnosis of AS is often underestimated or missed (Raja and Azzoni, 2008, Skeppar et al., 2013). On the other hand, the diagnosis of comorbid psychiatric disorders may also be complicated by the high frequency of atypical manifestations (Tantam and Girgis, 2009). One of the most common comorbidities in clinical settings is Bipolar Disorder (BD). The purpose of this review is to examine the relationship between AS and BD and their epidemiological, clinical and therapeutic implications.
Section snippets
Methods
A systematic review of the existing literature has been conducted through PubMed and Scopus using combinations of the following search terms: Asperger׳s Syndrome (AS), Autism Spectrum Disorders (ASD), Bipolar Disorder, depression, mood disorder, psychiatric comorbidity, treatment, mood stabilizers, anticonvulsants, antipsychotics, and antidepressants along with terms related to each of the areas of focus listed above. For prevalence and family data we considered eligible all the studies on
Comorbidity rates of Bipolar Disorder and Asperger׳s Syndrome in adulthood
Data regarding comorbidity between BD and AS in adults are relatively few and controversial (Table 1), although the presence of depressive symptoms and episodes of manic-depressive illness has been reported since the first descriptions of ASD (Rutter, 1970).
Most of the available literature on comorbidity between AS and Mood Disorders (MD) are limited to childhood and adolescence and, in generalizing the results to adulthood, some limitations should be considered. In clinical samples of very
Discussion
An increasing body of evidence indicates a frequent association between BD and AS in clinical samples, although it is difficult to estimate the actual prevalence of this comorbidity in general population. The literature also strongly supports that ASDs may be associated with a family history for mood disorders (Bolton et al., 1998, Ghaziuddin, 2005, Lajiness-O’neill and Menard, 2008, Piven et al., 1991) and that the most frequent association is reported with BD in family members of AS patients (
Role of funding source
Nothing declared.
Conflict of interest
Prof. Giulio Perugi has acted as consultant of Sanofi Aventis, Bristol Myers Squibb, Astra Zeneca, Eli Lilly, Boehringer Ingheleim; received grant/research support from Eli lilly, Astra Zeneca, Boehringer Ingheleim, Glaxo-SmithKline; is on the speaker/advisory board of Sanofi Aventis, Bristol Myers Squibb, Astra Zeneca, Eli Lilly, Boehringer Ingheleim, Glaxo-SmithKline, Pfizer, Wyeth, Jannsen-Cilag, Lundbeck.
Dr. Gabriele Masi has served on advisory boards for Eli Lilly, Shire and Novartis; has
Aknowledgements
None.
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