Addiction and Autism Spectrum Disorder

© Springer-Verlag Berlin Heidelberg 2015
Geert Dom and Franz Moggi (eds.)Co-occurring Addictive and Psychiatric Disorders10.1007/978-3-642-45375-5_14

14. Addiction and Autism Spectrum Disorder

Patricia J. M. van Wijngaarden-Cremers  and Rutger Jan van der Gaag 
(1)
Department of Addiction and Developmental Psychiatry, Dimence GGz Zwolle, Center of Experitise Developmental Disorders, Deventer, The Netherlands
(2)
Clinical Child and Adolescent, UMCN Nijmegen, Nijmegen, The Netherlands
 
 
Patricia J. M. van Wijngaarden-Cremers (Corresponding author)
 
Rutger Jan van der Gaag
Abstract
At first glance, addictive and autism spectrum disorders (ASD) seem absolutely unrelated. However, in clinical practice this does not appear to be true at all. Many individuals with autism, neurobiological characterized by dopaminergic deregulations, are at high risk for developing addictive behaviors. A prime reason might be to alleviate the high levels of stress and anxiety that they experience in an environment with stimulus overload or in engaging in social situations. The use of substances or repetitive behaviors and bizarre habits may develop rapidly into substance use disorders or behavioral addictions. In some cases the diagnosis of ASD will have be made earlier in life, but parents and workers in the field of autism are often unaware of addiction as a comorbid condition to ASD. Conversely addicted individuals may have an autism spectrum condition that is not recognized, because both relatives and workers in the field of addiction and psychiatry are often unfamiliar with signs of ASD and unaware of the potential comorbidity. Thus the identification of both conditions is a core issue in managing comorbid ASD and addiction. Guidelines for ASD provide useful tools for assessment and guidance for treatment. In relapse prevention interventions, identifying those situations that cause stress and elicit addictive craving and behaviours is crucial. Training skills to learn how to cope, in another ways than by using substances, with these situations are essential within the treatment. In addition, rational pharmacotherapy may prove very helpful.

14.1 Introduction

Few people in the field of addiction and psychiatry are familiar with Autism Spectrum Disorders (ASD). Conversely most workers in the field of ASD are unaware of addiction and addictive behaviour in their patients. Yet in clinical populations prevalence of comorbid ASD and addiction is rather common (Singh et al. 2012; Sizoo et al. 2009; Van Wijngaarden-Cremers and Van der Gaag 2010). Due to a lack of awareness, knowledge and experience, both addictive behaviours in individuals with ASD as ASD in addicted individuals are often overlooked. This is detrimental for these patients and for their direct environment. Moreover, it leads to confusion and frustration in therapeutic teams that feel incapable of addressing these challenging behaviours that do not respond to the routine in their treatment plans and guidelines. Before entering into the theoretical overlaps between both disorders and the consequences for rational treatments, first two clinical cases two illustrate the point.

14.2 Case Histories

14.2.1 A late diagnosis: Peter, a case of marked autistic rigidity

Peter was 20 years of age when he was admitted to a detox unit with serious alcohol dependence and features of a cluster B personality disorder. He was pretty aggressive and would get extremely cross when hindered by his parents or others to consume alcohol. The detox did not pose any problems. These occurred when at the start of the rehabilitation he was assigned doing tasks within the group therapy. That day he had to do the shopping for the dinner. The therapeutic goal of such tasks is to learn how to perform tasks within a certain time frame and take responsibility for oneself and others. He managed to get the shopping done in time but was tidying them at the time when he was expected to join a group therapy session. When one of the nurses confronted him, he went out of his mind, became very aggressive, and bashed doors and broke windows whilst threatening the nurse verbally. Due to this unacceptable behaviour he was dismissed from the program immediately. A week later he came back to our outpatient clinic and was asked what had happened and had caused his extreme reaction. He said that he became very angry because the nurse had interrupted him. It was for him inconceivable that he should have joined the group leaving his task unfinished. In the clinical interview it became clear that these rigid patterns of behaviour, his incapacity to communicate and an impaired social sensitivity had been characteristics during his whole development. Alcohol helped him to ease the path towards social encounters with others. A thorough assessment including interviews with his parents and the reading school reports confirmed a diagnosis of Asperger’s within ASD. Once approached as such this difficult to handle young adult became compliant, cooperative, well willing, and managed to stop abusing alcohol.
Reflecting on this case one discovered that Peter’s parents were utterly shocked when they realised that he had been consuming large quantities of alcohol. They had always known him as a strikingly honest lad. As from preschool he was extremely interested in archaeology. So were his “friends”. These friends were very welcome, as he had none in his regular classes. He joined archaeological summer camps. In retrospect he may have started drinking at that point of time. Gradually his parents realized he was drinking before social events, possibly to reduce his “social” shyness (in retrospect anxiety). The explosions of anger such as they were seen in the detox, were also familiar to his parents. But they were surprised because up to then this only manifested in that way at home. He would have fierce anger tantrums whenever things did not go according to plan that is to say when he was not told on forehand. Parents were always worried about unexpected things beyond their control, such as spontaneous visitors, because they would have disastrous consequences. As a worker in the archive department at the town hall, he was valued for his accurate and precise way of working and his knowledge. Yet over the past months he was more stressed and a faint smell of alcohol during daytime had not gone unnoticed.

14.2.2 From ASD to Substance Abuse: Sarah, a preoccupation run out of hand

Sarah is a 14-year-old adolescent diagnosed with Asperger’s. At the elementary school she was well accepted as a pedantic eloquent, clumsy girl with a special interest for all that was related to nature. She collected leaves and feathers and always had a tame rat under her pullover. She was left alone and no one dared to tease or bully her. She did well and went to the gymnasium the highest secondary school type in our country with Latin, Greek and sciences. Her interest shifted from nature to gaming. She would spend hours in a row, playing games and chatting with virtual friends. Once in a while these would organize meetings. There she met people who drank and smoked pot. She liked it because it helped her overcome her shyness. The group went on and experimented with speed. Her parents are amazed to witness a metamorphosis from socially aloof towards suddenly, spending time with “friends”. One day they get a phone call from the police. Their daughter has been arrested for dealing drugs. She has been used and (sexually) abused by dealers and used as a drugs courier. She confessed in a very naive manner, once in the detox, that she thought these were her first real friends and would do anything to be their friend. Once in detox she reappeared to be the socially isolated and clumsy intelligent young girl.
Reflecting on this case: Sarah is anxious and confused. She experiences flashback memories of being forced into sex by “boys” in her junk scene. Often she feels a complete outsider and a spectator of her own life. She feels filthy and betrayed when she finally thought she had found friends in the scene. It felt so much better than having only her tame rat as a companion. In secondary school her preoccupation was entirely out of tune with her peers who wanted to date and have fun. She was surprised when a boy showed interest in her rat. He asked her to join him and offered her a joint. When he insisted that they should have sex, she complied not daring to refuse, but feeling awfully miserable. She wanted to be part of the group and gave in. Finally people seemed interested in her. But as she was abused over and over again, things got out of hand and lead to her decompensation.

14.3 Epidemiology

Awareness to addictive behaviours in individuals with ASD has only been raised recently. There is a remarkable paucity of solid epidemiological data on the extend of the problem. Only recently have studies on comorbidity in ASD included substance use disorders in their listings on clinical samples in adults (Hofvander et al. 2009; Lugnegård et al. 2011). The prevalence of addiction in those ADS populations (19 %, respectively 16 % in both studies) is higher than that reported in the general population but lower than the reported prevalence of substance use disorders in other developmental psychiatric disorders such as ADHD and schizophrenia. Yet it could be hypothesized that one in five to six in individuals with ASD is only the top of an iceberg as in none of the studies thus far behavioural addictions such as (internet) gaming, Internet use, shopping, and stalking were taken into account.

14.4 Theoretical Underpinnings and Causal Pathways

At first glance addiction and autism seem very different disorders. In some respects they even seem to be each other’s antipodes. The socially aloof naïve person with autism on one side, and the cunning, lying addicted individual on the other. But alongside these big differences some striking behavioural similarities can be found, e.g. both groups are extremely detail oriented and compulsive. Moreover both are developmental brain disorders with a strong dopaminergic component in their pathogenesis (Dichter et al. 2012). At the start preoccupations (e.g. with spinning objects) and stereotype movements (rocking, whirling, swinging: sometimes leading to trance-like state) in ASD are aimed at soothing over-arousal, stress, and anxiety. Likewise addiction often starts with taking substances or behaviours (gambling) to feel better and regulate difficult to manage tensions. Stimulation of the dopaminergic reward system by substance use or habit behaviour might not only give a “good” feeling but also help to cope with scary, stressful situations.
So are there common neurobiological characteristics to both conditions? Recent studies provide some evidence for such neurobiological overlap in the dopaminergic deregulation of the cortico-striatal-limbic loop (leading to skewed and compulsive behaviours) both in addiction and autism (Langen et al. 2011). In this respect ASD is in terms of dopaminergic deregulation at the interface of ADHD on one side, addiction on the other along with obsessive–compulsive disorder (OCD). The motor stereotypies may point to a motor component related to motor neurological disorders such as Parkinson’s disease. But this is yet small evidence in need of far more research to identify these relationships and the possible neurobiological links explaining the enhanced vulnerability to addictions in ASD.

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Dec 3, 2016 | Posted by in PSYCHOLOGY | Comments Off on Addiction and Autism Spectrum Disorder

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