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Psychosis in autism: Comparison of the features of both conditions in a dually affected cohort

  • Felicity V. Larson (a1), Adam P. Wagner (a2), Peter B. Jones (a3), Digby Tantam (a4), Meng-Chuan Lai (a5), Simon Baron-Cohen (a3) and Anthony J. Holland (a3)...



There is limited information on the presentation and characteristics of psychotic illness experienced by people with autism spectrum disorder (ASD).


To describe autistic and psychotic phenomenology in a group of individuals with comorbid ASD and psychosis (ASD–P) and compare this group with populations affected by either, alone.


We studied 116 individuals with ASD–P. We compared features of their ASD with people with ASD and no comorbid psychosis (ASD–NP), and clinical characteristics of psychosis in ASD–P with people with psychosis only.


Individuals with ASD–P had more diagnoses of atypical psychosis and fewer of schizophrenia compared with individuals with psychosis only. People with ASD–P had fewer stereotyped interests/behaviours compared with those with ASD–NP.


Our data show there may be a specific subtype of ASD linked to comorbid psychosis. The results support findings that psychosis in people with ASD is often atypical, particularly regarding affective disturbance.

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This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Corresponding author

Felicity Larson, PhD, Department of Psychology (Clinical Psychology Section), Frankland Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. Email:


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See editorial, pp. 241–242, this issue.

Declaration of interest




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1 King, BH, Lord, C. Is schizophrenia on the autism spectrum? Brain Res 2011; 1380: 3441.
2 Mouridsen, SE, Rich, B, Isager, T. Psychiatric disorders in adults diagnosed as children with atypical autism. A case control study. J Neural Transm 2008; 115: 135–8.
3 Selten, J-P, Lundberg, M, Rai, D, Magnusson, C. Risks for non-affective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: a population-based study. JAMA Psychiatry 2015; 72: 483–9.
4 Khandaker, GM, Stochl, J, Zammit, S, Lewis, G, Jones, PB. A population-based longitudinal study of childhood neurodevelopmental disorders, IQ and subsequent risk of psychotic experiences in adolescence. Psychol Med 2014; 44: 3229–38.
5 Clarke, D, Baxter, M, Perry, D, Prasher, V. The diagnosis of affective and psychotic disorders in adults with autism: seven case reports. Autism 1999; 3: 149–64.
6 Lai, M-C, Baron-Cohen, S. Identifying the lost generation of adults with autism spectrum conditions. Lancet Psychiatry 2015; 2: 1013–27.
7 Lord, C, Rutter, M, Goode, S, Heemsbergen, J, Jordan, H, Mawhood, L, et al. Austism Diagnostic Observation Schedule: a standardized observation of communicative and social behavior. J Autism Dev Disord 1989; 19: 185212.
8 Lord, C, Rutter, M, Le Couteur, A. Autism Diagnostic Interview-Revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J Autism Dev Disord 1994; 24: 659–85.
9 Castle, DJ, Jablensky, A, McGrath, JJ, Carr, V, Morgan, V, Waterreus, A, et al. The diagnostic interview for psychoses (DIP): development, reliability and applications. Psychol Med 2006; 36: 6980.
10 Prosser, H, Moss, S, Costello, H, Simpson, N, Patel, P, Rowe, S. Reliability and validity of the Mini PAS-ADD for assessing psychiatric disorders in adults with intellectual disabilities. J Intellect Disabil Res 1998; 42: 264–72.
11 McGuffin, P, Farmer, A, Harvey, I. A polydiagnostic application of operational criteria in studies of psychotic illness: development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991; 48: 764.
12 World Health Organisation. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). WHO, 2007.
13 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 2000.
14 Spitzer, RL, Endicott, J, Robins, E. Research Diagnostic Criteria: rationale and reliability. Arch Gen Psychiatry 1978; 35: 773.
15 Wechsler, D. Wechsler Abbreviated Scale of Intelligence. The Psychological Corporation, 1999.
16 Baron-Cohen, S, Wheelwright, S, Robinson, J, Woodbury-Smith, M. The Adult Asperger Assessment (AAA): a diagnostic method. J Autism Dev Disord 2005; 35: 807–19.
17 Lai, M-C, Lombardo, M V, Ruigrok, AN V, Chakrabarti, B, Wheelwright, SJ, Auyeung, B, et al. Cognition in males and females with autism: similarities and differences. PLoS One 2012; 7: e47198.
18 Kirkbride, JB, Fearon, P, Morgan, C, Dazzan, P, Morgan, K, Tarrant, J, et al. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AESOP study. Arch Gen Psychiatry 2006; 63: 250–8.
19 Cohen, J. Statistical Power Analysis for the Behavioral Sciences (2nd edn). Erlbaum, 1988.
20 Green, SB, Salkind, NJ, Akey, T. Using SPSS for Windows: Analyzing and Understanding Data. Prentice-Hall, 1997.
21 Tantam, D. Lifelong eccentricity and social isolation. I. Psychiatric, social, and forensic aspects. Br J Psychiatry 1988; 153: 777–82.
22 Lugnegård, T, Hallerbäck, MU, Gillberg, C. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Res Dev Disabil 2011; 32: 1910–7.
23 Tantam, D. Autism Spectrum Disorders through the Life Span. Jessica Kingsley, 2012.
24 DeLong, R. Autism and familial major mood disorder: are they related? J Neuropsychiatry Clin Neurosci 2004; 16: 199213.
25 Sullivan, PF, Magnusson, C, Reichenberg, A, Boman, M, Dalman, C, Davidson, M, et al. Family history of schizophrenia and bipolar disorder as risk factors for autism. Arch Gen Psychiatry 2012; 69: 1099–103.
26 Smalley, SL, McCracken, J, Tanguay, P. Autism, affective disorders, and social phobia. Am J Med Genet 1995; 60: 1926.
27 Nuechterlein, KH, Dawson, ME. A heuristic vulnerability/stress model of schizophrenic episodes. Schizophr Bull 1984; 10: 300–12.
28 Happé, F, Ronald, A. The “fractionable autism triad”: a review of evidence from behavioural, genetic, cognitive and neural research. Neuropsychol Rev 2008; 18: 287304.
29 Tolosa, A, Sanjuán, J, Dagnall, AM, Moltó, MD, Herrero, N, de Frutos, R. FOXP2 gene and language impairment in schizophrenia: association and epigenetic studies. BMC Med Genet 2010; 11: 114.
30 Cheniaux, E, Landeira-Fernandez, J, Versiani, M. The diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder and unipolar depression: interrater reliability and congruence between DSM-IV and ICD-10. Psychopathology 2009; 42: 293–8.
31 Jones, P, Rodgers, B, Murray, R, Marmot, M. Child developmental risk factors for adult schizophrenia in the British 1946 birth cohort. Lancet 1994; 344: 1398–402.
32 Hallerback, MU, Lugnegard, T, Gillberg, C. Is autism spectrum disorder common in schizophrenia? Psychiatry Res 2012; 198: 12–7.
33 Woodberry, KA, Giuliano, AJ, Seidman, LJ. Premorbid IQ in schizophrenia: a meta-analytic review. Am J Psychiatry 2008; 165: 579–87.
34 Sullivan, S, Rai, D, Golding, J, Zammit, S, Steer, C. The association between autism spectrum disorder and psychotic experiences in the Avon longitudinal study of parents and children (ALSPAC) birth cohort. J Am Acad Child Adolesc Psychiatry 2013; 52: 806–14.e2.
35 Miller, GA, Chapman, JP. Misunderstanding analysis of covariance. J Abnorm Psychol 2001; 110: 40–8.
36 Holtmann, M, Bölte, S, Poustka, F. Autism spectrum disorders: sex differences in autistic behaviour domains and coexisting psychopathology. Dev Med Child Neurol 2007; 49: 361–6.
37 Peralta, V, Cuesta, MJ. A dimensional and categorical architecture for the classification of psychotic disorders. World Psychiatry 2007; 6: 100–1.
38 Läge, D, Egli, S, Riedel, M, Strauss, A, Möller, H-J. Combining the categorical and the dimensional perspective in a diagnostic map of psychotic disorders. Eur Arch Psychiatry Clin Neurosci 2011; 261: 310.
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Psychosis in autism: Comparison of the features of both conditions in a dually affected cohort

  • Felicity V. Larson (a1), Adam P. Wagner (a2), Peter B. Jones (a3), Digby Tantam (a4), Meng-Chuan Lai (a5), Simon Baron-Cohen (a3) and Anthony J. Holland (a3)...
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Psychosis in Autism

Michael Fitzgerald, Psychiatrist, Trinity College Dublin
30 May 2017

The Editor,

British Journal of Psychiatry,

Re: Psychosis in Autism.

Dear Editor,

Larson i et al, report on a major study on Psychosis in Autism, which is an important topic ii


They point out that it is a non-representative sample, but then go on to use the, “ADI-R” iii and

ADOS iv for clinical diagnosis. This vastly increases the non-representativeness of the sample

unnecessarily and takes it a very long way away from Autism in the general population. The

criteria they used to define Autism are very narrow, (old fashioned), concepts of Autism. These

clinical diagnoses based on this narrow view of Autism tell us very little about Autism as seen

in routine clinical practice, where professionals throughout the world now accept that the

broader Autism phenotype. I see many parents who come to me in great distress knowing that

their child has Autism and the school also observe this, having been told that their child did not

have Autism based on the ADI-R and that they were, “ADI negative”. This instrument is not

appropriate to making a sole diagnosis of Autism in clinical practice. It not uncommonly

misses high functioning Autism. In addition, Ventola v

has shown that the, ADI-R was significantly, “under-diagnosing toddlers”. How biased and unrepresentative the patients in

this survey can be seen by Professor Gillian Baird’s work on Autism in the general population vi


Indeed, using these narrow criteria gives you a prevalence of Autism of 25 per 10,000. When

you use the broader Autism Spectrum you get a truer rate of Autism of 116 per 10,000. One of

the problems also is that the National Institute for Health & Clinical Excellence, (NICE),

Guidelines vii on the diagnosis of Autism, which are accepted throughout the world, are not

followed. These state that there is no specific instrument recommended for a diagnosis of

Autism and that it is a clinical diagnosis by an experienced clinician in the diagnosis of Autism.

Professor Dorothy Bishop, Professor of Developmental Neuropsychology at the University of

Cambridge told Adam Feinstein that, “if you could be shown that there were real benefits in

accuracy of diagnosis from adopting this lengthy procedure, then I’d be happy to say, “okay”,

but the originators of the instrument have never demonstrated … it is really more an article of

faith with them”. Feinstein viii reports that at the prestigious International Meeting for Autism

in London in 2009, senior Autism researchers, “lambasted” these narrow instruments, “for

missing many cases of Autism”.

i Larson F.V., Wagner A.P., Jones P.B., Tantam D., Meng-Chuan L., Baron-Cohen S., and Holland A.J.

Psychosis in Autism: Comparison of the features of both conditions in a dually affected cohort. Br. J. Psychiatry

(2017); 2, 10: 269-275.

ii Fitzgerald M. Schizophrenia and Autism/Aspergers Syndrome: Overlap and Difference. Clinical

Neuropsychiatry. (2012); 9: 4, 171-176.

iii Lord C., Rutter M., Le Couteur A., Autism Diagnostic Interview – Revised: A revised version of a diagnostic

interview for caregivers of individuals with possible pervasive developmental disorders. J. Autism Dev. Disord.

(1994): 24: 659-85.

iv Lord C., Rutter M. Goode S., Heemsbergen J., Jordan H., Mawhood L., et al, Autism Diagnostic Observation

Schedule: A standardised observation of communicative and social behaviour. J. Autism Dev. Disord. (1989):

19: 185-211.

v Ventola P. E., Kleinman J. Pandey P., Barton M., Allen S., Greene J., Robins D., Fein D. Agreement among

Four Diagnostic Instruments for Autism Spectrum Disorders in Toddlers, Journal of Autism and Developmental

Disorders, 36, 7, 839-847.

vi Baird G., Simonoff E., Pickles A., Chandler S., Loucast Meldrum D., Charman T., Prevalence of Disorders of

the Autism Spectrum Disorder in a Population Cohort of Children in South Thames: The Special Needs and

Autism Project. Lancet 2006, 368, July 15th

, 2010-2015.

vii National Institute for Health & Clinical Excellence, Autism, The British Journal of Psychological Society and

the Royal College of Psychiatrists, (2012).

viii Feinstein A., A History of Autism. Wiley–Blackwell (2010).

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Conflict of interest: None Declared

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Autism and Psychosis: comorbidity or differential diagnosis?

Helen Lazaratou, Associate Professor of Child and Adolescent Psychiatry, National and Kapodistrian University of Athens, Greece
03 January 2017

The paper by Larson et al 1 published in the British Journal of Psychiatry, focused on comorbidity between Autistic Spectrum Disorders and Psychosis.

The difficulty in the distinction between psychotic and autistic features is not recent. E. Bleuler 2, introduced the term “autism” to describe a symptom of schizophrenia. L Kanner3 used the term in 1943 when he published his work on the "Autistic Disturbances of Affective Contact." In the earlier classification systems autism was considered as psychose. Only after 1980, with the publication of DSM-III, Psychosis and Pervasive Developmental Disorders were distinguished as separate clinical conditions.

The finding of superiority of atypical psychosis in dual diagnosis with autism shows that current knowledge on the causation, clinical manifestations and course of the disorders has allowed the differentiation of the diagnostic criteria between schizophrenia and autism. However, there is still controversy regarding autistic and psychotic ways of psychological functioning. As rightly pointed out by the authors, the above-mentioned finding brings again into question the use of dimensional or categorical classification models.

In the study by Larson et al, whilst psychosis is subcategorised further, this is not the case for the autistic spectrum disorders, and no distinction is made, for example, between typical autism and high-functioning autism /Asperger syndrome. It is a well-known phenomenon that individuals with typical autism, even if they are verbal, have difficulties in effectively expressing dysfunctional thoughts or changes in their emotional state. Moreover, it is very difficult to estimate “the decline from previous functioning” included to the diagnostic criteria of psychosis, since their functioning level is already low. In their study Larson et al, measured only the Verbal IQ and not the Full Scale IQ, which would indicate the proportion of people with high-functioning autism included in the sample. The finding that individuals with co-morbidity of autism and psychosis exhibit less stereotypical behaviours, may be due to the fact that individuals with Asperger syndrome outnumber those with typical autism in the sample.

Finally, in the section “clinical implications” it would be helpful to highlight the different approach taken by child psychiatrists and adult psychiatrists in this specific subject. Child psychiatrists tend to put often the diagnosis of “autistic spectrum disorders” in children of preschool and school age, often ignoring the fact that the reported symptoms may represent early symptoms of schizophrenia. On the contrary, in later adolescence and adulthood (especially in cases of high functioning autism/Asperger syndrome) adult psychiatrists tend to underdiagnose autistic disorders in favour of a diagnosis of schizophrenia. This practice is likely to lead to potentially unnecessary use of pharmacotherapy.

There is an urgent need for closer cooperation between child and adult psychiatrists that would enable the development of specific diagnostic and therapeutic approaches for the accurate diagnostic evaluation and effective long-term management of these patients.

1.Felicity V. Larson, Adam P. Wagner, Peter B. Jones, Digby Tantam, Meng-Chuan Lai, Simon Baron-Cohen, Anthony J. Holland : Psychosis in autism: comparison of the features of both conditions in a dually affected cohort The British Journal of Psychiatry December 2016, bjp.bp.116.187682. DOI: 10.1192/bjp.bp.116.187682

2.Bleuler E. Dementia praecox or the group of schizophrenia. IUPEE edition. New York; 1911

3.Kanner L. Autistic disturbances of affective contact. Nervous Child, 1943, 2, 217-250.

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Conflict of interest: None Declared

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