Psychiatric comorbidities in autism spectrum disorder: A comparative study between DSM-IV-TR and DSM-5 diagnosis

Abstract

Background/Objective: The heterogeneous clinical presentations of individuals with Autism Spectrum Disorders (ASD) pose a significant challenge for sample characterization. Therefore the main goal of DSM-5 must be to identify subgroups of ASD, including comorbidity disorders and severity. The main goal of this study is to explore the psychiatric comorbidities and the severity of symptoms that could be relevant for the phenotype characterization in ASD and also to compare these results according to the different classification criteria between the DSM-IV-TR and the DSM-5. Method: A comparative study of severity and psychiatric comorbidities was carried out between a sample of participants that only met criteria for Pervasive Developmental Disorder (PDD) according to the DSM-IV-TR and a sample of participants that also met ASD criteria according to DSM-5 classification. The recruitment of children was via educational (N=123). The psychiatric symptoms, comorbid disorders and severity of symptoms were assessed through The Nisonger Child Behavior Rating Form, clinical interview and The Inventory of Autism Spectrum Disorder, respectively. The psychiatric comorbidities considered were: anxiety, eating behavioural problems, self-aggressiveness, hetero–aggressiveness, self-harm, obsessive compulsive disorder and attention deficit and hyperactivity disorder. Results: Statistically significant differences between both groups were found regarding obsessive compulsive disorder, eating behavioural problems and severity. Conclusions: The results support the hypothesis that patients who meet the DSM-5 criteria have more severe symptoms, not only regarding the core autistic symptoms but also in relation with psychiatric comorbidities.

Full text

International
Journal
of
Clinical
and
Health
Psychology
(2016)
16,
266---275
www.elsevier.es/ijchp
International
Journal
of
Clinical
and
Health
Psychology
ORIGINAL
ARTICLE
Psychiatric
comorbidities
in
autism
spectrum
disorder:
A
comparative
study
between
DSM-IV-TR
and
DSM-5
diagnosis
Marina
Romeroa,b,∗,
Juan
Manuel
Aguilarc,
Ángel
Del-Rey-Mejíasd,
Fermín
Mayoralc,
Marta
Rapadod,
Marta
Peci˜
nae,
Miguel
Ángel
Barbanchob,
Miguel
Ruiz-Veguillaf,
José
Pablo
Larab
aKing’s
College
London,
United
Kingdom
bUniversidad
de
Málaga,
Andalucía
TECH,
IBIMA,
Spain
cHospital
Carlos
Haya
Málaga,
Spain
dHospital
General
Universitario
Gregorio
Mara˜
nón
Madrid,
Spain
eUniversity
of
Michigan,
USA
fUniversidad
de
Sevilla,
IBIS,
Spain
Received
11
January
2016;
accepted
29
March
2016
Available
online
3
June
2016
KEYWORDS
Autism
spectrum
disorder;
DSM-IV-TR;
DSM-5;
Psychiatric-
comorbidities;
Descriptive
study
Abstract
Background/Objective:
The
heterogeneous
clinical
presentations
of
individuals
with
Autism
Spectrum
Disorders
(ASD)
pose
a
significant
challenge
for
sample
characterization.
Therefore
the
main
goal
of
DSM-5
must
be
to
identify
subgroups
of
ASD,
including
comorbidity
disorders
and
severity.
The
main
goal
of
this
study
is
to
explore
the
psychiatric
comorbidities
and
the
severity
of
symptoms
that
could
be
relevant
for
the
phenotype
characterization
in
ASD
and
also
to
compare
these
results
according
to
the
different
classification
criteria
between
the
DSM-IV-TR
and
the
DSM-5.
Method:
A
comparative
study
of
severity
and
psychiatric
comor-
bidities
was
carried
out
between
a
sample
of
participants
that
only
met
criteria
for
Pervasive
Developmental
Disorder
(PDD)
according
to
the
DSM-IV-TR
and
a
sample
of
participants
that
also
met
ASD
criteria
according
to
DSM-5
classification.
The
recruitment
of
children
was
via
educational
(N
=
123).
The
psychiatric
symptoms,
comorbid
disorders
and
severity
of
symptoms
were
assessed
through
The
Nisonger
Child
Behavior
Rating
Form,
clinical
interview
and
The
Inventory
of
Autism
Spectrum
Disorder,
respectively.
The
psychiatric
comorbidities
considered
∗Corresponding
author:
Institute
of
Psychiatry,
Psychology
&
Neuroscience,
King’s
College
London,
De
Crespigny
Park,
London
SE5
8AF,
United
Kingdom.
E-mail
address:
marina.romero
gonzalez@kcl.ac.uk
(M.
Romero).
http://dx.doi.org/10.1016/j.ijchp.2016.03.001
1697-2600/©
2016
Asociaci´
on
Espa˜
nola
de
Psicolog´
ıa
Conductual.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Psychiatric
comorbidities
in
autism
spectrum
disorder
267
were:
anxiety,
eating
behavioural
problems,
self-aggressiveness,
hetero---aggressiveness,
self-
harm,
obsessive
compulsive
disorder
and
attention
deficit
and
hyperactivity
disorder.
Results:
Statistically
significant
differences
between
both
groups
were
found
regarding
obsessive
com-
pulsive
disorder,
eating
behavioural
problems
and
severity.
Conclusions:
The
results
support
the
hypothesis
that
patients
who
meet
the
DSM-5
criteria
have
more
severe
symptoms,
not
only
regarding
the
core
autistic
symptoms
but
also
in
relation
with
psychiatric
comorbidities.
©
2016
Asociaci´
on
Espa˜
nola
de
Psicolog´
ıa
Conductual.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/
by-nc-nd/4.0/).
PALABRAS
CLAVE
Trastorno
del
Espectro
Autista;
DSM-IV-TR;
DSM-5;
comorbilidades
psiquiátricas;
estudio
descriptivo
Comorbilidades
psiquiátricas
en
los
trastornos
del
espectro
autista:
estudio
comparativo
entre
los
criterios
DSM-IV-TR
y
DSM-5
Resumen
Antecedentes/Objetivo:
Los
Trastornos
del
Espectro
Autista
(TEA)
incluyen
un
grupo
heterogéneo
en
cuanto
a
su
presentación
clínica,
que
supone
un
desafío
a
nivel
de
caracter-
ización
diagnóstica.
Por
consiguiente,
el
objetivo
principal
de
la
clasificación
DSM-5
debería
de
ser
identificar
subgrupos
de
TEA
incluyendo
severidad
y
comorbilidades
psiquiátricas.
El
objetivo
principal
de
este
estudio
es
explorar
las
comorbilidades
diagnósticas
que
pueden
ser
relevantes
como
descriptores
de
fenotipos
autistas
así
como
la
severidad
de
los
síntomas
de
autismo
y
comparar
los
resultados
de
las
diferentes
criterios
de
clasificación
entre
el
DSM-
IV-TR
y
el
DSM-5.
Método:
Se
realiza
un
estudio
comparativo
de
severidad
y
comorbilidades
psiquiátricas
entre
una
muestra
con
diagnóstico
de
Trastorno
Generalizado
del
Desarrollo,
según
criterios
DSM-IV-TR,
y
una
muestra
que
cumplía
también
criterios
para
TEA
según
la
clasificación
DSM-5.
La
muestra
fue
obtenida
en
centros
educativos
(N
=
123).
Las
comorbili-
dades
psiquiátricas
y
la
severidad
de
los
síntomas
se
evaluaron
a
través
del
The
Nisonger
Child
Behavior
Rating
Form,
entrevista
clínica
y
el
Inventario
de
Trastorno
del
Espectro
Autista,
respectivamente.
Las
comorbilidades
estudiadas
fueron
ansiedad,
alteraciones
de
la
conducta
alimentaria,
auto-agresividad,
hetero-agresividad,
autolesiones,
trastorno
obsesivo-compulsivo
y
déficit
de
atención
e
hiperactividad.
Resultados:
Se
encontraron
diferencias
estadística-
mente
significativas
entre
ambos
grupos
para
trastorno
obsesivo-compulsivo,
alteraciones
de
la
conducta
alimentaria
y
severidad.
Conclusiones:
Se
apoya
la
hipótesis
de
que
los
individuos
que
cumplen
criterios
diagnósticos
según
DSM-5
tienen
mayor
severidad
sintomática,
no
sólo
con
respecto
a
los
síntomas
autistas
centrales,
sino
también
en
relación
con
comorbilidades
psiquiátricas.
©
2016
Asociaci´
on
Espa˜
nola
de
Psicolog´
ıa
Conductual.
Publicado
por
Elsevier
Espa˜
na,
S.L.U.
Este
es
un
art´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Autism
Spectrum
Disorder
(ASD)
is
characterized
by
deficits
in
social
interaction
and
communication,
as
well
as
the
presence
as
stereotyped
behaviour
and
restrictive
interests
(American
Psychiatric
Association,
APA,
2013).
In
the
past,
all
psychiatric
problems
in
children
and
adults
with
autism
used
to
be
attributed
to
autism
itself.
However,
an
increasing
number
of
studies
are
arguing
for
accepting
behaviours
and
symptoms
that
had
been
considered
addi-
tional
or
associated
features
of
ASD
as
potentially
indicating
the
presence
of
comorbidities
warranting
additional
diag-
nosis.
Individuals
diagnosed
with
ASD
often
present
other
psychiatric
disorders,
such
as
attention
deficit
and
hyperac-
tivity
disorder
(ADHD),
anxiety
disorders,
mood
alterations,
etc.
(Simonoff
et
al.,
2008).
It
has
been
suggested
that
comorbidity
will
generally
lead
to
more
severe
impairments
as
a
result
of
the
cumulative
effects
of
having
more
than
one
disorder
(Gadow,
Guttmann-Steinmetz,
Rieffe,
&
Devincent,
2012).
Autism
is
generally
a
lifelong
condition
beginning
in
childhood
and
with
pathological
outcomes
in
adulthood.
Outcomes
are
often
described
as
difficulties
or
issues
in
finance,
employment
and
socialization
(Fountain,
Winter,
&
Bearman,
2012).
When
other
problematic
symptoms
are
rec-
ognized
as
manifestation
of
comorbid
psychiatric
disorders,
rather
than
just
isolated
symptoms,
more
specific
treat-
ment
is
possible.
For
this
reason,
comorbidity
identification
should
include
those
symptoms
which
are
sufficient
for
a
comorbidity
diagnosis
and
those
isolated
symptoms
which
can
be
relevant
as
descriptors
of
individual
phenotypes
such
as
eating
behaviour
problems,
behaviour
difficulties
such
as
self-aggression
or
hetero-aggression.
One
of
the
goals
of
the
new
classification
(DSM-5)
must
be
to
identify
subgroups
of
ASD,
including
comorbidity
disor-
ders,
which
may
be
important
to
understand
the
biological
mechanisms,
the
clinical
results
and
the
reactions
of
the
individuals
with
ASD
to
the
treatment.
It
has
been
proposed
a
phenotypic
characterization
to
improve
the
classification

268
M.
Romero
et
al.
of
ASD
based
not
only
on
the
specific
items
of
ASD,
but
involving
other
specific
characterizations
such
as
cognitive
and
adaptive
function,
language
skills,
comorbidity,
other
medical
conditions
and
other
psychiatric
features
in
order
to
standardize
the
clinical
characteristics
of
individuals
with
ASD
(Grzadzinski,
Huerta,
&
Lord,
2013).
The
publication
of
the
fifth
edition
of
the
DSM
has
inten-
sified
a
debate
since
the
announcement
of
the
changes
in
diagnostic
criteria
proposed
by
the
APA.
There
is
an
increment
of
studies
that
open
many
questions
about
the
diagnostic
validity
of
the
DSM-5
(Robles
et
al.,
2014;
Rodríguez-Testal,
Senín-Calderón,
&
Perona-Garcelán,
2014;
Timimi,
2014).
One
of
the
important
controversies
is
the
diagnosis
of
ASD.
The
DSM-5
unifies
the
first
and
the
sec-
ond
domain
into
a
single
category
which
include
meeting
all
three
distinctions
of
Social
Communication
and
Interac-
tion
(SCI).
The
DSM-5
classification
assembles
the
Pervasive
Developmental
Disorders
(PDD)
with
different
diagnostic
subtypes
into
a
single
dimensional
category
of
ASD,
grouped
by
severity
levels
(McPartland,
Reichow,
&
Volkmar,
2012;
Worley
&
Matson,
2012).
There
is
an
accord
in
different
articles,
stating
that
the
new
classification
requires
more
severe
symptomatology
for
the
diagnosis
(Gibbs,
Aldridge,
Chandler,
Witzlsperger,
&
Smith,
2012;
Matson,
Kozlowski,
Hattier,
Horovitz,
&
Sipes,
2012;
Turygin,
Matson,
Beighley,
&
Adams,
2013).
The
DSM-5,
with
difference
to
DSM-IV-TR,
admits
comor-
bidity
with
Attention
Deficit
and
Hyperactivity
Disorders
(ADHD)
in
patients
diagnosed
with
ASD.
Many
studies
showed
a
high
percentage
of
children
diagnosed
with
ASD,
who
require
health
services,
have
ADHD
comorbidity
(Brereton,
Tonge,
&
Einfeld,
2006;
Holtmann,
Bolte,
&
Poustka,
2007;
Sinzig,
Walter,
&
Doepfner,
2009;
Yerys,
Wallace,
Jankowski,
Bollich,
&
Kenworthy,
2011).
Also,
estimates
of
impairing
anxiety
range
from
11---84%
in
school-aged
children
with
ASD
and
as
many
as
40%
meet
criteria
for
an
anxiety
disorder
(Kerns
&
Kendall,
2013;
van
Steensel,
Bogels,
&
Perrin,
2011;
White,
Oswald,
Ollendick,
&
Scahill,
2009).
These
reviews
note
a
wide
range
of
estimates
attributable
to
differences
in
the
sample
source,
sample
size
and
assessment
methods
employed.
These
rates
of
anxiety
disorders
in
youth
with
ASD
are
nearly
two-fold
higher
than
current
estimates
in
typically
developing
children
(Costello,
2005).
Other
reports
indicate
that
Separation
Anxiety
and
Generalized
Anxiety
(Gadow,
DeVincent,
Pomeroy,
&
Azizian,
2004)
also
occur
at
higher
than
expected
rates
in
youth
with
ASD.
Although
the
majority
of
previous
studies
involved
clinic-based
samples,
community-based
studies
also
indicate
that
children
with
ASD
are
at
greater
risk
of
anxiety
(Simonoff
et
al.,
2008).
Because
of
pure
phenomenological
reasons,
the
Obses-
sive
Compulsive
Disorders
(OCD)
and
autism
include
the
behavioural
appearances
(e.g.,
the
compulsions
in
the
OCD;
rituals
and
routines
in
ASD)
and
cognitive
appearances
(the
obsession
in
the
OCD;
equality
insistence
and
worries
in
ASD).
Although
the
form
and
content
of
these
symptoms
are
different
in
both
disorders
(McDougle
et
al.,
1995;
Zandt,
Prior,
&
Kyrios,
2007);
autism
tends
to
involve
less
complex
forms
which
are
perhaps
due
to
the
existence
of
cogni-
tive
disorders
and/or
language.
Despite
of
any
overlap,
the
profile
of
repetitive
behaviours
in
autism
and
OCD
is
also
dif-
ferentiable
(Bejerot,
2007).
For
example,
individuals
with
OCD
usually
do
not
have
repetitive
motor
behaviours
often
associated
with
autism
(e.g.,
hand
flapping).
In
addition,
individuals
with
OCD
exhibit
more
cleaning,
checking
and
counting
behaviours,
while
individuals
with
autism
engage
in
more
hoarding,
ordering,
touching/tapping,
and
self-
inflicted
injuries
(McDougle
et
al.,
1995).
The
underlying
causes
of
repetitive
behaviour
are
unclear,
although
the
modulation
of
arousal
is
usually
suggested
for
ASD,
and
anx-
iety
for
OCD
(Zandt
et
al.,
2007).
In
addition,
children
with
early
symptoms
of
neuropsy-
chiatric
disorders
present
a
higher
frequency
of
behavioural
eating
problems
(Bandini
et
al.,
2010)
compared
with
children
who
do
not
have
any
disorders
(Bryant-Waugh,
Markham,
Kreipe,
&
Walsh,
2010).
Some
published
studies
of
children
diagnosed
with
ASD,
show
an
estimated
90%
preva-
lence
of
eating
problems
(Kodak
&
Piazza,
2008).
According
to
another
study,
the
prevalence
of
eating
problems
was
0.6%
in
the
control
study
population
and,
among
children
with
eating
problems,
40%
were
screened
positive
for
ADHD
and/or
ASD
(Rastam
et
al.,
2013).
Similarly,
self-harm,
self-
injurious
behaviours
and
hetero-aggression
are
very
common
in
children
diagnosed
with
Pervasive
Developmental
Disor-
der
(PDD).
In
fact,
the
drugs
used
in
ASD
are
aimed
at
treating
behavioural
and
symptomatic
problems,
despite
these
symptoms
are
not
part
of
the
core
symptoms
of
ASD
(Soutollo,
2010).
For
this
reason,
the
characterization
of
ASD
should
consider
the
assessment,
not
only
of
the
comorbid
disorders
but
also,
the
independent
symptoms
that
might
influence
on
the
functionality
or
on
the
medical
treatment
of
this
population.
Therefore,
the
main
goal
of
the
present
study
was
to
ana-
lyse
the
clinical
diagnostic
comorbidities
and
the
isolated
psychiatric
symptoms
which
can
be
relevant
as
descriptors
of
autistic’s
phenotype.
A
comparative
study
was
carried
out
between
a
sample
of
patients
with
PDD
diagnosis
accord-
ing
to
the
DSM-IV-TR
criteria
and
a
sample
of
patients
with
clinical
diagnosis
of
ASD
according
to
DSM-5.
It
is
hypothe-
sized
that
the
group
of
patients
who
met
the
DSM-5
criteria
have
more
severe
symptomatology,
not
only
regarding
the
severity
of
core
autistic
symptoms
but
also
in
relation
with
different
comorbid
conditions.
Method
Participants
The
recruitment
of
patients
was
via
educational
institutions
in
Málaga
(Southern
Spain).
According
to
the
census
of
indi-
viduals
between
5
and
15
years
registered
in
the
province
of
Malaga
and
data
from
the
Spanish
National
Institute
of
Statistics,
the
number
of
individuals
enrolled
in
school
was
56,839.
The
study
was
conducted
accordingly
with
the
Helsinski
Declaration
and
was
approved
by
the
Local
Com-
munity
Ethics
Committee.
See
flow
diagram
in
Figure
2.
Individual
and
parents’
interviews
were
made
in
the
Unit
of
Child
and
Adolescents
Mental
Health
in
Carlos
Haya
Hos-
pital
in
Malaga
(Southern
Spain),
after
signing
the
informed
consent.
Psychiatrists
and
psychologists
with
experience
in
children
and
adolescents
carried
out
the
assessments.
Firstly,
it
was
confirmed
the
community
diagnosis
for
PDD
by
the
clinical
interview
and
according
to
the
checklist
DSM-IV-
TR/ICD-10
scale.
In
term
of
demographic
features;
the
mean

Psychiatric
comorbidities
in
autism
spectrum
disorder
269
Autism Spectrum Disorders
Criteria ACriteria B
Non-verbal social communication
Reciprocal relationships
Repetitive speech/movements or use of objects ?
Adherence to routines/rituals
Restricted/intense interests
Unusual sensory interests/reactions
Social-emotional reciprocity
Language
level
Intellectual &
adaptive
funtioning
Type of
onset
ADHD
Language
delay
Expressive
language
SLI
Anxiety
Mood
Etc...
Comorbid
symptoms
Medical
conditions
Figure
1
Proposed
Diagnostic
and
Statistical
Manual
of
Mental
Disorders,
5th edition
(DSM-5)
criteria
and
associated
features
to
be
considered
when
characterizing
autism
spectrum
disorder
(ASM)
samples
(Grzadzinski
et
al.,
2013,
with
permission).
Contacting
Assessments Participation Identification
Census of individuals registered in schools in Malaga, Southern Spain.
[Spanish National Institute of Statistics]
(n=5.6839)
Initial contact to schools via telephone where there were
students with diagnosed of PDD according to
(n=71 schools)
Contact with families via schools
(n=49 schools) Schools refused participat
e
(n=19 schools)
All families accepted participate
(n=22)
Partial families participations
(n=30 schools)
Families direct assessments in Child and Adolescent Mental
Health Unit
(n=130)
Included
Children who meet DSM IV-TR criteria for PDD
[checklist DSM-IV-TR / ICD-10 scale]
(n=123 children)
Children who do not meet DSM IV-TR
criteria for PDD (clinical assessments)
(n=7 children)
Excluded
Children who do not meet DSM 5
criteria for ASD
(n=66)
Children who meet DSM
5
criteria for ASD
(n=57)
Figure
2
Flow
diagram.

270
M.
Romero
et
al.
age
of
participants
was
10.62
and
82%
of
the
sample
were
males.
Instruments
and
Procedure
In
order
to
confirm
the
clinical
diagnosis
of
PDD,
the
DSM-IV-TR/ICD-10
Checklists
were
selected.
Psychometric
properties
of
the
DSM-IV-TR/ICD-10
Checklist
have
been
shown
to
be
satisfactory
as
inter-rater
reliability
(r
=
.89),
test-retest
reliability
(r
=
.97),
and
internal
consistency
(␣
=
.95)
were
all
robust
(Gonzalez,
2008;
Matson,
Dempsey,
Lovullo,
&
Wilkins,
2008;
Worley
&
Matson,
2012).
The
DSM-5
clinical
diagnosis
for
ASD
was
assessed
by
child
psychiatrists
according
to
the
DSM-5
manual,
published
in
May,
2013.
As
we
can
see
in
the
Figure
1,
and
consistently
with
the
DSM-5,
patients
should
have
meet
the
three
items
of
the
criteria
A,
belonging
to
the
domain
of
sociability
and
at
least
two
items
for
the
criteria
B,
restrictive
interest
and/or
repetitive
behaviour
domain
(RRB).
The
DSM-IV-TR/ICD-10
checklist
scale
was
also
used
for
this
purpose.
Finally,
the
total
sam-
ple
of
patients
diagnosed
with
PDD
according
to
DSM-IV-TR
was
divided
into
two
groups:
(1)
DSM-5
group;
individuals
who
met
also
the
DSM-5
criteria
for
ASD
and
(2)
Non
DSM-5
group;
individuals
who
only
met
DSM-IV-TR
criteria
for
PDD
(not
DSM-5
criteria).
Variables
of
psychiatric
comorbidities
were
obtained
by
the
clinical
assessment,
and
parents’
interviews,
using
the
DSM-IV-TR
criteria.
The
comorbid
conditions
studied
were:
(1)
Attention
Deficit
and
Hyperactivity
Disorder
and
(2)
Obsessive
Compulsive
Disorder.
Moreover,
the
following
independent
psychiatric
symptoms
were
assessed
the
same
way:
(1)
Anxious
or
too
fearful,
(2)
Physically
harms
or
hurts
self
on
purpose,
(3)
Physically
attacks
people,
(4)
Self-harm
enough
to
leave
tooth
marks
or
break
skin
and
(5)
Eating
behavioural
problems.
The
prevalence
and
frequency
of
some
of
these
symptoms
(1,
2,
3),
were
collected
according
to
The
Nisonger
Child
Behaviour
Rating
Form
(NCBRF)
(Problem
behaviour
sub-
scale)
(Aman,
Burrow,
&
Wolford,
1995).
The
NCBRF
(Norris
&
Lecavalier,
2011)
is
a
factor-analytically
derived
scale
with
items
rated
from;
did
not
occur
or
was
no
a
problem
(0)
to
behaviour
occurred
a
lot
or
was
a
severe
problem
(3).
There
are
two
versions
of
the
NCBRF:
a
parent
and
teacher
version.
The
Conduct
subscale
of
the
NCBRF
has
been
used
as
an
outcome
measure
in
placebo
controlled
tri-
als
of
children
with
mild
developmental
disabilities
(Brown,
Aman,
&
Havercamp,
2002;
Snyder
et
al.,
2002).
It
has
also
been
used
to
characterize
a
large
sample
of
children
with
ASD
(Lecavalier,
2006).
Concerning
the
item
of
(4)
self-harm
enough
to
leave
tooth
marks
or
break
skin,
the
symptom
was
collected
through
the
clinical
history
of
the
emergency
visits
or
medical
specialist
consultation
due
to
this
cause
(YES/NO).
Finally,
the
information
about
eating
behaviour
problems
was
collected
during
the
clinical
interview
with
the
parents.
It
was
codified
according
to
the
frequency
of
appearance,
similar
to
the
NCBRF
scale;
from
did
not
occur
or
was
no
a
problem
(0)
to
behaviour
occurred
a
lot
or
was
a
severe
problem
(3).
Severity
of
symptomatology
was
assessed
by
Autism
Spectrum
Disorder
Inventory
(IDEA)
(Rivière,
2002).
It
is
an
inventory
that
includes
12
dimensions
of
development,
divided
into
4
areas
(Social
development,
language
and
communication,
anticipation
and
flexibility,
symbolizing).
Each
dimension
is
scored
from
0
(no
qualitative
disorder)
to
8
(maximum
involvement
level)
at
intervals
of
2
(0,
2,
4,
6,
8),
being
able
to
use
odd
scores
when
considering
that
the
symptomatology
is
at
an
intermediate
point
between
2
consecutive
items.
The
inventory
was
built
with
the
aim
of
assess
the
severity
of
the
core
features
of
ASD.
Statistical
analysis
Statistical
analysis
was
performed
using
SPSSTM 21.0
with
1000
samples
bootstrapping.
After
checking
the
linear
model
assumptions
(Kolmogorov---Smirnov
and
Shapiro---Wilk
tests)
dimensional
variables
and
frequencies
were
compared
by
parametric
or
non-parametric
tests
as
appropriate
(Chi
Square
Test
and
Student
t-test).
The
bivariate
association
between
the
two
groups
(DSM-5
vs.
Non
DSM-5)
and
inde-
pendent
variables
(comorbid
disorders,
other
psychiatric
symptoms
and
severity
of
symptoms)
was
initially
explored
using
either
two-way
cross-tabulations
or
mean
compar-
isons.
We
assumed
a
significance
level
of
p
≤
.05.
Results
Clinical
and
sociodemographic
distribution
The
Table
1
shows
the
distribution
of
the
number
of
patients
who
met
DSM-5
criteria
(DSM-5
group)
and
patients
who
did
not
(Non
DSM-5)
and
the
prevalence
of
the
different
Autism
Spectrum
Disorders
(ASD)
subgroups
according
to
the
DSM-IV
TR
[Autistic
Disorder,
Asperger’s
and
pervasive
developmen-
tal
disorder-not
otherwise
specified
(PDD-NOS)].
There
were
no
significant
differences
between
both
groups
in
relation
with
the
distribution
of
ASD
subtypes
(2=
0.99;
p
=
.61).
Also,
no
significant
differences
in
age
was
found
between
both
groups
(t-Student
=
-0.47;
p
=
.64)
(mean
age:
10.62;
SD:
2.99).
The
82%
of
the
sample
were
males
and
the
eth-
nicity
of
the
sample
was
100%
Caucasian.
Comorbidity
with
Attention
Deficit
Hyperactivity
Disorder
(ADHD)
The
Table
1
illustrates
the
distribution
of
the
number
of
par-
ticipants
who
had
clinical
comorbidity
with
ADHD.
Statistical
analysis
showed
a
non-significance
value
(2=
3.48;
p
=
.06),
although
it
had
a
tendency
toward
the
significance,
as
there
was
a
higher
percentage
of
participants
with
comorbidities
in
the
DSM-5
group.
Comorbidity
with
Obsessive
Compulsive
Disorder
(OCD)
As
it
can
be
seen
in
the
Table
1,
statistically
significant
dif-
ferences
between
both
groups
were
observed
(2=
18.96;
p
=
.0001).
In
conclusion,
patients
fulfilling
the
DSM-5
crite-
ria
for
ASD
had
higher
prevalence
of
OCD
diagnosis.

Psychiatric
comorbidities
in
autism
spectrum
disorder
271
Table
1
Distribution
of
the
number
of
patients
who
met
DSM-5
criteria
(DSM-5
group)
and
patients
who
did
not
(Non
DSM-5)
showing
the
prevalence
of
the
different
Autism
Spectrum
Disorders
(ASD)
subgroups
and
comorbidity
with
Attention
Deficit
Hyperactivity
Disorder
(ADHD),
Obsessive
Compulsive
Disorder
(OCD),
Anxiety,
Eating
behavior
problems,
Auto-aggression,
Hetero-aggression
and
Self-harm.
Statistical
differences
between
both
groups
are
described.
No
DSM-5
Count
(%)
DSM-5
Count
(%)
Total
Count
(%)
p
ASD
subtypes Autism
17
(25.8%)
17
(29.8%)
34
(27.6%) .61
Asperger
13
(19.7%)
14
(24.6%)
27
(22%)
PDD-NOS
36
(54.5%)
26
(45.6%)
62
(50.4%)
Total
66
(100%)
57
(100%)
123
(100%)
ADHD No
33
(50%) 19
(33.3%)
52
(42.3%) .06
Yes 33
(50%) 38
(66.7%) 71
(57.7%)
Total 66
(100%) 57
(100%) 123
(100%)
OCD No
51
(77.3%)
22
(38.6%)
73
(59.3%) .0001
Yes
15
(22.7%)
35
(61.4%)
50
(40.7%)
Total
66
(100%)
57
(100%)
123
(100%)
Anxiety No
occur
6
(9.5%)
4
(7%)
10
(8.3%) .09
Occasional
39
(61.9%)
24
(42.1%)
63
(52.5%)
Quite
often
4
(6.3%)
5
(8.8%)
9
(7.5%)
Severe
problem
14
(22.2%)
24
(42.1%)
38
(31.7%)
Eating
behaviour
problems
No
occur
33
(52.4%)
16
(28.6%)
49
(41.2%) .05
Occasional
12
(19%)
17
(30.4%)
29
(24.4%)
Quite
often
4
(6.3%)
3
(5.4%)
7
(5.9%)
Severe
problem
14
(22.2%)
20
(35.7%)
34
(28.6%)
Auto-aggression No
occur
42
(66.7%)
31
(54.4%)
73
(60.8%) .57
Occasional
5
(7.9%)
6
(10.5%)
11
(9.2%)
Quite
often
4
(6.3%)
6
(10.5%)
10
(8.3%)
Severe
problem
12
(19%)
14
(24.6%)
26
(21.7%)
Hetero-aggression No
occur
40
(64.5%)
31
(56.4%)
71
(60.7%) .31
Occasional
12
(19.4%)
12
(21.8%)
24
(20.5%)
Quite
often
1
(1.6%)
5
(9.1%)
6
(5.1%)
Severe
problem 9
(14.5%)
7
(12.7%)
16
(13.7%)
Self-harm No
54
(81.8%)
41
(71.9%)
95
(77.2%) .20
Yes 12
(18.2%)
16
(28.1%)
28
(22.8%)
Total 66
(100%) 57
(100%)
123
(100%)
Anxiety
or
too
fearful
Assessing
the
frequency
of
symptoms
of
anxiety
or
too
fear
between
both
groups,
it
was
observed
a
tendency
of
hav-
ing
more
severe
problems
in
the
group
of
participants
who
met
DSM-5
criteria
(63%),
although
there
were
no
statisti-
cally
significant
differences
between
both
groups
(2=
6.43;
p
=
.09).
See
Table
1.
Eating
behaviour
problems
The
Table
1
shows
the
distribution
and
the
frequency
of
participants
who
presented
eating
behaviour
problems.
Sta-
tistically
significant
differences
were
found
between
both
groups
in
relation
with
this
symptom
(2=
7.57;
p
=
.05).
A
higher
prevalence
of
eating
behaviour
problems
was
observed
in
participants
who
met
the
criteria
for
ASD
according
to
the
DSM-
5.
Auto-aggression,
hetero-aggression,
self-harm
Comorbidities
with
auto-aggression,
hetero-aggression
and
self-harm,
are
shown
in
Table
1,
respectively.
When
both
groups
were
compared,
not
significant
differences
were
found
(2=
2.01;
p
=
.57),
(2=
3.65;
p
=
.31)
and
(2=
1.70;
p
=
.20),
respectively.
Severity
of
Autism
Spectrum
Disorder
In
order
to
assess
the
severity
of
the
core
autistic
symptoms,
The
Autism
Spectrum
Inventory
(IDEA)
was
used
(Table
2).
The
null
hypothesis
of
equal
variances
(Levene’s
test),
was
rejected
and
it
was
concluded
that
there
was
a
significant
difference
between
the
variances
of
these
measures.
Con-
sequently,
the
statistical
analysis
Kolmogorov-Smirnov
was
used
and
it
showed
that
the
group
of
patients
who
met
DSM-
5
criteria
had
more
severe
symptoms
than
the
Non
DSM-5
group
with
statistical
significant
differences
(p
=
.0001).

272
M.
Romero
et
al.
Table
2
Comparative
study
between
No
Autism
Spectrum
Disorders
(ASD)
DSM-5
and
ASD
DSM
5
group
for
severity
of
autistic
symptoms.
Mean
(SD)
[CI
95].
Total
Sample
(n
=
120)
No-ASD
DSM-5
(n
=
63)
ASD
DSM-5
(n
=
57)
p
IDEA
43(8.82)
[41.41
to
44.59]
38,86
(8.69)
[36.67
to
41.04]
47,58
(6.41)
[45.88
to
49.28]
.0001
Discussion
Based
on
the
data
presented
in
this
study,
there
is
no
question
that
comorbid
symptomatology
are
quite
prevalent
in
children
with
ASD.
Variables
such
as
spe-
cific
behavioural
symptoms,
ADHD,
OCD
and
severity
of
symptoms,
likely
have
an
influence
on
the
autism
indi-
vidual’s
experience.
The
present
study
shows
that
the
new
classification
DSM-5
requires
more
severe
symptoma-
tology
for
the
diagnosis
of
ASD
and
also,
the
group
of
patients
who
met
the
DSM-5
criteria
for
ASD,
are
more
likely
to
develop
psychiatric
comorbidities,
specifically
OCD
and
eating
problems.
Previous
studies
have
supported
the
hypothesis
of
the
DSM-5
could
significantly
improve
the
specificity
at
the
expense
of
loss
sensitivity
in
ASD
(APA,
2013;
Frazier
et
al.,
2012;
Grzadzinski
et
al.,
2013;
Wing,
Gould,
&
Gillberg,
2011).
However,
to
the
best
of
our
knowledge,
no
previous
studies
have
compared
both
classifications
in
term
of
severity
and
comorbidities
in
this
population.
Therefore,
this
study
suggests
that
DSM-5
classification
has
been
able
to
identify
children
with
the
most
severe
symptomology;
however,
it
might
fail
to
identify
those
with
high
functioning
autism
or
less
severe
sympto-
matology.
Consequently,
in
term
of
clinical
implication,
the
DSM-5
criteria
could
have
a
high
impact
in
the
diagnosis
of
ASD.
Authors
of
the
present
study
also
support
the
proposal
of
a
phenotypic
characterization,
to
improve
the
DSM-5
clas-
sification
for
ASD.
Methodology
issues
and
further
research
By
addressing
methodological
issues
that
limit
the
findings
of
this
study,
future
studies
can
contribute
noticeably
to
our
better
understanding
about
the
impact
of
the
new
classifi-
cation
in
this
population
and
answer
more
pointed
scientific
questions
in
relation
with
the
phenotypic
characterization.
The
present
study
did
not
employ
any
independent
‘gold
standard’
confirmation
for
the
ASD
diagnoses
[i.e.,
Autism
Diagnostic
Interview-Revised
(ADI-R);
(Lord,
Rutter,
&
Le
Couteur,
1994)
or
Autism
Diagnostic
Observation
Schedule
(ADOS)
Lord
et
al.,
2000)];
instead,
including
children
based
on
community
and
clinical
diagnosis
with
the
DSM-IV-TR/ICD-
10
Checklists
confirmation.
This
study
was
also
limited
by
the
fact
that
the
diagnosis
of
ASD
according
to
DSM-5
was
completed
using
the
items
of
DSM-IV-TR/ICD-10
Checklists.
Although
this
method
has
been
also
used
previously
in
other
studies
(Beighley
et
al.,
2013;
Matson,
Hattier,
&
Williams,
2012),
new
objective
measures
will
need
to
be
developed
in
order
to
accurately
capture
the
patients
who
meet
ASD
criteria
according
to
DSM-5
classifi-
cation
if
valid
and
reliable
measures
cannot
be
identified
at
the
current
time.
In
relation
with
the
assessment
for
comorbid
psychi-
atric
symptoms
such
as
eating
disorders,
anxiety,
auto-and
hetero-aggressiveness
and
self-arm,
research
on
the
appli-
cability
of
traditional
measures
of
childhood
psychiatric
symptoms,
is
sorely
needed.
Until
we
have
consensus
on
‘best
practice’
measures,
a
healthy
skepticism
is
called
for
with
respect
to
the
precision
of
the
tools
we
currently
have
for
measuring
symptoms
of
comorbid
problems
in
children
with
ASD.
Assessment
of
global
severity
is
another
important
consideration
in
treatment
outcome
research;
yet,
there
is
little
guidance
on
its
evidence-based
assessment
for
children
with
ASD
(White,
Smith,
&
Schry,
2014).
One
of
the
main
strength
of
the
methodology
in
this
study
was
in
relation
with
the
representativeness
of
the
sample
of
participants.
The
present
study
drew
their
ASD
sample
from
a
large
population-derived,
non-clinical
patients.
Clin-
ical
samples
are
often
needed
to
accrue
an
adequate
number
of
participants
and
for
ensuring
statistical
power,
but
such
samples
can
make
it
difficult
to
generalize
findings.
Clinic-
based
samples
are
likely
not
representative
of
all
children
with
ASD
in
many
important
respects,
such
as
degree
of
parental
investment,
level
of
behaviour
disturbance,
etc.
Main
results
The
findings
of
the
current
study
support
the
overall
a
priori
hypothesis.
It
was
found
that
participants
who
met
DSM-5
criteria
had
higher
prevalence
of
clinical
comorbidities
and
severity.
According
to
the
analysis
of
comorbidity
with
atten-
tion
deficit
disorder
and
hyperactivity
(ADHD),
the
results
showed
that
there
were
no
statistical
significant
differences
between
both
groups.
However,
there
is
a
tendency
toward
higher
prevalence
in
the
DSM-5
group.
The
absence
of
a
sta-
tistical
significance
could
be
due
the
sample
size
of
patients
with
comorbid
ADHD
(n
=
71).
According
to
the
last
review,
the
prevalence
has
been
remarkably
heterogeneous,
ran-
ging
from
4%
to
94%
(weighted
mean
prevalence
=
48%;
Frias,
Palma,
&
Farriols,
2015).
For
example,
Rao
and
Landa
(2014)
obtained
a
lower
percentage
of
29%
as
it
focused
on
a
non-
clinical
recruitment
to
avoid
over
diagnosis.
Congruently,
the
current
study
was
focused
on
non-clinical
participants
and
we
found
a
prevalence
of
57.7%.
These
findings
support
the
hypothesis
that
the
comorbidity
with
ADHD
may
consti-
tute
a
distinctive
phenotype
of
ASD,
and
these
children
may
be
at
a
greater
risk
of
involvement
and
socially
adaptive
problems.
Moreover,
ADHD
is
a
condition
that
produces
high
academic
dysfunctionality
and
therefore,
exacerbates
the
academic
and
social
needs
of
children
who
present
comor-
bidity
with
ASD.
This
is
important
because
participants
with
both
conditions
are
given
various
treatments
or
strength
requirements
than
those
which
have
only
ASD.
These
results
are
congruent
with
a
growing
number
of
studies
that
have
shown
that
both
pathologies
can
co-exist
(Rao
&
Landa,
2014).
In
the
present
study
the
results
have
showed
that
par-
ticipants
meeting
DSM-5
criteria
for
ASD
have
more
OCD
comorbidity.
The
ASD
diagnosis
according
to
DSM-5
requires
greater
rigidity
in
the
behavioural
domain,
unlike
in
the

Psychiatric
comorbidities
in
autism
spectrum
disorder
273
DSM-IV-TR.
One
of
the
most
significant
changes
in
the
DSM-5
classification
is
the
higher
requirement
in
the
area
of
repet-
itive
and
restrictive
behaviour,
requiring
two
of
the
four
items
compared
to
the
DSM-IV-TR
criteria
where
only
one
item
was
required
for
the
diagnosis
of
PDD
(Howlin,
Goode,
Hutton,
&
Rutter,
2004;
Mattila
et
al.,
2011).
For
that
rea-
son,
the
similarities
that
exist
between
routines
and
rituals
behaviour
in
ASD
and
compulsions
in
OCD;
obsession
in
the
OCD
and
equality
insistence
and
worries
in
ASD,
indicate
that
clinicians
should
make
the
assessment
very
carefully
in
order
to
make
a
correct
differential
diagnosis.
If
the
assessment
is
only
focused
on
the
DSM-5
criteria,
the
comor-
bid
diagnosis
of
OCD
might
be
imprecise
in
individuals
with
ASD.
Therefore,
exploration
into
the
overlapping
and
dis-
tinct
phenotypic
presentations
of
individuals
with
comorbid
presentations
(e.g.,
ASD
with
OCD)
versus
presentations
of
OCD
or
ASD
singly
may
be
of
potential
importance
for
under-
standing
the
biological
markers
of
these
disorders.
Further
genetic
and
neuro-imaging
studies
are
needed
in
order
to
better
understand
this
approach.
In
addition,
the
present
study
found
significant
differ-
ences
with
eating
behaviour
problems
between
both
groups,
supporting
the
hypothesis
of
having
more
comorbidity
in
the
DSM-5
group.
Previous
published
studies
of
children
diag-
nosed
with
ASD
showed
an
estimated
eating
problem
which
reaches
90%
of
prevalence
(Kodak
&
Piazza,
2008).
However,
in
this
study
we
obtained
a
lower
percentage
between
28.6%
and
51%
because
we
focused
on
a
non-clinical
recruitment
to
avoid
over
diagnosis.
Even
without
a
clinical
diagnosis,
the
results
found
that
31.7%
of
patients
had
severe
problems
with
anxiety,
congru-
ent
with
the
review
of
van
Steensel,
Bogels,
and
Perrin
(2011),
in
which
a
percentage
of
40%
was
found.
Anxiety
is
an
important
factor
in
the
daily
lives
of
many
children
and
adolescents
with
ASD
diagnosis.
Children
and
adolescents
with
ASD
generally
take
longer
to
communicate
their
symp-
toms
of
anxiety
due
to
their
communication
problems,
many
of
which
only
manifest
themselves
internally
(i.e.,
constant
worry).
These
limitations
make
it
difficult
for
people
with
ASD
to
be
diagnosed
because
of
the
difficulties
to
express
their
own
feelings
or
problems.
Unfortunately,
there
is
lit-
tle
clarity
on
how
best
to
assess
other
psychiatric
comorbid
symptoms
in
this
population
and
the
direct
impact
on
the
ASD
severity.
Finally,
these
findings
do
support
the
proposal
of
Grzadzinski
et
al.
(2013),
in
order
to
highlight
the
impor-
tance
of
carrying
out
a
phenotypic
characterization
to
improve
the
DSM-5
classification,
based
not
only
on
the
spe-
cific
core
symptoms
of
ASD
but
also
in
their
comorbidities
and
other
factors
that
may
influence
on
the
functionality
of
this
complex
spectrum
of
autism
(Fig.
1).
Conclusions
This
study
supports
the
hypothesis
that
the
DSM-5
classi-
fication
includes
patients
who
are
more
prone
to
clinical
severity
not
only
in
relation
to
the
core
items
of
ASD,
but
also
at
the
level
of
psychiatric
comorbidities.
Patients
who
met
DSM-5
criteria
had
more
comorbidity
with
OCD,
eat-
ing
behaviour
problems
and
severity
than
patients
who
only
met
the
DSM-IV-TR
criteria.
Future
studies
can
contribute
markedly
to
our
better
understanding
the
effect
of
the
new
classification
in
this
population
and
answer
more
pointed
scientific
questions
in
relation
with
the
phenotypic
catego-
rization
of
children
with
autism
spectrum
disorder.
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