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Autism, intellectual disabilities and additional psychosis, and affiliation to groups with violent ideology: short communication

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Abstract

Purpose People with autism spectrum disorders (ASD) have been associated with criminal acts and affiliation with groups and organisations with violent ideology and practice. The purpose of this paper is to present patients in mental health services with both ASD and psychosis, who are affiliated with such groups. Design/methodology/approach Three vignettes are used as examples. Some of the information is combined for the three participants for presentation. They were scored for mental health symptoms and behaviour problems on admission and discharge from inpatient care. Findings The combination of ASD and psychosis aggravates the problems of both conditions, which may elicit a collapse of both cognitive functioning and especially impulse control, and of the ability to judge whether situations are dangerous or offensive or not. Originality/value The present paper may contribute to a better understanding of the combination of ASD, psychosis and affiliation with groups and organisations as described, especially regarding the importance of identifying psychosis.
Journal of Intellectual Disabilities and Offending Behaviour
Autism, intellectual disabilities and additional psychosis, and affiliation to groups with violent ideology:
short communication
Ann Magritt Solheim Inderberg, Kristin Horndalsveen, Arne-Henrik Elvehaug, Yugbadal Mehmi, Ingvild Jørstad, Trine Lise
Bakken,
Article information:
To cite this document:
Ann Magritt Solheim Inderberg, Kristin Horndalsveen, Arne-Henrik Elvehaug, Yugbadal Mehmi, Ingvild Jørstad, Trine Lise
Bakken, (2019) "Autism, intellectual disabilities and additional psychosis, and affiliation to groups with violent ideology: short
communication", Journal of Intellectual Disabilities and Offending Behaviour, https://doi.org/10.1108/JIDOB-09-2018-0010
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https://doi.org/10.1108/JIDOB-09-2018-0010
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Autism, intellectual disabilities and
additional psychosis, and affiliation to
groups with violent ideology:
short communication
Ann Magritt Solheim Inderberg, Kristin Horndalsveen, Arne-Henrik Elvehaug,
Yugbadal Mehmi, Ingvild Jørstad and Trine Lise Bakken
Abstract
Purpose People with autism spectrum disorders (ASD) have been associated with criminal acts and
affiliation with groups and organisations with violent ideology and practice. The purpose of this paper is to
present patients in mental health services with both ASD and psychosis, who are affiliated with such groups.
Design/methodology/approach Three vignettes are used as examples. Some of the information is
combined for the three participants for presentation. They were scored for mental health symptoms and
behaviour problems on admission and discharge from inpatient care.
Findings The combination of ASD and psychosis aggravates the problems of both conditions, which may
elicit a collapse of both cognitive functioning and especially impulse control, and of the ability to judge whether
situations are dangerous or offensive or not.
Originality/value The present paper may contribute to a better understanding of the combination of ASD,
psychosis and affiliation with groups and organisations as described, especially regarding the importance of
identifying psychosis.
Keywords Psychosis, Extremism, Autism spectrum disorders, Inpatient treatment,
Specialized mental health care, Violent ideology
Paper type Viewpoint
Introduction
Autism spectrum disorder (ASD) is considered to be a neurodevelopmental disorder. Core
symptoms include impaired communication and social interaction, and a restricted repertoire of
activities and interests (APA, 2013). Besides these core symptoms, ASD is closely associated with
impaired executive functions, central coherence and mentalising. Impaired mentalising includes
not seeing other peoples perspectives, and also introspection (Lind and Williams, 2011).
Experiencing intellectual disabilities (ID) in addition to ASD aggravates these problems. The core
symptoms of psychosis include delusions, hallucinations and severely disorganised speech and
behaviour. The most severe psychosis, schizophrenia, also encompasses negative symptoms
such as apathy, fatigue, lack of motivation and emotional dysfunction (APA, 2013). When people
with ASD (with or without ID), develop psychosis, their impaired cognitive, emotional and practical
functioning caused by ASD and/or ID will be severely aggravated (Bakken, 2014; Bakken et al.,
2007). They may show severe global functional deterioration and disorganised speech and
behaviour,and be unable to maintain basic self-care tasks and social relationships (Bakken, 2014).
Recent research indicates that adolescents and adults with ASD may have extensive difficulties
in understanding that their actions can cause other people pain and suffering, physically and/or
Received 26 September 2018
Revised 27 November 2018
Accepted 27 November 2018
Ann Magritt Solheim Inderberg,
Kristin Horndalsveen,
Arne-Henrik Elvehaug,
Yugbadal Mehmi and
Ingvild Jørstad are all based at
the Oslo University Hospital,
Oslo, Norway.
Trine Lise Bakken is Head of
Advisory Unit at the
Oslo University Hospital,
Oslo, Norway.
DOI 10.1108/JIDOB-09-2018-0010 © Emerald Publishing Limited, ISSN 2050-8824
j
JOURNAL OF INTELLECTUAL DISABILITIES AND OFFENDING BEHAVIOUR
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psychologically (Helverschou et al., 2015). There are indications of an association between ASD
and violent offences in convicted adults who have ASD ( Billstedt et al., 2017; Im, 2016;
Søndenaa et al., 2014). Case descriptions indicate that adolescents and young adults with ASD
may start associating with political or religious groups that spread violent ideologies and
practice (Faccini and Allely, 2017; Palermo, 2013). There is no evidence to suggest that people
with ASD are more violent than neurotypicals (Im, 2016). However, a recent review on mass
shootings showed that people with ASD were highly overrepresented in such acts.
Nevertheless, knowledge about violent offenders with ASD is generally limited (Chaplin et al.,
2013; Helverschou et al., 2018).
In a study comparing adults with and without ASD in a low-security unit in the UK, Haw et al.
(2013) found that within the ASD group three out of four had mental illness, with psychosis
being the most frequent. The results of this study correspond to clinical experience in a
regional specialised psychiatric unit for adult patients with ID at Oslo University Hospital,
Oslo, Norway. During the last 510 years, an increasing number of young men with ASD and
additional psychosis who have associated with groups with violent ideologies and practice
have been admitted to this unit. Clinical experience from this unit indicates that patients with
ASD and additional psychosis who have committed crimes will engage in less violent
and criminal acts once they have been properly assessed and their psychosis has been
adequately treated.
This paper aims to highlight that identifying and treating psychosis in adults with ASD who
associate with violent groups may reduce the chances of them engaging in criminal acts.
Methods
This study uses information from case files. First, a systematic search was conducted using the
terms autism/ASD and psychosis/psychotic disorder/schizophrenia and prisoners/criminals/
violence/terrorism/delinquency. This approach yielded zero hits. An additional hand search was
conducted using Google Scholar and relevant websites, which also yielded zero hits. Combining
the first and third search terms yielded 11 hits, of which 4 were relevant to the present study
(Billstedt et al., 2017; Im, 2016; Helverschou et al., 2015). As the treatment of psychosis is crucial
to this paper, outcome measures following admission to a specialist psychiatric inpatient unit for
patients with ID/ASD were scored by using the Psychopathology in Autism Checklist (PAC)
(Helverschou et al., 2009) and the Aberrant Behaviour Checklist (ABC) (Aman and Singh, 1986).
The PAC and ABC were first scored upon admittance and at discharge. The scores were
analysed using the Wilcoxon signed-rank test, a non-parametric test.
The setting is an adult regional specialist psychiatric inpatient and outpatient unit for adults with ID
and/or autism (SPID) in the South-East Health Authority in Norway (Bakken and Høidal, 2018).
Three males in their 20s were invited to participate. Permission to conduct the study was granted
by the director of the SPID and the hospitals Privacy Protection Supervisor. Parents or legal
guardians gave their informed consent for participation on behalf of the patients. Background
information, diagnostic and treatment information and information about scores have been
provided on a group level in order to ensure confidentiality.
Cases A, B and C
The three male participants are in their 20s. Two have mild ID, and one has a borderline IQ. Two
have been diagnosed with disorders in the autism spectrum, one with autistic traits. The latter
was diagnosed in adulthood. Two have been diagnosed within the schizophrenia spectrum,
and one in the affective spectrum. The three patients had difficulties socialising with peers from
their early adolescence. Before being admitted to the SPID, A, B and C had been active on the
internet and had associated with radicalised religious groups. This resulted in them being
monitored by the police authorities. An overview of psychotic symptoms and warning signs was
prepared for the three patients during inpatient stays at the SPID. The following warning signs
were reported: insufficient sleep, insufficient food intake, severe physical aggression, verbal
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threats, paranoid ideations and delusions. The three patients had already received a diagnosis
in the autism spectrum before their SPID stay. The Social Communication Questionnaire
(Rutter et al., 2003) was used to confirm a previous ASD assessment. Psychiatric diagnoses
were conducted using the ICD 10 and also using psychometric instruments: the PAC and the
MINI Plus, as well as clinical interviews and 24/7 observation of symptoms at the SPID. Risk
assessments were conducted for A and C and indicated a high risk of violence, associated with
a high psychotic symptom load.
The three patients received similar treatment, including milieu therapy that emphasised safe
surroundings, activities and psychological validation (Bakken et al., 2017), psychotherapy, as well
as psychotropic medication. Upon discharge, the three patients showed no positive psychotic
symptoms. They were followed up by the SPID for six months. They engaged in no criminal acts
during follow-up. The patients were discharged in accordance with the Norwegian Mental Health
Act on involuntary care outside a psychiatric hospital. This means that a patient is obliged to
co-operate regarding the follow-up plan, which is one of the conditions of discharge. The patients
were also monitored by the police authorities following discharge.
The global functioning of Case A had deteriorated severely two years prior to admission to the
SPID. From early adolescence, he was involved in serious criminal activity. He had also used
harmful drugs regularly for several years. Through a friend, A had started associating with an
Islamic group that encouraged the use of violence. When admitted to the SPID, A was agitated,
hostile and suffered from severe anxiety and paranoid delusions. He was disorganised, tense
and had impaired attention. The patient stayed at the SPID for a few months. He showed limited
social understanding and experienced difficulties in seeing other peoples perspectives,
combined with limited insight into social relations and emotions. He quickly came into conflict
with others. His social, extrovert yet disturbed interaction with others demonstrated a serious
inability to understand how his behaviour impacted others. The patient appeared to be
surprised at how his behaviour affected others.
Case B was diagnosed with ID and ASD in primary school. His problems escalated in upper
secondary school and he developed additional symptoms of anxiety. He became interested in
radical Islam and started associating with people in Islamic groups. At the same time, he
experienced a severe deterioration in global functioning that encompassed tasks, social
relationships and self-care. He suffered from delusions. During hospitalisation at the SPID, B
attended weekly psychotherapeutic sessions, including psycho-education about ASD. B stayed
at the SPID for around six months. Psychotherapy and milieu therapy were adjusted to his
cognitive impairments and his mental illness symptoms.
Case C adapted socially when at primary school; he played with friends and he played football.
His cognitive skills were behind his peers. Consequently, he was moved into a class for
pupils with special needs. He was diagnosed with ID and was found to have ASD traits during
his adolescence. When he was in his teens, his family moved to a rough neighbourhood.
C changed and stopped socialising and playing football. He also withdrew socially and
his practical and self-care skills declined. He showed concurrent psychotic symptoms including
delusions, hallucinations and disorganised speech and behaviour. He committed his first crime
during his teens. Several incidents occurred after this. In his late adolescence, he associated
with a group known for its violence and conservative religious ideology. He started using
alcohol and illicit drugs. C was admitted to the SPID and stayed for more than six months.
A, B and C scores
A, B and C were scored for behavioural problems and mental health problems on two checklists,
the ABC and the PAC. The scores are presented in Table I.
Table I shows a clinically-relevant reduction in irritability and social withdrawal scored by the
ABC, as well as a reduction in general problems including passivity, irritability, aggression/
violent behaviour and breaking items, psychosis and anxiety. However, clinically-relevant
differences were not significant using a non-parametric test. This is probably due to the low
number of participants.
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Discussion
As we were unable to find any articles on this specific phenomenon, it is not possible to state how
widespread it is, other than that psychosis is found to be a risk factor for violent behaviour in
people with ASD (Im, 2016). The three patients had been in frequent contact with the police
authorities. We are aware that certain religious groups may offer simple rules about what to do
and what not to do, as well as a strong social cohesion. It is easy to imagine that rules and a sense
of social cohesion may be attractive to young people who, for the most part, have no friends, are
unemployed and living on the margins of society. The three patients had developed severe mental
health problems in their adolescence. At the SPID, thorough observations of symptoms were
conducted addressing in particular to separate ASD symptoms from psychotic symptoms,
mood symptoms and anxiety symptoms. The clinical implications of the findings suggest that it is
crucial to differentiate between ASD and psychosis as ASD is considered a life-long condition,
while psychosis can be treated and achieve a successful outcome, as in the three cases
presented. Maintaining the psychotic symptoms of this patient group at the lowest possible level
could help to prevent them from engaging in criminal activities.
Differentiating between ASD and psychosis might be difficult, as the manner in which the patient
speaks or behaves could be interpreted as a single disorder (Nylander, 2014; Helverschou and
Martinsen, 2011). Conversely, ASD may easily be overlookedinpeoplewithmentaldisorderswho
are treated by the general psychiatric services (Nylander and Gillberg, 2001). It is essential to organise
the categories of symptoms. Furthermore, it is essential to recognise the warning signs, because
psychotic and mood disorders tend to relapse (Birchwood et al., 2000). The clinical experience of
the SPID is that people with autism, even those with IQs in the general range, are unable to cope with
recognising signs that they are experiencing a relapse, even if they have been given a list of warning
signs. Thus, the symptom load should be closely monitored by the specialist psychiatric services.
Another clinical perspective is that improved mental health may also enhance the patients
relationships with significant others, especially family members. A, B and C improved their family
relationships, in which there had previously been severe conflicts on occasions, including physical
attacks. During follow-up by SPID, the patients did not engage in any violent behaviour or crimes.
The ABC and PAC scores reflect the significant improvement in both mental health and behavioural
problems for A, B and C. Another perspective on mental health services is their twofold mandate: to
improve mental health in the individual patient, thereby preventing any recurrent criminal behaviour
through an improvement in their mental health. Studies into ASD and crime have suggested that
excessive preoccupations and rigid routines may lead to criminal acts when a person with ASD
becomes isolated (Haskins and Silva, 2006). Combined with a lack of understanding of other
peoples emotions, it may contribute to the way such people fail to understand the implications of
their actions until they have been arrested by the police (Sutton et al., 2013). In the current examples,
the patientstroubled lives were the result of a combination of impaired cognitive and practical skills
Table I Paired differences of ABC and PAC scores, at admission and at discharge
At admission At discharge
Mean SD Mean SD
Subscales ABC
Irritability 13.00 2.00 2.33 3.22
Social withdrawal 9.67 4.04 3.33 3.06
Stereotypy 3.33 2.08 0.33 0.58
Hyperactivity 22.67 9.07 2.00 2.00
Inapp. speech 4.33 3.22 0.67 1.56
Subscales PAC
General problems 2.48 0.47 1.47 0.43
Psychosis 2.63 0.93 1.20 0.10
Depression 2.35 0.58 1.78 0.83
Anxiety 2.56 0.32 1.22 0.39
OCD 1.26 0.15 1.00 0.00
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resulting from ID, ASD, psychosis, drug use and criminal activity at a young age, and then being
attracted to radical religious groups and becoming involved in violence. Multidisciplinary and
cross-service co-operation may be essential to keeping these young men out of the criminal justice
(Haw et al., 2013). They may become less at risk through a more accurate diagnostic assessment of
their psychosis and an overall understanding of their complex diagnostic states. Follow-up by the
mental health services and discharge from inpatient care to involuntary care outside a psychiatric
hospital may be necessary to ensure that the patient does not engage in criminal acts.
Conclusion
Young men who have experienced social and cognitive difficulties from an early age and who are
attracted to groups that hold extreme and violent ideological views should be examined carefully
for signs of a combination of ASD and psychosis, or other severe mental illness, if they display any
kind of psychotic symptoms. A combination of ASD and psychosis aggravates the problems of
both conditions, which could lead to both a severely impaired cognitive functioning and impulse
control in particular, and of the ability to judge whether or not situations are dangerous or
offensive. Follow-up should be maintained after discharge from psychiatric units.
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Corresponding author
Trine Lise Bakken can be contacted at: uxtlba@ous-hf.no
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... increased social naivete, over-rigid adherence to rules, not understanding social situations, aggressiveness, obsessional interests). Similarly,Inderberg et al. (2019) offer three vignettes based on primary materials of the impact of autism and psychosis and how they engender a collapse of cognitive functioning and impulse control, and the ability to gauge the dangerousness/offensiveness of a situation.Post (2000) outlines his expert witness account of a trial in which the accused bomber had suffered from depression and PTSD prior to the offence and their functional roles.Ludot et al. (2016) report the cases of two teenagers undergoing psychological treatment and the relationship between their complex needs and radicalisation.Hemmingby and Bjorgo (2018) examine the impact of psychological make-up upon one terrorist attack using unique access to police and investigative files. Other in-depth case studies look at the impact of mental health crises upon the adoption of violent extremist views also(Gill, 2015;Holt et al, 2018;Erlandsson & Meloy, 2018;. ...
... They demonstrate how different autism-related deficits can contribute differently (e.g., increased social naivete, over-rigid adherence to rules, not understanding social situations, aggressiveness, obsessional interests). Similarly, Inderberg et al. (2019) offer three vignettes based on primary materials of the impact of autism and psychosis and how they engender a collapse of cognitive functioning and impulse control, and the ability to gauge the dangerousness/offensiveness of a situation. Post (2000) outlines his expert witness account of a trial in which the accused bomber had suffered from depression and PTSD prior to the offence and their functional roles. ...
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