Hostname: page-component-586b7cd67f-tf8b9 Total loading time: 0 Render date: 2024-12-08T19:17:26.193Z Has data issue: false hasContentIssue false

Rumination and altered reactivity to sensory input as vulnerability factors for developing post-traumatic stress symptoms among adults with autistic traits

Published online by Cambridge University Press:  15 January 2024

Liliana Dell’Osso
Affiliation:
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Giulia Amatori*
Affiliation:
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Federico Giovannoni
Affiliation:
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Enrico Massimetti
Affiliation:
UFSMA Val di Cornia, Azienda USL Toscana Nord Ovest, Pisa, Italy
Ivan Mirko Cremone
Affiliation:
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Barbara Carpita
Affiliation:
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
*
Corresponding author: Giulia Amatori; Email: g.amatori1992@gmail.com
Rights & Permissions [Opens in a new window]

Abstract

Objective

Recent literature has suggested that individuals with autism spectrum disorder (ASD) or autistic traits (ATs) would be more likely to encounter traumatic events in their lifetime and to develop post-traumatic stress disorder (PTSD). However, the nature of this relationship has not yet been fully elucidated. The aims of this study were to evaluate the relationship between AT and PTSD and to investigate which specific autistic dimension was more associated with trauma and stress-related symptoms.

Methods

A total of 68 subjects with ASD and 64 healthy controls (HCs) were assessed with the Adult Autism Subthreshold Spectrum (AdAS Spectrum) and the Trauma and Loss Spectrum (TALS) questionnaires. Statistical analyses included Mann–Whitney U test, chi-square test, calculation of Spearman’s coefficients, and logistic regression analysis.

Results

Patients with significant AT reported a 30% rate of PTSD and higher TALS total and domain scores than HCs, among whom no PTSD was found instead. Significant positive correlations were reported between AdAS Spectrum and TALS-SR scores in the whole sample. AdAS Spectrum total scores were statistically predictive of the presence of PTSD. High scores at AdAS Spectrum Hyper-Hyporeactivity to sensory input and Restrictive interest and rumination domains were identified as positive predictors of a probable PTSD.

Conclusion

Compared to HCs, subjects with significant AT are more likely to present symptoms of PTSD. In particular, AT related to ruminative thinking, narrow interests, and sensorial reactivity would seem to predict the presence of post-traumatic stress symptomatology.

Type
Original Research
Copyright
© The Author(s), 2024. Published by Cambridge University Press

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by two main features: persistent difficulties in social communication and social interaction as well as restrictive and repetitive patterns of behavior and interests.1Reference Lai, Lombardo and Baron-Cohen4 Research in the field of ASD has been mainly focused on child samples, being the onset of the disorder typically in early life years.Reference Billeci, Calderoni and Conti2Reference Lai, Lombardo and Baron-Cohen4 However, more recently, increasing attention has been paid on adult forms of ASD, with a specific interest on evaluating those milder forms, without intellectual disability or language development alterations, which may reach clinical attention only in adulthood when developing other disorders in comorbidity.Reference Lai, Lombardo and Baron-Cohen4Reference Dell’Osso and Carpita7 In addition, the current scientific literature is also stressing the importance of identifying subthreshold manifestations of ASD, such as autistic traits (ATs), due to their possible impact on quality of life and their role as a vulnerability factor for the development of other psychiatric conditions.Reference Dell’Osso, Luche and Gesi5Reference Dell’Osso and Carpita7 This kind of subthreshold manifestations, such as impaired social and communication skills, unusual and aloof personality, and repetitive and stereotyped behaviors, was originally detected among first-degree relatives of ASD probands, where they have been labeled as “broad autism phenotype.”Reference Billeci, Calderoni and Conti2, Reference Dell’Osso, Dalle Luche and Maj6, Reference Losh, Childress, Lam and Piven8Reference Dawson, Estes and Munson12 However, further studies highlighted how AT seem to be continually distributed in the population, being particularly high in specific high-risk groups, such as university students of scientific coursesReference Choteau, Raynal, Goutaudier and Chabrol13Reference Tchanturia, Smith and Weineck18 or clinical groups of psychiatric patients with other kinds of mental disorders.Reference Suzuki, Miyaki, Eguchi and Tsutsumi17Reference Dell’Osso, Conversano and Corsi22 In this framework, it has been noted how both ASD and AT seem to play a significant role as vulnerability factors for the development of different psychiatric conditions, with a wide range of comorbidities between autism spectrum and several mental disorders.Reference Dell’Osso, Cremone and Amatori20Reference Dell’Osso, Cremone and Carpita30 In this framework, a certain number of studies also reported a correlation between autism spectrum and trauma/stress-related symptoms.Reference Dell’Osso, Conversano and Corsi22 Some authors reported a post-traumatic stress disorder (PTSD) prevalence in children with ASD of approximately 67%, suggesting that these patients may be considered as a low resilient group with a greater vulnerability to the development of trauma and stress disorders.Reference Dell’Osso, Conversano and Corsi22, Reference Stavropoulos, Bolourian and Blacher31Reference Roberts, Koenen, Lyall, Robinson and Weisskopf37 However, some data differ from those listed above, reporting lower prevalence rates between autism and PTSD.Reference Stavropoulos, Bolourian and Blacher31 The controversial reports about the association between ASD and PTSD has been hypothesized to be underlain by the fact that often ASD subjects are not able to properly mentalize and communicate eventual traumatic event.Reference Stavropoulos, Bolourian and Blacher31, Reference King38, Reference Dell’Osso, Abelli and Pini39 Individuals in the autism spectrum typically show difficulties in verbal and nonverbal communication with consequent problems in externalizing emotions, seeking help and adapting to stressful events.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Abelli and Pini40Reference Motlani, Motlani and Thool43 On the other hand, the inflexibility and prowess toward rumination may facilitate the development of post-traumatic symptoms such as hyperarousal, intrusive thoughts, and re-experiencing.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Abelli and Pini40Reference Dell’Osso, Lorenzi and Carpita42, Reference Ehlers and Clark44, Reference Kitamura, Makinodan and Matsuoka45

Some authors also suggested that these autistic features may easily lead to an inability to successfully cope not only with major traumatic events but also with minor events, the so-called microtraumas, developing chronic post-traumatic symptoms.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Abelli and Pini40Reference Dell’Osso, Lorenzi and Carpita42 According to the concept of PTSD complex (cPTSD), the development of post-traumatic symptoms following prolonged and/or repeated mild traumatic events may be more frequent in vulnerable subjects and characterized by a greater tendency to chronicization, higher rates of dissociative symptoms, maladaptive behaviors, emotional dysregulation, and negative self-perception.Reference Dell’Osso, Conversano and Corsi22, Reference Carpita, Muti and Muscarella41, Reference Dell’Osso, Lorenzi and Carpita42, Reference Terr46Reference Maercker, Brewin and Bryant52 It is also interesting to highlight that while, according to literature, ASD seems to be more prevalent among males,Reference Dell’Osso, Gesi and Massimetti14, Reference Baron-Cohen53 PTSD is more frequent in females.Reference Carmassi, Akiskal and Yong54Reference Carmassi, Corsi and Bertelloni56 These data should be considered in light of recent studies suggesting a possible under-recognition of ASD among females due to gender difference in the presentation of the disorder, including a better ability in female patients to camouflage social difficulties by imitation strategies. As a consequence, autism spectrum among females may remain masked by other diagnosis, spanning from eating disorder to social anxiety, borderline personality disorders, and trauma and stress-related disorders.Reference Dell’Osso and Carpita7, Reference Dell’Osso, Gesi and Massimetti14, Reference Baron-Cohen, Cassidy and Auyeung57Reference Marazziti, Abelli and Baroni59 Other studies also stressed that individuals with AT after traumatic exposure may more likely develop mood disorders, enhanced by PTSD symptoms and altered circadian rhythms symptoms. This hypothesis is in line with previous researches that highlighted a role of trauma/stress-related symptoms in the relationship between autism spectrum and increased suicidal risk.Reference Takara and Kondo19, Reference Kato, Mikami and Akama60 A previous study from Dell’Osso et al.Reference Dell’Osso, Conversano and Corsi22 also reported that, among university students, the presence of AT plays a role in the development of mood symptoms both directly and indirectly, through a mediating effect of trauma/stress-related symptoms. Furthermore, the authors suggested that traumatic experiences and the subsequent development of PTSD-like symptoms may on the development of mood condition. Finally, it is important to underline that, according to our vision, PTSD would not represent the end point of the disease pathway but the first step of a psychopathology trajectory that, starting from a neurodevelopmental impairment, may evolve toward mood disorders and catatonia, another condition often associated with both autism spectrum and PTSD.Reference Dell’Osso, Lorenzi and Carpita42, Reference Dell’Osso, Toschi, Amatori and Gesi61Reference Dell’Osso, Amatori and Cappelli63

Our main hypothesis is that there is a correlation between elevated AT and post-traumatic stress symptoms and that, in this relationship, some symptom domains of autism, such as ruminative thinking and altered responsiveness to sensory stimuli, may play an important role.

Thus, the main aim of this study was to evaluate, in a sample of adults with significant AT and healthy controls (HCs), the relationship between autism symptoms and PTSD. The secondary aim was to investigate which specific autism dimension was more associated with trauma and stress-related symptoms in this population and eventually statistically predictive of developing PTSD.

Methods

Participants

We recruited a sample of 132 adult subjects without intellectual impairment or language development alteration who were addressed at the university psychiatric department. The recruitment period lasted from May 2015 to April 2017. The sample was divided in two groups: 68 subjects diagnosed with ASD according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and scored above the cutoff for significant AT on the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire (Autism Spectrum group). The second group was composed of 64 HCs who did not meet any criteria for ASD and scored below the threshold for significant AT on the AdAS Spectrum. All participants were assessed by trained clinicians according to DSM-5 criteria. All subjects received clear information about the study and had the opportunity to ask questions before providing a written informed consent. The study was led in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Azienda Ospedaliero Universitaria Pisana (protocol code: 2015551).

Psychometric scales

All subjects were assessed with the AdAS Spectrum questionnaire and with the Trauma and Loss Spectrum (TALS) questionnaire, self-report version.

AdAS Spectrum

The AdAS Spectrum is a self-report instrument developed and validated in order to assess the wide range of subthreshold and full-threshold ASD manifestations among adults without intellectual disability or delayed language development. The questionnaire features 161 items with dichotomous answers (yes/no) divided into the seven domains: Childhood/adolescence, Verbal communication, Non-Verbal communication, Empathy, Inflexibility and adherence to routine, Restricted interests and rumination, and Hyper-hypo reactivity to sensory input. In the validation study, the AdAS Spectrum demonstrated good reliability and internal consistency, with Kuder–Richardson coefficients above 0.964. Also, in the sample of the present study, the AdAS Spectrum showed an excellent internal consistency (0.970). Although the AdAS Spectrum have been developed mainly as a qualitative and dimensional tool, it can also be use in a quantitative way, with a threshold of 43 for identifying significant AT and a threshold of 70 suggesting the presence of possibly clinically relevant ASD.Reference Dell’Osso, Gesi and Massimetti14, Reference Dell’Osso, Carmassi and Cremone64

Trauma and Loss Spectrum, Self-Report

The Trauma and Loss Spectrum, Self-Report (TALS-SR) is a self-report questionnaire with the aim to assess the broad range of symptoms related to stress, trauma, and loss in a dimensional fashion, evaluating the presence of a full-blown clinical picture as well as subthreshold or atypical symptoms across lifetime. The instrument features 116 items with a dichotomous answer (yes/no) organized in nine domains. According to the validation study, the instrument showed a good internal consistency and reliability.Reference Dell’Osso, Carmassi and Rucci65 Even in the sample of the present study, the TALS-SR showed an excellent internal consistency (0.970). Following the procedure described in previous studies, the TALS-SR can also be used for assessing the fulfillment of DSM-5 symptomatological criteria for PTSD (criteria B-E) on the basis of matched TALS-SR items.Reference Carmassi, Gesi and Simoncini66

Statistical analysis

We performed Mann–Whitney U test in order to compare mean age and scores obtained on the TALS-SR among groups. Chi-square tests were used in order to compare sex composition among groups as well as the presence or absence of a probable diagnosis of PTSD according to the TALS-SR. Spearman correlation coefficients were used for evaluating the association between AdAS Spectrum and TALS-SR scores in the whole sample. The sample size ensures 88.3% power for an α = 0.05 when comparing total TALS-SR scores between groups and 97.7% for an α = 0.05 when calculating correlations between total AdAS Spectrum and TALS-SR scores in the total sample. Furthermore, in order to identify the best predictors of the presence of a probable PTSD according to the TALS-SR, a first stepwise logistic regression analysis was performed with AdAS Spectrum total score as independent variable, followed by a second logistic regression analysis with AdAS Spectrum domain scores as independent variables to identify noteworthy predictors of PTSD symptomatology within the AdAS Spectrum domains and to quantify the extent to which the average risk of PTSD escalates with each one-point increase in AdAS Spectrum scores.

Results

The sample was composed of 83 males and 49 females. The mean age of the sample was 25.33 ± 0.73. No significant difference was reported among groups with respect to sex composition and mean age (see Table 1). The Autism Spectrum group reported a mean AdAS Spectrum total score of 76.09 ± 22.56, while HCs reported a mean score of 22.83 ± 11.50 (t = −17.23; p < .001). Subjects in the Autism Spectrum group reported a 30% rate of probable PTSD diagnosis according to TALS-SR, while no subjects in the HCs reported a PTSD diagnosis (see Table 2). Moreover, participants in the Autism Spectrum group also reported significantly higher scores on TALS total and domain scores when compared with HCs (see Table 3). Significantly positive and medium to strong correlations were reported between AdAS Spectrum and TALS-SR scores in the whole sample (see Table 4). According to the first logistic regression analysis, AdAS Spectrum total scores were reported to be statistically predictive of the presence of a probable PTSD diagnosis based on TALS-SR (see Table 5). The second logistic regression analysis, performed with a forward stepwise model including all AdAS Spectrum domain scores as independent variables, identified the AdAS Spectrum Hyper-Hyporeactivity to sensory input (step 1 and 2) and the Restrictive interest and rumination (steps 2 and 3) domains as positive predictors of a probable PTSD diagnosis based on TALS-SR (see Table 6).

Table 1. Comparison of Sociodemographic Variables Between Groups

Table 2. Differences in Prevalence Rates of a Probable Diagnosis of PTSD According to TALS-SR Between Groups

Table 3. Comparison of TALS-SR Total and Domain Scores Among Groups

Table 4. Spearman Correlations Between AdAS Spectrum and TALS-SR Scores in the Whole Sample

** p ≤ .001.

* p < .01.

Table 5. Logistic Regression Analysis with AdAS Spectrum Total Score as Independent Variable and Presence/Absence of a Probable Diagnosis of PTSD Based on TALS-SR as Dependent Variable

Table 6. Logistic Regression Analysis with AdAS Spectrum Domain Scores as Independent Variables and Presence/Absence of a Probable Diagnosis of PTSD as Dependent Variable

R 2 (Cox/Smell) = 0.229; R 2 (Nagelkerke) = 0.393; correct classification total percentage = 85.6%.

Discussion

The main aim of this study was to evaluate, in a sample of adults, whether the presence of PTSD spectrum symptoms was associated with autism spectrum, also evaluating which autism spectrum dimension may be more associated with trauma/stress-related symptoms and statistically predictive of PTSD clinical picture. In order to assess the presence of PTSD full-fledged symptoms, we chose to refer only on symptomatological criteria (B-E), as assessed by the TALS-SR excluding the criterion A (which assess the presence of critical traumatic experiences). This choice was made in light of the rising cPTSD model, according to which vulnerable subjects may develop a PTSD condition also after minor traumatic events not included in criterion A, especially if prolonged or repeated in time.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Abelli and Pini40, Reference Carpita, Muti and Muscarella41, Reference Motlani, Motlani and Thool43, Reference Kitamura, Makinodan and Matsuoka45Reference Dell’Osso, Lorenzi and Carpita50 In addition, subjects in the autism spectrum, even when having experienced major traumatic events, may not be able to properly report it due to their difficulties in processing and communicating life experiences.Reference Dell’Osso, Luche and Gesi5, Reference Dell’Osso and Carpita7, Reference Stavropoulos, Bolourian and Blacher31, Reference Van der Kolk48 According to our findings, autism spectrum subjects reported a strikingly higher rate of PTSD when compared with the HC group from our study (30% versus 0%). The reported prevalence was higher also when compared with ranges reported in the general population, which are around 3–4%.1, Reference Javidi and Yadollahie67Reference Christiansen and Berke70 On the other hand, the absence of cases among HCs, with a consequent prevalence rate likely lower to that reported in general population samples, may also be ascribed to the fact that participants in the HC group were specifically selected among people without significant subthreshold AT, which are instead continuously distributed in the general population.

This finding was further supported also by the significantly higher scores reported on all TALS-SR domains by autism spectrum subjects than HCs. Our data are in line with studies reporting an increased prevalence of PTSD symptoms among subjects diagnosed with ASD or with higher AT,Reference Dell’Osso, Conversano and Corsi22, Reference Stavropoulos, Bolourian and Blacher31Reference Roberts, Koenen, Lyall, Robinson and Weisskopf37, Reference Carpita, Muti and Muscarella41, Reference Dell’Osso, Lorenzi and Carpita42, Reference Van der Kolk48, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Dell’Osso, Toschi, Amatori and Gesi61, Reference Golan, Haruvi-Lamdan, Laor and Horesh71 eventually supporting the hypothesis that ASD may act like a factor of vulnerability for developing symptoms after traumatic events.Reference Dell’Osso, Conversano and Corsi22, Reference Stavropoulos, Bolourian and Blacher31, Reference Dell’Osso, Lorenzi and Carpita42, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Dell’Osso, Amatori and Massimetti62, Reference Dell’Osso, Amatori and Cappelli63 In particular, the presence of AT, which results in reduced coping strategies and difficulties in processing stressful experiences, may lead to an increased vulnerability to a wide range of trauma or stress-related symptom.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Lorenzi and Carpita42, Reference Ehlers and Clark44, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Dell’Osso, Toschi, Amatori and Gesi61, Reference Dell’Osso, Amatori and Cappelli63 Considering that subjects with AT may have difficulties also in emotional expression and impairment in peer relationships, the lack of ability to request and obtain social support may enhance the negative impact of the stressors.Reference Dell’Osso, Conversano and Corsi22, Reference Carpita, Muti, Cremone, Fagiolini and Dell’Osso29, Reference Dell’Osso, Abelli and Pini39, Reference Dell’Osso, Lorenzi and Carpita42, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Dell’Osso, Toschi, Amatori and Gesi61, Reference Dell’Osso, Amatori and Cappelli63 Noticeably, the autism spectrum group reported higher scores also on TALS domain, investigating the wide spectrum of loss events and potentially traumatic events. These domains do not assess only major traumatic or loss events but also minor ones for which the subject experienced distress (such as changes in home or school, school or work failures, etc.). While people with AT may be more frequently exposed to traumatic events, especially relational ones, due to their difficulties in understanding social clues, it is also possible that, if directly asked, they recall as distressing a wider range of events with respect to subjects without AT.Reference Dell’Osso, Dalle Luche and Maj6, Reference Dell’Osso, Conversano and Corsi22, Reference Kanne, Christ and Reiersen26, Reference Stavropoulos, Bolourian and Blacher31, Reference Dell’Osso, Lorenzi, Nardi, Carmassi and Carpita36, Reference Roberts, Koenen, Lyall, Robinson and Weisskopf37, Reference Dell’Osso, Lorenzi and Carpita42, Reference Van der Kolk48, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Kato, Mikami and Akama60, Reference Dell’Osso, Amatori and Cappelli63, Reference Rumball, Happé and Grey72

According to our data, significant and positive correlations were found between AdAS Spectrum and TALS-SR scores, with the highest correlations reported between TALS-SR total score and AdAS Spectrum domains related to rumination, altered reactivity to sensory input, inflexibility, and adherence to routine. In addition, according to the regression analysis, in our sample, the AdAS Spectrum total scores were statistically predictive of the presence of a symptomatic diagnosis of PTSD. The AdAS spectrum domains significantly predictive of the presence of a PTSD clinical picture were Restrictive Interests and Rumination and, to a lesser extent, Hypo-Hyperreactivity to sensory input. These results are in line with the previous literature which stressed a significant role of ruminative thinking for the development of PTSD in subjects previously exposed to a trauma.Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Abelli and Pini40, Reference Ehlers and Clark44, Reference Baron-Cohen, Cassidy and Auyeung57, Reference Lai, Baron-Cohen and Buxbaum58, Reference Dell’Osso, Amatori and Cappelli63, Reference Woodward, Sachschal, Beierl and Ehlers73, Reference Viana, Paulus and Garza74 In this framework, ruminative thinking may act both as a maintaining and exacerbating factor for PTSD.Reference Roley, Claycomb and Contractor75Reference Olatunji and Wolitzky-Taylor77 On the other hand, the altered reactivity to sensory input may be considered as a further element of enhanced vulnerability to external events, which, together with inflexibility traits, may impair the ability to adjust to changes in the environment.Reference Dell’Osso, Dalle Luche and Maj6, Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Lorenzi and Carpita50 In clinical terms, being aware of a correlation, as evidenced by scientific literature, between elevated AT and post-traumatic stress symptoms could assist clinicians in preventive efforts for individuals within the autism spectrum. This may involve primarily psychoeducational interventions aimed at reducing the likelihood that traumatic experiences encountered by these vulnerable individuals could lead to the development of full-fledged PTSD or complex PTSD. This study should be considered in light of some important limitations. First of all, it is impossible to identify the temporal relationship between AT and the appearance of stress and trauma-related symptoms due to the cross-sectional design of the study. Secondly, the investigated sample was relatively limited in number, limiting the extensibility of our results. Furthermore, we used self-reported questionnaires that may cause a hyper- or under-evaluation of symptoms by the subjects. In addition, we have to consider that the presence of PTSD may have influenced obtaining high scores at some AdAS domains such as altered responsiveness to sensory stimuli, especially considering the complex interaction between AT and post-traumatic symptoms in composite and still not formally categorized frameworks such as complex PTSD. Despite these limitations, globally, our study seems to confirm a strong correlation between autism spectrum and PTSD symptoms. Further studies should address the issue of stress/trauma-related disorders in this population, considering also that the development of a PTSD-like syndrome, if not properly recognized and treated, may facilitate the development of other disorders in comorbidity, worsening the illness trajectory of ASD.Reference Dell’Osso, Dalle Luche and Maj6, Reference Dell’Osso, Conversano and Corsi22, Reference Dell’Osso, Lorenzi and Carpita50

Conclusion

High rates of PTSD were found in subjects with significant AT. In particular, among the symptom dimensions of autism, ruminative thinking, restricted interests, and altered sensitivity to sensory stimuli were found to be predictive of the presence of a PTSD diagnosis.

Author contribution

Conceptualization: B.C., L.D.O.; Investigation: B.C., F.G., I.M.C., G.A.; Supervision: B.C., L.D.O.; Writing – review & editing: B.C., I.M.C., G.A.; Formal analysis: E.M.; Software: E.M.; Writing – original draft: F.G.; Data curation: G.A.

Financial support

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.

Competing interest

All authors declare that they have conducted the research without any financial, professional, contractual, or personal relationships that could be interpreted as a potential conflict of interest. The authors have nothing to disclose.

Footnotes

The original version of this article was published with an error in the abstract. A notice detailing this has been published, and the error rectified in the online HTML and PDF versions.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed., text rev). Washington, DC: American Psychiatric Association Publishing; 2022.Google Scholar
Billeci, L, Calderoni, S, Conti, E, et al. The broad autism (endo)phenotype: neurostructural and neurofunctional correlates in parents of individuals with autism spectrum disorders. Front Neurosci. 2016;10:346.CrossRefGoogle ScholarPubMed
Carpita, B, Marazziti, D, Palego, L, et al. Immune system and autism spectrum disorders: an integrative model towards novel treatment options. Curr Med Chem. 2020;27(31):51195136.CrossRefGoogle ScholarPubMed
Lai, MC, Lombardo, MV, Baron-Cohen, S. Autism. Lancet. 2014;383(9920):896910.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Luche, RD, Gesi, C, et al. From Asperger’s autistischen psychopathen to DSM-5 autism spectrum disorder and beyond: a subthreshold autism spectrum model. Clin Pract Epidemiol Ment Health. 2016;12:120131.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Dalle Luche, R, Maj, M. Adult autism spectrum as a transnosographic dimension. CNS Spectr. 2016;21(2):131133.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Carpita, B. What misdiagnoses do women with autism spectrum disorder receive in the DSM-5? CNS Spectr. 2023;28(3):269270.CrossRefGoogle ScholarPubMed
Losh, M, Childress, D, Lam, K, Piven, J. Defining key features of the broad autism phenotype: a comparison across parents of multiple- and single-incidence autism families. Am J Med Genet B Neuropsychiatr Genet. 2008;147B(4):424433.CrossRefGoogle ScholarPubMed
Losh, M, Adolphs, R, Poe, MD, et al. Neuropsychological profile of autism and the broad autism phenotype. Arch Gen Psychiatry. 2009;66(5):518526.CrossRefGoogle ScholarPubMed
Taylor, MJ, Gillberg, C, Lichtenstein, P, Lundström, S. Etiological influences on the stability of autistic traits from childhood to early adulthood: evidence from a twin study. Mol Autism. 2017;17(8):5.CrossRefGoogle Scholar
Carpita, B, Carmassi, C, Calderoni, S, et al. The broad autism phenotype in real-life: clinical and functional correlates of autism spectrum symptoms and rumination among parents of patients with autism spectrum disorder [published correction appears in CNS Spectr. 2021 Aug;26(4):435]. CNS Spectr. 2020;25(6):765773.CrossRefGoogle Scholar
Dawson, G, Estes, A, Munson, J, et al. Quantitative assessment of autism symptom-related traits in probands and parents: Broader Phenotype Autism Symptom Scale. J Autism Dev Disord. 2007;37(3):523536.CrossRefGoogle ScholarPubMed
Choteau, L, Raynal, P, Goutaudier, N, Chabrol, H. Psychopathological traits in college students from top-ranking french schools: do autistic features impair success in science when associated with schizotypal traits? Psychiatry Res. 2016;237:218223.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Gesi, C, Massimetti, E, et al. Adult autism subthreshold spectrum (AdAS spectrum): validation of a questionnaire investigating subthreshold autism spectrum. Compr Psychiatry. 2017;73:6183.CrossRefGoogle ScholarPubMed
Skylark, WJ, Baron-Cohen, S. Initial evidence that non-clinical autistic traits are associated with lower income. Mol Autism. 2017;8:61CrossRefGoogle ScholarPubMed
Dell’Osso, L, Bertelloni, CA, Di Paolo, M, et al. Problematic internet use in university students attending three superior graduate schools in Italy: is autism spectrum related to suicide risk? Int J Environ Res Public Health. 2019;16(7):1098.CrossRefGoogle ScholarPubMed
Suzuki, T, Miyaki, K, Eguchi, H, Tsutsumi, A. Distribution of autistic traits and their association with sociodemographic characteristics in Japanese workers. Autism. 2018;22(8):907914.CrossRefGoogle ScholarPubMed
Tchanturia, K, Smith, E, Weineck, F, et al. Exploring autistic traits in anorexia: a clinical study. Mol Autism. 2013;4(1):44.CrossRefGoogle ScholarPubMed
Takara, K, Kondo, T. Autism spectrum disorder among first-visit depressed adult patients: diagnostic clues from backgrounds and past history. Gen Hosp Psychiatry. 2014;36(6):737742.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Cremone, IM, Amatori, G, et al. Investigating the relationship between autistic traits, ruminative thinking, and suicidality in a clinical sample of subjects with bipolar disorder and borderline personality disorder. Brain Sci. 2021;11(5):621.CrossRefGoogle Scholar
Dell’Osso, L, Carpita, B, Cremone, IM, et al. Autism spectrum in patients with schizophrenia: correlations with real-life functioning, resilience, and coping styles [published online ahead of print, 2021 Apr 12]. CNS Spectr. 2021;111.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Conversano, C, Corsi, M, et al. Polysubstance and behavioral addictions in a patient with bipolar disorder: role of lifetime subthreshold autism spectrum. Case Rep Psychiatry. 2018;2018:1547975.Google Scholar
Towbin, KE, Pradella, A, Gorrindo, T, Pine, DS, Leibenluft, E. Autism spectrum traits in children with mood and anxiety disorders. J Child Adolesc Psychopharmacol. 2005;15(3):452464.CrossRefGoogle ScholarPubMed
Kunihira, Y, Senju, A, Dairoku, H, Wakabayashi, A, Hasegawa, T. Autistic’ traits in non-autistic Japanese populations: relationships with personality traits and cognitive ability. J Autism Dev Disord. 2006;36(4):553566.CrossRefGoogle ScholarPubMed
Pine, DS, Guyer, AE, Goldwin, M, Towbin, KA, Leibenluft, E. Autism spectrum disorder scale scores in pediatric mood and anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2008;47(6):652661.CrossRefGoogle ScholarPubMed
Kanne, SM, Christ, SE, Reiersen, AM. Psychiatric symptoms and psychosocial difficulties in young adults with autistic traits. J Autism Dev Disord. 2009;39(6):827833.CrossRefGoogle ScholarPubMed
Matsuo, J, Kamio, Y, Takahashi, H, et al. Autistic-like traits in adult patients with mood disorders and schizophrenia. PLoS One. 2015;10(4):e0122711.CrossRefGoogle ScholarPubMed
Liu, J, Gong, J, Nie, G, et al. The mediating effects of childhood neglect on the association between schizotypal and autistic personality traits and depression in a non-clinical sample. BMC Psychiatry. 2017;17(1):352.CrossRefGoogle Scholar
Carpita, B, Muti, D, Cremone, IM, Fagiolini, A, Dell’Osso, L. Eating disorders and autism spectrum: links and risks. CNS Spectr. 2022;27(3):272280.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Cremone, IM, Carpita, B, et al. Rumination, posttraumatic stress disorder, and mood symptoms in borderline personality disorder. Neuropsychiatr Dis Treat. 2019;15:12311238.CrossRefGoogle ScholarPubMed
Stavropoulos, KK, Bolourian, Y, Blacher, J. Differential diagnosis of autism spectrum disorder and post traumatic stress disorder: two clinical cases. J Clin Med. 2018;7(4):71.CrossRefGoogle ScholarPubMed
Storch, EA, Sulkowski, ML, Nadeau, J, et al. The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders. J Autism Dev Disord. 2013;43(10):24502459.CrossRefGoogle ScholarPubMed
Haruvi-Lamdan, N, Horesh, D, Golan, O. PTSD and autism spectrum disorder: co-morbidity, gaps in research, and potential shared mechanisms. Psychol Trauma. 2018;10(3):290299.CrossRefGoogle ScholarPubMed
Lobregt-van Buuren, E, Hoekert, M, Sizoo, B. Autism, adverse events, and trauma. In: Grabrucker, AM, editor. Autism spectrum disorders [Internet]. Brisbane: Exon Publications; 2021. 3342.CrossRefGoogle Scholar
Kerns, CM, Newschaffer, CJ, Berkowitz, SJ. Traumatic childhood events and autism spectrum disorder. J Autism Dev Disord. 2015;45(11):34753486.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Lorenzi, P, Nardi, B, Carmassi, C, Carpita, B. Post traumatic growth (PTG) in the frame of traumatic experiences. Clin Neuropsychiatry. 2022;19(6):390393.Google ScholarPubMed
Roberts, AL, Koenen, KC, Lyall, K, Robinson, EB, Weisskopf, MG. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015;45:135142.CrossRefGoogle ScholarPubMed
King, R. Complex post-traumatic stress disorder: implications for individuals with autism spectrum disorders-part 1. J Dev Disabil. 2010;16:91100.Google Scholar
Dell’Osso, L, Abelli, M, Pini, S, et al. The influence of gender on social anxiety spectrum symptoms in a sample of university students. Riv Psichiatr. 2015;50(6):295301.Google Scholar
Dell’Osso, L, Abelli, M, Pini, S, et al. Dimensional assessment of DSM-5 social anxiety symptoms among university students and its relationship with functional impairment. Neuropsychiatr Dis Treat. 2014;10:13251332.Google ScholarPubMed
Carpita, B, Muti, D, Muscarella, A, et al. Sex differences in the relationship between PTSD spectrum symptoms and autistic traits in a sample of university students. Clin Pract Epidemiol Ment Health. 2019;15:110119.CrossRefGoogle Scholar
Dell’Osso, L, Lorenzi, P, Carpita, B. Autistic traits and illness trajectories. Clin Pract Epidemiol Ment Health. 2019;15:9498.CrossRefGoogle ScholarPubMed
Motlani, V, Motlani, G, Thool, A. Asperger syndrome (AS): a review article. Cureus. 2022;14(11):e31395.Google ScholarPubMed
Ehlers, A, Clark, DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319345.CrossRefGoogle ScholarPubMed
Kitamura, S, Makinodan, M, Matsuoka, K, et al. Association of adverse childhood experiences and precuneus volume with intrusive reexperiencing in autism spectrum disorder. Autism Res. 2021;14(9):18861895.CrossRefGoogle ScholarPubMed
Terr, LC. Childhood traumas: an outline and overview. Am J Psychiatry. 1991;148(1):1020.Google ScholarPubMed
Herman, JL. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress. 1992;5:377391.CrossRefGoogle Scholar
Van der Kolk, B. Developmental trauma disorder. Toward a rational diagnosis for children with complex trauma histories. Psychiatr Ann. 2005;35:401408.CrossRefGoogle Scholar
Hofvander, B, Delorme, R, Chaste, P, et al. Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorder. BMC Psychiatry. 2009;9:35.CrossRefGoogle Scholar
Dell’Osso, L, Lorenzi, P, Carpita, B. The neurodevelopmental continuum towards a neurodevelopmental gradient hypothesis. J Psychopathol. 2019;25:179182.Google Scholar
Cloitre, M, Garvert, DW, Brewin, CR, Bryant, RA, Maercker, A. Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. Eur J Psychotraumatol. 2013;4.Google ScholarPubMed
Maercker, A, Brewin, CR, Bryant, RA, et al. Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry. 2013;12(3):198206.CrossRefGoogle ScholarPubMed
Baron-Cohen, S. The extreme male brain theory of autism. Trends Cogn Sci. 2002;6(6):248254.CrossRefGoogle ScholarPubMed
Carmassi, C, Akiskal, HS, Yong, SS, et al. Post-traumatic stress disorder in DSM-5: estimates of prevalence and criteria comparison versus DSM-IV-TR in a non-clinical sample of earthquake survivors. J Affect Disord. 2013;151(3):843848.CrossRefGoogle Scholar
Cénat, JM, Derivois, D. Assessment of prevalence and determinants of posttraumatic stress disorder and depression symptoms in adults survivors of earthquake in Haiti after 30 months. J Affect Disord. 2014;159:111117.CrossRefGoogle ScholarPubMed
Carmassi, C, Corsi, M, Bertelloni, CA, et al. Mothers and fathers of children with epilepsy: gender differences in post-traumatic stress symptoms and correlations with mood spectrum symptoms. Neuropsychiatr Dis Treat. 2018;14:13711379.CrossRefGoogle ScholarPubMed
Baron-Cohen, S, Cassidy, S, Auyeung, B, et al. Attenuation of typical sex differences in 800 adults with autism vs. 3,900 controls. PLoS One. 2014;9(7):e102251.CrossRefGoogle ScholarPubMed
Lai, MC, Baron-Cohen, S, Buxbaum, JD. Understanding autism in the light of sex/gender. Mol Autism. 2015;6:24.CrossRefGoogle ScholarPubMed
Marazziti, D, Abelli, M, Baroni, S, et al. Neurobiological correlates of social anxiety disorder: an update. CNS Spectr. 2015;20(2):100111.CrossRefGoogle ScholarPubMed
Kato, K, Mikami, K, Akama, F, et al. Clinical features of suicide attempts in adults with autism spectrum disorders. Gen Hosp Psychiatry. 2013;35(1):5053.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Toschi, D, Amatori, G, Gesi, C. Rethinking catatonia: new insights from the autism spectrum. CNS Neurol Disord Drug Targets. 2023;22(4):462465.Google ScholarPubMed
Dell’Osso, L, Amatori, G, Massimetti, G, et al. Investigating the relationship between autistic traits and symptoms and catatonia spectrum. Eur Psychiatry. 2022;65(1):e81.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Amatori, G, Cappelli, A, et al. Catatonia spectrum: validation of a questionnaire investigating catatonia spectrum. Front Psychiatry. 2022;13:913286.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Carmassi, C, Cremone, IM, et al. Defining the optimal threshold scores for adult autism subthreshold spectrum (AdAS spectrum) in clinical and general population. Clin Pract Epidemiol Ment Health. 2020;16:204211.CrossRefGoogle ScholarPubMed
Dell’Osso, L, Carmassi, C, Rucci, P, et al. A multidimensional spectrum approach to post-traumatic stress disorder: comparison between the structured clinical interview for trauma and loss spectrum (SCI-TALS) and the self-report instrument (TALS-SR). Compr Psychiatry. 2009;50(5):485490.CrossRefGoogle ScholarPubMed
Carmassi, C, Gesi, C, Simoncini, M, et al. DSM-5 PTSD and posttraumatic stress spectrum in Italian emergency personnel: correlations with work and social adjustment. Neuropsychiatr Dis Treat. 2016;12:375381.CrossRefGoogle ScholarPubMed
Javidi, H, Yadollahie, M. Post-traumatic stress disorder. Int J Occup Environ Med. 2012;3(1):29.Google ScholarPubMed
Koenen, KC, Ratanatharathorn, A, Ng, L, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017;47(13):22602274.CrossRefGoogle ScholarPubMed
Bonsaksen, T, Brunes, A, Heir, T. Post-traumatic stress disorder in people with visual impairment compared with the general population. Int J Environ Res Public Health. 2022;19(2):619.CrossRefGoogle ScholarPubMed
Christiansen, DM, Berke, ET. Gender- and sex-based contributors to sex differences in PTSD. Curr Psychiatry Rep. 2020;22(4):19.CrossRefGoogle ScholarPubMed
Golan, O, Haruvi-Lamdan, N, Laor, N, Horesh, D. The comorbidity between autism spectrum disorder and post-traumatic stress disorder is mediated by brooding rumination. Autism. 2022;26(2):538544.CrossRefGoogle ScholarPubMed
Rumball, F, Happé, F, Grey, N. Experience of trauma and PTSD symptoms in autistic adults: risk of PTSD development following DSM-5 and non-DSM-5 traumatic life events. Autism Res. 2020;13(12):21222132.CrossRefGoogle ScholarPubMed
Woodward, E, Sachschal, J, Beierl, ET, Ehlers, A. Night-time rumination in PTSD: development and validation of a brief measure. Eur J Psychotraumatol. 2019;10(1):1651476.CrossRefGoogle ScholarPubMed
Viana, AG, Paulus, DJ, Garza, M, et al. Rumination and PTSD symptoms among trauma-exposed Latinos in primary care: is mindful attention helpful? Psychiatry Res. 2017;258:244249.CrossRefGoogle ScholarPubMed
Roley, ME, Claycomb, MA, Contractor, AA, et al.The relationship between rumination, PTSD, and depression symptoms. J Affect Disord. 2015;180:116121.CrossRefGoogle ScholarPubMed
Elwood, LS, Hahn, KS, Olatunji, BO, Williams, NL. Cognitive vulnerabilities to the development of PTSD: a review of four vulnerabilities and the proposal of an integrative vulnerability model. Clin Psychol Rev. 2009;29(1):87100.CrossRefGoogle Scholar
Olatunji, KN-G, Wolitzky-Taylor, KB. Specificity of rumination in anxiety and depression: a multimodal meta-analysis. Clin Psychol Sci Pract. 2013;20(3):225257.Google Scholar
Figure 0

Table 1. Comparison of Sociodemographic Variables Between Groups

Figure 1

Table 2. Differences in Prevalence Rates of a Probable Diagnosis of PTSD According to TALS-SR Between Groups

Figure 2

Table 3. Comparison of TALS-SR Total and Domain Scores Among Groups

Figure 3

Table 4. Spearman Correlations Between AdAS Spectrum and TALS-SR Scores in the Whole Sample

Figure 4

Table 5. Logistic Regression Analysis with AdAS Spectrum Total Score as Independent Variable and Presence/Absence of a Probable Diagnosis of PTSD Based on TALS-SR as Dependent Variable

Figure 5

Table 6. Logistic Regression Analysis with AdAS Spectrum Domain Scores as Independent Variables and Presence/Absence of a Probable Diagnosis of PTSD as Dependent Variable