Psychopathology with origins in early life – autism, conduct disorder, cognition
Two papers in the Journal this month examine causal hypotheses for the development of autism spectrum disorder (ASD). In contrast to the ‘extreme male brain’ theory of autism causation, Bejerot et al (pp. ) have found evidence to indicate that autism spectrum disorder may constitute a gender defiant disorder. In their study, adult women with ASD had elevated testosterone levels and masculinised physical features while affected males displayed feminised characteristics. Given the high heritability of ASD, the search for potential environmental risk factors for the disorder have been somewhat neglected but evidence of a rising prevalence of the disorder in many settings supports the need to rectify such neglect. In this context, Magnusson et al (pp. ) examined the impact of parental migration status on risk of ASD in a total child population sample obtained from Stockholm County between 2001 and 2007. The authors found that children born to migrant parents were at increased risk of developing low-functioning autism but at reduced risk of high-functioning autism. The former association was particularly marked among those whose parents had migrated from regions with low indices of human development and peaked when migration occurred around pregnancy. In a linked editorial, Simonoff (pp. ) highlights the importance of considering both genetic and environmental risks and their interaction if the causes of ASD are to be elucidated. Childhood conduct problems are common and can herald poor long-term outcomes; as a result, they have become a focus for development of intervention programmes internationally. Baker-Henningham et al (pp. ) have undertaken a cluster randomised controlled trial evaluation of a universal school-based approach which was delivered within community preschools in inner-city areas of Kingston, Jamaica. Children in the intervention schools showed reduced levels of observed conduct problems and increased social skills as well as improvements in teacher- and parent-reported behavioural difficulties. In a linked editorial, Bywater (pp. ) comments that while the focus of many child mental health services is on treatment, there is a need to prioritise the implementation of evidence-based interventions focused instead on prevention. Poorer cognitive function in childhood is a well-established risk factor for later development of psychosis, but whether this association is a specific one is not clear. Barnett et al (pp. ) utilised data from the 1946 British birth cohort to examine outcomes for those with poor childhood cognitive test scores. Psychotic-like experiences assessed in adulthood were associated with poorer cognitive performance at ages 8 and 15 years but such impairment was not a risk factor for non-psychotic psychopathology.
Improving clinical recognition of common conditions: adjustment disorder and problem drinking
In the context of ICD and DSM revision processes, Fernández et al (pp. ) undertook a study of the prevalence, recognition and use of services associated with adjustment disorder presenting in primary care. They found evidence to support consideration of adjustment disorder as a distinct clinical entity intermediate between no mental disorder and affective disorder, but recognition by general practitioners was found to be low. Over one third of affected patients had been prescribed at least one psychotropic medication. Casey & Doherty (pp. ) argue in a linked editorial for a change in the status of adjustment disorder in DSM-5 and ICD-11 from a residual to a full syndromal category in order to improve its recognition, treatment and to encourage future research. Recognition of problem drinking by clinicians in primary and secondary care has also been identified as a particular concern despite the significant public health impact of alcohol disorders. Mitchell et al (pp. ) conducted a meta-analysis of results from previous studies and conclude that healthcare professionals have significant difficulty identifying alcohol problems in clinical practice. In their data, around half of those with alcohol problems were identified on the basis of clinical judgement while correct recording in clinical records was found in only 30% of cases. The authors recommend that clinicians consider augmenting clinical judgement with simple screening methods, but comment that the added value of such methods remains unclear.
Antispsychotic treatment: side-effect myths and a call for patient choice
Sexual dysfunction is commonly reported by those with psychotic disorders and is often assumed to be the result of antipsychotic treatment. In contrast, sexual dysfunction was found to be prevalent among those at ultra-high risk of psychosis and not associated with administration of prolactin-raising antipsychotics among those with first-episode psychosis in a study conducted by Reis-Marques et al (pp. ). The authors suggest that sexual dysfunction may be intrinsic to the development of psychosis. In an editorial in the Journal this month, Morrison et al (pp. ) pose a challenge to clinicians to consider the proposition that patients with psychosis should be offered more choice with regard to treatment options, given that the balance between antipsychotic efficacy and toxicity does not clearly support antipsychotic treatment in all cases.