Notes (imp things)

- CAUSAL FACTORS ONLY FOR SCHIZO, NOT ANY OTHER DISORDER.

Intro
Diagnostic criteria + Case Study = Clinical picture
Prevalence rates (Indian Stats - 1 Study, Rural urban divide)
Gender differences
Comorbidity
Onset (optional)

Personality Disorder -
● Intro - Features and Type A,B,C (why they are classified like this) and what comes under
them (should write 1 line abt that).
● Clinical picture- (How does it look like) Diagnostic criteria and Case Study of Antisocial
and Borderline Personality Disorder, specifically.
● Prevalence rates (Indian Stats - 1 Study, Rural urban divide)
● Gender differences
● Comorbidity
Schizophrenia
Intro
Schizophrenia is a severe disorder that is often associated with considerable impairments
in functioning. Hallmark of schizophrenia is a significant loss of contact with reality
(psychosis).

History
● John Haslam – First detailed clinical description; described the case of a patient
who appears to have suffered from a variety of symptoms— including delusions
● Benedict Morel – 13-year-old boy, formerly most brilliant pupil but lost interest in
his studies, increasingly withdrawn, lethargic, reclusive, and quiet; forgotten
everything learned; Used the term démence précoce (mental deterioration at an
early age)
● Emil Kraepelin –
- Careful description of schizophrenia
- Used “dementia praecox” to refer to a group of conditions that all seemed
to feature mental deterioration beginning early in life
- Described the patient – “becomes suspicious of those around him, sees
poison in his food, is pursued by the police, feels his body is being
influenced, or thinks that he is going to be shot or that the neighbours are
jeering at him”
● Eugen Bleuler (1857–1939) – Gave us the diagnostic term; In 1911, used
schizophrenia (Greek roots of sxizo - “to split or crack,” and phren - “mind”)
because he believed characterized primarily by disorganization of thought
processes, a lack of coherence between thought and emotion, and an inward
orientation away (split off) from reality.

NOTE - Here, splitting does not refer to multiple personalities, ❌ DID ; Split within
the intellect, between the intellect and emotion, and between the intellect and external
reality.
Comorbidity
Psychiatric comorbidities are common among patients with schizophrenia.
Substance abuse comorbidity predominates. Anxiety and depressive symptoms are
also very common throughout the course of illness, with an estimated prevalence
of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for
obsessive-compulsive disorder. It is estimated that comorbid depression occurs in
50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime
diagnosis of comorbid substance abuse (Buckley et al., 2009).

Prevalence/ Epidemiology
Schizophrenia occurs in people from all cultures and from all walks of life.
- Average lifetime risk estimate - Risk of developing schizophrenia over the course
of one’s lifetime - 0.7 percent (Saha et al., 2005). Means 1 out of every 140
people alive today who survive until at least age 55 will develop the disorder.
- Higher chances in those with parents with schizo than those where no fam schizo
history
- Esp high risk of developing schizophrenia -
1. Fathers at 50 years or more @ birth (Miller et al., 2011)
2. Having a dry cleaner parent - risk factor! (Perrin, Opler, et al., 2007)
3. Higher first & second generation immigrants, particularly those from black
Caribbean and black African countries who live in majority white
communities (Matheson et al., 2014).

Prevalence (Indian Stats) - A significant study conducted in Madras, known as the

Longitudinal Study of Functional Psychoses in an Urban Community (SOFPUC),
estimated the prevalence rate of schizophrenia at 2.62 per 1,000 individuals in a
population of over 100,000. When age-corrected, this rate increased to 3.87 per 1,000.
This study's findings were higher than those reported in other Indian studies, likely due to
differences in methodology and the larger population size involved (Thara et al., 1993).

Onset
- Vast majority of cases - Late adolescence and early adulthood; 18 to 30 years –
peak time for onset (Tandon et al., 2009)
- Rare in children (Green et al., 1992).
- Can onset in middle age or later; not typical
Gender differences
- Characteristic age of onset differs in men and women
1. MEN - Peak btwn ages 20 & 24
2. Same peak in women but the peak is less marked than it is for men.
After age 35, schizophrenia cases drop in men, but not women, who
instead experience a second rise around age 40 and a third spike in
their early sixties (Abel et al., 2010).
- Males - Severe form of schizophrenia; Severe anomalies of brain structure.
- Common in males; Ratio - 1.4:1.
- Better clinical outcome of women with schizophrenia- female sex hormones play
some protective role. When estrogen levels are low (as is true premenstrually) or
are falling, psychotic symptoms in women with schizophrenia often get worse
(Bergemann et al., 2007). The protective effect of estrogen may therefore help
explain both the delayed onset of schizophrenia and the more favorable clinical
course of the disorder in females. Declining levels of estrogen around menopause
might also explain why late-onset schizophrenia is much more likely to strike
women than men. There is some evidence that this late-onset pattern in women is
associated with a more severe clinical presentation (Haffner et al., 1998).

Clinical Picture (Symptoms)

The DSM is a work in progress, with diagnostic criteria changing over time as new
research emerges. The current DSM-5 criteria for schizophrenia are similar to those in
DSM-IV-TR and the ICD (WHO, 2003), but with one notable change: elimination of the
requirement that only one other symptom had to be present if delusions were bizarre or if
the auditory hallucinations were of a certain type.

Delusions
- Def - Erroneous belief that is fixed and firmly held despite clear contradictory
evidence
- (Derived - Latin verb “ludere” meaning “to play”)
- Essence - Feels like tricks being played on mind
- Beliefs not shared by others with same social, relg & cultural bg
- Disturbance in content of thought
- Not all delusional people suffer from schizophrenia BUT common (+90%)
- Common delusions or false beliefs -
1. Thoughts, feelings, or actions are being controlled by external agents
 2. Thought broadcasting - Private thoughts are being broadcast
indiscriminately to others
3. Thought insertion- Thoughts are being inserted into one’s brain by some
external agency
4. Thought withdrawal- External agency has robbed one of one’s thoughts
5. Delusions of reference - Some neutral environmental events believed
having special and personal meaning intended only for the person.
6. Delusions of bodily changes - Removal of organs (For eg- bowels do not
work)
Sometimes delusions are not just isolated beliefs but elaborated into a complex delusional
system.

Hallucination
Def - Sensory experience that seems real to the person having it, but occurs in the
absence of any external perceptual stimulus.
- Different from an illusion (misperception of existing stimulus)
- Latin verb hallucinere or allucinere, meaning “wander in mind” or “idle talk”
- Occur in any sensory modality (auditory, visual, olfactory, tactile, or gustatory)
- Auditory hallucinations - MOST COMMON
- 7 dif nations mai auditory hallucinations found (75% of schizophrenics)
- Visual hallucinations - 39 %
- Olfactory, tactile, and gustatory hallucinations - 1–7%
- Deaf people – schizophrenia – report auditory hallucinations (Aleman & Larøi,
2008).
- Can be induced in healthy people if lot stress & lot caffeine
- Have affective, conceptual, or behavioral level relevance for patients
- Emotionally involved with hallucinations, incorporating them into their delusions.
- Acts on hallucinations and on what the voices tell them to do
- Nayani and David (1996)’s study of the phenomenology of auditory hallucinations
interviewed 100 hallucinating patients -
1. Majority of patients – voices spoke at nrml convo volume
2. Hallucinated voices often of known people; Unfamiliar voices or the voices
of God or Devil
3. Worse when alone
4. Most uttered rude and vulgar expletives or else were critical (“You are
stupid”), bossy (“Get the milk”), or abusive (“Ugly bitch”), although some
voices were pleasant and supportive (“My darling”)
 - Neuroimaging studies shows hallucinating patients – reduction in brain (gray
matter) volume in the left hemisphere auditory & speech perception areas
- This leads to a failure to correctly identify internally generated speech,
erroneously tagging it as coming from external source.
- Neuroimaging studies reveal increased activity in Broca’s area—an area of the
temporal lobe that is involved in speech production.
- Pattern of brain activation that occurs when patients experience auditory
hallucinations is very similar to that seen when healthy volunteers are asked to
imagine that there is another person talking to them (Shergill et al., 2000).
- Indeed, if transcranial magnetic stimulation (in which a magnetic field passing
through the skull temporarily disrupts activity in underlying brain areas) is used to
reduce activity in speech production areas, hallucinating patients actually show a
reduction in their auditory hallucinations (Hoffman et al., 2005) - Future
treatment.
- Occurs when patients misinterpret their own self-generated and verbally mediated
thoughts (inner speech or self-talk) as coming from another source – THUS,
misperceived subvocal speech

Disorganised Speech
- Disorganized speech – external manifestation of a disorder in thought form.
- Person fails to make sense, despite seeming to using language in a conventional
way and following the semantic and syntactic rules governing verbal communica
tion
- Failure – not attributable – low intelligence, poor education, or cultural deprivation
- Meehl (1962) aptly referred to “cognitive slippage”; others – “derailment” or
“loosening” of associations; most extreme form – “incoherence.”
- Word and/ or combinations sound communicative, but the listener is left with little
or no understanding of the point
- Completely new, made-up words known as neologisms (literally, “new words”).
Eg: “detone” which looks and sounds like a meaningful word but is a neologism
- Formal thought disorder (a term clinicians use to refer to problems in the way that
disorganized thought is expressed in disorganized speech)

Disorganised Behaviour
- Manifested in various ways.
- Goal-directed activity – universally disrupted in schizo
 - Impairment occurs – work, social relations, and self-care, to the extent that the
person is not himself anymore.
- For eg: person may no longer maintain minimal standards of personal hygiene or
may exhibit a profound disregard of personal safety and health. Grossly
disorganized behavior appears as silliness or unusual dress (e.g., wearing an
overcoat, scarf, and gloves on a hot summer day).
- Researchers attribute these disruptions of “executive” behavior to impairment in
the functioning of the prefrontal region of the cerebral cortex
- Catatonia – more striking behavioral disturbance (virtual absence of all movement
and speech – catatonic stupor)
- Other times, the patient may hold an unusual posture for an extended period of
time without any seeming discomfort.

Negative Symptoms
- General symptom patterns
1. Positive symptoms - Reflect an excess or distortion in a normal repertoire
of behavior and experience, such as delusions and hallucinations.
Disorganized thinking (as revealed by disorganized speech) is also thought
of in this way.
2. Negative symptoms - Reflects an absence or deficit of behaviors that are
normally present
- Negative symptoms (Barch, 2013; Kring et al., 2013) -
1. Reduced expressive behavior—either in voice, facial expression, gestures
or speech. Shows in the form of blunted affect or flat affect or in alogia,
which means very little speech.
2. Reductions in motivation or in the experience of pleasure. Inability to
initiate or persist in goal-directed activity is called avolition. For eg : the
patient may sit for long periods of time staring into space or watching TV
with little interest in any outside work or social activities. Diminished
ability to experience pleasure is called anhedonia.
- Most patients exhibit both pos + neg symptoms during the course
- Presence of negative symptoms in the clinical picture is not a good sign for the
patient’s future outcome.
- May seem emotionally unexpressive, how they appear and how they are feeling
are two different things. In an important early study, Kring and Neale (1996)
studied unmedicated male patients with schizophrenia while they were watching
film clips. Three different types of film clips were used, the scenes in them being
 very positive, very negative, or neutral in terms of the emotions they were
designed to elicit in the viewers. Videotapes of how the patients looked while they
were watching the films were then coded by trained raters. As might be expected,
the patients with schizophrenia showed less facial expressiveness than a group of
healthy controls. What was surprising was that when the patients were asked about
their emotional experiences during the films, they reported as many emotional
feelings as the controls— and sometimes slightly more. Measures of autonomic
arousal also showed that when they were watching the films, the patients exhibited
more physiological reactivity than the controls did - SAME WITH WOMEN
- Schizophrenics may sometimes appear emotionally unexpressive, they are
nonetheless experiencing plenty of emotion.

Subtypes of Schizo - Marked in Book

Other Psychotic Disorders - Marked (Write in Flowchart form)

Case Study (schizophrenia)

Although the clinical presentation of schizophrenia differs but this quite typical.
DSM Criteria
Gender Dysphoria
Intro
Gender dysphoria is discomfort with one’s sex-relevant physical characteristics or with
one’s assigned gender.

General features/ characteristics

- New term used in DSM-5, previously gender identity disorder
- Change - Usefully descriptive & theoretically neutral
- Individuals who have been previously diagnosed with gender identity disorder
certainly experience gender dysphoria, but whether or not this is always due to
atypical gender identity development is less clear
- Consistent with a dimensional approach (the degree of dysphoria can vary) and
may fluctuate over time within the same individual (Cohen- Kettenis & Pfafflin,
2010).

Onset
Gender dysphoria can be diagnosed at two different life stages -
1. Childhood (gender dysphoria in children)
2. Adolescence or adulthood (gender dysphoria in adolescents and adults).

Gender Differences
GD in Boys -
- Preoccupation with traditionally feminine activities
- Prefer female clothing
- Enjoy stereotypical girls’ activities such as playing dolls and playing house
- Avoids rough-and-tumble play and often expresses the desire to be a girl.

GD in Girls -
- Prefer traditional boys’ clothing and short hair
- Fantasy heroes – powerful male figures
- Little interest in dolls and interest in sports
- Considered to be “tomboys” frequently have many or most of these traits
- Girls with gender dysphoria – desires of being boy or grow up as man
- Girls treated better by their peers than are boys CUZ cross-gender behavior in girls
is better tolerated (Cohen Kettenis et al., 2003).
In clinic-referred gender dysphoria, boys outnumbered girls five to one in one study
(Cohen-Kettenis et al., 2003) and three to one in another study (Cohen-Kettenis et al.,
2006) CUZ greater parental concern about femininity in boys than about masculinity in
girls.

Outcome
- The most common adult outcome of boys with GD has been homosexuality rather
than transsexualism (Zucker, 2005). In Richard Green’s (1987) prospective study
about three-quarters became gay or bisexual men who were evidently satisfied
with their biological sex – inconsistent studies also there though.
- Several smaller prospective studies of girls with GD have shown that 35 to 45
percent may show persistent gender dysphoria (leading to a desire for sex
reassignment surgery in many), and approximately half had a homosexual
orientation – inconsistent studies are also there though.

Prevalence & Gender Differences

Estimated prevalence in natal males is between 5 and 14 per 1,000 and for natal females
between 2 and 3 per 1,000 (American Psychiatric Association, 2013; 2015), occurring
approximately 3 times more frequently in natal males than in natal females (American
Psychological Association, 2008; Judge, O’Donovan, Callaghan, Gaoatswe, & O’Shea,
2014; Sohn & Bosinski, 2007).

Indian Stats - The prevalence of gender dysphoria in India is not extensively documented,
but existing studies provide some insights. Limited data suggests that awareness and
acceptance of gender diversity are crucial for understanding its prevalence (Sanyal &
Majumder, 2016).

Should be considered “disordered”?

- Not be considered “disordered” because primary obstacle – society (intolerant of
cross-gender behavior)
- Researchers believe that distress and unhappiness are consistent with this being
called a mental disorder (Zucker, 2005, 2010)
- Frequently mistreated by peers & strained relo with parents - EVEN WHEN
cross-gender behavior harms no one.
- Research from non-Western cultures shows that stigmatization of
gender-nonconforming children is not universal (Vasey & Bartlett, 2007). In
Samoa, very feminine males – called “fa’afafine” – a kind of third gender. Young
 children by their behavior and usually are accepted by their families and culture.
Sexually attracted to other men & typically have sexual relations with heterosexual
men. Have to face no distress. Because of this, some have argued that childhood
gender dysphoria should not appear in DSM-5 but still retained.

Comorbidity
The study on psychiatric comorbidity in gender dysphoric adolescents revealed that
67.6% of participants had no concurrent psychiatric disorders. Among those with
comorbidities, anxiety disorders were present in 21%, mood disorders in 12.4%, and
disruptive disorders in 11.4%. Notably, natal males exhibited a higher prevalence of
comorbid diagnoses, with 22.6% experiencing two or more compared to 7.7% of natal
females. Mood disorders were significantly more common in natal males (20.8%) than in
natal females (3.8%). Additionally, adolescents classified as 'delayed eligible' for medical
interventions were older and had lower intelligence, although both 'delayed' and
'immediately eligible' groups did not differ significantly in overall psychiatric
comorbidity rates .

DSM-5 Criteria
Case Study

- The case study involves a 14-year-old boy who is experiencing gender dysphoria, which is a
condition where a person feels a mismatch between their assigned sex at birth and their gender
identity .
- The boy's mother reported that he has expressed a desire to identify as female for over six
months. He has become increasingly isolated, spending most of his time on social media, and
has shown signs of anxiety and academic decline .
- His family background includes a modest socio-economic status, with a civil servant father and
a housewife mother. He is the youngest of three siblings .
- The boy's symptoms began around the age of 9, marked by changes in behavior such as
social withdrawal, sadness, and insomnia. He has also had two suicide attempts in the past .
- During psychiatric evaluations, he displayed signs of distress related to his gender identity,
expressing that he feels more like a girl and prefers to be called by a girl's name. He has also
engaged in self-harm, with scars noted on his thighs .
- The treatment plan included psychotherapy, family psychoeducation, and medication with
antidepressants, which led to slight improvements in his mood and a reduction in suicidal
thoughts .
- The case highlights the importance of a multidisciplinary approach to evaluate and treat
gender dysphoria, considering both psychological and medical aspects .
- The study emphasizes the need for early intervention and support for adolescents
experiencing gender dysphoria to prevent further psychological distress and complications .
- Overall, the case illustrates the complexities of managing gender dysphoria in adolescents,
particularly in a socio-cultural context where such issues may be stigmatized .

Transsexualism (Just write 4-5 points)

- Occurs in adults with gender dysphoria who desire to change their sex, and
surgical advances have made this goal partially feasible.
- Represents the extreme on a continuum of transgenderism, or the degree to which
one identifies as the other sex (Cohen-Kettenis & Pfafflin, 2010)
- Very rare disorder
- European studies suggested-
1. 1 in 30,000 adult males
2. 1 in 100,000 adult females – seek sex reassignment surgery

BUT Recent estimates – 1 in 12,000 men (Western countries) has actually undergone the
surgery

- Researchers assumed that transsexualism – adult version of childhood gender

dysphoria – often the case
- Appeared case for large majority of female-to-male transsexuals (individuals born
female who become male) — had extremely tom boyish, with masculinity
persisting unabated into adulthood. Sexually attracted to women.
- Two kinds of male-to-female transsexuals: homosexual and autogynephilic
transsexuals (Bailey, 2003; Blanchard, 1989).
1. Homosexual transsexual men – Very feminine and have the same sexual
orientation as gay men (attracted to biological males), experience their
gender identity as female, define sexual orientation as heterosexual, resent
being labeled gay.
THUS, genetic male seeking a sex change operation who describes himself as a woman
trapped in a man’s body and who is sexually attracted to heterosexual male partners
(Bailey, 2003).
2. Autogynephilic transsexuals are motivated by autogynephilia—a paraphilia
in which their attraction is to thoughts, images, or fantasies of themselves
as a woman (Blanchard, 1991, 1993).
Alcohol Use Disorder
(Nandini’s Notes)

Neurodevelopmental Disorder
- Group of conditions characterized by an early onset and persistent course that are
believed to be the result of disruptions to normal brain development (Andrews et al.,
2009; Insel, 2014)
- Must be onset-ed during childhood
- Differ from ODD and CD – result of significant delays or disruptions in brain development
that persist into adulthood (with a few exceptions discussed below)
- Heterogeneous in nature, often overlap and share common risk factors

Attention-deficit/hyperactivity disorder (ADHD)

- Persistent pattern of difficulties sustaining attention and/or impulsiveness and excessive
or exaggerated motor activity
- Problems have to be numerous, persistent, and causing impairment at home, school, or
the workplace for being clinically diagnosed
- Partially due to beh probs, ADHD children
1. Score approximately 7 to 15 points lower on intelligence quotient (IQ) tests
(Barkley, 1997)
2. Show deficits on neuropsychological testing that are related to poor academic
functioning (Biederman et al., 2004)
3. Show specific learning disabilities such as difficulties in reading or learning other
basic school subjects
- Significantly higher risk of school problems – suspension /repeating a grade CUZ
disruptive beh probs (Kessler et al., 2014).
- Can lead to significant social impairment
1. Hyperactive children – diff. – getting along with their parents (CUX disobedience)
2. Negatively viewed by peers (Hoza et al., 2005)
- ADHD is seen in cultures all around the world. For example, one study of 1,573 children
from 10 European countries reported that ADHD symptoms are similarly rec ognized
across all countries studied and that the children have significant impairments across a
wide range of domains (Bauermeister et al., 2010).

Prevalence
- Fairly prevalent - approx 9% of children and adolescents
- Most frequently diagnosed by health professionals
 - WHY - Parents are much likely to bring a ADHD child for treatment than with a less
disruptive disorder

Indian Stats - Pooled prevalence of ADHD among children and adolescents in India is
estimated to be 7.1% with a 95% confidence interval (CI) ranging from 5.1% to 9.8%. This
indicates that approximately 7 out of every 100 children and adolescents may be affected
by ADHD in India

Gender differences
- Higher in boys (13 %) > girls (4 %) (Merikangas et al., 2010)

Comorbidity
- Commonly comorbid with other externalizing disorders such as ODD and CD
(Beauchaine et al., 2010; Frick & Nigg, 2012).
- ADHD kids also show specific learning disabilities such as difficulties in reading or
learning other basic school subjects

Case Study

Adhd Beyond Adolescence

- Studies done in US and internationally suggest that approx half of children with ADHD
will continue to meet criteria in adulthood
- Most cases of adult ADHD are characterized by inattention (95 %)
Smaller percentage – Hyperactivity (35 %) (Kessler, Green, et al., 2010)
- Approx 4% of U.S. adults meet criteria for ADHD — higher rates -– male, divorced, and
unemployed
- UNEMPLOYMENT!!?? - Trouble finding work BUT ALSO poor work performance or
absenteeism

DSM Criteria
Autism Spectrum Disorder
Intro
- It is a neurodevelopmental disorder
- First described in 1943 by Kanner.
- Involves a wide range of problematic beh – like: deficits in lang, perceptual & motor
develpt; defective reality testing; and impairments in soc com

Case Study

Prevalence
- Estimates range between 30 and 60 people in 10,000 (Fombonne, 2005) – USA
- Study by Centers for Disease Control and Prevention – rate among children – 1 in 68.
Reported increase in autism is likely due to changes in diagnostic practice, awareness, and
methodology, rather than an actual increase in prevalence (Williams et al., 2006)

Indian Stats -
The systematic review included four studies that collectively screened and diagnosed a
total of 130,599 children. The pooled percentage prevalence of ASD in children aged 1-18
years from rural settings was found to be 0.11% (95% confidence interval [CI] 0.01-0.20),
while in urban settings, it was 0.09% (95% CI 0.02-0.16) for children aged 0-15 years [1].

The prevalence estimates in India are relatively lower than those reported in countries like
the United States and the United Kingdom, where the prevalence is approximately 1% and
1.5%, respectively (Chauhan et al., 2019).
Onset
- Identified < 30 months of age and diagnostic stability over the childhood years is quite
high as proved by Lord and colleagues (2006) report that children diagnosed with autism
by age 2 tend to be similarly diagnosed at age 9
- Early signs of problems with social com can be detected in the first 6 months of an
infant’s life (Jones & Klin, 2014).
- Children later diagnosed with autism show a significant decline in their focus on the eyes
of others from 2 to 6 months of age and this decline continues until 24 months—at which
point it is approximately half the level of focus as that seen in typically developing
children (see Figure 15.6; Jones & Klin, 2014). In contrast, while their attention to other
peo ple’s eyes decreases, infants later diagnosed with autism show a significant
increase in their focus on inanimate objects, which is double the level of typically
developing children by 24 months

The Clinical Picture In Autistic Spectrum Disorder

- Varying degrees of impairments and capabilities
- TYPICAL SIGN - Child seems apart or aloof from others, even in the earliest stages of
life (Hillman et al., 2007).
- Mom described — Non cuddly babies, not reaching out when being picked up, not
smiling or looking at them while being fed, and not appearing to notice the comings and
goings of other people.

A Social Deficit :
- Children with autism – No need for affection or contact

❌ ❌
- Researchers are questioning this “emotionally flat” nature BUT studies shown — do
express emotions AND lacking emotional reactions (Jones et al., 2001)
- Inability to respond DUE TO lack of social understanding—a deficit to attend to social
cues
- Neuroimaging studies —
1. ↓ activity in medial prefrontal cortex (region responding with understanding the
mental states of others)
2. ↑ activation in ventral occipitotemporal regions (resp. for object perception)

- Show deficits in attention and in locating and orienting to sounds in their environment
(Hillman et al., 2007).
- Show an aversion to auditory stimuli, crying even at the sound of a parent’s voice
- Severely agitated or panicked by a very soft sound and at another time be totally
oblivious to a loud noise- however, not consistent.

An Absence of Speech :
- Do not effectively learn by imitation (Smith & Bryson, 1994)
- Explains their characteristic absence or severely limited use of speech
- Speech in autism is rarely used for communication, except in simple ways like saying
"yes" to a question or through echolalia (the parrot-like repetition of a few words).
 - While some normal children echo verbal behavior of parents, persistent echolalia is
found in about 75% of children with autism (Prizant, 1983).

Self-Stimulation :
- Usually takes form of such repetitive movements as head banging, spinning, and
rocking, which may continue by the hour.

Maintaining Sameness
- Become preoccupied with & form strong attachments to unusual objects such as rocks,
light switches, or keys.
- When disturbed (by removal or by substitution or slight alteration), show violent temper
tantrum or a crying spell that continues until the familiar situation is restored
- THUS, “obsessed with the maintenance of sameness.”

Gender Differences
- Apparent in ASD with the average reported male to female estimate being 4.5 to 1
(Centers for Disease Control and Prevention, 2014).
- ASD appears to be a universal phenomenon, identified in every part of the world,
including Sweden (Gillberg, 1984), Japan (Sugiyama & Abe, 1989), Russia
(Lebedinskaya & Nikolskaya, 1993), and Hong Kong (Chung, Luk, & Lee, 1990).

Comorbidity
It is estimated that approximately 31% of individuals with ASD have intellectual disabilities
(defined as an IQ score less than 70, comparable deficits in adaptive functioning, and present
before the age of 18) (Centers for Disease Control and Prevention, 2014). To make comorbid
diagnoses of autism spectrum disorder and intellectual disability, social communication should
be below that expected for general developmental level.

DSM Criteria
Intellectual Disabilities