Johan Nyrenis and front cover of thesis

Autism in adult psychiatry outpatients


Follow-up interview with Johan Nyrenius on his thesis "Autism in adult psychiatry outpatients – Prevalence, comorbidity, suicidality and cognition"

In our recent interview with Johan Nyrenius, "Adult psychiatric patients with neuropsychiatric symptoms, in particular Autism Spectrum Disorders (ASD)" he told us about his career so far and the topic of his doctoral thesis.

Anna Spyrou meets up with Johan who is very busy preparing for his PhD defense this week. He discusses the rest of his work to date and talks about the thesis as a whole.

Johan, welcome back. Please can you tell me about the 2nd paper you have just published? What was the study about and what results have you found?

Johan Nyrenius

- The second article in the thesis was about how common autism is among applicants to general psychiatry. The article was published in January 2022. We examined those who came for a new visit to general psychiatry in northwestern Skåne. We contacted the patients who scored above a certain number of points on a questionnaire about autism, and those who participated in the study underwent an examination. It turned out that autism was much more common among applicants to general psychiatry than in the general population, almost 19% compared to around 1.5%. It was equally common among men and women. David Eberhard et al's article published in May 2022 showed similar figures at an adult psychiatric clinic in Stockholm. More studies are needed before we can be sure that it is really this common in general psychiatry, but at least this is what it looked like in Helsingborg - and in Stockholm. "Traits of autism, i.e. having one or more symptoms of autism but not meeting the criteria for a diagnosis, were so common among our patients that it was difficult to recruit a control group.

What about your third study?

- The third article will soon be published and is a description of patients in general psychiatry who have autism and have not been diagnosed in childhood. We describe the patients from a number of different perspectives, such as the psychiatric disorders they have, how they live and what their relationships are like, educational background and so on. We could see that general psychiatric patients with autism have great similarities with general psychiatric patients without autism, especially in terms of socio-demographic parameters such as educational background, social and economic situation. Patients with autism had more anxiety problems and more developmental difficulties, such as ADHD or tics.

How about your fourth study?

- The fourth article has just been submitted to a journal for review. It deals with suicidal thoughts, suicide plans, suicide attempts and self-harm in general psychiatric patients with autism. What we have seen in the fourth article is that suicidality and self-harm are common in this group. High alcohol or drug consumption and depression were associated with suicide attempts, while self-harm was more common among women, participants with antisocial personality and those with suicide plans. Unfortunately, at follow-up about a year after participation, we could see that high alcohol or drug use had often not been recognized in the care of women with autism, but fortunately none of our study participants had completed suicide.

What has been one of the most unexpected findings to date?

- That autism was so very common in general psychiatry. We thought that it would be much more common among general psychiatric patients than among the general population, but the fact that it turned out to be almost every fifth patient was very surprising to me.

5 figures, 4 in green one in red

What are the implications of all your findings for practice and therefore for clinical work?

- Many things! One is how common it turned out to be. This means that adult psychiatry needs to increase its expertise on autism and the combination of autism and psychiatric disorders. If it is as common as almost every fifth patient, everyone working in adult psychiatry must have good knowledge of what autism is and how to adapt information, treatments and other things to people who have this way of functioning.

Another is that at an overall level, adult psychiatric patients with autism are very similar to adult psychiatric patients without autism. The main difference between the groups is precisely the symptoms of autism. Several things that have previously been considered as some kind of "truths" were not true in our group; for example, we could see that high alcohol and drug consumption was as common among those with autism as those without autism, and self-harm also looked similar among those with autism compared to those without autism. The fact that the groups were so similar means that we should not take anything for granted and must always be careful in our assessments.

If you were about to embark on this PhD subject again, what would you do the same and what would you change?

- I would have liked to continue and collect data for a longer period, so that we could draw more conclusions - unfortunately this was not possible due to the pandemic. I would also have liked to avoid some mistakes in the detailed planning of the study. But then I would have made at least as many other mistakes.

If you were granted one wish for adult psychiatry, what would it be?

-That adult psychiatry begins to understand that 'neuropsychiatry' and 'psychiatry' are the same thing. The division that has arisen is not healthy and I believe it has contributed to an "either/or" approach. This approach has created an artificial conflict about how we should understand mental illness. Is the patient's condition somehow congenital or has it arisen from a dysfunctional environment? It is of course infinitely more complicated than that and adult psychiatry needs to shift its focus to the fact that in most cases it is "both". An example might be a person with autism and normal intelligence who has fallen ill with depression. It would be difficult, if not impossible, to treat the depression without taking into account the presence of autism. It is equally difficult to treat depression if you think that everything is about the person's autism. Unfortunately, many patients today fall through the cracks because of this 'either/or' thinking and don't get the help they need."

If you were to carry on the same path as your thesis topic, what would you study next and why?

- Psychoses in people with autism, because it is very difficult to distinguish psychoses from autism, the phenomena are very similar and my clinical experience is that those who have "both" receive too little help, partly because there is a lack of knowledge. Or investigate whether there is a group of adults with autism who never seek help for psychiatric problems and never seek investigation - who are they? How do they feel? Or investigate how different treatment methods in adult psychiatry work for the group with autism. Or understand more about depression. Or...

Ok, that’s enough! I’ll stop you there. You will be defending your thesis this spring, how do you feel about this?

- Excited and panicked at the same time. It feels very strange that the project is almost over. At the same time, I believe that the work will not accumulate as much as it does right now at any other time in life. So it will be both empty and nice when it's done.

What are your plans post dissertation?

- I want to start new projects, preferably around this group of people. But preferably at a slightly less hysterical pace than the last year. After the dissertation, I will have some time to refocus and, together with partners, plan new projects more concretely and in detail, and apply for funding. I want to continue running clinical studies and continue working with all the fantastic people who have been involved in and supported this project.

If you would like to listen attend Johan's dissertation, in real life or via zoom, all are welcome. More details can be found here