“Driven and Tense, Stressed Out and Anxious”: Clinicians’ Perceptions of Post-Traumatic Stress Disorder Symptom Expressions in Adults with Autism and Intellectual Disability

Abstract

Introduction: Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) seem to be at increased risk for post-traumatic stress disorder (PTSD), but knowledge is sparse regarding its identification in this population. Previous research indicates that certain symptoms of PTSD may be more easily recognized, and that identifying reexperiencing and avoidance is particularly challenging. Methods: Interpretative phenomenological analysis was used to explore 18 experienced clinicians' perceptions of PTSD symptom expression in ASD and ID through individual, qualitative interviews. Results:Informants provided examples from all symptom groups, but these differed in how frequently they were described. Recognition of reexperiencing may rely on knowledge about individuals' trauma experience. Avoidance may present in a wider range of ways. Conclusion: Development of reexperiencing and avoidance may follow different trajectories in this population, contributing to challenges in recognition. Reexperiencing may be more severe in ASD/ID. Implications are discussed in light of current diagnostic criteria.

Trauma experiences of people with an intellectual disability and their implications: A scoping review

“…Eleven studies reported on signs and symptoms of psychological trauma which appeared to be specific to adults with an intellectual disability, noting differences in how some of the diagnostic symptoms of PTSD are expressed, more generally the preponderance of behavioural expressions, and deterioration of adaptive skills for people with a more severe to profound intellectual disability. Kildahl et al's (2020b) study with clinicians reported that while symptoms of altered arousal were easily observable, symptoms of avoidance may present in a variety of ways and symptoms of re-experiencing were difficult to recognize, often dependent on knowledge of the person's trauma. Lemmon and Mizes (2002) also noted differences in how flashback symptoms might be experienced.…”

Case study: identification of anxiety and subsequent intervention in an adolescent male with autism, severe intellectual disability and self-injurious behaviour

“…Moreover, interventions aiming to increase flexibility and tolerance of uncertainty in individuals with ASD have primarily been explored in individuals without cooccurring ID (Rodgers et al 2018(Rodgers et al , 2017. According to theories of emotional development (Sappok et al 2014), individuals with ASD and more severe levels of ID may not be able to understand that their subjective experience of their surroundings does not constitute objective reality, and this has previously been suggested to affect how trauma-related symptoms are experienced and expressed in this population (Kildahl et al 2020b). For anxiety, this may suggest that individuals such as the current patient may have difficulties distinguishing situations that feel dangerous from situations that are objectively dangerous.…”

“…Differentiating anxiety and trauma-related symptoms is challenging in people like Philip (Kildahl et al 2020a(Kildahl et al , 2020b(Kildahl et al , 2019a, and it has previously been reported that behavioural management practices involving use of physical restraint may lead to development of post-traumatic stress disorder in individuals with ASD and ID (Kildahl et al 2020a). While the previous strategy used to manage Philip's SIB may be considered a form of abuse, it is unclear whether it may be considered a traumatic event according to current diagnostic criteria for post-traumatic stress disorder (American Psychiatric Association, 2013).…”

“…While the previous strategy used to manage Philip's SIB may be considered a form of abuse, it is unclear whether it may be considered a traumatic event according to current diagnostic criteria for post-traumatic stress disorder (American Psychiatric Association, 2013). Based on direct observation, it was viewed as a possibility that the panic-like state observed in Philip during SIB constituted a behavioural manifestation of re-experiencing or flashbacks (Kildahl et al 2020b), triggered by being held face down on the floor. Because he did not have the verbal language skills to disclose his mental state during these episodes, however, the differentiation between panic, flashbacks and other possible explanations was not possible.…”

“…However, the relationship between "challenging" behaviours and psychiatric disorder remains poorly understood (Cooper 2016). While these behaviours may constitute behavioural manifestations of psychiatric disorders, including anxiety and trauma-related disorders (Kildahl et al 2020b, 2019a, Bakken et al 2016a, Kerns et al, 2015, Helverschou et al 2011a, Bitsika et al 2016, Rzepecka et al 2011, particularly in more severe levels of ID (Painter et al 2018), all instances of problematic behaviours are unlikely to be associated with underlying psychiatric disorder (Cooper 2016, Hemmings 2007, Emerson 2001.…”