neuro-behavioural approach to understand; Repetitive Behaviour / stereotypy / rigid routines, in Autism

1. 1
Repetitive Behaviour in
Autism:
A Neurobehavioural Approach
Dr Khalid Mansour
Locum Consultant Psychiatrist
Hesketh Centre
2019

2. Index
Cerebellum
• Cerebellum & R.
• Functional Anatomy.
• Models of Functioning.
• Psych. Aspects of Cerebellar
Dis.
• Cerebellar Ab. in Psych. Dis. -
General.
• Cerebellar Ab in Psych. Dis. -
Specific.
• Primary Cerebellar
Neuropsychiatric Disorders
Cerebellar Therapies for Psych.
Dis.
2
Autism &
Routines
• Routine Disorders &
Autism
• Maturity & R.
• Environment & R.
• Stress & R.
• Brain Circuits of R.
• Arousal / Drives & R.
• Filtering & R.
• Cognition & R.
• Obsessions & R.
• Reward & R.
• Impulse control & R.

3. Cerebellum &
Learnt Behaviour
(Routines)
3
Part - I

4. Cerebellum: Traditional Thinking
(Klein et al, 2016; Timmann et al, 2010; Stoodley et al, 2010)
10% of brain
weight & 80% of
brain neurones (Llinas
et al, 2004; Herculano-Houzel,
2010).
 Traditional
thinking:
cerebellum is
mainly involved in
posture, balance
& motor activity.

5. Cerebellum: Advanced Thinking
(Klein et al, 2016; Timmann et al, 2010; Stoodley et al, 2010)
Cerebellum is not involved in initiating
motor activity, but coordinating them
(Flourens, 1824).
It has Abundant connections with non-motor
brain regions & is involved in coordinating all
non-motor functions e.g. perceptions,
emotions, cognition, speech, personality,
etc.
Cerebellar abnormalities exist in most mental
illnesses and mental abnormalities exist in
most cerebellar disorders. 5

6. •Kenji Doya (2000):
“Neural computation”.
•Katz & Steinmetz (2002):
“Regulates brain processes”.
•Boydon (2004):
“Makes fine adjustments to the way
an action is performed”.
•Masao Ito (2005):
“Matches intentions with actual
performance”.
•Reeber et al (2013):
“computational task … recognizing
neural patterns … predict optimal
movements”. 6
Masao Ito
Kenji Doya
Cerebellar Learning: “Software Programmer”

7. Cerebellar Learning: Behavioural Routines
(Burguiere et al, 2010, Kalmbach et al, 2011)
Cerebellum > does not initiate
new learning.
> It develops frequently needed
learnt behaviour into a
Behavioural Routine with:
1. Minimum Errors
2. Minimum Time
3. Minimum Effort
4. Minimum Attention /
awareness
5. Maximum Stability.
7Chase Britton

8. Cerebellum:
Functional Anatomy
8

9. Cerebellar Lobes:
•(Vestibulocerebellum)
(flocculonodular lobe).
•Spinocerebellum
(vermis & paravermis).
•Cerebrocerebellum
(lateral cerebellar
hemispheres).
9

10. Cerebellar Cortex
Molecular Layer,
Dendrites of Purkinje
cells,
Parallel Fibers
Stellate cells and Basket
cells.
Purkinje Layer
Granular Layer, Granule
cells and Golgi cells. 10

11. Cerebellar Connections:
• Afferent:
• Brainstem, spinal cord and cerebrum > Mossy Fibers >
Granular cells> Parallel Fibers > Purkinje Cells.
• Inferior Olivary Nucleus > Climbing Fibers > Purkinje cell.
• Efferent:
• Purkinje cell > Deep Cerebellar Nuclei > Inferior Olivary
Nucleus, Brainstem, spinal cord and cerebrum
11

12. Models of Cerebellar
Functioning
12

13. Marr & Albus Model for
Cerebellar Learning
(Eccles, Ito & Szentagothai,1967)
•Several theories about cerebellum
and learnt behaviour.
•Most theories about Cerebellar
functioning / learning are derived
from early models of David Marr
(1969) and James Albus (1971).
•Albus (1971) formulated his model
as a software algorithm: Cerebellar
Model Articulation Controller, which
has been tested in a number of
computer applications.
13
David Marr
James Albus

14. Marr & Albus Model for Cerebellar Learning
(Eccles, Ito & Szentágothai,1967; Oscarsson, 1979; Fujita 1982; Mial et al,
1998; Llinas et al, 2004; Apps & Garwicz, 2005; Apps & Garwicz, 2005; Dean &
Porell, 2008; Ohtsuki et al, 2009; Dean et al, 2010 )
1. Feedforward processing; no reverberation.
2. Modularity / Compartmentalization >
zones and micr-ozones (1000 Purkinje cells).
3. Divergence and Convergence > 100 Moss
Fibres > 2 billion spines of Purkinje cells > 1
Deep Nuclei Cells.
4. Plasticity: a neurone depolarization: >
Simple spike, Complex spike, Long-term
depression (LTD) or Long-term potentiation
(LTP).
5. Adaptive Filtering > Elimination of noise;
Fine tuning; Optimality ; Execution not creativity14

15. Psychiatric Aspects
of
Cerebellar Disorders
15

16. 1 - Psychological Studies of Normal
Individuals with Reduced Cerebellar
Volume
•Individuals with
reduced cerebellar
volume > higher
scores on scales of
anxiety, type A
personality,
phobia,
tenderness and
hostility (Chung et al, 2010).
16
Chase Britton

17. 2 - Psychiatric Aspects of Cerebellar
Disorders: (Wolf et al, 2007)
17

18. 3 - Psychiatric Aspects of Anatomically
Specific Cerebellar Abnormalities
•Vermal Agenesis >
severe LD & Autism (Tavano
et al, 2007).
•Vermal lesions > affective
and relational disorders
(Schmahman et al, 2007).
•Spinocerebellar Ataxia >
impairment in attention,
memory, executive
functions and theory of
mind (Garard et al, 2008).
18

19. 4 - Cerebellar Cognitive Affective Syndrome
(Schmahman et al, 2007; Tavano et al, 2007; Levisohn et al, 2000):
19
Cerebellar Syndromes > motor
impairments +
 Cognitive impairments:
Executive dysfunctions, visuo-
spatial abnormalities, linguistic
dysfunction.
 Affective impairments: Anxiety,
lethargy, depression, lack of
empathy, ruminativeness,
perseveration, anhedonia and
aggression.
Jeremy
Schmahmann

20. Cerebellar Abnormalities
in Psychiatric Disorders:
General
20

21. Cerebellar Abnormalities in
Psychiatric Disorders
•Bipolar Affective
Disorder: e.g.
reduced Cerebellar /
Vermis volume (Glaser
et al, 2006)
•Anxiety: e.g.
cerebellar-vestibular
dysfunction (Levinson,
1989)
•Depression: e.g.
reduced posterior
cerebellar activities
(Fitzgerald et al, 2009)
21
ADHD:
•Smaller cerebellar
volume (Berquin et al 1998;
Giedd et al, 2001).
•Abnormalities in post-
inferior cerebellar
hemispheres and
vermis (Casey et al, 2007;
Steinlin, 2007).
•Reduction in the
activity of cerebellum
and vermis (Mackie et al,
2007).

22. Cerebellar Abnormalities in
Psychiatric Disorders:
•Post Traumatic
Stress Disorder:
e.g. altered
function of the
vermis (Anderson et al,
2002)
•Alcohol abuse:
e.g. induced
reduction in
Cerebellar /
Vermis volume
(Glaser et al, 2006) 22
•Gender
differences: (Dean &
McCarthy, 2008)
•Antisocial
Personality
Disorder: e.g.
reduced Cerebellar
volume (Barkataki et al, 2006).
•Alzheimer
Dementia: e.g.
cerebellar atrophy
(Wegiel et al, 1999)

23. Psychiatric Disorders with
Specific Cerebellar Models of
Pathophysiology
23

24. (1) Cerebellum & Dyslexia:
•Developmental Dyslexia:
(Stoodley & Stein, 2011; Nicolson et al,
2001; Pernet et al, 2009)
•Dyslexia > cerebellar
structural and functional
abnormalities in 80% of
cases.
•Dyslexia > impairment
in the ability to perform
skills automatically.
•Cerebellar syndromes >
impairments in reading and
writing characteristic of
dyslexia.
24
The Cerebellar
Deficit
Hypothesis of
Dyslexia: (Nicolson &
Fawcett, 1990; Nicolson et al,
2001): dyslexia is an
impaired
automatization of
high-order sensory-
motor procedures
in reading.

25. (2) Cerebellum &
Schizophrenia:
Cerebellar Glutamate
Theory
25
•Hypo-
functioning of
the Glutamate
NMDA receptors
in cerebellum >
cognitive
dysmetria >
schizophrenia.
• Yeganeh-Doost et al,
2011):

26. (2) Cerebellum & Schizophrenia:
(Andreasen et al, 1998)
•The Cortico-Cerebellar-
Thalamo-Cortical circuit
is dysfunctional > poor
mental coordination >
(Cognitive Dysmetria)
> Schizophrenia.
•The theory has been
criticised by other
researchers (e.g. Kaprinis et
al, 2002, Kaprinis et al, 2002;
Shanagher et al, 2006)
Nancy
Andreasen

27. (3) Cerebellar & Autism:
General Studies
•One of the most consistent
abnormalities found in ASD (DiCicco-Bloom
et al, 2006).
•95% of post mortem examinations of
autistic individuals (Delong, 2005)
•Consensus related to cerebellar
involvement in autism (Fatemi et al, 2012):
• Abnormal cerebellar anatomy,
• Abnormal neurotransmitter systems,
• Oxidative stress,
• Cerebellar motor and cognitive deficits,
• Neuro-inflammation
27
S. Hossein
Fatemi

28. (3) Cerebellum & Autism:
Cerebral Involvement
•Associated with mal-development of the frontal
lobe and any other brain regions > ASD (Carper &
Courchesne, 2000; Kuemerle et al, 2006; Reeber et al, 2013).
•Loss of modulatory control of Frontal Cortex >
ASD, (Catani et al, 2008).
•Cerebellum malfunction hinders neural development (Wang
et al, 2014).
Sam Wang

29. Primary Cerebellar
Neuropsychiatric Disorders
29

30. •The Clumsy Child
Syndrome
•Minimal Brain
Dysfunction (MBD)
•Developmental Apraxia
•Specific
Developmental
Disorder Of Motor
Function (ICD-10)
•Developmental
Coordination Disorder
(DCD) (DSM-5).
30

31. •Dyslexia &
Dyscalculia:
“Ideomotor or Executive
Dyspraxia” (Gibbs et al 2007).
•Autism: Clumsy
expression of, well
developed, emotional,
social or
communication
interactions due to
difficulties (Dziuk et al, 2007; Baxter
2011 ). 31

32. Cerebellar Therapies
for Psychiatric
Disorders
32

33. Cerebellar Exercises, Dance & Movement Therapies
(Levi, 1988; Jeong et al, 2005 Schmahmann, 2010)
• Some claims (e.g. DORE) > Physical exercises (movement +
balance) > speed up information processing and improve cerebellar
functioning > improve dyslexia, ADHD and Asperger’s syndrome:
• ? Could improve some mental illnesses like schizophrenia .
• No known scientific studies.
• Controversial treatments (Reynolds & Nicolson, 2007; Bishop, 2007;
Rack, 2007)
33

34. Cerebellar Transcranial Magnetic
Stimulation (TMS)
(Koch et al, 2010; Minichino et al, 2015, Bersani et al, 2015)
•Demirtas-Tatlidede et al (2010): stimulation of the
vermis in 8 schizophrenic patients > improvements in
mood, alertness, memory, attention, visual-spatial
skills and energy.
•Very early stages (Minks et al, 2010)
•No RCT
34

35. Part-II
Routine Disorders in
Autism
35

36. What is Different about Autistic
Routines?
•Starts in childhood
•Too Bizarre
•Resistive to change: poor
cognitive and/or emotional input.
•Extensive pathology: > Problems
with 3 major parts of the brain:
• Frontal Neocortex,
• Limbic Lobe.
• Cerebellum.
•“Neurodevelopmental: All
while in a developmental-
adaptive course. 36

37. “Rigid Routines” of Autism
Usually:
•Dysfunctional or Maladaptive
Routines > Behavioural therapy.
•Reflexive behaviour: e.g.
usually routines including self-
harm and aggression > usually
medications
•Usually not:
• Mental Health Syndromic
Routines: e.g. ADHD, OCD, Anxiety
& Addiction Routines.
• Physical Health related Routines :
e.g. repetitive behaviour while having
a painful condition or epilepsy.
• “Healthy / Functional” Routines >
nurturing. 37

38. Important Factors in
Autistic Routine Disorders
-General Factors
-Specific Factors
38

39. General Factors :
39

40. (1) Environment & Routines
•Environment = individuals,
objects & space.
•Neurodevelopmental
disorders > heavily
dependant on environmental
enhancement > support &/or
compensation.
•Family Model > perfect
model for environmental
mental health care
Perfect Environment

41. 41
•Healthy Environment:
•Stimulations
•Support
•Stability
•Structure
•Unhealthy Environment:
•Regressive
•Threatening
•Unpredictable
•Confusing
(1) Environment & Routines
Oxana Malaya The Feral Child

42. (2) Stress & Routines
•Stress:
• A common cause of deterioration
• Can be very difficult to manage.
•Types:
• Positive Stress: introduction of a
disturbing new situation.
• Negative Stress: (removal of support
stabilising situation.
•Treatment:
•Identifying
•Removal
•Compensating
•Coping
•Medications (??). 42

43. (3) Maturity & Routines
43
Social
Developmental
Stages
Age Achievements Autistic Regressive Routines
Expansive Social Parenting Social Legacy
Symbiotic Social 16 -
Adulthood
Social Integration
Narcissistic Social 11 - 18 Social Autonomy
Concrete Social 5-12 Social Engagement Awkward Social R > Pyromania
Narcissistic
Emotional
3-5 Basic Trust Regressive Emotional R >
Hostile Dependence / Stalking
Autistic Physical 1-3 Physical Autonomy Objects & Space R > Hoarding
Autistic Visceral 1-2 Visceral Autonomy Visceral R > rocking / sensory
processing

44. Specific Factors :
Brain Circuits of Routines
44

45. Doya’s Model of Motor Learning (Doya, 2000)
(also Imamizu et al, 2000; Hikosaka et al, 2002, Bosch-Bouju et al, 2013)
Kenji DoyaFerreira et al, 2008

46. 46
Mentation / Cognition
Neocortex
Reflexive Behaviour
Midbrain
Satisfaction
SeptalNuclei
Emotional
Labelling
Amyg. /ACC
ResponseControl
BasalGanglia
Routines
Cerebellum
Behaviour
Filtering
Thalamus
Drive
Brain Stem
mesocortical
pathway

47. 47
Cognition
Neocortex
Reflexes
Midbrain/Brain Stem
Satisfaction
Septal Nuclei
Emotional Labelling
Amygdala / ACC
Response Control
Basal Ganglia
Coordination
Cerebellum
Dysfunctional
Routines
Clumsy / poor adaptive
Addiction-like pathology
anxiety / mistake
avoidance routines
Exaggerated inhibition
Exaggerated release
Dysautonomia / rocking /
SIB / rage
Awkward routines
None motor dyspraxia
Arousal / Drive
Brain Stem
Filtering
Thalamus
Easily overwhelmed >
regression
e.g. ADHD > Fleeting /
fragmented routines

48. System Disturbed
functioning
Correction e.g.:
Drive e.g. Self-isolation Support and
Stimulation
Filtering Overwhelm Limiting choices in
environment
Mentation Poor awareness /
poor planning
Functional insight;
help, Negotiation
Satisfaction Addiction Channelling /
restriction
Emotional labelling Anxiety Desensitisation
Control Extra inhibition /
Extra disinhibition
Channelling /
restriction
Reflexes Excessive reflexive
responses
Desensitisation
C. Routine Clumsiness & Training 48
Autistic R.D.: Types & Corrections

49. Reflections
on
Specific Factors
49

50. 50
Drive-Arousal System
Sustained
Attention
Motor
Excitement
Emotionality
Filtering (Overwhelm / Distraction)
Shut
Down
Physiological
Arousal
Response / Control (Inhibition / Release)
Vocalisation
Arousal
YDL

51. (1) Arousal / Drive & Routines
Common problem:
• Low Drive System (e.g.
Amotivational Syndrome) >
low key stimulation > pica,
rocking, blocking toilets,
etc.
•High Drive System (e.g.
ADHD) > dissocial
hyperactivity > agitation,
hostility, etc.
• Antipsychotics in agitation >
reduce Mesolimbic activity.
• Healthy life style can be
measured by the YDL level.
51

52. Functional / Satisfactory Social Life
(Fredrickson, 2001, Seligman & Csikszentmihalyi, 2000)
• Learning,
• Work,
• Social
Network,
• Emotional
Relationships,
• Hobbies,
• Leisure. 52

53. (2) Thalamic Inhibition/ Filtering & Routines
(Mori et al, 2016)
53

54. Thalamic Inhibition/ Filtering & Routines
•Poor filtering = poor resilience
•Poor coping with choices or
changes.
•Poor functioning.
•Increased Anxiety, irritability.
•Avoidance of exposure to more data
> restricted interest.
•Low regressiveness point.
•Low overwhelm (shock) point.
•Open to training >
•Desensitization
•Open to compensation >
•Limited choices
•Positive support
54

55. (3) Cognition & Routines
55

56. Dysfunctional neocortex >
Poor abstract thinking:
•Poor “Central Coherence”
(Pina et al, 2013; Booth & Happé, 2010; Frith & Happé,
1994).
•Poor cognition > Poor
social abstract awareness
(+ poor theory of mind) > >
extreme socio-emotional
thinking. (Allely et al, 2014; 2017)
56
Cognition & Routines
Alek Minassian
Incel Saint
Anders Breivik
2011 Norway attacks

57. •OCD-like routines > fear
driven routines > common
in autism e.g. hoarding.
•Usually ego-syntonic
? limited cognitive
oversight
A challenge to SSRI
therapy
•SSRI and SNRI > mainly
enhance resilience > To get
result > context dependent >
patient needs to resist OCD
(Bagot et al, 2017, Dankoski et al, 2014,
Russo et al, 2012; Elke et al, 2011;
Oreland et al, 2010) 57
(4) Fear/negativity Driven Routines

58. •Inward (self)
negative
attribution >
hesitance,
self-harm, etc.
•Outward
(environment)
negative
attribution >
avoidance /
aggression,
destructive
behaviour,
uncluttering, etc.
58
(4) Fear/negativity Driven Routines

59. (5) Reward Driven Routines
Volkow et al, 2011
59

60. Reward-Based Behavioural as
Therapy:
• Can be compromised by fear
driven behaviour, poor cognition,
etc.
• Can be compromised by highly
fixated dysfunctional reward
driven behaviour e.g. rocking,
Pica, sexual interests, pyromania,
hoarding; territorial behaviour,
stalking etc.
Play, Vocalisation & Nursing in
severe autism
• Triune Brain Theory
• Paul MacLean, 1993
Reward Driven Behaviour in Autism

61. (6) Response Control & Routines
(Clark & Dagher, 2014; Hwang, 2013; Seibyl et al, 2012; Aron et al, 2007; )
61

62. • High impulsivity > usually with
autism with ADHD, some forms
of OCD, paedophilia, pyromania,
gambling addiction, drug
addiction, etc.
• Open to Behavioural therapy
but can be factor-specific e.g.
• Structure; e.g. hospital
structure
• Non-exposure to trigger (e.g.
a child in paedophilia)
• Model-facilitation; e.g. when a
staff member is the main
factor in controlling impulse,
etc.
62
(6) Response Control and Routines
(Ganos et al, 2015; Aron et al, 2007; Hymas et al, 1991; Wing & Attwood, 1987)
Shaun Tudor:
St Andrews Hospital
2011

63. •Excessive inhibition:
another prevalent
response-control problems
in autism > (?) poorly
understood and poorly
treated e.g.
•Autistic Catatonia (Withane
& Dhossche, 2019; Hare &
Malone, 2004; Wing & Shah,
2000),
•Obsessional Slowness
(Ganos et al, 2015)
(6) Response Control and Routines
(Ganos et al, 2015; Aron et al, 2007; Hymas et al, 1991; Wing & Attwood, 1987)
“Interview: Catatonic
Schizophrenic” 7M views

64. Conclusion
• Autistic Routine Disorders have many
reasonably defined factors and sub-
factors that are clinically relevant to
the enhancement of clinical services.
• Recent discoveries in neuroscience >
big room for more refined concepts,
diagnosis, classification,
assessments, diagnosis &treatment of
disorders like Autism or Rigid
Routines.
• RDoC studies (NIMH) (Insel et al, 2010).
• ROAMER studies (Horizon 2020 -
European Commission) (Schumann et al,
2014).
• Clinical psychiatry is probably the
most crucial factor in completing this
task.
64

65. Thank you
Comment
65