Background: In this paper, we discuss the presence and implications of a triple diagnosis problem (TDP) for patients with Asperger’s syndrome, obsessive-compulsive disorder (OCD), and attention deficit and hyperactivity disorder (ADHD) comorbidity. Purpose: The primary purpose of this paper is to offer a clinical and therapeutical perspective of the Triple Diagnosis Problem due to the frequent comorbidity of the three syndromes. The objective is to help therapists to care for this population. Methods: After a review of the available literature on the subject, we discuss our clinical experience on a limited number of cases. We then describe the psychodynamic context of these syndromes and the feedback loop we have observed in our clinical practice. Then, we present this disorder’s personal, familial, and societal effects. Results: Based on our observations, instead of focusing on the differential diagnosis problem, we propose considering the three syndromes as the expression of a single major etiological factor. We advance the hypothesis that this factor is an epileptic-like syndrome that causes both the neurodevelopmental disorder and the “mental loop” these patients describe as extremely anxiogenic and paralyzing. Conclusions: We propose therapeutical approaches to this condition, both pharmaceutical and environmental, and further studies that could corroborate or refute our hypothesis.
Andersson, M., Tangen, Ä., Farde, L., Bölte, S., Halldin, C., Borg, J., & Lundberg, J. (2021). Serotonin Transporter Availability in Adults with Autism—A Positron Emission Tomography Study. Molecular Psychiatry, 26, 1647-1658. https://doi.org/10.1038/s41380-020-00868-3
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., Kurzius-Spencer, M., Zahorodny, W., Robinson, C., Rosenberg, White, T., Durkin, M. S., Imm, P., Nikolaou, L., Yeargin-Allsopp, M., Lee, L.-C., Harrington, R., Lopez, M., Fitzgerald, R. T., et al. (2018). Prevalence of Autism Spectrum Disorder among Children Aged 8 Years—Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR. Surveillance Summaries, 67, 1-23. https://doi.org/10.15585/mmwr.ss6706a1
Baron-Cohen, S., Wheelwright, S., Robinson, J., & Woodbury-Smith, M. (2005). The Adult Asperger Assessment (AAA): A Diagnostic Method. Journal of Autism and Developmental Disorders, 35, 807-819. https://doi.org/10.1007/s10803-005-0026-5
Boedhoe, P. S. W., van Rooij, D., Hoogman, M., Twisk, J. W. R., Schmaal, L., Abe, Y., Alonso, P., Ameis, S. H., Anikin, A., Anticevic, A., Arango, C., Arnold, P. D., Asherson, P., Assogna, F., Auzias, G., Banaschewski, T., Baranov, A., Batistuzzo, M. C., Baumeister, S., et al. (2020). Subcortical Brain Volume, Regional Cortical Thickness, and Cortical Surface Area across Disorders: Findings from the ENIGMA ADHD, ASD, and OCD Working Groups. American Journal of Psychiatry, 177, 834-843. https://doi.org/10.1176/appi.ajp.2020.19030331
Brakoulias, V., Starcevic, V., Albert, U., Arumugham, S. S., Bailey, B. E., Belloch, A., Borda, T., Dell’Osso, L., Elias, J. A., Falkenstein, M. J., Ferrao, Y. A., Fontenelle, L. F., Jelinek, L., Kalogeraki, L., Kay, B., Laurito, L. D., Lochner, C., Maina, G., Marazziti, D., et al. (2019). Treatments Used for Obsessive-Compulsive Disorder—An International Perspective. Human Psychopharmacology: Clinical and Experimental, 34, e2686. https://doi.org/10.1002/hup.2686
Brakoulias, V., Starcevic, V., Belloch, A., Dell’Osso, L., Ferrão, Y. A., Fontenelle, L. F., Lochner, C., Marazziti, D., Martin, A., Matsunaga, H., Miguel, E. C., Reddy, Y. C. J., do Rosário, M. C., Shavitt, R. G., Sundar, A. S., Stein, D. J., & Viswasam, K. (2016). International Prescribing Practices in Obsessive-Compulsive Disorder (OCD). Human Psychopharmacology: Clinical and Experimental, 31, 319-324. https://doi.org/10.1002/hup.2541
Brem, S., Grünblatt, E., Drechsler, R., Riederer, P., & Walitza, S. (2014). The Neurobiological Link between OCD and ADHD. ADHD Attention Deficit and Hyperactivity Disorders, 6, 175-202. https://doi.org/10.1007/s12402-014-0146-x
CADDRA (2017). Canadian ADHD Resource Alliance. https://www.caddra.ca
Cadman, T., Spain, D., Johnston, P., Russell, A., Mataix-Cols, D., Craig, M., Deeley, Q., Robertson, D., Murphy, C., Gillan, N., Wilson, C. E., Mendez, M., Ecker, C., Daly, E., Findon, J., Glaser, K., MRC AIMS Consortium, Happé, F., & Murphy, D. (2015). Obsessive-Compulsive Disorder in Adults with High-Functioning Autism Spectrum Disorder: What Does Self-Report with the OCI-R Tell Us? Autism Research, 8, 477-485. https://doi.org/10.1002/aur.1461
Carminati, G. G., Carminati, F., Zecca, G., & Zecca-Tagan, C. (2022a). Asperger’s Syndrome, Obsessive-Compulsive Disorder and Attention Deficit Comorbidity. Psychology, 13, 964-978. https://doi.org/10.4236/psych.2022.137066
Carminati, G. G., Carminati, F., Zecca, G., & Zecca-Tagan, C. (2022b). Les trois petits cochons. Les Cahiers de la SIPsyM. http://www.sipsym.com/images/CahiersSIPsyM/N35-LesTroisPtsCochons.pdf
Carminati, G. G., Deriaz, N., & Bertschy, G. (2006). Low-Dose Venlafaxine in Three Adolescents and Young Adults with Autistic Disorder Improves Self-Injurious Behavior and Attention Deficit/Hyperactivity Disorders (ADHD)-Like Symptoms. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30, 312-315. https://doi.org/10.1016/j.pnpbp.2005.10.002
Carminati, G. G., Gerber, F., Darbellay, B., Kosel, M. M., Deriaz, N., Chabert, J., Fathi, M., Bertschy, G., Ferrero, F., & Carminati, F. (2016). Using Venlafaxine to Treat Behavioral Disorders in Patients with Autism Spectrum Disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 65, 85-95. https://doi.org/10.1016/j.pnpbp.2015.09.002
Carminati, M. V. (2020). Personal Communication.
Derksen, M., Feenstra, M., Willuhn, I., & Denys, D. (2020). The Serotonergic System in Obsessive-Compulsive Disorder. In C. P. Müller, & K. A. Cunningham (Eds.), Handbook of Behavioral Neuroscience (Vol. 31, pp. 865-891). Elsevier. https://doi.org/10.1016/B978-0-444-64125-0.00044-X
Faraone, S. V., & Larsson, H. (2019). Genetics of Attention Deficit Hyperactivity Disorder. Molecular Psychiatry, 24, 562-575. https://doi.org/10.1038/s41380-018-0070-0
Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-Based Conclusions about the Disorder. Neuroscience & Biobehavioral Reviews, 128, 789-818. https://doi.org/10.1016/j.neubiorev.2021.01.022
Fayyad, J., Sampson, N. A., Hwang, I., Adamowski, T., Aguilar-Gaxiola, S., Al-Hamzawi, A., Andrade, L. H. S. G., Borges, G., de Girolamo, G., Florescu, S., Gureje, O., Haro, J. M., Hu, C., Karam, E. G., Lee, S., Navarro-Mateu, F., O’Neill, S., Pennell, B.-E., Piazza, M., et al. (2017). The Descriptive Epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. ADHD Attention Deficit and Hyperactivity Disorders, 9, 47-65. https://doi.org/10.1007/s12402-016-0208-3
Fombonne, E., & Tidmarsh, L. (2003). Epidemiologic Data on Asperger Disorder. Child and Adolescent Psychiatric Clinics of North America, 12, 15-21. https://doi.org/10.1016/S1056-4993(02)00050-0
Gadke, D. L., McKinney, C., & Oliveros, A. (2016). Autism Spectrum Disorder Symptoms and Comorbidity in Emerging Adults. Child Psychiatry & Human Development, 47, 194-201. https://doi.org/10.1007/s10578-015-0556-9
Girgis, R. R., Slifstein, M., Xu, X., Frankle, W. G., Anagnostou, E., Wasserman, S., Pepa, L., Kolevzon, A., Abi-Dargham, A., Laruelle, M., & Hollander, E. (2011). The 5-HT2A Receptor and Serotonin Transporter in Asperger’s Disorder: A PET Study with [11C]MDL 100907 and [11C]DASB. Psychiatry Research: Neuroimaging, 194, 230-234. https://doi.org/10.1016/j.pscychresns.2011.04.007
Kanarik, M., Grimm, O., Mota, N. R., Reif, A., & Harro, J. (2022). ADHD Co-Morbidities: A Review of Implication of Gene × Environment Effects with Dopamine-Related Genes. Neuroscience & Biobehavioral Reviews, 139, Article ID: 104757. https://doi.org/10.1016/j.neubiorev.2022.104757
Mazzone, L., Ruta, L., & Reale, L. (2012). Psychiatric Comorbidities in Asperger Syndrome and High Functioning Autism: Diagnostic Challenges. Annals of General Psychiatry, 11, Article No. 16. https://doi.org/10.1186/1744-859X-11-16
McFayden, T., Jarrett, M. A., White, S. W., Scarpa, A., Dahiya, A., & Ollendick, T. H. (2022). Sluggish Cognitive Tempo in Autism Spectrum Disorder, ADHD, and Their Comorbidity: Implications for Impairment. Journal of Clinical Child & Adolescent Psychology, 51, 195-202. https://doi.org/10.1080/15374416.2020.1716365
Mirafiori, G. (2022). Communication Privée.
Mollard, E., Cottraux, J., & Bouvard, M. P. (1970). Version française de l’échelle d’obsession-compulsion de Yale-Brown. / Yale-Brown Obsessive-Compulsive Scale: A French Version. L Encéphale, 15, 335-341.
Nieminen-von Wendt, T. S., Metsähonkala, L., Kulomäki, T. A., Aalto, S., Autti, T. H., Vanhala, R., Eskola, O., Bergman, J., Hietala, J. A., & von Wendt, L. O. (2004). Increased Presynaptic Dopamine Function in Asperger Syndrome. NeuroReport, 15, 757-760. https://doi.org/10.1097/00001756-200404090-00003
Oades, R. D. (2010). The Role of Serotonin in Attention-Deficit Hyperactivity Disorder (ADHD). In C. P. Müller, & B. L. Jacobs (Eds.), Handbook of Behavioral Neuroscience (Vol. 21, pp. 565-584). Elsevier. https://doi.org/10.1016/S1569-7339(10)70101-6
Postorino, V., Kerns, C. M., Vivanti, G., Bradshaw, J., Siracusano, M., & Mazzone, L. (2017). Anxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder. Current Psychiatry Reports, 19, Article No. 92. https://doi.org/10.1007/s11920-017-0846-y
Robbins, T. W., Vaghi, M. M., & Banca, P. (2019). Obsessive-Compulsive Disorder: Puzzles and Prospects. Neuron, 102, 27-47. https://doi.org/10.1016/j.neuron.2019.01.046
Sasson, Y., Zohar, J., Chopra, M., Lustig, M., Iancu, I., & Hendler, T. (1997). Epidemiology of Obsessive-Compulsive Disorder: A World View. The Journal of Clinical Psychiatry, 58, 7-10.
Satterstrom, F. K., Kosmicki, J. A., Wang, J., Breen, M. S., De Rubeis, S., An, J.-Y., Peng, M., Collins, R., Grove, J., Klei, L., Stevens, C., Reichert, J., Mulhern, M. S., Artomov, M., Gerges, S., Sheppard, B., Xu, X., Bhaduri, A., Norman, U. et al. (2020). Large-Scale Exome Sequencing Study Implicates both Developmental and Functional Changes in the Neurobiology of Autism. Cell, 180, 568-584. https://doi.org/10.1016/j.cell.2019.12.036
Tsai, L. Y. (2007). Asperger Syndrome and Medication Treatment. Focus on Autism and Other Developmental Disabilities, 22, 138-148. https://doi.org/10.1177/10883576070220030101
Verbeeck, W., Bekkering, G. E., Van den Noortgate, W., & Kramers, C. (2017). Bupropion for Attention Deficit Hyperactivity Disorder (ADHD) in Adults. Cochrane Database of Systematic Reviews, No. 10, Article No. CD009504. https://doi.org/10.1002/14651858.CD009504.pub2