DOI: 10.1192/j.eurpsy.2026.11081 ISSN: 0924-9338

Atypical and Severe Psychotic Presentations in Adults with Autism Spectrum Disorder: Clinical Insights from Three Cases

A. K. Rios-Landeo, S. Albarzani, E. Ros-Cucurull, F. Palma-Alvarez, O. Akpubi
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Introduction

Autism Spectrum Disorder (ASD) is recognised as a significant vulnerability factor for the development of psychotic disorders in adulthood. Presentations are frequently atypical and variable trajectories that challenge timely recognition and management. Overlapping features can obscure emerging psychosis. Pharmacological treatment is often constrained by poor tolerability, inconsistent efficacy, and higher rates of treatment resistance compared with non-ASD populations. Despite these clinical challenges, systematic case-based data in adults remain limited, hindering the development of tailored therapeutic approaches.

Objectives

To present three adult cases with ASD exhibiting atypical or severe psychotic symptoms, highlighting diagnostic complexity, functional impact, and treatment challenges.

Methods

Three adults with ASD were systematically evaluated through comprehensive clinical histories, structured psychiatric assessments, detailed mental state examinations, and longitudinal treatment records. Emphasis was placed on atypical psychotic features, functional impairment, and individualized pharmacological and psychosocial management strategies.

Results

Table 1.

Table 1. Long description.

Case
Age
Sex Primary Diagnosis ASD Features Psychotic/Affective Symptoms Triggers Treatment Outcome
1
25
M Schizoaffective Social withdrawal, rigid behaviours Severe negative symptoms, self-harm, minimal insight Psychosocial stressors Clozapine + Aripiprazole + Valproate Partial remission,
ongoing support (residential care)
2
30 F Schizoaffective Social naivety, sensory sensitivity Polymorphic delusions, affective dysregulation Psychosocial stressors, sleep loss Lithium + Quetiapine + Paliperidone + Psychotherapy + psychosocial support Full remission
3
32 F Delusional Disorder High-functioning ASD, social naivety, rigid behaviours Persecutory delusions, severe self-harm, minimal insight Psychosocial stressors, sleep loss Olanzapine + Aripiprazol + psychosocial support Full remission

Conclusions

Psychosis in ASD is not only more frequent than previously recognised but also clinically distinct, often presenting with polymorphic, severe, and treatment-resistant profiles. The three cases illustrate key clinical scenarios: (1) profound negative symptoms hindering recovery, (2) polymorphic psychosis complicated by pharmacological intolerance, and (3) severe persecutory delusions masked by high cognitive functioning and minimal insight. These insights stress the need for early recognition, tailored pharmacological strategies, structured psychosocial interventions, and sustained multidisciplinary care. Broader clinical awareness and targeted research are essential to improve outcomes in this highly vulnerable subgroup.

(Beebani et al., 2022; Deste et al., 2020; Strålin & Hetta, 2019; Yalcin et al., 2016; Bargiela et al., 2016; Downs et al., 2017; Chisholm et al., 2015; Sporn et al., 2004)

Disclosure of Interest

None Declared

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