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The Impact of Autism Spectrum Disorder Traits on the Treatment Outcome of Patients with Obsessive Compulsive Spectrum Disorder

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The Impact of Autism Spectrum Disorder Traits on the Treatment Outcome of Patients with Obsessive Compulsive Spectrum Disorder The impact of autism spectrum disorder traits on the treatment outcome of patients with obsessive compulsive spectrum disorder Master Thesis: Health Psychology, specialisation: Clinical Psychology University of Amsterdam, July 20th, 2016 Research performed at the Academic Medical Centre in Amsterdam, Department of Psychiatry Student Supervisors Vrouwkjen Frederieke Joanne UvA: dr. L. Boyette Glas AMC: drs. M. van der Pol (6065244) 1 Index Title Page………………………………………………………………………………… 1 Index……………………………………………………………………………………... 2 Abstract…………………………………………………………………………………... 3 Introduction……………………………………………………………………………… 3 Methods………………………………………………………………………………….. 7 Results……………………………………………………………………………………. 11 Discussion………………………………………………………………………………… 15 References………………………………………………………………………………... 20 Appendix 1 – Autism-spectrum Quotient (in Dutch)……… ……………………………. 25 Appendix 2 – Yale-Brown Obsessive Compulsive Scale (in Dutch)……………………. 28 2 Abstract Despite a high comorbidity between obsessive compulsive disorder (OCD) and autism spectrum disorder (ASD), the relation between both disorders is not yet fully understood. There is some evidence that ASD traits could have an negative impact on a regular OCD treatment, however limited research has focused on the treatment of OCD in people with ASD traits. Therefore, this study focused on whether people with more ASD traits would (A) profit less from cognitive behavioural therapy (CBT) for obsessive compulsive spectrum disorder (OCSD), (B) have more severe OCSD symptoms before the treatment and (C) a higher dropout rate. 67 subjects followed a 16-week CBT for OCSD, in which treatment efficacy and ASD traits were assessed. Results showed no impact from ASD traits on treatment efficacy, OCSD severity before treatment and the dropout rate. From this it can be concluded that slightly elevated ASD-traits made no impact on the treatment outcome. However, a limitation in this study was that there was little variation in ASD traits between subjects. Future research can be directed at clinical ASD and components of CBT that are most effective for people with ASD and comorbid OCSD. Introduction Obsessive compulsive disorder is an anxiety disorder within the obsessive compulsive spectrum. The obsessive compulsive spectrum (OCSD) contains a range of disorders, such as OCD, trichotillomania and body dysmorphic disorder (BDD). Obsessive compulsive symptoms are persistent thoughts, urges or images that are experienced as intrusive. Symptoms also include repetitive behaviours or mental acts which are performed in response to an obsession or according to rules that must be applied rigidly (American Psychiatric Association, 2013). Obsessive compulsive behaviour can also be characterized by preoccupations and attempts to stop the compulsions or obsessions. The nosology of OCD has 3 been subject of recent debate, since the phenomenology of OCD has many different features and in some cases non-specific symptoms (Ivarsson & Melin, 2008). Certain phenomenology and neurophysiology of OCSD is associated in the literature with autism spectrum disorder (ASD), which will be explained further on. Autism is a neurodevelopmental disorder which often first appears in early childhood. General characteristics of ASD are persistent deficits in social communication and interaction in addition to restricted and repetitive patterns of behaviour, interests and activities (American Psychiatric Association, 2000). The prevalence of ASD in adults and children is estimated at 1% (Brugha et al., 2011, Kan et al., 2013). Recent literature shows that people with ASD report a lower level of quality of life than their peers without ASD (van Heijst & Geurts, 2015; de Vries & Geurts, 2015). Furthermore, people with ASD have a higher risk on developing comorbid psychiatric disorders (Bradley et al., 2004; Hofvander et al., 2009). For instance, anxiety disorders appear to be more common among people with ASD than people without ASD (Brereton et al., 2006; Gadke, 2016; Reaven, 2011). Children with ASD have a higher risk on developing anxiety related symptoms than children without ASD (Brereton et al., 2006; Gillot et al., 2001). Specifically OCD is relatively common in ASD, with a comorbidity rate estimated at 10% (Neil & Sturmey, 2014). ASD traits are prevalent in OCD as well and there are reasons to assume ASD traits are associated with OCD severity (Bejerot, 2001; Ivarsson & Melin, 2008; Stewart et al., 2016). Literature suggests there are several reasons to assume a link between OCSD and ASD. Behaviour that is typical in ASD is often seen in obsessive compulsive spectrum disorders (OCSD) as well, such as rigidity and repetitive behaviour. Repetitive behaviour is a non- specific symptom, seen in many different psychiatric disorders (Lewis & Bodfish, 1998), including ASD and OCD (Ruzzano et al., 2015). Also, social competence deficits are not only common in ASD, but evidence suggests OCD and BDD are also associated with slight deficits 4 in social competences, such as shyness and social anxiety (Chasson et al., 2011). There are indications that people with ASD and people with BDD have difficulties with emotion recognition (Chasson et al., 2011). Also ritualistic behaviour, such as counting and following a rigid routine, are common in both ASD and OCSD (Allen et al., 2003). In addition to this phenomenological overlap, there is certain related pathophysiology between ASD and OCD. For example, a cluster of diseases, which include OCD and ASD, are associated with a certain variant of the serotonin transporter gene (Ozaki et al., 2003). Overlap in behaviour and neurophysiology generates growing attention for the linkage between OCSD and ASD, but the course of treatment for ASD traits in OCSD remains understudied. To date, most research in this area focuses on children or adolescents and on anxiety disorders in general. Studies on the treatment of anxiety disorders show that cognitive behavioural therapy (CBT) is more effective than treatment as usual (TAU) for people with ASD (Storch et al., 2015; Sukhodolsky et al., 2013). Meta-analysis shows CBT has moderate treatment gains for people with ASD and an anxiety disorder (Ung et al., 2015). The same study shows that (young) people with ASD and a comorbid anxiety disorder can profit from CBT. However, there are also indications that people with more ASD-traits profit less from CBT for anxiety disorders than people with less ASD-traits. Van Steensel et al. (2015) show for example that children with ASD and a comorbid anxiety disorder have more anxiety symptoms after CBT compared to children with only an anxiety disorder. People with ASD can profit (moderately) from CBT, but it is unclear whether CBT is less effective for people with more ASD traits. Mito et al. (2014) did research similar to the present study and compared people with more ASD-traits and OCD to people with less ASD-traits and OCD. They found that higher levels of ASD traits did not correlate with a lower treatment outcome. However, their CBT- treatment lasted 47-weeks, and in regular Dutch treatment settings an OCD (group) treatment 5 is less extensive. It cannot be ruled out that shorter treatments will show less improvement in people with ASD compared to people with pure OCD. It is therefore hypothesized in this study that a standard OCSD-treatment could be less effective for patients with more ASD traits. For example, next to persistent deficits in communication and forming social relationships, people with ASD often have difficulties integrating sensory information (Baker et al., 2008). People with ASD often thrive in highly structured settings (Krasny et al., 2003; Hum et al., 2014) and it is possible that a regular (group-) treatment setting does not offer enough structure or offers information in a relatively high pace. It is also possible that symptomatic overlap between both disorders causes difficulties in the treatment, since repetitive and ritualistic behaviour can be helpful for people with ASD whereas for people with OCSD this behaviour it is often dysfunctional. Also, social deficits can be a limiting factor, especially in a group treatment. Because of these traits it is possible that people with a more ASD-traits can experience difficulties in a regular treatment program for OC(S)D and profit less than people with less ASD-traits. If CBT would prove to be less effective in people with OCSD and comorbid ASD, this could be a reason to study different treatment components and adjust them for this specific sub-population. Having a less effective treatment for people with ASD would indicate that there might be components in the treatment that could be adjusted, for it to be more profitable for people with ASD and OCD. The main objective of our research is therefore to evaluate the impact of ASD traits on the treatment outcome of patients with OCSD. We have preferred this objective above the alternative of investigating OCSD symptoms in the context of ASD, for clinical reasons mainly. It seems clinically more relevant to study ASD traits in the context of OCSD than, reversely, OCSD in the context of ASD, since we expect there will be more variation in ASD traits in OSCD than OCSD symptoms in ASD. The aim of this study is to examine (A) 6 whether people with higher levels of ASD traits have a lower treatment outcome of cognitive behavioural therapy (CBT) for OCSD than people with lower levels of ASD traits. In addition, (B) it is examined whether a higher level of ASD traits lead to a higher dropout rate during treatment.
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