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Aymerich C, Pacho M, Catalan A, Yousaf N, Pérez-Rodríguez V, Hollocks MJ, Parellada M, Krebs G, Clark B, Salazar de Pablo G. Prevalence and Correlates of the Concurrence of Autism Spectrum Disorder and Obsessive Compulsive Disorder in Children and Adolescents: A Systematic Review and Meta-Analysis. Brain Sci 2024; 14:379. [PMID: 38672028 PMCID: PMC11048346 DOI: 10.3390/brainsci14040379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) and obsessive compulsive disorder (OCD) are two common and impairing neurodevelopmental conditions with partial symptomatic overlap. The aim of this study is to systematically and meta-analytically examine the following: (i) the prevalence of an OCD diagnosis among young people with ASD, (ii) the prevalence of an ASD diagnosis among young people with OCD, and (iii) the clinical and therapeutic implications of such comorbidity. METHOD A multistep literature search was performed from database inception until 17 November 2023. This PRISMA/MOOSE-compliant systematic review, registered in PROSPERO (CRD42023480543), identified studies reporting on the prevalence, sociodemographic, psychopathologic, prognostic, and therapeutic correlates of OCD and ASD concurrence in children and adolescents. A quantitative meta-analysis with random effects was conducted to analyse the pooled prevalence of OCD among samples with a mean age of < 18 years old with ASD and the prevalence of ASD among individuals under 18 with OCD. Sensitivity analyses were performed to investigate the effect of diagnostic criteria and different continents. Meta-regression analyses were conducted to examine the effect of gender, age, IQ, and OCD severity scores. A narrative review of the clinical and therapeutical implications of the comorbidity was provided. RESULTS 42 studies were selected for the systematic review (SR), and 31 of them were also included in one of the meta-analyses. The pooled prevalence of OCD among ASD youth samples (n = 8916, mean age = 10.6 ± 1.6; 16.4% female) was 11.6% (95% confidence intervals [CI] = 6.9%; 18.8%), and the pooled prevalence of ASD among OCD children and adolescent samples (n = 6209, mean age = 14.1 ± 1.4; 45.7% female) was 9.5% (95% CI = 6.0%; 14.7%). Meta-regressions found a statistically higher prevalence of ASD among samples with a lower prevalence of females (β = -4.7; 95%CI = -8.6; -0.8). Children with both OCD and ASD present higher rates of functional impairment, psychopathology, and other comorbidities, compared to youth with either of the disorders alone. CONCLUSIONS OCD and ASD are highly concurrent conditions in youth, with symptomatic, prognostic, severity, and therapeutic implications. Future research should focus on conducting longitudinal cohort studies prospectively to determine development trajectories, along with randomized controlled trials to assess the efficacy of specific therapeutic interventions.
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Affiliation(s)
- Claudia Aymerich
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London WC2R 2LS, UK
- Biobizkaia Health Research Institute, Basque Country University, Basurto University Hospital, OSI Bilbao-Basurto, Centro de Investigación en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 48903 Barakaldo, Spain
| | - Malein Pacho
- Biobizkaia Health Research Institute, Basque Country University, Basurto University Hospital, OSI Bilbao-Basurto, Centro de Investigación en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 48903 Barakaldo, Spain
| | - Ana Catalan
- Biobizkaia Health Research Institute, Basque Country University, Basurto University Hospital, OSI Bilbao-Basurto, Centro de Investigación en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 48903 Barakaldo, Spain
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London WC2R 2LS, UK
| | - Noorulain Yousaf
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Violeta Pérez-Rodríguez
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Matthew J. Hollocks
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London WC2R 2LS, UK
- Service for Complex Autism & Associated Neurodevelopmental Disorders, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Mara Parellada
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Centro de Investigación en Red en Salud Mental (CIBERSAM), 28007 Madrid, Spain
| | - Georgina Krebs
- Research Department of Clinical, Educational and Health Psychology, University College London, London WC1E 6BT, UK
- National & Specialist OCD, BDD and Related Disorder Clinic, South London & Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Bruce Clark
- National & Specialist OCD, BDD and Related Disorder Clinic, South London & Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Gonzalo Salazar de Pablo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London WC2R 2LS, UK
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Centro de Investigación en Red en Salud Mental (CIBERSAM), 28007 Madrid, Spain
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Church MJ, Mangen KH, Stiede JT, Spencer SD, Storch EA. The role of between-session homework in cognitive-behavioral therapy for comorbid obsessive-compulsive disorder and autism: A case vignette. J Clin Psychol 2024; 80:855-870. [PMID: 37561065 PMCID: PMC10858296 DOI: 10.1002/jclp.23580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Cognitive-behavioral therapy (CBT), which includes a decided emphasis on exposure and response/ritual prevention (ERP) and between-session practice of treatment principles, has consistently demonstrated efficacy for the treatment of obsessive-compulsive disorder (OCD) and is a gold standard, recommended first-line treatment. CBT with ERP has been successfully adapted to fit the needs of autistic individuals with OCD. The present article provides a brief overview of CBT for OCD and outlines special considerations and adaptations needed when working with patients with OCD and comorbid autism, with an emphasis on the importance of between-session homework. METHOD A case vignette is presented. RESULTS This case study illustrates the role of homework in the exposure-based treatment of an adult autistic individual with comorbid OCD. CONCLUSION Implications of this case vignette are discussed, and recommendations are offered for clinicians working with autistic individuals with OCD, especially in regard to bolstering completion of between-session ERP homework.
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Affiliation(s)
- Molly J Church
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Katie H Mangen
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan T Stiede
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Samuel D Spencer
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
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Dell’Osso L, Nardi B, Bonelli C, Amatori G, Pereyra MA, Massimetti E, Cremone IM, Pini S, Carpita B. Autistic Traits as Predictors of Increased Obsessive-Compulsive Disorder Severity: The Role of Inflexibility and Communication Impairment. Brain Sci 2024; 14:64. [PMID: 38248279 PMCID: PMC10813392 DOI: 10.3390/brainsci14010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Due to similar manifestations, some authors have proposed a potential correlation between autism spectrum disorder (ASD) and obsessive-compulsive disorder (OCD). This link has long been recognized and debated, with some authors arguing that these disorders frequently occur comorbid but distinct while others believe they are part of the same spectrum. The aim of our study was to explore the prevalence and correlates of autistic traits in 55 OCD patients and 55 matched controls and to assess possible autistic dimensions predictive of higher OCD symptoms. All participants were assessed with the Obsessive-Compulsive Spectrum-Short Version (OBS-SV) and the Adult Autism Subthreshold Spectrum (AdAS Spectrum). The OCD group scored significantly higher in both questionnaires. Total OBS-SV scores and domains were significantly correlated with all AdAS Spectrum domains and total score. The AdAS Spectrum total, Verbal Communication and Inflexibility and adherence to routine domain scores were significant positive predictors of higher OBS-SV scores. Lastly, when two clusters of subjects (high and low autism) were determined, Inflexibility and adherence to routine domain presented the greatest influence in forming the clusters. Our findings support the association between OCD and autistic traits in the adult population, supporting the hypothesis of a neurodevelopmental basis for these psychiatric conditions.
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Affiliation(s)
- Liliana Dell’Osso
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Benedetta Nardi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Giulia Amatori
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Maria Alessandra Pereyra
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Enrico Massimetti
- UFSMA Val di Cornia, Azienda USL Toscana Nord Ovest, 54100 Massa, Italy;
| | - Ivan Mirko Cremone
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Stefano Pini
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
| | - Barbara Carpita
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.D.); (C.B.); (G.A.); (M.A.P.); (I.M.C.); (S.P.); (B.C.)
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Højgaard DRMA, Arildskov TW, Skarphedinsson G, Hybel KA, Ivarsson T, Weidle B, Melin K, Torp NC, Thomsen PH. Do Autistic Traits Predict Outcome of Cognitive Behavioral Therapy in Pediatric Obsessive-Compulsive Disorder? Res Child Adolesc Psychopathol 2023:10.1007/s10802-023-01078-5. [PMID: 37199908 PMCID: PMC10368553 DOI: 10.1007/s10802-023-01078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
The first aim of this study was to explore whether children with obsessive compulsive disorder (OCD) and subclinical autistic traits can be differentiated from children with OCD without these traits based on clinical OCD-related characteristics, distinct OCD symptom patterns, and type of comorbidity. The second aim was to investigate whether autistic traits predict immediate and long-term outcome of exposure-based cognitive behavioral therapy (CBT) in pediatric OCD.The participants in this study were a total of 257 children and adolescents aged 7-17 years, recruited from Denmark, Norway, and Sweden as a part of the Nordic long-term OCD treatment study (NordLOTS). Inclusion criteria were an OCD diagnosis based on DSM-IV criteria and a Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) total severity score of 16 or higher. No children with a diagnosis on the autism spectrum were included. An Autism Spectrum Screening Questionnaire (ASSQ) cut-off score of ≥ 17 was used to define the group of OCD patients with autistic traits and all participants were treated with 14 weekly sessions of manualized CBT.Comorbid attention-deficit/hyperactivity disorder and tic disorders, subclinical internalizing and externalizing symptoms, lower insight into OCD symptoms, more indecisiveness and pervasive slowness, and ordering/arranging OCD symptoms were found to be significantly associated with having OCD with autistic traits. No difference was found between the groups on treatment outcomes.Results suggest that children and adolescents with OCD and autistic traits portray a different clinical profile than those without these traits, but that CBT is equally effective for those with and without autistic traits.
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Affiliation(s)
- Davíð R M A Højgaard
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Palle Juul-Jensens Boulevard 175, Entrance K, 8200 Aarhus N, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Trine Wigh Arildskov
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Palle Juul-Jensens Boulevard 175, Entrance K, 8200 Aarhus N, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Katja A Hybel
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Palle Juul-Jensens Boulevard 175, Entrance K, 8200 Aarhus N, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tord Ivarsson
- Regional Centre for Child and Youth Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, Norway
| | - Karin Melin
- Department of Child and Adolescent Psychiatry, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Nor Christian Torp
- Division of Mental Health and Addiction, Department of Child and Adolescent Psychiatry, Vestre Viken Hospital, Drammen, Norway
- Akershus University Hospital, Oslo, Norway
| | - Per Hove Thomsen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Palle Juul-Jensens Boulevard 175, Entrance K, 8200 Aarhus N, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Guastello AD, Lieneman C, Bailey B, Munson M, Barthle-Herrera M, Higham M, Druskin L, McNeil CB. Case report: Co-occurring autism spectrum disorder (Level One) and obsessive-compulsive disorder in a gender-diverse adolescent. Front Psychiatry 2023; 14:1072645. [PMID: 37260756 PMCID: PMC10227521 DOI: 10.3389/fpsyt.2023.1072645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/06/2023] [Indexed: 06/02/2023] Open
Abstract
This fictionalized case report captures the common themes and considerations during the diagnostic assessment and behavioral treatment of adolescents demonstrating symptoms of autism spectrum disorder (ASD), obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD), as well as gender-diversity concerns. Our patient was a white, non-Hispanic 17-year-old individual who identified as gender-neutral but had been assigned female at birth. Symptoms presented were social withdrawal, rigid rule-following behavior, unusual repetitive behavior, impairments in social communication skills, sensory sensitivity, body dissatisfaction, self-injury, and anxiety related to contamination, perfectionism, and social interactions. These symptoms contributed to functional impairment with school attendance, school achievement, family relationships, and the activities of daily living. This case report summarizes instruments employed for differential diagnosis concerning cognitive functioning, ASD, OCD, ADHD, depression, anxiety, and commonly co-occurring repetitive behavior. This patient was ultimately diagnosed with ASD, level one for both social communication and restricted, repetitive behaviors, without accompanying intellectual or language impairment; OCD with panic attacks; gender dysphoria; major depressive disorder (single episode and moderate); and ADHD. The subsequent 40-session course of cognitive-behavioral therapy with exposure and response prevention (CBT/ERP) to treat OCD tailored to an individual with ASD and gender diversity concerns is described in detail. Components of family involvement are highlighted. As a result, significant improvements in school attendance, OCD symptoms, depression, social relationships, and adaptive functioning were measured. Lastly, recommendations for clinicians are summarized.
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Affiliation(s)
- Andrea D. Guastello
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Corey Lieneman
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, United States
| | - Brittany Bailey
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Melissa Munson
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Megan Barthle-Herrera
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Miranda Higham
- Department of School Psychology, University of Florida, Gainesville, FL, United States
| | - Lindsay Druskin
- Department of Psychology, West Virginia University, Morgantown, WV, United States
| | - Cheryl B. McNeil
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
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Teunisse AK, Pembroke L, O’Gradey‐Lee M, Sy M, Rapee RM, Wuthrich VM, Creswell C, Hudson JL. A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people. JCPP ADVANCES 2022; 2:e12080. [PMID: 37431458 PMCID: PMC10242975 DOI: 10.1002/jcv2.12080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/01/2022] [Indexed: 07/29/2023] Open
Abstract
Background Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny. Aims This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years. Method Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure. Results From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication. Conclusions A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.
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Affiliation(s)
- Alessandra K. Teunisse
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Lorna Pembroke
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Maddison O’Gradey‐Lee
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
- Black Dog InstituteUniversity of New South WalesRandwickNew South WalesAustralia
| | - Megan Sy
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Ronald M. Rapee
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Viviana M. Wuthrich
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Cathy Creswell
- Department of Experimental Psychology and Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jennifer L. Hudson
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
- Black Dog InstituteUniversity of New South WalesRandwickNew South WalesAustralia
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Graat I, Balke S, Prinssen J, de Koning P, Vulink N, Mocking R, van Rooijen G, Munckhof PVD, Schuurman R, Denys D. Effectiveness and safety of deep brain stimulation for patients with refractory obsessive compulsive disorder and comorbid autism spectrum disorder; A case series. J Affect Disord 2022; 299:492-497. [PMID: 34952108 DOI: 10.1016/j.jad.2021.12.089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/15/2021] [Accepted: 12/19/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is effective for patients with treatment refractory obsessive-compulsive disorder (OCD). Autism spectrum disorder (ASD) is present in up to a third of all patients with OCD, but it is unknown whether effectiveness of DBS for OCD also applies for patients with comorbid ASD. The present case series is the first to examine effectiveness on OCD symptoms and safety of DBS in patients with OCD and ASD specifically. METHODS Six consecutive patients with treatment-refractory OCD and comorbid ASD received DBS of the ventral anterior limb of the internal capsule (vALIC) or medial forebrain bundle (MFB). We examined effectiveness of DBS on symptoms of OCD and depression with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Hamilton Depression Rating Scale (HAM-D), respectively. We included qualitative data to describe the course of treatment in individual patients with OCD and ASD. RESULTS We found that DBS significantly decreased symptoms of OCD (p < .001) and depression (p = .007). Four out of six patients with OCD and comorbid ASD were responders (decrease ≥ 35% in Y-BOCS), one patient was partial-responder (decrease 25-35% in Y-BOCS) and one patient did not respond (decrease ≤ 25% in Y-BOCS). Serious adverse events were an infection of the DBS system, and a suicide attempt. CONCLUSIONS Though present results are preliminary, DBS reduced symptoms of OCD and depression in patients with OCD and comorbid ASD. Comorbid ASD should therefore not be seen as a contra-indication for DBS in OCD.
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Affiliation(s)
- Ilse Graat
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands.
| | - Sofie Balke
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Janine Prinssen
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Pelle de Koning
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Nienke Vulink
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Roel Mocking
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Geeske van Rooijen
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Damiaan Denys
- Department of Psychiatry, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam UMC, Meibergdreef 9, 1105 Amsterdam, the Netherlands
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Elliott SJ, Marshall D, Morley K, Uphoff E, Kumar M, Meader N. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD). Cochrane Database Syst Rev 2021; 9:CD013173. [PMID: 34693989 PMCID: PMC8543671 DOI: 10.1002/14651858.cd013173.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Autistic spectrum disorder (ASD) is an increasingly recognised neurodevelopmental condition; that is, a neurologically-based condition which interferes with the acquisition, retention or application of specific skills. ASD is characterised by challenges with socialisation and communication, and by stereotyped and repetitive behaviours. A stereotyped behaviour is one which is repeated over and over again and which seems not to have any useful function. ASD often co-occurs with mental health disorders, including obsessive compulsive disorder (OCD). People with ASD may show certain cognitive differences (i.e. differences in ways of thinking) which influence their response to therapies. Thus, there is a need for evidence-based guidelines to treat mental health issues in this group. OCD, a common condition characterised by repeated obsessional thoughts and compulsive acts, occurs with greater frequency in persons with ASD than in the general population. Genetic, anatomic, neurobiological and psychological factors have been proposed to explain this co-occurrence. However, care should be taken to distinguish stereotyped and repetitive behaviours characteristic of ASD from obsessive compulsive acts in OCD. Cognitive behavioural therapy (CBT) is the recommended treatment for OCD, but studies have suggested that this treatment may be less effective in those with OCD co-occurring with ASD. Hence, modifications to CBT treatment may be helpful when treating OCD co-occurring with ASD to optimise outcomes. OBJECTIVES To assess the effectiveness of behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in children and adults with autism spectrum disorder (ASD). SEARCH METHODS We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, five other bibliographic databases, international trial registries and other sources of grey literature (to 24 August 2020). We checked the reference lists of included studies and relevant systematic reviews to identify additional studies missed from the original electronic searches. We contacted subject experts for further information when needed. SELECTION CRITERIA We included randomised controlled trials (RCTs), cross-over, cluster- and quasi-randomised controlled trials involving both adults and children with diagnoses of OCD and ASD. We included studies of participants with co-occurring conditions (i.e. those experiencing other mental illnesses or neurodevelopmental conditions at the same time), but we did not include individuals who had a co-occurring global learning difficulty. Treatment could be in any setting or format and include behavioural therapy (BT) and cognitive behavioural therapy (CBT), which may have been adapted for those with ASD. Comparator interventions included no treatment, waiting list, attention placebo (where the control group receives non-specific aspects of therapy, but not the active ingredient) and treatment as usual (TAU, where the control group receives the usual treatment, according to accepted standards). DATA COLLECTION AND ANALYSIS Three review authors independently screened studies for inclusion. The authors extracted relevant data from the one eligible study, assessed the risk of bias and certainty of evidence (GRADE). Outcomes of interest were changes in OCD symptoms and treatment completion (primary outcome), and severity of depressive symptoms, anxiety symptoms and behavioural difficulties, as well as degree of family accommodation (secondary outcomes). We did not conduct meta-analyses as only one study met the selection criteria. MAIN RESULTS We included only one RCT of 46 participants in our analysis. This study compared CBT for OCD in persons with high-functioning ASD with a control group who received anxiety management only. There were no differences in rates of treatment completion between the CBT (87%) and anxiety management (87%) groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.80 to 1.25; low-certainty evidence). Behavioural difficulties were not included as an outcome measure in the study. This study showed that there may be a benefit at the end of treatment favouring CBT compared with anxiety management in OCD symptoms (mean difference (MD) -3.00, 95% CI -8.02 to 2.02), depression symptoms (MD -1.80, 95% CI -11.50 to 7.90), anxiety symptoms (MD -3.20, 95% CI -11.38 to 4.98), and quality of life (MD 5.20, 95% CI -1.41 to 11.81), but the evidence was of low certainty. AUTHORS' CONCLUSIONS: Evidence is limited regarding the efficacy of CBT for treatment of OCD in ASD. There is much scope for future study, not only examining the efficacy of CBT for OCD in ASD, but also the particular ways that OCD manifests in and affects people with ASD and the role of the family in treatment response.
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Affiliation(s)
- Sarah J Elliott
- Elm House, East Cheshire Child and Adolescent Mental Health Service, Cheshire and Wirral Partnership NHS Foundation Trust, Macclesfield, UK
| | - David Marshall
- Centre for Reviews and Dissemination, University of York, York, UK
- Cochrane Common Mental Disorders, University of York, York, UK
| | | | - Eleonora Uphoff
- Centre for Reviews and Dissemination, University of York, York, UK
- Cochrane Common Mental Disorders, University of York, York, UK
| | - Mrityunjai Kumar
- Wigan Child and Adolescent Mental Health Service, Greater Manchester Mental Health NHS Foundation Trust, Wigan, UK
| | - Nicholas Meader
- Centre for Reviews and Dissemination, University of York, York, UK
- Cochrane Common Mental Disorders, University of York, York, UK
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Jassi A, Fernández de la Cruz L, Russell A, Krebs G. An Evaluation of a New Autism-Adapted Cognitive Behaviour Therapy Manual for Adolescents with Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 2021; 52:916-927. [PMID: 33025371 PMCID: PMC8405512 DOI: 10.1007/s10578-020-01066-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 12/28/2022]
Abstract
Obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) frequently co-occur. Standard cognitive behaviour therapy (CBT) for OCD outcomes are poorer in young people with ASD, compared to those without. The aim of this naturalistic study was to evaluate the effectiveness of a novel adolescent autism-adapted CBT manual for OCD in a specialist clinical setting. Additionally, we examined whether treatment gains were maintained at 3-month follow-up. Thirty-four adolescents underwent CBT; at the end of treatment, 51.51% were treatment responders and 21.21% were in remission. At 3-month follow-up, 52.94% were responders and 35.29% remitters. Significant improvements were also observed on a range of secondary measures, including family accommodation and global functioning. This study indicates this adapted package of CBT is associated with significant improvements in OCD outcomes, with superior outcomes to those reported in previous studies. Further investigation of the generalizability of these results, as well as dissemination to different settings, is warranted.
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Affiliation(s)
- Amita Jassi
- OCD, BDD and Related Disorders Clinic, South London and Maudsley NHS Trust, Michael Rutter Centre, De Crespigny Park, London, SE5 8AZ, UK.
| | - Lorena Fernández de la Cruz
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden ,Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Ailsa Russell
- Department of Psychology, Centre for Applied Autism Research, University of Bath, Bath, UK
| | - Georgina Krebs
- OCD, BDD and Related Disorders Clinic, South London and Maudsley NHS Trust, Michael Rutter Centre, De Crespigny Park, London, SE5 8AZ UK ,Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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10
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Pazuniak M, Pekrul SR. Obsessive-Compulsive Disorder in Autism Spectrum Disorder Across the Lifespan. Psychiatr Clin North Am 2020; 43:745-758. [PMID: 33127006 DOI: 10.1016/j.psc.2020.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Obsessive-compulsive disorder is a relatively common disorder seen in autism spectrum disorder across the lifespan. Many obsessive-compulsive disorder symptoms can present similarly to the core features of autism spectrum disorder and it is often difficult to differentiate between obsessive-compulsive disorder and stereotypic behaviors or restricted interests in autism spectrum disorder. However, there are differences between the 2 disorders. This article is a review of the current literature with the goal of helping the clinician to diagnose and treat obsessive-compulsive disorder in a patient with autism spectrum disorder.
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Affiliation(s)
- Markian Pazuniak
- Department of Child and Adolescent Psychiatry, University of Maryland Medical Center, 701 West Pratt Street, 2nd Floor, Baltimore, MD 21201, USA
| | - Scott R Pekrul
- Sheppard Pratt Health System, 6501 North Charles Street, Baltimore, MD 21204, USA.
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11
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Jones G, Jassi A. Modified Cognitive Behavior Therapy for Severe, Treatment Resistant Obsessive-Compulsive Disorder in an Adolescent With Autism Spectrum Disorder: The Importance of Parental Involvement. J Cogn Psychother 2020; 34:319-335. [PMID: 33372126 DOI: 10.1891/jcpsy-d-20-00019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevalence of obsessive-compulsive disorder (OCD) is higher among young people with autism spectrum disorders (ASD). Case studies and randomized controlled trials show that modified cognitive behavioral therapy (CBT) can be effective for young people with OCD and co-morbid ASD. This case study describes modified CBT for an adolescent with severe, treatment-resistant OCD and co-morbid ASD, and highlights the importance of family accommodation and parental mental health in pediatric OCD. Modifications to the standard evidence-based CBT for OCD protocol included extended psychoeducation, visual session material, mini exposure and response prevention hierarchies and parallel parent sessions to address familial accommodation and parental mental health. Progress was measured at seven times points throughout treatment using clinician administered, youth and parent self-report measures. Outcome data indicated significant improvements in OCD symptoms, general functioning, and maternal mental health as well as significant reductions in family accommodation. Gains were maintained over a 12-month follow-up period. This case study illustrates that modified CBT can be effective in youth with OCD and ASD and discusses the importance of familial accommodation and parental mental health.
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Affiliation(s)
- Gazal Jones
- National Specialist Clinic for Young People With OCD, BDD and Related Disorders, South London, and Maudsley NHS Foundation Trust, London, UK
| | - Amita Jassi
- National Specialist Clinic for Young People With OCD, BDD and Related Disorders, South London, and Maudsley NHS Foundation Trust, London, UK
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12
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Abstract
Obsessive-compulsive disorder is a relatively common disorder seen in autism spectrum disorder across the lifespan. Many obsessive-compulsive disorder symptoms can present similarly to the core features of autism spectrum disorder and it is often difficult to differentiate between obsessive-compulsive disorder and stereotypic behaviors or restricted interests in autism spectrum disorder. However, there are differences between the 2 disorders. This article is a review of the current literature with the goal of helping the clinician to diagnose and treat obsessive-compulsive disorder in a patient with autism spectrum disorder.
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13
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Pickard K, Reyes N, Reaven J. Examining the inclusion of diverse participants in cognitive behavior therapy research for youth with autism spectrum disorder and anxiety. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2018; 23:1057-1064. [PMID: 30160515 DOI: 10.1177/1362361318795678] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Results of randomized controlled trials have demonstrated significant reductions in anxiety symptoms following cognitive behavior therapy participation. Although promising, the extent to which previous research has included families from low socioeconomic status or racially/ethnically diverse backgrounds is unknown. Aims of this study are as follows: (1) What is the race, ethnicity, and educational attainment of youth with autism spectrum disorder and their families who have participated in research examining the efficacy of cognitive behavior therapy for anxiety? and (2) How do the demographics of these participants compare to that of the United States census? A total of 14 studies were reviewed that included 473 participants. Chi-square analyses indicated that there are significant differences between the race/ethnicity of youth with autism spectrum disorder participating in cognitive behavior therapy research for anxiety and that of youth in the United States. Standard residuals indicated significant overrepresentation of White youth and significant underrepresentation of Black and Latino youth in cognitive behavior therapy research (all p-values <0.001). Similarly, there were significant differences in the educational attainment of caregivers participating in cognitive behavior therapy research, with a significant underrepresentation of caregivers from low socioeconomic status backgrounds ( p < 0.001). These findings have implications for the development of cognitive behavior therapy interventions for youth with autism spectrum disorder and anxiety that are both rigorous and inclusive.
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Affiliation(s)
| | - Nuri Reyes
- University of Colorado, Anschutz Medical Campus, USA
| | - Judy Reaven
- University of Colorado, Anschutz Medical Campus, USA
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