Using CBT in the treatment of OCD in Autism. Dr Amita Jassi Institute of Psychiatry, Kings College London South London & Maudsley NHS Trust

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1 Using CBT in the treatment of OCD in Autism Dr Amita Jassi Institute of Psychiatry, Kings College London South London & Maudsley NHS Trust

2 Overview What is OCD? Prevalence OCD in ASD Challenges in identifying OCD in ASD Evidence for psychological treatments What does CBT for OCD look like? Modifications to CBT for people with autism

3 OCD diagnostic criteria Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): (1) recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by (1) and (2): (1) repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

4 Prevalence Anxiety disorders very common in this group Anxiety disorders 30-50% (Kim et al, 2000; Green et al, 2000; White et al. 2009) OCD 25% (McDougle et al, 1995; Russell et al, 2005)

5 OCD in ASD McDougle et al (1995) Compared adults OCD vs. ASD using YBOCS and they could be distinguished on basis of types of repetitive thoughts and behaviour. ASD more likely to report compulsions vs. obsessions. Problems with study IQ differences and significant number mute. Russell et al (2005) Most ASD (40-60%) reported interfering and distressing OC symptoms 10 (25%) co-morbid OCD Group membership best predicted by somatic obsessions (> OCD) (F=6.730, df=1,53, p<0.01) and sexual obsessions (> ASD) (f=7.650, df=2,52, p<.001)

6 OCD in ASD Mack et al (2010) Compared children OCD & ASD vs. OCD & TS vs. OCD alone using YBOCS OCD & ASD OC symptoms equally distressing, time consuming and interfering vs other groups. Symptoms similar but OCD & TS greater ordering & arranging compulsions

7 Challenges Identifying OCD in ASD Difficulties with insight and introspection Repetitive behaviours (RB)

8 Difficulties with Insight & Introspection Some argue ASD individuals lack the concepts of mental states necessary to verbalise their inner world Inability to report does not imply their absence Can do with structure and direction Bejerot et al (2001) people with HFA do seek treatment and report distress Russell et al (2005) insight measure

9 RB Differences in OCD vs. ASD Phenomenological differences Epidemiological differences course & onset Both types of RB, disentangling can be challenging

10 Phenomenological Differences Compulsion Purposeful serve a function Prevent dreaded event Reduce distress Not connected in a realistic way to the event Distressing in itself Need to complete correctly Repetitive Behaviours Purposeless? Unvarying consistent topography Reduce distress? Not particularly connected to situation/feared events Not distressing in itself

11 Epidemiology Course & Onset Childhood OCD Mean age onset 10.3 years ( ) Bimodal peak: puberty and young adulthood 1/3 adults recall < 15 yrs Often fluctuating but chronic course Repetitive Behaviours Infancy Peak in TDC mths Vary in form over time Course unlikely to fluctuate persistent and chronic Reduce in early adolescence

12 Best practice: CBT as Psychological Treatment NICE guidelines recommend CBT +/- SSRI s Studies are few in number, but promising results Single case studies - Reaven & Hepburn (2003) AS & OCD - Lord (1996) - Lehmkuhl et al (2008) Group treatment studies - Sofronoff, Attwood & Hinton (2005) anxiety - Chalfant et al (2006) - Wood et al (2009)

13 CBT for OCD in ASD Pilot Study Russell et al (2009) Open, non-randomised treatment evaluation 24 adults with ASD and OCD 12 TAU vs. 12 CBT 12 received at least 20 sessions of individual CBT Matched on Verbal IQ Y-BOCS before and after treatment

14 Pre/Post YBOCS Severity Scores YBOCS severity Pre-Rx Mean (SD) Post-Rx Mean (SD) P TAU Group: Total severity (8.86) (6.12).601 Obsessions 10.75(4.59) 9.5 (3.75).096 Compulsions 9.42 (5.83) 9.75 (4.47).806 CBT Group: Total severity (6.51) (8.7).019* Obsessions (2.63) (4.51).004** Compulsions (4.65) (4.51).099

15 Results Mixed model anova significant group-time interaction effect (f=4.341, df=1, 22, p=.049, partial eta=0.165) >25% reduction on the YBOCS: 7 (58%) of CBT group 2 (16%) of no-rx group

16 CBT for OCD in ASD RCT Russell, Jassi et al (2013) 46 people included in study (n=13 from 14 to 18 years old) Manual: CBT for OCD with adaptations for ASD Expert recommendations (Attwood, 1999; Anderson & Morris, 2006) Experience from pilot study Theoretical literature 20 sessions (Mean 17 sessions (sd=4.5)) Longer period of assessment/formulation Education about anxiety and OCD Visual aides Special interest/concrete analogy Exposure & Response Prevention (ERP) Graded hierarchy Therapist modelling/direction Cognitive elements

17 Results Self-Informant-Clinician report ANCOVA: End of treatment YBOCS (controlling for pre-rx symptom ratings) ns: F 1,37, =1.127, p=0.295 Univariate analyses: Significant effect of treatment: CBT group pre-end of treatment (p=.001), 1M (p=.005), 3M (p=.008), 6M (p=007) and 12M (p=.011) follow-up AM group pre-end of treatment (p=<.001), 1M (p=<.001) Effect Size: CBT group (ES 1.1) AM group (ES 0.6) Treatment responders: 45% CBT group, 20% AM group Standardized effect sizes: Cohen s d (mean CBT-mean AM/σpooled) ES: 0.4 YBOCS total and 0.3 CGI

18 YBOCS total severity YBOCS total severity ratings pre, end of treatment and 1MFUP by group (3M, 6M, 12M FUP CBT group) AM CBT pretreatment endtreatment 1month 3month 6month 12month

19 Limitations Lack of statistical power: Use of pilot data CBT not optimal AM: Treatment Responders: Mild symptom severity Specific effects in ASD Whittal et al. (2010) - SMT ES:1.49, CT:ES 1.76

20 Conclusions Psychological treatment for co-morbid OCD can be effective Treatment gains were sustained over 12 months Adaptations CBT foundation skills Measurement Issues Self-Report

21 What does CBT for OCD look like? For TDC we do that following: Sessions 1 & 2 = psychoeducation on OCD and anxiety & developing hierarchy Sessions 3-12 ERP (review session 7) Sessions 13 & 14 relapse prevention Follow-up at 1, 3, 6 and 12 months

22 Psychoeducation on Anxiety

23 Modifications Affective Education Extended psycho-education on anxiety Emotion recognition and measurements See emotions on continuous scale rather than categorical One case couldn t measure so used external means of measuring anxiety Use their special interests Exposure to capture feelings Behavioural, physiological and cognitive cues of different emotions marked on a scale Go through body and discuss what each would feel like at different levels e.g. what would heart do?

24 Anxiety Psycho-education Shak y hands Sick in the stomach special interest/concrete analogy Voldemort Wormtail Lucius Draco Professor Snape The Dursley Professor Telawny Hagrid Neville Hermione Ron Harry Fight or Flight Response

25 Exposure tasks

26 Modifications - Therapeutic Relationship ASD qualitative impairments in reciprocal social interaction Therapist take the lead and more directive Rules for session turn taking, one off download of personal information, information sharing. Emphasis on information exchange vs. empathic aspects of the relationship

27 Modifications - Communication Literal interpretation style Concrete, matter of fact & clear explanations Don t assume you understand each other Explicit agreements on joint purpose of the sessions Ask specific and detailed questions, multiple choice Visual aids to help with communication - diagrams, diaries, hierarchy, OCD etc. Also takes pressure off the interpersonal aspect of sessions

28 Modifications Cognitive Restructuring Difficulty in coming up with alternatives alone, may need to provide them and give them list to choose from More directive approach and concrete examples backed with logical evidence Cognitive rigidity might not challenge held beliefs but rather consider an alternative

29 Modifications Neuropsychological Profile Difficulties in planning, prioritising and organising Longer sessions to allow extra time for slower information processing or shorter sessions Difficulties shifting attention, so may need external prompts to help. Help them to generalise look at similarities and differences between situations (use of parent/carer)

30 Collaborators Ailsa Russell David Mataix-Cols Martin Anson Miguel Fullana Isobel Heyman Kate Johnston Hilary Mack Declan Murphy

31 A few little plugs National Specialist OCD Team Maudsley Hospital ( ) HSOCD service: Severe OCD, course of CBT and SSRI s Main service: Assessment and treatment of OCD in youth with/out ASD. Consultation to services. /camhs/camhs-ocd/