By Dr. Eda Gorbis, Assistant Clinical Professor at UCLA and Larissa Dooley, B.A.
Eda Gorbis, Ph.D., LMFT, is an Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences at the UCLA School of Medicine, and the Founder/Clinical Director of the Westwood Institute for Anxiety Disorders, Inc. Larissa Dooley, B.A., is a Research Assistant at the UCLA Anxiety Disorders Research Center. The authors would also like to thank Dr. Surfas for his collaboration and inspiration when putting together this article.
This article was initially published in the Summer 2011 edition of the OCD Newsletter.
Treating Obsessive Compulsive Disorder (OCD) can be challenging even on its own, but treating OCD when it co-exists alongside other disorders can be even more difficult. Studies have shown that almost all (92%) of OCD patients also suffer from at least one other disorder. Therapists refer to such co-existing disorders as “comorbid”. In patients with OCD, the average number of comorbid disorders is almost three per patient (LaSalle et al., 2004). One of the most common categories of disorders to appear along with OCD is Autism Spectrum Disorders (ASD). ASD describes a category of pervasive developmental disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) that include Autistic Disorder and Asperger’s Disorder. The aim of this article is to give patients, families, and professionals information about the specific challenges and successfully treat for OCD in patients who have comorbid diagnosis of ASD.
Many behaviors associated with OCD such as anxiety, repetitive behaviors, and social problems are also typical of ASD. While the appearance of ASD and OCD may be similar on the surface, the processes that drive these behaviors are quite different, and each requires a different kind of treatment. Using typical OCD treatment interventions with individuals with OCD comorbid with ASD will not be effective and vice versa. It is important to determine which behaviors arise from a patient’s OCD and which arise from ASD. This has proven to be one of the major challenges in treating patients with both disorders. Other difficulties in treating patients with OCD comorbid with ASD are:
- Lack of insight
- General inability to emotionally and socially connect
- Angry outbursts
- Frequent, extreme and unpredictable changes in mood
Typical OCD patients can gain insight into the connection between their obsessions and their compulsions. They can identify the fears behind their anxiety as well as the compulsive behaviors they perform in order to relieve this anxiety. They can recognize the difference between normal behaviors and their own bizarre obsessions and compulsions. They are able to see that these behaviors are disabling; however, OCD patients comorbid with ASD generally lack this ability for insight. They do not see their compulsive behaviors as bizarre. Their compulsions are not associated with obsessional anxiety, but are instead self-contained rituals. For example, both OCD and ASD patients may compulsively turn a light switch on and off. For the typical OCD patient, this behavior would be a ritual performed to ward off some impending disaster or protect against perceived external threats. Any pleasure they get from the action comes from a temporary relief from the anxiety they experience at the thought of what could happen if they did not perform the ritual. In contrast, an ASD patient might turn a light switch on and off because they experience self-soothing pleasure from the act itself, not because it shields them from some obsessional fear. Typically, ASD patients have no interest in changing their behaviors because their compulsions are pleasurable. They may even feel that their compulsive actions are positive and helpful.
Essential for successful diagnosis and treatment of OCD is to determine which behaviors are due to a patient’s OCD and which are due to their ASD. For instance, trying to analyze the fears behind compulsive behaviors in individuals diagnosed with ASD would be pointless, since their behaviors aren’t driven by fear as they are in individuals with OCD. Similarly, using only behavioral methods on an OCD sufferer without working on the underlying fears would be just as ineffective. Each disorder requires its own particular treatment program. Typical treatment for OCD compulsions involves controlling antecedent events, meaning controlling the thought processes and fears that cause the compulsive actions. A therapist might use repeated prolonged exposure response prevention interventions to lower levels of anxiety for OCD patients; however, in an individual diagnosed with ASD, anxiety arises from a different source, e.g., impulsivity, overstimulation, or misunderstanding of social cues. Instead, the treatment approach will have to be more about consequential control of behaviors, i.e., treating the behavior itself. This can be done with behavioral techniques such as anger management or desensitization techniques, and reinforcing these replacement behaviors with a reward system.
Another challenge in treating OCD patients comorbid with ASD stems from social problems inherent in ASD. Social issues can make it difficult for such patients to successfully work with a cognitive therapist. Basic social skills training are essential for successful cognitive therapy and should be used to treat both OCD and ASD. With this training, patients are able to understand their behaviors are atypical and caused by neurological irregularities, and also learn to socially connect. Basic social skills training may take longer with ASD patients because of their general lack of insight, but with perseverance, these skills will eventually take hold. By beginning with basic social skills training, the effectiveness of the therapy that follows will be greatly enhanced.
Another issue that may arise in treatment of individuals with ASD is they often show intense and sudden bursts of anger and frustration. They often take far longer to regain peaceful composure than the general population. The sudden burst of anger and difficulty regaining calm make mindfulness training for OCD patients very difficult. Since mindfulness is one of the core parts of many treatment models, finding ways to work around this problem is essential. One solution is to begin with teaching anger management, social skills, and mindfulness training followed by gradual introduction of Exposure Response Prevention (ERP) and Cognitive-Behavioral Therapy (CBT).
Treating patients who have OCD comorbid with ASD is difficult, but not impossible. OCD treatment should begin only after proper diagnosis and careful assessment of all of the patient’s conditions. Then, therapy should begin with anger management and basic social skills training. The therapist must overcome obstacles in these two areas before successful OCD treatment can happen.
While treating patients with both OCD and ASD may take longer and present more challenges, research studies suggest that patients with both disorders tend to retain their improvement better than other patients. For example, Dr. Michael Strober and Dr. Mark De’Antonio of the UCLA Adolescent Psychiatry department have observed that although it takes longer for insight to improve, autistic children keep their therapeutic gains in personal communication better than non-autistic patients. In my own professional experience, I have found this also to be true with ASD adults. Generally, gains from therapy become incorporated into the autistic system and so become an integral part of their lives. The gains they make, however, tend to be narrow and specific. Since most patients with ASD exhibit an inherent lack of insight, they are unable to understand how to transfer gains in one area to another. So, each and every trigger must be dealt with. It becomes especially important to work with others within the patient’s living situation and train them to continue the process of exposure. With careful treatment, ASD and OCD treatments can prove effective and deliver lasting improvements in the lives of patients and their families.
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