Can Adapted Cognitive Behavioral Therapy Help People with Both OCD and Autism?

What you need to know

• This study tested an adapted form of cognitive behavioral therapy (CBT) for adults who have both obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD).
• The treatment led to significant reductions in OCD symptoms that were maintained 3 months later.
• However, the improvements were modest compared to CBT for OCD in people without autism, suggesting further refinement of the treatment approach is needed.

Background on OCD and autism

Obsessive-compulsive disorder (OCD) is characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that a person feels driven to perform to reduce anxiety. Autism spectrum disorder (ASD) involves difficulties with social interaction and communication, as well as restricted interests and repetitive behaviors.

OCD and autism commonly occur together - studies estimate that around 10-30% of people with autism also have OCD. This combination can be particularly challenging to treat, as the social and cognitive differences associated with autism may make it harder for individuals to engage in standard cognitive behavioral therapy (CBT) for OCD.

What did this study do?

Researchers in Sweden recruited 19 adults who had both OCD and autism to test an adapted form of CBT specifically designed for this group. Key features of the adapted treatment included:

• 20 therapy sessions
• Extra time spent on education about OCD and anxiety
• Visual aids and concrete examples to explain concepts
• Involvement of family members to support treatment
• Tailoring of exposure exercises to each person’s specific symptoms

The main component was still exposure and response prevention - gradually facing feared situations while resisting compulsions. But the delivery was modified to be more suitable for people with autism.

Participants completed assessments of their OCD symptoms before treatment, halfway through, right after treatment ended, and 3 months later. The main measure was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a standardized rating of OCD severity.

Key findings

The adapted CBT treatment led to significant improvements in OCD symptoms:

• The average Y-BOCS score dropped by 7.7 points from before to after treatment.
• This reduction was maintained at the 3-month follow-up.
• 16% of participants were classified as treatment “responders” based on the amount of symptom reduction.
• Self-reported OCD symptoms and depression also showed significant decreases.

However, the results were modest compared to CBT studies in OCD patients without autism:

• Only 21% of participants achieved remission right after treatment, dropping to 5% at follow-up.
• The average symptom reduction was smaller than typically seen with standard CBT for OCD.
• There were no significant improvements in overall functioning or quality of life.

Challenges with treatment engagement

The researchers noted several issues that may have limited the treatment’s effectiveness:

• Participants completed an average of only 8 therapist-led exposure exercises over the course of treatment.
• Homework compliance was rated as “poor” for 35% of assignments.
• The treatment was spread out over 33 weeks on average, rather than weekly sessions.
• 8 participants changed therapists during treatment.

These factors suggest that the typical CBT format of weekly one-hour sessions may not be optimal for this population. Many participants struggled to regularly attend sessions and follow through on exposure practice between sessions.

Conclusions

• Adapted CBT can lead to meaningful reductions in OCD symptoms for adults with autism, but the effects are smaller than for OCD patients without autism.
• Challenges with treatment engagement and homework compliance may limit effectiveness.
• Further modifications to the treatment approach are needed to better meet the needs of this population.

Suggestions for improving treatment

The researchers proposed several ideas for enhancing CBT for people with both OCD and autism:

1. Provide in-home support from a treatment team to increase adherence to exposure practice.

2. Deliver treatment in a more intensive format over a shorter time period (e.g. daily sessions for a week) rather than weekly sessions.

3. Incorporate strategies specifically targeting life functioning and quality of life, not just OCD symptoms.

4. Consult individuals with OCD and autism when designing treatments to ensure interventions meet their needs and preferences.

While this study showed promising results, it’s clear that effectively treating OCD in the context of autism requires creative adaptations to standard CBT approaches. Continued research and treatment innovation are needed to better serve this population.