OCDand ASD Hudak Sachs Final - OCD:ASD PCTS - 1...routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions,

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OCD and ASD

Robert Hudak, MD, Associate Professor of PsychiatryUniversity of Pittsburgh

Rebecca Sachs, PhD ABPP, Private Practice

Autism Spectrum Disorders• Developmental Disorder- Lifelong• Spectrum & Severity level rating: how much support is needed

• Deficits in social-communication & social interaction– Social-emotional reciprocity– Nonverbal communication– Developing, maintaining & understanding relationships/social contexts

• Restricted, repetitive patters of behavior, interests– Repetitive motor movements, use of speech– Insistence on sameness, routines & rituals– Highly restrictive, fixated interests, abnormal in intensity/focus– Sensory sensitivities

Autism Spectrum Disorders

• Autistic• On the Spectrum• Person with Autism• Asperger’s Syndrome/Aspie

ASD Diagnostic Criteria

• Persistent deficits in social communication and social interaction across multiple contexts, as manifested by:– Deficits in social-emotional reciprocity,

ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions


– Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication


– Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

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ASD Diagnostic Criteria-Practically Speaking

Deficits in developing, maintaining, and understanding relationships. Difficulty….• Understanding social situations/don’t realize what's

expected• Adjusting behavior to suit various social contexts, as if

there are “unwritten social rules” or a “hidden social curriculum” not privy to

• Sharing imaginative play or in making friends (Have you every had a best friend? Ask about friendships operationally)


Deficits in social communication/interaction:• Respond inappropriately/oddly in conversations• Misreads nonverbal interactions• Difficulty building relationships appropriate to age• Little interest communicating experience or over-sharing• Lack of spontaneous shared enjoyment• Difficulty noticing when others are happy, sad, hurt and/or responding appropriately to their emotions

• Miscommunicate the emotion of empathy, offering comfort is it ever to a degree that’s uncomfortable


Deficits in nonverbal communicative behaviors:• Poorly integrated verbal and nonverbal communication• Atypical/Abnormal eye contact* • Atypical/Abnormal body language• Difficulty/deficits understanding & using of gestures,

facial expressions, social routines • Difficulty/deficits understanding & using

pragmatics/suprasegmentals (pitch, stress, length, intonation)


• Keep in mind the role of Social Camouflage/Masking• Keep in mind how ASD can “look” differently in

girls/women• Keep in mind “Hyper-Verbal” Autistics• Keep in mind how this can functionally look different as

social demands become more complex/sophisticated• Keep in mind, ASD social interaction with peers vs. with

younger/older individuals


• Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following:– Stereotyped or repetitive motor movements, use

of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).


– Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

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– Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

– Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).


Deficits in social communication/interaction:• Highly sensitive to changes in the environment• Overly dependent on routines• Intensely focused on inappropriate items/topics• Easily distracted AND appears to have a “one track mind” • Fear of failure when problem solving, tendency to focus on

errors • Good at attending to detail but difficulty perceiving &

understanding the overall picture/gist• Hypervigilance, tense & distractible in sensory stimulating

environments

ASD DSM 5 Changes

• Diagnoses of Asperger’s Syndrome and Pervasive Developmental Disorder (PDD-NOS) no longer exist

• Better allows clinicians to account for variability in symptoms across individuals

• More useful is diagnosing younger children• No longer in ‘child’ section

ASD DSM 5 ChangesSeverity

LevelSocial

CommunicationRRB

Level 3: Requiring very substantialsupport

Severe deficits in verbal and nonverbal social communication that causes severe impairment in functioning.

Inflexibility of behavior, extreme difficulty coping with change, or other rrb that markedly interfere with functioning in all spheres. Great distress/difficulty changing focus/action.

Level 2: Requiring substantialsupport

Marked deficits in verbal and nonverbal social communication; impairments apparent even with supports in place.

Inflexibility of behavior, difficulty coping with change, or other rrb that appear frequently enough to be obvious and interfere with functioning in a variety of contexts. Distress/difficulty changing focus/action.

Level 1: Requiring support

Without supports in place, deficits in social communication cause noticeable impairments.

Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Changes with DSM 5

• “Disruptive, Impulse-Control, and Conduct Disorders” is a new chapter in DSM 5– Includes: Intermittent Explosive Disorder,

ODD, Conduct Disorder, Anti-social PD, pyromania, and kleptomania

Intermittent Explosive Disorder

• Salient diagnosis for patients with ASD• Diagnosis involves verbal aggressions or

behavioral outbursts• Can be made in addition to ASD diagnosis

if episodes “warrant independent clinical attention”

• Often caused by transition, anxiety (E/RP implications)

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Changes in DSM 5 To Consider

• Disorders related to OCD– Body Dysmorphic Disorder– Hoarding Disorder– Trichotillomania (Hair Pulling)– Excoriation (Skin Picking)

– Tic Disorders

Spectrums of the Spectrum

Executive Functioning

IQ

Social Skills

EmotionalRegulation

CommunicationSkills

Sensory Motor

Adaptive Skills

Autism Features

• “Once you’ve seen one ASD patient, you’ve seen one ASD patient” but…

• There are common features that are likely to occur in your patients

• Many ASD features are distributed throughout the general population (but are more common in OCD patients)

Autism & Pathology

• Why do people with ASD seek therapy?– Just like NT’s experience anxiety, mood disorders, OCD

and related disorders… likely at an even at a higher rate– Core deficits of ASD may have have negative functional

impact (academic, occupational, social, parental desire)– Feeling different/ “unexplained not fulfilling potential”

• Greater risks: anxiety and suicidality– Worry & Distress in social situations– Bullying and perceived trauma– Masking/social camouflage

Adaptive Skills & ASD

Adaptive behavior and cognitive development • Self-care skills & adaptive functions are often below the

level expected for age & intellectual ability• Often require support for development of adaptive skills

due to EF difficulties (i.e. planning, organization, task initiative, etc.)

• Often require support for initiating and maintaining independence

• Often lack of social motivation in this area

Autism Features-

From ”Living Well on the spectrum” by Valerie L. Gaus

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Responses to Misophonia– Hyperacusis: unusual tolerance to ordinary

environmental sounds– Misophonia: a strong dislike or hatred of specific sounds

• In the former, they are bothered by noises seeming loud, the latter they dislike specific sounds such as chewing

• Aversive physical reaction including disgust• Anger- may lead to agression• Avoidance of the sound, causes significant distress• Treatment can include E/RP in people with anxiety/disgust;

cognitive restructuring or stress inoculation in people with anger (Cavanna et al 2015)

Autism Features

• Synesthesia is increased in ASD• It occurs when input in one sense triggers a

response in a different sense• Patients may not complain about it

– Purple banana• It can have E/RP implication

Autism Features

• Sleep issues are prominent- reversed sleep/wake cycle issues, and occasional (1-2x per week) episodes of little sleep are not unusual

• Day light savings, time zone changes, light exposure can be very dysregulating

• Affect on Mood/Mood Disorders– Beware bipolar explosion

Autism Features- Medical Issues

• Increased constipation and other GI issues are typical

• Response to pain can be all over the map (some patients even enjoy blood draws).

• Consider ‘perceived pain’ rather than pain (is there an analogy here when doing ERP?)

• Dental needs often overlooked• May need explicit instruction on puberty

and sex related ADL’s

Restricted Repetitive Behaviors(RRBs)

• Two types:– Repetitive sensory motor behaviors

• Stereotyped movements such as hand flapping and/or repetitive use of specific objects (e.g. grillwork in my office

– Insistence on Sameness Behaviors• Ritualistic habits and strict adherence to

routine

RRBs in ASD

• No significant gender differences have been noted• May be some decrease in lower level RRBs with

age (Ebensen et al 2009)• Self-injurious RRBs more common in younger

and lower functioning cohorts (be aware of OCRD confounding this)

• Should not be approached like OCD. If dysfunction present, may address in other ways

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OCD

• The importance of educating patients, as well as families and caregivers on the difference between compulsions and RRB cannot be overstated

• Case example: Lorrine who plays with her eyelashes

• Case example: Jodi and the solo cup

Normal Development

• Rituals related to symmetry, germs ordering, just right peak at age 3.

• Hoarding continues to age 6.• Could these behaviors be persistent in

children with ASD or ID?

ASD Comorbidity

• Social Phobia 30%• OCD 17%• Agoraphobia 17%• GAD 15%• Separation Anxiety 9%• “Anxiety Attacks” 2%

OCD and ASD

• OCD occurs in ASD much higher than previously thought- at least 25%

• Possible decrease in somatic obsessions in ASD?

• Possible higher ordering or hoarding in ASD?

• Decrease in ego-dystonicity in ASD due to higher rates of ID*

OCD and ASD

• People with both may have more clinically severe illness

• People with both may be more resistant to treatment

• ?Less insight into OCD sxs (studies are mixed)

OCD and ASD

• People with ASD are twice as likely to be later diagnosed with OCD

• People with OCD are four times as likely to be diagnosed with ASD

• Increasing evidence for a genetic link between OCD and ASD Chasson 2011, Guo 2017

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OCD and ASD

• Children with OCD are more likely to have ASD traits as measured by the Social Responsiveness Scale (SRS)

• CY-BOCS and SRS-2 do not distinguish compulsions and stereotypies well– Though the SRS-2 does contain Social

Communication info

• Stewart et al 2016

OCD and ASD

• Genuine OCD in ASD is likely higher than previously thought: >10%

• Must distinguish from repetitive behaviors common in ASD

• Treatment studies are few, although some data showing SSRI’s may be safe in ASD

Russel et al 2005

OCD and ASD

• Social competence impairments in OCSD may be similar to ASD

• Cause and/or effect of this link is not clear• Higher rates of OCD in relatives of ASD

probands (contradicted by van der Plas et al 2016)

OCD with ASD Features

• Increased hoarding and other OCD dimensional sxs (checking and ordering)

• May not impact degree of improvement in OCD

• Self reporting of sxs similar to OCD alone• May occur in up to 20% of OCD patients• May effect males>females

OCD in ASD

• Just Right and Harm Avoidance symptoms in have been hypothesized to be more common in ASD patients or a core feature.

• Early studies have not showed this. However…

• Just Right OCD demonstrate sensory abnormalities and earlier age of onset.

ASD and Hoarding

• >25% rate of hoarding in children• Not associated with anxiety sxs• Acquisition associated with attentional

difficulties and not anxiety

Storch et al 2016

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OCRD in ASD

• SPD and HPD are psychiatric disorders• Often, you will not be told about these, as

family/staff/patients think they are autism ‘habits’

• Screen routinely

OCD & ASD: Side by SideOCD

• Recurrent and persistent thoughts– Intrusive– Unwanted

• Repetitive behaviors that the individual feels driven to perform to alleviate distress/neutralize obsession

ASD• Insistence on sameness,

inflexible adherence to routines).

• Highly restricted, fixated interests --atypical in intensity or focus.

• Stereotyped or repetitive motor movements

OCD & ASD: DifferencesOCD

• Focus of thoughts and behaviors: – Contamination – Harm/Violent/Sexual– Checking Hoarding– Counting– Asking for reassurance,

doubt– Not “so right” feeling

ASD• Focus of thoughts and behaviors:

– Repetition/Stereotypies (spinning objects, rocking back and forth, repeating a questions)

– “Stuck” need for sameness– Strength in attention to details

of a specific interest (dates, facts)


• Unwanted/bothersome thoughts and behaviors:– WANTS to stop thought

from occurring– Insight that behaviors are

odd– Distress about inability to

“control” symptoms

ASD

• Not bothered by thoughts and behaviors: – Does not necessarily want to

stop/control the thoughts– There is likely enjoyment of

interest


• Impact on functioning: Obsessions– Most Interfere with

functioning: socially, occupationally, academically

ASD

• Impact on functioning: Fixations/Preferred Interests – May have a functional

quality: Help learn new ideas, information, learn a trade or skill

– While it can be a strength, it can still impact functioning


• Change/Course– Significant change from

past is possible– Increase in severity of

symptoms or waxing and waning or symptoms

ASD• Change/Course

– Symptoms typically recognized 12-24 months

– Some get first diagnosis in adulthood

– Core symptoms typically stable

– Fixations generally change little

– 3 Severity levels: how much support required

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Differential diagnosis, Ask about:• Family History• Atypical response to medication• Developmental course & previous Dx of other

Disorders• Situational vs Pervasive Behaviors; 1:1

situations vs group• Performance with same age peers vs

younger/older• “Illusion of Competency”

Differential diagnosis, Ask about:

• Thoughts/Purpose: Ego-syntonic or Ego-dystonic• Physical sensations & Sensory sensitivities• Purpose/Function of compulsive behavior• Behaviors: Antecedents, Maintenance factors

• Try to actually observe, not just have described

Assessment: Domains of functioning• General Intellectual Functioning• Executive Functioning• Verbal/Language Functioning• Nonverbal/Visual-Spatial Functioning• Learning/Memory Functioning• Adaptive Functioning• ASD Diagnostic Measures, OCD Diagnostic Measures• Social Emotional Functioning• Structured/Semi-Structured Interviews:

– & Structured Clinical Interview for DSM- Axis I (SCID-I)

Gold Standard ASD DX Tools• Autism Diagnostic Interview – Revised (ADI-R)

– Structured interview with parent/caregiver– Utilizes a diagnostic algorithm indicating ASD vs. non-ASD– Focuses on three functional domains: Language/Communication,

Reciprocal Social Interactions, Restricted, Repetitive, and Stereotyped Behaviors and Interests

• Autism Diagnostic Observation Schedule – 2nd Edition (ADOS-2)– Semi-structured, standardized, direct with patient– Select one of 5 modules (Toddler, 1-4) depending upon patient’s age

and language functioning level– Utilizes a diagnostic algorithm (Autism, Autism Spectrum, or non-

ASD)– Designed with the intention of being used together*Long Administration, Specialized Training

Autism Mental Status exam (AMSE)• Not intended to diagnose people with ASD. The AMSE is meant

to support an expert's clinical diagnosis when a patient is suspected of having ASD.

• Initial validation data published indicates a sensitivity of 94% and a specificity of 81% in an unstratisfied high risk population. – 8-item observational assessment administered by health professionals. – Social, Communicative & Behavioral functioning in children/adults

with ASD is observed and documented – Standardized clinical examination, charting & documentation of

autistic signs & symptoms. May be utilized in the context of a routine clinical examination.

– Score cutoffs (≥ 5) can support clinical judgment that a patient has ASD.

J Autism Dev Disord. 2012 mar; 42 (3): 455-9. Doi: 10.1007/s10803-011-1255-4.Brief report: the Autism Mental Status Examination: development of a brief autism-focused exam.

Grodberg DI, Weinger PM, Kolevzon A, Soorya L, Buxbaum JD.

The Autism Mental Status Exam (AMSE; Grodberg et al, 2011)

Adult Asperger Assessment (AAA)• Comprised of 4 sections + Two Rating Scales (AQ & EQ)

– Social*– Obsessions– Communication*– Imagination*

• Final section describing 5 key prerequisites– Delays: across development– Impairment in functioning– No general delay in language– No clinically significant delay in cognitive development or in the development of age-

appropriate self-help skills, adaptive behavior – Criteria are not met for another specific Pervasive Developmental Disorder or

Schizophrenia. • Incorporates all the symptoms from the DSM-IV diagnosis of Asperger’s Disorder as well as

additional relevant symptoms.

Autism Research Center, University of Cambridge https://www.autismresearchcentre.com/arc_tests

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The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R)

• Comprised of 80 questions in 4 sections sections– Social Relatedness– Circumscribed Interests– Language– Sensory Motor

• Incorporates symptoms from DSM 5• May screen ASD women/their behavior better than other

measures *limited research • Self-Report Measure

Executive Functioning-ASDAssessment of Adaptive Living Skills: Important component identifying:

• Behaviors & Symptoms of ASD• Areas of need for treatment planning purposes• Behavior Rating Inventory of Executive Function

BRIEF-A & BRIEF-2 (for Children)– Rating Formats, Parent/Caregiver, Teacher Rating,

Self for Teens & Adults– Measures EF in several domains:

*Planning/Prioritizing & Flexibility/Shift are most implicated in ASD

• Smart but Scattered – Book Series

Adaptive Assessment- ASDAssessment of Adaptive Living Skills: Important component identifying:

• Behaviors & Symptoms of ASD• Areas of need for treatment planning purposes• Vineland Adaptive Behavior Scales-2nd Ed (Vineland-II)

– Interview & Rating Formats, Parent/Caregiver, Teacher Rating, Birth-90 years– Measures personal and social skills; adaptive behavior refers to typical

performance of the day-to-day activities required for personal and social sufficiency- these scales assess what a person actually does, rather than what he or she is able to do. The Vineland-II assesses adaptive behavior in four domains: Communication, Daily Living Skills, Socialization, and Motor Skills.

• Adaptive Behavior Assessment System- 2nd Ed (ABAS-II)– Parent, caregiver, and/or teacher rating (self-rating option for adults), birth- 89

years– Assessment of adaptive skills across the life span– Allows for comparison for self-report with other reporters– Assessment across 3 domains: Conceptual, Social and Practical

• Sensory• Escape• Attention• Tangible• (Medical)

SSRIs in ASD

• Difficult to assess literature and aggregate studies

• Most studies have different targeted behaviors (e.g. OCD, OC behaviors, repetitive behaviors) and are not always consistent in their own criteria

• Generalization is markedly difficult as a result

SSRIs in ASD

• Useful for anxiety, aggression, and ‘repetitive behavior’

• Best data with fluoxetine, although all likely work

• Marked difference in tolerability in kids vs adults

• Consider rechallenge in adults even if they had severe reactions as children

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Medication Treatment

• There is a growing interest in the use of glutamatergic meds in OCD patients with ASD

• Memantine is commonly used• Studies on-going in Europe (Hage 2017)

Treatment

• First randomized behavioral treatment study• Only patients with established ego-dystonic

obsessions were taken• Patients randomized to AM or CBT• Both groups effective, but CBT had 2x

more responders • AM worked best in milder patients only

Russell et al 2013

Behavioral Treatment

• Subsequent studies have confirmed that ERP is effective in OCD+ASD patients

• Efficacy may be lower than in OCD alonepatients with decrease gray matter in prefrontal cortex may be

less likely to respond

Case Example

• Ethan (video tape)• Has elaborate fantasies that have been

mistaken for psychosis• Fantasies have an OC component• discussion

Case Example

• Hal has ASD- very difficult to interview as he gets the thought that he needs to masturbate whenever he hears ‘me’, ‘what’, or an adverb’. Gets agitated and angry when interviewer slips up

• Responded to escitalopram equivalent 40mg

Case Example

• Eric 25 year old with ASD. Extreme anxiety and negative thoughts when hears a certain song. Reminds him of bad memories from high school

• This in turn triggers thoughts about Timothy McVeigh

• Significant avoidances of areas with overhead music

• No OCD sxs

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Case Example

• 30 year old female with OCD, college graduate, diagnosed with ASD age 25.

• Difficulties with ERP– 1) When SUDS increased could not tell if it was joy or

anxiety– 2) OCD and ASD triggers were often the same (e.g.

dusty plants- contamination as well as sensory grittiness)

Case Example

• James is a 25 year old with DS and OCD. Mild to Moderate ID

• No ASD comorbid• Responded to rudimentary E/RP in office-

cannot participate due to 5 hour round trip commute

• Consider E/RP even in patients with DS or ID

Documents

OCDand ASD Hudak Sachs Final - OCD:ASD PCTS - 1...routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions,