Treating Anxiety, Depression & OCD in ASD Individuals

Guest:   Dr. Anthony Bailey, Phd, Chair, Child & Adolescent Psychiatry, UBC                                                                                                        

This meeting was our follow-up from ACT’s webinar Part 2: Looking Beyond Autism: Treating Anxiety, Depression & OCD in children & youth with ASD, we are continuing to explore the co-existence of these mental health conditions with Autism.

Dr. Bailey’s presentation at our meeting was based on his segment at this above conference, Part 4, on Depression & ASD. Part 1 was ACT’s Deborah Pugh’s introduction, and Part 2, was Melanie McConnell, Phd, R. Psychologist in Neuropsychiatry at BC Children’s Hospital, speaking on Anxiety & ASD, and Part 3, was David Worling, R.Psychologist, Westcoast Child Development, speaking on Obsessive Compulsive Disorder & ASD.   Parts 5 & 6, featured  panelists, Georgina Robinson, of POPPARD, and David Batstone, Phd, R.Psychologist. Please see link below:

http://www.actcommunity.ca/education/mentalhealth/treating/

Our focus, at Square Peg, is on the adult population – we are interested in which of the treatments discussed are applicable to adults, and which existing programs might be effective, accessible and affordable for our ASD individuals.

What was presented:

The subject of depression is particularly relevant – it is pervasive, 1 in 2 people will experience depression at least once in their lifetime, and approximately 25% of ASD individuals have experienced depression. The rate of occurrence of anxiety is even higher – 50 -60% of ASD individuals have also experienced significant anxiety. These conditions tend to emerge in puberty or later. There is a genetic component – ASD individuals have family members with a history of a mental health disorder. While several studies indicate that these mental health disorders occur more frequently at the higher functioning end of the autism spectrum, others conclude that this finding is due to the inability of the lower functioning population to express their symptoms, which therefore go undiagnosed, and untreated.

These co-morbid mental health issues interfere with all aspects of a person’s life – with their ASD treatments, with schooling, homelife, and overall quality of life. Often anxiety and depression are missed in ASD individuals, either because the symptoms do not present in the same way as in the neurotypical population and/or because ASD individuals may not self-report in a typical manner.

Anxiety

Some anxiety in life is normal but it is pathological when it is disproportionate to the stimulus, and prolonged. This occurs for a variety of reasons in different individuals – a lack of social understanding, uncertainty around or resistance to change, impaired imagination resulting in an inability to imagine other outcomes, impaired cognitive coping strategies, and a biological predisposition to anxiety. The consequences range from fairly moderate to extreme, and include over-preoccupation with issues or circumstances, avoidance of situations or issues, fatigue/irritability, poor sleep, impaired executive functioning, physiological impairments, low mood, and even psychosis.

Approaches to treating anxiety include:

• changing the anxiety producing environment
• stress management, distraction
• graduated exposure to the stress-provoking stimuli
• cognitive strategies, such as breaking down a situation logically & rationally, particularly, Cognitive Behavourial Therapy – CBT- an approach with which Dr. Bailey likes for its practicality, and with which he has had success. While there are many self-help books that employ CBT techniques, people tend not to use them long enough. Most people seem to need a guide through this process. (However, it was brought to my attention that the problem with non-specific CBT programs is that the ASD tends not to be understood or addressed. To make these programs more effective would be to have a mental health clinician work with the ASD individual in the program, and/or to adapt the CBT program to accommodate the needs of the ASD. Also, using CBT in conjunction with other “therapy” methods (e.g., psychodynamic) would be more effective.
• vigorous exercise (in which the heart rate is raised for more than 1/2hr, for at least 3 times per week)
• Mindfulness techniques/programs
• Medication   Bailey does not prescribe benzodiazanpines (habituating), but along with others prescribes SSRIs – serotonin reactive uptake inhibitors.
• One-on-one psychotherapy. Dr. Bailey emphasized that this is not a quick fix undertaking, but rather, about 5 years from his 1^st meeting with a patient.

Depression

Depression is usually co-morbid with anxiety. Some of the usual indicators may be absent, but are likely to include some of the following: social withdrawl, unhappy or flat facial expression, prosody, low mood, negative cognitions, irritability, and decreased activity level. Depression can be genetic and/or caused by environmental factors such as bullying, social isolation, academic failure, perception of arrested development, an uncertain future.

Approaches to treating depression include:

• Changing the environment
• CBT
• Vigorous exercise
• Medication
• ECT (Electric Convulsive Treatment – shock therapy)

Obsessive Compulsive Disorder (OCD)

OCD symptoms are similar to those of the typically developing ASD population, and therefore, may be hard to tease out. They are likely to be OCD when the cognitions/behaviours become paralyzing – for example when an individual feels compelled to rewash all of their dishes at 2am.

Approaches to treating OCD include:

• CBT which focuses on the causes of the observed behavior
• Medication – higher doses of SSRIs.

As to the question of inadequate supports for programs and treatment for ASD individuals with co-occurring mental health conditions – Dr. Bailey placed the onus of this squarely back in our court, claiming that any advocacy in this area would be perceived by government, as a vested interest on his part, and that parents and ASD adults, en masse, have the post power to pressure politicians. When asked about research and data gathering to support our case for more support, he cited …..studies underway….

His focus is research and his clinical practice, and he did not seem to be engaged with programs outside of this. He noted that professionals are looking for treatable conditions, while parents are focused on unrealized potential.

As to group programs which might be of benefit to ASD individuals, at a more affordable cost than private therapy, Dr. Bailey favoured Mindfulness and CBT programs in combination with one-on-one psychological therapy, but noted that the ASD individual must be able and motivated to participate in a group program. We did not have the time, and Dr. Bailey did not seem to want to examine existing group programs and their efficacy for ASD individuals, perhaps, their success may depend on many factors, such as the individual facilitators and the participants of a group in a given session. Finally, Dr. Bailey noted that, for programs for adults to succeed, the ASD adults involved must be motivated to participate, or to make the changes asked of them. This was discussed in relation to social programs for people on the spectrum.

Many of our members felt re-assured by Dr. Bailey’s gentle reminder that the timeline of our individuals and families is, by virtue of the ASD diagnosis, longer – that we cannot examine our progress toward our life goals in light of the developmental stages of neurotypical individuals. However, he emphasized that growth in self-awareness, learning, and progress toward personal goals is entirely possible. He stressed that parents need to be persistent, and parents, professionals, and ASD adults need to be patient. This longer time frame, he believes, is offset by all of us today living longer life spans, and attention should be given to living well & healthily.