درمان شناختی رفتاری برای بزرگسالان مبتلا به اختلالات طیف اوتیسم و ابتلا همزمان روانی: مروری
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|31569||2015||12 صفحه PDF||سفارش دهید||9710 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Research in Autism Spectrum Disorders, Volume 9, January 2015, Pages 151–162
Co-morbid mental health conditions are highly prevalent in autism spectrum disorders (ASD). Cognitive behaviour therapy (CBT) is frequently used to treat these symptoms. Hence, a systematic review was undertaken to synthesise published data about the effectiveness of CBT interventions for adults with ASD and psychiatric co-morbidity. Only six studies met pre-determined review inclusion criteria: two RCTs; one quasi-experimental study; one case series; and two case studies. Meta-analysis was not possible due to study heterogeneity. A narrative analysis of the data suggested that CBT interventions – including behavioural, cognitive, and mindfulness-based techniques – were moderately effective treatments for co-morbid anxiety and depression symptoms, albeit that sample sizes were small, participant characteristics varied widely, and psychometric properties of self-report outcome measurements utilised in the ASD population remain subject to some debate. Several studies described adaptations to standard CBT including an increase in the number of sessions, or accommodation of core ASD characteristics and associated neuropsychological impairments within the therapy process. We suggest further empirical research is needed to (1) investigate the acceptability and effectiveness of a range of CBT interventions for adults who have ASD and co-morbidity, and (2) to identify which adaptations are requisite for optimising CBT techniques and outcomes in this population.
Autism-spectrum disorders (ASD) are lifelong neurodevelopmental disorders characterised by impairments in communication, reciprocal social interaction, and restricted and repetitive behaviours and interests (WHO, 1992). ASD affects at least 1% of the population (Brugha et al., 2011), although there is substantial heterogeneity in the ASD symptom profile and hence the level of resultant impairment. Individuals with ASD commonly experience co-morbid mental health conditions including anxiety and affective disorders (Joshi et al., 2013, NICE, 2012 and Simonoff et al., 2008), and “emotional and behavioural problems” including anger, disrupted sleep, and restricted eating (Maskey, Warnell, Parr, Le Couteur, & McConachie, 2013). Psychiatric co-morbidity can compound difficulties with social and occupational functioning, as well as attainment of independent living skills. Co-morbidity is also associated with a significantly increased carer burden (Cadman et al., 2012 and Karst and Van Hecke, 2012), highlighting the need for the development of targeted treatments (NICE, 2012). 1.1. Cognitive behaviour therapy For the typically-developing population, cognitive behaviour therapy (CBT) interventions are used routinely to treat a wide range of mental health disorders (NICE, 2011), as well as associated transdiagnostic characteristics such as insomnia (Vitiello, McCurry, & Rybarczyk, 2013) and worry (Covin, Ouimet, Seeds, & Dozois, 2008). CBT is a type of talking therapy (psychotherapy), which primarily aims to help individuals to (1) notice and understand how their thoughts, behaviours and emotions are inter-related and (2) develop new ways of thinking about, coping with and responding to, anxiety-provoking or distressing situations (Beck, 2011). CBT is a short-term goal-orientated approach: individuals are encouraged to identify specific measurable goals they would like to work towards in order to attain symptom reduction. In line with Stepped Care approaches to mental health service provision, for example the UK Improving Access to Psychological Therapies Initiative (IAPT) (Clark, 2011 and NICE, 2011) CBT is increasingly being delivered through novel modalities including guided self-help, computerised packages, and group-based formats. The therapist's tool-box is also expanding: interventions now commonly utilised range from traditional behavioural and cognitive techniques, to ‘third wave’ approaches, for example metacognitive, mindfulness-based, and acceptance and commitment (ACT) techniques. 1.2. Cognitive behaviour therapy for individuals with ASD It is hypothesised that the structure, process and content of standard CBT require adaptation for the ASD population for several reasons (Anderson and Morris, 2006, Attwood, 2004 and Gaus, 2011). First, core ASD characteristics such as socio-communication deficits and difficulties tolerating change and uncertainty can affect engagement with the therapist and the therapy process. Second, alexithymia, i.e. difficulties with describing and labelling emotions, commonly co-exists with ASD (Bird & Cook, 2013); hence individuals may find it hard to identify links between cognitions (thoughts and beliefs), emotions and resultant behavioural responses, all of which are integral to the development of a shared formulation of the presenting problem. Third, neuropsychological impairments commonly associated with ASD, such as deficits in theory of mind and cognitive flexibility, and weak central coherence (a preference for local versus global processing) (Brunsdon & Happe, 2014) may affect an individual's ability to utilise standard cognitive and behavioural techniques. For example, they may experience difficulties with generating alternative or additional perspectives for challenging negative thoughts, or be unable to generalise the findings from behavioural experiments and exposure-based tasks undertaken during sessions. Consequently, several adaptations are proposed to be pertinent for enhancing engagement, acceptability and utility of CBT approaches. These include (1) use of written and pictorial methods to enhance discussion during assessment, therapy and to facilitate recall; (2) identification of idiosyncratic descriptions of emotions (e.g. anxiety or low mood); (3) tailor-made individualised outcome measures (e.g. analogue scales); (4) enhancement of emotional literacy prior to ‘active’ CBT treatment; (5) emphasis on behavioural change and skills development; and (6) a less socratic therapeutic style (see also Anderson and Morris, 2006, Attwood, 2004 and Gaus, 2011). 1.3. Rationale for this review Several randomised controlled trials (RCTs) have investigated the effectiveness of modified CBT for children and adolescents with ASD and co-morbid anxiety disorders (e.g. Reaven et al., 2012, Sofronoff et al., 2005, Sofronoff et al., 2007, White et al., 2013 and Wood et al., 2009). Overall, reviews of the empirical data indicate that CBT can be effective for reducing anxiety symptoms and improving functioning in young people with ASD (Danial and Wood, 2013 and Lang et al., 2010). Generalisability of study findings to other young and adult ASD populations, however, is hampered by methodological limitations such as heterogeneity in participants’ clinical presentations, small sample sizes, variability in outcome measures used, and lack of independent assessment. With regard to the effectiveness of CBT for adults with ASD, a recent literature review – which focused on CBT for core and co-morbid symptoms, and included studies published until 2010 – highlighted the dearth of high quality studies in this area (Binnie & Blainey, 2013). Thus far, it has not been established whether certain types of CBT interventions – for example behavioural approaches versus cognitive techniques – are more effective in treating co-morbid mental health disorders and characteristics in adults with ASD. Similarly, the extent to which CBT interventions for co-morbidities are delivered via standard disorder-specific protocols (NICE, 2011) or deviate from these, is not certain, yet this has important implications for clinical service provision. Hence as an update to existing reviews and using a broader frame of reference, the aims of this review were (1) to determine whether CBT interventions are an effective treatment for psychiatric disorders and transdiagnostic mental health symptoms in adults with ASD; (2) to determine whether certain treatment modalities or interventions have been more commonly used to target co-morbid symptoms; and if so, whether any one of these were considered more effective, and (3) to outline clinical practice implications arising from the literature.
نتیجه گیری انگلیسی
Individuals with ASD are commonly considered to be at risk of developing co-morbid mental health conditions. To date, however, studies investigating causes and consequences of, and treatments for psychiatric co-morbidity, have primarily focused on children and adolescents with ASD. This review has sought to synthesise the data from published empirical studies about CBT for adults with ASD; the most widely evidence-based treatment for anxiety and affective disorders in typically-developing adult populations. The review findings indicate that CBT shows promise, but that adaptations are likely needed to augment the effectiveness and acceptability of standard interventions. Formally developing the evidence-base about the mediating and moderating mechanisms (for CBT for adults with ASD) is an important next step for clinicians and researchers.