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Schema Therapy for Adults with Autism Spectrum Disorder and Comorbid Personality Disorder: A Multiple-Baseline Case Seri

This study aims to test the effectiveness of cognitive-behavioral and experiential interventions using schema therapy as a treatment for adults with autism spectrum disorder and comorbid personality disorder.

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Schema Therapy for Adults with Autism Spectrum Disorder and Comorbid Personality Disorder: A Multiple-Baseline Case Seri

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  1. Richard Vuijk Clinical psychologist Sarr expertise centre for autism Address: Oudedijk 76 3062 AG Rotterdam The Netherlands Telephone: 088-3585500 E-mail: r.vuijk@bavo-europoort.nl Schema therapy as treatment for adults with autism spectrum disorder and comorbid personality disorder: Protocol of a multiple-baseline case series study testing cognitive-behavioral and experiential interventions.

  2. Temperament Variousdefinitions. • Result of biologicalevolution • Present in human beings and animals • From the moment one is born (Strelau 1984)

  3. Temperament (Cloninger) • Novelty seeking • exploratory excitability, impulsiveness, extravagance, disorderliness • Harm avoidance • anticipatory worry, fear of uncertainty, shyness, fatigability, asthenia • Reward dependence • sentimentality, attachment, dependence • Persistence. (Cloninger e.a. 1994)

  4. Character Various definitions. A maturity of personality in relation to self (self-directedness), to others (cooperativeness) and to a unique wholeness (self-transcendence). (Cloninger et al.,1993; Svarkic et al., 1993) • Self-directedness • responsibility, purposefulness, resourcefulness, self-acceptance, congruent second nature • Cooperativeness • social acceptance, empathy, helpfulness, compassion, pure-hearted • Self-transcendence • self-forgetful, transpersonal identification, spiritual acceptance (Cloninger e.a. 1994)

  5. Personality Variousdefinitions. Personality traits as dimensions of individual differences in tendencies to show consistent patterns of thoughts, feelings and actions (Costa and McCrae 1990 p. 23). Five-factor-model of personality (Costa and McCrae 1990) • Neuroticism • Extraversion • openness to experience • Agreeableness • Conscientiousness Structure and development of personality, conceptualized as the combination of and interaction between temperament and character as the two major domains of personality, whereby temperament is close to biological substrates and character is influenced by social-cultural factors (Cloninger et al. 1993).

  6. Personality disorder A personality disorder is an enduring, pervasive, inflexible and time stable pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, resulting in distress and/or impairment (APA 2013).

  7. People withautism spectrum disorder have personality!

  8. ‘Temperament, character and personality disorders in adults with autism spectrum disorder: a systematic literature review and meta-analysis’ (Vuijk et al. 2017, submitted) 15 studies (2002-2016): Soderstrom et al. (2002) Ozonoff et al. (2005) Anckarsäter et al. (2006) Ketelaars et al. (2008) Rydén & Bejerot (2008) Hofvander et al. (2009) Sizoo et al. (2009) Kanai et al. (2011ab) Lugnegård et al. (2012) Vuijk et al. (2012) Schriber et al. (2014)). Hesselmark et al. (2015) Strunz et al. (2015) Schwartzman et al. (2016)

  9. ‘Temperament, character and personality disorders in adults with autism spectrum disorder: a systematic literature review and meta-analysis’ (Vuijk et al. 2017, submitted) Results indicate that ASD is significantly and systematically associated with an introvert, rigid, passive-dependent temperament with low novelty seeking, high harm avoidance, low reward dependence and high persistence, and with an immature and poorly developed character with low self-directedness, low cooperativeness and high self-transcendence. The review further finds a positive correlation between ASD (severity) and neuroticism and a negative correlation between ASD (severity) and extraversion, openness to experience, agreeableness and conscientiousness. It also finds a positive correlation with paranoid, schizoid, schizotypal, avoidant and obsessive-compulsive PDs. However, the far from perfect associations indicate there is considerable variation between people with ASD in their personality and personality pathology.

  10. Adults with autism spectrum disorder Treatment options Review psychosocial interventions (Bishop-Fitzpatrick et al. 2013) • Most focussed on applied behavior analysis or social cognition training • Largely positive effects, although quantity and quality of studies is limited Review cognitive behaviour therapy (Spain et al. 2015): • Moderately effective for comorbid anxiety and depression symptoms • Adaptation to standard CBT: • increase in number of sessions • Accommodation of core ASD characteristics and associated neuropsychological impairments within therapy process • Little evidence that CBT can increase social and communicative functioning (Binnie & Blainey 2013)

  11. Adults with autism spectrum disorder Treatment options Reviews social skills training groups (Spain & Blainey 2015; Hotton & Coles 2016): • Effective at improving social skills, enhancing social knowledge and understanding • Some transfer effects to improvements in wider psychological wellbeing: reducing loneliness • Potentially alleviating comorbid psychiatric symptoms Review mindfulness (Cachia et al. 2016): • Reduction anxiety, depression and rumination • Increasing positive affects Review psychopharmacologic intervention (Taylor 2016) • Fluoxetine and risperidone as promising evidence-based pratice • Fluoxetine: reduction in repetitive and obsessive-compulsive behaviour • Risperidone: reduction repetitive, aggressive and self-injurious behaviour

  12. Adults with autism spectrum disorder and comorbid personality disorder – Treatment options The first systematic test of administering schema therapy to adults with ASD and comorbid personality disorder (Vuijk & Arntz 2017).

  13. Schema therapy The participants • 12 adults (age range: 19-62 years) • Male 9; female 3 • IQ > 80, at least completed secondary education • Single 9: partnered 3 • Asperger 7; PDD-NOS 4; Autism spectrum disorder 1 • Obsessive-compulsive PD 9; Avoidant PD 8; Depressive PD 8; Schizoid PD 1; Dependent PD 1; Borderline PD 1; Narcissistic PD 1. • Negative core beliefs: • I am worth nothing/ I am not good enough • I may not make mistakes/ I may not relax • I am clumsy in contact • Others do not understand me • I fail at everything I do • I am not important for others • I am not part of any community

  14. Schema therapy for comorbid ASD-PD patientsOverview of the schema therapy phases and interventions • 48-53 sessions • Screening procedure 2 sessions • Baseline and supportive sessions phase 10-week period with 4 to 9 weeks TAU-baseline and 6 to 1 weeks with weekly supportive sessions by study therapist • Exploration phase 5 weekly sessions • Treatment phase 15 weekly sessions of cognitive-behavioral interventions: • Correcting negative core beliefs, making early maladaptive schema modes less present in daily life by completing schema mode sheet, and a choice of psycho-education, past and actual test, pros and cons analysis, writing a positive diary, making a flash card or a relapse prevention plan, replacing negative core beliefs and behaviors with new, healthy cognitive and behavioral options, behavioral experiment/role-play. • Treatment phase 15 weekly sessions of experiential interventions • Psycho-education experiential interventions, choice of two-chair work or imagery rescripting of childhood memories, present or future situations. • Follow-up phase 10 monthly booster sessions (Vuijk & Arntz 2017)

  15. Schema therapy for comorbid ASD-PD patientsObjectives • To study in detail the cognitive-behavioraltechniques and experiential techniques on belief strength of negative core beliefs in comorbid ASD-PD patients. • Hypothesis: Less belief strenght of negative core beliefs. • To reduce the occurrence of dysfunctional schema modes (i.e. personality pathology in schema therapy terms). • Hypothesis: A reduction in dysfunctional schema modes and an increase in functional modes. • To reduce the occurrence of diagnostic criteria of personality disorders. • Hypothesis: A reduced occurrence of personality disorder traits. • A change in the severity of psychopathological symptoms, related to syndromic disorders like depression and anxiety disorders. • Hypothesis: Psychopathological symptoms will be diminished. • An improvement in social interaction and communication. • Hypothesis: More insight into one’s own functioning through the given treatment will lead to an improvement in social interaction and communication. (Vuijk & Arntz , 2017)

  16. Schema therapy for comorbid ASD-PD patientsInstruments and outcome measures Every week rating idiosyncratic belief strength: • Visual analogue scales (VAS) Assessment: 7 times • Schema Mode Inventory (SMI) • Structured Clinical Interview for Axis II Personality Disorders (SCID-II) • Symptom Check List (SCL-90) • Social Responsiveness Scale – Adult version (SRS-A) (Vuijk & Arntz 2017)

  17. Schema therapy for comorbid ASD-PD patientsStatistical analysis Concurrent multiple baseline case series design Mixed regression analysis for time, condition and time-within-treatment Wilcoxon’s Signed Rank test (for reduction in number of symptoms for the initially diagnosed PD) Resultstobeexpected at the end of 2018. (Vuijk & Arntz 2017)

  18. References Anckarsäter, H., Stahlberg, O., Larson, T., Hakansson, C., Jutblad, S-B., Niklasson, L., et al. (2006). The impact of ADHD and autism spectrum disorders on temperament, character and personality development. American Journal of Psychiatry,163, 1239-1244. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. Binney, J., & Blainey, S. (2013). The use of cognitive behavioral therapy for adults with autism spectrum disorders. A review of evidence. Mental Health Review Journal, 18(2), 93-104 Bishop-Fitzpatrick, L., Minshew, N.J., & Eack, S.M. (2013). A systematic review of psychosocial interventions for adults with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(3), 687-694. Cachia, R.L., Anderson, A., & Moore, D.W. (2016). Mindfulness in individuals with autism spectrum disorder: a systematic review and narrative analysis. Review Journal of Autism and Developmental Disorders, 3, 165-178. Cloninger, C.R., Svrakic, D.M., & Przybeck, T.R. (1993). A psychobiological model of Temperament and Character. Archives General Psychiatry, 50, 977-991.

  19. References Cloninger, C.R, Przybeck, T.R., Svrakic, D.M., Wetzel, R.D. (1994). The Temperament and Character Inventory (TCI): a guide to its development and use. St. Louis, MO: Center for Psychobiology of Personality, Washington University. Hesselmark, E., Eriksson, J.M., Westerlund, J., & Bejerot, S. (2015). Autism spectrum disorders and self-reports: testing validity and reliability using the NEO-PI-R. Journal of Autism and Developmental Disorders, 45(5), 1156-1166. Hofvander, B., Delorme, R., Chaste, P., Nydén, A., Wentz, E., Ståhlberg, O., et al. (2009). Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders. BMC Psychiatry, 9, 35. Hotton, M., & Coles, S. (2016). The effectiveness of social skills training groups for individuals with autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 3(1), 68-81. Kanai, C., Iwanami, A., Ota, H., Yamasue, H., Matsushima, E., Yokoi, H. et al. (2011a). Clinical characterization of adults with Asperger's syndrome assessed with self-report questionnaires Research in Autism Spectrum Disorders, 5, 185-190.

  20. References Kanai, C., Iwanami, A., Hashimoto, R., Ota, H., Tani, M., Yamada, T., & Kato N. (2011b). Clinical characterization of adults with Asperger’s syndrome assessed by self-report questionnaires based on depression, anxiety, and personality. Research in Autism Spectrum Disorders, 5(4), 1451-1458. Ketelaars, C.E.J., Horwitz, E.H., Sytema, S., Bos, J., Wiersma, D., Minderaa, R., & Hartman, C.A. (2008). Brief report: Adults with mild Autism Spectrum Disorders (ASD): Scores on the Autism Spectrum Quotient (AQ) and comorbid psychopathology. Journal of Autism and Developmental Disorders, 38, 176-180. Lugnegård, T., Hallerbäck, M.U., & Gillberg, C. (2012). Personality disorders and autism spectrum disorders: what are the connections? Comprehensive Psychiatry, 53, 333-340. Ozonoff, S., Garcia, N., Clark, E., & Lainhart, J.E. (2005). MMPI-2 personality profiles of high-functioning adults with autism spectrum disorders. Assessment, 12, 86-95. Rydén, E., & Bejerot, S. (2008). Autism spectrum disorders in an adult psychiatric population. A naturalistic cross-sectional controlled study. Clinical Neuropsychiatry, 5(1), 13-21.

  21. References Schriber, R.A., Robins, R.W., & Solomon, M. (2014). Personality and self-insight in individuals with autism spectrum disorder. Journal of Personality and Social Psychology, 106, 112-130. Schwartzman, B.C., Wood, J.J., & Kapp, S.K. (2016). Can the Five Factor Model of Personality account for the variability of autism symptom expression? Multivariate approaches to behavioral phenotyping in adult autism spectrum disorder. Journal of Autism and Developmental Disorders, 46, 253-272. Sizoo, B., Van den Brink, W., Gorissen, M., & Van der Gaag, R.J. (2009). Personality characteristics of adults with autism spectrum disorders or attention deficit hyperactivity disorder with and without substance use disorders. Journal of Nervous Mental Disorders, 197, 450-454. Soderstrom, H., e.a. (2002). Temperament and character in adults with Asperger. Autism, 6, 287-297. Spain, D., & Blainey, S.H. (2015). Group social skills interventions for adults with high- functioning autism spectrum disorders: a systematic review. Autism, 19, 874-886. Spain, D., Sin, J., Chalder, T., Murphy, D., & Happé, F. (2015). Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity: a review. Research in autism spectrum disorders, 9, 151-162.

  22. References Strelau, J. (1984). Temperament-Personality-Activity. London: Academic Press. Strunz, S., Westphal, L., Ritter, K., Heuser, I., Dziobek, I., & Roepke, S. (2015). Personality pathology of adults with autism spectrum disorder without accompanying intellectual impairment in comparison to adults with personality disorders. Journal of Autism and Developmental Disorders, 45(12), 4026-4038. Svarkic, D.M., Whitehead, C., Przybeck, T.R., & Cloninger, R. (1993). Differential diagnosis of personality disorders by the Seven-Factor Model of Temperament and Character. Archives of General Psychiatry, 50, 991-999. Taylor, L.J. (2016). Psychopharmacologicinterventionforadultswithautism spectrum disorder: a systematicliterature review. Research in Autism Spectrum Disorders, 25, 58-75. Vuijk, R. & Arntz. A. (2017). Schema therapy as treatment for adults with autism spectrum disorder and comorbid personality disorder: protocol of a multiple-baseline case series study testing cognitive-behavioral and experiential interventions. Contemporary Clinical Trials Communications, 5, 80-85. Vuijk, R., Deen, M., Sizoo, B., & Arntz, A. (2017 submitted). Temperament, character and personality disorders in adults with autism spectrum disorder: a systematic literature review and meta-analysis

  23. References Vuijk, R., Nijs, P.F.A. de, Vitale, S.G., Simons-Sprong, M., & Hengeveld, M.W. (2012). Persoonlijkheidsaspecten bij volwassenen met autismespectrumstoornissen gemeten met de ‘Temperament and Character Inventory’ (TCI). Tijdschrift voor Psychiatrie, 54(8), 699-707.

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