Cognitive Behavioral Therapy and Mindfulness Based stress Reduction Therapy for Anxiety and Depression Symptoms in Adults with Autism Spectrum Disorders

The discomfort for adults with autism spectrum disorder is often unnecessarily
high because of untreated comorbid anxiety and depression symptoms. Autism
itself is characterized by an impaired social interaction, communication
problems and by stereotyped patterns and restricted interests. This results is
a dysfunctional interaction with others in the environment. This leads to
people with autism being met with a lack of understanding, rejection or too
high expectations. Because of a cumulative effect of these negative
experiences, the risk of developing anxiety or depression increases. These
symptoms are often not recognized because of the autism-associated inability to
express feelings and emotions adequately, thereby aggravating the anxiety or
depressive symptoms.
Autism spectrum disorders are often comorbid worth other psychiatric problems.
Lugnegård (2011) reported that 70% of adults with Asperger*s Disorder
experience at least one depressive episode and that 50% fulfilled the criteria
for an anxiety disorder (Lugnegård, Hallerbäck, & Gillberg, 2011). Due to the
different presentation of anxiety and depression in ASD, there is probably
insufficient treatment because all symptoms are attributed to ASD.
Despite the high degree of impairment that anxiety and mood symptoms cause,
treatment interventions for adults with ASD have hardly been studied. From the
perspective of clients this calls for studies in which promising interventions
(like cognitive behavioral therapy (CBT-ASD) and mindfulness based stress
reduction (MBSR-ASD)) are systematically researched in an outpatient
population. In order to inform, clients better about the treatment
possibilities and to be able to advise them appropriately, it is important to
study whether (a) CGT-ASD or MBSR-ASD are effective methods and (b) whether the
effectiveness is correlated with client related factors. ,
Hypotheses:
Cognitive behavioral therapy (CBT-ASD)
1. completing a CBT-ASD is associated with a reduction of the anxiety and
depression symptoms in adults with ASD.
2. completing a CBT-ASD is associated with a reduction of the suffering and an
increase of positive feelings and social functioning in adults with ASD.
3. the effect of CBT-ASD is positively correlated with the level of education.
Mindfulness based stress reduction (MBSR-ASD):
1. completing a MBSR-ASD is associated with a reduction of the anxiety and
depression symptoms in adults with ASD.
2. completing a MBSR-ASD is associated with a reduction of the suffering and
an increase of positive feelings and social functioning in adults with ASD.
3. the effect of MBSR-ASD is not correlated with the level of education.

The central question is: are the recently published treatment methods (a)
cognitive behavioral therapy (CBT-ASD) (Schuurman 2011), and mindfulness based
stress reduction (MBSR-ASD) (Spek 2011) effective interventions to reduce
anxiety and depression in adults with autism spectrum disorders?
Secondary questions are:
(a) Can anxiety and depression symptoms de reduced in adults with ASD by
treatment with CBT-ASD?
(b) Can anxiety and depression symptoms de reduced in adults with ASD by
treatment with MBSR-ASD?
(c) Does the daily suffering reduce or do positive feelings and social
functioning increase after treatment with CBT-ASD or MBSR-ASD?
(d) Are personal goals attained after completing CBT-ASD or MBSR-ASD?
(e) Are there client related factors that can predict a reduction of symptoms
associated with CBT-ASD or MBSR-ASD?
(f) What is the cost effectiveness of both methods?

It concerns a randomised prospective cohort study of two existing treatment
protocols (MBSR-ASD and CBT-ASD)

The burden for participants consists of completing questionnaires at four
stages. Not all questionnaires are required each time. The total time required
amounts to 3 hours. (see protocol annex 2). It concerns the following
questionnaires:
The degree of anxiety and depression is assessed with the Dutch version of the
Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). This
questionnaire contains 14 items. Completion requires 5 to 10 minutes.
The Mindful Attention Awareness Scale (MAAS) is a process measure for
mindfulness and measures the frequency of everyday mindful experiences (Brown &
Ryan, 2003). This questionnaire contains 15 items. Completion requires 10 to
12minutes.
De process measure for cognitive change is quantified by the Irrational
Beliefs Inventory (IBI). It consists of 50 items. Completion requires 10 to 15
minutes.
The social relatedness scale (SRS) is a well validated self-report instrument
with 65 items that quantifies autistic symptoms and can be used to measure
change in social functioning after treatment (Constantino, et al., 2003).
Completion requires 15 to 20 minutes.
The degree of suffering is determined with the Dutch translation of the Global
Mood Scale (GMS). This instrument has 10 items and gives an indication of the
positive and negative affects resulting from physical and psychological
problems (Watson & Pennebaker, 1989). Completion takes about 5 minutes.
Adults with ASD form a heterogeneous group. By asking participants to formulate
their personal goals prior to randomization, it is possible to express the
success of an intervention on an individual level, without negative influences
of heterogeneity. The degree in which the goals are reached is measured with
the Global Attainment Scale (GAS) (Kiresuk & Sherman, 1968). The GAS is a
reliable and valid measure of personal (Schlosser, 2004). Therapists are blind
to the personal goals.