Third-Generation Psychotherapy Approach in the Treatment of Obsessive-Compulsive Disorder in a Patient with Autism: A Case Report

Flavia Marino¹, Germana Doria^1,2, Adele Lo Presti³, Chiara Failla^1,4* and Giovanni Pioggia^1
*Correspondence: Chiara Failla, Department of Classical Linguistic Studies and Education, Kore University of Enna, 94100 Enna, Italy, Tel: +3921985644, Email: ,

Keywords

Obsessive-compulsive disorder • Acceptance and commitment therapy • Matrix • Autism spectrum disorder • Mental health

Introduction

Obsessive-Compulsive Disorder (OCD) is a mental health condition that is characterized by persistent and intrusive thoughts, images, or urges (known as obsessions) that are unwanted and cause significant distress or anxiety. Individuals with OCD also engage in repetitive behaviors or mental acts (known as compulsions) as a way to reduce the anxiety caused by these obsessions. These compulsions may provide temporary relief, but they are often timeconsuming and interfere with daily life activities. OCD can significantly impact an individual's quality of life and may require professional treatment to manage symptoms effectively. Once considered to be rare in youth, epidemiological studies have found an estimated prevalence of 0.25%–4% among children and adolescents [1-3]. It is common for OCD to remain undiagnosed for a significant period of time, often many years, before an accurate diagnosis is made. In young people, delays in detection may be due to feelings of embarrassment and attempts to conceal symptoms, a lack of awareness of the condition and difficulty distinguishing true OCD from typical developmental rituals. Additionally, while OCD is often associated with certain symptoms such as excessive washing or repeated checking, the disorder can present with a wide range of symptoms that vary greatly between individuals. This heterogeneity can pose a challenge when it comes to diagnosis, as two individuals with OCD may exhibit completely different sets of symptoms [4,5]. The Acceptance and Commitment Therapy (ACT) is a third-generation psychotherapy that focuses on the acceptance of thoughts, emotions and physical sensations, in order to help people identify their values and engage in behaviors consistent with them [6]. The Matrix is an ACT protocol that visually presents two intersecting lines forming four quadrants, offering a perspective on psychological actions and experiences. The vertical line is the line of experience; the upper part corresponds to the experience of life linked to the five senses whereas the lower part refers to internal experiences, such as thoughts and feelings. The horizontal line is the behavior line, where in the left side concerns the actions that perform the function of moving us away from experiences, emotions and unwanted thoughts (experiential avoidance) and the right side indicates the actions we take to get closer to our values (committed action) [7].

Case Presentation

The patient is 15 years old child that was diagnosed with ASD through the Autism diagnostic Observation Schedule (ADOS-2). His intelligent quotient evaluated with Wechsler Intelligence Scale for Children (WISC-IV) was 118. G. is a 15-year-old male with autism who demonstrates good cognitive functioning and adaptive skills in daily living activities. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Committee of Research Ethics and Bioethics Committee (http:/ / www.cnr.it/ethichs, accessed on 17 December 2021) of the National Research Council of Italy (CNR) (Prot. No. CNR-AMMCEN 54444/2018 01/08/2018) and by the Ethich Committee Palermo 1 (http:// www.policlinico.pa.it/, accessed on 17 December 2021) of Azienda Ospedaliera Universitaria Policlinico Paolo Giaccono Palermo (report No. 10/2020-25/11/2020).

When G. was in preschool, he began exhibiting symptoms of anxiety, including difficulty adjusting to nursery and a strong dislike for his teachers. At the age of eight, G. underwent speech therapy to address a significant stutter. This therapy was successful and lasted for a period of two years. Additionally, during this time, G. underwent a painful surgical procedure for paramorphism in both feet, which required bed rest. During his first year of secondary school, he was diagnosed with lumbar scoliosis and required to wear a brace for at least sixteen hours a day, in addition to attending a motor rehabilitation center three times a week. His anxious state culminated at the beginning of his third year of school when he sought help for an undefined situation, he felt unable to handle alone, exhibiting obsessive symptoms.

During the assessment phase, the tools used to collect data include a clinical interview and a battery of tests, consisting of the Children's Yale- Brown Obsessive Compulsive Scale (CY-BOCS), the Symptom Checklist, the Italian Child and Adolescent Mindfulness Measures (I-CAMM) and the Italian Avoidance and Fusion Questionnaire-Youth (I-AFQ-Y8). The CY-BOCS assesses the severity of obsessions and compulsions, while the Symptom Checklist evaluates the presence of symptoms in the past two weeks. The I-CAMM measures mindfulness in childhood and adolescence and the I-AFQ-Y8 measures psychological inflexibility in developmental age.

The therapy consisted of 24 sessions, with a biweekly frequency, over a period of 3 months, excluding the pre- and post-treatment assessment sessions. After assessment session, the Matrix was presented to G. The purpose was to work together to construct his current condition from a new perspective. Additionally, to help G. understand his inflexible experiences in a more flexible way, he was asked to evaluate the effectiveness of his actions in detaching himself from internal experiences. This evaluation was conducted along three dimensions: short-term, long-term (with a temporal framing) and their effectiveness in moving towards what was important for him (with a hierarchical framing). This analysis revealed that G.'s compulsive behaviors are effective in the short term for avoiding what he does not want to feel, but they do not have a long-term effect. Certain actions taken by G. to alleviate his thoughts and sensations, such as listening to music, playing on his phone and watching YouTube videos, do not exhibit the repetitive and stereotypical nature commonly associated with OCD patients. However, they do possess a compulsive quality and serve the purpose of avoiding the anxiety that accompanies obsessive thoughts. Although these actions may seem age-appropriate for a boy his age, they hinder G. from engaging with people and things that hold importance to him because they consume a significant amount of time. Consequently, his relationships with friends and family become less frequent and consistent. Therefore, decreasing their frequency is a prerequisite for achieving clinical improvement. It is recommended that G. should view these behaviors as goals to be considered, rather than experiential avoidance behaviors. In this sense, the Matrix paradigm is effective because it does not question thoughts, does not prescribe exposure, but allows G. to use the same compulsive actions used to reduce anxiety, modifying them only in their psychological function, making them appear the same. In the fourth session, the aim was to explore the experiential difference between mental or internal experiences, such as thoughts, images and bodily sensations and the experience of the five senses. From the fifth to the tenth session, the focus was on practicing cognitive defusion to identify internal experiences that may be hindering progress. The goal in this case was to encourage distance from thoughts without attempting to alter them and to identify how those thoughts influence G.’s behavior. Between the eleventh and fifteenth sessions, Verbal Aikido was introduced to facilitate G.'s engagement with relevant contextual factors that may be contributing to feeling trapped or blocked in certain situations. Sessions sixteen through twenty provided G. with the opportunity to connect with his self, beyond his experiences and preconceptions of life. This involved experiencing himself as the "self as context Using the simplified observer position facilitated by the Matrix, which enables observation of both actions and experiential contents, perspective-taking exercises were proposed to G. between sessions. Between sessions twenty-one and twenty-four, we worked on exploring the link between values and suffering and in ACT terms, we tried to turn the aversive functions of suffering into appetitive functions for his values. The twenty-fifth session was used for the final post-treatment evaluation.

Results and Discussion

During the course of treatment, a significant change was observed in G.'s ability to classify his compulsive behaviors, such as listening to music, playing on his phone and watching YouTube videos, as increasingly useful in moving closer to what is important to him. Significantly, G. demonstrated an increasing ability to classify his behavior based on positive verbal contexts like his values and important people in his life, as opposed to being driven by aversive verbal contexts like anxiety and obsessions. Although some of his observable actions remained partially unchanged, G. perceived their quality in a more positive light, leading to improved relationships with his peers, including schoolmates. This psychological change highlights the potential of therapeutic interventions to shift the control of behavior from aversive to positive verbal contexts, consequently improving the quality of life for individuals with psychological disorders. This single-case study of a male adolescent with autism may serve as a valuable resource for clinical practitioners seeking to improve the psychological well-being of individuals with autism spectrum disorders (Table 1).

Conclusion

The findings suggest that the application of third-generation psychotherapy techniques and a focus on values may help shift the control of behavior from aversive to positive verbal contexts, leading to improved quality of life and relationships. As such, this case study may inform best practices for clinicians working with individuals with autism spectrum disorders.

Conflict of Interest

There is no conflict interest to declare.

Funding

This research was funded by Project INTERPARES “Inclusione, Tecnologie e Rete: un Progetto per l’Autismo fra Ricerca, E-health e Sociale”- POC Metro 2014-2020, Municipality of Messina, ME 1.3.1.b CUP F49J18000370006, CIG 7828294093.

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