Treating Social Anxiety Disorder with CBT in the Context of
Asperger’s Syndrome: A Single-Subject Report
LeeAnn Cardaciotto, James D. Herbert, Brandon A. Gaudiano, Elizabeth M. Nolan, & Kristy L. Dalrymple Drexel University
Contact: LeeAnn Cardaciotto, Department of Psychology, Drexel University, Mail Stop 988, 245 N. 15thSt., Philadelphia, PA 19102-1192, phone: (215) 762-3327, fax: (215) 762-7471,
[email protected]
ABSTRACT
Asperger’s Syndrome (AS) is a developmental disorder characterized by social impairment, highly circumscribed interests, repetitive behaviors, and motor clumsiness. The social impairment features of AS are similar to characteristics of social anxiety disorder. However, there is no research examining the comorbidity of these diagnoses or the treatment of social anxiety in the context of AS. The present single-subject report examines the use of cognitive-behavior therapy (CBT) in treating social anxiety disorder in an individual with comorbid AS. The results suggest that a 14-week course of CBT was successful in reducing symptoms of anxiety and comorbid depression. In addition, improvements in social skills were observed (e.g., appropriate eye contact, conversational skills). Limitations and future directions for treatment are discussed.
INTRODUCTION
Asperger’s Syndrome (AS) is a relatively new diagnosis, receiving “official” recognition in the DSM-IV in 1994 as a pervasive developmental disorder. Since studies of AS were uncommon until the 1980’s, prevalence rates are not established. Beginning in young childhood, AS is a life-long disorder characterized by social impairment, highly circumscribed interests, repetitive behaviors, and motor clumsiness (Volkmar & Klin, 2000). In contrast to autism, there is no significant delay in language or cognitive development. Social impairment is manifested through deficits in the use of non-verbal behaviors, such as idiosyncratic facial expressions, gestures, or posture; the inability to recognize social cues; difficulty behaving according to accepted and implicit social conventions; lack of close peer relationships; and deficits in social or emotional reciprocity (Tantam, 1991). No systematic studies examining the efficacy of treatment for AS have been conducted; only suggestive information from clinician observations has been published.
The social impairment characteristics of AS overlap with associated features of social anxiety disorder (SAD), an anxiety disorder characterized by intense fear of negative evaluation in social situations. The shared social impairments include deficits in social skills and limited social support networks (American Psychiatric Association, 2000). Although AS has been associated with other psychiatric disorders such as Tourette’s syndrome (Kerbeshian & Burd, 1986), obsessive-compulsive disorder (Thomsen, 1994) and schizophrenia (Clarke, D.J. et al., 1989), research has not examined the relationship between SAD and .AS.
Cognitive behavioral interventions have been shown to be effective in treating SAD (for recent reviews, see Craske, 1999; Gould & Johnson, 2001). However, there is little research on the use of cognitive behavioral interventions with individuals diagnosed with AS. Since individuals with AS do not have cognitive impairment, cognitive behavioral approaches may be applicable with this population. Given the overlap of some of the symptoms of AS with SAD, the present single-subject study examines the use of cognitive behavior therapy (CBT) for symptoms of social anxiety & impairment in an individual with AS.
METHOD
Client
The client was a 23-year-old male diagnosed with SAD, generalized type and AS according to DSM-IV criteria (American Psychiatric Association, 2000). The SCID-IV (First et al., 1995) was used to make the diagnosis of SAD, and the client met criteria for AS according to The Asperger Syndrome Diagnostic Interview (ASDI; Gillberg et al., 2001). The client reported fearing and avoiding situations including talking to authority figures, speaking in front of a group, interviewing, being assertive, and initiating conversations.
Measures & Assessment
At each assessment after the start of treatment, an independent assessor administered the social phobia section of the SCID-IV to determine whether the client met diagnostic criteria for SAD. In addition, the assessor completed Clinical Global Impression-Severity (CGI-S) ratings at pre-, mid-, post-treatment, and follow-up (two months following the client’s last treatment session), and Clinical Global Impression-Improvement (CGI-I) ratings at mid-treatment, post-treatment, and follow-up. A series of questionnaires, including the Social Phobia and Anxiety Inventory (SPAI; Turner et al., 1989), Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987), and the Beck Depression Inventory-II (BDI-II; Beck, 1996), were completed two weeks prior to treatment (baseline), pre-, mid-, post-treatment, and at follow-up. In addition, the LSAS and BDI-II were ad-ministered weekly throughout treatment.
Treatment
The client received 14 weeks of individual cognitive behavior therapy (CBT) based on a version of a treatment protocol developed by Heimberg and Becker (2002) and modified by Herbert, Rheingold, and Goldstein (2002). Treatment focused on the reported feared and avoided social situations, including initiating, maintaining, and ending conversations, dating, assertiveness, and job interviewing. Techniques in treatment included cognitive restructuring, role playing, and weekly homework assignments. Homework assignments included performing thought-listing and cognitive restructuring exercises both prior to and immediately after social situations and in vivo exposure exercises of situations practiced in session. The CBT protocol was modified to include an emphasis on social skills training to attend to the client’s deficits in verbal (e.g., introductions, maintaining conversation), non-verbal (e.g., eye-contact, posture), and paralinguistic social skills (e.g., rate of speech, voice volume). Specific social skills were identified and rehearsed during role-play exercises in session, and were applied during the in vivo exercises performed for homework.
RESULTS
Regarding the CGI assessments, at pre-treatment, the client received a CGI-S rating of Severely Ill; at mid-treatment, he received a CGI-S rating of Markedly Ill with a CGI-I rating of Minimal Improvement; and at post-treatment, a CGI-S rating of Moderately Ill with a CGI-I rating of Much Improvement. At follow-up, the client no longer met criteria for social anxiety disorder, as he received a CGI-S rating of Mildly Ill and a CGI-I rating of Very Much Improved. At follow-up, the client reported significantly reduced anxiety in and avoidance of social situations, and increased coping skills for dealing with anxiety-provoking situations.
Questionnaire data show decreases in symptoms of social anxiety and depression though the course of treatment. As seen in Figure 1, there was a steady decline in Social Phobia subscale scores on the SPAI; in the context of clinical significance, the post-treatment SPAI score fell very near the 50
th
percentile for non-anxious controls, and the follow-up score fell very near the 40thpercentile for non-anxious controls. Although Figure 2 depicts an increase in fear ratings decrease in avoidance is shown on the Social Anxiety subscale of the SAS. Lastly, Figure 3 shows a decrease in depression on the BDI-II; at post-treatment and at follow-up, BDI-II scores remained at 4, which is well within the normal range. Even though there was a decrease in anxiety & depression, minimal changes in social skills were rated from the behavioral role-play tests. However, improvements in the client’s social functioning were noted. Increased appropriate eye contact and conversational skills were observed at post-treatment and follow-up. In addition, by the end of treatment, the client had expanded his social network by joining an arts group.
DISCUSSION
The results suggest that cognitive behavior therapy was successful in reducing symptoms of social anxiety, as well as comorbid depression, in an individual diagnosed with comorbid AS and SAD. Two months following treatment, the client no longer met diagnostic criteria for SAD. Evidence for the maintenance of treatment gains were evident, as the client’s anxiety symptoms and avoidance of social situations generally decreased two months following treatment, and depressive symptoms remained within the normal range. One interesting finding was that the client’s fear rating of social
situations seemed to slightly increase from post-treatment to follow-up, while his avoidance rating decreased. This finding was congruent with the client’s report of continued anxiety but better ways of coping with the anxiety, as it did not interfere with his daily functioning.
Although there were clinically significant decreases in anxiety and depression symptoms, improvements in the client’s social skills were limited, especially with regard to maintenance over time. Since social impairment is a stark characteristic of AS, long-term social skills training may be beneficial for continued development and generalization of social skills, as well as understanding of implicit expectancies and reciprocity embedded in social interaction. The design of the study precludes definitive statements about the specific benefits of the treatment; however, it seems likely that changes were related to treatment since both AS and SAD are chronic and unremitting without treatment. Further research examining the comorbidity of AS and SAD, as well as the treatment of SAD in the context of AS, is indicated.
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