Molehill Mountain feasibility study: Protocol for a non-randomised pilot trial of a novel app-based anxiety intervention for autistic people.

Up to 50% of autistic people experience co-occurring anxiety, which significantly impacts their quality of life. Consequently, developing new interventions (and/ or adapting existing ones) that improve anxiety has been indicated as a priority for clinical research and practice by the autistic community. Despite this, there are very few effective, evidence-based therapies available to autistic people that target anxiety; and those that are available (e.g., autism adapted Cognitive Behavioural Therapy; CBT) can be challenging to access. Thus, the current study will provide an early-stage proof of concept for the feasibility and acceptability of a novel app-based therapeutic approach that has been developed with, and adapted for, autistic people to support them in managing anxiety using UK National Institute for Health and Care Excellence (NICE) recommended adapted CBT approaches. This paper describes the design and methodology of an ethically approved (22/LO/0291) ongoing non-randomised pilot trial that aims to enrol approximately 100 participants aged ≥16-years with an existing autism diagnosis and mild-to-severe self-reported anxiety symptoms (trial registration NCT05302167). Participants will be invited to engage with a self-guided app-based intervention-'Molehill Mountain'. Primary (Generalised Anxiety Disorder Assessment, Hospital Anxiety and Depression Scale) and secondary outcomes (medication/ service use and Goal Attainment Scaling) will be assessed at baseline (Week 2 +/- 2), endpoint (Week 15 +/- 2) and three follow-ups (Weeks 24, 32 and 41 +/- 4). Participants will also be invited to complete an app acceptability survey/ interview at the study endpoint. Analyses will address: 1) app acceptability/ useability and feasibility (via survey/ interview and app usage data); and 2) target population, performance of outcome measures and ideal timing/ duration of intervention (via primary/ secondary outcome measures and survey/ interview)-with both objectives further informed by a dedicated stakeholder advisory group. The evidence from this study will inform the future optimisation and implementation of Molehill Mountain in a randomised-controlled trial, to provide a novel tool that can be accessed easily by autistic adults and may improve mental health outcomes.

Fatigue in an adult attention deficit hyperactivity disorder population: A trans-diagnostic approach.

OBJECTIVES: Trans-diagnostic approaches suggest that key cognitive and behavioural processes maintain symptoms across a wide range of mental health disorders. Fatigue is a common clinical feature of attention deficit hyperactivity disorder (ADHD) in adulthood; however, empirical data supporting its prevalence are lacking. This study aimed to collate outcomes from outpatient services to (1) investigate the prevalence of fatigue in adults with ADHD, (2) examine symptoms of ADHD in adults with chronic fatigue syndrome (CFS), and (3) consider secondary clinical characteristics common to both disorder groups. METHODS: Measures of self-reported fatigue were compared across groups of adults with ADHD (N = 243), CFS (N = 86), and healthy controls (HC) (N = 211) using a between-subjects cross-sectional design. Groups were also compared on secondary clinical measures of functional impairment, mood, anxiety, sleep, self-efficacy, and their beliefs about the acceptability of expressing emotions. RESULTS: The ADHD group were significantly more fatigued than HC with 62% meeting criteria for fatigue caseness. ADHD symptoms were significantly greater in the CFS group than in HC. ADHD and CFS groups did not differ significantly on measures of functional impairment, mood, and self-efficacy. No significant differences were detected on measures of anxiety when items relating to physical restlessness were removed from the analysis. CONCLUSIONS: Adults with ADHD experience greater fatigue than HC. Adults with CFS and ADHD share many trans-diagnostic clinical characteristics, including difficulties with low mood, anxiety, and reduced self-efficacy, which impact upon their overall functioning. Further research is required to investigate extraneous factors mediating fatigue severity in these clinical groups. PRACTITIONER POINTS: Fatigue is a common clinical feature of attention deficit hyperactivity disorder (ADHD) in adulthood. Evidence-based interventions for chronic fatigue syndrome could be adapted to address fatigue in ADHD in adults.

Protocol for a proof of concept randomized controlled trial of cognitive-behavioural therapy for adult ADHD as a supplement to treatment as usual, compared with treatment as usual alone.

BACKGROUND: ADHD is prevalent in adults and frequently associated with impairment and distress. While medication is often the first line of treatment a high proportion of people with the condition are not fully treated by medication alone, cannot tolerate medication or do not wish to take it. Preliminary studies suggest that psychosocial approaches are a promising adjunctive or alternative treatment option. To date, individual cognitive-behaviour therapy (CBT) has been found to be efficacious in three randomized controlled trials (RCTs). There is a need for more RCTs to be carried out in order to replicate these results in different sites, to further investigate the acceptability and feasibility of CBT in this population and to further develop CBT approaches based on a psychological model. This randomized controlled trial investigates the efficacy of individual, formulation-based CBT when added to treatment-as-usual as compared with treatment as usual alone. METHODS/DESIGN: Sixty patients with a diagnosis of adult ADHD attending a specialist clinic are randomly allocated to 1 of 2 treatments, 'Treatment as Usual' (TAU) or TAU plus 16 sessions individual CBT (TAU + CBT). In the TAU + CBT, the first 15 sessions take place over 30 weeks with a 16th 'follow-up' session at 42 weeks. Outcomes are assessed at 30 weeks and 42 weeks following randomization. The two primary outcomes are self-rated ADHD symptoms and functioning (occupational and social). Secondary outcomes include distress, mood, ADHD-related cognitions, ADHD-related behaviours and informant-rated ADHD symptoms. The primary analysis will include all participants for whom data is available and will use longitudinal regression models to compare treatments. Secondary outcomes will be analysed similarly. DISCUSSION: The results of the study will provide information about a) whether CBT adds benefit over and above TAU for ADHD and, b) if CBT is found to be efficacious, potential mechanisms of change and predictors of efficacy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN03732556, assigned 04/11/2010.

Attention deficit hyperactivity disorder symptoms in adults with autism spectrum disorders.

Features of attention deficit hyperactivity disorder (ADHD) and impairments on neuropsychological, tests of attention have been documented in children with autism spectrum disorders (ASDs). To date, there has been a lack of research comparing attention in adults with ASD and adults with ADHD. In study 1, 31 adults with ASD and average intellectual function completed self-report measures of ADHD symptoms. These were compared with self-report measures of ADHD symptoms in 38 adults with ADHD and 29 general population controls. In study 2, 28 adults with a diagnosis of ASD were compared with an age- and intelligence quotient-matched sample of 28 adults with ADHD across a range of measures of attention. Study 1 showed that 36.7% of adults with ASD met Diagnostic and Statistical Manual-IV criteria for current ADHD "caseness" (Barkley Current self-report scores questionnaire). Those with a diagnosis of pervasive developmental disorder-not otherwise specified were most likely to describe ADHD symptoms. The ASD group differed significantly from both the ADHD and control groups on total and individual symptom self-report scores. On neuropsychological testing, adults with ASD and ADHD showed comparable performance on tests of selective attention. Significant group differences were seen on measures of attentional switching; adults with ADHD were significantly faster and more inaccurate, and individuals with Asperger's syndrome showed a significantly slower and more accurate response style. Self-reported rates of ADHD among adults with ASD are significantly higher than in the general adult population and may be underdiagnosed. Adults with ASD have attentional difficulties on some neuropsychological measures.

Negative perfectionism increases the risk of fatigue following a period of stress.

Cognitive-behavioural models of excessive fatigue suggest that people who believe that failure to meet high standards indicates unacceptability to others (a form of 'negative perfectionism') are at risk of fatigue after a period of illness or stress. The present study investigates this using a prospective design and possible mediating factors between such beliefs and fatigue were also investigated. Undergraduate students completed questionnaires at the beginning of the academic year (time 1; n = 436) and again following a time of academic pressure, 16 weeks later (time 2; n = 206). Participants were significantly more fatigued at time 2 than at time 1. Negative perfectionism was positively associated with all measures of fatigue and predicted subsequent levels of physical fatigue after controlling for time 1 fatigue. Time 1 negative perfectionism was not associated with time 2 perfectionist studying behaviours, distress about academic work or specific health behaviours, but was associated with time 2 depression. Results also indicated that time 2 depression may account for the relationship between baseline negative perfectionism and subsequent fatigue. This is the first prospective study to demonstrate a significant relationship between perfectionism and subsequent fatigue.

Claustrophobia in MRI: the role of cognitions.

PURPOSE: This study aimed to investigate the role of cognitive and behavioural factors in the experience of claustrophobia in the context of magnetic resonance imaging (MRI) scanners. MATERIALS AND METHODS: One hundred and thirty outpatients attending an MRI unit completed questionnaires before and after their scans. Specific measures of experience in the scanner included subjective anxiety, panic symptoms, strategies used to stay calm and negative cognitions (such as 'I will suffocate' and 'I am going to faint in here'). Other general measures used included anxiety, depression, health anxiety and fears of restriction and suffocation. RESULTS: The amount of anxiety experienced during the scan was related to the perceived amount of time spent having physical symptoms of panic. Cognitions reported concerned the following: suffocation, harm caused by the machine and lack of perceived control. The number of strategies patients used to cope in the machine was also a related factor. Neither position in the scanner, nor head coil use nor previous experience of being in the scanner was related to levels of anxiety. CONCLUSION: The cognitions identified here may be used to construct a measure to identify those unable to enter the scanner or those most likely to become claustrophobic whilst undergoing the procedure and to further inform future brief, effective interventions.