A preliminary study of schema therapy for adults with high-functioning autism spectrum disorder: A single-arm, uncontrolled trial

A preliminary study of schema therapy for adults with high-functioning autism spectrum disorder: A single-arm, uncontrolled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research note A preliminary study of schema therapy for adults with high-functioning autism spectrum disorder: A single-arm, uncontrolled trial Fumiyo Oshima, Tomokazu Murata, Toshiyuki Ohtani, Mikuko Seto, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-136824/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective : Schema therapy (ST) has recently been shown to be effective for the treatment of various mental disorders, including personality disorders. This pilot clinical trial aimed to explore the feasibility, acceptability, and effectiveness of ST for adults with high-functioning autism spectrum disorder (HF-ASD) Results : From pre- to post-treatment, we found significant improvements in social functions (GAF and WHO-QOL), early maladaptive schema (YSQ), and depression and anxiety (BDI-II and STAI). Trial registration: UMIN000014535; registered on July 11, 2014. Laboratory Diagnostics Statistical Epidemiology autism spectrum disorder schema therapy social functioning quality of life Figures Figure 1 Introduction Autism spectrum disorder (ASD) is a neurodevelopmental disorder with persistent deficits in social communication and social interaction based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [ 1 ]. ASD adults tend to have difficulties with social functioning, contributing to poor quality of life (QOL) [ 2 ]. ASD children diagnosed before the age of 10 years tend to have higher psychosocial QOL than those who are not [ 3 ]. Unfortunately, most high-functioning ASD (HF-ASD) individuals remain undiagnosed at early ages because of high-functioning [ 4 ], signifying that they do not receive appropriate support, as symptoms remain unnoticed for the same reason [ 5 , 6 ]. Unawareness of their ASD traits could result in innate inferior traits and self-stigmatization, which may increase depression and anxiety [ 7 ]. Psychological interventions for ASD are classified into treatment for its core symptoms and related symptoms [ 8 – 10 ], with early interventions fundamental to the success of both [ 11 ]. Regarding treatment for the latter, cognitive-behavioral therapy (CBT) targeting ASD-related anxiety is ineffective [ 12 ]. Moreover, studies have shown that ASD after puberty is characterized by strong self-stigmatization due to chronic social isolation [ 13 ]. Since CBT is a symptom-specific treatment, it is not widely available for chronic maladjustment based on ASD. Therefore, improving CBT for ASD individuals is clinically important. Schema therapy (ST) [ 14 ], an innovative and integrative psychotherapy model, is used to treat those who face difficulties with personality disorder diagnoses [ 15 – 20 ]. ST is composed of early maladaptive schema (EMS), schema mode, limited reparenting, and core emotional needs [ 21 , 22 ]. EMS is an excessively generalized cognitive and emotional system composed of innate features and early childhood experiences. When an individuals’ core needs are unfulfilled in early childhood, they can form multiple EMSs, which exert a schema mode that temporarily comes to the fore and dominates their presentation, resulting in difficulties in interpersonal relationships [ 23 ]. We previously confirmed that individuals with HF-ASD EMSs had almost all EMSs. As EMSs are assumed to be the core of the psychopathology of HF-ASD and personality disorders, learning how to change EMS into more adaptive ones, and utilizing their adaptive coping responses, is the ultimate goal of ST [ 24 ]. The therapeutic purpose of ST is to cultivate a more constructive “healthy adult mode” (instead of schema mode) toward environmental stimuli by gratifying patients’ core needs using “limited reparenting.” ST, a structured type of psychotherapy, is effective [ 15 , 25 , 26 ] and suitable for many psychiatric disorders; HF-ASD adults are now considered suitable for ST, as they generally benefit from structured settings [ 27 ]. In this study, an author, Oshima, identified EMSs specific to HF-ASD individuals [ 28 ]. However, studies on the clinical efficacy of ST for HF-ASD are inadequate. Thus, this pilot study aimed to utilize ST for adults with HF-ASD and examine its feasibility and efficacy in improving patients’ social functioning. Materials And Methods This was a preliminary study with a single-arm and open trial design for examining the feasibility of ST for the treatment of HF-ASD in a Japanese clinical setting. Participants Participants (n = 13) were recruited through psychiatrist referral at the Safety and Health Organization, Chiba University, and Chiba University Hospital, Chiba, Japan. The inclusion criteria were: age between 18–40 years, intelligence quotient (IQ) of at least 80 (Wechsler Adult Intelligence Scale III [WAIS-III]) [ 29 ], and an ASD diagnosis based on the Autism Diagnostic Interview-Revised [ 30 ] and/or the Autism Diagnostic Observation Schedule – Second Edition [ 31 ]. The Mini-International Neuropsychiatric Interview [ 32 ] was used to evaluate comorbid psychiatric conditions. The exclusion criteria were: a history of substance abuse, active suicidality, and severe mental and physical conditions. Participants were adults of average intelligence with ASD, and could respond on their own initiative after understanding the reason for obtaining research consent. Procedures Recruitment, treatment, and data collection were conducted between September 2014 and March 2018; the trial flow chart is shown in Fig. 1 . Each weekly session lasted 50 minutes (Additional File 1). A follow-up interview was conducted 12 weeks after intervention completion (37th week). Treatment outcome The primary outcome measures were the Global Assessment Functioning (GAF) Scale [ 33 ], an interview rating of social functioning, World Health Organization quality of life assessment brief (WHO QOL-BREF) [ 34 ], and a self-rating scale measuring subjective feeling of social adaptiveness and QOL. The secondary outcomes were the scores of the Young Schema Questionnaire–Short Form 3 (YSQ-SF) [ 35 ] and the Schema Mode Inventory (SMI) [ 36 ], which measure the EMSs and the schema modes of patients, respectively. Other outcome variables measuring comorbid symptoms, such as depression, anxiety, and obsessive-compulsive symptoms, were assessed by the Beck Depression Inventory II (BDI-II) [ 37 ], the State-Trait Anxiety Inventory (STAI) [ 38 ], Liebowitz Social Anxiety Scale (LSAS) [ 39 ], and Obsessive-Compulsive Inventory [ 40 ], respectively. Permission was not needed to use these questionnaires. Analysis The data were analyzed using repeated-measures analyses of variance (ANOVAs) with time as the independent variable. In addition, a paired t-test adjusted by a Bonferroni correction was used for pairwise comparisons. For the primary outcomes and other comorbid symptom measurements, the adjusted α value was α = .05/3/9 = .002. For the secondary outcomes, the adjusted α value was α = .05/3/23 = .0007 for YSQ-SF and α = .05/3/16 = .001 for SMI, respectively. Effect sizes were calculated for changes in scale scores between time points (Cohen’s d ). All analyses were conducted using SPSS for Windows version 23 (IBM, Armonk, NY, USA). Results Patients’ demographics and baseline data Among thirteen patients, three dropped out, leaving ten patients (Fig. 1 ). The participants were aged 20 to 39 years, and met the DSM-5 criteria for ASD (Table 1 and Additional File 2). Table 1 Baseline demographic and clinical characteristics. Variable Mean (SD) / Frequency (%) Age 26.8 (6.39) Sex Female 5 (50%) Male 5 (50%) Education Master 2 (20%) Bachelor 7 (70%) High school 1 (10%) Employment Student 7 (70%) Part timer 1 (10%) Unemployed 2 (20%) Diagnosis ASD + OCD 4 (40%) ASD + ADHD 1 (10%) ASD + DEP 5 (50%) ADI-R Quality of reciprocal social interaction 16 (4.22) Communication 13.3 (4.37) Repetitive, restricted, and stereotyped patterns of behavior 3.2 (1.75) Abnormalities of behavior evident at or before 36 months 1.8 (1.14) ADOS-2 Communication 3.8 (1.48) Reciprocal Social Interaction 7 (2.54) Imagination / Creativity 1.4 (0.52) Restricted and repetitive behaviors 1.2 (0.63) WAIS-3 VIQ 120.8 (10.6) PIQ 117.7 (11.04) FIQ 120 (9.51) VC 119.7 (12.31) PO 120 (12.75) WM 112.6 (11.16) PS 109.7 (19.29) OCD, obsessive-compulsive disorder; DEP, depression; ADHD, attention deficit hyperactivity disorder; ADI-R, Autism Diagnostic Interview-Revised; ADOS-2, Autism Diagnostic Observation Schedule-2; WAIS-3, The Wechsler Adult Intelligence Scale-3; VIQ, Verbal IQ; PIQ, Performance IQ; FIQ, Full scale IQ; VC, Verbal Comprehension; PO, Perceptual Organization; WM, Working memory; PS, Perceptual Organization Treatment outcomes The repeated-measures ANOVA revealed a significant main effect of time on the primary outcome, GAF. A post hoc analysis revealed that there were significant differences between pre-and post-treatment ( p < 0.001, d = 3.30) and between pre-treatment and follow-up ( p < 0.001, d = 3.35) (Table 2 ). Additionally, the main effect of time for WHO QOL-BREF was significant; however, post hoc analyses result did not remain significant between each time point after the correction. Table 2 Changes in each evaluated item before ST, after ST, and at follow-up Pre-ST Post-ST Follow-up Cohen's d Variable Mean (SD) Mean (SD) Mean (SD) F Pre-ST vs. post-ST Post-ST vs. follow-up Pre-ST vs. follow-up GAF 45.90 (10.82) 76.00 (7.06) a 76.20 (6.83) c F (1.3, 11.67) = 151.65 ** 3.30 0.03 3.35 QOL 65.20 (16.03) 75.70 (14.28) 78.50 (12.77) F (1.21, 10.87) = 9.93 ** 0.69 0.21 0.92 BDI-Ⅱ 27.70 (17.54) 16.70 (13.94) 13.00 (11.76) F (1.16, 10.4) = 9.64 ** 0.70 0.29 0.99 STAI (state) 45.20 (9.47) 49.70 (8.21) 41.50 (6.92) b F (2, 18) = 3.93 * 0.51 1.08 0.45 STAI (trait) 55.80 (14.16) 53.00 (10.53) 47.50 (8.82) F (2, 18) = 3.56 * 0.23 0.57 0.70 OCI 67.70 (30.94) 59.40 (27.39) 49.70 (23.15) F (1.17, 10.49) = 3.98 0.29 0.38 0.66 LSAS_Total 62.70 (22.60) 62.80 (27.53) 50.70 (18.64) F (1.2, 10.81) = 2.71 0.00 0.52 0.58 LSAS_fear/anxiety 35.90 (13.54) 35.40 (15.18) 27.20 (9.32) F (2, 18) = 5.22 * 0.04 0.65 0.75 LSAS_escape 26.80(13.23) 27.40(13.70) 23.50 (11.21) F (1.27, 11.46) = 0.59 0.05 0.31 0.27 Note: ** p < 0.01, * p < 0.05 calculated using analysis of variance a: Significant difference between pre- and post-intervention values (p < .05, Bonferroni corrected), b: Significant difference between post-intervention and follow-up values, c: Significant difference between pre-intervention and follow-up values (p < .05, Bonferroni corrected). BDI-II, Beck Depression Inventory-II; STAI (State), State items from the State-Trait Anxiety Inventory; STAI (Trait), Trait items from the State-Trait Anxiety Inventory; OCI, Obsessive Compulsive Inventory; LSAS (Total score), Total items from the Liebowitz Social Anxiety Scale; LSAS (Fear/Anxiety), Fear and anxiety items from the Liebowitz Social Anxiety Scale; LSAS (Avoidance), Avoidance items from the Liebowitz Social Anxiety Scale Regarding the secondary outcomes, the repeated-measures ANOVA revealed a significant effect of time on the YSQ-SF (Total score), Disconnection and rejection, Impaired autonomy and performance, Impaired limits (Over-vigilance and inhibition), Social Isolation/Alienation schema, Failure schema, Dependence/Incompetence schema, Emotional Inhibition schema, Approval-Seeking/Recognition-Seeking schema, Negativity/Pessimism schema, and Punitiveness schema scores, but not on other subscales (Additional File 3). The Bonferroni post hoc test showed a significant difference between pre-treatment and the follow-up ( p = 0.00048, d = 1.01) for the YSQ-SF (Total score). Similarly, for Disconnection and rejection, a significant difference was found between post-treatment and follow-up ( p = 0.00026, d = 0.34). There was also a significant difference for Impaired limits (Over-vigilance and inhibition) between pre-treatment and follow-up ( p = 0.00002, d = 0.63). In addition, for the Emotional Inhibition schema and the Negativity/Pessimism schema, although the ANOVA showed a significant main effect of time, the Bonferroni post hoc test did not show any significance. Regarding the SMI, the repeated-measures ANOVA revealed a significant main effect of time for the Adaptive mode, Maladaptive mode, Vulnerable child mode, Angry child mode, Enraged child mode, Impulsive child mode, Undisciplined child mode, Happy child mode, Compliant surrenderer mode, Detached protector modes, Self-aggrandizer mode, Punitive parent mode, Demanding parent mode, and Healthy adult mode scores (Additional File 4). Conversely, there was no significant difference in the Detached self-soothing or Bullying and attack modes. Bonferroni post hoc tests showed a significant difference between pre-treatment and follow-up for the Maladaptive mode ( p = 0.00051, d = 1.57), Enraged child mode, ( p = 0.00012, d = 1.86), Undisciplined child mode ( p = 0.00066, d = 0.97), and Demanding parent mode ( p = 0.00010, d = 1.10). Regarding other outcomes, significant effects of time were observed for BDI-II, STAI-state and -trait, and LSAS fair/anxiety; however, post hoc comparison with Bonferroni correction did not remain significant between each time point. No aversive reports or effects were observed; thus, ST can be implemented and adapted for short-term use in outpatient settings for adults with HF-ASD. Discussion The results suggest that ST for HF-ASD adult patients significantly affected their social functioning and subjective well-being. Additionally, we proved that ST could be implemented and adapted for short-term use in outpatient settings for HF-ASD adults. We observed large effect size for the GAF score from pre- to post-intervention and from pre-intervention to follow-up ( d s = 3.30 and 3.35). Although the improvement in subjective well-being was not statistically significant after Bonferroni adjustments, the effect sizes were large from pre- to post-intervention and from pre-intervention to follow-up ( d s = 0.69 and 0.92). Seven patients indicated social participation, such as returning to school or removing themselves from self-imposed isolation and receiving employment support. It may take time for HF-ASD individuals to realize their social functioning improvements, and therefore, sharing their achievements in real-life during sessions would be an important component. Moreover, our results showed that ST was effective for the total score of YSQ, Disconnection and rejection subscale, and Impaired limits subscale. ST was developed to influence individuals’ EMS. Our results indicated that ST for HF-ASD may improve individuals’ disconnected feelings with others or the social environment, and enhance their self-control abilities. Subscales of EMSs in which individuals with ASD scored higher than individuals without were social isolation, failure, and dependence-incompetence [ 28 ]. The results of this study showed that these three EMSs were significantly reduced after the intervention. Moreover, they are considered to influence communication style and social relationships [ 28 ], and improvement in EMSs along with that of social functioning may be important ST outcomes for HF-ASD. Additionally, we found that ST for HF-ASD showed significant improvement in several subscales in SMI. Interestingly, these changes were statistically significant only from pre-intervention to follow-up, not from pre- to post-intervention. Since the schema mode is more stable than EMS, changes in the former may have delayed effects. When considering the underlying mechanisms of delayed improvement in SMI, decreased scores in the Enraged child, Undisciplined child, and Demanding parent mode may have reduced individual irritability and aggressive behavior, leading to less social interaction-related problems. Moreover, the maladaptive coping mode can enhance avoidance behaviors and/or over-adaptations, and the reduced maladaptive coping mode via ST may enable individuals to participate socially. The schema mode, being more rigid, can highlight CBT failures, as it does not usually treat schemas. Thus, ST is a unique therapeutic approach for changing patient schema modes. Finally, we did not observe any significant improvement in comorbid symptoms after ST. Since baseline scores for those measurements were not high compared with patients with major depressive disorder, anxiety disorder, and obsessive-compulsive disorder, those with comorbid symptoms may not have improved. However, among ASD individuals, the effects of CBT on depression and anxiety are likely to be diminished by the ASD status [ 12 ], and if we utilize ST for HF-ASD adults with severe mood disorders, ST may be useful in enhancing their social participation. Limitations The single-arm design without control groups restricted the comparison of this study with other psychological interventions, in terms of the clinical efficacy of ST on social adaptations. Additionally, the sample size was small, and controls were not used during secondary diagnoses. Therefore, the therapeutic efficacy of this study may be limited. Finally, it may be difficult to exclusively determine the efficacy of ST on social adaptiveness from this study. Since ST involves psychoeducation about ASD traits, the component of psychoeducation may influence social adaptiveness along with ST per se . ST targets maladaptive schemas at the deepest cognition level, and is considered better equipped to enable dysfunctional schematic processing changes at the schema level. For example, ST showed clinical efficacy in treatment-resistant patients, such as those with personality disorders [ 41 ]. Therefore, we suggest that ST may be effective in enhancing ASD adults’ awareness and acceptance of their ASD traits, which may also influence their social adaptiveness. Future studies with mediation analysis and randomized controlled trials are needed to understand the underlying mechanisms of ST for HF-ASD. Abbreviations ASD autism spectrum disorder BDI-II Beck Depression Inventory II CBT cognitive-behavioral therapy DSM-5 diagnostic and statistical manual of mental disorders EMS early maladaptive schema GAF global assessment functioning HAM healthy adult mode HF-ASD high-functioning autism spectrum disorder IQ intelligence quotient QOL quality of life SMI Schema Mode Inventory ST schema therapy WAIS-III Wechsler Adult Intelligence Scale III WHO QOL-BREF World Health Organization Quality Of Life Assessment Brief YSQ-SF Young Schema Questionnaire Short Form 3 Declarations Ethics approval and consent to participate: This trial was approved by the Chiba University Clinical Research Ethical Review Committee (No.1867). Written informed consent was obtained from the participants, by providing a consent form approved by the Chiba University Clinical Research Ethical Committee, following a verbal explanation of the trial along with the consent form. All personal information (including anonymized data) were treated as confidential. Participants could access these data after the follow-up upon request. This clinical trial was registered on the University Hospital Medical Information Network Center (No. UMIN000014535). The Chiba University Clinical Research Ethical Committee reviewed the study protocol. All sessions and psychological examinations were provided free of charge to the participants. Consent for publication : Not applicable. Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The study was supported by the Grant-in-Aid for Young Scientists (B) (15K17290) of the Japan Society for the Promotion of Science in Japan. The funders had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript. Author contributions: Study concept and design: FO. Statistical analysis for study design: TM. Drafting of the manuscript: FO & KS. Critical revision of the manuscript: HO. Study therapists: FO. Study supervision: ES. All the authors have approved the submitted version and any substantially modified version that involves the author’s contribution to the study. All authors have agreed to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. 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Psychol Psychother. 2017; doi:10.1111/papt.12112 Supplementary Files AdditionalFile1.docx Contents of schema therapy for high-functioning ASD. AdditionalFile2.docx Sociodemographic data. AdditionalFile3.docx Changes in Scores of Young Schema Questionnaire (YSQ) before and after ST at follow-up. AdditionalFile4.docx Changes in Schema Mode Inventory (SMI) before and after ST at follow-up. Cite Share Download PDF Status: Under Review Version 1 posted Review # 1 received at journal 16 Jan, 2021 Review # 3 received at journal 16 Jan, 2021 Editorial decision: Minor revision 16 Jan, 2021 Reviewer # 3 agreed at journal 07 Jan, 2021 Review # 2 received at journal 06 Jan, 2021 Reviewer # 2 agreed at journal 28 Dec, 2020 Editor assigned by journal 26 Dec, 2020 Reviewers invited by journal 26 Dec, 2020 Reviewer # 1 agreed at journal 26 Dec, 2020 Submission checks completed at journal 26 Dec, 2020 Editor invited by journal 26 Dec, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-136824","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research note","associatedPublications":[],"authors":[{"id":7137781,"identity":"9d10d81e-ef19-4944-8728-3f8bfaaa46d9","order_by":0,"name":"Fumiyo Oshima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIie3QPQrCQBCG4U8CsRlJGxHxCisBO/EqBsFKJAewSKWNmDbeQhBSRxa02VgLabxDwErU8acSSUwnsm+1DPuwzAI63Q9W9QEDArBAkM9ZnE8ofpG6X45wIqbnoTC+JzPPi1rOLtlIbwLXryT5zxDMYSMUaTtS474Mt0yw7+eSHqhjkEgr0YGEJPPKRImCV8jJmPTW4Z1c8BURDSbuymZSm35FeBcmg1CNhFwu4EyLdnn8GJ3TbjBTTuad0Azsgh9D6/g2MG2VLz5kzUsTnU6n++9uwd1ESeqRHEEAAAAASUVORK5CYII=","orcid":"","institution":"Chiba University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Fumiyo","middleName":"","lastName":"Oshima","suffix":""},{"id":7137782,"identity":"839ebb6b-612c-4af1-86bd-cb371559f7de","order_by":1,"name":"Tomokazu Murata","email":"","orcid":"","institution":"Chiba University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomokazu","middleName":"","lastName":"Murata","suffix":""},{"id":7137783,"identity":"2c5a7d54-d8a5-46f8-aed9-53208049ee62","order_by":2,"name":"Toshiyuki Ohtani","email":"","orcid":"","institution":"Chiba University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Toshiyuki","middleName":"","lastName":"Ohtani","suffix":""},{"id":7137784,"identity":"5e2b5b39-6b95-45df-a9e5-86e4583b81e4","order_by":3,"name":"Mikuko Seto","email":"","orcid":"","institution":"Chiba University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mikuko","middleName":"","lastName":"Seto","suffix":""},{"id":7137785,"identity":"84016b4d-98e6-4b5d-9e39-5f917dd130f5","order_by":4,"name":"Eiji Shimizu","email":"","orcid":"","institution":"Chiba University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eiji","middleName":"","lastName":"Shimizu","suffix":""}],"badges":[],"createdAt":"2020-12-27 17:58:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-136824/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-136824/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":4643001,"identity":"26db2cf2-4407-4a79-b498-bc68011799ee","added_by":"auto","created_at":"2020-12-31 23:38:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48250,"visible":true,"origin":"","legend":"CONSORT flow chart of the clinical trial","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/6aded2d5ec2f0d501fed23b7.png"},{"id":13643524,"identity":"e3ee8509-45c2-47da-9955-837b883108cd","added_by":"auto","created_at":"2021-09-17 09:11:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":467527,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/61ddc4ac-2149-4512-be4d-ccf8c8326f96.pdf"},{"id":4643269,"identity":"5436348c-e10e-4fa9-a950-0efc78af263c","added_by":"auto","created_at":"2020-12-31 23:47:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15236,"visible":true,"origin":"","legend":"Contents of schema therapy for high-functioning ASD. ","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/66f65bbbd296abe540aa593e.docx"},{"id":4643033,"identity":"8d701c0f-8b38-4195-87e2-e9986564e350","added_by":"auto","created_at":"2020-12-31 23:41:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15185,"visible":true,"origin":"","legend":"Sociodemographic data.","description":"","filename":"AdditionalFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/d6cce722b5aa954c380c1e2c.docx"},{"id":4643030,"identity":"fe2751f2-b2d5-42f6-b404-c7100b22fb87","added_by":"auto","created_at":"2020-12-31 23:41:51","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18513,"visible":true,"origin":"","legend":"Changes in Scores of Young Schema Questionnaire (YSQ) before and after ST at follow-up.","description":"","filename":"AdditionalFile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/e92c494b0a8fbf14a403bcbb.docx"},{"id":4643066,"identity":"17ed0e22-60ce-46af-8ed0-9f1959f8ccbc","added_by":"auto","created_at":"2020-12-31 23:44:51","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":17734,"visible":true,"origin":"","legend":"Changes in Schema Mode Inventory (SMI) before and after ST at follow-up.","description":"","filename":"AdditionalFile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-136824/v1/efab32e511fd6dfed4cf566a.docx"}],"financialInterests":"","formattedTitle":"A preliminary study of schema therapy for adults with high-functioning autism spectrum disorder: A single-arm, uncontrolled trial","fulltext":[{"header":"Introduction","content":" \u003cp\u003eAutism spectrum disorder (ASD) is a neurodevelopmental disorder with persistent deficits in social communication and social interaction based on the \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition\u003c/em\u003e (DSM-5) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. ASD adults tend to have difficulties with social functioning, contributing to poor quality of life (QOL) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. ASD children diagnosed before the age of 10\u0026nbsp;years tend to have higher psychosocial QOL than those who are not [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnfortunately, most high-functioning ASD (HF-ASD) individuals remain undiagnosed at early ages because of high-functioning [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], signifying that they do not receive appropriate support, as symptoms remain unnoticed for the same reason [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Unawareness of their ASD traits could result in innate inferior traits and self-stigmatization, which may increase depression and anxiety [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological interventions for ASD are classified into treatment for its core symptoms and related symptoms [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], with early interventions fundamental to the success of both [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Regarding treatment for the latter, cognitive-behavioral therapy (CBT) targeting ASD-related anxiety is ineffective [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, studies have shown that ASD after puberty is characterized by strong self-stigmatization due to chronic social isolation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Since CBT is a symptom-specific treatment, it is not widely available for chronic maladjustment based on ASD. Therefore, improving CBT for ASD individuals is clinically important.\u003c/p\u003e \u003cp\u003eSchema therapy (ST) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], an innovative and integrative psychotherapy model, is used to treat those who face difficulties with personality disorder diagnoses [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. ST is composed of early maladaptive schema (EMS), schema mode, limited reparenting, and core emotional needs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. EMS is an excessively generalized cognitive and emotional system composed of innate features and early childhood experiences. When an individuals\u0026rsquo; core needs are unfulfilled in early childhood, they can form multiple EMSs, which exert a schema mode that temporarily comes to the fore and dominates their presentation, resulting in difficulties in interpersonal relationships [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We previously confirmed that individuals with HF-ASD EMSs had almost all EMSs. As EMSs are assumed to be the core of the psychopathology of HF-ASD and personality disorders, learning how to change EMS into more adaptive ones, and utilizing their adaptive coping responses, is the ultimate goal of ST [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The therapeutic purpose of ST is to cultivate a more constructive \u0026ldquo;healthy adult mode\u0026rdquo; (instead of schema mode) toward environmental stimuli by gratifying patients\u0026rsquo; core needs using \u0026ldquo;limited reparenting.\u0026rdquo; ST, a structured type of psychotherapy, is effective [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and suitable for many psychiatric disorders; HF-ASD adults are now considered suitable for ST, as they generally benefit from structured settings [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, an author, Oshima, identified EMSs specific to HF-ASD individuals [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, studies on the clinical efficacy of ST for HF-ASD are inadequate. Thus, this pilot study aimed to utilize ST for adults with HF-ASD and examine its feasibility and efficacy in improving patients\u0026rsquo; social functioning.\u003c/p\u003e "},{"header":"Materials And Methods","content":"\u003cp\u003eThis was a preliminary study with a single-arm and open trial design for examining the feasibility of ST for the treatment of HF-ASD in a Japanese clinical setting.\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;13) were recruited through psychiatrist referral at the Safety and Health Organization, Chiba University, and Chiba University Hospital, Chiba, Japan. The inclusion criteria were: age between 18\u0026ndash;40 years, intelligence quotient (IQ) of at least 80 (Wechsler Adult Intelligence Scale III [WAIS-III]) [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e], and an ASD diagnosis based on the Autism Diagnostic Interview-Revised [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] and/or the Autism Diagnostic Observation Schedule \u0026ndash; Second Edition [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. The Mini-International Neuropsychiatric Interview [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] was used to evaluate comorbid psychiatric conditions. The exclusion criteria were: a history of substance abuse, active suicidality, and severe mental and physical conditions. Participants were adults of average intelligence with ASD, and could respond on their own initiative after understanding the reason for obtaining research consent.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eProcedures\u003c/h2\u003e\n\u003cp\u003eRecruitment, treatment, and data collection were conducted between September 2014 and March 2018; the trial flow chart is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Each weekly session lasted 50 minutes (Additional File 1). A follow-up interview was conducted 12 weeks after intervention completion (37th week).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eTreatment outcome\u003c/h2\u003e\n\u003cp\u003eThe primary outcome measures were the Global Assessment Functioning (GAF) Scale [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], an interview rating of social functioning, World Health Organization quality of life assessment brief (WHO QOL-BREF) [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e], and a self-rating scale measuring subjective feeling of social adaptiveness and QOL. The secondary outcomes were the scores of the Young Schema Questionnaire\u0026ndash;Short Form 3 (YSQ-SF) [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e] and the Schema Mode Inventory (SMI) [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e], which measure the EMSs and the schema modes of patients, respectively. Other outcome variables measuring comorbid symptoms, such as depression, anxiety, and obsessive-compulsive symptoms, were assessed by the Beck Depression Inventory II (BDI-II) [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e], the State-Trait Anxiety Inventory (STAI) [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e], Liebowitz Social Anxiety Scale (LSAS) [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e], and Obsessive-Compulsive Inventory [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e], respectively. Permission was not needed to use these questionnaires.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003eThe data were analyzed using repeated-measures analyses of variance (ANOVAs) with time as the independent variable. In addition, a paired t-test adjusted by a Bonferroni correction was used for pairwise comparisons. For the primary outcomes and other comorbid symptom measurements, the adjusted \u0026alpha; value was \u0026alpha;\u0026thinsp;=\u0026thinsp;.05/3/9\u0026thinsp;=\u0026thinsp;.002. For the secondary outcomes, the adjusted \u0026alpha; value was \u0026alpha;\u0026thinsp;=\u0026thinsp;.05/3/23\u0026thinsp;=\u0026thinsp;.0007 for YSQ-SF and \u0026alpha;\u0026thinsp;=\u0026thinsp;.05/3/16\u0026thinsp;=\u0026thinsp;.001 for SMI, respectively. Effect sizes were calculated for changes in scale scores between time points (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e). All analyses were conducted using SPSS for Windows version 23 (IBM, Armonk, NY, USA).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003ePatients\u0026rsquo; demographics and baseline data\u003c/h2\u003e\n\u003cp\u003eAmong thirteen patients, three dropped out, leaving ten patients (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The participants were aged 20 to 39 years, and met the DSM-5 criteria for ASD (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Additional File 2).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline demographic and clinical characteristics.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean (SD) / Frequency (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.8 (6.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEducation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaster\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBachelor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStudent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePart timer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnemployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiagnosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eASD\u0026thinsp;+\u0026thinsp;OCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (40%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eASD\u0026thinsp;+\u0026thinsp;ADHD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eASD\u0026thinsp;+\u0026thinsp;DEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eADI-R\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQuality of reciprocal social interaction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (4.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.3 (4.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRepetitive, restricted, and stereotyped patterns of behavior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.2 (1.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbnormalities of behavior evident at or before 36 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.8 (1.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eADOS-2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.8 (1.48)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReciprocal Social Interaction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (2.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImagination / Creativity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.4 (0.52)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRestricted and repetitive behaviors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2 (0.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWAIS-3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVIQ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120.8 (10.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePIQ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e117.7 (11.04)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFIQ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120 (9.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e119.7 (12.31)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120 (12.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e112.6 (11.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e109.7 (19.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003eOCD, obsessive-compulsive disorder; DEP, depression; ADHD, attention deficit hyperactivity disorder; ADI-R, Autism Diagnostic Interview-Revised; ADOS-2, Autism Diagnostic Observation Schedule-2; WAIS-3, The Wechsler Adult Intelligence Scale-3; VIQ, Verbal IQ; PIQ, Performance IQ; FIQ, Full scale IQ; VC, Verbal Comprehension; PO, Perceptual Organization; WM, Working memory; PS, Perceptual Organization\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eTreatment outcomes\u003c/h2\u003e\n\u003cp\u003eThe repeated-measures ANOVA revealed a significant main effect of time on the primary outcome, GAF. A post hoc analysis revealed that there were significant differences between pre-and post-treatment (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.30) and between pre-treatment and follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.35) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, the main effect of time for WHO QOL-BREF was significant; however, post hoc analyses result did not remain significant between each time point after the correction.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eChanges in each evaluated item before ST, after ST, and at follow-up\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePre-ST\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePost-ST\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFollow-up\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eCohen's \u003cem\u003ed\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePre-ST vs. post-ST\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePost-ST vs. follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePre-ST vs.\u003c/p\u003e\n\u003cp\u003efollow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGAF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45.90 (10.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.00 (7.06)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.20 (6.83)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.3, 11.67)\u0026thinsp;=\u0026thinsp;151.65\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.35\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQOL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65.20 (16.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75.70 (14.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78.50 (12.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.21, 10.87)\u0026thinsp;=\u0026thinsp;9.93\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBDI-Ⅱ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27.70 (17.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.70 (13.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.00 (11.76)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.16, 10.4)\u0026thinsp;=\u0026thinsp;9.64\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSTAI (state)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45.20 (9.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.70 (8.21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41.50 (6.92)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (2, 18)\u0026thinsp;=\u0026thinsp;3.93\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.45\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSTAI (trait)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55.80 (14.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53.00 (10.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47.50 (8.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (2, 18)\u0026thinsp;=\u0026thinsp;3.56\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.70\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67.70 (30.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59.40 (27.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.70 (23.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.17, 10.49)\u0026thinsp;=\u0026thinsp;3.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLSAS_Total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.70 (22.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.80 (27.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.70 (18.64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.2, 10.81)\u0026thinsp;=\u0026thinsp;2.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.58\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLSAS_fear/anxiety\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.90 (13.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.40 (15.18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27.20 (9.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (2, 18)\u0026thinsp;=\u0026thinsp;5.22\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLSAS_escape\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.80(13.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27.40(13.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.50 (11.21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e (1.27, 11.46)\u0026thinsp;=\u0026thinsp;0.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003eNote: \u003csup\u003e**\u003c/sup\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e*\u003c/sup\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05 calculated using analysis of variance\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003ea: Significant difference between pre- and post-intervention values (p\u0026thinsp;\u0026lt;\u0026thinsp;.05, Bonferroni corrected), b: Significant difference between post-intervention and follow-up values, c: Significant difference between pre-intervention and follow-up values (p\u0026thinsp;\u0026lt;\u0026thinsp;.05, Bonferroni corrected).\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003eBDI-II, Beck Depression Inventory-II; STAI (State), State items from the State-Trait Anxiety Inventory; STAI (Trait), Trait items from the State-Trait Anxiety Inventory; OCI, Obsessive Compulsive Inventory; LSAS (Total score), Total items from the Liebowitz Social Anxiety Scale; LSAS (Fear/Anxiety), Fear and anxiety items from the Liebowitz Social Anxiety Scale; LSAS (Avoidance), Avoidance items from the Liebowitz Social Anxiety Scale\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the secondary outcomes, the repeated-measures ANOVA revealed a significant effect of time on the YSQ-SF (Total score), Disconnection and rejection, Impaired autonomy and performance, Impaired limits (Over-vigilance and inhibition), Social Isolation/Alienation schema, Failure schema, Dependence/Incompetence schema, Emotional Inhibition schema, Approval-Seeking/Recognition-Seeking schema, Negativity/Pessimism schema, and Punitiveness schema scores, but not on other subscales (Additional File 3). The Bonferroni post hoc test showed a significant difference between pre-treatment and the follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00048, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.01) for the YSQ-SF (Total score). Similarly, for Disconnection and rejection, a significant difference was found between post-treatment and follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00026, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.34). There was also a significant difference for Impaired limits (Over-vigilance and inhibition) between pre-treatment and follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00002, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63). In addition, for the Emotional Inhibition schema and the Negativity/Pessimism schema, although the ANOVA showed a significant main effect of time, the Bonferroni post hoc test did not show any significance.\u003c/p\u003e\n\u003cp\u003eRegarding the SMI, the repeated-measures ANOVA revealed a significant main effect of time for the Adaptive mode, Maladaptive mode, Vulnerable child mode, Angry child mode, Enraged child mode, Impulsive child mode, Undisciplined child mode, Happy child mode, Compliant surrenderer mode, Detached protector modes, Self-aggrandizer mode, Punitive parent mode, Demanding parent mode, and Healthy adult mode scores (Additional File 4).\u003c/p\u003e\n\u003cp\u003eConversely, there was no significant difference in the Detached self-soothing or Bullying and attack modes. Bonferroni post hoc tests showed a significant difference between pre-treatment and follow-up for the Maladaptive mode (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00051, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.57), Enraged child mode, (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00012, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.86), Undisciplined child mode (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00066, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.97), and Demanding parent mode (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00010, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.10).\u003c/p\u003e\n\u003cp\u003eRegarding other outcomes, significant effects of time were observed for BDI-II, STAI-state and -trait, and LSAS fair/anxiety; however, post hoc comparison with Bonferroni correction did not remain significant between each time point. No aversive reports or effects were observed; thus, ST can be implemented and adapted for short-term use in outpatient settings for adults with HF-ASD.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe results suggest that ST for HF-ASD adult patients significantly affected their social functioning and subjective well-being. Additionally, we proved that ST could be implemented and adapted for short-term use in outpatient settings for HF-ASD adults. We observed large effect size for the GAF score from pre- to post-intervention and from pre-intervention to follow-up (\u003cem\u003ed\u003c/em\u003es\u0026thinsp;=\u0026thinsp;3.30 and 3.35). Although the improvement in subjective well-being was not statistically significant after Bonferroni adjustments, the effect sizes were large from pre- to post-intervention and from pre-intervention to follow-up (\u003cem\u003ed\u003c/em\u003es\u0026thinsp;=\u0026thinsp;0.69 and 0.92). Seven patients indicated social participation, such as returning to school or removing themselves from self-imposed isolation and receiving employment support. It may take time for HF-ASD individuals to realize their social functioning improvements, and therefore, sharing their achievements in real-life during sessions would be an important component. Moreover, our results showed that ST was effective for the total score of YSQ, Disconnection and rejection subscale, and Impaired limits subscale. ST was developed to influence individuals\u0026rsquo; EMS. Our results indicated that ST for HF-ASD may improve individuals\u0026rsquo; disconnected feelings with others or the social environment, and enhance their self-control abilities. Subscales of EMSs in which individuals with ASD scored higher than individuals without were social isolation, failure, and dependence-incompetence [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The results of this study showed that these three EMSs were significantly reduced after the intervention. Moreover, they are considered to influence communication style and social relationships [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and improvement in EMSs along with that of social functioning may be important ST outcomes for HF-ASD. Additionally, we found that ST for HF-ASD showed significant improvement in several subscales in SMI. Interestingly, these changes were statistically significant only from pre-intervention to follow-up, not from pre- to post-intervention. Since the schema mode is more stable than EMS, changes in the former may have delayed effects. When considering the underlying mechanisms of delayed improvement in SMI, decreased scores in the Enraged child, Undisciplined child, and Demanding parent mode may have reduced individual irritability and aggressive behavior, leading to less social interaction-related problems. Moreover, the maladaptive coping mode can enhance avoidance behaviors and/or over-adaptations, and the reduced maladaptive coping mode via ST may enable individuals to participate socially. The schema mode, being more rigid, can highlight CBT failures, as it does not usually treat schemas. Thus, ST is a unique therapeutic approach for changing patient schema modes.\u003c/p\u003e \u003cp\u003eFinally, we did not observe any significant improvement in comorbid symptoms after ST. Since baseline scores for those measurements were not high compared with patients with major depressive disorder, anxiety disorder, and obsessive-compulsive disorder, those with comorbid symptoms may not have improved. However, among ASD individuals, the effects of CBT on depression and anxiety are likely to be diminished by the ASD status [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and if we utilize ST for HF-ASD adults with severe mood disorders, ST may be useful in enhancing their social participation.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThe single-arm design without control groups restricted the comparison of this study with other psychological interventions, in terms of the clinical efficacy of ST on social adaptations. Additionally, the sample size was small, and controls were not used during secondary diagnoses. Therefore, the therapeutic efficacy of this study may be limited. Finally, it may be difficult to exclusively determine the efficacy of ST on social adaptiveness from this study. Since ST involves psychoeducation about ASD traits, the component of psychoeducation may influence social adaptiveness along with ST \u003cem\u003eper se\u003c/em\u003e. ST targets maladaptive schemas at the deepest cognition level, and is considered better equipped to enable dysfunctional schematic processing changes at the schema level. For example, ST showed clinical efficacy in treatment-resistant patients, such as those with personality disorders [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Therefore, we suggest that ST may be effective in enhancing ASD adults\u0026rsquo; awareness and acceptance of their ASD traits, which may also influence their social adaptiveness. Future studies with mediation analysis and randomized controlled trials are needed to understand the underlying mechanisms of ST for HF-ASD.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eautism spectrum disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBDI-II\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBeck Depression Inventory II\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecognitive-behavioral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSM-5\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ediagnostic and statistical manual of mental disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eearly maladaptive schema\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eglobal assessment functioning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehealthy adult mode\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHF-ASD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehigh-functioning autism spectrum disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintelligence quotient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003equality of life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSchema Mode Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eschema therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWAIS-III\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWechsler Adult Intelligence Scale III\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO QOL-BREF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization Quality Of Life Assessment Brief\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYSQ-SF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYoung Schema Questionnaire Short Form 3\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003eThis trial was approved by the Chiba University Clinical Research Ethical Review Committee (No.1867). Written informed consent was obtained from the participants, by providing a consent form approved by the Chiba University Clinical Research Ethical Committee, following a verbal explanation of the trial along with the consent form. All personal information (including anonymized data) were treated as confidential. Participants could access these data after the follow-up upon request. This clinical trial was registered on the University Hospital Medical Information Network Center (No. UMIN000014535). The Chiba University Clinical Research Ethical Committee reviewed the study protocol. All sessions and psychological examinations were provided free of charge to the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests: \u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThe study was supported by the Grant-in-Aid for Young Scientists (B) (15K17290) of the Japan Society for the Promotion of Science in Japan. The funders had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u003c/strong\u003eStudy concept and design: FO. Statistical analysis for study design: TM. Drafting of the manuscript: FO \u0026amp; KS. Critical revision of the manuscript: HO. Study therapists: FO. Study supervision: ES. All the authors have approved the submitted version and any substantially modified version that involves the author\u0026rsquo;s contribution to the study. All authors have agreed to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments: \u003c/strong\u003eOur deep appreciation is extended to Ida Shaw at the Schema Therapy Institute Midwest-Indianapolis and to Aki Tsuchiyagaito at the Laureate Instituto for Brain Research, Tulsa, for their immense contribution to this investigation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Psychiatric Association, DSM-5 Task Force. (2013).\u0026nbsp;Diagnostic and statistical manual of mental disorders: DSM-5\u003cem\u003e\u0026trade;\u003c/em\u003e\u0026nbsp;(5th ed.). American Psychiatric Publishing, Inc.\u0026nbsp;doi:10.1176/appi.books.9780890425596.\u003c/li\u003e\n\u003cli\u003eLever AG, Geurts HM. Psychiatric co-occurring symptoms and disorders in young, middle-aged, and older adults with autism spectrum disorder. J Autism Dev Disord. 2016; doi:10.1007/s10803-016-2722-8.\u003c/li\u003e\n\u003cli\u003eKamio Y, Inada N, Koyama T. A nationwide survey on quality of life and associated factors of adults with high-functioning autism spectrum disorders. Autism. 2013; doi:10.1177/1362361312436848.\u003c/li\u003e\n\u003cli\u003eBargiela S, Steward R, Mandy W. The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype. J Autism Dev Disord. 2016; doi:10.1007/s10803-016-2872-8.\u003c/li\u003e\n\u003cli\u003eCalzada LR, Pistrang N, Mandy, WPL. High-functioning autism and Asperger\u0026rsquo;s disorder: utility and meaning for families. J. Autism Dev Disord. 2012; doi:10.1007/s10803-011-1238-5.\u003c/li\u003e\n\u003cli\u003eMurphy CM, Wilson CE, Robertson DM, Ecker C, Daly EM, Hammond N, et al. Autism spectrum disorder in adults: diagnosis, management, and health services development. Neuropsychiatr Dis Treat. 2016; doi:10.2147/NDT.S65455.\u003c/li\u003e\n\u003cli\u003eHayes J, Ford T, Rafeeque H, Russell G. Clinical practice guidelines for diagnosis of autism spectrum disorder in adults and children in the UK: a narrative review. BMC Psychiatry. 2018; doi:10.1186/s12888-018-1800-1.\u003c/li\u003e\n\u003cli\u003eRussell AJ, Jassi A, Fullana MA, Mack H, Johnston K, Heyman I, et al. Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial. Depress Anxiety. 2013; doi:10.1002/da.22053.\u003c/li\u003e\n\u003cli\u003eSpain D, Sin J, Chalder T, Murphy D, Happ\u0026eacute; F. Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity: a review. Res. Autism Spectr Disord. 2015; doi:10.1016/J.RASD.2014.10.019.\u003c/li\u003e\n\u003cli\u003eSizoo BB, Kuiper E. Cognitive behavioural therapy and mindfulness based stress reduction may be equally effective in reducing anxiety and depression in adults with autism spectrum disorders. Res Dev Disabil. 2017; doi:10.1016/J.RIDD.2017.03.004.\u003c/li\u003e\n\u003cli\u003eEstes A, Munson J, Rogers SJ, Greenson J, Winter J, Dawson G. Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2015; doi:10.1016/j.jaac.2015.04.005.\u003c/li\u003e\n\u003cli\u003eTsuchiyagaito A, Hirano Y, Asano K, Oshima F, Nagaoka S, Takebayashi Y, et al. Cognitive-behavioral therapy for obsessive-compulsive disorder with and without autism spectrum disorder: Gray matter differences associated with poor outcome. 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BDI-II, Beck depression inventory: Manual. San Antonio, TX: Psychological Corporation; 1996.\u003c/li\u003e\n\u003cli\u003eSpielberger CD, Gorsuch RL, Lushene RE. STAI manual for the State-trait anxiety inventory (\u0026ldquo;self-evaluation questionnaire\u0026rdquo;). California: Consulting Psychologists Press; 1970.\u003c/li\u003e\n\u003cli\u003eLiebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry. 1987;22:141-73.\u003c/li\u003e\n\u003cli\u003eFoa EB, Kozak MJ, Salkovskis PM, Coles ME, Amir N. The validation of a new obsessive\u0026ndash;compulsive disorder scale: The obsessive\u0026ndash;compulsive inventory. Psychol Assess. 1998; doi:10.1037/1040-3590.10.3.206.\u003c/li\u003e\n\u003cli\u003eTaylor CDJ, Bee P, Haddock G. Does schema therapy change schemas and symptoms? A systematic review across mental health disorders. Psychol Psychother. 2017; doi:10.1111/papt.12112\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"autism spectrum disorder, schema therapy, social functioning, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-136824/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-136824/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: Schema therapy (ST) has recently been shown to be effective for the treatment of various mental disorders, including personality disorders. This pilot clinical trial aimed to explore the feasibility, acceptability, and effectiveness of ST for adults with high-functioning autism spectrum disorder (HF-ASD)\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: From pre- to post-treatment, we found significant improvements in social functions (GAF and WHO-QOL), early maladaptive schema (YSQ), and depression and anxiety (BDI-II and STAI).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e UMIN000014535; registered on July 11, 2014.\u003c/p\u003e","manuscriptTitle":"A preliminary study of schema therapy for adults with high-functioning autism spectrum disorder: A single-arm, uncontrolled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-31 23:38:49","doi":"10.21203/rs.3.rs-136824/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-01-17T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-01-17T00:00:00+00:00","index":3,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"decision","content":"Minor revision","date":"2021-01-17T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-01-08T00:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-07T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-29T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-12-27T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-12-27T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-27T00:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-12-26T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-12-26T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6b11fc4b-a616-47be-9d8c-e303530a434d","owner":[],"postedDate":"December 31st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":1661493,"name":"Laboratory Diagnostics"},{"id":1661494,"name":"Statistical Epidemiology"}],"tags":[],"updatedAt":"2020-12-31T23:38:49+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-31 23:38:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-136824","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-136824","identity":"rs-136824","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}