Back to table of contents Previous article Next article Clinical & ResearchFull AccessSpecial Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the LifespanEric Hollander, M.D., Casara Jean Ferretti, M.S., M.A., Ph.D. CandidateEric HollanderSearch for more papers by this author, M.D., Casara Jean FerrettiSearch for more papers by this author, M.S., M.A., Ph.D. CandidatePublished Online:23 Mar 2023https://doi.org/10.1176/appi.pn.2023.04.4.34AbstractInflexible thinking has important public health implications, as it not only affects an individual’s ability to adapt to a constantly changing world, but also contributes to workplace and relationship difficulties, increased risk for suicide, and even mass shootings.“Habit and routine have an unbelievable power to destroy.”—Henri de Lubac“The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.”—Daniel J. BoornstinFlexible thinking is necessary in order to adapt to a world with changing environmental demands. In recent years, as the world responded to the pandemic lockdown and then reemerged into the post-pandemic world, the challenges associated with inflexible thinking have become more apparent. While rates of depression, anxiety, and mental health conditions have increased in the general population during this time of rapid change, individuals with greater inflexible thinking have had the most difficulty adapting to our continuously changing environment.Figure 1Inflexible thinking is a transdiagnostic endophenotype, or vulnerability factor, present in some individuals across a range of disorders, including autism spectrum disorder (ASD), obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder, anorexia, body dysmorphic disorder, problematic use of the internet, and other conditions with repetitive thoughts and behaviors. Inflexible thinking may also occur in the first-degree family members of individuals with these disorders (see Figure 1).Various terms have been used in the literature to describe inflexible thinking, including cognitive inflexibility, cognitive rigidity, insistence on sameness, intolerance of uncertainty, set-shifting deficits, brooding rumination, black and white thinking, and impairment in cognitive control (see Table 1). Each of these terms describes a similar presentation of symptoms. Individuals with inflexible thinking often become stuck in ritualistic or repetitive patterns of behavior. They have a need for sameness and order, and tend to focus intensely on their own thoughts, beliefs, and behaviors, often to the exclusion of all others.Table 1Along with inhibitory control and working memory, cognitive flexibility is one of the three main components of executive functioning. (The other two are working memory and self-control.) The overarching definition of cognitive flexibility is the ability to efficiently disengage from one task or method of responding and switch to another. Individuals must use cognitive control to inhibit their initial response in addition to any previously learned response patterns. Cognitive flexibility is necessary for individuals to develop adaptive coping skills and use flexible problem-solving strategies. Cognitive as well as behavioral flexibility are needed for individuals to adjust their behavior and thoughts in response to changing environmental demands.Flexibility across the lifespan is modulated by the lateral and orbital frontoparietal, mid-cingulo-insular, and frontostriatal regions of the brain, and many neurocognitive tasks have been developed to assess irregularities in these neurocircuits. Set-shifting tasks are one method of measuring cognitive flexibility and involve testing an individual’s ability to switch from one learned rule to a new rule as behavioral contingencies change. Individuals with inflexible thinking often have challenges with set-shifting and can make two types of errors—either failing to shift from the previously learned response pattern (perseveration errors) or failing to maintain the new response set and reverting back to previously reinforced choices (regressive errors). Ventral-striatal circuits support the initial set shifting, while dorsostriatal circuits support maintenance of the new set following the shift. The frequency and type of these errors may differ depending on which disorder an individual presents with and influences their ability to be cognitively flexible.Long-standing research links inflexible thinking to anxiety and depression in typical adults, and more recent research has shown it also presents in disorders of childhood, such as ASD and other neurodevelopmental disorders; disorders presenting in adolescence and adulthood, such as OCD and related disorders; and disorders presenting in the elderly, such as dementing disorders.It is important to note that inflexible thinking, or cognitive rigidity, is predictive of emotional and behavioral difficulties across the lifespan for both those with and without mental illness. There are important public health implications of inflexible thinking, as it not only affects our ability to adapt to a constantly changing world, but also contributes to workplace and relationship difficulties, increased risk for suicide, and even mass shootings.Inflexible thinking is one component of the restricted and repetitive behavior (RRB) domain of ASD, which is a symptom domain required to make the diagnosis. Insistence on sameness and intolerance of uncertainty in individuals with ASD cause them extreme discomfort in response to unexpected changes in the environment. This often leads to protest behaviors, including tantrums, self-injury, and aggression.Figure 2Neurocognitive tasks used to understand the pathophysiology of inflexible thinking in individuals with ASD indicate that while they are able to recognize and learn new rules, patterns, and routines, they have difficulty maintaining them over longer periods of time and instead revert to previously learned routines. This preference for previously reinforced rules and patterns underlies the individual’s strong need for sameness in their environment, which is a main characteristic of ASD and contributes to the severity of RRB symptoms. Inflexible thinking is also linked to adaptive behavior impairments, social communication deficits, interpersonal challenges, and other executive functioning deficits. A lack of flexibility in social situations further strains relationships already affected by the deficits in social reciprocity, nonverbal communication, and interpersonal skills common in individuals with ASD. Less flexible coping strategies also make it more challenging for individuals with ASD to manage difficult emotions. This can lead to more externalizing symptoms, especially temper tantrums, while the enhanced uncertainty about whether rules will be followed leads to internalizing symptoms, such as anxiety.Individuals with ASD are more likely to experience repeated traumatic events such as bullying and social exclusion during critical developmental stages, especially early adolescence. This often results in high levels of comorbid posttraumatic stress disorder (PTSD) and exacerbates brooding rumination—a dysfunctional emotional strategy related to poorer emotion regulation and higher levels of burnout. Rumination is in part caused by difficulties in shifting attention. It involves repetitively thinking of the causes and consequences of one’s symptoms and current situation in a passive and judgmental manner and comparing it with a desired outcome without the reflective introspection needed to help solve problems. Over time, this inability to shift one’s attention to a more reflective problem-solving thought process leads to worsening externalizing symptoms (explosive episodes) and internalizing (self-injurious) behaviors (see Figure 2).ASD Is a Lifelong ConditionOverviewClinicians often think of ASD as a childhood neurodevelopmental disorder; however, it is a lifelong condition and is frequently underrecognized in adults who have good verbal skills and average levels of intelligence. With an estimated 2% worldwide prevalence rate, approximately 1 in 44 children has a diagnosis of ASD, according to the Centers for Disease Control and Prevention. Due to the complexity of the clinical presentation and the numerous factors contributing to symptomatology, the evaluation and treatment of individuals with ASD presents many challenges. According to DSM-5, the core symptom domains of ASD include persistent deficits in social communication and social interaction and a pattern of restricted and repetitive behaviors and/or interests. However, caregivers and individuals with ASD often seek treatment because of symptoms that fall outside the core symptom domains, including aggression, irritability, and self-injurious behaviors.Figure 3Symptom presentation and profiles vary significantly among individuals with ASD due to its heterogeneity, idiopathic pathophysiology, and high rates of medical and psychiatric comorbidities. Medical comorbidities include seizures and epilepsy, gastrointestinal dysfunction, metabolic syndromes, immune and inflammatory dysfunction, and sleep disorders. Additionally, approximately 70% of individuals with ASD have a comorbid psychiatric diagnosis, and almost half have two or more comorbid diagnoses. These include attention-deficit/hyperactivity disorder, OCD, anxiety and mood disorders, sensory impairments, and intellectual disability. Collaboration between families and multidisciplinary providers throughout the lifespan is needed.Clinicians should also be aware of high rates of gender dysphoria in patients with ASD compared with the general population and, conversely, high rates of autism traits in those who identify as transgender and gender diverse. Particularly during adolescence, gender-affirming medical requests may add to the comprehensive care provided by the primary clinician. The presentation of ASD symptoms may also differ between individuals due to cultural and ethnic variables, and interventions may have differing effects in these populations. In sum, clinicians must consider comorbid medical and psychiatric conditions and genetic, developmental, cultural, social, and environmental factors in working with individuals with ASD and their families (see Figure 3).Restricted and Repetitive BehaviorsAlthough many clinicians focus on the social communication deficits of ASD, the RRB symptoms of ASD often have the greatest impact on individual and family functioning over the lifespan. RRBs are divided into two categories, repetitive sensory-motor behaviors and insistence on sameness behaviors. Repetitive sensory-motor behaviors include stereotyped or repetitive sensory and motor movements and speech. They can present as hyper- or hyposensitivity and reactivity to sensory input and unusual interests in the sensory aspects of the environment. Examples include visual fascination with lights or movement and unusual interests or aversions to smells, textures, or sounds. For example, younger children may be observed peering at the wheels of toy cars or repeatedly playing the same sound or movie clip. Insistence on sameness behaviors typically involves well-established routines and ritualistic habits. This includes difficulties with transitions and changes in the environment and can be observed as an individual’s need to travel the same route, eat the same food, or complete mental rituals prior to completing tasks. Restricted interests are an extension of an individual’s need for sameness and cognitive rigidity and include unusually intense and specific preoccupations.Cognitive and language impairments in individuals with ASD are also correlated with the severity of RRBs and rigidity, particularly the frequency of repetitive sensory motor behaviors. RRBs also vary with development and across the lifespan, with younger children presenting with more frequent repetitive sensory motor behaviors, and older individuals presenting with more rigidity and insistence on sameness. Executive functioning deficits also influence the frequency and severity of RRBs, and clinicians should consider them as intervention and diagnostic targets.Sex and gender also impact how symptoms present in those with ASD, including the extent to which an individual uses camouflaging behaviors to compensate for autistic characteristics during social interactions. Although typical ASD prevalence rates cite a male-to-female ratio of 4:1, recent research has illuminated how often women with ASD are under- or misdiagnosed due to differences in the presentation of their symptoms, and truer ratios may be closer to 3:1. Women with ASD typically have lower levels of RRBs and may be better able to camouflage difficulties with social interactions and self-stimming behaviors. The suppression of these symptoms using camouflaging often causes higher levels of internalizing problems, including anxiety and depression.Pharmacological, Psychological, and Psychosocial Treatments for Inflexible ThinkingThere are only two FDA-approved treatments for ASD (risperidone and aripiprazole), and these are not approved for the treatment of core symptoms of ASD, but rather for irritability in pediatric ASD. Nevertheless, pharmacological, psychological, and psychosocial interventions may impact cognitive inflexibility, although with only varying levels of success, in part by addressing other RRBs, attention, social skills, and mood/anxiety symptoms. For example, SSRIs may reduce other RRBs and anxiety, whereas atypical antipsychotics may impact inflexible thinking by reducing perseverative behaviors and anticonvulsants may reduce irritability and aggression symptoms associated with protest behaviors. Stimulants may help with other executive functioning deficits, including inhibitory control, inattention, and set-shifting difficulties. There is even less information on experimental treatments, but they offer some promise as we understand more about homogenous subgroups within this heterogenous population.Table 2For example, anti-inflammatory treatments such as Trichuris suis ova (TSO) may improve cognitive and behavioral rigidity symptoms in ASD patients with immune-inflammatory dysfunction. TSO is a pig whipworm that acts as an immunomodulator and is frequently studied in conditions with immune dysfunction, such as ASD, inflammatory bowel disease, and multiple sclerosis. The neuropeptide hormone oxytocin was also shown to improve repetitive sensory motor behaviors when administered intravenously. Psychological and psychosocial treatments in ASD may initially focus on applied behavioral analysis interventions (ABA) during early childhood.While individuals with ASD may have challenges understanding others’ perspectives and mental states (theory of mind), they still have emotional self-awareness, introspection, and insight. This can contribute to increased anxiety and depression symptoms, including feelings of loneliness and sadness. Thus, individuals with ASD may be better candidates for cognitive-based treatments, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) than previously thought, particularly when the therapy is adapted to better meet patients’ needs. Acceptance and commitment therapy, which focuses on improvements in psychological flexibility, needs further study but has also shown promise. Clinicians should also consider interventions that target social skills and deficits in daily living skills, including occupational therapy and job-coaching programs. Improvements in these areas may tangentially improve cognitive and behavioral flexibility and overall quality of life.Table 3When outpatient and community-based services are not enough and/or individuals with ASD can no longer reside in their homes, residential treatment and group homes may be considered. This often occurs when individuals present with severe behavioral symptoms, including physical aggression and self-injury, in addition to intellectual disability, language impairment, and multiple medical and psychiatric comorbidities. Well-informed residential facilities can provide a multidisciplinary organizational structure needed for the provision of family- and evidence-based interventions (see Table 2 and Table 3).Case Study of Inflexible Thinking in ASDSam (not the patient’s real name) is a 40-year-old Caucasian male who is unemployed and has been living in a residential facility for the past year since his parents became ill. He presents with severe inflexible thinking and has diagnoses of ASD, OCD, intermittent explosive disorder, and bipolar II disorder. Sam is the only child of retired chemistry and physics professors. He has a close relationship with his mother, who has dementia, and a conflicted relationship with his father, who has a history of angry outbursts. There is a family history of OCD.As a child, Sam was very shy and timid and was often bullied. He had few friends, which continued as he reached adolescence and adulthood, and has never had a sexual relationship. He has struggled all his life with severe inflexible and rigid thinking, characterized by the need to describe in extreme detail any changes in his circumstances and his inappropriate urges and intrusive thoughts. A sense of guilt pushes him to share all suicidal, homicidal, self-harming, and angry thoughts and feelings immediately and in detail with each of the members of his treatment team in a ritualistic and repetitive manner.Sam’s inflexibility also lends itself to a need to control his environment. He has multiple rituals related to his daily tasks, such as the order in which he takes his medicine. If interrupted, Sam experiences extreme discomfort, becomes agitated, and needs to start his ritual and recitations over. He has also engaged in checking rituals since childhood, needing his environment to be “just-so” and repeating questions over and over to gain reassurance from others and reduce his anxiety. Sam has obsessional slowness in completing tasks, particularly his washing and bathroom rituals. If these tasks are interrupted, Sam becomes extremely agitated and has meltdowns characterized by yelling, screaming, breaking objects, and hitting those nearby. Sam also spends several hours a day organizing his medications and needs to repeat the times and doses of his medications many times. He also has rubbing, smoothing, and wiping rituals; makes moaning sounds; and has mental rituals accompanied by subvocalizations. Due to his need to complete these rituals, Sam regularly experiences urinary incontinence and in the past year has started wearing a diaper. He was, and continues to be, intellectually gifted, with a special restricted interest in botany. Through this interest, Sam has developed other talents including drawing and sketching plants and maintaining a valuable, world-class collection of succulent plants.Despite his high IQ, Sam struggled in school and dropped out of a private high school in 10th grade due to slowness, stress, and challenges in completing his homework assignments. Sam’s high intelligence lends him insight into how his behaviors limit him and affect others. Although he lacks impulse control, he recognizes that these behaviors isolate him and regularly has self-deprecating thoughts and feelings of loneliness and sadness. Emotional triggers, such as what his friends have achieved in comparison with him, often lead to suicidal thoughts and gestures. Sam completes these gestures in front of others to gain the attention and support that he desires from friends and true relationships.Sam has been hospitalized repeatedly throughout his life for severe outbursts that have often included suicidal thoughts and gestures. He has had multiple trials of SSRI treatments to address his compulsivity, but they resulted in increased frequency and severity of his rapid-cycling agitated states. Other antidepressants also precipitated rapid-cycling agitated episodes. Therapeutic doses of atypical antipsychotics (risperidone, quetiapine, aripiprazole, and ziprasidone) and mood stabilizers (valproate, oxcarbamazepine, verapamil, and lithium), resulted in only a mild reduction in explosive episodes, while clozapine increased Sam’s compulsivity. Clonidine has shown some success in decreasing Sam’s impatience. Sam also completed trials of transcranial magnetic stimulation, including low-frequency stimulation to the pre-supplementary motor area and high-frequency stimulation to the left dorsolateral prefrontal cortex, but they were ineffective. Sam received maintenance bilateral and unilateral ECT every four weeks for many years to treat his rapid-cycling bipolar agitated states, with some partial improvement in explosive outbursts. He also underwent limbic leukotomy neurosurgery, consisting of bilateral anterior cingulotomy and subcaudate trachtotomy, which resulted in improvement of his rigidity and a decrease in the frequency of his explosive episodes. This allowed Sam to discontinue his maintenance ECT.Sam has recently started esketamine infusions, which has resulted in a significant improvement in his mood. Psychological interventions have included CBT with exposure and response prevention and dialectical behavior therapy. Sam was unable to fully participate in either, and minimal treatment responses were observed. His family was not able to participate in family therapy.Recent psychological treatment has taken an integrative approach, pulling from DBT, CBT, and psychodynamic orientations to target each symptom area. Sam is working to build his distress-tolerance skills using acceptance and humor to move through difficult intrusive thoughts. He and his therapist are examining the emotional roots of these thoughts using self-reflection and self-examination, including understanding his relationship with his parents and their role in his self-development. ■ReferencesEric Hollander, M.D., is the director of the Autism and Obsessive-Compulsive Spectrum Program at the Psychiatry Research Institute of Montefiore-Einstein at Albert Einstein College of Medicine, Montefiore Medical Center. He is also the editor-in-chief of the Journal of Psychiatric Research.Casara Jean Ferretti, M.S., M.A., Ph.D. candidate, is an instructor and project director in the Autism and Obsessive-Compulsive Spectrum Program at the Psychiatry Research Institute of Montefiore-Einstein at Albert Einstein College of Medicine, Montefiore Medical Center. ISSUES NewArchived
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