The Autism-Anxiety Connection
Autism spectrum disorder is generally characterized by social and communication difficulties and by repetitive behaviors. Severe forms of ASD are often diagnosed in the first two years of a child’s life, but high-functioning individuals may not be diagnosed until much later in life. Adults with autism who are high functioning may have only mild challenges, which are sometimes mistaken for symptoms of attention deficit hyperactivity disorder (ADHD or ADD)1; others may have more severe symptoms, like impaired spoken language. No two people with ASD will experience the same behaviors in the same way.
Though anxiety is not considered a core feature of autism, generalized anxiety disorder is the most common comorbid condition found in adults with autism. A recent study found that anxiety disorders are diagnosed in more than 20% of adults with autism spectrum disorder (ASD), compared to just 8.7% of neurotypical adults. Psychosocial symptoms of anxiety can include difficulty sleeping, obsessive thinking, and difficulty concentrating. Physical symptoms can range from an upset stomach to heart palpations or dizziness.
Recognizing and treating anxiety in individuals with ASD is particularly important since it can greatly impact core aspects of autism, namely repetitive behaviors and social withdrawal. Anxiety complicates life for people on the autism spectrum, especially when navigating the social world. It can interfere with job placement and independent living.
Untreated comorbid anxiety has been linked to the development of depression, aggression, and self-injury in individuals with ASD. Susan G. Gilroy, co-director of Northeast Arc Autism Support Center in Massachusetts says, “There are individuals with developmental disabilities with severe anxiety who lead very limited lives because they’re not getting the help they need.”2
Better understanding of how to recognize and treat comorbid anxiety disorders has the potential to improve quality of life for adults with autism and anxiety.
How to Recognize Anxiety Disorders in Adults with Autism
Recognizing the presence of anxiety in patients with ASD is challenging because of overlapping symptomology and altered presentations of symptoms. For example, minimally verbal patients may not be able to express their internal states and instead demonstrate anxiety through disruptive behaviors. Other patients might be verbally fluent but struggle to understand and express their own emotions.
For these reasons and others, the questionnaires typically used to diagnose anxiety may not work for individuals with ASD. Medical providers should instead look for physical signs of anxiety, such as tremors, restlessness, sweating, body aches, and sleep problems.3 Family members can also be asked questions to see if they notice signs of anxiety.
The Anxiety and Depression Association of America4 explains how anxiety disorders may present differently depending on the patient and demands from their environment:
- A specific phobia, namely an intense, irrational fear of something that poses little or no actual danger, may arise early in the course of ASD because of over responsiveness to sensory stimulation, such as a loud environment; specific phobias in these patients usually involve highly unusual stimuli (e.g. advertisement jingles, balloons popping, vacuum cleaners, toilet flushing, alarms at school), but may also present fears (e.g. of the dark, insects, needles) that are typical of developing youth.
- Obsessive compulsive disorder, characterized by unwanted and intrusive thoughts and consequent compulsive behaviors, is often comorbid with ASD. Identifying comorbid OCD in these patients is important because, while the engagement in repetitive behaviors which is typical of ASD is unrelated to distress, compulsions are performed as a coping mechanism to relieve anxiety.
- Social anxiety may develop as a direct result of social communication impairment, especially if the patient is high functioning and aware of their social incompetence. Social anxiety, defined as intense anxiety or fear of being negatively evaluated in a social or performance situation, in turn leads to avoidance of social situations, therefore limiting the patient’s opportunities to practice social skills, and may predispose the individual to negative reactions from peers and even bullying.
- Separation anxiety may result from social impairment, which may inspire overprotective reactions from parents that in turn may strengthen avoidance behavior; separation anxiety may then arise when the patient has to separate from attachment figures.
Managing Autism and Anxiety with Medication
Since anxiety is a distinct disorder, it can be treated separately from other domains of ASD. Anti-depressants, anti-anxiety medications, and beta-blockers are used to treat anxiety in the general population. Few studies have been done discerning whether these drugs are equally effective in adults with ASD. A small study5 from the Cochrane Collaboration found that the drug Luvox may help treat obsessive-compulsive behaviors in adults with autism, and fluoxetine (Prozac) may likewise help with anxiety. The conclusion was that these drugs should be used on a “case-by-case” basis to treat OCD and anxiety in adults with ASD.
Other studies6 on fluoxetine in adults and children with ASD demonstrated improvement in repetitive behaviors, but a controlled trial showed that citalopram worked no differently than a placebo in reducing repetitive behaviors. Also, some patients had negative behavioral effects, such as hyperactivity, impulsivity, and insomnia. Medical professionals should keep in mind that patients with ASD may be sensitive to low doses of drugs. These adults present significant variations in treatment responses and adverse reactions to medications.
Managing Autism and Anxiety with Therapy
When treating ASD in adults, medication alone is unlikely to mitigate the symptoms of concern. Other interventions are typically needed and may include skills training, environmental changes, behavioral techniques, and the use of sensory inputs.
Cognitive behavioral therapy (CBT) effectively treats anxiety disorders and OCD in youth with ASD, especially in high-functioning individuals with adequate verbal skills. CBT focuses on changing how an individual interprets a situation with the intention of reducing negative feelings and unhealthy responses. CBT for anxiety in individuals with ASD involves:
- learning to differentiate between helpful and unhelpful anxiety
- learning to identify anxious thoughts and improve executive functions
- progressive exposure to feared stimuli
- interventions with parents
- practicing reciprocity skills to improve engagement with others
- visual prompts to help the patient cope with difficulties in abstract thinking
Daily interventions are equally important for helping an adult with ASD manage and understand their anxiety. The National Autistic Society of the United Kingdom7 details strategies like keeping a diary, using apps, and creating a meltdown prevention plan.
Autism and Anxiety in Adults: Next Steps
- Download: Free eBook About Autism in Adults
- Read: What Does Autism Spectrum Disorder Look Like in Adults?
- Understand: “What an Anxiety Attacks Actually Feels Like”
1Rosenn, Daniel. Is It Asperger’s or ADHD?. Asperger’s/ Autism Network. (2020). https://www.aane.org/is-it-aspergers-or-adhd/
2Sarris, Marina. Anxiety’s Toll on People with Autism. Interactive Autism Network (Jan. 2018). https://iancommunity.org/anxietys-toll-people-autism
3Sarris, Marina. Anxiety’s Toll on People with Autism. Interactive Autism Network (Jan. 2018). https://iancommunity.org/anxietys-toll-people-autism
4Burchi, Elisabetta, Hollander, Eric. Anxiety in Autism Spectrum Disorder. Anxiety and Depression Association of America. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/anxiety-autism-spectrum-disorder
5Sarris, Marina. What Anxiety Treatments Work for People With Autism. Interactive Autism Network (Jan. 2018) https://iancommunity.org/what-anxiety-treatments-work-people-autism
6Burchi, Elisabetta, Hollander, Eric. Anxiety in Autism Spectrum Disorder. Anxiety and Depression Association of America. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/anxiety-autism-spectrum-disorder
7Anxiety in Autistic Adults. National Autistic Society. https://www.autism.org.uk/about/behaviour/anxiety.aspx
Updated on August 17, 2020