Last week, National Autism Network published an article detailing how anxiety impacts individuals on the autism spectrum. Regardless of whether or not you’re on the spectrum, anxiety can be physically, mentally, and socially damaging. Anxiety seems to affect individuals with autism to a larger degree and is considered one of the disorder’s most common comorbidities.1 Anxiety on the autism spectrum can be a vicious cycle. An inability to manage emotions can lead to high anxiety, which, in turn, can lead to a diminished capacity for managing your emotions.2 Anxiety can be very detrimental if not managed properly. Fortunately, there are treatments available to individuals with autism who suffer from anxiety disorders and helpful strategies for regulating bouts of anxiety in individuals who may not meet the diagnostic criteria for a specific anxiety disorder.
NOTE: The information herein is intended for both individuals with autism and parents of children on the spectrum. However, for the sake of consistency, this article will mostly address individuals on the spectrum.
Recognizing Anxiety on the Spectrum
Due to the overlap of symptoms that occur with anxiety disorders and autism, accurately providing separate diagnoses can prove difficult. However, many clinicians believe that anxiety disorders often co-occur in individuals with autism. The DSM-V acknowledges that about 70 percent of people with autism may have another mental disorder and 40 percent “may have two or more.”3 It is important to obtain a separate diagnosis of anxiety for individuals with autism because this will help healthcare professionals provide better treatments. By receiving a specific diagnosis for an anxiety disorder, physicians and/or therapists can provide medication or therapies that alleviate anxiety symptoms, making it easier to treat the symptoms related specifically to an individual’s autism.3 Knowledge of a second disorder can also help parents to tailor IEP plans in such a fashion that their individualized program targets all of the student’s needs due to disability, not just their autism symptoms.3 Sadly, providers currently lack standardized tests for anxiety suitable for people with autism, but that doesn’t mean a diagnosis for anxiety disorder is out of reach. Nevertheless, the symptoms of autism present challenges in pinning down a separate diagnosis for anxiety. For example, individuals with autism may have limited verbal skills or may express emotions and obsessions differently from neurotypical individuals.3 Anxiety itself also fluctuates, with some individuals experiencing constant and severe periods of anxiety, while others only experiencing symptoms in certain situations, when faced with certain challenges, or when unexpected events arise, which can disrupt daily routines.4-5
It is important for parents and individuals to recognize if an evaluation for an anxiety disorder is warranted. If you know what to look for, the red flags of an anxiety disorder are difficult to miss. Since some individuals with autism have trouble with verbal communication, parents should be aware of outward manifestations of the disorder. Some researchers “suspect that outward, physical symptoms of anxiety may be especially prominent among those with ASD.”6 These may include strong internal sensations of tension, such as “racing heart, muscular tensions, sweating and stomach ache.”5 Other signs may include changes in eating or sleeping habits, an increase in challenging behaviors, or an increase in repetitive behaviors that seemingly serve no purpose.3 An escalation in meltdowns or increased isolation should also serve as a warning sign to seek out an evaluation for anxiety. Individuals who experience anxiety often engage in avoidance, which can manifest as “deletion” or “postponement.” In deletion, the “avoidance response removes the scheduled aversive event.”7 For example, if an individual has a phobia of heights, they may drive hours out of their way to avoid going over a bridge. In postponement, “avoidance responses prevent or postpone the scheduled aversive events.”7 A common scenario in which an individual may employ postponement is delaying their visit to a loved one in the hospital for a fear of germs. Continually engaging in patterns of avoidance isn’t healthy. Avoidance can make anxiety-related fears worsen over time.7 If you find yourself continually avoiding certain situations, experiencing the symptoms of anxiety in certain situations, or feel the necessity to change routines based upon certain fears, then you should seek out an evaluation for anxiety.
It is also important to bear in mind that certain phases in life tend to bring about increased anxiety. For example, social anxiety most often manifests during adolescence, when individuals are socially “on their own” for the first time as their aptitude for social engagement will determine their capacity for making friends.8 Certain transitions like new schools, new jobs, a new relationship, and physical transitions like puberty can also contribute to bouts of anxiety. Also, you should seek out an evaluation for anxiety if you feel you are experiencing an increase in anxiety-related symptoms.
Diagnosing Anxiety on the Spectrum
According to the Anxiety & Depression Center, “many children receive a diagnosis of an anxiety disorder before the ASD is correctly identified or as a secondary diagnosis once ASD is identified.”9 An evaluation for anxiety should consist of an examination of your medical and family history, a physical examination, and a diagnostic evaluation specific to anxiety.10 A 2011 study found that it is imperative to “use multiple sources of information (e.g., child-, parent-, and clinician-report measures) for assessing anxiety and psychosocial functioning in youths with ASDs.”11 If a physical examination from your primary care physician yields no physical aliment clarifying the source of your anxiety, then he or she will recommend you to a psychologist, psychiatrist, or other mental health professional.12 One benefit to seeking out a diagnosis from a psychiatrist as oppose to a psychologist is that “as a medical doctor, he or she has the knowledge and training to evaluate underlying medical problems or drug effects that could cause emotional or behavioral symptoms.”13 Based on the severity of the disorder, it may be difficult for individuals on the spectrum to self-report their anxiety symptoms to a trained professional. In cases such as these, a mental health professional may seek out information from parents, teachers, or other individuals who spend time with the child.14
Overcoming Anxiety in Autism
Regardless of whether or not you meet the criteria for a specific anxiety disorder there are ways to quell the symptoms of anxiety. Similar to the lack of standardized tests for anxiety for individuals with autism, there currently aren’t anxiety interventions specifically designed for people on the spectrum.15 Fortunately, treatments for neurotypical individuals have been successfully adapted for individuals on the spectrum in the past. Below are some of the recommended treatments for anxiety disorders, along with other helpful ways to quell anxiety in general:
Cognitive Behavioral Therapy: This form of therapy is considered a first-rate treatment for anxiety disorders, but has only recently been adapted to meet the unique needs of individuals with autism.11 CBT works on the basis that one’s thoughts cause their feelings and behaviors, which means “we can change the way we think to feel/ act better even if the situation does not change.”16 In CBT, a therapist and the patient explore “patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts.”17 The foundation for many anxieties are irrational fears. Let’s take separation anxiety for example. The likelihood of something bad happening to a parent or loved one when they are not in your presence is miniscule, but the fact that you’re are unable to see that person causes you to assume the worse has occurred, increasing anxiety. Cognitive therapy examines how these negative thoughts contribute to anxiety and behavior therapy examines how people behave and react in situations that trigger anxiety.18 The first step is to pinpoint the individual’s fear, for example social situations. After a therapist has identified “the perceived threat, the therapist can help the individual logically challenge [their] anxieties with evidence.”6 Secondly, the individual and the therapist evaluate “anxiety-provoking thoughts” by “questioning the evidence for [their] frightening thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions.”18 Once you have identified irrational beliefs you can replace them with new thoughts that are more accurate and positive.18 The criteria for CBT certification varies slightly across programs, but mental health professionals are generally required to possess a Masters or doctoral degree in psychology, counseling, social work, psychiatry, or related field, have at least one year of experience in a clinical setting, and must successfully complete a certification program to become a certified cognitive behavioral therapist.19-20
Exposure Therapy: CBT is sometimes paired with exposure therapy, which is pretty much exactly what it sounds like. Individuals undergoing exposure therapy confront their anxieties head on to demonstrate that their fears are indeed irrational. This is often done in either one of two ways:
Systematic Desensitization: This form of exposure therapy consists of instilling the patient with relaxation techniques and then gradually exposing the person to their fear through an “anxiety hierarchy” until they are able to overcome it.21 For example, for an individual with a phobia of spiders, the anxiety hierarchy may begin with the individual first shown a picture of a spider, then being asked to observe one through a terrarium, and finally being given a spider to handle. The client gradually moves on to each stage as tolerance to the phobia manifests. Think of it as dipping your toe in the water and gradually working your way up to the deep end. By facing more anxiety-inducing situations progressively, and consistently pairing relaxation techniques with the cause of anxiety, “relaxation rather than anxiety becomes associated with the source of their anxiety. Thus, a gradual desensitization occurs, with relaxation replacing alarm.”21 The two stages of systematic desensitization are described below:
Relaxation Techniques: There are numerous benefits to learning relaxation techniques, from lowering your blood pressure to reducing anger and frustration.22Relaxation techniques, such as progressive muscle relaxation, visualization, or autogenic relaxation, in which “you use both visual imagery and body awareness to reduce stress,” would be taught to you by a therapist and practiced during sessions and at home.22 Practice is important because when it comes time for exposure you are going to want to be instantly able to employ a relaxation technique. However, don’t let the need to practice relaxation techniques become yet another stressor.22 Also, if one technique fails to work, then try another.
Progressive Exposure: Once relaxation techniques have been mastered, the second component of systematic desensitization known as “progressive exposure” is implemented. This is when the “anxiety hierarchy” comes into to play as you are gradually exposed to the object or situation instigating your anxiety.21 When exposure to certain situations become too overwhelming, you are trained to switch to a learned relaxation technique.18 Once you are relaxed again, you can turn their attention back to present situation. You would employ this technique throughout each step of the anxiety hierarchy until you’re able to completely face your fear without feeling distressed.18
Flooding: If systematic desensitization is dipping your toe in the water, then flooding is the equivalent of throwing yourself in the middle of the ocean without a life preserver. In this method, the individual “completes a prolonged exposure to the feared stimulus at full intensity and would remain in the anxiety-provoking situation until his or her self-reported levels of anxiety reduce.”23 Patients must agree to this method before it is implemented, which may be difficult for some individuals on the spectrum. While this method tends to produce quicker results, flooding is often less preferred by both parents and individuals due to its intensity.23 Exposure techniques are thought to be effective for reducing anxiety because they demonstrate through personal involvement that the individuals’ fears regarding the object, situation, or event are unfounded.23
Medication: Although there are only two drugs approved for treating irritability in autism, aripiprazole and risperidone (the latter of which has recently come under a great deal of controversy), research has shown that nearly one-third of children with the disorder are on more than one medication.24 However, neither of the aforementioned drugs are designed to expressly treat anxiety in autism.4 Individuals on the spectrum who suffer from anxiety disorders often combine medication with behavioral therapy.4 A 2011 study found that “antidepressant medications have demonstrated preliminary efficacy in targeting anxiety in youth with ASDs. However, results have been mixed, and more conclusive trials are needed.”11 Sadly, medication is sometimes used as a substitute for individuals who cannot access behavioral treatment for their anxiety. Moreover, there are obvious side effects with taking medications and some parents worry about how medication can “change” their children.26 A recent study found that “although many children with ASDs are currently treated with medical interventions, strikingly little evidence exists to support benefit for most treatments.”27 Aside from the obvious need to consult a health care professional with regards to medication and its potential side effects, Autism Speaks has developed the ATN/AIR-P Medication Decision Aid to assist with the decision to medicate. For more on understanding anti-anxiety medication, visit here.
Self-Help Anxiety Strategies: These tips and strategies are offered under the pretext that “chronic worrying is a mental habit that can be broken.”28 After all, anxiety is linked to irrational fears individuals build up in their minds regarding certain objects and situations. Below are some ways you can alleviate bouts of anxiety and practice stress management on your own:
Worry Period: One self-help tip is to “create a worry-period” in which you set off a block of the day, ideally the same time every day, to indulge in your worries.28 If a worrying thought enters your brain, jot it down and ignore it until your worry period arrives. During your worry period reflect on these worries and if they still bother utilize this period of the day to address them. However, don’t ever exceed your set time limit, but feel free to cut the worrying period short if the things on your list don’t seem as important anymore.28
Challenge Anxious Thoughts: Irrational fears linked to anxiety exist because you likely “overestimate the possibility that things will turn out badly, jump immediately to worst-case scenarios, or treat every negative thought as if it were fact.”28 If you address your anxious thoughts as possibilities, rather than as matters of fact, you will begin to develop a more balanced prospective. See number 4 of this article to learn how you can “retrain your brain” to avoid the destructive patterns linked to your irrational thoughts or “cognitive distortions.”28
Worry Diary: Whenever you begin to feel anxious, jot down the thoughts you are feeling and what triggered them. Over time a pattern will emerge.28
Meditation/ Exercise: Meditation is a great way to reflect on things without letting them get the better of you. A 2012 meta-analysis of studies related to the implementation of a meditative therapies for reducing anxiety found “some efficacy of meditative therapies in reducing anxiety symptoms, which has important implications for applying meditative techniques in treating anxieties. However, most studies measured only improvement in anxiety symptoms, but not anxiety disorders as clinically diagnosed.”29 Exercise can help with both the physical and the mental symptoms related to anxiety. Exercise tends to lead to greater self-esteem and a healthier disposition. If your body feels better, then so does the mind.30 For more information on how exercise impacts our levels of anxiety, visit here.
Natural Remedies: Some have opted for natural remedies as a means of quelling their anxiety symptoms. These may have side effects of their own, so you may want to consult a professional before ingesting any foreign substances.
Music: Either as a therapy or in general, beloved music can reduce stress and anxiety. According to an article from the Autism Science Foundation on the subject of music therapy, “classical music or music with a steady rhythm is thought to be the best for alleviating anxiety in children with autism due to the predictability of the beat.”31
Improve Communication: Individuals who struggle to communicate due to autism may benefit from picture and schedule cards. These tools can help individuals communicate more effectively when they may need a break from certain activities or when stress levels rise.15 Being able to communicate effectively can increase confidence and self-esteem, which may result in a reduction of anxiety. In general, it also helps to communicate your worries and stresses to somebody you trust as oppose to keeping them pent up inside without a release.
These are just a few of the dozens of ways to quell bouts of anxiety. Please comment below to our fellow members any anxiety remedies that have worked for you in the past.
Conclusion
Anxiety can be detrimental to an individual in several ways, and individuals on the spectrum tend to experience anxiety on a greater scale than neurotypical individuals. The above information is designed to help individuals on the spectrum overcome their anxiety. Anxiety is a serious issue that should be addressed as soon as possible. Ignoring your condition will only cause your anxiety to worsen. For more on the types of anxiety disorder and how they affect individuals with autism, we insist you read Part 1 of our “Anxiety on the Spectrum” series.
References:
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