Autism and anxiety
What do you mean by ‘anxiety’?
The online Cambridge dictionary defines anxiety as “an uncomfortable feeling of nervousness or worry about something that is happening or might happen in the future”.
Is heightened anxiety common in autistic people?
In the general population and notably amongst teens, anxiety seems to be on the increase. A BBC News report in February 2019 reported that an NHS study of 10,000 young people indicated a small but genuine rise in diagnosable emotional disorders like depression and anxiety, especially among girls. Researchers found the proportion of under-16s experiencing any mental disorder had risen from 11.4% to 13.6% between 1999 and 2017. That total includes things like anxiety and depression as well as behavioural disorders and hyperactivity.
In autistic people, anxiety disorders are very common. According to the National Autitistic Society roughly 40% of people on the autism spectrum have symptoms of at least one anxiety disorder at any time, compared with up to 15% in the general population. Understandably, this can lead to sadness or depression – one reason why a mixture of anxiety and depression is common.
The causes of anxiety in autistic people seem to stem from 3 key factors.
- Cognitive rigidity:
The way that autistic people think in terms of images and predict what they expect to see in their daily lives can lead to heightened anxiety if there is any change in plan and their experience deviates from what they pictured in their mind. Starting or changing school, having to move classroom or have a new teacher, or even having to sit in a different chair can all create anxiety in the child. In neurotypical children, these sort of changes in routine are mostly seen as just a normal part of life. When changes come which are unpleasant or annoying, most people can rationalise the situation and sit it out. Autitistic children struggle to activate this type of logical response and instead are driven by their animal instinct which tells them that this situation is threatening and they should escape it. This of course builds a new picture of a situation to be afraid of and escape in future, which only leads to an even more anxious response the next time this happens.
There is a research paper on “Sensory, Emotional and Cognitive Contributions to Anxiety in Autism Spectrum Disorders” by South and Rodgers (2017) which investigates an aspect of this cognitive rigidity, intolerance of uncertainty (or IU), in much more detail. For those who want to dig a little deeper into the neuroscience of anxiety in autistic people, you can investigate further here.
- Sensory overwhelm:
Many autistic people process sensory information differently to neurotypicals. Sounds may be heard as louder and more scary, lights may look brighter and more intense, smells may be overpowering and even nauseating, textures of materials can feel scratchy and abrasive and tastes can be delicious or disgusting and nothing in between. A combination of intense sensory experiences which all come along at once can overwhelm the autistic person and lead to an urgent need to physically escape the situation. This state of extreme discomfort or near panic …..
- Social anxiety;
It is thought that a combination of factors, leading to vulnerability to stress, is likely to explain why anxiety disorders are so common in autistic people. Biological differences in brain structure and function, a history of social difficulties (leading to decreased self-esteem and a tendency to think of threats as greater than they are) and problems with finding flexible responses to apparent threats are all likely to contribute.
5 strategies to reduce anxiety in autistic people
- Exposure therapy
- Counselling / CBT
- Movement / exercise
- Breathing exercises / meditation
- Exposure therapy
Slight exposure to the thing that scares us, with no actual harm occurring, helps our brains to make new pathways and reduce the association of that item or situation (eg spiders, heights, cauliflower) with the thought of real danger. A simple example of this is therapeutic courses which help people to overcome a fear of flying.
The same way as we tried to help Nick to overcome his phobia about certain foods (yoghurts) through very slight exposure to the item, then over time gradually increasing the level of exposure until it came close to ‘normal’, so the use of exposure can be effective for most phobias and fears.
The problem remains that the anxiety is triggered by the animal brain (amygdala) and the logic used to rationally explain why there is no danger from the spider/height/cauliflower is processed by the human brain (the prefrontal cortex). The animal brain (amygdala) is pretty much paranoid and triggers the fight-or-flight response when it senses danger. It probably kept your ancestors alive a very long time ago, by warning them to stay away from predators, cliffs and (potentially poisonous) berries and vegetation they were unfamiliar with.
The problem now is that we have far fewer “real” physical threats in modern life, but nobody told the amygdala! Also, due to our need to survive, our animal brains are not as sophisticated as our human brains, but they are more powerful. So the fight-or-flight response happens much faster than you can logically respond to a potential danger, to assess if it is a real threat or not. It is a good thing in the physical world: It keeps you alive! If a car swerves towards you, your amygdala responds and tells your body to get out of the way NOW, in a fraction of a second. Your human brain doesn’t even have time to respond; the amygdala gets in and out super quick and keeps you alive. That’s its job. Your human brain can reflect afterwards if the car was actually going to hit you or might have missed; the animal brain doesn’t care. The car COULD have hit you, the danger felt real, so it got you out of there. Your survived. The amygdala did its duty: you are alive.
So how to reduce this animal brain anxiety?
Numerous books on this subject, including the excellent The Chimp Paradox by Steve Peters and Habits of a Happy Brain by Loretta Breuning, indicate that a combination of responses are required.
- Deep breathing: this triggers a physical slowing of the heart rate as it has to work less hard to access the oxygen it requires to fuel the fight-or-flight response. It also tells your amygdala: “ok, I got the message about the danger now see that I am responding”. So the amygdala feels that the job is done.
- Movement: most of your survival instinct is telling you to avoid the current danger Movement tells your brain that you have heard the warning and are moving. Note: maybe don’t try this with heights, especially near the edge of a cliff.
- Logically debunking the myth that you are in real danger: as well as trying to alleviate the physical symptoms of anxiety with deep breathing and movement, you should also engage your human brain to logically unpick the phobia and logically show that there is nothing to be afraid of. The key to remember is that this is the THIRD step in this 3 step approach; trying to overcome your animal brain with human brain logic seems very clever but is actually pointless: you cannot out wrestle your inner chimp, as Prof Steve Peters describes it. It is way too strong and is uninterested in your human musings when it is trying to keep you alive. So don’t try. Acknowledge it, respond to it (see steps A and B), THEN talk to it. You will get a better response.
- Counselling / CBT
To deal with anxiety many people (regardless of autism) find it helpful to talk through their problems with a sympathetic listener. Whatever the specific type of counselling, whether it be wellbeing or Cognitive Behavioural Therapy, it is all about talking. The sessions should be with a trained and accredited counselling professional and each session should last around an hour.
The most common way to access counselling support is via GP referral. If you feel that the waiting time to get seen is too long (a common problem unfortunately) you may decide to go private, but investigate the options and costs carefully.
- Movement / exercise
Most of us could benefit from more exercise and so it is with autistic kids. Children with autism tend to be more introverted and focus on solitary pursuits such as playing video games and building lego. So vigorous physical activity can be lower in autistic people than others, which is bad for all aspects of health. Trying to build in some sort of exercise or movement is good for us physically and mentally, as it can release muscle tension, encourages us to breathe deeply due to moderate exertion and can cathartically release a lot of the anxiety carried around by the young person. Team sports can be tricky due to the social and communication difficulties, but anything from helping walk the family dog, walking to the shops or playing frisbee (even badly) in the park can all help. The use of a treadmill or exercise bike at a local gym may be helpful, especially as the equipment remains stationary so there is less uncertainty about where the walk or bike ride is going. If getting out of the house is difficult, maybe consider buying some equipment which can be used in the home. We bought an exercise bike and found it to be a simple way to ensure some sort of physical activity several times a week. Although try-before-you-buy, as sensory issues may create further challenges if the smell / look / sound / feeling of the saddle agitate the senses of the young person.
Temple Grandin says….Spin
In her book ‘Emergence’ famous autist Temple Grandin mentions vestibular stimulation (eg spinning around) as a way to reduce anxiety or overstimulation in an autistic child. This could be a playground roundabout (or spinning teacup, or whatever is available) or as simple as an office chair which can spin! In fact a study of hyperactive children by Bhatara et al (‘Hyperkinesis treated by vestibular stimulation: An exploratory study‘) was carried out in 1981 which found that spinning the children in a chair twice per week significantly reduced hyperactivity. The object seems to be not to spin the child to the point of nausea, but just to the point of nystagmus, which is the flickering of the eye as the body regains its balance.
- Breathing exercises / meditation
Again, many of us have too much stress in our lives and could benefit from deep breathing exercises; with all of the anxiety experienced by so many autistic children, they need it even more. It may be difficult to convince a child to take part in such activity, even if it is just sitting in a chair breathing deeply and counting breaths in and out for a specific time period (start with 2 or 3 minutes; about 20 minutes is ideal, but good luck with it if you start at 20 minutes as a target!).
How about combining exercise and deep breathing? Even moderate physical activity will require deeper breathing; is using a stationary bike or treadmill then the focus can be on moderate movement with some counting of breaths. Hey presto: “moving meditation”. We have tried this on an assault bike in the family home and it works well. Ok, when we can persuade Nick to do it, but it is relatively straightforward and does not require travel or good weather.
Obviously this is controversial. If you have tried a number of different psychology-based anxiety treatments for your autistic child and need further help, you can contact your GP to discuss medical alternatives.
Selective serotonin reuptake inhibitors (SSRIs)
In most cases, the first medication you’ll be offered will be a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI).
This type of medication works by increasing the level of a chemical called serotonin in your brain. Serotonin is one of the brain’s 4 “happy chemicals”, along with dopamine, oxytocin and endorphins. Serotonin is released by the brain when you take action which improves your status. It is essentially nature’s prompt to remind you to assert your status within the herd. It will prompt you not to challenge more physically-dominant animals for food, for fear of conflict and physical harm, but nudge you to assert yourself over weaker creatures within the herd to ensure you get your fair share of food, or a mate, or your mother’s milk, or whatever resource your brain thinks you need for survival.
Of course, modern life in the developed world holds far fewer real survival scenarios, but nobody told our animal brain this. How we identify status indicators might now be more related to our popularity amongst our peers, social media presence and status (number of followers, number of ‘likes’), nature of familial relationships, academic success, sporting ability, achievements.
Examples of SSRIs you may be prescribed include:
SSRIs can be taken on a long-term basis but, as with all antidepressants, they can take several weeks to start working. You’ll usually be started on a low dose, which is gradually increased as your body adjusts to the medicine.
It should be noted that there are many potential side effects of SSRIs including feelings of agitation, nausea, upset stomach, insomnia, dizziness as well as sexual dysfunction. So try all the other approaches first before approaching your doctor about meds.
Temple Grandin says…..consider medication
In her book, Emergence, Temple Grandin writes in some depth about the benefits of anti-depressant medication to help with anxiety in autistic people. When she was 16 years old, she was desperate for relief from anxiety and frequent panic attacks.
Temple herself uses Tofranil (Imipramine) which adjusts her metabolism and reduces the sensitivity of the central nervous system to incoming sensory input. It does so by reducing the sensitivity of B-adrenergic receptors in the brain, which process sensory input. Therefore the imipramine has the effect on these receptors of, in Grandin’s own words, “reducing the idling speed of the engine”. She describes the benefits of taking the medication in everyday life as:
- Making her more relaxed generally
- She has less fixations / obsessions
- She is able to interact better socially
- No eczema / colitis from stress.