Autism and Anxiety: Insights from Medical Experts

What’s the Link Between Autism and Anxiety? Experts Weigh In

There’s a saying that if you’ve met one autistic person, you’ve met one autistic person. The truth is that no one person on the autism spectrum is the same as another. Still, research suggests that autistic people as a whole may be more prone to anxiety. To the layperson, autism spectrum disorder (ASD) and anxiety may look similar, and it may be difficult to distinguish between them. Experts say that a better understanding of the relationship between autism and anxiety can help improve the quality of life for autistic people. Here’s what we know — and don’t know — about autism and anxiety.

How anxiety shows up in autism spectrum disorder

Research suggests that anxiety is more common in autistic people. A 2019 study of sibling pairs indicated that about 20 percent of autistic people had anxiety compared with about 9 percent of the population controls. Many autistic people are fully aware they’re struggling in ways their peers may not be, and that they have some sensitivities and issues that their peers may not.

Unique characteristics

Just as no two people on the spectrum are alike, no two people with anxiety are the same. Knowing some of the common and unique characteristics in autistic people can aid in diagnosis and support. According to board certified pediatric neurologist Dr. Dilip Karnik, there may be similarities in people with anxiety, whether they’re on the spectrum or not, including:

• Separation anxiety, or distress when separated from a loved one or caregiver.
• Difficulty transitioning to new environments.
• Nervousness or fear over meeting new people.

Anxiety in autistic people may feel even more distressing, particularly if the distress is caused by a change to a routine, a common experience for autistic individuals. When they feel a surge in anxiety, it can feel disorienting and discombobulating in addition to the feeling of anxiety itself.

Behavioral symptoms

Anxiety can present through behavioral symptoms in autistic people, some of which may overlap with autism itself. The Anxiety and Depression Association of America says common behaviors in both autistic people and people with anxiety include:

• A severe, specific, and irrational phobia.
• Obsessive-compulsive disorder (OCD).
• Intense fear of being judged in social situations, or social anxiety.
• Separation anxiety.
• Severe distress about changes to a routine or environment.

Recognizing anxiety becomes a problem when it affects day-to-day living. If it’s interfering with work, school, and life, it may meet diagnostic criteria. If you’re concerned about an adult loved one, speaking with them about their feelings can be helpful. Ask whether they feel anxious or another emotion, such as anger. However, self-diagnosis of developmental and mental health conditions is not recommended. It is best to see a neurologist or psychologist for an official diagnosis. Still, taking note of symptoms can be the first step in getting evaluated.

Communication cues

When it comes to communicating, people on the spectrum may speak to varying degrees, including not at all. For individuals without much language, observation and discussion with those who know them very well can be helpful. Caregivers can take a similar approach with children. Have conversations and observe. What are they avoiding? What is making them upset? What are the triggers? Why? In older children who are speaking and can label their feelings, it is important to encourage them to let them know what’s going on.

Causes of anxiety and autism

Autism is neurodevelopmental, whereas anxiety is a mental-emotional disorder. Still, the area of the brain involved in the expression of fear, called the amygdala, may play a role in comorbid anxiety and ASD, according to a 2020 study. Development may also play a role. In neurotypical children, the amygdala continues to grow into adulthood. But in children on the spectrum, it grows faster in the early period, until around 12 years old, and then slows down. Sometimes, it may even shrink. These areas play a significant part in the behaviors of children on the spectrum, especially anxiety. Social and emotional factors may also contribute to anxiety. Autistic individuals may need support to learn how to read body language and other social cues, as these situations can make them feel overwhelmed and anxious.

Symptoms of Anxiety and Autism

Knowing symptoms may empower you to reach out for an evaluation for yourself or a loved one. Though symptoms will vary, here are some common ones to look out for.

General Symptoms of Anxiety

The National Institute of Mental Health says that common symptoms of generalized anxiety disorder include:

• Feeling on edge
• Fatigue
• Trouble with concentration and memory
• Irritability
• Muscle tension
• Uncontrollable worries
• Reduced amount or quality of sleep

Anxiety can also present in other ways, including:

• Avoiding certain situations, such as crossing the street
• Excessive sweating
• Increased heart rate

Social Anxiety vs. Generalized Anxiety

Social anxiety is more focused on situations involving people, such as giving a presentation at work or meeting friends for dinner. It has to do with someone feeling that others’ evaluations of them are going to be negative. A small study of autistic men indicated that social anxiety could develop for similar reasons in autistic and non-autistic people, including negative social experiences. Researchers also suggested that the core traits of autistic people may contribute to their social anxiety, though more research is needed on the topic.

Separation Anxiety

Separation anxiety is common in young autistic people but can also show up in adults. An autistic child with separation anxiety will not necessarily develop anxiety later in life. It’s not an absolute indicator.

Diagnosis

Anxiety is common in autistic people, and a trained healthcare professional can distinguish between the two conditions. Children with ASD need a comprehensive evaluation and medical history, which should include discussing social anxiety, generalized anxiety, or any specific phobias. Anxiety and ASD symptoms often overlap, therefore careful screening is needed in these cases. Seeing a behavioral psychologist for a screening is suggested. They can ask questions about symptoms and triggers, which can help make a correct diagnosis. Adults can also benefit from these screenings.

Treatment

The following treatments and supports can be effective for both autistic and non-autistic people who have anxiety.

Treatment for anxiety can include:

• Psychotherapy
• Cognitive-behavioral therapy (CBT)
• Exposure therapy
• Management techniques
• Lifestyle changes
• Medication

Additional supports for anxiety can include:

• Meditation
• Breathing exercises
• Natural remedies
• Complementary treatments like acupuncture or hypnosis

Coping Strategies

Many strategies can help autistic people with anxiety manage their symptoms based on their individual goals. Different methods fall into different categories, like environmental strategies, behavioral interventions and skill-building, cognitive behavioral therapy and psychotherapy, medication, and personal strategies.

Environmental Strategies

Autistic people with anxiety can often go to school, work, and live fulfilling lives. Some basic strategies can help people cope in public or at home.

• At school: Establishing agreed-upon strategies for when a child feels upset, such as using a special signal to leave the classroom for a drink of water.
• In the workplace: Building on coping strategies learned as a child, such as focusing on breathing, taking short walks, or getting a drink of water.
• In social settings: Using techniques like deep belly breathing or finding a quiet space like the bathroom to manage anxious feelings.
• At home: Prioritizing self-care by taking time to recharge, getting enough sleep, exercising, and maintaining a balanced diet.

Behavioral Interventions and Skill-Building

Beyond coping mechanisms, specific behavioral strategies often help autistic people with anxiety. These strategies can improve social interactions and academic or professional performance.

• Social skills training: Learning how to interact with others, such as saying hello or asking about someone’s day, can be beneficial in reducing social anxiety.
• Applied behavioral analysis (ABA): ABA focuses on replacing unhelpful behaviors with more appropriate ones, rewarding desirable behavior and setting consequences for undesirable behavior. It may be helpful for some individuals but should not be forced on anyone.
• Occupational therapy: This therapy helps individuals learn skills for self-sufficiency and can be particularly beneficial for younger people with sensory integration issues.

Cognitive Behavioral Therapy and Psychotherapy

Cognitive behavioral therapy (CBT) has shown promise in reducing anxiety for both autistic and non-autistic individuals.

• CBT sessions can focus on emotional regulation, social coaching, and improving peer interactions.
• A significant improvement in anxiety symptoms was observed in autistic children who underwent CBT sessions.

Medication

Medication may help manage anxiety symptoms, but it is not a cure. It is important to undergo a full evaluation by a neuroscience expert before taking medications. Some commonly prescribed medications for anxiety include:

• Selective serotonin reuptake inhibitors (SSRIs) like sertraline, fluoxetine, and escitalopram.
• Other medications like buspirone, propranolol, and clonazepam may also be prescribed.

Personal Strategies

Personal strategies can play a crucial role in managing anxiety for individuals with autism.

• Mindfulness: Practicing mindfulness regularly can provide strategies for managing anxiety in public settings.
• Pursuing hobbies and passions: Having activities and interests outside of work and social circles can serve as a form of self-care.
• Setting aside time to vent worries: Allotting a specific time each night to write down or express worries can help release anxiety.

It’s important to remember that coping strategies should be personalized to the individual’s needs and preferences.

Resources for Support

Testing and support are best done in conjunction with professionals. If you or a loved one are on the autism spectrum, have anxiety, or both, help is available.

Testing

To receive a proper evaluation, autistic individuals who may also have anxiety should undergo a psychological or neuropsychological evaluation. You can find a psychologist or neurologist through:

• Your insurance company
• Referrals from your primary care doctor or pediatrician
• Your child’s school
• Early intervention programs
• Healthline’s FindCare directory

Therapy

Once a formal diagnosis is obtained, there are various resources to find a therapist. In addition to the options mentioned above, you can find a therapist through:

• Employee assistance programs
• Referrals from friends and family
• The National Alliance on Mental Illness (NAMI)

Support Groups

While not all autistic individuals will benefit from support groups, some may find them helpful. Support groups can also be valuable for parents of autistic children who may have anxiety. You can find support groups through:

• Local nonprofits
• Local hospitals
• Mental Health America

Takeaway

Autism and anxiety can exhibit similar symptoms, such as difficulties in social situations and with routine changes. However, they are separate conditions that often co-occur. Autism is a neurodevelopmental disorder, while anxiety is a mental health condition. Research indicates that autistic individuals are more prone to experiencing anxiety compared to the general population.

It is important for autistic individuals who may have anxiety to receive a formal evaluation by a mental health professional. Coping mechanisms and services such as mindfulness, cognitive-behavioral therapy (CBT), applied behavioral analysis (ABA), and social skills training can help manage anxiety and improve overall well-being.