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Thursday, January 2, 2014

Anxiety Disorder Comorbid to Autism

From Questioning Answers
News and Views on Autism Research and Other Musings

By Paul Whiteley
September 25, 2013

I've said it before and I'll say it again: a diagnosis of autism (or autism spectrum disorder) is seemingly protective of nothing when it comes to other comorbidity. Indeed, with the range of comorbidity associated with autism - physical (see here) and psychiatric (see here) - in some instances, one has to wonder whether some of that comorbidity is actually more 'disabling' for a person than the autism itself. Think epilepsy for example (see here) and where that can lead...

As a case in point, look at the paper by Charlot and colleagues* and a quote from their abstract: "Anxiety disorders were reported in 62% of individuals with ASD," referring to perhaps one of the more widely discussed comorbidities with autism in mind.

Indeed, in today's post I'm going to explore some of that collected work on anxiety and autism bearing in mind that the diagnostic label anxiety includes quite a few elements one to two of which have already been discussed on this blog (see here). I will also tip my hat to Zoe over at Food for Thought and her recent post on social and emotional development in autism (see here) which was also contributory to my undertaking this post and topic.

The National Autistic Society (NAS) here in the UK carry about as good a description as any of what anxiety is and just how much anxiety can affect the life of a person with autism (see here). Interestingly, the NAS carry a link to the 'survival guide' written by the late Marc Segar (see here) and his very insightful view of his life and the various observations he made including the ways and means he coped with his Asperger syndrome. Dare I say that there are also a few tips included for everyone there irrespective of autism or not...

More recently, the final strand of the NICE guidance for autism also carries quite a bit of discussion about anxiety and autism and in particular, the potential merits of CBT - cognitive behavioural therapy - to tackle said issue. I'm not necessarily going too far into the pros and cons of CBT for anxiety occurring alongside autism; allowing that is, for the paper by Micah Mazurek and colleagues (discussed here) and the notion that CBT is probably not going to be right for everyone.

There are several areas of interest when it comes to anxiety and autism. One of the more interesting ones for me is the issue of whether autism, or autistic traits, are somehow predisposing to anxiety (i.e. whether anxiety should perhaps be classified as a core part of autism) or whether it is something independent bearing in mind the notion of a social anxiety spectrum (see here).

In attempting to answer this question I was drawn to the paper by Freeth and colleagues** who are quoted as saying that: "students with high levels of autistic traits were more likely to report increased social anxiety" in their analysis of autistic traits and social anxiety in a UK University population.

Similarly, the results reported by van Steensel and colleagues*** are also potentially pertinent: "As compared to the AD [anxiety disorder] group, parents from the ASD group reported their children to have higher scores for total anxiety, social anxiety disorder, and panic disorder". One of other points this particular question leads into is whether anxiety is more or less of a feature of certain types of autism; so Asperger's Syndrome / high-functioning autism compared with those who are more severely affected with autism.

One can see how for those who are more floridly autistic in terms of the presence of speech and communication issues and intellectual disability, it might be more difficult to diagnose anxiety. But does that necessarily mean anxiety is less of an issue in such cases? Indeed, what are the implications for screening for anxiety?

Drawing on the mention of CBT as a potential therapeutic route for anxiety in autism****, are the other suggestions reported to ameliorate the signs and symptoms. Again, the Mazurek paper***** might offer some options here if we assume that anxiety, sensory issues and gastrointestinal (GI) complaints are all inter-linked. Treat one element and you treat all?

A familiar name in autism research has also been pitted against anxiety, at least occurring in cases of Fragile X syndrome: oxytocin. The trial by Hall and colleagues****** talked about ameliorating social anxiety via oxytocin administration, bearing in mind the small participant numbers included and the exclusivity of the group analysed.

Although perhaps met with a rolling of the eyes by some people, there is a growing interest in the use of animal-assisted interventions as being a potential ameliorative tool for anxiety*******. I'm taken back for example, to the 'pets win prosocial prizes' suggestion as a starting point, following on from the speculation on the amygdala.

Obviously I'm not suggesting that animal-assisted intervention just targets one area of the brain (don't be absurd) or that such intervention is for everyone with autism and anxiety. Indeed, anxiety about animals may very well be a feature for some people on the spectrum as it is for quite a few people not diagnosed with autism.

Whilst it may not be a great topic of conversation, I do also wonder whether there may be some self-medicating strategies already being adopted by some people on the autism spectrum when it comes to anxiety. Without casting any aspersions or making any sweeping generalisations, I've heard accounts of alcohol use (and abuse) being used by some of those on the spectrum as a way of dampening down things like anxiety issues. Anyone who has drunk a little too much knows what effect alcohol can have on various cognitive and social features.

That, and the quite strong association between social anxiety disorder and alcohol issues******** provides some food for thought in terms of screening for, and potentially explaining, such problem habits when they do occur.

Finally(!) I recently talked about the application of a Chan-based mind-body exercise program being experimentally tested with autism in mind (see this post). Mentioning also the concept of mindfulness and the particular interest that this technique seems to be enjoying for all manner of things (including autism), one has to wonder whether there is merit in looking at such approaches for anxiety with greater assiduity.

I can't possibly do justice to all the research that has been done on anxiety issues presenting alongside autism. What I hope you will take from this post is (a) that anxiety issues (in all their forms) can and do present alongside cases of autism; also able to be self-reported too*********, and (b) when it comes to the question of which aspects of autism (or its comorbidities) most fundamentally affect daily quality of life, anxiety must rank up near the top of the list for quite a few on the spectrum.

Perhaps some factors to consider when it comes to the question of how to improve quality of life?


* Charlot L. et al. Mood and Anxiety Symptoms in Psychiatric Inpatients with Autism Spectrum Disorder and Depression. J Ment Health Res Intellect Disabil. 2008;1(4):238-253.

** Freeth M. et al. The distribution of and relationship between autistic traits and social anxiety in a UK student population. Autism. 2013 Sep;17(5):571-81.

*** van Steensel FJ. et al. Anxiety and quality of life: clinically anxious children with and without autism spectrum disorders compared. J Clin Child Adolesc Psychol. 2012;41(6):731-8.

**** Storch EA. et al. The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry. 2013 Feb;52(2):132-142.e2.

***** Mazurek MO. et al. Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. J Abnorm Child Psychol. 2013 Jan;41(1):165-76.

****** Hall SS. et al. Effects of intranasal oxytocin on social anxiety in males with fragile X syndrome. Psychoneuroendocrinology. 2012 Apr;37(4):509-18.

******* Muñoz Lasa S. et al. Animal-assisted interventions in internal and rehabilitation medicine: a review of the recent literature. Panminerva Med. 2011 Jun;53(2):129-36.

******** Buckner JD. et al. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety. 2008;25(12):1028-37.

********* Ozsivadjin A. et al. Brief Report: The Use of Self-Report Measures in Young People with Autism Spectrum Disorder to Access Symptoms of Anxiety, Depression and Negative Thoughts. J Autism Dev Disord. September 2013.


Charlot L, Deutsch CK, Albert A, Hunt A, Connor DF, & McIlvane WJ Jr (2008). Mood and Anxiety Symptoms in Psychiatric Inpatients with Autism Spectrum Disorder and Depression. Journal of mental health research in intellectual disabilities, 1 (4), 238-253 PMID: 24009649

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