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Autism can mask anxiety symptoms

by  /  17 February 2015

Cases and concepts: Matthew Siegel looks at autism case by case.
Ivan Canu

I first met Greg, an 18-year-old with autism, when he was admitted to our developmental disorders unit after hitting staff members at his school. Over the past year Greg had become increasingly agitated much of the time: pacing, resisting going into the community and becoming aggressive when asked to vary his routine.

After taking a detailed history and observing him for a number of days, it was clear to us that Greg was highly anxious. He resisted entering new settings, was hyper-alert and appeared distressed during transitions throughout the day. Although some of these behaviors are associated with autism, Greg’s degree of distress far exceeded the norm.

Anxiety appears to be common in individuals with autism. In fact, a study of our inpatient unit published in December found that 63 percent met criteria for an anxiety disorder, such as social phobia or obsessive compulsive disorder. This is in line with results from previous studies.

Despite this notable prevalence, however, we lack standardized tests for anxiety that are suitable for people with autism, brief enough for clinical practice and sensitive to the full spectrum of communication skills and cognitive abilities. We are still unclear whether what we call anxiety is simply a feature of autism that is more pronounced in some individuals or a separate disorder, and how this might vary based on an individual’s specific subtype of autism.

For this reason, the National Institute of Mental Health (NIMH) has challenged the field to look beyond diagnostic categories to underlying mechanisms, such as physiologic arousal level, ability to inhibit impulses and emotion regulation. Not only will this help to identify more objective measures of anxiety, it may also yield treatment targets.

For now, we have tried to help Greg by adapting treatments designed for neurotypical people. We slowly exposed him to new environments and used medication to temper his arousal and reactivity. We also gave him tools to better communicate his needs, including a visual schedule and ‘break’ cards, providing him with a safe way to manage his distress.

These interventions have been largely unstudied in people with autism, but we were fortunate. Greg became calmer and more comfortable. He was also more willing to resume his favorite activities and, not surprisingly, less likely to hit people. But Greg’s case highlights the dire need for diagnostic tools and treatments for, as well as a deeper understanding of, anxiety in people with autism.

Matthew Siegel is director of the Developmental Disorders Program of Spring Harbor Hospital in Portland, Maine, clinical investigator at the Maine Medical Center Research Institute and assistant professor of psychiatry and pediatrics at Tufts University in Massachusetts.

12 responses to “Autism can mask anxiety symptoms”

  1. Shannon Doty says:

    Here’s a great article on autism and social anxiety for those who are interested.

  2. Carol says:

    Who in the Phoenix Az area can test a young adult for ashbergers ?

    • victimofmeds says:

      find alternate treatment my grandson 12 years old has been severley altered by serious side effects from medications not approved for autism

    • victimofmeds says:

      find alternate treatment my grandson 12 years old has been severley altered by serious side effects from medications not approved for autism

    • victimofmeds says:

      find alternate treatment my grandson 12 years old has been severley altered by serious side effects from medications not approved for autism

  3. sally Evans says:

    I have a 23 year old daughter diagnosed at 8 years old, she also has SPD and ocd she weighs 250 pounds mostly because of medications. She has major outbursts and attacks family members, very aggressive. I don’t know how to provide the sensory input that she needs. Any suggestions!!!

  4. Jenn says:

    What tests would we ask for? Also worried about suppressing feelings and leading to depression. Where would I take the child for such testing? 12 yr old – feels like he has to fix everyone else and put himself last.

  5. Julie says:

    What medication do you recommend to temper arousal?

  6. Robert Cox says:

    I will be presenting at the Autism Society’s national conference for the second time and addressing this very issue there. In my research I am finding that cortisol is spiked in individuals with autism who are experience what I call “sensory trauma”. They are under consistent attack by their environment and in research studies involving a stressor applied (a pin prick in one study) cortisol levels have been increased. We also know that cortisol increase is indicated in heightened anxiety and the expression of psychosis. I agree that research along these lines needs to be more extensive and could lead to treatment implications. I have found a good deal of success in treating high functioning individuals by teaching mindfulness excercises. Not coincidentally I feel, there is a good amount of research showing that these techniques lead to significant reductions in cortisol levels. I am in the process of finishing my research and presentation for the 2015 conference in Denver along these lines and would love to see you there so we can discuss this further.

  7. gregboustead says:

    For family members and others seeking information about autism resources, services, and participating in research, I recommend visiting the Interactive Autism Network community site:

    Also note: is not a resource for medical information. We cover a range of autism science, including basic research as well as translational and treatment studies. However, the vast majority of potential treatments we describe are a long way from being comprehensively tested to ensure effectiveness, suitability, or safety. And although we welcome in the comments a diversity of perspectives on the research, as part of the scientific discourse, we discourage and will actively moderate any treatment recommendations based on experimental data.

    Thank you for helping keep comments on-topic and appropriate, per our community guidelines:

    Greg Boustead, community manager

  8. Paula Weerkamp-Bartholomeus says:

    ReAttach for autism is a psychotherapeutic intervention in which external arousal regulation (without medication) is used to reduce anxiety problems.
    More information about this promising intervention is published in professor Michael Fitzgerald s book Autism Recent Advances (open access, free download):

    A first impression of ReAttach for Autism is available by watching this video on You Tube

    A research paper title “ReAttach a multimodal intervention for ASD?” will be published in Clinical Neuropsychiatry soon.

    Paula Weerkamp-Bartholomeus

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