Autism And Anxiety: Understanding The Connection

We all experience anxiety from time to time, but for autistic individuals, anxiety can be a frequent and overwhelming companion.

Autism and anxiety often intertwine, creating a complex landscape for those navigating both experiences.

While autism is primarily characterized by traits such as differences in social communication, restricted interests, and repetitive behaviors, anxiety can significantly impact the daily lives of autistic individuals.

The relationship between autism and anxiety is multifaceted, with each condition potentially exacerbating the other.

Understanding this intricate connection is crucial for autistic individuals, their families, and healthcare professionals alike.

This article explores the unique ways anxiety manifests in autism, the factors that contribute to heightened anxiety in autistic individuals, and effective strategies for managing these challenges.

Signs of anxiety in autistic individuals

Autistic individuals may display anxiety in many ways. Below are some common signs that may indicate someone is experiencing anxiety.

It’s important to note that anxiety may manifest differently in each autistic individual. Some may show more obvious signs, while others might internalize their anxiety.

• Heightened sensory sensitivities
• Increased repetitive behaviors or stimming
• Increased meltdowns or shutdowns
• Difficulty concentrating or processing information more than usual
• Overthinking
• Increased irritability or agitation
• Difficulty transitioning between activities
• Seeking more reassurance than normal
• Withdrawal or avoidance of social situations
• Emotional reactions such as crying or anger
• Physical symptoms like stomachaches, headaches, or muscle tension
• Changes in sleep patterns or difficulty sleeping
• Verbal or non-verbal expressions of worry or stress

Many of the signs of anxiety in autism may overlap with those associated with signs of sensory overload or autistic burnout.

There is probably not a clear distinction between anxiety and these other autistic experiences, it is likely they all impact each other or anxiety is the starting point before sensory overload and then eventually burnout occurs.

If an autistic person also has a co-existing anxiety disorder, they might also show the typical signs associated with these.

What can cause an autistic person to be anxious?

There are several ways in which anxiety can be triggered in autistic individuals. Below are some of these ways, but note that this is not an exhaustive list:

Sensory differences

Autistic individuals often experience sensory sensitivities, and research has shown a correlation between sensory processing difficulties and anxiety in autistic individuals.

Sensory overload, caused by hypersensitivity to stimuli such as loud noises, bright lights, or certain textures, can trigger anxiety and lead to avoidance behaviors.

“The idea of going to shopping malls makes me extremely anxious. The bright, florescent lights, loud chatter of other shoppers, crowds, and feeling stuck indoors can make me feel panicked and overstimulated. If I want to shop, I would prefer to shop on a high street and at quieter times, so I have access to fresh air and less noise.”

‘Hattie’

Communication differences

Communication difficulties can hinder an autistic individual’s ability to express their anxiety and internal experiences, making it difficult for others to recognize and provide appropriate support.

The inability to effectively communicate their needs and anxieties can lead to feelings of being misunderstood, which can further exacerbate anxiety.

“When I’m given the time to process and be creative, I can articulate words well. It’s just when speaking I feel pressured and rushed to respond.”

‘Milo’

Social situations

Navigating social situations can be particularly challenging for autistic individuals due to inherent difficulties with social communication and interaction.

These difficulties can lead to heightened social anxiety, as autistic individuals may experience anxiety related to potential negative evaluation or judgment from others.

“Often, I would just stay quiet in social situations because they felt too stressful. Then, I would be labeled as shy. I developed an aversion to that word because it always felt like it was used as a criticism against me as a kid.”

‘Abed’

Changes in routine and uncertainty

The need for predictability and adherence to routines is common among autistic individuals, and deviations from established routines or exposure to unexpected events can be particularly anxiety-inducing. 

Research indicates that difficulties with uncertainty are prevalent among autistic individuals and are strongly associated with anxiety.

“I have this need to always know exactly what is going on. If something doesn’t make sense and no one is able to tell me why something is the way that it is, then I feel anxious because I do not have the full picture.”

‘Sam’

Masking or camouflaging

Camouflaging, which involves masking or compensating for autistic traits, can lead to increased anxiety in autistic adults. This is because the effort to maintain a ‘neurotypical’ facade is often experienced as draining and stressful.

Autistic individuals may feel anxious before or during times of masking because of this.

Moreover, camouflaging can create a sense of inauthenticity and disconnect from one’s true self, potentially leading to lower self-esteem, feelings of isolation, and a diminished sense of belonging.

“Once I realized I was autistic, it made me rethink my whole personality and the way I acted, and I realized that I was pretty disconnected from who I actually was deep down and that I’d been repressing a lot of my interests. Realizing this really helped me reconnect with myself, but it also started feeling more and more exhausting to mask because I was repressing so much of myself and acting in a way unnatural to me.”

‘Maria’

Executive function demands

Executive functioning demands can trigger anxiety in autistic individuals due to challenges with information processing.

The need to quickly filter, prioritize, and respond to multiple inputs can be overwhelming, especially paired with multiple stimuli at once.

This can cause confusion and fear of misunderstanding, especially in fast-paced environments requiring quick processing and decision-making, resulting in heightened anxiety.

“During this group project discussion at school, I had to process multiple people speaking at the same time, formulate my own responses, recognize when it was the appropriate time for me to speak, and try to problem-solve for the actual task at hand. All of this made me feel overloaded and that I could not participate effectively.”

‘Julien’

Anxiety disorders in autism

Many autistic individuals may have co-existing anxiety disorders that can present with further difficulties or can exacerbate signs of anxiety associated with autism:

Social Anxiety Disorder

Social anxiety disorder (SAD) is consistently highlighted as a frequently diagnosed condition in autistic individuals. There also are a lot of overlaps in signs of autism and social anxiety.

Challenges in social communication and interaction in autism can lead to social anxiety due to difficulties understanding social cues and fear of negative evaluation in social situations.

Research indicates a strong association between SAD and difficulties with social skills, social functioning, and reduced social motivation in autistic individuals.

Social anxiety disorder in autism:

• May manifest as extreme avoidance of eye contact or physical touch, beyond typical autistic traits
• Could result in selective mutism in social situations due to overwhelming anxiety
• Might lead to intense preparation or scripting before social interactions to manage anxiety

Specific Phobias

Specific phobias are very common in autistic individuals, particularly in children.

Specific phobias in this population can manifest as fears of common childhood stimuli (e.g., needles, insects, animals) as well as more uncommon or idiosyncratic fears.

The latter often relate to sensory sensitivities (e.g., loud noises, bright lights, specific textures), changes in routine, or unfamiliar situations.

Notably, these phobias frequently stem from sensory hypersensitivity, a core characteristic of autism.

Specific phobias in autism:

• Could involve intense fears of seemingly harmless objects or situations due to sensory associations
• May lead to extreme avoidance behaviors that significantly impact daily functioning
• Might manifest as meltdowns or shutdowns when confronted with phobia triggers unexpectedly

Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is marked by excessive and persistent worry and reportedly has a higher prevalence in autistic individuals compared to the general population.

Autistic individuals with GAD may often experience worries about a wide array of topics, including school, finances, the future, and potential negative events.

These anxieties can be exacerbated by difficulties with understanding and navigating social situations and an increased sensitivity to sensory stimuli.

Generalized anxiety disorder in autism:

• May present as excessive fact-checking or information-seeking about topics of worry
• Could result in increased stimming or repetitive behaviors as a way to self-soothe
• Might lead to difficulty with decision-making due to constant worry about potential outcomes

Obsessive-Compulsive Disorder

While no longer classified as an anxiety disorder in the DSM-5, Obsessive-Compulsive Disorder (OCD) is often discussed in the context of anxiety in autistic individuals.

OCD is characterized by obsessions (intrusive thoughts) and compulsions (repetitive behaviors).

While present in both autistic and non-autistic individuals, OCD can stem from distinct underlying mechanisms. For instance, in autism, these may be rooted in a need for sameness and predictability rather than solely from anxiety.

Obsessive-compulsive disorder in autism:

• May involve rituals or compulsions that are more complex or elaborate than typical autistic routines
• Could manifest as an intense focus on symmetry or ordering objects beyond usual autistic preferences
• Might include intrusive thoughts related to special interests or sensory experiences unique to the individual’s autism

Managing anxiety as an autistic person

Address your sensory sensitivities

Create a list of specific triggers that lead to anxiety or sensory overload in a journal. You could group these triggers into categories based on type:

• Sensory Triggers (e.g., visual and auditory)
• Environmental Triggers (e.g., crowded spaces, disorganized environments)
• Social Triggers (e.g., extended social interactions, misunderstandings in communication)
• Cognitive Triggers (e.g., information overload, complex instructions or tasks)

Next, try to adjust your environment as much as you can to limit sensory input and have a sensory-friendly environment. This can depend on the situation you are in and what is causing you to feel anxious, for instance:

• Adjusting lighting to comfortable levels
• Reducing background noise
• Organizing spaces to minimize visual clutter
• Having a designated quiet space for low-intensity activities at home

By proactively addressing sensory needs, autistic individuals can reduce anxiety triggers and create a more comfortable daily experience.

Communicate your needs

Ideally, communicating with people you live with, friends, and family is helpful for them to understand what makes you anxious and how they can help you.

Below are some ways in which you can communicate your needs:

• Agree on specific non-verbal gestures with close friends and family as an indicator of when you need a break.
• Practice assertive phrases to express your needs, e.g., “I need a quiet space for 10 minutes.”
• Use smartphone apps to type out your needs when speaking is difficult.
• Use colored badges or wristbands to indicate current tolerance level, e.g., green for “I’m okay,” yellow for “I’m getting overwhelmed,” and red for “I need immediate help.”

It’s important not to rely on another person to help you entirely as you still need to put in the work yourself, but there may be things that they can feasibly do to help.

Plan ahead

Planning ahead is important because it can allow you to anticipate and prepare for challenging environments or situations.

By thinking through potential triggers and having strategies ready, you can reduce your anxiety and be better equipped to navigate potentially anxiety-inducing experiences.

Some examples of planning ahead include:

• Previewing new environments or situations where possible
• Carrying a “sensory emergency kit” with items such as sunglasses, earplugs, and comforting objects
• Establishing exit strategies or finish times for overwhelming situations
• If you already have a hectic schedule, say no to additional plans or schedule in low sensory breaks
• Avoiding situations where you know you will feel overstimulated
• Gradually introducing change and novelty into routines

Sleep hygiene

Research indicates a strong link between chronic sleep problems and anxiety in autistic adolescents and young adults. Addressing sleep issues can be a crucial aspect of anxiety management for autistic individuals.

Improve your sleep hygiene by:

• Establishing consistent bedtime routines
• Creating a calm and conducive sleep environment
• Limiting screen time before bed
• Avoiding caffeine and heavy meals close to bedtime

Implement relaxation techniques before bed, such as gentle stretching, deep breathing exercises, or listening to calming music. Keep a sleep diary to track patterns and identify triggers that may be affecting your sleep quality.

Gradually unmask

Unmasking, or allowing yourself to be your authentic autistic self, can be a powerful tool for reducing anxiety. However, it’s important to approach this process gradually and thoughtfully.

Steps to start unmasking:

1. Reflect on your masking behaviors: Identify specific ways you mask (e.g., suppressing stimming, forcing eye contact) and consider which behaviors feel most draining or anxiety-inducing
2. Identify safe spaces and people: Start with trusted friends or family members and choose environments where you feel comfortable being yourself
3. Set small, achievable goals: Begin with minor unmasking behaviors in safe situations. For example, Stimming openly in a private setting or sharing a special interest with a close friend
4. Practice self-reflection: After each unmasking experience, consider how it went. Note others’ reactions and your own feelings

Gradually increase your unmasking as you become more comfortable. Remember to practice self-compassion throughout this process, as it can be emotionally challenging. Celebrate your progress and recognize that setbacks are normal.

Consider disclosing your autism to trusted individuals if you feel safe doing so. This can often lead to more understanding and allow for more authentic interactions. Seek support from friends, family, therapists, or support groups as needed.

Remember, unmasking is a personal journey that looks different for everyone. Find a balance that feels safe and authentic to you, and go at your own pace.

Have your own coping strategies

It can be crucial to equip yourself with a toolbox of coping mechanisms tailored to your individual needs and preferences when anxiety strikes.

Some ideas of these include:

• Relaxation techniques: Engaging in mindfulness practices, deep breathing, or progressive muscle relaxation can help manage anxiety and sensory overload.
• Sensory Breaks: Taking breaks in a calming environment, even for short periods, can help reduce anxiety. This could involve finding a quiet space or engaging in calming activities.
• Sensory Tools: Using sensory tools like sunglasses, headphones, or fidget toys can help regulate sensory input.
• Personal rating system: Regularly check in with yourself about current anxiety levels and take action based on your personal threshold rating.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT), a form of therapy that addresses negative thought patterns and behaviors, can be beneficial in managing anxiety in autistic individuals. This may be particularly helpful for those with co-occurring anxiety disorders.

However, it may be necessary to modify standard CBT approaches to better suit the cognitive and social-communication styles of autistic individuals.

Research suggests the following modifications may increase the effectiveness of CBT for autism:

• Incorporating visual aids
• Focusing on practical skills training
• Addressing sensory sensitivities
• Visual strategies

References

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Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools (pp. 125–148). American Psychological Association. https://doi.org/10.1037/14338-007

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