by Dr. Elisabetta Burchi and Dr. Eric Hollander

The Autism and Obsessive Compulsive Spectrum Program and the Anxiety and Depression Program at the Albert Einstein College of Medicine and Montefiore Medical Center :

Spectrum Neuroscience and Treatment Institute:

Last publication for APPI


In recent history, autism has been identified in several gifted artists and scientists, although it is more generally associated with severe and impairing conditions. Today, we talk about “autism spectrum disorder” (ASD), a definition that recognizes the heterogeneity and complexity of a lifelong condition, whose symptoms fall into a continuum and account for large variations from patient to patient. A number of medical and psychiatric comorbidities ranging from gastro-intestinal and autoimmune disorders, to ADHD, depression, OCD and anxiety disorders, contribute to challenges in assessment and treatment of this condition, which requires a multidisciplinary approach. 

Although anxiety is not considered a core feature of ASD, anxiety disorders are the most common comorbid conditions in these patients. Because of the great impact on the course of the disorder, recognizing anxiety and treating it properly is particularly important for the well-being of these patients. 

Core Aspects Of ASD And Their Clinical Presentation

As the Diagnostic and Statistical Manual of Mental Disorders- 5th edition states, the core symptom domains of ASD are constituted by deficits in social communication across multiple contexts (deficits in social-emotional reciprocity, non-verbal communication and developing relationships), as well as restricted, repetitive patterns of behavior and interests. 
These symptoms must be present in the early developmental period, however they may not become apparent until later in life.

  • Deficits in social communication 
    • Atypical or absent eye contact is one of the first symptom observed in early childhood. Facial expressions may be difficult to read; vocal characteristics also appear to be atypical, such as monotonous, flat, exaggerated or inappropriate voice; atypical gestures may also be present, with a lack of pointing to orient other’s attention.  On the other hand, these children have troubles in reading facial expressions, gestures, and emotions in others; these difficulties along with language delays promote consequent difficulties in social interactions. 
  • Repetitive patterns of behavior, restricted interests and resistance to change 
    • Children with ASD typically present with lack of interest in others, showing preference for objects that may be used in a nonplay stereotyped manner or for self stimulation, sometimes linked to unusual response to sights, sounds, smells or textures. Rigidity may encompass ritualistic habits (eg eating the same food everyday) and restricting interests, defined as unusually intense interest with an object or a topic that usually lead to activities with no functionality (eg because of a preoccupation with cars, memorizing all makes and models). Resistance to change is usually expressed with any deviance to routine (for example, during travel routes, if a detour is taken, children can act out with tantrum and self-injury).

When Do These Patients Seek Help?

The main reasons why patients with ASD seek help can be divided into two categories, reflecting two different subgroups of the disorder: 

  • behavioral issues, such as aggression, irritability, self-injurious behaviors,  linked to the core aspect of repetitive behaviors and compulsivity; these issues especially concern the subgroup with intellectual disabilities and language difficulties.
  • internalizing symptoms, such as depression and anxiety, that patients with ASD, especially those with “high functioning autism” may develop as a result of their insight but continued lack of social communication skills

Is Anxiety An Important Problem In Autism?
Although anxiety is not considered a core feature of ASD, 40% of young people with ASD have clinically elevated levels of anxiety or at least one anxiety disorder, including obsessive compulsive disorder. 
It is particularly important to recognize and treat anxiety in ASD since it has a great impact on the course and the core aspects of the disorder, exacerbating social withdrawal as well as repetitive behaviors. 
Moreover, while untreated comorbid anxiety has been associated with the development of depression, aggression, and self-injury in ASD, an early recognition and treatment may convey better prognosis for these patients. 

How Anxiety Arises In ASD And How To Recognize It
It’s not easy to recognize the presence of anxiety in patients with ASD, because of overlapping symptomatology and altered presentations of symptoms. 
Patients who are minimally verbal may be unable to report their internal states (eg worry) and instead demonstrate anxiety through disruptive behaviors, while others may be verbally fluent but present with difficulties in understanding ones’ own emotions and expressing these emotions. 

Typically, anxiety may present with different features at different times in the course of ASD and in association with different demands from environment:

  • Specific phobia: a specific phobia, namely an intense, irrational fear of something that poses little or no actual danger, may arise early in the course of ASD because of over responsiveness to sensory stimulation, such as a loud environment; specific phobias in these patients usually involve highly unusual stimuli  (eg advertisement jingles, balloons popping, vacuum cleaners, toilet flushing, alarms at school..), but may also present fears (eg of the dark, insects, needles) that are typical of developing youth.
  • Obsessive compulsive disorder:  characterized by unwanted and intrusive thoughts and consequent compulsive behaviors, OCD is often comorbid with ASD; identifying comorbid OCD in these patients is important because while the engagement in repetitive behaviors which is typical of ASD is unrelated to distress, compulsions are performed as a coping mechanism to relieve anxiety.
  • Social anxiety: as the patient ages and the environment becomes more demanding, social communication impairment may underline the development of social anxiety, especially if the patient is high functioning and aware of his/her social incompetence. Social anxiety, defined as intense anxiety or fear of being negatively evaluated in a social or performance situation, in turn leads to avoidance of social situations, therefore limiting the patient’s opportunities to practice social skills, and may predispose the individual to negative reactions from peers and even bullying. 
  • Separation anxiety: social impairment may evoke overprotective reactions from parents that in turn may strengthen avoidance behavior in the child; separation anxiety may then arise when the patient has to separate from attachment figures, for example at the moment of leaving the family for college.
  •  Other atypical symptoms of anxiety: youth with ASD often experience symptoms of anxiety that not necessarily fit within a diagnosis, for example intense levels of distress related to changes in their routine or environment.

How To Treat Anxiety In ASD. A Personalized Approach 

The evidence concerning the impact of anxiety on the course of ASD highlight the importance of treating anxiety problems in a timely fashion to improve overall functioning of individuals with ASD. 
While not a core aspect of ASD, but rather a distinct disorder arising in the course of ASD, anxiety can be treated separately from the other domains of the disorder, but treatments have to be adapted to this population. 
Specific approach for the treatment of anxiety in this population include:

  • Pharmacological treatment for anxiety in ASD
    • Although selective serotonin reuptake inhibitors (SSRIs) are considered the first line of pharmacological treatment for anxiety disorders and OCD in the general population, research examening their use in ASD is limited and controversial, with modest efficacy and high rates of negative effects. Our studies on Fluoxetine in adults and children with ASD showed improvement in repetitive behaviors, however a large controlled trial showed that Citalopram doesn’t differ from placebo in reducing repetitive behaviors and that some patients have negative behavioral effects, such as hyperactivity, impulsivity and insomnia. ASD patients may be sensitive to low doses of drugs and present considerable variations in treatment responses and adverse events to medications. Our group has seen that a genetic variant can be associated with adverse events to SSRIs in these patient. There is limited evidence to support the use of Buspiron for anxiety in autism.  
  • Psychotherapy and social skills interventions for anxiety in ASD
    • Cognitive behavioral therapy (CBT) has demonstrated robust efficacy for treating anxiety disorders and OCD in youth with ASD, especially in those with high functioning and adequate verbal skills. The core treatments components of CBT for anxiety involve: 
      • psychoeducation about anxiety (eg learn to differentiate between helpful and unhelpful anxiety, identify physiological components of anxiety)
      • cognitive strategies (eg learn to identify anxious cognitions and improve executive functions and flexibility) 
      • behavioral strategies (eg graded exposure to feared stimuli) 
      • interventions with parents: psychoeducation and parent-meditated interventions for core symptoms (eg building helpful parenting responses to anxious behaviors and assisting the child to implement techniques outside the session) and maladaptive behaviors (eg changing maladapting behaviors in parenting style, such as over protection that limit the child’s independent daily skills). 
    • Just as ASD patients need personalized use of medications, psychological interventions should be adapted to the characteristics of these patients to be fully effective.
    • Clinicians should integrate standard CBT with approaches that focus on the core characteristics of autism that can mediate the development of anxiety or also limit the effectiveness of standard approach:
      • emotional literacy and mindfulness-based approach may be helpful to improve those emotional recognition skills that are required to consequently tolerate the experience of aversive emotions and respond flexibly to stressors; 
      • social skills interventions, such as in vivo practice of reciprocity skills, in order to improve engagement with others and emotional responses;
      • make large use of concrete examples, visual prompts and also virtual reality environment to help the patient to cope with difficulties in abstract thinking.
  • New investigational approaches:  our research group is currently conducting clinical trials investigating oxytocin, vasopressin receptor 1A antagonists and cannabinoids (CBDV) as treatments to specifically target the mechanisms thought to be involved in the core aspects fo ASD, namely social communication and repetitive behaviors, which are also linked to anxiety. Further research is needed.

Take Home Messages

  • There are many treatments for ASD patients, such as pharmacotherapy, psychotherapy, educational therapy, occupational therapy, physical therapy and family interventions.
  • These patients need a personalized and multimodal assessment and treatment. 
  • Consideration of co-occurring conditions is particularly important in designing interventions that improve overall functioning. 
  • Anxiety should never be neglected in ASD and may be treated as a separate diagnosis, but therapy should be adapted for these patients.
  • Early intervention programs for infants with or at-risk for ASD with the goal of facilitating skills to improve coping and resilience, may prevent the escalation of anxiety symptoms.

About the Authors

BurchiHollander.PNGDr. Elisabetta Burchi is resident in psychiatry at the University of Florence (Italy) and research fellow at the Autism and Obsessive Compulsive Spectrum Program at Montefiore Medical Center and the Albert Einstein College of Medicine

Dr. Eric Hollander is the Director of Spectrum Neuroscience, as well as a Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine and Director of the Autism and Obsessive Compulsive Spectrum Program at Montefiore Medical Center and the Albert Einstein College of Medicine.

Dr. Hollander has published more than 500 scientific publications in the professional literature. Dr. Hollander is listed for the past ten years in NY Magazine’s and Castle Connolly’s “Best Doctors”, and “Best Doctors in America”.

Nowhere in this article does it mention the devastating, long-term physical consequences of anxiety and stressors which are very well known. Attention should be paid to this issue for the benefit of those on the spectrum as well as the alarming financial burden of these consequences on families and society. Inflammation alone, created by effects of anxiety, wreaks havoc on the human body. This needs to be addressed in the research and literature.

I totally agree. I was hoping atypical presentations of anxiety (the debilitating type) would be mentioned and for these cases, other methods of treatment whether in psychotherapy or pharmacotherapy would be presented in these otherwise stubborn cases of anxiety in the struggling population of young people with ASD.

Programs and services are not available for patients over 18. A significant number of ASD patients begin to exhibit anxiety and depression closer to high school graduation and after when they realize they are entering the adult world without structure and safety of the school, IEP and resources end after graduation and nothing is available in th communities. A large population is falling through the cracks because services and programs for adults with these issues are not there.

I agree Suzanne! My son just graduated high school and is having a tremendous amount of anxiety. We tried to start him in a Jr. college and he could not handle it. The sad part is that he is crying so hard, because he wanted this to work. He can’t go to college, can’t work, can’t drive! All because of his terrible anxiety. How can he go on with his life with nothing out there to help him?

He needs to take care of himself and find his own limitations. I say to your son: Do not stretch too far but begin to understand yourself and the limitations that are you. It is not your fault and you can find enough coping tricks to make your life a success. That takes time, lots of time and creativity. I am 72 and I managed falling down and standing up not knowing till recently that I am on the spectrum. Get your collage education or whatever through the internet. Find other aspergers on the net too. Take care of yourself by whatching over yourself. It is a lifelong condition and I do believe that anxiety is a core deficit of autism. You only break yourself by stepping over the lines of your sanity. Good luck you will make it!

I have 2 adult sons on the Autism Spectrum. We had genetic testing for MTHFR to discover both of them had double mutations. They both now take Deplin or L-methy Folate. Please check into the need for supplementation and how it helps those with anxiety.

I'm not sure, but I believe I am on the spectrum with Asperger's. So much anxiety. Some things I am really good at. People say I'm social and I am, but I didnt instinctively know how to communicate. No self worth?? I have a master's degree yet deep down I know I'm different..I share too much personal info trying to figure out who I am and why do I feel things so deeply, analyze all thoughts..what I said and what others said. I was bullied in adult life via my ex husband and his family and my siblings never understood me. Emotional neglect with HSP and aspergers..I feel alone because I want to understand. So I'm not sure but the anxiety is killing me. I absorb abusive words and behaviors and thrive with supportive people. I take 250 mg of Ashwaghanda, 250 mg of Gaba and 50 mg of to two times a day. It has helped so much but I know environment is important. I've suffered from controlling and abusive people my whole life..if I'm Aspergers with OCD and possibly ADHD, it will explain a lot. It's hard to endure life when people don't like you being different..

I read a book called "Reset Your Child's Brain." It mentions that screens of all types (smart phones, video games, social media, online pornography) are at the root of, or highly related to, many of the issues Asperger's/Autistic young men and women are facing today. I hope you have considered that possibility. Excessive screen time often makes an organic problem even worse.

Your storey is heartbreaking and hits close to home for my family. My son is going through this for several months now. Hard to see him suffer. Your in our prayers

I have ASD I have anxiety blow outs. On the verge of becoming homeless. I have found no real help just doctor's offering anti-psychotics. Ones the cause deep depression & suicidal thoughts. My social skills are shot I have no real social skills talking face to face with people for very long. sound sensitivity. yes curtain sounds or volumes trigger anxiety for me. I'm dealing with allot here. And Salem don't have the help I need all they got is more pills....

Hello! Have you read
From Anxiety to Meltdown
How Individuals on the Autism Spectrum Deal with Anxiety, Experience Meltdowns, Manifest Tantrums, and How You Can Intervene Effectively
By Deborah Lipsky · 2011
About this edition
ISBN:9780857005076, 0857005073
Page count:240
Published:August 15, 2011
Publisher:Jessica Kingsley Publishers
Author:Deborah Lipsky

I've found this very useful and hopefully can use it to help my son, 9, who has been suffering with anxiety for over a year.
It effects his every day life, he physically makes himself sick to avoid school trips (because the tigers at the zoo might escape and eat the kids), he can't sleep (because what if the smoke alarms go off and it doesn't wake him up), there's more and I have no idea where it comes from. No matter what I say or how I try and explain and get him to feel safe, it doesn't work, I'm no where near qualified enough for this. And of course this has lead to OCD behaviour, checking sockets are off, smoke alarms must be tested, doors must be checked, windows have to be closed and locked. I'm torn between not wanting to harm him by refusing to let it be done or enabling him. But after 12 months of begging Drs, being refused by local child mental health services (because he's not suicidal, that's no joke by the way that's actually what we were told) and having private councillors turn us away because he's autistic, I'm stuck with hoping what I read on the Internet will help us help him.

I was told by a very experienced behavioral therapist consultant that in order to find a psychiatrist or psychiatric nurse practitioner who would evaluate my autistic adult son and provide medication monitoring that I must not approach mental health professionals with stating that my son was autistic but rather my approach must be a solid statement about my son's anxiety, depression, agitation, and aggression. I took her advice. I did mention that my son was autistic as well. I stated that my son is aware he is different and that he is aware he cannot do those things that other men his age do ie go to college, get a job, keep a job, go out on dates, drive an automobile, etc. The awareness of his limitations causes my son extreme anxiety that exhibits as depression, violent thoughts, banging his head on a wall (new behavior), anxiety, agitation, and agression some of the time. I discovered that these are the words that fit the type of work mental health professionals are there to address which in turn more adequately describe my 30 year old son's mental health state. My son is an only child. I am my son's advocate, care provider, biological mother; and his power of attorney both medical and financial.

I am the grandfather of a male child who is 2 and a half years old and he is suspected of having ASD when left in my care he is a well behaved child who likes to play on his own but when his father is present he is like a shadow and follows his father everywhere and tries to hold onto his fathers legs and when he gets handed back to his mother every second Friday he screams and can be heard screaming when he is 100 metres down the road. Do you have any suggestions on how we should deal with this.

So last night I would be watching a show around those it was the last panic attacks but I'm doing all right full of rage and just a movie romance movies not into movies that makes you cry so much that most people wanted a woman has like tons of her cousins want a trophy husband lazy ones that a panic attack strikes open fears and sad