Autism and Anxiety in Adults Dr. Barbara Luskin, PhD, LP Who is the Autism Society of Minnesota? Established in 1971, the Autism Society of Minnesota (AuSM) is a 501(c)(3) nonprofit organization committed to education, support, and advocacy designed to enhance the lives of those affected by autism from birth through retirement. AuSM members throughout the state of Minnesota and the upper Midwest include families, educators, caregivers, and professionals who support individuals with autism spectrum disorders (ASD). Dr. Barbara Luskin, PhD, LP Dr. Luskin is a licensed psychologist who has worked closely with children and adults with ASD for more than 30 years in professional and home settings. She specializes in providing both assessments and counseling to individuals with ASD and those who support them. Dr. Luskin earned her PhD from the University of Chicago in Human Development. Her practice includes the diagnosis and therapy for adults with ASD. She also facilitates a support group for independent adults with ASD and provides training and education to families and service providers. 1
Autism and Anxiety How does an autism diagnosis go hand in hand with anxiety? Review: What is Autism? DSM-5 Criteria (2013): A. Persistent deficits in social communication and social interaction B. Repetitive and stereotyped patterns of behavior, interests, and/or activities - Symptoms must be present in early childhood - Symptoms must cause clinically significant impairment in daily functioning How Does ASD Connect to Anxiety? Social and Communication differences: It is difficult for people with ASD to predict other s behaviors They often have experienced confusing negative reactions to their own behavior They have difficulty processing social cues Therefore: they are often on high alert when around others anticipating problems 2
How Does ASD Connect to Anxiety? continued Inflexibility: Lack of ability to control changes leads to anticipation of negative events Sensory Issues: Inability to filter sensory input also leads to anticipation of negative events Fear and Anxiety Fear: Reaction to an imminent threat Anxiety: Fear caused by anticipating a future threat Generalized Anxiety Disorder (GAD) Characterized by: Excessive, uncontrollable and often irrational worry about everyday things an anxiety that is disproportionate to the actual source of worry The anxiety will apply to several aspects of life, not just one. If the person has a specific fear, it s a phobia, not GAD 3
Social Anxiety Disorder (aka SAD, SAnD, or Social Phobia) Characterized by: Intense fear in social situations, causing distress and impaired ability to function in at least some parts of daily life It often develops after repeated attempts to interact with others fail Obsessive-Compulsive Disorder (OCD) Characterized by: Invasive, typically irrational thoughts that cause uneasiness, apprehension, fear, or worry; leads to repetitive actions to reduce anxiety If left untreated, can often increase over time, resulting in more and more extreme repetitive behavior (e.g., checking, hoarding, cleansing) Obsessive-Compulsive Disorder (OCD) continued Compulsions and obsessions are a response to anxiety, which differs from repetitive behavior displayed in people who have autism. For people with ASD, repetitive behaviors are a source of relaxation or of relief from physical discomfort. 4
Post Traumatic Stress Disorder (PTSD) Severe anxiety disorder or trauma-related disorder : Caused by: exposure to an intense event or repeated events Results in: psychological trauma overwhelming an individual s ability to cope *May result from overwhelming and/or chronic bullying or other abuse* Post Traumatic Stress Disorder (PTSD) - continued Diagnostic symptoms: Re-experiencing the original trauma(s) through flashbacks and nightmares Avoidance of stimuli associated with trauma Increased arousal: difficulty falling or staying asleep; anger; and/or hyper-vigilance (jumpy, easily startled) Fight/Flight/Freeze Rooted in the non-conscious part of the brain 5
Emotions Feeling Meaning Limbic System Frontal Cortex The limbic system usually reacts first to a crisis, and may not respond wisely. Example: A Spider Encounter 1. Person sees spider. 2. Limbic system reacts. 3. Body gets ready for action. Butterflies Begin 4. Muscles tense 5. Blood moves from digestive system 6
The Frontal Cortex Asks 6. Frontal Cortex activates and asks: 7. Is there a real threat? 8. What do I do now? Thought Ruts Watering the fear plant What is the Goal? Willingness to accept emotion but denial of its truth or ability to control our response 7
Cognitive Behavioral Therapy Learning to: Trust what you know (Logic) Not what you feel (Emotions) Have a plan for how to act even when emotions are strong Acceptance and Commitment Therapy (ACT) ACT is a variety of CBT that focuses on the fact that our language ability often leads to repetitive thought loops. The goal of ACT is to distinguish both feelings and thoughts from actions based on values. Coping Strategies Don t let anxiety be the boss 8
Recognize Be aware of your body Danger Adrenaline Body Changes We describe those body changes as emotions or feelings. Know What You Are Feeling Body Scan be aware of all the parts of your body that may respond to stress hormones: Face Torso Arms and Legs Gut Heart Lungs Know Your Own Emotions Learn the pattern of body sensations that characterize the feeling for you. 9
Label I am feeling anxious vs. I am anxious Fear (imminent) Anxiety (possible) Evaluate Many things are possible. Make sure you are looking at what is happening right now and what the likelihood of a negative event really is. Evaluate continued If there is a real threat: decide on an action If there is a realistic possibility of threat: decide what you can do to prevent or prepare If there is a remote possibility of threat or only the memory of threat: recognize, label, and use coping strategies 10
REMEMBER ALL FEELINGS PASS! Strategies for Reducing Anxiety Physical strategies: Breathing Rapid relaxation Progressive relaxation Deep pressure Exercise Physical Strategies: Breathing Breathing can be under conscious control but is closely tied to heart rate and other autonomic responses Breathe from your gut (abdominal breathing) Breathe through your nose Focus on the sensation of breathing Counting may help (in for 4 out for 4) 11
Self-Regulation: Rapid Relaxation Can be done anywhere quickly Rapid Relaxation Rapid Relaxation one technique (repeat four or more times): Take a deep slow breath Tense your body, hold tight, count to five Breathe out slowly Say to yourself, I am in control. Progressive Relaxation Start at the top of your head Tense and relax Proceed downward until you reach your toes 12
Deep Pressure Use your own body to provide deep pressure (isometrics) Push against something (pushups, wall pushups, etc.) Weighted blankets or similar tools Exercise Running, swimming, biking, sports, yoga, etc. Exercise provides both deep pressure and distraction Can be used preventatively as well Strategies for Coping Changing your focus: meditation and related strategies 13
Meditation Various techniques of refocusing your mind Two basic types: internal focus and external focus Most people need to practice meditation try it regularly when you are not overwhelmed with emotion. Visualization Does not have to be visual Imaging oneself in a calm, safe space can trigger relaxation response in the limbic system May require practice to maintain focus Focus on the Body Closely related to physical techniques Maintaining intense focus on breathing or other sensations you are feeling in the moment 14
External Focus Being Mindful or Present Focusing all of one s attention on an aspect of the immediate environment (sight, sound, touch, etc.) This prevents getting stuck in a thought rut Other Strategies Writing (journal, diary, blogging) Enjoying favorite activities Talking to friends/family/support staff Sensory input (increase or decrease as needed) Medication To do, or not to do 15
Should I Medicate for Anxiety? Cost/benefit analysis Both ongoing stress (anxiety) and medication can have negative effects There is no RIGHT decision. Medication: Positives and Negatives Positives: Medication can help smooth out moods, which results in improved focus and energy Positive effects can outweigh side effects Medication: Positives and Negatives Negative: all medications have side effects. Common side effects of medications include: Slowed down feeling Unclear thinking Flat affect Sleep and digestive problems, weight gain In some cases, intrusive thoughts or other changes in mental health symptoms 16
Medication: Paradoxical Responses Although it is hard to prove statistically, there is evidence that some people with ASD suffer paradoxical responses to medications Examples: Anti-depressants which increase suicidal thoughts and/or psychosis Anti-anxiety drugs which do little for anxiety but result in increased symptoms of autism (flat affect, etc.) Mood stabilizers which result in increased self-injurious behavior Medication: Cautions & Suggestions Some useful tips about medication: If possible, find a psychiatrist with autism experience Start with low, even sub-clinical, doses to reduce odds of side effects and paradoxical responses. Many people with autism respond to very low doses Don t assume it will work just because it works for neurotypicals (it doesn t work for all of them either) When a medication is started, keep a log of dosage, time taken, and apparent effects Know who to call for help at once if there are problems Medication: A Personal Decision The Internet is no substitute for a good physician! A knowledgeable patient can help a good physician Individuals respond differently to each medication, especially individuals with ASD It often helps to bring in a carefully-prepared written record of problems and side effects to give the physician rather than trying to remember on the spot. 17
Medication: A Personal Decision Medication should be: Reviewed regularly Tapered off if ineffective Wary of too many Rx medications What can medication do? It will not eliminate completely It can reduce anxiety Regular vs. PRN SSRIs/antidepressants Types of Medication Benzodiazepines/anti-anxiety: Klonopin, Valium, Ativan, Lorazepam Anti-seizure: Depakote, Tegretol, Trileptal, Topamax, Gabapentin Antipsychotics: Risperdal, Seroquel, Abilify, Clozaril, Geodon, Latuda, Zyprexa 18
Questions? Thank you! Dr. Babara Luskin www.ausm.org 19