In the third part of our four-part series on Exploring Autism, Professor Tony Attwood describes some conditions that commonly co-occur with autism. In the first part of our series, Tony discussed autism in an historical context. In the next part he shares his observations on how different individuals cope with autism, and the various outcomes of these coping mechanisms. Next week Tony will discuss prognosis in autism.
We now recognise that there is an association between autism and anxiety, with approximately 80% of autistic children and adults feeling mildly anxious for much of their day, and for most of their life. They often experience intense anxiety in specific situations, such as when there are changes in routine or expectations, uncertainty in what to do or what is going to happen, fear of imperfection and making a mistake and specific sensory experiences. There can also be anxiety in crowded places such as a shopping mall on a Saturday. Research has confirmed that an anxiety disorder is the most common mental health problem for autistic adults. Sometimes, the level of anxiety experienced may be perceived as actually more disabling than the diagnostic characteristics of autism.
Research and clinical experience indicate that approximately one third of autistic adults experience cyclical feelings of sadness and pessimism that can evolve into a clinical depression. There are many reasons why an autistic person may become sad and depressed. These include feelings of social isolation, loneliness, and not being valued and understood by family members and colleagues. Another reason for depression is the exhaustion experienced due to socializing, trying to manage and often suppress emotions, especially anxiety, and coping with sensory sensitivity. The person is constantly alert, trying to endure perpetual anxiety whilst suffering a deficit in emotional resilience and confidence. The mental effort of intellectually analysing everyday interactions and experiences is draining, and mental energy depletion leads to thoughts and feelings of despair.
Recent research has explored the association between autism and alexithymia, that is the ability to recognize or describe one’s own thoughts and emotions. An autistic person will have genuine difficulty converting their thoughts and feelings into speech. When asked why they may have done something, or to describe their feelings regarding an event, they may simply reply, ‘I don’t know’. This is not their being obtuse or evasive, but an expression of a recognized difficulty with self-reflection and self-disclosure of inner thoughts and feelings through speech. Psychological therapy for mental health issues will need to accommodate the profile of abilities and experiences associated with autism, such as alexithymia, the lifetime experience of extensive bullying and teasing, and sensory sensitivity. We now have psychological therapy manuals specifically designed for adults who have autism and I have been able to contribute with my colleague Dr Michelle Garnett to many of the manuals and therapy programmes. We have designed and evaluated individual and group programmes for anxiety and depression, to build resilience to bullying and teasing, and acquire abilities in the areas from love and romance to employment.
There is increasing evidence that autism is associated with specific learning disorders such as dyslexia and hyperlexia, attention deficit hyperactivity disorder, intellectual disability, and specific language disorders. Thus, the diagnostic journey does not end with confirmation of autism. Conversely, the diagnostic journey for autism may start with the accurate diagnosis of another mental or personality disorder and a detailed developmental history indicates the presence of autism. Research and my own clinical experience suggest that around one in four patients with an eating disorder, substance abuse, gender dysphoria and borderline personality disorder have a dual diagnosis. There is also an association between autism and Tourette’s disorder, sleep disorders and bipolar disorders. Clinicians in all areas of psychology and psychiatry need to be aware of the characteristics of autism in a patient’s developmental history and profile of abilities. When the diagnosis is confirmed, adapt their psychotherapy to accommodate the autistic patient who has a different way of perceiving, thinking, learning, and relating compared to other patients.
While we acknowledge the concept of autism plus, we also acknowledge the concept of autism pure. Around 15 per cent of autistic adults have no additional diagnoses and they often have a different prognosis.