Autism Spectrum Disorder (ASD) and Anxiety

Anxiety evolved in humans as an adaptive survival mechanism. It is characterised by fear, worry, or distress that helps protect us from potential or perceived danger. Brain regions such as the amygdala rapidly detect possible threats and trigger physiological responses—including increased heart rate, heightened alertness, and the release of stress hormones—to prepare the body for action¹. While this “fight or flight” response can act as a protective measure in genuinely threatening situations, it can become problematic when activated too frequently or in response to situations that pose little or no actual danger. Some individuals are more prone to experiencing anxiety than others, and a person’s level of anxiety can fluctuate depending on the presenting situation and can range from mild to severe. Different types of anxiety include separation anxiety, social anxiety, generalised anxiety, obsessive compulsive disorder (OCD), and specific phobias.

Research studies show that anxieties are commonly experienced by individuals on the autism spectrum^2,3 and can significantly affect daily functioning, emotional well-being, learning, and quality of life.

1. Separation Anxiety: Separation anxiety manifests as excessive distress when separated from a parent or caregiver. Although it is not uncommon in early childhood, it can persist into later childhood and beyond in some individuals with ASD because of a strong preference for routine, familiarity, and predictability. A child experiencing separation anxiety can become emotionally overwhelmed and refuse to attend creche or school, or engage in activities without reassurance from a trusted adult.
2. Social Anxiety: Social anxiety is characterised by intense fear or discomfort in situations where a person feels they may be judged, negatively evaluated, or misunderstood by others, potentially leading to strong feelings of embarrassment. Individuals with autism (without an intellectual disability) are particularly vulnerable to social anxiety due to their limited social skills and difficulty reading and interpreting social cues. Studies show that many children with ASD experience social rejection (or perceived social rejection) and/or bullying, which can further increase anxiety and reduce self-confidence. As a result, some individuals on the autism spectrum may avoid social interactions, withdraw from group activities, or rely on rehearsed social scripts. Some adults with autism may use their phone (or pretend to use it) or go to the bathroom to avoid having to interact with others.
3. Generalised Anxiety: Generalised anxiety refers to persistent and excessive worry across many areas of life rather than in response to one specific trigger. Generalised anxiety can be experienced by individuals with ASD, leading to excessive worry about future events or the safety of loved ones. Such anxiety is associated with restlessness, difficulty relaxing, sleep difficulties, fatigue, repetitive questioning, or reassurance-seeking. Physical symptoms are a feature of generalised anxiety and can include muscle tension, headaches, gastrointestinal discomfort, increased heart rate, and sweating.
4. Obsessive Compulsive Disorder (OCD): OCD is characterised by intrusive, unwanted thoughts, obsessions, and repetitive behaviours or mental rituals (compulsions) performed to help manage and alleviate anxiety. Although OCD and ASD both involve routines and repetitive behaviours, they differ in their underlying causes. In OCD, behaviours are driven by distressing and unrealistic fears (e.g., if I walk a different route to work, something terrible will happen to my family or friends), whereas repetitive behaviours in ASD typically provide predictability, emotional regulation, or sensory comfort rather than reducing OCD-type fears. Nevertheless, some individuals with ASD can also experience co-occurring OCD.
5. Specific Phobias: Many people, including those on the autism spectrum, have specific phobias. Phobias are characterised by intense fear of particular situations or objects; e.g., thunderstorms, spiders, medical or dental visits, public transport, or certain animals. Sensory sensitivities, previous distressing experiences, and difficulties coping with uncertainty may all contribute to the development of phobias.
6. Sensory-Related Anxiety: Many individuals with autism experience anxiety that is closely linked to sensory processing issues. Bright lights, loud noises, crowded environments, or certain textures may be experienced as overwhelming and can lead to sensory overload. Anticipation of these situations can itself produce anxiety, resulting in avoidance of places such as shopping centres, classrooms, or public transport, thus limiting participation in everyday activities.

Interventions and Supports

The efficacy of any intervention for anxiety depends on an individual’s specific abilities, needs and the severity of the anxiety experienced. Cognitive Behavioural Therapy (CBT) is an evidence-based form of therapy and is widely used to help reduce anxiety. Therapists who work with individuals with ASD generally use an adapted form of CBT to cater for the individual’s language, social and adaptive functioning skills^4,5.

When anxiety is severe, medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) may be prescribed by a GP or psychiatrist. However, research findings regarding the effectiveness of anti-anxiety medications for individuals on the autism spectrum are mixed, with studies often yielding contradictory results^6,7. The use of such medication requires careful monitoring by a physician (medical doctor) due to variability in patient response and potential side effects. When medication is prescribed, it is generally used alongside psychotherapeutic interventions rather than as a standalone treatment.

Environmental supports can also play an important role in reducing anxiety. Predictable routines, visual schedules, clear communication, sensory-friendly spaces, structured support plans, and appropriate accommodations in school or the workplace can all help reduce anxiety, improve emotional regulation, and promote participation in everyday activities.

– The Autism Hub Team, 13/07/2026

References

1. Pittman, C. M. & Karle, E. M. (2015). Rewire your anxious brain: How to use the neuroscience of fear to end anxiety, panic & worry. Oakland: New Harbinger Publications.
2. van Steensel, F. J., Bögels, S. M., & Perrin. S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14(3). 302-317. doi: 10.1007/s10567-011-0097-0
3. Zaboski, B. A. & Storch, E. A. (2018). Comorbid autism spectrum disorder and anxiety disorders: A brief review. Future Neurology, 13(1), 31-37. doi: 10.2217/fnl-2017-0030
4. McDonald, M. E., & DiGennaro Reed, F. D. (2018). Distinguishing science and pseudoscience in the assessment and treatment of autism spectrum disorder. In S. Goldstein & S. Ozonoff (Eds.), Assessment of autism spectrum disorder, 2nd edition (pp. 415–441). New York, NY: The Guilford Press.
5. Gaus, V. (2019). Cognitive-behavioural therapy for adults with autism spectrum disorder, 2nd edition. New York: The Guilford Press.
6. Deb, S., Roy, M., Lee, R., Majid, M., Limbu, B, Santambrogio, J. et al. (2021). Randomised controlled trials of antidepressant and anti-anxiety medications for people with autism spectrum disorder: Systematic review and meta-analysis. BJPsych Open, 7(6):e179. doi: 10.1192/bjo.2021.1003
7. Manter, M. A., Birtwell, K. B., Bath, J., Friedman, N. D. B., Keary, C. J., Neumeyer, A. M. et al. (2025). Pharmacological treatment in autism: A proposal for guidelines on common co-occurring psychiatric symptoms. BMC Medicine, 23(1), 11. doi: 10.1186/s12916-024-03814-0.

Author: autismhub