Psychiatric Annals

CME Article 

Symptoms of Anxiety in Patients with Autism Spectrum Disorder

Hillarie Budoff, MD

Abstract

CME Educational Objectives

1. Understand that symptoms of anxiety are common in patients with autism spectrum disorder (ASD).

2. Incorporate into practice the knowledge that research suggests that selective serotonin reuptake inhibitor (SSRI) treatment for patients with ASD plus anxiety symptoms is effective in reducing anxiety.

3. Know when cognitive-behavior therapy, in conjunction with direct instruction of social skills using applied behavior analysis intervention components, may be effective for treating anxiety in individuals with high-functioning ASD.

The patient is a 15-year-old boy who began exhibiting behavioral difficulties shortly after birth. At age 2 months, he cried all day, every day, and this lasted until he was 8 months old. He would have to be rocked violently to be soothed. He had to be touched constantly, and for months could not sleep without his mother’s touch; if she withdrew her hand he would start screaming. He complains of ongoing sleep issues.

Abstract

CME Educational Objectives

1. Understand that symptoms of anxiety are common in patients with autism spectrum disorder (ASD).

2. Incorporate into practice the knowledge that research suggests that selective serotonin reuptake inhibitor (SSRI) treatment for patients with ASD plus anxiety symptoms is effective in reducing anxiety.

3. Know when cognitive-behavior therapy, in conjunction with direct instruction of social skills using applied behavior analysis intervention components, may be effective for treating anxiety in individuals with high-functioning ASD.

The patient is a 15-year-old boy who began exhibiting behavioral difficulties shortly after birth. At age 2 months, he cried all day, every day, and this lasted until he was 8 months old. He would have to be rocked violently to be soothed. He had to be touched constantly, and for months could not sleep without his mother’s touch; if she withdrew her hand he would start screaming. He complains of ongoing sleep issues.

The patient is a 15-year-old boy who began exhibiting behavioral difficulties shortly after birth. At age 2 months, he cried all day, every day, and this lasted until he was 8 months old. He would have to be rocked violently to be soothed. He had to be touched constantly, and for months could not sleep without his mother’s touch; if she withdrew her hand he would start screaming. He complains of ongoing sleep issues.

When the patient started preschool at age 3 years, he had tremendous difficulty separating from his mother. He would cry hysterically and refused to enter the school. It became so extreme that he bit his teacher in the neck, kicked, hit, and tried to escape.

Once he did enter the school, he would cry and only sit in one spot all day, and he would not participate in activities. His teachers had difficulty engaging him in anything that did not include his interests. These interests, almost obsessions, began at a young age and ranged from “obsessions” about dinosaurs to genetics.

Because of his difficulties, he attended four different nursery schools over a period of 2 years. He received his first Individualized Education Plan (IEP) when he was 4 years old, providing him with speech, occupational, and physical therapies. Even though he was very verbal early in life, he had early language difficulties because he did not develop the conversational language necessary for him to succeed socially. He was evaluated at age 4 years by a psychiatrist and diagnosed with a sensory and motor integration disorder with a variety of sensitivities and anxiety. At that time, he was started on fluoxetine and recommended treatment services.

The youth also had difficulty succeeding in elementary school. He attended five different schools in 6 years because his needs were not met academically or emotionally. During these years, he received speech, occupational, and physical therapies, but these services were not adequate to meet his specialized needs.

When he was in seventh grade, the patient moved with his mother, father, and brother to New Jersey and was sent to a large public school. His teacher did not follow his IEP and he had a disastrous year. The boy was bullied so badly that he tried to run away. He was so depressed that the school would not allow him to return until he received a psychiatric evaluation stating that he was not a threat to himself. This caused him to miss 2 weeks of school until he was able to receive an adequate psychiatric evaluation. He felt very isolated and alone. Also, his assignments were handed in very late and he constantly felt tremendous anxiety that he did not handle well.

Because of this, his parents decided to home school him with an online curriculum this past academic year. He continues to suffer emotionally and academically because of his rigid thinking, emotional fragility, inability to think abstractly, and lack of social understanding. He also feels lonely because he has very limited socializing opportunities.

Currently, the patient’s anxieties and social limitations present in numerous ways. For instance, when new people come to visit, he locks himself in his bedroom and refuses to come out. He often spends all day in his lower bunk bed, “cocooned” with blankets and wedged between the mattress and the wall because this makes him feel “safe.” He often “catastrophizes” by thinking things like, “If I can’t finish my assignments, then I won’t pass my class, then I won’t graduate from high school, and I won’t be able to go to college. If I can’t do any of this then I will never be able to get a job.” He has tremendous anxiety about not succeeding in life.

Diagnosis

Autism Spectrum Disorder with Co-occurring Anxiety Disorder

The patient was first diagnosed with sensory integration disorder and anxiety in March 2001 and started on fluoxetine at age 4 years. In December 2001, he was given a “rule out” diagnosis of schizophrenia and treated with risperidone, an antipsychotic medication. In 2002 and 2003, he was diagnosed with obsessive-compulsive disorder, bipolar disorder, and nonverbal learning disorder and was treated with trileptal and paroxetine. In 2007, he was diagnosed with Asperger’s syndrome.

When the patient came for evaluation 6 months prior, the diagnosis of autism spectrum disorder (ASD) was conferred and the youth was also diagnosed with anxiety disorder, not otherwise specified. The mother and patient were oriented to symptoms of ASD and symptoms of anxiety.

It was explained that autism is a pervasive developmental disorder affecting three key domains: impaired communication; social interaction; and stereotyped or restricted/repetitive behaviors.1 They were given psychoeducation that anxiety disorders often involve symptoms of excessive worry about everyday life events when no obvious reasons for worry are present. They were told that anxiety is common in individuals with ASD and may complicate treatments designed to improve the symptoms of ASD. It was explained that the prevalence of ASD is 1 in 88 children, according to recent US Centers for Disease Control estimates based on tracking select populations in the US.2 Estimates of the prevalence of anxiety disorders in the ASD population vary from 11% to 84%.3

Although it is often assumed that individuals with ASD prefer isolation and minimal social contact, many people with ASD are intensely aware of their social disconnectedness and appear to wish it could somehow be different.4 Therefore, if a child has a co-occurring anxiety disorder, it could compound the overall social impairment associated with ASD.

The boy and his mother were told that anxiety may worsen during adolescence, as he faces an increasingly complex social milieu and becomes more aware of his differences and interpersonal difficulties.

Treatment

The patient is being treated with fluoxetine 40 mg/d and weekly cognitive-behavioral therapy. There are presently no empirically supported treatments that target the behavioral and emotional concerns frequently presented by school-age children and adolescents with ASD, including anxiety.5

Pharmacologic studies have reported preliminary evidence for the efficacy of certain medications for the treatment of anxiety with ASD; however, none of these studies included a control group or placebo condition, and the sample sizes were small.6 There have been case reports, chart reviews, and retrospective studies indicating that anxiety symptoms have been diminished with patients with ASD when treated with monotherapy of selective serotonin reuptake inhibitors, including sertraline,7,8 fluvoxamine,9 fluoxetine,10 and citalopram.11 An open-label trial of buspirone was also conducted to treat anxiety and irritability in children with ASD.12 Thus, conclusions based on this research are tenuous at best.13

Psychosocial treatments have also been investigated. Systematic reviews and randomized clinical trials suggest that cognitive-behavior therapy in tandem with direct instruction of social skills using applied behavior analysis intervention components may be effective for treating anxiety in individuals with high-functioning ASD.14

For individuals with an ASD and an anxiety disorder but no intellectual disability, cognitive-behavior therapy seems effective when it is modified by direct instruction of social skills, increased family involvement, visual supports, individualized reinforcers, embedded perseverative interests in sessions, and reduced emphasis on abstract concepts and visualization.14 For individuals with an ASD and an anxiety disorder who do have an intellectual disability, much less evidence is available.14

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn., text rev. Washington, DC: American Psychiatric Publishing; 2000.
  2. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2008 Principal Investigators. Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2008. MMWR Surveill Summ. 2012;61(3):1–19.
  3. White SW, Oswal D, Ollendick T, Scahill L. Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev. 2009;29:216–229. doi:10.1016/j.cpr.2009.01.003 [CrossRef]
  4. Attwood T. Strategies for improving the social integration of children with Asperger syndrome. Autism. 2000;4:85–100. doi:10.1177/1362361300004001006 [CrossRef]
  5. White SW, Oswal D, Ollendick T, Scahill L. Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev. 2009;29:216–229. doi:10.1016/j.cpr.2009.01.003 [CrossRef]
  6. White SW, Oswal D, Ollendick T, Scahill L. Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev. 2009;29:216–229. doi:10.1016/j.cpr.2009.01.003 [CrossRef]
  7. Bhardwaj A, Agarwal V, Sitholey P. Asperger’s disorder with co-morbid separation anxiety disorder: a case report. J Autism Dev Disord. 2005;35:135–136. doi:10.1007/s10803-004-1041-7 [CrossRef]
  8. Ozbayrak KR Sertraline in PDD. J Am Acad Child Adolesc Psychiatry. 1997;36:7–8.
  9. Kauffmann C, Vance H, Pumariega AJ, Miller B. Fluvoxamine treatment of a child with severe PDD: a single case study. Psychiatry. 2001;64:268–277. doi:10.1521/psyc.64.3.268.18456 [CrossRef]
  10. Silveira R, Jainer AK, Bates G. Fluoxetine treatment of selective mutism in pervasive developmental disorder. Int J Psychiat Clin. 2004;8:179–180. doi:10.1080/13651500410006143 [CrossRef]
  11. Couturier JL, Nicolson R. A retrospective assessment of citalopram in children and adolescents with pervasive developmental disorders. J Child Adolesc Psychopharmacol. 2002;12:243–248. doi:10.1089/104454602760386932 [CrossRef]
  12. Buitelaar JK, van der Gaag J, van der Hoeven J. Buspirone in the management of anxiety and irritability in children with pervasive developmental disorders: results of an open-label study. J Clin Psychiatry. 1998;59:56–59. doi:10.4088/JCP.v59n0203 [CrossRef]
  13. White SW, Oswal D, Ollendick T, Scahill L. Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev. 2009;29:216–229. doi:10.1016/j.cpr.2009.01.003 [CrossRef]
  14. Lang R, Mahoney R, Zein F, Amidon M. Evidence to practice: treatment of anxiety in individuals with autism spectrum disorders. Neuropsychiatr Dis Treat. 2011;7:27–30. doi:10.2147/NDT.S10327 [CrossRef]
Authors

Hillarie Budoff, MD, is a child and adolescent psychiatrist in the Bronx Public School System and an Attending Psychiatrist at Montefiore Medical Center.

Address correspondence to: Hillarie Budoff, MD, 1623 Third Avenue, Suite 202, New York, NY 10128; email: Htishler@yahoo.com.

Disclosure: Dr. Budoff has no relevant financial relationships to disclose.

10.3928/00485713-20120806-05

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