Even though mental illness can be more common for people on the autism spectrum than in the general population, the mental health of autistic people is often overlooked. Here we look at anxiety, obsessive compulsive disorder (OCD) and depression.
By Dr Anastasios Galanopoulos, Dr Dene Robertson, Ms Debbie Spain and Dr Clodagh Murphy. This information is drawn from an article that first appeared in the Mental Health supplement of Your Autism Magazine, Vol 8(4), Winter 2014.
Anxiety disorders are very common amongst people on the autism spectrum. Roughly 40% have symptoms of at least one anxiety disorder at any time, compared with up to 15% in the general population. Understandably, this can lead to sadness or depression – one reason why a mixture of anxiety and depression is common.
It is thought that a combination of factors, leading to vulnerability to stress, is likely to explain why anxiety disorders are so common in autistic people. Biological differences in brain structure and function, a history of social difficulties (leading to decreased self-esteem and a tendency to think of threats as greater than they are) and problems with finding flexible responses to apparent threats are all likely to contribute.
Many people on the autism spectrum may have difficulty describing the symptoms they experience. A sudden change in behaviour could mean they have developed an anxiety disorder, even if there is no complaint of the typical symptoms.
Treating anxiety disorders
Most of the time we learn to cope with difficult situations, whether or not we are autistic – often by "sitting it out" and learning that we have not come to harm from the situation that worried us.
However, if we have an anxiety disorder, we are more likely to try to escape from the difficult situation. This leads to a greater fear of the same situation and an even earlier escape the next time it occurs. In other words, anxiety tends to build on and reinforce itself. It is important to try to break this vicious cycle, and this is why cognitive (to do with thoughts) and behavioural psychological treatments are often as important in treatment as medication.
Usually these treatments involve forming a working relationship with a therapist, building up any necessary skills, and deciding to work through a set of challenges (involving exposure to an aspect of the feared situation) one step at a time that are anxiety-provoking but not intolerable. This way both the mind and the body learn that the feared situation isn't as dreadful as was thought, and this leads to a gradual reduction in anxiety. Such an approach is often very effective. Mind's website has further information about common anxiety disorders.
Obsessive compulsive disorder (OCD)
OCD is an anxiety disorder. If someone has OCD, it means that they experience repetitive thoughts and behaviours that are upsetting to them. OCD occurs in about 2-3% of people who are not autistic and is more common in people who are autistic. It is thought that our genes (DNA) and our psychological predisposition can make us vulnerable to developing OCD, which can run in families. OCD can be distressing, exhausting and can get in the way of everyday life for the person who has it and their families. However, it is treatable.
There are two main parts to OCD: obsessions (thoughts) and compulsions (behaviours). OCD can be overlooked in people on the autism spectrum as it may be mistaken for repetitive behaviour. However it is very different. If you think that you have OCD, let your GP know about your concerns. They will help you think about what to do and can refer you for a specialised assessment to help work out what may be OCD (or not) and what may be autism. Although there is increasing awareness of OCD, it is still under-recognised and therefore under-treated. If you are autistic and think that you may have OCD, it's best to get an assessment and treatment by a team that specialises in both autism and OCD.
There are two recommended treatments for OCD: Cognitive Behavioural Therapy (CBT) and medication. CBT gives you tools to help you change the way you think and act. As the most researched psychological treatment for OCD, there is now evidence that specialised CBT is effective for treating OCD and anxiety in people on the autism spectrum.
Medication can be used either alone or in combination with CBT. The types of drugs that are usually prescribed for OCD are called Selective Serotonin Reuptake Inhibitors, or SSRIs. These include drugs like Fluoxetine (trade name Prozac) and Paroxetine (Seroxat). Some autistic people can be vulnerable to side-effects from medication and so it’s best to start with a low dose, which you and your doctor can increase slowly over time if needed, monitoring your symptoms with an OCD monitoring scale.
Information about autism and OCD (psychoeducation) and social skills work can also form part of a helpful package of individualised care for people on the autism spectrum and OCD.
MIND’s website has further information about OCD.
It is very common to have times in our lives when we feel a bit sad or low. But when these feelings last for more than a few weeks and get in the way of day-to-day functioning, this can indicate a period of depression. This is no different in an autistic person than a non-autistic person. It is estimated that at least 20% of the population will experience a period of depression at some point but it is even more common in people on the autism spectrum. People who are depressed can experience a range of symptoms which vary from person to person in their combination, and can be mild or severe.
It may be especially hard for depressed people on the autism spectrum to seek help because they might find change daunting and anxiety-provoking, feel worried that they will be blamed, or feel unsure about how to describe their symptoms. Anxiety and depression can also make people more generally introverted, withdrawn and isolated. All people with depression may have difficulty sharing their thoughts and feelings. But because people with autism can have difficulty labelling their feelings, it can be especially hard to communicate symptoms or concerns.
Read more about the causes and treatment for depression on the Mind website.
Treatments for depression can be psychological or medical, regardless of whether a person is autistic.
The most important step to getting help is for the autistic person to tell someone they trust, such as a family member, a close friend, their GP or another professional. Some people need a referral to a specialist service, either because they would benefit from psychological therapy adapted for autistic people, or due to a more complex set of problems.
Anxiety disorders, OCD and depression are just a few of the mental health problems people on the autism spectrum may experience. For more information on other types of mental health problems, you may find it useful to visit the websites listed below.
- Mind www.mind.org.uk, for more information on all types of mental health problems
- Young Minds www.youngminds.org.uk, for advice on mental health for young people
- OCD Action www.ocdaction.org.uk, for OCD information and support
- SANE www.sane.org.uk, working to improve quality of life for anyone affected by mental illness
- Mental Health Foundation www.mentalhealth.org.uk, the UK’s leading mental health policy, research and service improvement charity
- Depression Alliance www.depressionalliance.org, bringing people together to end the loneliness and isolation that so often come with depression
- CALM (Campaign Against Living Miserably) https://www.thecalmzone.net/, exists to prevent male suicide in the UK
- The National Autistic Society’s Autism Helpline www.autism.org.uk/enquiry, can be contacted for information about counselling and other therapies/interventions
Our authors are from The South London and Maudsley Hospital Adult Autism and Behavioural Genetics Clinic. Find out more about their work at www.national.slam.nhs.uk/adultautism or call 020 3228 4653.