Becky beamed as she walked out the front door of her friend’s house, hurried down the steps and out to her mom’s car. The excitement of the party was overshadowed a bit by another kind of happiness—triumph. She had survived the party without an anxiety attack, for the first time ever.
Social anxiety had been an issue for Becky for as long as she could remember. Having autism and social anxiety disorder together made social gatherings even more complex. At 12, she finally had the chance to experience a social event from beginning to end: activities, gifts, food—all of it.
Her mom’s smile matched her own as they both silently celebrated the win and the milestone. They would talk about this incredible moment tomorrow. Right now, the ability to meet her current need for a quiet debrief was just icing on the cake of a perfect day.
In this article we will discuss autism and social anxiety (SA), how they interact with each other, and what can be done to bring your children and adolescents with autism and/or SA the same joy and success as Becky.
What is social anxiety?
According to a report titled: Social Anxiety in Adults with Autism: A Qualitative Study: “SA is characterized by physiological anxiety manifesting before or during social situations, concerns about negative evaluation and a tendency for avoiding interactions (APA, 2013). For some individuals, symptoms are mild, solely occurring in specific contexts (e.g., workplace presentations or at parties); for others, SA is pervasive, affecting most interactions (NICE, 2013).
“Symptoms typically start during adolescence, and persist for several years before help is sought. Importantly, SA is associated with an increased risk of other clinical problems, such as anxiety and affective disorders, excessive substance or alcohol use and poorer quality of life (Wong et al., 2012).”
Is social anxiety part of autism?
Since social cues are difficult for many on the autism spectrum, some would assume that social anxiety would be almost a given. However, social anxiety and autism do not always go hand in hand. An individual can have both social anxiety disorder and autism, they can also only be autistic, or only have social anxiety disorder.
The same study also found that “data from multiple samples, across settings, consistently indicate that a significant proportion, but not all, individuals with autism have SA”.
How do social anxiety and autism affect each other?
The way these two conditions interact can be described as exacerbation. Someone with autism can develop social anxiety because of repeated negative outcomes after social interaction. Someone with social anxiety and autism could find their obstacles to social skills compounded, making them that much more difficult to manage.
What are the similarities between autism and social anxiety?
The similarities of social anxiety disorder and autism are significant. Let’s look at a few of them together.
One similarity autism and social anxiety share is the way they are believed to be caused. According to most researchers (although this is debatable), both are triggered by a combination of biological and environmental influences. Both seem to run in families, but no one is exactly sure why.
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Social anxiety can be caused by challenges related to autism as well. The difference is, social anxiety does not cause autism. The similarities lie in their presentation, mainly.
Both autism spectrum disorders and social anxiety disorder share a commonality of being “invisible”. As such, they are both also widely misunderstood.
The challenges they pose are often seen as something to “just get over” by others. This can take a toll on self esteem, social skills, and connection with others.
Some of the situational avoidance of social anxiety and autism overlap as well. The Mayo Clinic outlines difficulties of social anxiety disorders as follows:
“Common, everyday experiences may be hard to endure when you have social anxiety disorder, including:
- Interacting with unfamiliar people or strangers
- Attending parties or social gatherings
- Going to work or school
- Starting conversations
- Making eye contact
- Entering a room in which people are already seated
- Returning items to a store
- Eating in front of others
- Using a public restroom”
Some of the social difficulties of autism spectrum disorder often include: making eye contact, starting conversations, and interacting with unfamiliar people. These coincide with the list above.
In a study titled Autistic Traits and Symptoms of Social Anxiety are Differentially Related to Attention to Others’ Eyes in Social Anxiety Disorder, we can see the reasons behind difficulty making eye contact, and how they overlap in autism and social anxiety.
“Individual differences in SAD symptoms in individuals with ASD may be related to atypical functioning and structure of the amygdala, a subcortical area linked to fear processing, association learning and social cognition, particularly orienting to human faces (Amaral et al. 2003; Whalen et al. 2013). In line with this, South et al. (2011) found that autonomic fear conditioning in a group with ASD was positively related to social anxiety, but negatively related to autistic traits. Taken together, this suggests that a dimensional approach is important for understanding the biological mechanisms underlying ASD.
“The overlap between ASD and SAD can be attributed to a number of causes. First, it is likely that some individuals with ASD or autistic traits develop social anxiety over time, as a consequence of repeated difficulties in social interactions (Bejerot and Mörtberg 2009; White et al. 2011). Secondly, the high incidence of social anxiety in biological relatives of people with ASD suggest a degree of genetic overlap (Piven and Palmer 1999).
“On the other hand, there is also a concern that superficial similarities in overt behaviors result in inflated correlations between self- or parent-report targeting the two conditions (Cholemkery et al. 2014). For example, a lack of close friendship could be the result of reduced social motivation (Chevallier et al. 2012b) or a lack of social skills (Jobe and White 2007) as well as anxiety driven avoidance. An improved characterization and differentiation of the two conditions is therefore desirable.”
Someone with high functioning autism, or asperger syndrome, may present the same symptoms socially, and this could cause them to be diagnosed with social anxiety disorder instead. Conversely, someone with social anxiety disorder could also be diagnosed as being on the autism spectrum, if their other symptoms are not properly examined. This is why an autism diagnosis, and a diagnosis for social anxiety disorder should come from a qualified person offering professional medical advice.
What are the differences between autism and social anxiety?
The diagnostic criteria for both social anxiety disorder and autism are vastly different. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for social anxiety is:
“Fear or anxiety specific to social settings, in which a person feels noticed, observed, or scrutinized. In an adult, this could include a first date, a job interview, meeting someone for the first time, delivering an oral presentation, or speaking in a class or meeting.
“In children, the phobic/avoidant behaviors must occur in settings with peers, rather than adult interactions, and will be expressed in terms of age appropriate distress, such as cringing, crying, or otherwise displaying obvious fear or discomfort.
- typically the individual will fear that they will display their anxiety and experience social rejection
- social interaction will consistently provoke distress
- social interactions are either avoided, or painfully and reluctantly endured
- the fear and anxiety will be grossly disproportionate to the actual situation
- the fear, anxiety or other distress around social situations will persist for six months or longer and
- cause personal distress and impairment of functioning in one or more domains, such as interpersonal or occupational functioning
- the fear or anxiety cannot be attributed to a medical disorder, substance use, or adverse medication effects or
- another mental disorder, and
- if another medical condition is present which may cause the individual to be excessively self conscious- e.g., prominent facial scar, the fear and anxiety are either unrelated, or disproportionate. The clinician may also include the specifier that the social anxiety is performance situation specific – e.g., oral presentations (American Psychiatric Association, 2013)
The criteria for autism spectrum disorder is:
“a child must have persistent deficits in each of three areas of social communication and interaction (see A.1. through A.3. below) plus at least two of four types of restricted, repetitive behaviors (see B.1. through B.4. below).
- Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.”
Though autism does present social challenges, the development of social anxiety disorder would be considered a comorbid condition.
How does the combination of autism and social anxiety affect mental health?
Poor social skills can wreak havoc on a person’s mental stability and health. Especially if their skills are limited by social anxiety disorder and autism spectrum disorders. Self esteem is often built, and torn down, within the context of social circles.
If someone has social anxiety alone, it is often difficult for them to relate to others in social settings, as well as for others to relate to them. If you add in the challenges of autism such as:
- difficulties reading social cues
- hyper fixation of special interests
- inability to make or keep eye contact
This can cause a perfect storm of disappointment, hardship, and added anxiety symptoms.
“Rates of co-occurring mental health problems are incredibly high. More than 40% of adults with autism have one, or more, mental health conditions, including, anxiety disorders, obsessive compulsive disorder (OCD), low mood and depression, psychosis and post-traumatic stress disorder (PTSD; Joshi et al., 2013; Lever & Geurts, 2016; Russell et al., 2016). Mental health comorbidities exacerbate functional impairment, reduce propensity for independent living, decrease health-related quality of life and increase carer burden (Mason et al., 2018; Murphy et al., 2018).”
In one study, the effects of social support on resilience to stress concluded:
“The literature reviewed above clearly demonstrates the harmful consequences of poor social support and the protective effects of having access to rich and functional social networks on maintaining physical and psychological health.”
The importance of social support has been well documented in individuals with mental struggles. If someone is cut off from social support because of anxiety or the misunderstandings autism can bring, their chances of struggling mentally increases, while their chance of receiving support socially for those conditions decreases. This is a dangerous combination.
So what can be done?
Can social anxiety disorder be cured?
There are treatment options available to those with social anxiety disorder. As always, each person is unique, and their treatment plan should be tailored to them.
How is social anxiety disorder treated?
Treating social anxiety symptoms begins with a formal diagnosis. Once the diagnosis is in place, then solutions can be gained. Social skills can improve over time with social skills training.
According to the Mayo Clinic: “Your health care provider will want to determine whether other conditions may be causing your anxiety or if you have social anxiety disorder along with another physical or mental health disorder.
Your health care provider may determine a diagnosis based on:
- Physical exam to help assess whether any medical condition or medication may trigger symptoms of anxiety
- Discussion of your symptoms, how often they occur and in what situations
- Review of a list of situations to see if they make you anxious
- Self-report questionnaires about symptoms of social anxiety
- Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association
Once a diagnosis is made, treatment can be planned and executed. Treatment for social anxiety can include:
- alternative therapies, lifestyle changes
- practicing learned skills and coping strategies”
When dealing with social anxiety disorder from an autistic perspective, the above treatment options will take into consideration an autistic person’s specific needs and challenges. Alternative therapies, for one, could include things like occupational therapy and applied behavior analysis therapies. These options may already be a part of an autistic person’s schedule, and learning social skills can reduce the risk of anxiety altogether.
Some individuals on the autism spectrum have comorbid social anxiety disorder. Watching out for your loved one on the spectrum whether they are adolescents with autism spectrum disorders, autistic adults, and young children who are not yet experiencing social anxiety, is important.
Social anxiety disorder does not cause autism and developmental disorders. However, the challenges that those disorders can bring, can cause social anxiety. If you suspect your loved one is fighting social anxiety symptoms, seek professional medical advice.
There are resources available to protect and encourage them. The worst thing we can do for our loved ones with SA is to ignore, criticize, or punish them for their inability to overcome their “invisible” symptoms.
Relatable to us or not, they are real, and they can be powerful. Doing all we can to encourage, understand, and empower our loved ones can make the difference between life and death.
The support we provide, the services we engage, and the resources we take advantage of are all powerful allies in the work to reduce social anxiety, triumph over the obstacles presented by autism, and improve the mental health of our loved ones!
There are some resources I would like to provide to anyone who may need them. These are personal recommendations only.
Book: Raising a Shy Child, Christine Fonseca
Book: All My Stripes, Shaina Rudolph
Spain, D., Zıvralı Yarar, E., & Happé, F. (2020). Social anxiety in adults with autism: a qualitative study. International journal of qualitative studies on health and well-being, 15(1), 1803669. https://doi.org/10.1080/17482631.2020.1803669
aOzbay, F., Johnson, D. C., Dimoulas, E., Morgan, C. A., Charney, D., & Southwick, S. (2007). Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont (Pa. : Township)), 4(5), 35–40.
Kleberg, J. L., Högström, J., Nord, M., Bölte, S., Serlachius, E., & Falck-Ytter, T. (2017). Autistic Traits and Symptoms of Social Anxiety are Differentially Related to Attention to Others’ Eyes in Social Anxiety Disorder. Journal of autism and developmental disorders, 47(12), 3814–3821. https://doi.org/10.1007/s10803-016-2978-z