Anxiety as Comorbidity By Nicole Seaward & Hari Srinivasan

Over the summer, I was part of a Stanford Rebuilt Project - NDGifts (Neuro diversity, Giving Individuals full team success.). It was a collaborative effort by around 72 people from across the world. It is the idea of helping employers better understand ND so that ND folks also become part of the employment landscape. I wrote the section on Anxiety as Comorbidity of the 81 page report.
Link to the Report: My section starts on Page 50. Here it is again for reference. 

Anxiety as Comorbidity in Neurodiversity

By Nicole Seaward & Hari Srinivasan 

Reviewed by Kamel Webster 

Overview of Anxiety 

Anxiety is a universal human experience that triggers the impulses to fight, flee, or freeze. Symptoms of anxiety include “persistent feelings of restlessness, irritability, difficulty concentrating, sleep disturbance, fatigue, nausea, diarrhea, and muscle cramps” (Bandelow, Michaelis, & Wedekind, 2017). Anxiety is the result of both biological and environmental factors. “Childhood adversity, stress, or trauma” contribute to the development of anxiety disorders with the age of onset being around eleven (Bandelow, Michaelis, & Wedekind, 2017). Anxiety can be extremely intense and result in illness and lost time at work or from school. Chronic, pervasive anxiety is often characterized by excessive worry, rumination, and anticipatory anxiety. This generally results in avoidance behavior which reinforces anxious feelings (Riordan & Singhal, 2018) and can impact one’s participation in daily life. While optimal anxiety increases performance, too much can have a detrimental impact, and when left untreated, anxiety can cause significant functional impairments (Riordan & Singhal, 2018). When one is experiencing anxiety, the state of arousal can be so distracting that learning and memory are negatively affected (Riordan & Singhal, 2018). Furthermore, anxiety can disrupt relationships as well as social development (Riordan & Singhal, 2018). Common treatments for anxiety include both therapy and pharmacological treatments. It is important to identify and treat severe anxiety, but also to recognize the occasional benefits of anxiety in its milder forms. 

Autism Spectrum Disorder (ASD) 

Anxiety is common in those who are autistic as a result of sensory sensitivities, societal expectations, disclosure, and camouflaging. The illustration by Halim, Richdale, & Uljarević (2018) below provides a succinct overview of the many causes of anxiety in autistics. Estimates of the co-occurrence of anxiety and autism range from 40% (Rosen et al., 2018) to 48% (Smith, Ollendick, & White, 2019). Furthermore, research has shown that the added presence of anxiety can significantly impact quality of life (Smith, Ollendick, & White, 2019). Autistics prefer routines and when one is disrupted this can cause significant stress to the individual. Therefore, the management of the “intolerance of uncertainty” is an important factor in addressing anxiety in autistics. (Hwang et al., 2019).

In addition to the factors noted above, there are various ways in which the social environment can cause or exacerbate anxiety in autistic individuals. One of the authors of this section, Hari Srinivasan, has autism, ADHD and Dysgraphia. He can testify to the pressure of constantly trying to fit into “normal” societal expectations beginning in childhood. Since the societal “normal” itself is ill-defined, it is akin to chasing a moving target which is a constant source of stress. The result is constantly facing gatekeeping at every step, be it in education, social opportunities and in the field of employment. Autism can be both visible and invisible both of which can contribute to anxiety in their own way. For instance, Srinivasan’s autistic traits, with atypical body mannerisms and limited speech, are very visible. Therefore, disabilityrelated stigma may exist, whether overt or subtle, from employers and co-workers from the start. Those with an invisible form of autism face the dilemma of trying to camouflage their autism or disclosing their disability in order to avail of the ADA accommodations; either choice contributing to anxiety. In addition, a common misconception is that autism somehow magically disappears in adulthood, when in reality, years of therapy have only served to ‘mask’ some of the more overt atypical mannerisms. This means that anxiety associated with being autistic continues into adulthood though the intensity of anxiety may well depend on an individual's physiology and resilience. 

Untreated anxiety will negatively impact entering the workforce, sustaining employment and enjoying the quality of life one expects from productive employment. Another author of this section, Nicole Seaward experienced autistic burnout after too many years of camouflaging and trying to fit in as “normal” in the workplace. Seaward experienced daily panic attacks and anxiety related to work that eventually became too much and she temporarily lost many of her executive functioning skills making independent living difficult and working impossible. Autistic burnout is still a new term and is characterized by “chronic exhaustion, loss of skills, and reduced tolerance to stimulus” (Raymaker et al., 2020, p. 136). Autistic burnout has serious consequences that can be reduced when the proper supports are in place and the individual no longer feels the need to hide their autistic traits (Raymaker et al., 2020).

Attention Deficit Hyperactivity Disorder (ADHD) 

ADHD presents varying degrees of challenges in the areas of hyperactivity, inattention, impulsivity, concentration, productivity, memory, and focus. Comorbid and ‘hidden impairments’ are common among those with ADHD, including anxiety (Adamou et al. 2013). In fact, nearly 25% of children diagnosed with ADHD had some form of anxiety disorder (Bilgiç et al., 2013). Many of the challenges associated with ADHD “generate anxiety-provoking situations” (Bilgiç et al., 2013). Individuals with ADHD may struggle to maintain their focus which can impact task completion. Their memory might be poor due to being distracted while intaking information and learning. In other studies, a physiological link has shown that anxiety in the ADHD population correlates with lower neural activity or poor performance with visuospatial working memory tasks (Meer et al., 2017).

Srinivasan points to his experience of ADHD as a cause of anxiety. In his case, ADHD can mean an impulsive fidgeting body, which society does not regard as an appropriate social mannerism. There are also some internal conflicts when ADHD is combined with autism - ADHD can mean a certain need for newness (easily bored) which conflicts with “sameness” that the Autism desires. Depending on the situation, environment and topic, attention itself can go from hyper focus to inattention. The level of body activity too can go from hyperactive to hypoactive. Having to navigate the terrain of a potentially unaccepting social or workplace environment on top of the uncertainty of your own body reaction creates for constant anxiety laden scenarios which affect productivity

Dyslexia 

Anxiety is often higher in dyslexic individuals due to the near constant challenges related to learning, subsequent feelings of inadequacy, and fear of failure (Carroll & Iles, 2006). Dyslexia is marked by challenges with writing and reading, along with functioning memory, processing speed, organization, and time management. As a result of these challenges, dyslexics are associated with “depression, anxiety, lower self-esteem, and often, behavioral problems” (Livingston, Siegel, & Ribary, 2018). Weak reading skills can contribute to lower academic achievement which has shown to lead to an increase in levels of social anxiety (Carroll & Iles, 2006). Negative emotions from living with dyslexia can contribute to “lower self-efficacy and competency relating to work, and increased work anxiety” (Livingston, Siegel, & Ribery, 2018, p.126). The challenges of dyslexia start in the early years of education, continue into adulthood and can impact success in the workplace. 

Dysgraphia

Dysgraphia can be developmental or acquired through injury and is characterized by difficulty with the physical act of writing or typing due to challenges with fine motor skills (Tafti & Abdolrahmani, 2014). Difficulty with gripping a writing utensil, typing written words, discerning units of language (especially new words), and managing working memory contribute to frustration and low self-esteem (McCloskey & Rapp, 2017). Furthermore, when an individual is focused entirely on writing words, they are not fully able to concentrate on learning and therefore can fall behind. The experiences of repeated failures, bullying, and loneliness associated with dysgraphia are tied to increased levels of anxiety (Biotteau et al., 2019). As mentioned above, feelings of anxiety lead to avoidance behaviors and this can result in the dysgraphic individual opting out of experiences that will increase their education and chances of engaging in fulfilling employment.

Srinivasan offers an explanation of his experience of dysgraphia as related to motor apraxia, motor memory, motor planning issues and even dysregulation in the ability to form a body schema. There is more to writing than just the ability to grip and pick up a pen or pencil and scribble on paper. There is a lot of motor planning involved, in what direction the hand should move, by how much, at what angle, the font size, and the spacing. These tiny adjustments can be hard for a person with poor fine motor skills. A whole sequence of movements go into writing each letter. A poor body schema means the brain is constantly trying to keep track of where the hand is in space and time on top of the other tasks involved. For a typical person, these movements are embedded in their motor memory, making the writing task automatic, but motor apraxia and poor body schema means that such sequences of motor movements take much longer or do not make it into the motor memory. So, the act of writing itself ends up as a laborious task of having to motor plan all over again each time and distracts from the attention and thinking processes. Srinivasan can see the letters in his head but is never quite sure if he will be able to pen it on paper, which leads to tremendous anxiety. He says his motor instinct is to write his name, as that is an activity he was made to do over and over again in his special education years. When compared to writing, the act of typing, though it has its own challenges, seems a relatively easier motor task, as it requires the press of just a single key for each letter most of the time.

All neurodivergent individuals are unique, though anxiety seems to be common to many of them (Tafti & Abdolrahmani, 2014). Individuals may not be aware that their work performance or behavior is being impacted by anxiety. Deficits in social interactions and transitions are a challenge for many who are neurodivergent and may further contribute to anxiety. There is also a great deal of stigma with neurodiversity, which creates anxiety around disclosure and impacts emotional health (Livingston, Siegel, & Ribery, 2018). By understanding and accepting the challenges associated with neurodivergence and working to increase self-advocacy, employers can reduce employees’ stress and anxiety. The goal is an accepting, welcoming environment, creating a win-win for both employers and neurodivergent employees. 

Life’s challenges include facing the uncertainty of societal expectations, in addition to dealing with autism’s core features, such as sensory sensitivity, repetitive behaviors and sameness behaviors, and other less discussed issues like lack of a body schema and poor fine motor skills in Srinivasan’s case. He feels that anxiety is a very real and often unacknowledged comorbidity of neurodivergence, though the intensity of anxiety may depend on an individual’s diagnosis and resilience. While anxiety management and coping techniques can be useful, helping employers understand neurodiversity and create an accepting workplace may do even more to develop resilient employees. The neurodivergent mind, when nurtured in the right environment, has much to offer in the workplace, including creativity and innovation