Autism and stress | Door Marjon KuipersGeplaatst op 18 februari 2020 door Marjon Kuipers
Autism and stress
Nowadays, in our society, stress plays a significant role in life (Capel, 2018; Gonnissen & Goudsmet, 2013). A certain amount of stress is healthy. In the event of stress, an automatic system sets the body in motion, which makes the body ready to fight, flight or freeze (Armour & Ardell, 2004; Capel, 2018; Gonnissen & Goudsmet, 2013; Kolk, van der, 2016; Ogden & Fisher, 2015). The stress response requires an enormous effort from the body but should not be harmful if sufficient recovery emerges afterwards (Ogden & Fisher, 2015). With prolonged stress, the body has no time to recover, and exhaustion will follow (Porges, 2009; Porges, 2007). People with a form of autism are more sensitive to stress (Goodwin et al., 2006; Hirvikoski & Blomqvist, 2014). Autism is a lifelong developmental disorder that influences social functioning, behaviour and cognition (Delfos & Delfos, 2016). The sensory perception of people with autism works differently. They have a contrasting perception of the world and divergent way of processing information that could be confusing for people without autism to understand (Ben-Sasson et al., 2019; Dunn et al., 2002; Kern et al., 2007; Schauder & Bennetto, 2016). People with autism teach themselves multiple strategies and compensational behaviour to cope with different situations, as these do not come naturally. This adaptive behaviour costs much energy and causes much stress (Bruin et al., 2017; A. A. Spek, 2012). Research shows that many adults with autism are initially diagnosed with a burn-out and subsequently diagnosed with autism and are barely able to function. The characteristics of autism become more visible under stress (Fuld, 2018; Gepner & Féron, 2009). This paper describes what stress is, what influence it has on health and cognition and finally, what possibilities there are for reducing stress for people with autism.
There is an increase in scientific evidence about the influence of stress on human behaviour and the associated emotions that are related to stress (Lazarus, 1990; Capel, 2018; Gonnissen & Goudsmet, 2013; Kolk, van der, 2016; Ogden & Fisher, 2015). Stress is a subjective experience (Robinson & Johnson, 1997). The stress response emerges from the automatic and unconscious brain with the sole purpose of survival (Karasek, 1992; Kolk, van der, 2016; Ogden & Fisher, 2015; Porges, 2011). During the survival process, humans are capable of little or no thinking. The priority is on “responding” rather than “thinking” (Levine & Frederick, 1997). The subcortical brain takes over control from the neo-cortex and causes a response for survival. This survival response, also known as the fight-flight or freeze response, was first described by Walter Bradford Cannon (1932) in The Wisdom of the Body (Nuland, 1997). He noticed the relation between the response of various animals to acute danger and a series of physiological responses afterwards. Cannon (1932) recognized the hormones adrenaline, noradrenaline and cortisol. These hormones are released during a stressful situation and cause several automatic physiological reactions like faster breathing, increased in heart rate, higher blood pressure and can slow down the digestive system (Lee et al., 2015; Kolk, van der, 2016; Ogden & Fisher, 2015; Borod, 2000). Cannon (1932) discovered that this reaction mechanism ensures that animals respond alertly and appropriately to threatening situations. This reaction occurs in both animals and humans and enables us, since prehistoric times, to be able to respond quickly and adequately to dangerous situations, both real and imaginary (Panksepp, 2004; Schiavone et al., 2013; Darwin, 2008).
Autism and stress
For people with autism, stress has a more severe effect on their health and wellbeing than for people without autism (Crane et al., 2009; Dunn et al., 2002; Kern et al., 2007). People with autism process impulses more intensely than people without autism. The other way of processing impulses creates a different sensitivity in handling sensory information and causes an accelerated reaction to the nervous system, which makes behavioural regulation more difficult (O’Donnell et al., 2012; Porges, 2009; Robertson & Simmons, 2012).
There are three types of stress factors that affect our health. The first stress factor is physical stress (Dispenza, 2014, 2017a; Mueller & Maluf, 2002; Quick et al., 1987; Wasmund et al., 2002). Physical stress can be described as, everything that affects the physical body from the outside, like injuries, fractures, and surgery (Dispenza, 2014, 2017a). The second stress factor is chemical stress. Chemical stress is a chemical reaction to something inside the body. Examples are viruses, bacteria, pesticides, alcohol, smoking and different types of allergies (Dispenza, 2017a, 2017b; Lipton & de Wit, 2017; Menzel, 1994). Lastly, there is emotional stress, which has more to do with someone’s mental state. Examples are family affairs, work, debts, divorces, traumas and other worries (Capel, 2018; Dayas et al., 2001; Dispenza, 2014, 2017a, 2017b; Gonnissen & Goudsmet, 2013; Kolk, van der, 2016; Levine & Frederick, 1997; Norris, et al., 1992). According to research (Van der Kolk 2016), up to 90% of physical complications are stress-related. Nowadays, the degree of stress can be measured by a heart rate monitor or a heart- inherence cortisol level saliva test (De Vente, 2003; Edwards, 2015; Hollocks et al., 2014; Kushki et al., 2013). To measure the level of stress for people with autism, questionnaires such as The Adolescent – Adult sensory profile (Rieke & Anderson, 2009), The Five-Point Stress Scale for children (ErinoakKids, z.d.), Perceived Stress Scale and the Childhood anxiety and related emotional disorders (Reaven et al., 2012) are used. When prolonged stress is experienced, the body produces increasing amounts of adrenaline and cortisol (Bruin et al., & van Schagen, 2017; Capel, 2018; Dispenza, 2014, 2017a, 2017b; Edwards, 2015; Gonnissen & Goudsmet, 2013; Gregson & Looker, 1994). Adrenaline is produced in the adrenal marrow and can be felt directly in the body, but drains immediately after the action and makes the body comes to rest again. Cortisol is the second stress hormone and is generated via the hypothalamic-pituitary-adrenal- HPA axis (Aguilera & Rabadan-Diehl, 2000; Capel, 2018; Dispenza, 2014, 2017a, 2017b; Kolk, van der, 2016; Levine & Frederick, 1997; Lipton & de Wit, 2017; Ogden & Fisher, 2015; Porges, 2011; Sorgdrager et al., 2017; Xiong & Zhang, 2013). Cortisol protects the body against the harmful effects of stress and is necessary for mental and physical performance. Cortisol activates the production of sugar, increases muscle tension and influences heart strength and blood pressure (Lovallo, 2015). Cortisol is, in a healthy dose, always present inside the body but remains longer after a stress peakwhich results in the accumulation of this stress hormone (Hewagalamulage et al.,2016). This accumulation of cortisol can result in physical as well as mental illness (Puterman et al., 2011; Taylor & Corbett, 2014). As long as there is a balance between stress and recovery, the cortisol hormone can level itself out. Chronic stress has a negative influence on the ageing and recovery processes in diseases and can cause lasting changes to the DNA (Capel, 2018; Kolk, van der, 2016; Lipton & de Wit, 2017; Meneghini, 1997; Wei & Lee, 2002). The DNA change can even manifest itself into the next generation (Capel, 2018; Lipton & de Wit, 2017). Many health complaints regarding sleep, appetite, digestion and dealing with stimuli have their origin in the psychological system but express themselves physically (Buwalda et al., 2005; Capel, 2018; Dispenza, 2014, 2017a, 2017b; McFarlane, 2010).
The triune brain
Our brain works as a coherent entity but can be divided in three areas that all have their focus area (Ogden & Fisher, 2015; Gainotti, 2019). The three areas of the brain are the neocortex, limbic system, and reptile brain. (Capel, 2018; Kolk, van der, 2016; Levine & Frederick, 1997; Ogden & Fisher, 2015; Ploog, 2003). The stress response system, responsible for the production of stress hormones, is deeply embedded in the limbic system and the reptile brain (Capel, 2018; Kolk, van der, 2016; Levine & Frederick, 1997; Ogden & Fisher, 2015). In the next paragraphs, a more detailed explanation of these areas in the brain is provided.
The neocortex is the youngest part of our brain and is responsible for cognitive processing, thinking, language, reasoning, decision making and self-reflection (Miller & Cohen, 2001). This part of the brain is highly sensitive to stress and can be hijacked by the limbic and reptile brain under minimal levels of stress and has hardly any control when this occurs (Gazzaniga, 2012; Cesario et al., 2019). The neocortex is the part of the brain where there is a focus on speech and language. When under stress, the neocortex is eliminated and with it the part of the brain that processes language as well as the ability to think clearly (Lieberman, 2002). Stress causes stupidity. A disabled neo-cortex means that talking about the stress-causing event is not the solution. A re-experience of the event, insofar as it is still well-remembered, can fully evoke the feelings of stress again with the difference that the event itself concerned a defining moment and the re-experience can last as long as the listener has time (Capel, 2018; Dispenza, 2014, 2017a, 2017b; Kolk, van der, 2016; Levine & Frederick, 1997; Mate, z.d.).
The limbic brain is where our emotions are generated. It ensures that we can experience emotions, social involvement and attachment and it labels previous experiences as safe or unsafe. The development of this part of the brain takes place through our interaction with our environment (Dispenza, 2014, 2017a, 2017b; Kolk, van der, 2016; Levine & Frederick, 1997; McCraty, 2019; Ogden & Fisher, 2015). The limbic part of the brain is formed in a user dependent mode. When someone grows up in a safe environment, there is the possibility for secure attachment and the brain’s default setting is based on safety and trust. When someone grows up in an environment where it is unsafe or where they feel unwanted (unconsciously or consciously), there is insecure attachment, and the brain will be specialized in experiencing feelings of anxiety (Minton & Ogden, 2006; Kolk, van der, 2016). The Limbic brain gives instructions to the body to respond in an appropriate manner. Whether this is always the best way from the neocortex point of view is doubtful, but the limbic brain does not take this into account.
The reptile brain is the oldest part of the brain, it works instinctively and has a self-acting capacity. The reptile brain is responsible for all functions concerning our survival such as heartbeat, breathing, digestion and body temperature. These are all things that newborn babies can do without being aware of it (Dispenza, 2014; Kolk, van der, 2016; Ogden & Fisher, 2015). People naturally have a particular preference, or sometimes a combination of both, for a movement ‘away from pain and danger’ or a movement ‘towards safety and trust'(Higgins, 2011). Approximately 60% of people have an avoiding style, 25% seem motivated to reach goals, and the remainder is mixed (Bandler & Grinder, 2006; Liekens, 2007). The significant difference in these conditioned mindsets is the type of hormone being released. People with a towards mindset automatically produce healthy hormones. These hormones are oxytocin, dopamine, serotonin, endorphin, melatonin and testosterone, and are also known as the life juices (Capel, 2018; Dispenza, 2014, 2017a, 2017b, 2018; Kolk, van der, 2016; Lipton & de Wit, 2017; Ogden & Fisher, 2015; Porges, 2011). People with an attaining mindset are less likely to get stuck in unpleasant events. They draw their energy more out of the present and goals for the future, rather than being stuck in the past. While people with an avoiding mindset produce more stress hormones, this does not imply that people with an attaining thinking style do not experience stress at all. They still experience stress, but do recover sooner (Kolk, van der, 2016; Ogden & Fisher, 2015). How a person experiences a stressful situation has a lot to do with their thoughts. Stress is a subjective experience and can, therefore, sometimes for an outsider be challenging to understand (Koolhaas et al., 2011).
It is essential to find a balance in the physical, chemical and emotional environment. Natural balance can be achieved through sports, hiking, yoga, massage. Specific to autism sensory integration therapy, mindfulness and enough sleep (Reaven et al., 2012b; Singh et al., 2011; A. A. Spek et al., 2013). Chemical balance can be achieved through good unprocessed food. The intestinal flora of people with autism seems to differ from people without autism (Mayer et al., 2014). Two of these three aspects of balance need to be right in order to gain or maintain a healthy life. Especially when the third aspect is not in balance yet and needs to be improved (Dispenza, 2017a). Only eating healthy but forgetting about mental and physical challenges will result in valuable nutrients not being adequately absorbed (Pelsser et al., 2009; Foster & McVey, 2013). During stress, the survival mechanism switches on, and the cells in the body close themselves to information from the outside world of the system (Capel, 2018; Lipton & de Wit, 2017). Between 75% – 95% of health complaints are related to emotional stress (Kolk, van der, 2016). As long as there is stress somewhere in the body caused by fears, worries, perfectionism or rigidity, as is often the case with autism, even the best food does not affect because closing cells takes up more energy to digest the food than that it provides nutrients and people are still getting sick. Nutrition has no priority during periods of stress. Fighting or fleeing comes first. After the stress period, there is an increased production of cortisol in the body, causing a feeling of hunger and the risk of binge eating. At this moment people often reach for unhealthy food (Capel, 2018; Dispenza, 2014, 2017a, 2017b; Kolk, van der, 2016; Levine & Frederick, 1997; Lipton & de Wit, 2017). The intake of the food is not optimal in this situation, so people get fat and risk diabetes (Adam & Epel, 2007; Sominsky & Spencer, 2014). People with autism can achieve emotional balance through EFT, EMDR, meditation, stress reduction or mindfulness (Kabat-Zinn, 2012; A. A. Spek et al., 2013, Watson, 2012). Negative thoughts are just as powerful as positive thoughts. What we imagine has a direct impact on our physiology. This also applies to thoughts that generate harmful stress hormones. Van der Kolk (2016) states that it is not necessary for a person to relive the negative feelings in order to be able to process an event. By talking about negative feelings, these feelings are activated, and the reliving of the feelings can be experienced even more strongly than the feelings during the event itself. because the re-experience can take place endlessly, it can become damaging (Kolk, van der, 2016). An overview study, with studies of mindfulness-based stress reduction therapy and mindfulness-based cognitive therapy, shows that stress reduction therapy improves mental health and cognitive therapy prevents relapse in to depression (Spanaki et al., 2015). Cognitive-behavioural therapy is proven to be an effective method for anxiety disorders in autism (Fjorback et al., 2011; Olthuis et al., 2015; Russell et al., 2013). With mindfulness, the focus is on acceptance of thoughts and feelings without the need to change them. Studies show that mindfulness has a positive effect on stress reduction in people with autism by lowering feelings of depression and anxiety (Singh et al., 2011; A. Spek, 2010; A. A. Spek, van Ham, & Nyklíček, 2013).
The functioning of the brain and the stress response system is universal. The stress experienced is subjective and personal. Sensitivity to stress is more significant for people with autism than for people without autism. The sensitivity to stress manifests itself in experiencing and expressing stress more and is often accompanied by mental and physical health problems. Despite the universal functioning of the brain and the stress response system, there is no evidence-based intervention for stress reduction for people with autism. In case of autism, the personal subjective experience of the triggers of stress is ignored, precisely because of the triggers. And the experience is individual, more research in the field of individual stress reduction in the short and long term is desirable. A recommendation is to look outside the field of autism studies to develop more knowledge on the individualized approach for people with autism.
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