Some hardly recognized problems of autism provide for the most common and severe disabling symptoms.  When present, they serve to limit the senses, activities, and the joy of living of affected individuals.  Indeed, early in the morning, as they wake up, many autistic individuals already find the world around them overwhelming and physically exhausting.  They have difficulties in sleeping and once they wake up, their thoughts and heart rate try to outrace each other.  Problems in communication makes the affected individual act out as a way of expressing themselves.  In such instances, maladaptive behaviors are a way of managing both the external and internal demands that seem overwhelming to them.  Productivity at school and/or work is diminished as the sheer effort entailed in participation taxes their physical and mental stamina.  Self-doubt digs a hole in their self-esteem from where they fear coming out.  In the end, they cease to make an effort and give up.  They retreat to their bedroom and into the comforting doldrums of routines and screen time with their tablets and/or computers.   Parents and caregivers cave in to the choice for isolation.  At least there, in their bedrooms, parents feel that their loved one is calm and therefore safe. However, withdrawal from the world only promotes the relentless mental and physical deterioration of the autistic individual. The sedentary lifestyle and attendant comorbidities ultimately play havoc with their well-being. After a decade or so, the patient finds himself in poor physical health, overweight, and at risk for diabetes and high blood pressure.  Most commonly, a doctor will attribute the withdrawal to the fact that the patient is, after all, autistic. For other cases the doctor may proffer a diagnosis of depression, anxiety or a mixed affective disorder.  Drug therapy and cognitive behavioral interventions may prove to no avail and, in the best of circumstances, patients remain trapped in the same mental and emotional state. Some people call this “autism burnout”. What is happening? Is this necessarily a psychological condition? Are there other possible explanations or contributing factors?

It is now recognized that many autistic individuals suffer from an abnormal regulation of their autonomic nervous system (ANS). This is the control system that regulates unconscious body functions like heart rate and digestion.  This system has two branches, the sympathetic and parasympathetic nervous system.  Some people think of these branches as the accelerator (sympathetic) and brake (parasympathetic) of a car.  Whenever you face highly demanding circumstances, the  “flight or fight” response of the sympathetic system is activated.  This results in priming your body for action; your heart starts beating faster, blood flow is directed towards the muscles of the extremities, and digestion is slowed down.

In autistic individuals the sympathetic system is overactivated. Physically you can see this state of arousal in their dilated pupils. I believe that some of the more common gastrointestinal symptoms of autism stem from this autonomic imbalance. Emotionally, however, the state of sympathetic arousal is manifested as a sense of dread or anxiety.  A famous theory of emotions (James Lange) proposes that physiological changes, such as increased heart rate, drive our emotions.  According to this theory, an elevated heart rate and palpitations, rather than emotional preoccupations, provide the nidus for anxiety.  Treating patients, that have an overactivated sympathetic system, with anxiolytic agents may provide little in terms of relief while predisposing them to side-effects. It is for this reason that I welcome clinical trials in autism using propranolol to treat anxiety as well as other emotional and behavioral problems. Propranolol inhibits the sympathetic nervous system by blocking the beta-adrenergic receptors. It decreases the rate of heart beats and therefore the feeling of anxiety that rides with it.

It is noteworthy that many autistic individuals experience their concerns immediately upon getting up from bed. The ANS controls blood flow and tries to compensate for the effect of gravity upon our bodies.  As we stand up, gravity pulls blood towards our lower extremities.  Exercise is important as muscle contraction of our legs squeezes our veins and pushes blood back towards the heart.  A sedentary lifestyle negates the helpful return of blood into our arterial circulation.  The brain, a metabolically demanding organ, is especially susceptible to the effects of blood flow and oxygenation. Poor blood flow to the brain may lead to memory problems, difficulties in concentrating and sometimes to a temporary loss of consciousness called syncope.  Loss of consciousness from poor blood flow can imitate seizures with jerky muscle movements, oral automatism, head turning, and urinary/fecal incontinence. The only way to clearly differentiate between the autonomic mediated loss of consciousness and seizures is an electroencephalogram (EEG).  In the case of syncope, slow waves in the EEG provide a record for global cerebral hypoperfusion while in epilepsy the EEG shows a paroxysmal discharge of abnormal brain activity.  As many as 35% of patients with a diagnosis of epilepsy are usually misdiagnosed (Zaidi et al., 2000; Akhtar, 2002).  According to recent research, “A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts” (Zaidi, et al., 2000).

Treating syncope patients with anticonvulsants won’t provide a beneficial outcome. Such patients are said to be refractory or intractable to therapy and end up at the receiving end of polypharmacy and its consequent side effects.   A better treatment option is drinking liquids with electrolytes, fludrocortisone, and even the use of compression stockings.  Sometimes patients need to be reminded of their medications.  Problems of interoception (body awareness) may necessitate incorporating liquids as part of a routine or schedule.  Aquatherapy offers the advantage of the soothing properties of water and for socialization (most hydrotherapy session are done in group).

It is a pity that in this day and age physicians may miss a diagnosis, like autonomic dysregulation, that should have been easily picked up at physical examination.  Physicians no longer “touch” patients.  Blood pressure is usually relegated to the nurse, who will probably take it while you are still wearing your long sleeve shirt. Moreover, autonomic disturbances are seldom in the mind of the physician.  Be wary of this possibility if a patient acts out without an apparent reason, especially after surgery, trauma or a viral illness.  In addition, watch out for symptoms suggestive of an autistic burnout, e.g., poor concentration, tiredness, weakness, sleep disorder, difficulty in exercising, anxiety. Sometimes instituting a treatment trial with sports drinks (e.g., Gatorade), green tea, or broth will improve the symptoms and prove diagnostic.

References

Akhtar MJ. All seizures are not epilepsy, many have a cardiovascular cause. J Pak Med Assoc 52(3):116-20, 2002.

Zaidi A, Clough P, Cooper P, Scheepers B, Fitzpatrick AP. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol 36(1):181-4, 2000.

Casanova MF. Usefulness of exercise. Corticalchauvinsm.com

Casanova MF. Interoception: The eight sensory system. Corticalchauvinism.com

Casanoa MF. Autism Updated: Symptoms, Treatments and Controversies. Amazon Publishing, 2019.