Psychophysiological arousal and auditory sensitivity in a cross-clinical sample of autistic and non-autistic anxious adults
Open accessAbstract
Many autistic people report overwhelming sensory experiences and also elevated levels of anxiety. Understanding how these experiences are linked to each other can contribute to improved support and intervention for reducing sensory overload and anxiety. This study included 95 young adult participants including autistic adults, non-autistic adults reporting to a psychotherapy clinic with high levels of anxiety, and neurotypical adults with no psychiatric concerns. We measured pupil size using including a baseline task with no auditory stimulus followed by two blocks of simple auditory habituation. In a subset of 80 participants we also measured self-report levels of sensory processing, anxious apprehension, and intolerance of uncertainty. The autism group showed atypical sensory processing on all four measured domains of the Adolescent and Adult Sensory Profile including sensory sensitivity, sensory seeking, sensory avoidance, and low registration subscales. Dimensional analyses across all participants showed significant positive correlations between sensory sensitivity, sensory seeking, and sensory avoidance domains with scores from the Intolerance of Uncertainty Scale-Short Form and Penn State Worry Questionnaire. The autism group showed significantly larger pupil size than other groups at baseline, before any auditory stimulation. There were no group differences in the rate of auditory habituation, nonetheless the overall, absolute larger pupil size remained in the autism group throughout the experiment. We suggest that this and other findings could indicate chronic hyperarousal in many autistic people. Treatment for anxiety in autism should be informed by knowledge of unique aspects of anxiety in autism and consider the role of sensory experience and everyday psychophysiological arousal.
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BackgroundKerns, C. M., Roux, A. M., Connell, J. E., & Shattuck, P. T. (2016) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2016.06.002 · Cited by 80 · see citing works
Intolerance of Uncertainty Predicts Anxiety Outcomes Following CBT in Youth with ASD.
Keefer, A., Kreiser, N. L., Singh, V., Blakeley-Smith, A., Duncan, A., Johnson, C., Klinger, L., Meyer, A., Reaven, J., & Vasa, R. A. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-016-2852-z · Cited by 72 · cited 1× · see citing works
“As understanding grows of cognitive, emotional, and sensory contributions to anxiety in autism, it is imperative to assimilate targeted treatment approaches—certainly behavioral and possibly pharmacological approaches—into autism interventions (9, 36, 39, 79, 82, 83).”
BackgroundSymptom overlap on the srs‐2 adult self‐report between adults with asd and adults with high anxiety
South, M., Carr, A. W., Stephenson, K. G., Maisel, M. E., & Cox, J. C. (2017) · Autism Research · doi:10.1002/aur.1764 · Cited by 71 · see citing works
Amygdala Volume Differences in Autism Spectrum Disorder Are Related to Anxiety
Herrington, J., Maddox, B., Kerns, C., Rump, K. M., Worley, J. A., Bush, J. C., McVey, A. J., Schultz, R., & Miller, J. S. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3206-1 · Cited by 71 · cited 2× · see citing works
“But it is equally necessary to realize that there are important, unique aspects of anxiety in autism including (a) differences in central and autonomic nervous system function (15, 48, 84); the validity of typical anxiety symptom questionnaires (90–92); and helpful modifications for treatment (80, 81, 93).”
BackgroundCorbett, B. A., Muscatello, R. A., & Blain, S. D. (2016) · Frontiers in Neuroscience · doi:10.3389/fnins.2016.00278 · Cited by 70 · cited 2× · see citing works
“(15) reported that cortisol response to stress was higher for autistic children than neurotypical controls, during an ecologically-relevant peer interaction.”
BackgroundPriorities for Advancing Research on Youth with Autism Spectrum Disorder and Co-occurring Anxiety
Vasa, R. A., Keefer, A. J., Reaven, J., South, M., & White, S. W. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3320-0 · Cited by 64 · cited 1× · see citing works
“As understanding grows of cognitive, emotional, and sensory contributions to anxiety in autism, it is imperative to assimilate targeted treatment approaches—certainly behavioral and possibly pharmacological approaches—into autism interventions (9, 36, 39, 79, 82, 83).”
BackgroundGlod, M., Creswell, C., Waite, P., Jamieson, R., McConachie, H., South, M., & Rodgers, J. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3118-0 · Cited by 63 · cited 1× · see citing works
“…is equally necessary to realize that there are important, unique aspects of anxiety in autism including (a) differences in central and autonomic nervous system function (15, 48, 84); the validity of typical anxiety symptom questionnaires (90–92); and helpful modifications for treatment (80, 81, 93).”
BackgroundUnderstanding, recognising and treating co-occurring anxiety in autism
Rodgers, J., & Ofield, A. (2018) · Current Developmental Disorders Reports · doi:10.1007/s40474-018-0132-7 · Cited by 62 · cited 2× · see citing works
“…is equally necessary to realize that there are important, unique aspects of anxiety in autism including (a) differences in central and autonomic nervous system function (15, 48, 84); the validity of typical anxiety symptom questionnaires (90–92); and helpful modifications for treatment (80, 81, 93).”
BackgroundAcevedo, B. P., Jagiellowicz, J., Aron, E. N., Marhenke, R., & Aron, A. P. (2017) · Cited by 62 · see citing works
Magiati, I., Lerh, J. W., Hollocks, M. J., Uljarević, M., Rodgers, J., McConachie, H., Ozsivadjian, A., South, M., Hecke, A. V. V., Hardan, A. Y., et al. (2017) · Autism Research · doi:10.1002/aur.1809 · Cited by 58 · see citing works
Conner, C. M., Maddox, B. B., & White, S. W. (2012) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-012-1728-0 · Cited by 47 · cited 2× · see citing works
“These anxiety symptoms can cause significant additional distress, and have been linked to increased levels of problematic behavior (11, 12), difficulty with decision making (13), and considerable stress on family systems (14).”
BackgroundMethodAnxiety problems in young people with autism spectrum disorder: A case series
Ozsivadjian, A., & Knott, F. J. (2011) · Clinical Child Psychology and Psychiatry · doi:10.1177/1359104511404749 · Cited by 47 · see citing works
Nuske, H. J., Vivanti, G., & Dissanayake, C. (2015) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2479-5 · Cited by 45 · cited 1× · see citing works
“With this limition in mind, some studies have found that autism samples have a larger tonic pupil size–indicative of elevated physiological arousal–than neurotypical comparison groups (44, 45) though others have found no difference (46) or the opposite trend (47).”
BackgroundAtypical amygdala response to fear conditioning in autism spectrum disorder
Top Jr., D. N., Stephenson, K. G., Doxey, C. R., Crowley, M. J., Kirwan, C. B., & South, M. (2016) · Biological Psychiatry Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2016.01.008 · Cited by 45 · cited 3× · see citing works
“This idea was also suggested by the first ever fMRI study of fear conditioning in autism (43), where we found much stronger amygdala activation to threat vs.”
BackgroundTakahashi, H., Komatsu, S., Nakahachi, T., Ogino, K., & Kamio, Y. (2015) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2593-4 · Cited by 44 · cited 4× · see citing works
“(42) did not find differences in habituation between autistic and neurotypical children during a acoustic startle response paradigm, but a number of other studies have shown reduced or atypical habituation (or increased sensitization, which is the opposite of habituation) in autistic children for various stimulus moda…”
BackgroundInfluentialUljarević, M., Carrington, S., & Leekam, S. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2557-8 · Cited by 39 · see citing works
Soumiya, H., Godai, A., Araiso, H., Mori, S., Furukawa, S., & Fukumitsu, H. (2016) · PLoS ONE · doi:10.1371/journal.pone.0158583 · Cited by 39 · cited 1× · see citing works
“Effective sensory processing is a critical evolutionary component for managing stress and danger [see (21–23)] and there are demonstrated links between sensory sensitivity and affective disorders, including anxiety, outside of autism (24–27).”
BackgroundFirst evidence of sensory atypicality in mothers of children with Autism Spectrum Disorder (ASD)
Uljarević, M., Prior, M. R., & Leekam, S. (2014) · Molecular Autism · doi:10.1186/2040-2392-5-26 · Cited by 36 · cited 1× · see citing works
“One of the few studies of adults featured mothers with autistic children (30).”
BackgroundSensory Modulation for People with Anxiety in a Community Mental Health Setting
Wallis, K., Sutton, D., & Bassett, S. F. (2017) · Occupational Therapy in Mental Health · doi:10.1080/0164212x.2017.1363681 · Cited by 32 · cited 1× · see citing works
“Effective sensory processing is a critical evolutionary component for managing stress and danger [see (21–23)] and there are demonstrated links between sensory sensitivity and affective disorders, including anxiety, outside of autism (24–27).”
BackgroundJärvinen, A. M., Ng, R., Crivelli, D., Neumann, D., Arnold, A. J., Woo‐VonHoogenstyn, N., Lai, P. T., Trauner, D. A., & Bellugi, U. (2015) · Developmental Psychobiology · doi:10.1002/dev.21335 · Cited by 26 · cited 1× · see citing works
“…between autistic and neurotypical children during a acoustic startle response paradigm, but a number of other studies have shown reduced or atypical habituation (or increased sensitization, which is the opposite of habituation) in autistic children for various stimulus modalities (54–56).”
BackgroundSpecificity of autonomic arousal to anxiety in children with autism spectrum disorder
Chiu, T. A., Anagnostou, E. A., Brian, J. A., Chau, T. T., & Kushki, A. (2015) · Autism Research · doi:10.1002/aur.1528 · Cited by 22 · cited 1× · see citing works
“there are an increasing number of suggestions that everyday physiological arousal is atypical inmany autistic people and could include chronic physiological arousal (35, 42, 69).”
Background
Flagged first, then by citations
Research works printed but not linked: 1
- [6]American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. DSM-V. American Psychiatric Association Publishing (2013).
Cited by
Sorted by citations
Sensory processing difficulties in psychiatric disorders: A meta-analysis
van den Boogert, F., Klein, K., Spaan, P., Sizoo, B. B., Bouman, Y. H. A., Hoogendijk, W. J. G., & Roza, S. J. (2022) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2022.04.020 · Cited by 132 · see citing works
Sellick, T., Ure, A. M., & Williams, K. J. (2021) · Systematic Reviews · doi:10.1186/s13643-021-01830-2 · Cited by 90 · see citing works
“These deficits are further compounded in individuals with ASD as anxiety can be triggered by or exacerbate the social difficulties inherent in the disorder resulting in significant distress and relationship difficulties with family members, teachers, and peers [5, 6].”
BackgroundAutistic Cognition: Charting Routes to Anxiety
Stark, E., Stacey, J., Mandy, W., Kringelbach, M. L., & Happé, F. (2021) · Trends in Cognitive Sciences · doi:10.1016/j.tics.2021.03.014 · Cited by 77 · see citing works
Is autonomic function during resting-state atypical in Autism: A systematic review of evidence
Arora, I., Bellato, A., Ropar, D., Hollis, C. P., & Groom, M. J. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.02.041 · Cited by 68 · see citing works
Sensory Sensitivity and Intolerance of Uncertainty Influence Anxiety in Autistic Adults
Normansell-Mossa, K. M., Top, D. N., Russell, N., Freeston, M., Rodgers, J., & South, M. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.731753 · Cited by 45 · see citing works
“We have previously published data regarding psychophysiological arousal in autistic adults ( n = 31) with both anxious and non-anxious non-autistic comparison groups, which included data from the self-report Adolescent/Adult Sensory Profile (AASP) and an IU measure (Top et al., 2019).”
MethodSelf-citationAmbrose, K., Simpson, K., & Adams, D. (2021) · Clinical Psychology Review · doi:10.1016/j.cpr.2021.102086 · Cited by 41 · see citing works
Keehn, B., Kadlaskar, G., Bergmann, S., McNally Keehn, R., & Francis, A. (2021) · Frontiers in Integrative Neuroscience · doi:10.3389/fnint.2021.716447 · Cited by 35 · see citing works
Zhao, S., Liu, Y., & Wei, K. (2022) · Journal of Neuroscience · doi:10.1523/jneurosci.0223-22.2022 · Cited by 29 · see citing works
Bemmouna, D., & Weiner, L. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1238116 · Cited by 20 · see citing works
“Sensory hypersensitivities have also been linked to increased psychophysiological arousal and increased anxiety in autistic people (40, 110, 111).”
BackgroundDahlstrom-Hakki, I., Alstad, Z., Asbell-Clarke, J., & Edwards, T. (2024) · Virtual Reality · doi:10.1007/s10055-023-00933-6 · Cited by 21 · see citing works
Cummings, K. K., Jung, J., Zbozinek, T. D., Wilhelm, F. H., Dapretto, M., Craske, M. G., Bookheimer, S. Y., & Green, S. A. (2023) · Journal of Neuroscience Research · doi:10.1002/jnr.25250 · Cited by 19 · see citing works
“…multiple groups, including in neurotypical adults (Engel-Yeger & Dunn, 2011; Ludlow et al., 2015), ASD (Green et al., 2012; Lidstone et al., 2014; Top Jr. et al., 2019), and individuals with elevated anxiety (Conelea et al., 2014; Top Jr. et al., 2019), but the neurobiological mechanisms…”
Wang, X., Delgado, J., Marchesotti, S., Kojovic, N., Sperdin, H. F., Rihs, T. A., Schaer, M., & Giraud, A. (2023) · Journal of Neuroscience · doi:10.1523/jneurosci.0112-22.2023 · Cited by 17 · see citing works
“This interpretation aligns well with the clinically described auditory avoidance in ASD children (Haesen et al., 2011; Top et al., 2018).”
ResultState and Trait Anxiety of Adolescents with Autism Spectrum Disorders
Kim, S. Y., Kim, Y. A., Song, D., Bong, G., Kim, J.-M., Kim, J. H., & Yoo, H. J. (2021) · Psychiatry Investigation · doi:10.30773/pi.2020.0328 · Cited by 16 · see citing works
Neural Markers of Auditory Response and Habituation in Phelan-McDermid Syndrome
Isenstein, E. L., Grosman, H. E., Guillory, S. B., Zhang, Y., Barkley, S. B., McLaughlin, C. S., Levy, T., Halpern, D. B., Siper, P. M., Buxbaum, J. D., et al. (2022) · Frontiers in Neuroscience · doi:10.3389/fnins.2022.815933 · Cited by 15 · see citing works
The appraisal of roadway environment and infrastructure by drivers with autism: A qualitative study
Dirix, H., Ross, V., Brijs, K., Vermeiren, E., Timmermans, C., Alhajyaseen, W., Brijs, T., Wets, G., & Spooren, A. I. F. (2021) · Transportation Research Part F Traffic Psychology and Behaviour · doi:10.1016/j.trf.2021.01.016 · Cited by 12 · see citing works
Elevated and accelerated: Locus coeruleus activity and visual search abilities in autistic children
Keehn, B., Kadlaskar, G., & Keehn, R. M. (2023) · Cortex · doi:10.1016/j.cortex.2023.08.016 · Cited by 11 · see citing works
Nutritional Intake and Sensory Processing in School-Aged Children with Autism Spectrum Disorder
Olson, A., Krall, J. R., Baranova, A. V., & Slavin, M. (2025) · Nutrients · doi:10.3390/nu17040604 · Cited by 11 · see citing works
Mahak, S., Malone, S. A., Elsherif, M. M., Hand, C. J., & Morsanyi, K. (2025) · Scientific Reports · doi:10.1038/s41598-025-21504-6 · Cited by 10 · see citing works
Xu, S., Zhang, H., Fan, J., Jiang, X., Zhang, M., Guan, J., Ding, H., & Zhang, Y. (2024) · Journal of Speech Language and Hearing Research · doi:10.1044/2024_jslhr-23-00553 · Cited by 7 · see citing works
Rosqvist, H. B., Hultman, L., & Hallqvist, J. (2023) · Alter · doi:10.4000/9ifu · Cited by 6 · see citing works
A body-brain (dis)equilibrium regulating transitions from health to pathology
Criscuolo, A., Czepiel, A. M., Schwartze, M., & Kotz, S. A. (2025) · Physics of Life Reviews · doi:10.1016/j.plrev.2025.07.003 · Cited by 6 · see citing works
“Altered interoceptive capacities, hypersensitivity, and hyperarousal states lead not only to anxiety symptoms but are also observed in schizophrenia [210,211], dementia [212,213] and autism [200,214,215].”
Podesta, L. M., & Bosman, A. M. T. (2025) · Emerging Adulthood · doi:10.1177/21676968251327246 · Cited by 4 · see citing works
“They may also feel overwhelmed by rapid life changes, potentially leading to chronic hyperarousal (as evidenced by large pupil size baseline; Top et al., 2019).”
Is autonomic function during resting-state atypical in Autism: A systematic review of evidencePreprint
Arora, I., Bellato, A., Ropar, D., Hollis, C. P., & Groom, M. J. (2020) · doi:10.31234/osf.io/cs94b · Cited by 4 · see citing works
“…hyperarousal came equally from studies of children and adolescents (Bal et al., 2010; Mat-sushima et al., 2016) and adults (Mathewson et al., 2011; Top et al., 2018) and findings of hypoarousal were also equally likely from studies of children and adolescents (Bujnakova et al., 2017; Pace and…”
Pupillometry reveals hyper-arousal in response to auditory stimuli in autistic children
Song, C., Ma, R., Ni, W., Peng, X., Li, X., Shi, R., Zhang, Y., & Yi, L. (2024) · Journal of Zhejiang University SCIENCE B · doi:10.1631/jzus.b2300462 · Cited by 1 · see citing works
Huo, C., Meng, C., Qian, H., Li, W., Shao, M., Huang, Y., & Meng, J. (2025) · BMC Psychology · doi:10.1186/s40359-025-02452-2 · Cited by 1 · see citing works
Moore, H. L., Brice, S., Spraggon, N., Ingham, B., Freeston, M. H., Parr, J. R., & Rodgers, J. (2025) · Autism Research · doi:10.1002/aur.70145 · Cited by 1 · see citing works
Agostinho, D., Correia, R., Duarte, I. C., Sousa, D., Abreu, R., Rodrigues, A. P., Castelo-Branco, M. S., & Simoes, M. (2021) · Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) · doi:10.1109/embc46164.2021.9630013 · Cited by 1 · see citing works
Rodrigo Goycolea, M., Angulo, C. B. S., Henríquez, C. F. S., & Ayuso, D. M. R. (2024) · Cadernos Brasileiros de Terapia Ocupacional · doi:10.1590/2526-8910.ctoar270635303 · Cited by 1 · see citing works
Rodrigo Goycolea, M., Angulo, C. B. S., Henríquez, C. F. S., & Ayuso, D. M. R. (2024) · Cadernos Brasileiros de Terapia Ocupacional · doi:10.1590/2526-8910.ctoar270635302 · Cited by 1 · see citing works
Bui, T. A., Shatto, J., Cuppens, T., Droit, A., & Bolduc, F. V. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.730987 · Cited by 1 · see citing works
Autism Spectrum Disorder Versus Anxiety Disorders
South, M., Brewe, A. M., Kerns, C. M., & White, S. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197516881.003.0006 · Cited by 1 · see citing works
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PPI Questionnaire on Adaptive Wearable Appropriateness as an Autistic InterventionPreprint
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Reduced Habituation: A Key to Understanding Sensory Sensitivity in Autism
Tarantino, V., Santostefano, A., Catania, A., Giordano, S., Montalto, G., Calistro, F., Oliveri, M., & Turriziani, P. (2026) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-026-07241-3
Layton, C., Keith, J. M., & Bennetto, L. (2026) · Research in Autism · doi:10.1016/j.reia.2026.203047
- Authors
- Top Jr., D. N., Luke, S. G., Stephenson, K. G., & South, M.
- Affiliations
- Brigham Young University (US)
- Nationwide Children's Hospital (US)
- Corresponding author
- South, Mikle
- Venue
- Frontiers in Psychiatry
- Publisher
- Frontiers Media SA
- Published
- 2019-01-29
- Volume
- 9
- Pages
- 783-783
- ISSN
- 1664-0640 (ISSN-L)
- PMC
- PMC6361859
- OpenAlex
- W2912973770
- Cited by
- 36
- References
- 91
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 5 · 2023: 6 · 2022: 5 · 2021: 10 · 2020: 2
- FWCI
- 2.47
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychiatry (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Brigham Young University
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Keywords
- autism spectrum disorder, anxiety, sensory processing, sensory sensitivity, sensory seeking, sensory avoidance, intolerance of uncertainty, worry, pupil size, psychophysiological arousal, auditory habituation, hyperarousal, Penn State Worry Questionnaire, Intolerance of Uncertainty Scale
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