The sympatho-adrenomedullary (see the left-hand side of the figure) and hypothalamic-pituitary-adrenocortical (HPA) (see the right-hand side of the figure) axes are the primary systems for maintaining or reinstating homeostasis during stress. Stressor exposure results in activation of preganglionic sympathetic neurons in the intermediolateral cell column of the thoracolumbar (T and L, respectively) spinal cord (shown in blue). These preganglionic neurons project to pre- or paravertebral ganglia that in turn project to end organs and to chromaffin cells of the adrenal medulla. This sympathetic activation represents the classic 'fight or flight' response that was first characterized by Walter Cannon and colleagues in the early twentieth century152; it generally increases circulating levels of adrenaline (primarily from the adrenal medulla) and noradrenaline (primarily from sympathetic nerves), heart rate and force of contraction, peripheral vasoconstriction, and energy mobilization. Parasympathetic tone can also be modulated during stress. In the parasympathetic system (shown in red), activation of craniosacral preganglionic nuclei activates postganglionic nuclei located in or near the end organs that they innervate; parasympathetic actions are generally opposite to those of the sympathetic system.For the HPA axis, stressor exposure activates hypophysiotrophic neurons in the paraventricular nucleus of the hypothalamus that secrete releasing hormones, such as corticotropin-releasing hormone (CRH) and arginine vasopressin (AVP), into the portal circulation of the median eminence. These releasing hormones act on the anterior pituitary to promote the secretion of adrenocorticotropic hormone (ACTH), which in turn acts on the inner adrenal cortex (that is, the zonafasciculata) to initiate the synthesis and release of glucocorticoid hormones (for example, corticosterone in rats and cortisol in humans). Circulating glucocorticoids then promote the mobilization of stored energy and potentiate numerous sympathetically mediated effects, such as peripheral vasoconstriction. Moreover, the adrenal cortex is directly innervated by the sympathetic nervous system, which can regulate corticosteroid release153. Thus, the HPA axis and sympathetic system have largely complementary actions throughout the body, including energy mobilization and maintenance of blood pressure during stress.
Stress and meltdownsDigby TantamPaper given to conference on ‘Stressand Autism’ organized by ResearchAutism, given in London on 13 May2013
Ulrich-Lai, Yvonne M., & Herman, James P. (2009). Neural regulation of endocrine and autonomic stress responses. Nat Rev Neurosci, 10(6), 39
Engelmann, Mario, Landgraf, Rainer, & Wotjak, Carsten T. (2004). The hypothalamic–neurohypophysial system regulates the hypothalamic–pituitary–adrenalaxis under stress: An old concept revisited. Frontiers in Neuroendocrinology, 25(3–4), 132-149.
Gordon, I, Carina, M., Feldman, F, & Leckman, J. (2011).Oxytocin and SocialMotivation. Developmentand cognitivescience, 1(4), 471-493.
Gordon, I, Carina, M., Feldman, F, & Leckman, J. (2011).Oxytocin and SocialMotivation. Developmentand cognitivescience, 1(4), 471-493.TEND AND BEFRIEND VS FIGHT AND FLIGHT
Stress and ASD: social corollaries• Reduced response to soothing becausereduced oxytocin• Reduced access to peers and socialsolutions• Social interaction as a source of threat• Failure of social sanctions• Challenging behaviour and not assault, orcriminal damage, or threatening behaviour• Perceived lack of planned impact on others
Parents stressedEstes, A., Olson, E., Sullivan, K., Greenson, J., Winter, J., Dawson, G., & Munson, J. (2012). Parenting-related stress andpsychological distress in mothers of toddlers with autism spectrum disorders. Brain & Development. doi:10.1016/j.braindev.2012.10.004• Mothers of 18-30 month old infants withautism, intellectual disability, or infants whoare normally developing• Mothers did not differ on anxiety ordepression• Parenting stress greater for mothers ofchildren with autism• Anxiety or depression and parenting stresscorrelated with child’s problematic behaviour
People with an ASD are stressed andthis contributes to challenging behaviour• Anxiety contributes to challenging behaviour(Pruijssers, van Meijel, Maaskant, Nijssen, & van Achterberg, 2013)especially in children with ASD where poor sleep is also a factor(Rzepecka, McKenzie, McClure, & Murphy, 2011)• People with ASD have chronic stress states (Kushki et al., 2013)• Displacement (e.g. rituals) relieves stress (Mohiyeddini & Semple, 2013)Kushki, A., Drumm, E., Pla Mobarak, M., Tanel, N., Dupuis, A., Chau, T., et al. (2013). Investigating the autonomic nervoussystem response to anxiety in children with autism spectrum disorders. PLoS One, 8(4), e59730, Mohiyeddini, C., &Semple, S. (2013). Displacement behaviour regulates the experience of stress in men. Stress, 16(2), 163-171, Pruijssers, A.C., van Meijel, B., Maaskant, M., Nijssen, W., & van Achterberg, T. (2013). The relationship between challenging behaviourand anxiety in adults with intellectual disabilities: a literature review. J Intellect DisabilRes, Rzepecka, H., McKenzie, K., McClure, I., & Murphy, S. (2011). Sleep, anxiety and challenging behaviour in children withintellectual disability and/or autism spectrum disorder. Res Dev Disabil, 32(6), 2758-2766.
Catastrophes and stress• Life-threatening stressor• Integrity threatening stressor• Social integrity: shame• Control: outrage at broken rules or coercion• Inner integrity: catastrophic reaction/ meltdown
Catastrophic reaction in dementiaYeom, H.-A., & Watson, N. M. (2009). Patterns of Antecedents of Catastrophic Reactions in Nursing Home ResidentsWith Dementia in the United States. Asian Nursing Research, 3(3), 99-110.• Fight: extreme angeror hostility• Perhaps influencedby modelling• Flight: extremesorrow or withdrawal• Combination of fightand flight: agitation
Meltdowns in ASD are a kind of catastrophicreaction, supervening on chronic stress, with an expression that isshaped by modelling, with one trigger being cognitive overload• Executive function• What have I forgotten?• There’s not enough time…• Nonverbal interpretation task• Was that a joke?• What’s going on in this group?• Language task• What does that mean?
Implications• Track an increase in ‘stress’• Be aware of shame and humiliation ascontributory factors• Can sensory factors be a trigger—perhapsespecially olfaction• Reduce complex cognitive demands• Take fatigue into account