Stress and Anxiety

STRESS AND ANXIETY

In this post I write up the notes drawn from various programmes and classes on health and anxiety I attended between 2017 and 2020. The above image is a handout we received in one class, which formed the basis of a deep dive into the damaging effects of anxiety on the body. It made for an uncomfortable, and sometimes harrowing, afternoon, but the lessons were important ones to learn.

Those concerned with identifying and managing stress should ignore the autobiographical commentary at the end. There are reasons why I added the commentary, however. Since this is a website created specifically to talk about my own personal experience of life and the issues it raises for me as an autistic person. I approach the issue of stress and anxiety with all the added complications of ASC, but the non-autist will find much to appreciate here. Anxiety and autism are two different things. For most, it is possible to address issues of stress and anxiety directly. Those on the spectrum need to approach these issues in light of their own underlying condition. 

This post is part 1 of a two part examination of autism and anxiety. This part focuses mainly on stress and anxiety. Throughout, however, I return to the relation to autism.  

The information below is drawn from various classes and programmes I attended and courses I took between 2017 and 2020, namely a) my cardiac rehabilitation programme in 2017; b) the Stress Less course I took in 2019; c) information and links provided by my doctor in discussions between 2018 and 2019; d) the anxiety classes I attended at St Helens Adult and Community Learning centre.

In the classes I attended I listened to the talks and studied the handouts with a view to making sense of my own issues. It is for others to do likewise with regard to their own issues. Whilst the focus of this post is on stress and anxiety as conditions which affect all people, I shall be paying attention to my own personal experience as someone diagnosed with Autism Spectrum Condition. I shall therefore keep switching between objective fact and subjective experience, conveying the information I received in classes accurately whilst adding a personal commentary of my own which will be of significance to all those with underlying conditions. That my issues are many, various, and complicated made me an active and interesting member of the groups I attended. I attended these classes before being diagnosed with Autism Spectrum Condition, although I had been referred by the time of the second class and was 99% certain of my self-diagnosis. Whilst stress was noted as a significant factor in my condition in the classes of 2017, it was clear to me even then that there was an underlying condition present and driving my physical problems. I really shouldn't have been struck down with the serious physical ailments I was suffering given that I had always been active and exercised well, ate fairly healthily, hardly drank alcohol (one pint of Guinness or lager once, maybe twice a week) and had never smoked. By 2019 I was clear that I suffered from what I called 'psycho-social anxiety,' something that expert investigation revealed to be AS. I deal with that issue more explicitly in another post, entitled 'Anxiety and Autism.' Here, the main focus shall be on stress and anxiety as such, the physiological processes involved, their effects on the body, and what can be done to manage and reduce them.

OVERVIEW

The biological, physical, cognitive, and emotional viewpoints;

The distinction between good stress and bad stress;

The techniques to avoid and/or decrease stress.

Knowledge is power

Whilst everyone experiences stress, with some suffering more than others, the good news is that you can act in light of knowledge. Knowing what your body is doing is empowering, enabling you to identify what is going on the better to understand and take practical steps to control it.

There are great advantages in learning the signs and cues and responding accordingly.

You can learn how to identify the signs of acute stress turning bad and respond effectively to the cues we received from the body.

Stress effects on the body

How does stress affect the body?

It is possible to identify and monitor the mental and physical signs of stress and learn how to manage and reduce stress levels.

The first step towards managing and reducing stress is to recognize the symptoms of stress. This may not be as easy as you may think. We are so used to being stressed that we don't recognize stress until we are at breaking point through suffering its effects over a period of time. There is, therefore, a need to know what stress is and identify its signs, symptoms, and causes of stress with a view to bringing it under control long before breaking point is ever reached. It is important to do this for health reasons. A person who is constantly stressed out and who has no way of coping is at risk of developing serious, even chronic, illness. Constant stress increases the risk of strokes, high blood pressure, diabetes, depression, and heart disease.

The distinction between good stress and bad stress

There is a distinction to be made between good and bad stress.

Is all stress bad? we were asked in the first class in 2019. I have been around enough classrooms over the years to know that a question like that is designed to introduce us to the complexity of a subject, inviting us to expand our understanding by further examination. I deduced that not all stress is bad, which implied that there is such a thing as good stress. And I was right. The tutor explained why.

Not all stress is bad. Indeed, small doses of stress can help you accomplish tasks that need to be accomplished and hence keep you from harm. There is a distinction to be made between good stress and bad stress. Stress is normal. It would be abnormal if people didn't feel stress. Stress is the trigger for appropriate reaction and response, telling your mind and body to act in response to an event. This could lead to a helpful positive response. It is a good thing to get out of the way of the various lions that life constantly has jumping out at you from the bushes. If you hear a car peeping its horn at you when you are wandering aimlessly the middle of the road, it is wise to take evasive action, and the quicker the better. Acute stress is what tells us to get out of harm's way. Being warned to take timely and effective action to avoid harm is a good thing. 

Stress

Stress is the body's reaction to potentially harmful situations and events. Life is full of threats, both real and perceived. Distinguishing between the two is not always easy, and the fact is that all stress is felt as real. It is also real in its effects.  

The human body is equipped to handle stress in small doses. Not all stress is bad. Stress is a natural and essential part of the body’s response system and stems from an innate survival instinct that we share with other animals. Stress is a natural mental and physical reaction to the everyday events of life. It is thus normal for people to experience stress. Stress drives us to react in a timely way whenever we experience something that is dangerous, triggering a ‘fight or flight’ response. The “fight or flight” response was designed to protect your body in an emergency by preparing you for timely and effective response. The presence of a threat initiates a chemical reaction in the body, enabling a person to act so as to avoid harm. Stress is thus necessary to incite a response to events. Stress can give us a short-term boost to help us meet the threats we face. During the stress response your heart rate increases, your breathing quickens, the blood pressure rises, and your muscles tighten in readiness for action. You are now ready to protect yourself. The problems come when the stress response doesn’t stop firing, and stress levels stay elevated for much longer than isrequired for survival. A lot of stress can trigger a deeper anxiety, becoming chronic over time. And this is a very bad thing. Whilst the body is designed to handle small doses of stress, it is not equipped to handle long-term stress without suffering ill consequences. 

Some stress is a normal part of everyday life, e.g. the struggle to secure the essential things in life, the need for a regular income, shelter, relations to others. But constant stress causes anxiety. Our bodies are not designed to cope with constant stress. Constant stress has big physical and emotional consequences when it turns into chronic anxiety. 

Anxiety is an emotional state that we feel which can lead to panic, disorder,and depression. Chronic anxiety results when stress carries on beyond the initial response. If stressis caused by a lion jumping out at you from behind a bush, tellingyou to fight or flee, then anxiety is like the lion constantly jumping out at you, having you in constant fight or flight mode. When you feel as though a whole herd of lions is constantly jumping out atyou, then you have serious problems. The effect is exhausting and hasa detrimental impact on mind and body. That, I would suggest, can be the normal state of someone with Asperger's or Autism Spectrum Condition.

When the stress response keeps firing, day after day, over a long period of time, your health can be put at serious risk. Whilst short-term stress can help us achieve important goals, a stress that is constant and persistent can cause serious health problems. When stress becomes long-term, it can have a damaging impact on mental and physical health. Chronic stress can take a toll on your health and cause a variety of symptoms which affect your overall well-being. In fact, chronic stress is better termed chronic anxiety, something that can lead to chronic illness.  You need to identify the signs and take action to turn your life around.

Categories of stress

In short, the distinction between good stress and bad stress is a distinction between short-term stress and long-term stress.

1. Short term stress

In the short term stress is beneficial and useful. In response to stress the body goes through biological change to take appropriate action. 

Good stress is positive stress in that it incites the body into doing things in order to take appropriate action. Acute stress is good stress, a normal part of the body's functioning;

2. Long term stress 

Long term stress is chronic and leads to burn out.

If stress is in our lives all the time then it accumulates to become a constant presence beyond the passing of stressful events and circumstances. Long term stress is the stress that is mentally and physically damaging.

THE STRESS CURVE

Stress provokes a response and issues in appropriate action and then calm is restored. Unfortunately the body doesn’t always calm down. It is normal for certain events but the problems come when it becomes permanent. Whilst some stress is good in order to motivate performance, too much stress generates burnout and frazzle.

Physiological explanation

Stress comes in physical, emotional, cognitive, and behavioural forms. It can cause headaches, stomach pain, nausea, chest pain, teeth grinding, dilation of pupils. 

Emotional symptoms of stress include:

• Irritability. Becoming easily agitated, frustrated, and moody;
• Feeling overwhelmed, like you are losing control or need to take control; 
• Having difficulty relaxing and quieting your mind;
• Feeling bad about yourself (low self-esteem), lonely, worthless, and depressed;
• Avoiding others. 

Cognitive symptoms of stress include:

• Constant worrying;
• Racing thoughts;
• Forgetfulness and tendency to disorganization;
• Inability to focus;
• Poor judgment;
• Being pessimistic or seeing only the negative side.

Behavioural symptoms of stress include:

• Changes in appetite -- either not eating or eating too much;
• Procrastinating and avoiding responsibilities;
• Increased use of alcohol, drugs, or cigarettes;
• Exhibiting more nervous behaviours, such as nail biting, fidgeting, and pacing.

Long-term or chronic stress can cause a number of physical symptoms – such as muscle tension, headaches, and digestive problems, which in turn bring about worry and make us even more stressed! Recognizing the signs of stress and, importantly, identifying their causes, are crucial in taking effective action to manage and reduce it so as to break the vicious cycle.

Physical symptoms of stress include:

• Low energy;
• Headaches;
• Upset stomach, including diarrhoea, constipation, and nausea;
• Aches, pains, and tense muscles;
• Chest pain and rapid heartbeat;
• Insomnia;
• Frequent colds and infections;
• Loss of sexual desire and/or ability;
• Nervousness and shaking, ringing in the ear, cold or sweaty hands and feet;
• Dry mouth and difficulty swallowing;
• Clenched jaw and grinding teeth.

Consequences of Long-Term Stress

• Ongoing, chronic stress can cause or exacerbate many serious health problems, including:
• Mental health problems, such as depression, anxiety, and personality disorders;
• Cardiovascular disease, including heart disease, high blood pressure, abnormal heart rhythms, heart attacks, and stroke;
• Obesity and other eating disorders;
• Menstrual problems;
• Sexual dysfunction, such as impotence and premature ejaculation in men and loss of sexual desire;
• Skin and hair problems, such as acne, psoriasis, and eczema, and permanent hair loss;
• Gastrointestinal problems, such as GERD, gastritis, ulcerative colitis, and irritable colon.

Whilst this all takes some unpacking, the basic message is clear: Left unchecked, a severe stress that continues over a long period of time - months or years — is apt to lead to serious, even chronic, illness.

It may be enough to be able to identify the signs of stress and its effects upon the body, proceeding directly from there to stress-management strategies. Those can be found in the final part of the document. Some may want an understanding of the physiological processes involved. Those interested can read on.

RESPONSES OF THE BODY TO STRESS

Responses, Impacts, and Effects

Activating our alarm system.

The body is always assessing stress threats - internal and external.

The body’s alarm system works in terms of the fight or flight response.

The amygdala checks for threats and provokes a response; it is always alert and scanning for threats, leading to a heightened vigilance. 

The immediate adrenalin rush causes a state of heightened vigilance. Appropriate action taken and stressful events and situations passed, the body returns to its relaxed and unstressed state. When the body remains in a state of vigilance, a chronic condition is threatened. We therefore need to be able to identify the signals.

IDENTIFYING THE SIGNALS

Identifying the signals and developing the techniques to deal with them is key.

The problems come when parts of the brain don't work as they ought. This happens when the lower brain stem takes over and attempts to do the job of the higher brain. When this happens we are functioning from a more primitive part of the brain.  The amygdala is the reptilian brain taking over over the rational part of the brain and becoming hyper active and dominant. When this happens you will not be at your best mentally. The reasoning part of the brain is not working well. You start to overact as if the world is ending. The effect is exhausting, wearing mind and body down over time and bringing on any number of issues with respect to mental and physical health.

Spotting the physical signs of stress

A stress that is constant and long-term can develop into a chronic anxiety that can have a detrimental impact on all the systems of the body: the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous, and reproductive systems.

Musculoskeletal system

When the body is stressed, the muscles tense up in a reflex reaction. This is the body’s way of guarding against injury and pain. A sudden onsetof stress causes the muscles to tense up all at once, the tension releasing when the stress passes. The problems come when the stress doesn't pass, with the result that the muscles tend to to be in a constant state of guardedness. When muscles are taut and tense over long periods of time, other reactions of the body are triggered, going on to cause stress-related disorders.

For instance, chronic muscle tension in the area of the shoulders, neck and head have been known to cause tension-type headache and migraine headache. Stress has also been linked with musculoskeletal pain in the low back and upper extremities.

[This was important information for me to receive, since it overlapped with information I had received in cardiac rehabilitation and indicated symptoms which could also be easily associated with a heart attack. On three occasions now I have suffered pain across the shoulders, neck and into the jaw. One time it was a definite heart attack. On the other occasions, though, the causes were the result of something else, something I identified as “psycho-social anxiety” to my doctor. I had recently been subject to constant messaging and interference fromothers as I worked, and the effect brought on symptoms I had been taught to associate with a heart attack. I therefore called an ambulance. I was examined in hospital and there were no signs of having suffered a heart attack, even though I was enough of a borderline case for there to be talk of keeping me in overnight in order to make sure. My heart condition is so precarious as to have medical professionals being doubly cautious. We determined there and then to eliminate the physical causes of this “psycho-social anxiety” I kept complaining about. This was duly done after a series of tests. And a year on, having asked for a referral for AS, I was attending Anxiety classes again, knowing deep down what the underlying issue was. Such is life.]

Very many people suffer from painful conditions secondary to musculoskeletal disorders. It can often be a physical injury that leads to this state of chronic pain, but it is not so much the initial injury but how people respond to it that determines whether or not a person will go on to suffer from chronic pain. Individuals who are fearful of pain and re-injury, seeking only a physical cause and cure for their ailments, tend to have a worse recovery than individuals who maintain a certain level of moderate, physician-supervised activity. Muscle tension, leading eventually to muscle atrophy due to disuse of the body, serves to advance chronic, stress-related musculoskeletal conditions in a person.

It is imperative, then, to undertake stress-relieving activities and therapies as well as practice relaxation techniques in order to reduce muscle tension, decrease the incidence of certain stress-related disorders, and increase a sense of well-being. 

Respiratory system

[This aspect was close to my heart, given that my dad had COPD. I also lost both grandfathers in their early sixties due to lung disease.]

The respiratory system supplies oxygen to cells and removes carbon dioxide waste from the body. Air comes in through the nose and goes through the larynx in the throat, down through the trachea, and into the lungs through the bronchi. The bronchioles then transfer oxygento red blood cells for circulation.

Stress and strong emotions can induce respiratory problems in the form of shortness of breath and rapid breathing. During the stress response, you breathe faster in an effort to quickly distribute oxygen-rich blood to your body. If you already have a breathing problem like asthma or emphysema, stress can make it even harder for you to breathe.

This is caused by the airway between the nose and the lungs constricting. For those without respiratory disease this is not necessarily a problem, since the body can manage the additional work involved to breathe comfortably. For people with pre-existing respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD; includes emphysema and chronic bronchitis), psychological stressors can exacerbate breathing problems and cause serious issues.

Many studies show that an acute stress brought on by bereavement, relationship problems and breakup, moving house or losing shelter, the loss of a job and/or income can trigger rapid breathing—or hyperventilation – bringing on panic attacks and asthma attacks. These are the biggest stress points in life, any one of which can send a person into deep decline - I got three of these all at once.

Relaxation, meditation, and breathing techniques and other cognitive behavioural strategies can be of help here. These are all things you can learn and things you can do, making them habitual.

Cardiovascular system

[This was an area of particular interest to me. The information Ireceived here confirmed what I had learned in my cardiac rehabilitation classes in 2017. The most interesting thing for me to do here was to relate cardiovascular problems to the constant stress I suffer, and which forms into a chronic anxiety, all grace of an undiagnosed ASC. This, in a nutshell, is the “psycho-social” complaint I took to my doctor and which led to my diagnosis. Slowly but surely all the pieces were being fitted together. The fact is, though, that I already had more than enough information and knowledge to tell me I had before the diagnosis received official confirmation.]

In response to acute stress, the cardiovascular system prepares the body for the fight or flight response. This process involves an increase in all of the following:

heart rate;

contraction strength of the heart;

release of epinephrine, norepinephrine, and cortisol;

bloodflow to the major muscle groups.

When a person experiences long-term stress, these responses persist and can lead to inflammation. Chronic stress can lead to high blood pressure, heart attack, and stroke. Take anxiety very seriously and do not ignore it!

The heart and blood vessels comprise the two elements of the cardiovascular system that work together to provide the body's organs with oxygen and nourishment and oxygen. The activity of these two elements is directly involved in the body’s response to stress. It is here that the distinction between good stress and bad stress is crucial. Good stress refers to that acute stress which is momentary or short-term, inciting appropriate, timely, and effective response to life's demands. Acute stress is crucial in alerting us to a threat, such as averting an accident or meeting a deadline. Acute stress causes the brain to release a ‘stress response,' causing an increase in heart rate and stronger contractions of the heart muscle. These send signals via the pituitary gland to the adrenal gland to release the stress hormones cortisol, adrenaline and noradrenaline, which act as messengers for these effects.

Stress hormones are energising. They give you the motivation and focus to complete difficult tasks, solve problems, and reach your immediate goals. That’s why stress is good for you in small doses. These hormones raise the blood pressure and give the body a dose of glucose that goes straight to your muscles. The blood vessels that direct blood to the large muscles and the heart dilate, thus increasing the amount of blood pumped to these parts of the body and raising blood pressure. This is a case of the body working as it ought, inciting the fight or flight response. The whole process gives you the energy boost required for effective response to an immediate stressor. Once the events or situations causing acute stress pass, stress diminishes and the body returns to its relaxed state.

Acute stress is therefore good, a sign that the body is working as it ought. But ongoing, long-term stress – the kind that can’t easily be solved with a short burst of energy and focus – is a bad stress that can cause serious physical signs of stress.

Bad stress is that constant stress that is experienced over a prolonged period of time. This is a chronic condition which can engender long-term problems for heart and blood vessels. The constant  and ongoing increase in heart rate, and the elevated levels of stress hormones and of blood pressure, can inflict a serious strain on the body and have a deleterious impact, increasing the risk for hypertension, heart attack, or stroke. Repeated acute or chronic stress can also contribute to inflammation in the circulatory system, particularly in the coronary arteries, and is a recognized pathway that links stress to heart attack. It is also considered that how a person responds to stress can affect cholesterol levels.

“The stress hormones cortisol, adrenaline, and epinephrine affect most areas of the body, interfering with sleep and increasing the risk of strokes, high blood pressure, and heart disease, as well as causing depression and anxiety,” says Alka Gupta, MD, codirector of the Integrative Health and Wellbeing program at NewYork-Presbyterian/Weill-Cornell Medical Center in New York City. 

Stress causes the heart to pump faster. Stress hormones cause the blood vessels to constrict and divert more oxygen to the muscles so that you will have more strength to take action. This action, though, raises the blood pressure. Frequent, constant, and chronic stress thus serves to make your heart work too hard for too long, increasing the risk of heart attack. When your blood pressure rises, so do your risks for having a stroke or heart attack.

Seeing the extent to which constant stress can take a toll on the body and induce strokes and heart attacks makes it imperative to learn how to handle stress and thus protect against chronic illness. 

[I make no apologies for having over-written here. I think the problems here so important as to bear repetition. I also have a direct personal interest in the processes described here, given that I have a chronic heart condition as a result of having suffered a massive heart attack in December 2016. Managing these issues effectively depends upon the ability to identify and manage and/or eliminate their causes.

In making my condition – or conditions – public in the anxiety classes of 2019, I effectively became group leader, the poster boy for anxiety and its possible effects. The tutor appreciated my candour. There was no point in being shy. And toughing it out in silence can be positively lethal. My example gave practical, personal, force to the warnings she was issuing through the physiological explanations. At the same time, the prominent position I had assumed by being so open made me somewhat, well, anxious. I was the most vocal in the group, the one who seemed to have most to say, and the one to whom the tutor would turn in order to deliver her teaching points. Having started on the good foot, and gone so far down the road, there was no chance that I could shrink back and take a backseat. People were looking to me and I didn't like to disappoint or seem inadequate in some way. Which is quite the responsibility for an anxiety class. I was somewhat nervous wondering what may be coming next].

Endocrine system

The HPA axis and cortisol

When a person perceives a situation to be challenging, threatening, or uncontrollable, the brain initiates a series of events involving the hypothalamic-pituitary-adrenal (HPA) axis, which is the primary driver of the endocrine stress response. There is, as a result, an increase in the production of steroid hormones called glucocorticoids, which include the “stress hormone” cortisol.

Cortisol improves the way that the brain works and regulates other body systems. Cortisol is crucial to helping the body to take the immediate actions to survive stressful events and situations.

The hypothalamus is a collection of nuclei that connects the brain and the endocrine system. When the body is subject to stress, the hypothalamus, signals the pituitary gland to produce a hormone, which in turn signals the adrenal glands, located above the kidneys, to increase the production of cortisol. 

Cortisol increases the level of energy fuel available by mobilizing glucose and fatty acids from the liver. Cortisol is normally produced throughout the day in a cycle of energy, typically increasing in concentration upon awakening and declining slowly as the day comes to an end. An increase in cortisol in response to a stressful event serves to provide the energy required to deal with prolonged or extreme challenge.

Under stress the heart rate goes up, as does blood pressure. Cortisol is released under stress, but the level of this hormone should go down once the stressful event has passed. If this doesn't happen, then the heart comes under severe pressure.

Our liver gives us a boost of glucose when we’re stressed, enabling us to physically respond to stressors. A constant release over the long-term, however, increases the risk of developing type 2 diabetes, as well as making it harder for those suffering to maintain a healthy weight.

[Happily, I have always maintained a healthy weight and never been obese. Unhappily, I was diagnosed with type 2 diabetes. Given that I considered myself to be fit and healthy, this came as a shock. I now see the extent to which stress and anxiety grace of an undiagnosed ASC lie at the centre of my health problems, just as that ASC lies at the centre of all my other problems. This information was making sense of my problems with physical health. How sad to see how predictable it all was, and how avoidable with the right information and action. I present the materials here as a warning to others.]

The immune system

Stress may cause decreased immune function. In moments of acute stress, the body prepares for the possibility of injury or infection by activating the immune system, which protects it from outside dangers. Chronic inflammation is a risk factor for diseases such as atherosclerosis. Glucocorticoids, including cortisol, play a crucial role during stressful or threatening situations in regulating the immune system and reducing inflammation. Chronic stress, however, can cause impaired communication between the immune system and the HPA axis, something which has been linked to the development of a number of mental and physical health conditions, including chronic fatigue, metabolic disorders (e.g., diabetes, obesity), depression, and immune disorders. If stress becomes persistent, the long-term release of immune factors, such as proinflammatory cytokines, can cause chronic inflammation.

Stress inhibits the immune system in the first instance. The chemicals that the body releases to deal with immediate threats aren’t designed to keep us healthy in the long-term. Chronic stress or anxiety can, therefore, deleteriously affect the immune system making people susceptible to colds, flu and other infections.

Gastrointestinal system

Our guts are surprisingly sensitive organs, and respond to hormone imbalances, stress, and many physical and mental health conditions with pain, bloating, and sometimes changes in bowel habit.

The gut has hundreds of millions of neurons which can function fairly independently and are in constant communication with the brain—explaining the ability to feel “butterflies” in the stomach. Stress can affect this brain-gut communication, and may trigger pain, bloating, and other gut discomfort to be felt more easily. The gut is also inhabited by millions of bacteria which can influence its health and the brain’s health, which can impact the ability to think and affect emotions.

Stress is associated with changes in gut bacteria which in turn can influence mood. Thus, the gut’s nerves and bacteria strongly influence the brain and vice versa.

Early life stress can change the development of the nervous system as well as how the body reacts to stress. These changes can increase the risk for later gut diseases or dysfunctioning.

Esophagus

Stress affects eating habits for the worse. Individuals may come to eat much more or much less than usual when they are under stress. Increased intake of food, as well as an increase in the use of alcohol or tobacco – search for comfort under stress - can cause heartburn or acid reflux. Intense stress can also set of spasms in the esophagus which can be mistaken for a heart attack.

Stress also may make it more difficult to swallow food or increase the amount of air that is swallowed, causing burping, gassiness, and bloating.

Stomach

Stress may induce stomach pain, bloating, and nausea. If the stress is severe enough, vomiting may occur. 

[I had an appalling time in this respect throughout 2017 and 2018. For a long time I put it down to a violent reaction to the medication I was given in order to manage my heart condition. I suffered painful episodes of nausea, involving violent attacks and upsurges that had me worrying they might be putting too great a strain on the heart. The pain was such, though, that I reached the stage where I no longer cared. If the next attack got me then so be it, at least I shall have rest. I complained to my nurses in cardiac rehab, only to keep drawing a complete blank. They didn't pursue the causes. It could be that this was a time when my body was adjusting to the medication. But it seemed to be more to me. I noticed that the attacks always seemed to come whenever I had been in stressful contact with others. This was further proof to me that my physical complaints had an underlying cause that had yet to be detected.] 

Furthermore, stress may cause an increase or decrease in appetite that has people eating an unhealthy diet, which in turn brings on a deterioration in mental and physical health.

Bowels

The stomach pain, bloating, or discomfort induced by stress can affect the bowels in terms of the speed at which food moves through the body, causing either diarrhoea or constipation. 

Stress especially affects people with chronic bowel disorders, such as inflammatory bowel disease or irritable bowel syndrome. This may be due to the gut nerves being more sensitive, changes in gut microbiota, changes in how quickly food moves through the gut, and/orchanges in gut immune responses.

Nervous system

The nervous system can be divided between the central division and the peripheral division. The central division consists of the brain and spinal cord, the peripheral division of the autonomic and somatic nervous systems.

The autonomic nervous system, which plays a direct role in the physical response to stress, is divided into the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). When the body comes under stress, the SNS contributes to the “fight or flight” response, with the  body shifting its energy resources toward fighting off a threat or toward fleeing from an enemy.

The SNS signals the adrenal glands to release hormones called adrenalin (epinephrine) and cortisol. These hormones cause the heart to beat faster, respiration rate to increase, blood vessels in the arms and legs to dilate, digestive process to change and glucose levels (sugar energy) in the bloodstream to increase to deal with the emergency.

The SNS response is fairly sudden so as to prepare the body to respond in a timely manner to an emergency situation. This is good stress or acute stress involving short term stressors. Once the crisis events have passed, the body normally returns to its pre-emergency state, free from stress. This recovery is facilitated by the PNS. Over-activity of the PNS can, however, contribute to stress reactions, promoting bronchoconstriction or exaggerated vasodilation and compromised blood circulation.

The SNS and the PNS have powerful interactions with the immune system, which can also modulate stress reactions. 

The Central Nervous System

The central nervous system is particularly important in triggering stress responses, as it regulates the autonomic nervous system and plays a central role in interpreting contexts as potentially threatening. The central nervous system (CNS) is in charge of the “fight or flight” response. In your brain, the hypothalamus gets the ball rolling, telling your adrenal glands to release the stress hormones adrenaline and cortisol. These hormones rev up your heartbeat and send blood rushing to the areas that need it most in an emergency, such as your muscles, heart, and other important organs.

When the perceived fear is gone, the hypothalamus should tell all systems to go back to normal. If the CNS fails to return to normal, or if the stressor doesn’t go away, the response will continue.

Beyond the physiological explanation are the effects on the body. The big problems come when  acute stress involving short term stressors turns into a chronic stress, with a body experiencing stressors over a prolonged period of time. This is experienced as a long-term drain on the body. The way in which the autonomic nervous system continues to trigger physical reactions takes a gradual toll on the body. The problem is not simply the impact of chronic stress on the nervous system, but what the continuous activation of the nervous system does to the other bodily systems.

Chronic stress affects dopamine levels, which is one of the reasons long-term stress makes us more vulnerable to mental illness. It can particularly make us seek short-term rewards like sugary, fatty or salty foods, affecting our weight and overall health.

Through weight gain or loss increased cortisol levels stop our bodies from breaking down fat, so it can make it hard for us to lose weight o rkeep weight off. It can even influence our shape, with research suggesting it can lead to more abdominal fat. Chronic stress can also make us look for immediate comfort in foods. On the other hand, some people find that they have a decreased appetite when stressed, as adrenaline levels – and sometimes the depression that can go hand-in-hand with chronic stress – affects appetite.

The central nervous system comprises the brain and spinal cord. Stress effects on the central nervous system may include:

Headaches

Stress can be a trigger for tension headaches and migraine in some people.The release of stress hormones can cause changes in the blood vessels around the brain, causing tension, headaches and migraines.

Depression

Many studies indicate that stress may cause depression. Some researchers have proposed the term “stress-induced depression” to refer to depression that occurs when people have a history of stress before their diagnosis. Continual work-related stress can contribute to depression.

[This all seems eminently plausible to me. In 2019 and then 2020 I complete th ePatient Health Questionnaires at my medical centres, both times reporting 'severe depression.' If I am not depressive by nature, there are many times I can feel I am facing obstacles which are insurmountable. Life is stressful the best of times; having to deal with life when you have severe impairments in social interaction and communication can leave you unable to deal with stressful events, situations, and relations.]

Insomnia

People experiencing stress may develop insomnia or have worsening sleep issues. The hypothalamus is one of the key structures involved in the sleep-wake cycle. During stressful experiences, the body activates the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. These systems release hormones that stimulate attention and arousal, causing issues with sleep.

[In a line, the events of the day can have me thinking long into the night, keeping me from my bed and keeping me awake when I finally get to it.]

Reproductive system

Stress can affect both the male and female reproductive systems, potentially leading to issues with the libido, orgasms, and sustaining an erection.

[I shall quote from my notes. This whole area made me somewhat nervous in my 2019 anxiety class. It was an all-female class led by a female tutor. It was the kind of situation that could have been designed to make a male with ASC incredibly anxious, all the more so since I had been by far and away the most vocal in the group up until this point. To speak or not to speak, that is the question.]

Male reproductive system

The male reproductive system is influenced by the nervous system. The parasympathetic part of the nervous system causes relaxation whereas the sympathetic part causes arousal. In the male anatomy, th eautonomic nervous system, also known as the fight or flight response, produces testosterone and activates the sympathetic nervous systemwhich creates arousal.

Stress causes the body to release the hormone cortisol, which is produced by the adrenal glands. Cortisol is important to blood pressure regulation and the normal functioning of several body systems including cardiovascular, circulatory, and male reproduction. Excess amounts of cortisol can affect the normal biochemical functioning of the male reproductive system.

Sexual desire

Chronic stress, ongoing stress over an extended period of time, can affect testosterone production resulting in a decline in sex drive or libido, and can even cause erectile dysfunction (or, as the tutor in my anxiety class rather brutally put it, 'impotence.' If she did it for shock effect, it worked).

Men of all ages may experience erectile dysfunction in some shape or form caused by stress.

Men under the age of 30 are most likely to experience erectile dysfunction due to nervousness and anxiety. This form of psychological erectile dysfunction is generally short-lived.

Men over the age of 30 are more likely to be dealing with personal and professional stress which may lead to erectile dysfunction.

Men over the age of 50 are more likely to experience erectile dysfunction because of ageing. Life circumstances, such as losing a partner or adjusting to retirement, may also cause stress and anxiety in men.

“Anything that can lead to anxiety can inhibit the ability to get an erection,” says Dr. Berglund. That includes daily stressors.

Anxiety causes a mental distraction, making it difficult to focus on sex.

Stress can cause an increase in sympathetic nerve activity (think: the fight-or-flight response). Your body’s stress response counteracts the parasympathetic system, which works when you’re at rest. The result is that it is well-nigh impossible to stay aroused when you’re seized with fear and panic.

[It's a good job I am blessed by a sense of humour. I had got off to a confident start in the 2019 anxiety classes I attended (so confident as to beg the question as to why I was even there - I maintain that half the battle with anxiety is won by finding the company of others). I had emerged as the leader of the group, the class clown who was never short of an answer, and the tutor was using me to draw the others out of themselves to find their voices. The tutor would put questions to me whenever the group fell silent or stalled, just to get things moving. It's a good teaching technique, of course, using the stronger performers in the group in order to establish teaching points in ways the other learners can understand. There was just something about the way that the tutor insisted on using the words 'impotence' and 'impotency' that made me kind of nervous. All the women were admitting to were headaches and isomnia. In my idiosyncratically autistic way, I sat there trying to work out whether she was eliciting additional information from me, by way of confirmation or denial, as she tended to do throughout the course, or was just making an essential point as she covered all bases on the handout. I felt like telling her that the word 'impotence' has fallen out of favour. She may even have been inviting that correction on my part, just to open up the discussion. I felt that once I had started down this line I wouldn't be able to finish. I thus didn't much feel like commenting. But having already revealed that I suffer from diabetes and a heart condition, taking medication for both conditions, as well as suffering a stress so constant as to be chronic anxiety, I seemed to have
identified myself as a certain candidate for erectile dysfunction. Silence was tantamount to tacit confirmation. And yet it didn't seem quite appropriate to issue a statement of male virility and potency in an all-female class. I couldn't even think of a witty comment, my usual mode of escape. I've never suffered from insomnia, I said rather dolefully at yet another mention of  'impotence.'

I make a joke of things. Humour is my default position. But the issue is deadly serious, something that can destroy confidence and ruin relationships. It is also an issue of physical health, a barometer of overall health in a male. I was taught this in cardiac rehabilitation, where I brushed off a tentative enquiry with a promise to exercise more. Exercise alone, I was told, may not be enough. So there is a need for openness. 

I noticed how there was a much greater stress on the male as against the female aspects of sexual dysfunction. I'm not sure why. I could speculate that it was because I was deemed to be the most confident member of the group, and so more open to hear and speak on intimate issues. As the only male, I was left bearing all the weight on one side in the cause of balance. But the female side was covered in a most perfunctory manner. At least a couple of the ladies in the group seemed to be struggling badly, and the whole area seemed somewhat indelicate in mixed company. But I have noticed the same imbalance in health care, with males seemingly expected to be open and unafraid.

Female reproductive system

Menstruation

Stress may affect menstruation among adolescent girls and women in several ways. For example, high levels of stress may be associated with absent or irregular menstrual cycles, more painful periods, and changes in the length of cycles.

Sexual desire

Stress, distraction, fatigue, etc., may reduce sexual desire—especially when women are simultaneously caring for young children or other ill family members, coping with chronic medical problems, feeling depressed, experiencing relationship difficulties or abuse, dealing with work problems, etc.

And that's as far as I am going with women, because that's about all the ground we covered, and that's all I'm expert in (the fact that there was more coverage of male issues than female was most odd given it was an all-women group. I can only presume the need to tread carefully when covering intimate issues in mixed company, whilst noting it didn't apply to males. I'm not protesting, just noting.

I move on.

Mental health

Chronic stress is closely linked with an increased risk of serious mental health conditions, including depression. Chronic stress over time can make a person more susceptible to mental and emotional illness. Many people who suffer from chronic stress will have recourse to coping strategies that, although offering quick and immediate comfort, serve only to make us more unwell. Eating and drinking the wrong things as well as smoking are classic examples of unhealthy ways in which people try to handle stress.

Techniques to avoid and/or decrease stress.

Stress Management and Reduction

It's not all bad news! There are many strategies which help people deal with stress. Some strategies include behaviours which are designed to improve physical health, such as exercise and proper nutrition. Some techniques focus on behaviours that are beneficial for emotional functioning. It is possible to manage and reduce stress by doing small things like deep breathing, taking a walk, and meditating. Strategies such as these can help short-circuit the body’s fight-or-flight response, stopping the flood of stress hormones from revving up your bloodpressure and heart rate.

How to reduce stress levels

Symptoms, causes, and physiological explanations over, we came to the 'what is to be done?' question. This was the practical, the take-home which we need to absorb and enact.

Some of the stressors disturbing our lives are things that we can aim to take some practical control over. Some of them, however, are not. The advice is to take control of the things it is possible for you to take control of. When it isn't possible to remove the thing that is causing us stress, there is a need to find ways of managing and responding to that stress.

A greater understanding of mental and physical problems makes it more possible to devise effective stress management and reduction strategies. Taking appropriate and effective steps to manage and reduce stress can have many benefits for mental and physical health. A number of beneficial strategies can be identified. You need to explore these strategies, make them part of your action plan, and do them!

Regular physical exercise.

This is a no-brainer. Exercise has some direct stress-busting benefits. When I came through my physical tests at hospital in 2019 with flying colours, I told one of the cardiac nurses how good I felt when exercising. She told me that physical activity pumps up your endorphins, the brain's feel-good neurotransmitters. Exercise not only makes you fit, it makes you feel good and, in turn, boosts your confidence. You start to feel more powerful.

Keep Breathing

When people ask me how I'm doing, I say 'I'm still breathing; it's a good start.' When people would complain of their ailments, my grandmother would ask: 'are you still breathing?' When they replied 'yes,' she would say 'then you're alright.' I'm not altogether sure that that is true, but point taken – breathing is a good start. Breathing is important. Breathe well. 

Practising relaxation techniques, such as deep breathing, mindfulness, meditation, yoga, tai chi or massage. I was taught mindfulness and breathing techniques. Mindfulness requires a person to focus their attention on the present moment, be aware of their passing thoughts. Mindfulness-based stress reduction programs involve breathing meditation and yoga-inspired physical exercises. Breathing exercises and mindfulness techniques are stress-management strategies whose benefits are supported by good clinical evidence.

Eat well

Eating a healthy diet is one of the best things to do for mental and physical health. In a line, this means lots of fruit and vegetables, wholegrains, and lean proteins. 

Keep in Touch

Maintaining a healthy social support network is important, with feelings of belonging creating a well-being that impacts in other areas. Spending time with family and friends has positive health benefits. Even when, and especially when, you don’t feel like it, maintaining your social life by keeping in touch with others is important. The more people you see, the more it may be possible to talk to others about your troubles. If that seems too heavy, then the simple the act of socialising with others can be uplifting.

Enjoy yourself

Setting aside time for things you enjoy, interests, hobbies, and activities.

Get out and walk!

Time spent in the great outdoors energises us and helps us maintain a good sleep pattern, thereby improving mental and physical health. It is also a form of exercise. Exercise and seeing the sights is good for stress relief.

Sleep well

Getting enough sleep and sticking to proper and regular hours can have a huge impact on how well we cope with everyday stress. Such things as late-night screen time, alcohol, big meals and nicotine are things that people do at night for relaxation but are actually stimulants that can stop us getting to sleep. Since caffeine can still affect us some 6 hours after drinking it, it may be wise to cut coffee out early in the afternoon.

Keep your sense of humour.

In my teacher training I said I liked to encourage the class comedian. I was warned that the problem with class comedians is that, once they have started, they never know when to stop. I tend to see the funny side in most situations and, if I can't see it, I'll create it. In my anxiety classes I kept up a generally humourous and light-hearted commentary whilst at the same time pausing to make the point that the issues we were discussing were deadly serious and should be taken seriously. People need to see their problems being addressed whilst also being lifted.

These strategies have beneficial effects for mental and physical health, supplying the critical foundations for a healthy lifestyle.

TWO TECHNIQUES ENABLING YOU TO TAKE A MINUTE 

These were the two techniques we were taught and which we practised in the anxiety class of 2019.

Breathing

When under stress you breath shallowly

Here is a breathing activity that will calm you down, it is called 3-4-5, it calms the vagal nerve.

The in is shorter than the out. The count for the 'in' has to be shorter than the count for the 'out.'

Do 3 rounds of 3-4-5

The goal is to take a minute and do 3-4 rounds in this simple but effective breathing technique.

The 7-11 is longer for those who are fitter. 

Mindfulness

The other technique is mindfulness or focusing on the present moment.

There are five senses – sight, vision, touch, smell, taste

Ask what each of your senses tell you. 

As the brain concentrates on the present moment revealed by the senses it will calm you down and take you out of your thoughts.

Prevention is better than cure and prevents stress levels from getting too strong

Practice breathing

Practice mindfulness

Exercise, sufficient sleep at the right hour, and a healthy, balanced diet are obvious solutions. 

What needs to be explained, though, is why people get drawn away from the healthy into the unhealthy.

My own story offers a case-study of how easily you can lose mental and physical health as a result of life's stresses and strains.

I was on a superb health and fitness regime from 2017 to 2019. I was as fit as I had ever been in April of 2019, when I sailed through a series of physical tests at hospital. And somewhere I came off the plan and lost direction. This came as a result of a number of things, summed up under the heading 'life.' My father died, I had to start the process of moving house, which entailed the loss of my job,. Then Covid-19 struck and the world went into Lockdow. I became even more socially isolated just at the time I needed contact with others. I reached out for help and found that there was none forthcoming: my regular health checks were indefinitely postponed, my referral for ASC was delayed and delayed, my responses to a couple of Patient Health Questionnaires recorded a condition of 'severe depression.' The situation seemed so dire as to be beyond help and beyond hope. And behind all of these objective problems I knew that there was the subjective condition of undiagnosed ASC saddling me with problems of social interaction, communication, and participation which served to cut me off from normal society. That I am still alive, fairly fit, and (almost) sane is something of a miracle. Throughout nearly the entirety of this period I have been alone. At the same time, I am grateful for the lessons taught in my health and anxiety classes. I listened to what others were saying, took note, and made them part of my Action Plan.

The advice given at the end of my stress and anxiety classes and courses is pertinent:

When to seek help

If you've taken steps to control your stress but your symptoms continue, see your doctor. Stress and its physical symptoms are a common reason people speak to their GP. If you’re struggling with stress there are options available for support. But there may be something else going on. There is, therefore, a need to check for other potential or underlying causes. Your doctor can help you identify sources of yourstress and learn new coping tools.

[That is what I did after my Stress Less course and after suffering symptoms associated with a heart attack.]

Call for emergency help immediately if you have chest pain, especially if youalso have shortness of breath, jaw or back pain, pain radiating into your shoulder and arm, sweating, dizziness, or nausea. These may be warning signs of a heart attack and not simply stress symptoms.

[In December 2016 I ignored these symptoms and was lucky to survive a massive heart attack. I suffered these same symptoms again in 2018 and 2020. This time there was no indication of having suffered aheart attack. Stress of some form was implicated in each of these occasions. But my complaints were recurrent and persistent, indicating a chronic problem. I complained of “chronic anxiety” to the doctor who was examining me in 2018 and she asked if this had ever been diagnosed. I said no. But it struck me there and then that this was definitely the course of action I needed to pursue. This was the road that led me to Asperger's and Autism Spectrum Condition. It had been a long and painful process.

It's all about acquiring and maintaining good habits. I had already devised a good health and exercise programme in 2017. It's impossible to disagree with the advice to form good habits. I would just emphasise that stress solutions are easier to define and accept in the abstract than they are to practice in the real. The advice needs to be qualified by real life situations. It is here that the correct diagnosis of a problem and its causes is imperative. There are things that are within our control and things that may not be in our control. The fact is that I had already completed a 'stress less' course at the suggestion of my doctor in the first months of 2019. Itw as a good course as far as it went, but it didn't go so far as to even touch the source of my problems. The problem with stress for someone
with Asperger's or ASC is that it arises from normal social interaction and communication. For that reason it is not at all easy to make and maintain healthy social contact. Many people with Asperger's or ASC tend to lead isolated lives at a distance from healthy social supports and stabilizers. That is precisely what characterises AS as a problem and paradox. If social engagement and interchange causes stress and anxiety for persons on the spectrum, so social isolation in turn induces feelings of loneliness and misery. This causes other problems, including seeking comfort in things that are bad for you, especially when they become addictive. Eating and drinking to excess, especially of the bad things, can become a bad habit. It also leads to poor sleeping habits, with anxiety causing insomnia. There is also something described as 'revenge bedtime procrastination,' with individuals tend to live at night in an attempt to exercise a control over life that they cannot during the day or in social contexts. Another point worth making is that setting aside time for doing the things you enjoy is an invitation to absorption in special interests for a person with AS. Which makes the point that inactive ways to manage stress may well be relaxing but are bad for the health and have been linked to increasing stress over the long run. I read and write far too much, with thoughts and words running to inflation; others may watch television, surf the internet or play video games.

Identifying healthy strategies for dealing with stress is relatively easy. Avoiding unhealthy coping strategies can be quite difficult, not least when the supports and mechanisms making for healthy living are not easily available or have been removed. Exercise, diet, mindfulness and breathing techniques are excellent ways of dealing with stress. But knowing this at the conscious theoretical level and acting on it in practice are two different things that are not always easy to join. Other psycho-social conditions seem to be required for the unity of theory and practice. I did the classes, I even put the regime into practice for two or three years. And then I was derailed by 'events,' a seemingly impossible series of life-changing disturbances that could have been designed to steal the power of initiative and control from me. Lose that power, and you find yourself reverting to unhealthy coping mechanisms, accepting a short term comfort in the seeming absence of long term health.

In other words, whilst it is possible to identify clearly 'what is to bedone,' it is less than easy to do it without additional support. The advice to maintain a healthy social support network cannot but cause a certain resigned sadness on the part of those who have struggled their entire lives to make, let alone maintain, social contact.

Autobiographical Commentary

How stress is identified differs between different people. The same with respect to the response to stress. Stress means different things to different people. Some people are better able to handle stress than others. Impacts differ between  different people. Some people are constantly stressed by perceived threats and triggers. The things that cause stress in one person may be of little concern to another, or a different level of concern. All people experience stress. Most people are in control of it. Stress, I would suggest, is not only the normal state of an autistic person, but involves a stress that is more frequent, more persistent, more intensive, and more exhausting. It is a chronic, relentless anxiety and it is horrible, painful, debilitating, stealing your joy, your dreams, your desires. It can steal your health, it can steal your job, it can steal your life. I have missed out on so much as a result anxiety.

When it comes to autistic people, the techniques of stress-management and reduction identified above can go only so far and no further. They may not be enough to address problems of a stress so persistent and constant that it has turned into chronic anxiety. This level of stress can be a normal condition for people on the spectrum. It has been for me. This is what makes the issue of stress and anxiety so acute for so many autistic people. Having identified the signs of stress and having seen the damaging effects that stress has on mental and physical health, autistic people are still not in a position to take effective remedial action. They cannot go direct to stress-management and reduction the way that neurotypical people can, but have to address the issue through their 'special' condition. This makes mental and physical health conditional upon successful management of AS, which is a hard enough task in itself. Throw in chronic illness, and you can see how great the problems some people on the spectrum can face.

When it came to identifying the source of my physical problems, chronic stress and anxiety seemed obvious culprits. I went to my doctor complaining of “psycho-social stress” and an ever-present anxiety. These issues in themselves, however, explained nothing and begged the further question – what causes the stress and anxiety in the first place? In my own case, it was possible to identify a clear and constant thread – troubles arising from engagement with people and the encroachment of people on my life, which is to say an inability to deal with normal social interchange and communication on my part that indicated the presence of a deeper problem. I had, in truth, diagnosed my condition of ASC long before the professionals did and, indeed, long before I even knew what ASC was. I defined the condition perfectly in my descriptions of it to doctors and nurses, I just didn't have the name or the label. The mystery is why it took so long for others to identify ASC as the cause of my difficulties. I would suggest that the answer lies in the way I presented an image of personal and professional success whilst cultivating and maintaining a distance from the normal operations of society. Over the years I became accustomed to receiving requests for funds and sponsorship from students who evidently thought I was in charge of a lucrative tutoring business. No-one knew the reality of my life, they were all therefore guessing from the outside. And from the outside I looked like a success. Personally and privately, my life hardly existed at all.

The first classes I attended, those in 2017, were concerned explicitly with cardiac rehabilitation and addressed stress as something which could be a factor leading to heart disease. It seemed like a likely factor to me at the time, and I actively sought out more information on the links between stress and heart conditions. The issue of stress cropped up regularly on the fitness programme, so much so that it really should have been picked up by someone somewhere. Although I was noted as being open and friendly with others in the group, the nurses noted that my pulse rate had a tendency to race. For a long time they felt that dangerous upsurge happened as a result of the exercises, leading them to remove the dumbbells from me as I exercised or even forcing me to take a rest. I found this baffling, and not a little worrying, when I could see that elderly gentlemen in their seventies or older being allowed to continue. I began to think that my condition was much more serious than I had been told or had realised - and what I had been told was serious enough. My pulse rate was described as 'pathological.' I felt fine, and far from being tired. And yet the nurses called a halt to my exercises and forced me to rest on three or four occasions. I remember vividly the concerned/baffled expression on the faces of these nurses as they examined the results after testing my pulse. My the way they looked! I got the distinct impression that they thought I was at death's door.

The possibility of autism really ought to have been identified during this period of rehab and, in a one-to-one session I had with one of the nurses at the end, it very nearly was. The mystery of my 'pathological' pulse rate moved on to another level in this meeting, where I got to discuss my ailments face-to-face with a cardiac nurse. My pulse rate was again taken and once more recorded to be well above normal. There was no exercise involved this time, however, which the nurse found most perplexing. She noted how calm I seemed to be on the outside, so friendly and smiling as I chatted with her, yet at the same time recording a pulse rate that was considered 'pathological.' There was a mystery here, and it required an explanation. I seemed to be so calm on the exterior, and yet was racing on the inside. She noted the disparity as if trying to draw a response from me. I didn't know what to say. I didn't know anything about Asperger's or autism then. Had I known, I could have filled in the missing blanks and got the process leading to referral and diagnosis underway. Instead, I was hoping that someone among the medics who were examining me would make the necessary connections. Instead, the nurse stayed baffled. I started to wonder whether she simply concluded that I found her to be irresistibly attractive. If this was the case, then it was nothing personal. I had recorded the same racing figures with all the other nurses. But judging by the serious look on her face, she seemed genuinely puzzled. Clearly, there was something amiss. This nurse noticed it. But this was my final meeting with her. And she seemed more concerned with stressing the links between diabetes, heart disease, and erectile dysfunction, an issue she raised discretely, whilst pressing me for a response all the same. 'Well that's something to look forward to,' I said, which I hoped gave her the information she sought. She then proceeded to explain the processes involved and why it was important to monitor for signs. ED can anticipate heart problems, including heart attacks, by five years. So it was wise to raise any concerns without embarrassment. It was good advice which, with the links and information provided, I incorporated into my health and fitness programme. But this is not where the underlying problem was. The classes ended shortly after and the issue was not followed up. It was yet another missed opportunity in a life that has been littered with them. I have no doubt that had there been repeated meetings, the nurse would have identified the underlying cause of my physical problems. But there is the problem: I have never had enough close and reiterated encounters with others who may have been in a position to identify the causes of my problems.

Clearly, there was something about a social context that disturbed my internal state. I don't know if the nurses thought it was they themselves who were causing the quickening of my pulses through their undoubted charms. They noted the phenomenon but couldn't explain it and didn't pursue it. I had no idea of Asperger's or ASC at this point. But that there was clearly an underlying cause of my problems was apparent. Had I explained that this was my normal state in social situations, then surely the AS penny would have dropped. As it was, I was saddled with a 'pathological' pulse rate that had no obvious explanation.

I had attended a fairly extensive programme of cardiac rehabilitation. I took notes from the talks on the physiological and emotional processes, I learned the lessons concerning good diet and exercise, and I took on board the advice offered in the one-to-one sessions. It was all about knowing your body, identifying the signals and the places from where they are sent, learning to listen for the messages the body sends and responding quickly and effectively. Job done. I was restored to good physical health in short time. I lost weight and became lean. I felt as fit as I had ever been in April 2019, when I flew through my final physical exam at hospital. I was just six-to-eight pounds heavier than I had been in my mid-twenties. This was no mean achievement. But the fact that I was having tests in hospital at all indicates that things were still far from well. I had been taken to hospital by ambulance early December 2018. I had suffered shoulder and chest pain that extended into my neck and jaw and also had the fingers of my hand curling up into a ball. I suffered a horrible sleepless night, just as I had when suffering a heart attack in 2016. I used my GTN spray as I had been taught to use it, with first one, then two, then a third and final spray under the tongue if necessary. If the problem is found to persist then I am under orders to call an ambulance. I called an ambulance. For all that I had followed the health, diet, and fitness programme of my year in cardiac rehabilitation, I was still suffering from physical problems that had the same symptoms as a heart attack. I had tests in hospital, but they seemed inconclusive. The doctor who dealt with me was concerned, and she kept seeking a second opinion from other doctors. Clearly things were not quite right but there was little certainty and clarity as to what may be amiss. Whilst the first tests were not showing signs of a heart attack, the symptoms and my descriptions of the pain indicated something too close to heart problems for me to be safely sent home. I got quite a lot of time during the testing to talk to the doctor. I told her about the way I was badly affected by stress. I had been hard at work on a piece of writing, with the would-be editor, who was paying for this work, messaging me constantly as I tried to finish. It was a complete breakdown in communication. He had no idea of how, when I write, I write vast amounts of text and then seek to order it. He plainly thought that I would be writing in short bursts of 2,000 words, and was hassling me for this amount. I had written 200,000. I was overworking, certainly, and to an extent that could have been a possible cause of physical breakdown. Instead, I highlighted stress and anxiety. It was clear to me that I struggled to cope with normal interchange with people. The editor would have thought his messaging just normal communication. To me it was interference and I suffered a mental and physical breakdown in response. The doctor listened intently as I spoke. I mentioned 'chronic anxiety,' and she asked: 'have you ever been diagnosed with that?' I replied that I hadn't. But the idea was born that, once the physical causes of my problems were eliminated, it would be possible to go in search of any “psycho-social” causes.

I reported back to my own doctor. She took note of my complaints and conditions as well as my recent history with respect to my trip t ohospital. And she gave me the link to the Stress Less four week online course.

Areas covered on this course included:

What is stress?; spotting the warning signs of stress; understanding the difficulties linked to stress such as anxiety, worry, low self-confidence, poor sleep and panic attacks; responding to pressure and stress; the different stages of your response to stress; learning the techniques for managing; building resilience to improve how you’re feeling in your day to day life.

I did the course and learned some valuable lessons. Long before the end, however, I knew that the help and advice didn't touch my basic problem, whatever that was. I found that the issues I was having with stress and anxiety were unresolved, indicating an underlying condition that still needed to be identified. I reported back to my doctor and she raised the possibility of Asperger's. I asked for a referral. As I waited a date for assessment I was invited to join an Anxiety class at the local Adult and Community centre, and proceeded to study stress and anxiety in greater physiological depth.

By the time I attended the anxiety classes of 2019 I was certain that I had Asperger's and had been referred by my doctor. The class was small, just the five of us, and a everyone present had issues of their own, which they proceeded to make public. I therefore felt it safe to reveal my self-diagnosis openly to the class. Immediately, one of the women in the group told me that she, too, had Asperger's. So this became something of a side-theme in the classes. As the course progressed, I revealed that I had not one but two chronic illnesses, grace of the chronic anxiety brought on by an undiagnosed ASC. I made it clear that my physical problems stemmed not from poor diet and lack of exercise but from the “psycho-social anxiety” I described to my doctor. I was also concerned to emphasise that I was physically fit, capable of hiking long distances. I mentioned that I not only hiked up the hills in Wales, but also mountains in the US. I also mentioned that I do 15km in 30 minutes every day on my exercise bike. I have to admit that this was extreme male vanity on my part. I was the only male in an all female group of five, with a female tutor, and so felt the need to impress. I was uncomfortable with giving the impression of being broken and vulnerable as a result of chronic health conditions and AS. I should also point out that I joined the class only by accident. I had actually gone along to the Adult Community Learning Centre to enquire about possibilities for training courses for Classroom Assistants. I was unconvinced that had the skills and attributes for such a role and was seeking advice as well as information. As I discussed the issue with the course
leader, I mentioned to her that my father had just died and that it was a difficult time for me. By lucky coincidence, she informed me, ever ready to sell the courses on offer, that the Centre was about to launch an Anxiety class in a couple of days, dependent on sufficient numbers. The tutor who was to take the class happened to be present and was called over for a chat. She seemed very friendly so I thought why not and signed up, not quite knowing what I was getting myself into. I had already done a Stress Less course in early 2019, and knew that there was an underlying cause driving my stress and anxiety. So I felt that I would simply be covering old ground. But it got me out of the house and into company with others - and that kind of socialising is one of the greatest stress busters there is. People are the greatest sources of stress, but, somewhere among the great public, are those specific folks who can lift you up just by being there. I needed to talk to people. It's good to get out and talk. I enjoyed it. In the Anxiety classes we were taught to identify and monitor the mental and physical signs of stress and given advice as to how to manage and reduce stress levels. I received a lot of good information and took copious notes. Then Covid-19 struck and sent the world into social shutdown.  I hardly noticed. Such was my normal condition.

As for the lessons I learned, it's all about acquiring and maintaining good habits. It's impossible to disagree with the advice to form good habits. I had already devised a good health and exercise programme in 2017. The problem is that stress-less solutions are easier to define and accept in the abstract than they are to practice in the real. The advice given needs to be qualified by real life situations. It is here that the correct diagnosis of a problem and its causes is imperative. There are things that are within our control and things that may not be in our control. The fact is that I had already completed a 'stress less' course at the suggestion of my doctor in the first months of 2019. It was a good course as far as it went, but it didn't go so far as to touch the source of my problems. The problem with stress for autistic people is that it arises from normal social interaction and communication. For that reason it is not at all easy to make and maintain healthy social contact. Many autistic people tend to lead isolated lives at a distance from others and without healthy social supports and stabilizers. That is precisely what characterises AS as problem and paradox. If social engagement and interchange causes stress and anxiety for persons on the spectrum, so social isolation in turn induces feelings of loneliness and misery. This causes other problems, including seeking comfort in bad habits, eating and drinking to excess, especially of the bad things. It also leads to poor sleeping habits, with anxiety causing insomnia. There is also something described as 'revenge bedtime procrastination,' with individuals tend to live at night in an attempt to exercise a control over life that they cannot during the day or in social contexts. Another point worth making is that setting aside time for doing the things you enjoy is an invitation to absorption in special interests for a person with AS. Which makes the point that inactive ways to manage stress may well be relaxing but are bad for the health and have been linked to increasing stress over the long run. I read and write far too much, others may watch television, surfing the internet or playing video games.

Identifying healthy strategies for dealing with stress is important, of course, but is the easy part of resolving the problem. Avoiding unhealthy coping strategies can be quite difficult, not least when the supports and mechanisms making for healthy living are not easily available or have been removed. Exercise, diet, mindfulness and breathing techniques are excellent ways of dealing with stress. But knowing this at the conscious, theoretical level and acting on it in practice are two different things that are not always easy to join. Other psycho-social conditions seem to be required for the unity of theory and practice to be effected. I put the regime into practice for two or three years and it worked, physically. I was fitter than I had ever been. But the physical side is the easiest side to address. The psycho-social problems afflicting me had not been addressed. And then I was derailed by 'events,' a seemingly impossible series of life-changing disturbances that could have been designed to steal the life-preserving power of initiative and control from me. Lose that power, and you find yourself reverting to unhealthy coping mechanisms, accepting a short term comfort in the seeming absence of long term health.

In other words, whilst it is possible to identify clearly 'what is to be done,' it is less than easy to do it unless you have additional support, not to mention congenial circumstances. The advice to maintain a healthy social support network cannot but cause a certain resigned sadness on the part of those who have struggled their entire lives to make, let alone maintain, social connection with others.