Exposure, Extinction, and Cognitive Appraisals in Autistic Adults With Social Anxiety: Evidence From a Structured Speech Exposure Task.

Social anxiety (SA) is highly prevalent among autistic adults, yet little is known about how autistic people respond to common therapeutic strategies, such as exposure tasks. This study examined responses to a structured speech exposure task embedded within an 8-week modified cognitive-behavioral therapy (M-CBT) program. Thirty-two autistic adults with co-occurring SA completed pre- and post-task assessments of anxiety and related cognitive appraisals, including self-focused attention, perceived performance, appearance concerns, and threat appraisals. Participants reported appropriate engagement with the task, characterized by elevated anticipatory anxiety followed by reductions in anxiety during the speech. Responses were largely consistent with CBT models of social anxiety and with reports by those in a social anxiety disorder reference group. Participants overestimated anticipatory anxiety (predicted fear) relative to experienced peak fear during the task. Higher anxiety was associated with greater self-focused attention and stronger threat appraisals, although anxiety correlated positively with self-rated performance. Importantly, the extinction of fear during the speech task was associated with post-treatment response to CBT. Among participants classified as high-extinction, 59% showed clinically significant improvement on the Liebowitz Social Anxiety Scale, Self-Report (LSAS-SR), compared with 25% of those in the low-extinction group. A parallel pattern was observed in a social anxiety disorder comparison group, indicating that the extinction-outcome relationship was similar across autistic and non-autistic adults. This study provides evidence that autistic individuals report fear and anxiety responses in a manner largely consistent with CBT models and that extinction-based processes during exposure are meaningfully associated with treatment response. Further studies employing randomized controlled trials and objective measures of fear are now needed.