The ISSTD is a leader in advocating for and working towards better recognition and treatment of trauma and dissociation, including in marginalized and historically under-served populations. With this mission in mind, a group of members came together last year to improve recognition and treatment of trauma and dissociation in individuals with neurodevelopmental disabilities. Now, the Neurodiversity and Dissociation SIG is working to collect our shared clinical, research, and personal knowledge with the hope of helping professionals to better support autistic clients.[1]
The fields of trauma and neurodevelopmental disorders are historically siloed. In particular, professionals who specialize in autism spectrum disorders often receive no training in recognizing or treating trauma and its effects. In turn, most mental health and trauma professionals receive limited training on autism. The result is even as awareness about autism grows, and even as autistic adults increasingly seek mental health and trauma treatment, many professionals feel unsure of how to treat these clients and lack confidence in their ability to do so effectively. Autistic adults and children may be referred out until there’s nowhere left to go, or they may end up on a treatment path for either autism or mental health/trauma with no opportunity to have all of their concerns addressed.
It can be taken for granted that all members of the ISSTD understand the need to screen for and treat trauma, posttraumatic stress, and dissociation. However, the need to consider and address autism may be new to many. The following points are presented to help with the identification of autism in clients with known trauma and dissociation; the identification of trauma and dissociation in clients newly seeking treatment with an autism diagnosis; and basic treatment considerations for this population.
- If a client is seen for trauma, their autism may be overshadowed by posttraumatic and dissociative symptoms.
It’s well-recognized that autism can overshadow a PTSD diagnosis (Reuben et al., 2022), and the same can happen in reverse. This is in part because both can involve high levels of distress and dysfunction which stop clinicians from looking for other explanations for symptoms. It’s also because of overlap in symptoms; both can involve difficulties with emotional regulation, irritation, sleep, eating, and startle response. Many survivors of childhood interpersonal trauma have autistic traits such as social difficulties, differences in eye contact or body language, and dislike of physical contact. Hypervigilance and dissociation can be mistaken for sensory processing differences or vice versa. Similarly, depersonalization can overshadow or be overshadowed by experiences of alexithymia (difficulties recognizing and labeling emotions) and difficulties with interoception (recognizing internal experiences) and proprioception (recognizing where one’s body is in space). If all of these are attributed to one diagnosis, the other diagnosis could be missed.
One tool that has been made to help assist with this differential in children is the Coventry Grid (Flackhill et al., 2017; Moran, 2015). However, the best diagnostic is always performed by professionals who are well-informed about the various presentations of the disorders in question and who are willing to seek consultation, supervision, and external diagnostic services as relevant.
- Trauma can affect autism presentation.
In most cases, trauma worsens autism symptoms. However, for some individuals whose social skills are less affected by autism, trauma may provide strong pressure to “mask as neurotypical,” i.e., hide autistic traits in order to avoid rejection or abuse. This might mean clients try very hard to hide reactions to sensory stimuli, force eye contact, memorize small talk scripts, or lie about their experiences out of a sense of shame. Substance misuse can be both a posttraumatic maladaptive coping mechanism and a way to temporarily reduce social anxiety and seek social approval, which can make it more challenging to recognize masking. A pathological demand avoidance (PDA) profile could also complicate the differential because this profile often describes comparatively more subtle social deficits and an emphasis on demand avoidance, oppositional behaviors, impulsivity, and being drawn to fantasy, all of which may appear to be solely posttraumatic and lead to autism being unrecognized (Eaton et al., 2018; Flackhill et al., 2017). Autism symptoms may not become overt until the individual is in an environment where their capacities to cope are overwhelmed, and then other mental health symptoms may complicate the picture and still hide the autism diagnosis.
- Autism may affect dissociation presentation.
Autistic individuals may be more prone to catatonia, internal blankness, or other freeze responses as dissociative experiences. Their dissociation may be intertwined with autistic experiences such as alexithymia, difficulties with interoception and proprioception, or prosopagnosia (face-blindness). Their dissociation may also have different immediate triggers, including sensory overload, social overwhelm, or changes in their environment (Reuben & Parish, 2022). Flashbacks are often assumed to be highly sensory and emotional, but many autistic individuals struggle with sensory memory, emotional memory, and linear narratives. If individuals are high “maskers”, they may have genuine dissociative symptoms that nonetheless come across as artificial to clinicians because the individual may try too hard to conform to peers, media, or textbooks without having a strong ability to describe their actual experiences in their own words.
For DID/OSDD in particular, there can be confusion if parts present with “different” autism symptoms, such as some alters of the late autism activist Donna Williams/Polly Samuel having different language abilities, sensory processing, ability to navigate social situations, tics, and learning delays. It’s always important to remember that autism is a neurodevelopmental disorder that affects brain development from a very young age. It is not possible for an individual with DID/OSDD to have only one or a few alters with autism, just as it is not possible for an autistic individual to have one or a few alters without autism. However, it is well established that parts can differ in their presentation due to development, stress levels, and ability to use dissociation to push through stressful situations and deny needs. Those with autism may also differ between parts in their ability and willingness to mask as well as differ in the extent to which they associate visible autistic traits with rejection or abuse from others. Finally, certain parts may consistently switch out in response to unique autism-related stressors (e.g., an alter always switching out to have a meltdown in response to sensory overload) so that it falsely appears that only those parts are affected. If clinicians are not aware of this possibility, it could make it harder to recognize autism as a consistent underlying condition.
- Self-identification can complicate the picture.
There has been a lot of discussion around clients self-identifying as having DID/OSDD and/or autism, correctly or incorrectly. These disorders being “popular” or “trending” on social media, extensive information being easily accessible online, and personal or community stigma around alternative diagnoses complicates the problem (Cumin et al., 2022; Giedinghagen, 2022; Haltigan et al., 2023). Many have wondered if autism might make youth more vulnerable to incorrectly self-identifying as having DID. There are some potential reasons this might occur. Masking might result in prolonged identity confusion and a sense of being separate from one’s true self. Some autistic people have well-developed internal characters and worlds as a coping mechanism, and maladaptive daydreaming in general can be confused for DID/OSDD. Finally, literal or rigid patterns of thinking might make it more difficult for autistic individuals to make sense of confusing and contradicting information online, leading to over-identification with labels that might not be the best fit.
Conversely, people who “self-diagnose” with DID/OSDD are also more likely to self-identify as autistic. The COVID-19 pandemic may escalate the risk of autism mis-identification in part due to many youths experiencing high levels of stress and increased social isolation during key developmental periods. This might be an especially prominent risk for those with genuine DID/OSDD, many of whom already have social differences due to neglect and interpersonal victimization; it might feel less confronting to label these social differences as autistic rather than confront their traumatic origins. Additionally, autistic traits might be unconsciously introjected from others. As more and more individuals in communities for those with DID/OSDD open up about their self- or professional- autism diagnoses or identifications, some might even feel pressure to also identify as autistic in order to fit in.
The same may happen in reverse. Autistic youth in particular may be extremely socially isolated and desperate for a community, and they may be vulnerable to identifying with DID/OSDD because survivor communities accept them. It’s important to remember that many individuals with autism are actually less receptive to social pressures and peer group influences, but those who are not aware of the extent to which they mask might accidentally mirror those with DID/OSDD in a way that leads them to truly believe their experiences are the same. Finally, autistic individuals who genuinely have parts-based dissociation may still present a muddled picture of DID versus OSDD due to difficulties reporting or understanding very abstract and metaphorical concepts related to the degree of separation of self-states or what qualifies as parts-based amnesia.
Ultimately, it’s important to remember that autism is associated with higher rates of trauma (Reuben & Parish, 2022). This does include the stereotypical bullying, but it also includes contact physical and sexual abuse as well as higher rates of emotional abuse, neglect, insecure attachment with caregivers, community rejection and shaming, and disability-related abuse. Many autistic individuals are socially isolated, have a low socioeconomic status, and are blocked from meaningfully contributing to their communities through skilled employment or volunteering. All of this is in addition to unique stressors such as sensory overwhelm, social overwhelm, and difficulties coping with life changes, and it can be compounded by intersecting marginalization for women, racial and ethnic minorities, LGBT individuals, and individuals with other co-occurring disabilities (Kerns et al., 2022; Reuben & Parish, 2022). Accordingly, in my own research of autistic adults, I found very high rates of interpersonal trauma, posttraumatic stress, and all types of dissociation, and these experiences were strongly connected (Reuben et al., 2021, 2022). Other researchers have found that degree of autistic traits, not an autism diagnosis per se, predicts the risk of victimization and increases the likelihood of posttraumatic stress following a trauma (Haruvi-Lamdan et al., 2019, 2020; Roberts et al., 2015). Not only should an autism diagnosis or self-identification not decrease suspicions of DID/OSDD, it may in some cases indicate a higher risk.
- When autism and trauma are present, it’s important to recognize both.
If everything is attributed to trauma, the client may be confused, frustrated, or ashamed when neurodevelopmental symptoms are unresponsive to trauma treatment. Incorrectly believing that autistic traits and symptoms are posttraumatic or dissociative may reenact patterns of the client being told that their experiences aren’t what they think they are. This might be especially problematic for those with DID/OSDD who have dissociative parts with opposing perceptions on autistic symptoms and how amenable they are to change (e.g., self-blaming high-masking parts conflicting with parts who are severely affected and view the symptoms as insurmountable). Failing to acknowledge autism also blocks the client from finding coping mechanisms better suited to their neurotype, e.g., working with their sensory preferences instead of expecting grounding to make stimuli manageable. Failing to recognize autistic social difficulties may continually leave the client at risk for revictimization if there’s too much emphasis on learning to trust “intuition” that may not be as effective in those with an inborn impairment in ability to predict others’ behaviors or comprehend antisocial intent. Autism can cause a lot of impairment which might require long-term or even life-long external help, such as assistance cooking or communicating with doctors, whereas these impairments in someone with no neurodevelopmental disability may be assumed to be short-term or even interpreted as self-defeating, a sign of attachment-based dependency on others, or attention seeking. Recognizing typical autistic difficulties with generalizing information, communicating verbally, and understanding or using figurative language may help to better shape treatment approaches. Explicitly addressing disability-related shame, grief, and negative treatment by others may also prove vital to treatment. Finally, not recognizing autism denies the client the opportunity to form community and receive support from other autistic individuals.
- Gender can make recognizing both diagnoses more difficult.
In general, females are under-diagnosed with autism compared to males, and PTSD may worsen this trend. In my own research of autistic adults of different genders, I found that cisgender males were the least likely to have their PTSD recognized (Reuben et al., 2022). It’s possible that the opposite may happen for clinicians focused on an individual’s known trauma history. There’s been some discussion in particular about how adult female autism may combine with complex trauma to create a presentation that might be misdiagnosed as borderline personality disorder (although there is also the risk of BPD increasing self mis-identification of having autism; Cumin et al., 2022). It’s important to never assume that autism, if present, would have been identified during the individual’s childhood; for women especially, autism may not have been on the radar of anyone around them no matter how obvious their symptoms were.
- Autism is a spectrum.
In order to identify autistic clients, it’s important to remember that many autistic individuals are fully verbal and intelligent. Many can work fulltime, marry, or have kids. Many autistic individuals are extraverts, including those who have a high level of social difficulties. Some autistic individuals do mask successfully much of the time regardless of how much it costs them later. On the other hand, it’s vital not to lose sight of the more severely impacted end of the spectrum. There’s sometimes an assumption that those with DID/OSDD are necessarily more intelligent, more creative, strong visualizers, and good with metaphors and abstract thought. One or all of these things may not be true for many with autism. Not only may this affect diagnosis, it’s also vital to keep in mind for treatment.
“Looking inside” or “listening inside” may be confusing for a concrete thinker. Many grounding exercises that rely on visualization may not be helpful for someone who can only picture things they’ve seen or who’s completely aphantasiac. Differences in sensory and information processing may mean differences in the effectiveness of modalities such as EMDR and somatosensory therapies if the client’s unique processing strengths and weaknesses aren’t accounted for. Alexithymia or difficulties recognizing cause and effect may make it more difficult to identify triggers or report when treatment is moving too fast. Treatment may need to progress more slowly in general due to differences in ability or speed of processing information, fewer resources, more difficulties recognizing needs and understanding how to ask for support, more difficulties with emotional regulation, and the need to also manage disability-related stressors.
Most importantly, it can be highly shaming if clinicians make assumptions about what clients can handle or what their non-traumatized skill level must be. While some low support needs clients reject terms like “disorder”, “disability”, or “symptoms,” denying the potential severity of autism can be equally insulting and harmful to those who need higher levels of support just to survive. This includes individuals who may have strong skills or less impairment in some domains (e.g., high academic achievement; effective masking) but uneven skills and higher support needs in other domains (e.g., severe sensory sensitivities; frequent meltdowns). Co-occurring intellectual or language impairment can also increase the challenges autistic individuals face. Those working in community mental health in particular may need to be prepared to support clients who rely on augmentative or alternative forms of communication, engage in self-harming sensory seeking or regulatory behaviors, or rely on caregivers to help with treatment.
It is the hope of the Neurodiversity and Dissociation SIG that this article will encourage and empower clinicians to support autistic clients. There are very few clinicians who are willing and able to treat trauma in autistic clients, and fewer still who are willing and able to treat dissociation. Any dissociation-informed clinicians who make an effort to learn how to support autistic clients can make a major difference in vulnerable and under-served people’s lives.
[1] Many professionals are taught to use person-first language, e.g., “clients with disabilities.” However, the majority of autistic adults prefer identity-first language, as is recognized in the APA language guidelines and by autism self-advocacy organizations. To respect the diversity of views, a mix of language is used in this report, with preference given to identity-first language.
References
Cumin, J., Pelaez, S., & Mottron, L. (2022). Positive and differential diagnosis of autism in verbal women of typical intelligence: A Delphi study. Autism, 26(5), 1153-1164. https://doi.org/10.1177%2F13623613211042719
Eaton, J., Duncan, K., & Hesketh, E. (2018). Modification of the Coventry Grid Interview (Flackhill et al, 2017) to include the Pathological Demand Avoidant profile. Good Autism Practice, 19(2), 12-24.
Flackhill, C., James, S., Soppitt, R., & Milton, K. (2017). The Coventry Grid Interview (CGI): Exploring autism and attachment difficulties. Good Autism Practice, 18(1), 62-80.
Giedinghagen, A. (2022). The tic in TikTok and (where) all systems go: Mass social media induced illness and Munchausen’s by internet as explanatory models for social media associated abnormal illness behavior. Clinical Child Psychology and Psychiatry. https://doi.org/10.1177%2F13591045221098522
Haltigan, J. D., Pringsheim, T. M., & Rajkumar, G. (2023). Social media as an incubator of personality and behavioral psychopathology: Symptom and disorder authenticity or psychosomatic social contagion?. Comprehensive Psychiatry, 121, 152362. https://doi.org/10.1016/j.comppsych.2022.152362
Haruvi-Lamdan, N., Lebendiger, S., Golan, O., & Horesh, D. (2019). Are PTSD and autistic traits related? An examination among typically developing Israeli adults. Comprehensive Psychiatry, 89, 22–27. https://doi.org/10.1016/j.comppsych.2018.11.004
Haruvi-Lamdan, N., Horesh, D., Zohar, S., Kraus, M., & Golan, O. (2020). Autism spectrum disorder and post-traumatic stress disorder: An unexplored co-occurrence of conditions. Autism, 24(4), 884–898. https://doi.org/10.1177/1362361320912143
Kerns, C. M., Lankenau, S., Shattuck, P. T., Robins, D. L., Newschaffer, C. J., & Berkowitz, S. J. (2022). Exploring potential sources of childhood trauma: A qualitative study with autistic adults and caregivers. Autism, 26(8), 1987–1998. https://doi.org/10.1177/13623613211070637
Moran, H. (2015). The Coventry Grid 2 (2015) available from: https://www.oxfordshire.gov.uk/sites/default/files/file/virtual-school/coventrygrid.pdf
Reuben, K. E., Stanzione, C. M., & Singleton, J. L. (2021). Interpersonal trauma and posttraumatic stress in autistic adults. Autism in Adulthood, 3(3), 247-256. https://doi.org/10.1089/aut.2020.0073
Reuben, K. E., Self-Brown, S., & Vinoski Thomas, E. (2022). PTSD in autistic adults: Correlates of meeting DSM–5 criteria and predictors of professional diagnosis. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001365
Reuben, K. E., & Parish, A. (2022). Dissociation in autism spectrum disorders: An under-recognized symptom. In E. Christensen (Ed.), Perspectives of dissociative identity response: Ethical, historical, and cultural issues. HWC Press.
Roberts, A. L., Koenen, K. C., Lyall, K., Robinson, E. B., & Weisskopf, M. G. (2015). Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse & Neglect, 45, 135–142. https://doi.org/10.1016/j.chiabu.2015.04.010