Social Anxiety vs Autism
Social Anxiety vs. Autism
Anxiety and Autism co-occur at high rates. I suspect this is particularly true for high-masking Autistic people. Many Autistic people I work with have first been diagnosed with social anxiety while their underlying Autism has gone missed diagnosed.
How Autistic Masking Contributes to Anxiety
I suspect social anxiety is a common misdiagnosis of high-masking Autism. Here are some of the ways Autistic masking contributes to anxiety:
Masking requires a level of hypervigilance--vigilantly taking in one’s environment and adapting one’s whole self (our bodies, tone, language, scripts, etc.).
High-maskers develop a keen eye for judgment/criticism. The judgment of others becomes our feedback loop—we make a misstep, perceive judgment or criticism, and update our rule book. It’s hard to imagine how someone could navigate social space in this way and not develop an element of social anxiety.
Overlap Between Social Anxiety and Autism
Social anxiety is particularly common among all Autistics, with prevalence estimates reported to be as high as 50% (Bellini, 2004; Maddox & White, 2015; Spain et al., 2016). This is substantially higher than the Allistic population (estimates of SAD among non-ASD population range from 7–13%) (NICE, 2013a).
Given the high prevalence of social anxiety disorder within the Autistic population, a clinician should routinely offer Autism screening when diagnosing social anxiety. Before I delve into the specifics of how they may differ, let me provide a brief refresher on social anxiety.
Social Anxiety Defined
Social anxiety is characterized by the following symptoms:
Signs and symptoms of social anxiety disorder can include (source: Mayo Clinic):
Worry about embarrassing or humiliating yourself
Fear of situations where you may be judged negatively
Intense fear of interacting or talking with strangers
Fear that others will notice you look anxious
Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling, or having a shaky voice
Avoidance of doing things or speaking to people out of fear of embarrassment
Avoidance of situations where you might be the center of attention
Anxiety in anticipation of a feared activity or event
Intense fear or anxiety during social situations
Ruminating on your performance and identifying flaws in your social interactions
Expecting the worst possible consequences from a social situation
Autism Defined
To meet diagnostic criteria for Autism according to DSM-5, a child must have persistent differences in each of three areas of social communication and interaction (see A1-A3 below) plus at least two of four types of repetitive behaviors (see B1-B4 below). (Credit, the following strength-based list was developed by Matt Lowry, Autistic, which I have adapted and added to slightly).
A) Different social communication and interaction as evidenced by the following:
Differences in communication- the tendency to go off on tangents, the tendency to talk passionately about special interests, and the tendency to not engage in small talk. Social initiation may be limited. Small talk often relies on pre-scripted or pre-rehearsed sentences.
Differences in nonverbal communication including stimming while talking, looking at something else while talking, and being bored with conversations. Also includes difficulty intuitively understanding shifts in context and non-verbal body language.
Due to the above differences in communication, autistic people tend to be shunned by neurotypicals and therefore are conditioned to believe that they're somehow less social. May also experience reduced social motivation or interest and may get pleasure from solo activities.
B) Repetitive behavior or interests as evidenced by at least two of the following:
Stimming or engaging in echolalia.
Security in routines. Autistic people do not have a sensory filter, so the world is perceived as a constant state of chaos; routines and expectations give comfort to overwhelmed autistic people.
SPecial INterests (SPINS). Due to hyperconnected brains, autistic people feel more passionately about what they love, so when we have a special interest, we tend to fawn over and fixate on it.
Hyper or hyporeactivity to stimuli. Again, due to hyper-connections. We feel things more intensely. Sometimes, however, we feel things less intensely because we tune them out in favor of other stimuli.
Understanding the Differences Between Social Anxiety and Autism
As you can see from the above lists, there is a lot of overlap. Complicating matters, many Autistic people have social anxiety! Furthermore, people who have social anxiety tend to have more autistic traits.
Allistics with social anxiety are rarely misdiagnosed as autistic. More commonly, an Autistic person with social anxiety may just receive a social anxiety diagnosis while the more accurate diagnosis (Autism) is missed.
Given the significant overlap, it can be challenging to tease out the difference, particularly when they co-occur. Here are a few areas to consider when teasing out if it is social anxiety only vs. social anxiety in the context of Autism.
Eye Contact
One study found a difference in gaze avoidance between SAD and Autism.
One study found a difference in gaze avoidance between SAD and Autism. Socially anxious people made initial eye contact but then looked away. This eye contact pattern is associated with anxiety and is an emotional avoidance strategy.
Autistic people were slower to make eye contact. This was associated with a lack of motivation for eye contact and general discomfort with eye contact.
Overall, people with SAD were faster to orient away from the eyes, and Autistic people were slower to make eye contact. (Lundin Kleberg et al., 2017, Disord et al., 2017).
Social Motivation
It is not uncommon for there to be a difference in social motivation. While some Autists are highly socially motivated, many need substantial alone time and value their autonomy.
Non-autistic people with social anxiety may experience more sadness and strain when socially isolated. The Autistic person may feel more comfortable with less engagement.
For Autistic-ADHDers, their social profile may be more mixed, and they may have more of a social drive. And it's essential to keep in mind that while many Autistic people have less social motivation, this also exists on a spectrum.
Body Posture
People with social anxiety are likelier to talk in a timid voice and stand far from others. Autistic people (who aren’t masking) may be less aware of typical neurotypical social expectations and stand too close to people (Cuncic, 2021).
Note that Autistic people tend to either:
stand too close to people or
stand far away from people and experience discomfort when others stand close to them.
For the latter group, if you ask them about body boundaries, they will likely say something like, "I hate when people stand close to me or are in my space." They will have a marked reaction to their space being invaded that will be more noticeably distressing.
Social Cues
Non-Autistic people with social anxiety will intuitively read social cues. Autistic people either struggle to read social cues or will do so through their pre-frontal cortex (analyzing) (Todorov).
High-masking Autists may be very good at reading social cues (analytically). However, they will describe debilitating fatigue after being in situations where they must do this for prolonged periods.
Body Language
With SAD, the person tends to have a heightened sensitivity to the body language of others. In stereotypical Autism, the person will struggle to intuitively pick up the meaning of other people's body language. With high-masking Autists, the picture is more complex. High-maskers are more likely to be hypersensitive to emotional tone. This may be interpreted as an ability to interpret body language intuitively. A high-masking Autistic person may analytically study body language. Rather than intuitively understanding body language, they may use their prefrontal cortex to decode the meaning.
Summary
Social anxiety and autism commonly co-occur. Symptoms associated with social anxiety may also make it more difficult to detect autism when it is present. To understand the differences, it is important to get at the subjective experience of the person to better understand the source of the anxiety. For even more of a deep dive into autism and social anxiety, you can check out the full ebook here.
