# Chapter 4 - The Cost of Masking * [CHAPTER 4](#chapter-4) * [The Cost of Masking](#the-cost-of-masking) * [Propping Up the Mask: Problematic Coping Strategies and Why Masked Autistics Use Them](#propping-up-the-mask-problematic-coping-strategies-and-why-masked-autistics-use-them) * [Problem Drinking or Substance Use](#problem-drinking-or-substance-use) * [Eating-Disordered Behavior](#eating-disordered-behavior) * [Detachment and Dissociation](#detachment-and-dissociation) * [Adherence to Rigid Rules and Belief Systems](#adherence-to-rigid-rules-and-belief-systems) * [“Fawning” and Compulsive People-Pleasing](#fawning-and-compulsive-people-pleasing) * [Problem Drinking and Substance Use](#problem-drinking-and-substance-use) * [Eating-Disordered Behavior](#eating-disordered-behavior-1) * [Detachment and Dissociation](#detachment-and-dissociation-1) * [Adherence to Rigid Rules and Belief Systems](#adherence-to-rigid-rules-and-belief-systems-1) * [Warning Signs of a High-Control Group](#warning-signs-of-a-high-control-group) * [Fawning and Compulsive People Pleasing](#fawning-and-compulsive-people-pleasing-1) * [Fawning and People-Pleasing Reflection Tool](#fawning-and-people-pleasing-reflection-tool) --- # CHAPTER 4 ## The Cost of Masking “I’m pretty sure my dad was Autistic,” Thomas tells me. “I think his drug use was a way to blunt the world’s edges.” Thomas is a programmer and he was diagnosed as Autistic a few years ago. For much of his life before that, he relied on alcohol just as his father had relied on drugs. Getting drunk was the only way he could move through the world with any degree of comfort. “When I was in my teens, I found that having a couple drinks in me allowed me to perceive myself differently. I had more confidence and felt more social. But more importantly it dulled the razor-sharp edges of reality enough where I could be in a crowded loud area. Because I really couldn’t bring myself to do that without alcohol.” To neurotypical people, Thomas often seems like a “high-functioning” person. But there has always been immense turmoil simmering beneath the surface. In college he nearly attained a 4.0 GPA—then dropped out very suddenly, because he couldn’t handle the social aspects of school. A few years later, he had a good job and could maintain a sixty-hour workweek, but was sneaking drinks and coming to work hungover. He had a partner, but they barely spoke to one another. His home life was a mess. Through it all, he remained convinced that alcohol was the only thing keeping him sane. He couldn’t fall asleep without it, desperately needed it to prop up his otherwise unsustainable life masquerading as a neurotypical person. Soon that life would all begin to crumble, and he’d be forced to finally confront why he (and his father) had always fallen back on substances in order to make life bearable. Research shows that Autistics who mask tend to suffer from intense social anxiety,[^4.1] and some of us learn to self-medicate that anxiety with drugs or alcohol. We may also reach for substances to help blunt our sensory issues or help us pretend to be more confident. Alcohol, weed, and other depressants are also an appealing and socially acceptable way of unwinding after a stressful day of constantly gaming out how every move we make will be received by other people. Masked Autistic people fall back on a variety of flawed strategies in order to relax, mute our most disruptive behaviors, or conform with neurotypical standards. Some use compulsive exercise or calorie restriction to make their jittery, unruly Autistic bodies settle down or shrink into a more convenient shape. Some self-harm in order to regulate their anxiety or sensory overwhelm. Others become so lonesome they seek out approval from high-control groups and cults, or find themselves trapped in abusive domestic relationships they are unable to escape. Even many mental health professionals are unaware that these disorders and self-destructive behaviors are highly comorbid with Autism. The stereotype that Autistic people are withdrawn “losers” who just sit at home on the computer all day runs very deep, and it prevents many of us from recognizing ourselves and understanding the roots of our struggles. It’s hard for many masked Autistic people to recognize that being a hard-drinking party animal who routinely gets swept away in abusive relationships can be a sign they are struggling with an unrecognized disability. When we compensate in those ways, we often believe it’s because we’re just toxic, weak-willed people. Below is a table listing some of the problematic coping strategies that research shows masked Autistics fall back on, and a few bullet points explaining why we tend to reach for them. ### Propping Up the Mask: Problematic Coping Strategies and Why Masked Autistics Use Them #### Problem Drinking or Substance Use * Dulls sensory sensitivities * Provides “liquid courage” for intimidating social situations * Relaxes inhibitions and filters * Provides energy to get through an overly demanding world * Stimulates the senses * Entertains an anxious or preoccupied mind * Silences the inner critic #### Eating-Disordered Behavior * Grounds life in daily goals and rituals * Provides physical stimulation via hunger, exercise, purging, etc. * Distracts from social struggles by focusing on the body * Defines “goodness” and “worthiness” in terms of behavior or appearance * Gives the Autistic person a sense of self-control or discipline * Explains away feelings of gender dysphoria or physical dissociation #### Detachment and Dissociation * Prevents rejection by disengaging first * Blunts painful emotions such as grief, sorrow, and regret * Allows the Autistic person to focus only on what they’re naturally “good” at * Removes the pressure to learn challenging emotional or social skills * Silences needs and emotions others find bothersome * Preserves limited energy #### Adherence to Rigid Rules and Belief Systems * Makes a confusing reality feel more understandable and concrete * Translates vague social norms into specific expectations * Creates an in-group to which the Autistic person can belong * Provides daily structure and soothing rituals * Soothes self-doubt and fears about being a “bad person” * Promises salvation from the present, unjust world #### “Fawning” and Compulsive People-Pleasing * Earns the Autistic person praise * Offers a false promise of acceptance * Simplifies complicated relationship dynamics * Flattens social interactions into one easy rule: always say “yes” * Validates the Autistic person’s belief they should ignore their feelings and needs * Minimizes conflict and reduces anger As you look over this list of behaviors, bear in mind that the line between “good” coping and “bad” coping is often blurry, and there’s no shame in having used imperfect strategies in order to survive. A method that may have worked pretty harmlessly for a while, like drinking a beer before going out with friends, may sometimes morph into something more compulsive, like sneaking drinks at work. Or drinking might only become a problem during times of high stress. Excessive exercise can be both a useful way to calm yourself down when you’re on the verge of a meltdown, and a compulsive habit that is damaging your joints. These things aren’t binary. Sometimes we are forced by circumstance to ignore our physical and mental health because maintaining our job or housing situation is the most pressing thing. When we lack a clear understanding of our disability, and no one around us recognizes us as disabled, we make do the best we can. In this chapter, we’ll get to meet a variety of masked Autistic people who have used elaborate, at times flawed strategies to maintain their masks. They’ve overexercised or drugged their way into social acceptance; some of them have spent years detached from other people, or sought out belonging in reactionary groups. These individuals have come to recognize that in addition to protecting them from social rejection, masking has gotten in the way of them leading authentic, happy lives. They’ve also begun to reexamine their coping mechanisms, aiming to identify the unmet needs they can satisfy with more appropriate disability accommodations, rather than self-destructiveness and denial. ### Problem Drinking and Substance Use As he grew older and he became even more reliant upon alcohol in order to “stay sane,” Thomas’s life began unspooling. He had grown resentful of his partner, and they were looking into breaking up. Around this same time, Thomas quit his job, and attempted suicide. Then he moved across the country for another job, but quit it pretty shortly thereafter. He kept fantasizing about death, seeing it as the only way out of an existence that had become utterly unmanageable. The therapists Thomas saw during this period diagnosed him with Bipolar Disorder and Borderline Personality Disorder, because his relationships were unstable and his emotions sometimes became explosive, in addition to him experiencing long periods of depression. He kept trying to get sober but couldn’t make it work. “Literally, it took me six months to get my first thirty-day coin [^4.in Alcoholics Anonymous],” he says. “And even then, I was still very unhappy. During that crazy summer of repeated relapse and plotting of my own death, my ex put me in contact with a new therapist.” Thomas’s ex-partner was a social worker and had recently attended a panel about Autism Spectrum Disorder while at a conference. He was struck by how much one panelist’s description of Autism mirrored his experiences being with Thomas. The panelist turned out to be a therapist, and Thomas’s ex put the two in touch. With the help of a therapist who actually understood the comorbidity between Autism and alcoholism, Thomas was finally able to make progress in dealing with his addiction. “I came to figure out I have had massive social anxiety and sensory issues all my life, and I was using alcohol to numb them,” Thomas explains. One of the most common and subtly debilitating experiences Autistics have is sensory overwhelm. I’ve already described how the bottom-up nature of Autistic sensory processing leads to us being overstimulated and easily distracted by things like ambient noise and visual clutter. There is an additional neurological feature of Autism that contributes to our sensory issues and meltdowns in a significant way—our difficulty adjusting to a stimulus over time. Neurotypical brains engage in sensory adaptation and habituation: the longer they are in the presence of a sound, smell, texture, or visual cue, the more their brain learns to ignore it, and allow it to fade into the background. Their neurons become less likely to be activated by a cue the longer they are around it. The exact opposite is true for Autistic people: the longer we are around a stimulus, the more it bothers us.[^4.2] As I’ve already mentioned, our neurons are also “hyperexcitable,” meaning our senses get set off more easily by small input that neurotypicals don’t even notice, such as a hair falling into our face or a pile of mail being left on our desk.[^4.3] We’re better at noticing small details and changes in our environment,[^4.4] which can be a real advantage for meticulous work (like programming, Thomas’s profession), but we are also more prone to being startled or distracted.[^4.5] When an Autistic person is flooded with upsetting sensory information for too long, they enter a state of sensory overload. Sensory overload can look like a temper tantrum or a crying fit, it can take the form of a shutdown or meltdown, or it can present as the Autistic person becoming confused and responding to questions in routinized or nonsensical ways. Sensory overload makes it hard to complete complex tasks, think through things rationally, or manage emotions. When we’re overloaded, we become irritable, or filled with despair; we might even start self-harming to get an endorphin rush or ground ourselves. Our bodies are visibly tense with anxiety, and we’re difficult to engage with during these times. What non-Autistic folks often don’t realize is that Autistic people experience intense sensory input as if it were physical pain.[^4.6] Unfortunately, when an Autistic person complains about the sensory pain they’re in, people think they’re being overly dramatic, needy, or even downright “crazy.” I can’t fully convey how frustrating it is to be in deep distress over a persistent noise my boyfriend can’t even hear. When I find myself stomping around the house anxiously, pounding on the floor with a broom to get my neighbor to turn down her music, I feel like I’m being “crazy.” My partner knows I’m not making this stuff up, and he tries his best to be accommodating and patient. But for most of my life, people were unsympathetic to my sensory complaints. They acted as if I chose to be distracted and furious every day. In response to sensory overload I’ve yelled, and sobbed, and needed to be held; I’ve tried punching pillows, hitting myself on the arms and legs with a hairbrush, running away from people, and hitting myself in the head. Very few of these reactions are socially acceptable, so I’ve mostly resorted to them in private. In recent years, I’ve learned how to prevent these meltdowns before they occur, by giving myself lots of quiet time alone, and extricating myself from stressful situations before they make me bubble up with anxiety. The second I feel myself suppressing frustration that I feel I don’t deserve to voice, I know I need to get out of the area. However, once a true meltdown hits there’s very little I can do—I need to either escape the situation, or find an outlet for all my energy. Drinking is really the only release valve neurotypical people can respect—as long as you present it as a fun habit, rather than a compulsion. Many Autistic adults report problematic drinking habits, or substance use disorders.[^4.7] Dulling our sensory sensitivities is one of the key reasons for this link.[^4.8] Another reason is that substances assist us with social regulation. When you’re used to carefully monitoring and modulating your actions all the time, a stiff drink can help you let your guard down, and momentarily relax.[^4.9] Social norms are loosened when people are drinking. Drunk allistic people talk for too long and interrupt one another, too! If you say something weird at a party, drunk people might forget it even happened. The ease of being around other drunk people can itself be kind of intoxicating. Unfortunately, relying on substances in order to feel at ease or connected can rapidly become self-destructive. The 2020 Netflix series The Queen’s Gambit depicts the life of Beth Harmon, a fictional chess prodigy living in the mid-twentieth century. Beth is heavily coded as Autistic.[^4.10] She’s blunt and analytical, with little time for other people’s emotions. She confronts her opponents with a cool, almost reptilian stare, and rattles off chess facts and move sets in an obsessive, flat monotone many Autistic viewers instantly found recognizable. She’s also addicted to sedative pills, and drinks heavily. Unlike most Autistic characters on TV, Beth isn’t just a hypercompetent nerd; she’s a wild, free spirit who compulsively uses drugs, shoplifting, and sex to keep herself stimulated. Her self-destructive habits are also part of her mask: she disarms her chauvinistic male competitors and superficial classmates by seeming cool and wild. I’ve never related to an Autistic character quite as much as Beth. Like her (and like Thomas) I spent my teen and early adult years racking up achievements while absolutely wrecking my personal life. In high school I’d black out drunk during the day sometimes, slipping vodka into my Gatorade in the high school parking lot to win the approval of my friends. I skipped class, forged early dismissal paperwork to get out of orchestra, and shoplifted frequently. At one point I was nearly expelled, but I was spared when a sympathetic school administrator “lost” my expulsion paperwork with a wink. I didn’t get in much trouble for my bad behavior because I was earning A’s and was a nationally ranked debate team competitor. The same insouciant, smart-but-self-destructive energy carried me through my early twenties. In early adulthood I got into a lot of messy, destructive relationships and self-harmed with nicotine, anorexia, and random hookups. It was all part of the jaded, “mature” mask I’d started wearing all the way back in middle school. I thought if I was excelling on paper, and living a cool, glamorous life, there was no way anyone could ever say I was “childish” or “pathetic.” No one could accuse me of being too sensitive if I hid my sensory issues by pouring Amaretto into my coffee and drinking during developmental psych. I never had the alcohol tolerance to become an addict (I threw up far too easily for that), but if that hadn’t been the case, I might have easily ended up on the same path as Thomas. Eventually, Beth Harmon’s drinking turns from glamorous to grim. She uses some of her closest male friends for sex and then dismisses them; she alienates her entire support network, botches a few crucial chess matches because she’s hungover, and resigns herself to padding drunkenly throughout her filthy home, overlining her eyes with kohl while taking pulls from a wine bottle. The partying and self-destruction that was once her social crutch slips out from under her, just as it did for Thomas and myself. Unlike us, though, Beth’s fictional downward spiral doesn’t lead to seeking out therapy or arriving at an Autism diagnosis. She’s a beautiful, accomplished, unhappy woman living in the 1950s. No one knows how to name her troubles yet. Understanding the physical, sensory, emotional, or psychological needs that you’ve been trying to meet with your substance use may help you identify other, more beneficial coping strategies. A survey of more than five hundred Autistic adults published in the journal Autism in Adulthood found that the most commonly reported reasons for binge drinking were social reasons, and to boost positive feelings.[^4.11] Alcoholism and substance use can mask Autism super effectively, because most people still believe Autistics are buttoned-up geeks who prefer to stay home. If you’ve been unaware of your disability for a long time, or been in denial about it, you may have used getting high or drunk to cover up your suffering, or to give you the energy to socialize. You may believe, for example, that you can’t be interesting or fun without the aid of substances. If you have trauma related to abuse you’ve endured as a masked Autistic person (or from other sources), you might use substances to self-medicate post-traumatic stress. When a substance use disorder co-occurs alongside other mental health conditions, such as post-traumatic stress or depression, research shows most patients prefer and benefit from an integrated treatment approach that addresses the multiple, interlocking issues at the same time.[^4.12] Autism isn’t a disorder that needs to be treated, but most Autistic people do have mental health struggles related to living in an unaccepting neurotypical world. For Autistic people who do have substance addictions, exploring an integrated treatment program is likely to be a good fit. If you suspect you have an unhealthy relationship to drugs or alcohol, it will be important to identify a treatment method that suits your neurotype, or find a mental health provider who has experience with Autistics. Since a growing body of research suggests cognitive behavioral therapy (CBT) approaches don’t work as well for Autistics as they do for neurotypicals,[^4.13] CBT-based addiction treatment might not be a good fit—at least not without modifications. One exploratory clinical study published in 2019 did find that when mental health providers were taught about how to communicate effectively with Autistic patients (a skill set most providers lack), the cognitive behavioral therapy they offered did help Autistic adults with their substance use disorders.[^4.14] Unfortunately, most care providers are not well informed about how Autistic people think and communicate, and there is very little published research into which addiction treatment programs consistently work best for adult Autistics. Many of the effective treatment plans that do assist Autistic adults involve making sure our health care, housing, and other material needs are also being met, in addition to ensuring we are plugged into a network of supportive people. Often the fears that CBT therapists train their patients to view as irrational (if I say the wrong thing, I’ll lose my job and wind up on the street!) are completely rational for Autistics, and rooted in genuine experience. In Thomas’s case, cutting back on alcohol laid bare the sensory sensitivities and anxiety that lingered underneath. It also rapidly became clear that he couldn’t maintain a high-stress, high-stimulation job that would be more likely to provoke him to drink. Today he manages his sensory issues using noise-canceling headphones, and he forces himself to take regular breaks away from busy, noisy settings. He’s working from home, and learning to recognize when he’s getting overloaded by anxiety or noise. There’s less need for him to camouflage his Autistic traits now, and thus less desire to drink. He’s now been completely sober for several years. For many Autistic people, taming a fraught relationship with substances may necessitate getting comfortable with being more visibly Autistic, which can be a very slow process. In their essay “Alcohol: An Autistic Masking Tool?”[^4.15] Jesse Meadows describes their relationship to unmasking and sobriety this way: “I made friends by drinking. Alcohol gave me dating and adventures and sex. Without it, all of these things are much harder, some of them impossible. I don’t leave the house very much anymore. In a lot of ways, I became a more autistic person when I got sober.” The flip side of this can sometimes be true. In order to get sober, sometimes you have to be willing to be more Autistic. ### Eating-Disordered Behavior Dorian Bridges is a horror writer and YouTuber whose channel, Of Herbs and Altars, features discussions about early 2000s alternative fashion and culture, eating disorder and drug addiction recovery, and issues in the Autism and Asperger’s communities. In the early 2000s, Dorian was an undiagnosed Aspie[^4.16] teenager who was struggling socially and in school. In one especially poignant video, Dorian describes how growing up without a diagnosis fundamentally changed the course of their life.[^4.17] “I knew innately from a very young age I find life harder than other people,” they say, “but there was never any reason. It was always just you are lazy; you are being lazy.” Dorian says they had many clear Asperger’s Syndrome traits. They inhaled books and sat off alone in the corner at family gatherings. They spoke “like a thesaurus” and did well on IQ tests, but found daily classwork hard to keep up with. But like so many other masked Autistics, they were seen as a “girl,” and were assumed to be gifted and a little weird, rather than disabled. “My parents were told, there’s nothing wrong with your kid…. Your child is going to go far! Your child has nothing that’s going to ever get in their way.” Many masked Autistics are sent to gifted education as children, instead of being referred to disability services.[^4.18] Our apparent high intelligence puts us in a double bind: we are expected to accomplish great things to justify our oddness, and because we possess an enviable, socially prized quality, it’s assumed we need less help than other people, not more. Dorian couldn’t handle the pressure of such high expectations, or the lack of compassion. So they began to self-harm. At age thirteen, they happened upon a magazine article about a girl with anorexia and felt incredibly envious. This visibly sick girl was being showered with affection and care. She wasn’t expected to excel at anything but staying alive. “What I got from this article was this girl made herself so close to death that her family were afraid they were going to lose her, and now she has all this love and support around her. And she doesn’t have to achieve anything, because she nearly died,” Dorian says. Dorian held on to this article for years, rereading it until they had it nearly memorized. They began to starve themselves, hoping that if they looked like they were dying, people would finally go easy on them. They also started frequenting pro-anorexia (or “pro Ana”) forums, where they befriended other eating disordered teens and traded weight loss strategies and “thinspiration” photos. Eventually they began meeting up in person and having binge-purge parties. Dorian says this community was filled with self-destructive people who were often a bad influence on one another, but also that it was the only nonjudgmental place they had access to, the only space where they could truly let their pain show.[^4.19] My own eating disorder had different motivations than Dorian’s did, but it was no less tied to my Autism. From age fifteen until about twenty-five, I denied myself food because I wanted to look “androgynous,” and I believed that meant looking thin. I overexercised because I thought it proved I was strong. The pain of an empty stomach was physically satisfying to me; the throb in my legs after two hours of playing Dance Dance Revolution on calorie counter mode made me feel like I’d finally reined in an out-of-control body. Unlike Dorian, I didn’t want people to know I was having a hard time. Ever. I wanted to be an otherworldly creature, free from silly human needs. I pulled a lot of all-nighters, thinking that staying up late exercising was a better use of my time than rest. When a friend on the debate team told me that I seemed like a “robot” because I never seemed to sleep, eat, or like people, I felt an immense sense of triumph. My mask was solid steel. Autism and eating disorders are highly correlated, especially among women,[^4.20] trans people,[^4.21] and maskers diagnosed late in life. A lot of factors account for this. Some maskers believe that being conventionally pretty and thin will help them blend in. Others neglect their physical needs because they’ve mentally detached from their bodies. Purging can be used to self-harm, or to regulate a disrupted sensory system. It floods the body with endorphins, which can be calming and addictive. In one video, Dorian describes how a friend from the pro-Ana forums used to pace her hallway all night, every night, in a desperate bid to burn calories. This sounds a lot like a repetitive self-stimulatory behavior,[^4.22] in addition to a purge. My compulsive DDR playing was absolutely a sneaky way to self-stimulate, as well as an attempt to lose weight. Some masked Autistics are drawn to the structure and sense of control that an eating disorder can provide. We often seek out clear “rules” for good behavior, which we then adhere to rigidly, hoping they will keep us socially safe and finally render us worthy.[^4.23] When I was an undiagnosed Autistic teen, my brain was constantly buzzing with vague anxiety. Calories, checking my body in the mirror, and weighing myself were concrete things I could focus on instead of inchoate fear. The fatphobic society I was living in had taught me that being thin was superior to being fat, and I attempted to follow that rule with fervor. Running myself ragged with exercise meant I’d eventually be able to fall asleep. The online eating disorder community gave me routines to craft my day around. It was all quasi-religious. I didn’t believe in God, but I could worship at the altar of Dance Dance Revolution every night, sweating and gulping down ice water while my brain floated above me in a nutrient-deprived haze. Exercise bulimia also gave me a way of connecting with the girls around me. Wanting to be thin was one of the few gender-conforming traits I had. Clinical research has found that somewhere between 20 and 37 percent of diagnosed anorexia nervosa sufferers are Autistic.[^4.24] Since Autism is underdiagnosed in the populations who are most likely to be diagnosed with eating disorders (women, trans people, and gay men), the actual rate of co-occurrence might be much higher. In conventional eating disorder treatment, Autistic patients have worse outcomes: they require longer hospital stays, are less likely to reduce their eating disordered behaviors, and experience more depression and social isolation in recovery groups.[^4.25] However, eating disorder clinics and inpatient programs have started taking steps to accommodate their Autistic patients, with some promising results. Here’s how Tchanturia and colleagues (2020)[^4.26] described their newly Autism-friendly eating disorder ward: We invested in materials necessary to create a more [^4.Autism-] friendly ward environment, including redecorating the ward to create a neutral colour scheme, developing a “sensory box” for patients with items such as weighted blankets and sensory toys, and we began hosting wellbeing groups for autistic patients and for those without autistic traits together with members of the multi-disciplinary team to support sensory difficulties and enhance social communication (e.g., introducing communication passports and other strategies). Tchanturia and colleagues found that Autistic patients on this accessible ward had significantly shorter stays, and follow-up research suggests Autism-friendly eating disorder treatment does result in better outcomes.[^4.27] Since eating-disordered behavior is at least partially socially motivated for many Autistic people, it may also be beneficial to seek belonging and social structure in new ways that feel less performative and most authentic. In their videos, Dorian says that their health was at its worst when they tried to seem like a normal, perky, preppily dressed woman.[^4.28] Presenting as a transmasculine goth with loud outfits and intense makeup helps them feel far more at home in their body, and hanging out with other “weird” alternative types gives them the sense of belonging they once sought in pro-Ana groups. Now that they know they’re Autistic, they’re also able to be more vulnerable about when and why they’re struggling, so they don’t have to use a shared compulsion to bond with other people. ### Detachment and Dissociation To cope with the pressure of masking, many Autistics disappear into our own heads. I can’t tell you how many times I’ve heard an Autistic person say they wish they could just be a floating brain in a jar, or a dark, sentient mist with no physical form. It’s a common neurodivergent fantasy, because our bodies can seem so at odds with what the world wants them to be. Dissociation is also a means of controlling the social and sensory data we’re taking in, ignoring inputs that have become too intense. For example, when there are too many people around, my friend Angel says he goes away into “Angel World” in his head, and everyone around him becomes blurry. He has some relatives that he has never seen the faces of, because he’s only ever met them at big family gatherings where everyone blends into a sea of muddy, vague shapes. When he’s dissociating, he can still go through the motions of eating, bathing, and walking around, but mentally he’s not really there. The only thing that brings Angel back is having plenty of time to rest and disengage. For other Autistic people that I know, including myself, having to mask and socialize for an extended period increases the odds we’ll begin to dissociate or shut down. People don’t literally become “blurry” for me when I’m overwhelmed, but I do stop gazing at people’s faces and often fail to recognize people I know or hear their voices unless they get in my face and wave their hands. Putting less cognitive effort into masking can help, as can escaping the overloading situation that was provoking me to detach in the first place. In the short term, mentally detaching works great. It frees up a lot of energy and attention, so we can focus on activities we’re good at, or think only about the ideas that capture our interest. But in the long term, retreating inward alienates us from our needs even more. Some research suggests that Autistic people have a diminished sense of agency; in other words, we feel less in control of ourselves and our bodies than non-Autistic people do.[^4.29] A lifetime of being corrected for incompetence and childishness affects our self-concept, and makes it hard for us to develop basic skills of self-advocacy or assertiveness. In one study of Autistic agency, Autistic and non-Autistic people were both asked to manipulate a cursor on a screen as part of a computer game.[^4.30] Random time lags and movement glitches were added to the game, so that players didn’t always have full control over what the mouse was doing. Players were told to attempt to win the game, and were also asked to report when they thought they had control of the mouse and when they didn’t. Neurotypical people were pretty accurate in judging when they had control of the mouse. They could tell when a mouse movement was caused by a lag or glitch rather than their own hands. Autistic players instead struggled to tell the difference. They tended to believe they were more in control of the game when they were winning, and that they were not in control when they were losing, even when the two were unrelated. In particular, this result appeared to be driven by Autistic people trusting internal cues less: they didn’t trust their own feelings of whether they were in control or not, so much as external benchmarks of success in the game. This may be a bit of a contrived example from a laboratory setting, but it points to a tendency many of us have to view ourselves as powerless, and fundamentally detached from our bodies and the broader world. We rely on external signs of success (winning a game, getting praised by another person) to guide us, rather than trusting our perceptions and power of discernment. Unfortunately, when we disengage from our bodies, we miss out on a lot of valuable self-protective physical signals. Research shows that most Autistic people have a reduced sense of the body’s warning signals, or interoception.[^4.31] Most of us tend to feel like our bodies are not really our own, and struggle to draw connections between the external world and how we feel inside.[^4.32] For example, a neurotypical person might notice that their coworkers are leaving for lunch, and then check in with their own body and recognize they’re hungry, too. An Autistic person might instead be lost in their own head, and fail to draw a connection between their coworkers departing and the need to check for hunger within themselves. It’s unclear how much this is caused by a neurological feature of Autism, and how much it’s a by-product of masking and social pressure. After all, masked Autistics are socially conditioned to silence the physical needs we do notice. If I have to suppress my desire to pace around the room and sing songs to myself because doing so makes me look like a “freak,” how am I supposed to know that listening to hunger or tiredness is fine? Though Autistic people tend to be hypersensitive to sensory input, most are relatively numb to physical pain.[^4.33] It may sound paradoxical, but it makes sense when you recall the research showing that Autistic brains are generally detail oriented and hyperexcitable. When my shirt gets untucked, I cannot stand the little burst of cool air I feel hitting my belly. It’s a persistent, small stimulus that is too annoying to ignore. Yet I’ve walked for miles with bleeding fissures on my heels and barely felt a thing. Masking also tends to involve swallowing your anguish in order to keep the neurotypicals around you happy. Complaining about discomfort that no one else is experiencing can make you seem “crazy” or “demanding.” Many of us become quite adept at ignoring pain, just as we neglect our own hunger or thirst. Unfortunately, this isn’t just true of physical pain. It extends to emotional pain, too. Research by psychologist Geoff Bird indicates that about half of all Autistics suffer from alexithymia,[^4.34] or the inability to recognize and name emotions.[^4.35] For those of us with alexithymia, we may know in a vague way that we’re distressed, but might not be able to name a specific feeling like jealousy or resentment. We also struggle to figure out why we’re feeling emotions. This trait is yet another reason that neurotypicals stereotype us as unfeeling and detached. Alexithymia may arise, in part, because Autistics aren’t given the tools to understand how emotions feel in our bodies, and because we are taught to prioritize others’ feelings above our own. Growing up, we’re told how neurotypical emotions look and feel. We’re encouraged to track other people for signs of discomfort or disapproval, so we can change our actions and become more pleasant or compliant. Our own facial expressions, nonverbal signals, and perceptions of our bodies and surroundings are different, and neurotypicals frequently ignore them. So when we’re upset or uncomfortable, we often fail to recognize it until we’re nearly on the verge of a complete meltdown. As we begin to unmask, we stop monitoring the reactions of other people so closely and with so much hypervigilance; this allows us to check in with our bodies more. Our reflexive self-censorship may begin to reduce, allowing us to notice our discomfort and honor it. However, many Autistic people (myself included) still need time alone to reflect on how we’re feeling, because the social information given off by other people is so distracting. Today I’m sometimes able to notice in the heat of the moment that I’m uncomfortable with the topic of conversation, for instance, or the way someone is pushing me to do something I don’t wish to do, and I can tell them to stop; other days I simply feel panicky and frantic, and can’t figure out what’s wrong until hours or days later. Because Autistic people often struggle to look after our bodies or to recognize and advocate for our needs, work, school, and other social settings can be incredibly painful for us to navigate. An oft-cited statistic claims that 85 percent of Autistic adults are unemployed,[^4.36] though higher-quality cross-sectional research puts the number closer to 40 percent.[^4.37] Some research suggests that Autistics who disclose their disability at work often regret having done so, because they don’t get many useful accommodations and may be underestimated or othered.[^4.38] For these and many other reasons, Autistic people often have no choice but to work from home, and as a population we’re digitally self-employed at high rates.[^4.39] Work-from-home and consulting positions frequently undercompensate and overwork us, but they offer a level of flexibility and privacy that more stable jobs lack. In addition to compensating by working from home or pursuing digital work, a significant percentage of Autism maskers disengage from reality via internet and gaming.[^4.40] Digital work and gaming are incredibly appealing to Autistic people’s brains. Online and in games, cause and effect are clearer than in “real” life.[^4.41] It’s easy to ignore subtext or nonverbal cues and focus only on shared tasks and clear, measurable outcomes. In digital communication, Autistic people get the time we need to carefully process a message, google any terms that are unfamiliar, and carefully reflect on how we might want to respond. There’s nothing innately wrong with using the internet to help meet your need for social contact and structure. Disabled people have found community and shared resources on the internet for decades. However, excessive and compulsive internet use and gaming can prove damaging to Autistic people and inhibit our social connections and development.[^4.42] When we spend too much time online, it can limit how much practice we get interacting and communicating out in the world, contribute to feelings of loneliness and depression, and further the detachment so many of us feel from our bodies. Hiding our struggles away from the world is not a productive means of gaining acceptance, and there’s a difference between using the internet as a way to develop a sense of fluency and competence, and retreating into it because we feel we have no other choice. Thomas tells me that as he’s come to understand his own Autism and work on unmasking, he’s gotten better at noticing how he feels and figuring out how to care for himself. For many years, particularly before his diagnosis, he would just push his emotions and desires away. “This week I noticed my energy replenishment was at a standstill,” he says. “I couldn’t focus on data work, which is normally one of my passions. I journaled about it a bit and realized my girlfriend has been home more than usual lately. I love her, but being around her all day was overstimulating me. The next day the weather was beautiful, and all I did was sit outside and read. It felt wonderful, there wasn’t all this stimuli hyper-activating me.” Thomas still carries the baggage of being fully masked and undiagnosed, and thinking he was simply a difficult or angry person. Over the years, though, he’s learned to push past this cultural programming and actually construct a life that’s authentic to him. Building that kind of self-knowledge and acceptance has been vital to his happiness and his sobriety. “I enjoy hanging out in train yards, and learning ridiculous amounts of useless knowledge, and I’d rather work on jigsaw puzzles than watch TV. Because my life is aligned with who I am now, I have much less need to drink. Recovery is predicated on aligning your life with your values, and you aren’t going to be able to align anything until you know who you are.” This is just as true of Autistics who reflexively detach from reality because they’re so accustomed to camouflaging their every feeling and need. You cannot craft a comfortable or worthwhile life if you don’t know who you really are, or if your self-image is shaped entirely by rules imposed on you by other people. Thankfully, it is possible to step away from defining yourself by the approval of other people, and by your adherence to society’s rules. In later chapters, we’ll explore how that process can look, and hear from several people who have walked away from a life defined by seeking approval and masking. ### Adherence to Rigid Rules and Belief Systems Masked Autistics sometimes find structure and belonging in “high control” groups, such as radicalized political organizations, religious communities with very restrictive beliefs, and cults. High control groups famously prey on people who are lonely and desperately seek a sense of purpose. Their repetitive rituals, seemingly close-knit social bonds, and ironclad rules about who is “good” and who is “bad” appeal to isolated people who yearn for connection and structure. I’ve spoken to a wide array of masked Autistic adults, and over a dozen have shared stories with me of belonging to fringe religious communities, conspiracy theory groups, multilevel marketing schemes, and other high control organizations. There isn’t any empirical research I can find that documents just how prevalent this is for our population. However, recent research by Griffiths and colleagues (2019) does describe Autistic adults as having an elevated vulnerability to financial exploitation, domestic violence, relational abuse, and emotional manipulation.[^4.43] These are the precise qualities that define cults—and they’re part of what makes such spaces alluring to us. We’re susceptible to manipulation for tons of reasons. Autistic adults tend to be in socioeconomically precarious positions, which can make it hard for us to escape people who mistreat us. When you’re unemployed or underemployed, you’re going to be more willing to move in with a romantic partner, or become dependent on an extremist religious group quickly, as a matter of necessity. Our yearning to be accepted and tendency to downplay our own feelings also leaves us prone to mistreatment. ABA therapy and social masking instruct us to be compliant and conformist. Orthodoxy and rules about how we’re supposed to act can feel grounding and “rational.” Growing up Autistic in the rural western United States, Andrew found himself lured into a controlling religious community. He says members of the church quickly identified him as a potential mark. “I was living alone, clearly one of the only nonwhite people in a very white small town, depressed, anxious all the time, drinking coffee all day at the diner, and they started talking to me, saying they just wanted to get to know me.” He was getting “love bombed,” a common technique in cults where new members are showered with excessive affection and special attention.[^4.44] Love bombing trains a person to let their guard down and relax their boundaries around the new group. For Autistic people who have been on the fringes of society all our lives, it can be exhilarating to suddenly, inexplicably be adored. Once Andrew decided to join the church, things began to change. Members kept him up on the phone late at night, asking intense questions about his family, from whom he was estranged. One of the church’s leaders interrogated him about his bisexuality, and how he could reconcile it with their faith’s teachings. Andrew stopped going on dates with men, because that stopped all the questions. Expectations continued to ramp up: volunteering to help church members with babysitting once a week ballooned into a nightly commitment. “I still blame myself for falling for these tactics, because it’s not as though they had a gun to my head,” he says. But, he explains, it was controlling behavior, nonetheless. “They’re hugging you and joking with you one day, they won’t even look at you the next, and it shapes how you think and act over time.” Controlling and dogmatic groups promise a life filled with meaning, and a new family who will never leave you. In reality, they entrap people in a complex web of sometimes incompatible expectations, with rejection forever looming. Since many of these organizations rely on their members’ devotion, free labor, and donations in order to function, they have a vested interest in making people feel like their efforts are never enough. Andrew says it took him a couple of years to figure out he was being played. The stress of being in the church began to give him panic attacks, but members saw it as a betrayal of their “family” for him to seek group therapy. That made him begin to question their beliefs. It’s also when he sorted out that he was Autistic. Some of the Autistic people I spoke to had less dramatic experiences that were still damaging. Things like becoming unhealthily attached to graduate student advisors, or devoting years to nonprofits or activist groups whose goals they truly believed in, but which had really unhealthy boundaries or a toxic, workaholic culture. Other Autistic people I interviewed became adherents to rigid belief systems of their own making, without the influence of anyone else. They wanted to make their own worlds predictable, easy to make sense of, small. It began as a way to take charge of their lives, until the number of self-imposed rules they followed spiraled out of control. Some Autistic people end up being radicalized by far-right online communities, which tailor themselves to appeal to lonely, frustrated men.[^4.45] Groups like QAnon, the Proud Boys, and Men Going Their Own Way provide a sense of belonging to people who have persistently been alienated. They offer friendship and a place where it is safe to ask taboo questions and say offensive things without fear of social consequences. These communities also prey on the Autistic tendency to fixate on a narrow array of topics. They bombard members with propaganda, teach them obscure language that no one outside of the group will understand, and desensitize them to bigotry using jokes and memes. Once deeply embedded within these subcultures, it’s very difficult for an Autistic person to claw their way out; their extreme beliefs and hyperspecific way of communicating make it harder than ever to get a job or make friends. Neurodiverse women and gender nonconforming people are similarly preyed upon by “gender critical,” transphobic communities, which use many of the same thought-controlling tactics. A former member of one of these groups, the writer Ky Schevers, says they were basically subjected to anti-trans conversion therapy by fellow group members.[^4.46] They were taught to censor their own feelings of gender dysphoria, and to view the desire to transition as a betrayal of the group and of womanhood in general. I’ve read up on these groups extensively and followed a lot of anonymous “gender critical” accounts for years, and it’s shocking to me how many of its members are Autistic. This fact has even become a part of their ideology: they claim to be protecting Autistic women from being lured into the “trans cult.” In actuality, they’re the culty ones, seeking out vulnerable, gender-dysphoric people and working to isolate them from the broader trans community. In the list below I’ve listed a few attributes common to high-control groups, which were originally observed by psychiatrist Robert Lifton in his classic text, Thought Reform and the Psychology of Totalism.[^4.47] Lifton’s research focused on manipulation techniques pushed on political prisoners and prisoners of war, but subsequent work has found similar processes being invoked by American extremist groups,[^4.48] as well as groups that might not qualify fully as cults but still exert a strong pull on their members, such as many evangelical faith communities.[^4.49] Abusive, manipulative dynamics appear on a smaller scale in multilevel marketing schemes,[^4.50] exploitative workplaces, and even communities that pride themselves on being progressive bastions of free thought, such as academia.[^4.51] It’s important for Autistic people to be aware of the warning signs of psychological manipulation, because we are at an elevated risk of being targeted by organizations (and even informal social groups) that employ such methods. ### Warning Signs of a High-Control Group * The group promotes an antagonistic view of the outside world and nongroup members: “It’s us versus the world.” * Group members constantly feel insecure about their position within the group; members may be punished for any small mistake or failure. * Personal boundaries are discouraged; people are expected to view the group as a “family,” and sacrifice as much as they can for it. * Any perspective that challenges the group’s orthodoxy is unspeakable; members feel shame about thinking or feeling the “wrong” things. * Repetitive language and group jargon are used to dismiss criticism. Group members repeat empty clichés in order to silence difficult conversations. Most Autistic people never become radicalized by hate groups, of course, and it would be both ableist and ethically troubling to claim someone’s disability excuses their adopting a racist, sexist, transphobic ideology. However, it’s important for each of us to recognize how a mix of social exclusion, Autistic hyperfocus and rule-abiding, and cultlike programming can blend to taint a vulnerable person’s thinking. When you have never been able to move through the world comfortably, you’ll seek relief and meaning where you can get it. For a subset of Autistic people, that means falling into abusive, cultlike communities. For others, it takes the form of rationalizing or excusing abuse in private relationships. Many of us mask through compulsive people pleasing and compliance. ### Fawning and Compulsive People Pleasing The Big Bang Theory is one of the most popular sitcoms in TV history, which makes the show’s character Sheldon perhaps the most famous Autistic-coded character around. He’s infamously curt and socially detached, a jerk who gets away with being inconsiderate because he’s such a know-it-all. Lisbeth Salander from the Girl with the Dragon Tattoo series is another classic example of the asshole Autistic genius trope. She uses her almost robotic perceptiveness and rationality to upbraid and insult people, as well as solve crimes. Rick from Rick and Morty is another standout example. He’s actively abusive to his grandchildren, and a total slob who frequently destroys his adult daughter’s home, but his entire family (and most of the show’s fandom) look up to him because his brilliant, no-nonsense analytical mind invented portal technology. As real, living people, Autistics are forever running away from the “asshole genius” trope. In a 2016 survey of college students’ attitudes toward Autistics, psychologists found that people associated the neurotype with introversion, social withdrawal, and having a “difficult” personality.[^4.52] These stereotypes of Autism existed before shows like Big Bang Theory and Rick and Morty, but those portrayals certainly reinforced biases that were already there. In the average person’s mind, there is a singular image of how Autism presents in adults: a genius, almost always a man, who is blunt and direct to the point of cruelty. To avoid embodying this trope, Autistic people fold ourselves into all kinds of accommodating shapes. We do what we can to not seem difficult, cruel, or self-absorbed. We internalize the message that talking about ourselves and our interests bores other people, that we’re socially inept and bad at reading emotions, and that our sensory needs make us big babies who never stop complaining. For fear of becoming a Sherlock, we morph ourselves into Watsons: agreeable, docile, passive to a fault, always assuming that the larger personalities around us know what’s best. Masked Autistics are frequently compulsive people pleasers. We present ourselves as cheery and friendly, or nonthreatening and small. Masked Autistics are also particularly likely to engage in the trauma response that therapist Pete Walker describes as “fawning.”[^4.53] Coping with stress doesn’t always come down to fight versus flight; fawning is a response designed to pacify anyone who poses a threat. And to masked Autistics, social threat is just about everywhere. “Fawn types avoid emotional investment and potential disappointment by barely showing themselves,” Walker writes, “by hiding behind their helpful personas, over-listening, over-eliciting or overdoing for the other.”[^4.54] Walker notes that by never revealing their own needs or discomfort with other people, fawners spare themselves the risk of rejection. But they also fail to connect with people in any meaningful way. It’s a lonesome state to live in. It’s also deeply draining. Many masked Autistic adults struggle to balance full-time work with social lives or hobbies at all because maintaining a conciliatory mask for eight hours per day is just too labor intense to have energy for anything else.[^4.55] The connections we do form may never feel satisfying or authentic to who we truly are, because they rely on us meeting people’s needs reflexively and always telling them what we think they want to hear. Autistic wellness coach Samuel Dylan Finch has written a lot about why Autistic people fawn, and how fawning frays our relationships. He’s also a fawner himself, though it took some time to recognize this. “I am a people-pleaser,” he writes on his blog.[^4.56] “It took me a long time to realize this, though. Because I’m opinionated! And I speak my mind!” Finch writes that when he really wants to connect with another person, his instinct is to censor his real self and “mirror” the other person: “The more invested I was in an emotional connection, the less likely I was to criticize that person, vocalize when my boundaries were crossed, express unhappiness with their behavior, or share anything that I felt might damage that relationship.” Here are some of the signs of having a “fawning” response to stress and social threat, inspired closely by Finch’s work and writing. #### Fawning and People-Pleasing Reflection Tool[^4.57] Consider each statement and reflect on how true each one is for you. * It doesn’t feel like anyone knows the “real” me. * I don’t know how to say no to people. * I feel responsible for managing other people’s feelings and reactions, even when they don’t involve me. * I sometimes feel like I’m betraying myself by going along with things I don’t agree with. * I closely monitor social situations to see when conflict is brewing, and try to stop it before it starts. The impulse to fawn that Finch describes is very familiar to me. I find it easy to correct a coworker if they make a factual statement that’s wrong, but when I was trapped in an abusive relationship with a person I deeply loved, contradicting him terrified me. Just the idea of telling him that he’d treated me unfairly made me want to sputter and flee the room. Years later, I still have trouble criticizing people, including those who make me feel safe and accepted. My brain knows better, but my body expects a rage outburst all the same. Autistic people are at an increased risk of domestic abuse, in part because we tend to be a bit gullible or overly trusting, and are quick to alter ourselves to placate others.[^4.58] When you’re trapped under the mask, all love feels conditional. It’s hard to know which needs are acceptable to voice. It’s also easy for us to feel responsible for serving as an intermediary or peacekeeper when any tension arises between other people, because for us, conflict can be very dangerous. Some psychological research suggests that there are heavy emotional and relational costs to constantly aiming to please other people and project back at them the emotions and responses they wish to see. One common fawning tactic among Autistics is mirroring: lightly mimicking the actions and emotions of another person, trying to meet the energy they are giving off so that they view us as normal and similar to themselves. However, paying close attention to a person’s actions and feelings and then mimicking it as best you can is a very cognitively draining and distracting endeavor. A study by Kulesza and colleagues (2015) found that when experimental study participants were asked to subtly mimic the behavior of a conversation partner, the mimicker actually had a harder time recognizing the emotions of the person they were mimicking.[^4.59] Even though the (neurotypical) participants in the study were successfully imitating the emotional displays of their conversation partners, they were so focused on the performance that they stopped really thinking about what those emotional displays meant. This study has not been replicated in an Autistic or neurodiverse sample, but if mirroring other people is so mentally labor-intensive that it reduces the empathy of neurotypicals, it’s likely true of Autistic people as well. In fact, these results suggest that all the attention we put toward masking our own emotions and mirroring another person’s contributes to our struggles with empathy in the first place. Since Autistic people often struggle to identify our emotions as well (particularly in the heat of a stressful social interaction), we often have a hard time recognizing when someone’s actions have hurt us or made us uncomfortable. It takes time for me to reflect on how and why someone’s actions might have hurt me. Autistic sex educator and writer Stevie Lang has observed that Autistic people sometimes find it challenging to negotiate sexual consent as well, because we can’t always tell the difference between wanting something, and wanting to want it in order to make someone else happy: “Our aversion to rejection and desire to be accepted may make it difficult to know when we are experiencing consent,” he writes, “and when we are trying to conform to social expectations to be liked or to avoid rejection.”[^4.60] Ultimately, all masking is about setting our feelings aside so we can focus on pleasing others or conforming to social norms. This is always going to be a self-destructive values system to live by, regardless of the coping mechanisms we use to prop it up. Whether we use alcohol, excessive exercise, overwork, social isolation, codependency, or some other self-destructive strategies to help us blend in, it’s always going to be damaging to put social approval and “passing” as neurotypical above our actual needs. We don’t actually have to live this way. Autistic people can learn to listen to ourselves again, challenge the shame society has pushed on us, and become radically visible and outspoken about the accommodations we require and deserve. It may be challenging and daunting to detach from years of reflexive, self-protective masking, but a life free from its confines is possible for us. In the next few chapters, we’ll review the research on how Autistic people can accommodate their neurotype in all facets of their lives, hear from coaches and specialists who are helping fellow Autistics learn to unmask, and meet several masked Autistic people who have begun to embrace who they are, and question the forces that taught them to hide themselves away. [^4.1]: Bellini, S. (2006). The development of social anxiety in adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 21(3), 138-145. [^4.2]: Lawson, R. P., Aylward, J., White, S., & Rees, G. (2015). A striking reduction of simple loudness adaptation in autism. Scientific Reports, 5(1), 1–7. [^4.3]: Takarae, Y., & Sweeney, J. (2017). Neural hyperexcitability in autism spectrum disorders. Brain Sciences, 7(10), 129. [^4.4]: Samson, F.; Mottron, L.; Soulieres, I.; & Zeffiro, T. A. (2012). Enhanced visual functioning in autism: An ALE meta-analysis. Human Brain Mapping, 33, 1553–1581. [^4.5]: Takahashi, H.; Nakahachi, T.; Komatsu, S.; Ogino, K.; Iida, Y.; & Kamio, Y. (2014). Hyperreactivity to weak acoustic stimuli and prolonged acoustic startle latency in children with autism spectrum disorders. Molecular Autism, 5, 23. [^4.6]: Jones, R. S., Quigney, C., & Huws, J. C. (2003). First-hand accounts of sensory perceptual experiences in autism: A qualitative analysis. Journal of Intellectual & Developmental Disability, 28(2), 112–121. [^4.7]: Rothwell, P. E. (2016). Autism spectrum disorders and drug addiction: Common pathways, common molecules, distinct disorders? Frontiers in Neuroscience, 10, 20. [^4.8]: https://www.theatlantic.com/health/archive/2017/03/autism-and-addiction/518289/. [^4.9]: Rothwell, P. E. (2016). Autism spectrum disorders and drug addiction: Common pathways, common molecules, distinct disorders? Frontiers in Neuroscience, 10, 20. [^4.10]: https://devonprice.medium.com/the-queens-gambit-and-the-beautifully-messy-future-of-autism-on-tv-36a438f63878. [^4.11]: Brosnan, M., & Adams, S. (2020). The Expectancies and Motivations for Heavy Episodic Drinking of Alcohol in Autistic Adults. Autism in Adulthood, 2(4), 317–324. [^4.12]: Flanagan, J. C., Korte, K. J., Killeen, T. K., & Back, S. E. (2016). Concurrent Treatment of Substance Use and PTSD. Current Psychiatry Reports, 18(8), 70. https://doi.org/10.1007/s11920-016-0709-y. [^4.13]: Sze, K. M., & Wood, J. J. (2008). Enhancing CBT for the treatment of autism spectrum disorders and concurrent anxiety. Behavioural and Cognitive Psychotherapy, 36(4), 403. [^4.14]: Helverschou, S. B., Brunvold, A. R., & Arnevik, E. A. (2019). Treating patients with co-occurring autism spectrum disorder and substance use disorder: A clinical explorative study. Substance Abuse: Research and Treatment, 13, 1178221819843291. For more on modifications to CBT (though this research is very limited, in that it’s based on a child sample and reflects a lot of ableist assumptions about the socia skills of Autistics) see J. J. Wood, A. Drahota, K. Sze, K. Har, A. Chiu, & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry,50: 224–234. [^4.15]: https://jessemeadows.medium.com/alcohol-an-autistic-masking-tool-8aff572ca520. [^4.16]: Dorian identifies as an Aspie, not an Autistic person, because the diagnosis they received at age twenty-four was of Asperger’s Syndrome, not Autism Spectrum Disorder. [^4.17]: https://www.youtube.com/watch?v=q8J59KXog1M. [^4.18]: Assouline, S. G., Nicpon, M. F., & Doobay, A. (2009). Profoundly gifted girls and autism spectrum disorder: A psychometric case study comparison. Gifted Child Quarterly, 53(2), 89–105. [^4.19]: https://www.youtube.com/watch?v=zZb0taGNLmU. [^4.20]: Hobson, H., Westwood, H., Conway, J., McEwen, F. S., Colvert, E., Catmur, C.,…& Happe, F. (2020). Alexithymia and autism diagnostic assessments: Evidence from twins at genetic risk of autism and adults with anorexia nervosa. Research in Autism Spectrum Disorders, 73, 101531. [^4.21]: Wiskerke, J., Stern, H., & Igelström, K. (2018). Camouflaging of repetitive movements in autistic female and transgender adults. BioRxiv, 412619. [^4.22]: Coombs, E., Brosnan, M., Bryant-Waugh, R., & Skevington, S. M. (2011). An investigation into the relationship between eating disorder psychopathology and autistic symptomatology in a non-clinical sample. British Journal of Clinical Psychology, 50(3), 326–338. [^4.23]: Huke, V., Turk, J., Saeidi, S., Kent, A., & Morgan, J. F. (2013). Autism spectrum disorders in eating disorder populations: A systematic review. European Eating Disorders Review, 21(5), 345–351. [^4.24]: Tchanturia, K., Dandil, Y., Li, Z., Smith, K., Leslie, M., & Byford, S. (2020). A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost-savings. European Eating Disorders Review. [^4.25]: Tchanturia, K., Adamson, J., Leppanen, J., & Westwood, H. (2019). Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism, 23(1), 123–130. https://doi.org/10.1177/1362361317722431. [^4.26]: Tchanturia, K., Dandil, Y., Li, Z., Smith, K., Leslie, M., & Byford, S. (2020). A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost-savings. European Eating Disorders Review. [^4.27]: Li, Z., Dandil, Y., Toloza, C., Carr, A., Oyeleye, O., Kinnaird, E., & Tchanturia, K. (2020). Measuring Clinical Efficacy Through the Lens of Audit Data in Different Adult Eating Disorder Treatment Programmes. 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