Part 1: Autism, Pathological Demand Avoidance, and …Sociopathy?

Pathological Demand Avoidance (PDA) is a term used to reference a pattern of severe, chronic resistance toward cooperation with ordinary requests in daily life. PDA is considered by many to be an atypical presentation of autism, and has qualities that are seemingly inverse. Also referred to as Extreme Demand Avoidance, or Pervasive Drive for Autonomy, the UK acknowledges PDA as a behavioral profile of autism.

What is Pathological Demand Avoidance?

Before sharing research and more defining characteristics below, it is of course reasonable to acknowledge that a measure of demand avoidance is perfectly normal (and wise).

Generally speaking, autism without a PDA profile still presents with more demand avoidance than the average allistic individual. Demand avoidance associated with autism may occur due to rigid adherence to routine; difficulty transitioning between preferred and non-preferred activities; sensory overstimulation, which in turn creates overwhelm; inflexible thinking in regard to problem-solving; difficulty stopping perseveration; and social or performance anxiety in general. Poor executive functioning can look like demand avoidance – and might be, especially if strategies are resisted in implementation. Ordinary demand avoidance with ASD is selective or circumstantial. PDA encompasses a chronic resistance to comply with basic requests that are routine, familiar, and even personally beneficial sometimes. Pathological Demand Avoidance surrounds a desire to control – control autonomy, control threat perception internally – and control other people, alongside their expectations.

The referencing of a “demand” with PDA encompasses any want, need, expectation or request that is direct or indirect – a question, instruction, obligation, insinuation, guidance, rule, stipulation, internal feeling (hunger, thirst, fatigue), or prompting. The more pressure put upon compliance for a demand, the more escalation of resistance from a PDA individual. PDA avoidance is not necessarily the circumstances of the demand; but simply because there is a demand – internally or externally. PDA is often described as propelled by anxiety or uncertainty, but there is also observational research to suggest that PDA can be agenda-driven, such as seeking attention, access, or outcome of preference (Lucyshyn, 2015). PDA individuals “also seem to find reward in upsetting other people (Wing, 2002).”

This summary references the original journal article developed by Elizabeth Newson, a developmental psychologist who first proposed Pathological Demand Avoidance as a separate syndrome related to autism. “Descriptively, the key characteristics of PDA are an obsessive resistance to everyday demands and requests, use of socially manipulative or outrageous behaviour to avoid demands, sudden changes in mood apparently associated with a need to control, and ‘surface’ sociability… Newson described non-compliance in PDA as obsessive, not limited to unpleasant tasks, but at worst, a blanket resistance to accept suggestions, to talk, sit down, take part in fun activities… resorting to extreme, aggressive or socially shocking behaviour if pressed to comply. Newson et al. (2003) described them as… unlike most children with ASD, they tended to subvert requests by distraction, diversion, threats, or behaviour intended to shock, or upset. In addition, they lacked a sense of responsibility to others, and failed to moderate their behaviour for others’ benefit.”

This is a visual of Elizabeth Newson’s construct of PDA. Her aim was to classify PDA as a separate syndrome under the same developmental disorder umbrella.

PDA is not yet included in the ICD-11 or DSM- 5 as a differential diagnosis. Viewpoints on how to classify PDA remain varied among clinicians, researchers, parents, families, and those who self-identify with PDA. There is a lack of consensus as to whether PDA is truly autism, or a separate neurotype; if it is a syndrome co-occurring only with autism or if it can occur alongside other conditions; or if it is a behavior profile covered under similar diagnoses (possibilities of which are discussed below). Some believe that PDA is parsing ASD behavior unnecessarily, and is simply part of autism, unworthy of definition otherwise. (See “symptoms but not a syndrome” – here.) Others find offense that PDA is conceptualized as being related to autism at all – because aspects such as social behavior are different, among other nuances. However, there is an overall recognition that this cluster of rare, highly specific traits does exist – whether termed PDA, or not.

In the UK, PDA is referenced by the National Autism Society as a descriptive category of autism. In the US, PDA is gaining recognition, but much more limited in comparison… or interest. However, it’s not unusual in the United States to see dual diagnoses with ASD that seem to reference PDA-like behavior, such as: Disruptive Mood Dysregulation Disorder, Oppositional Defiant Disorder with ADHD, Intermittent Explosive Disorder, Conduct Disorder, and personality disorders (in adulthood). Many aspects of these disorders certainly seem to describe attributes of PDA. However, proponents of differential diagnosis for PDA insist that it cannot be encapsulated by the above labels, citing the uniqueness of categorically resisting ordinary demands of daily life. Additionally, strategies that are helpful for disruptive conditions listed above can be unsuccessful for shifting problematic PDA behavior. (This study notes that neural activity in the brain for disruptive behavior and ASD symptom severity have “separate neural basis. Critically, these findings imply that differential treatment should be provided to treat disruptive behavior in ASD.” )

What are the differences in social behavior when comparing ASD to PDA?

I choose to focus on this particular aspect of PDA presenting inversely with a typical ASD Level 1 (formerly Asperger’s Syndrome) profile, because for neurotypical or allistic partners – it is by far the most profoundly confusing aspect. It is difficult to conceptualize behavior that still merits an ASD diagnosis, but is not consistent with the fairly limited literature that depicts ASD in adults.

One reason PDA is considered an “atypical” presentation of autism is that soft social skills are more developed (and utilized to avoid demands). This study suggests that theory of mind is less impaired in the PDA profile of autism, which is perhaps an explanation for why PDA individuals can use social strategy and manipulation to avoid cooperation. PDAers are sometimes referred to as “super-maskers,” because their social skills lack common ASD interactional deficits (such as awkward body language, poor eye contact, difficulty with discourse, inability to maintain topic, etc).

Also in the realm of inverse social behavior ascribed to typical autism – comfortability in role-play, escaping into fantasy, and playing “pretend” is a PDA trait. This can manifest with dishonesty that seems confusing – the adult PDA individual (childhood PDA “pretend” is different) may believe they are being clever, but the lies require suspension of reality to be true. Sometimes this manifests as issuing strong reversals of previous accountability, or emphatic denial of their personal actions that have been admitted on a separate occasion There is a comfort with “pretending” that an incident never happened, even when irrefutable proof is presented.

PDA individuals can become fixated upon a specific person. Instead of a topic or hobby, another person (or character) might become a special interest, in a positive or negative regard – excessive admiration, or excessive dislike (with potential harassment). The PDA person may lose interest rather abruptly in the case of excessive admiration, and be drawn to the next shiny, interesting person. …and we can imagine the impact on a confused neurotypical spouse when the fascination directed at them doesn’t just pass, but disappears seemingly overnight.

PDA individuals often have high degrees of emotional fluctuation. One might go from calm, caring, and regulated – to verbally aggressive behavior in a mere moment – because an obligation, request, or expectation is presented. Other times, resistance is quite passive, and the mood shift is into withdrawal. A PDAer might hear, “hey, can you put your dish in the sink?” or, “it’s almost time for dinner,” or, “did you read the email I sent you?” – or countless other iterations of mild ‘demands,’ can quickly shift the PDA individuals mood and behavior. While PDA is not reduced to only simplistic demands by any stretch, resistance of ordinary demands are absolutely a hallmark aspect of PDA. Emotional lability is seen through outbursts and irritability, but also through withdrawal and passivity. Social “strategies” might be distraction, excuses, deflection, delay, meltdowns, shutdowns, flight, or bizarre measures to render oneself incapable, etc. Additionally, PDA individuals are prone to abandon any social filter in public if it serves to avoid a “demand.”

One of the most troubling aspects of PDA for intimate partners to understand, or endure, is the component of disregard from their PDA spouse. The remorseless demeanor after a hurtful experience in which harm occurred, plus the seemingly manipulative behavior in a self-serving regard, is incredibly confusing (and disturbing) for loved ones. It does not seem consistent with the information about ASD, which depicts a socially naive and unintentionally hurtful person – who, when informed of harm, is contrite and motivated to make amends. With PDA, there is little if any acknowledgement of harm or impact of one’s actions – and moods shift back to “calm and loving” as if rupture never happened.

Some literature explores the reality of overlap between Pathological Demand Avoidance and anti-social traits (also referred to as sociopathy, psychopathy, or Anti-Social Personality Disorder in some cases). While PDA is not synonymous with ASPD, and autism is CERTAINLY not synonymous in any regard to ASPD – PDA has some elements of commonality in presentation that researchers have felt important to explore. Given how impactful PDA behavioral symptoms are upon individuals, their families, and relationships – it is highly important for anyone involved to understand what PDA feels and looks like to individuals and loved ones, just as much as understanding what it is and isn’t as a differential diagnosis.

To examine the seemingly antisocial behavior, such as Callous-Unemotional (CU) traits, and Conduct Problems (CP) noticed in PDA, Liz O’Nions (who developed a screening tool to identify PDA) created the first “systematic comparison” in Pathological demand avoidance: Exploring the behavioural profile, juxtaposing children with the PDA label to two other groups: one group with ASD-only, and the other group with anti-social (CP/CU) traits (more below). She wrote, “while PDA has historically been thought of in connection with ASD, the current data suggest that children receiving the PDA label show manipulative behavior similar to that seen in CP/CU; 44% of the PDA group scored in the “atypical” range on the APSD [anti-social personality disorder] measure. Indeed, very high levels of manipulative or controlling behaviour, and lack of remorse evident in descriptions of PDA, are similar to the CP/CU profile (Newson et al., 2003). Discrepant between the descriptions is the elicitation of these behaviours in response to demands, obsessive need for control, and lack of social constraint, despite social insight sufficient to render them able to manipulate. Very low levels of…pro-social behaviour in PDA is consistent with reported lack of concern for socially appropriate behaviour, and poor sense of responsibility towards others. Whether disruptive behavior in PDA and CP/CU is underpinned by different underlying motivations or neurocognitive deficits remains to be tested.”

What is a CP/CU profile? Callous-Unemotional (CU) traits refer to reduced affect, lack of empathy, cruel disregard for others, absence of remorse, and indifference toward personal responsibility. Conduct Problems (CP) are behaviors associated with deceit, defiance, aggression, destruction, and violating the rights of others. Sufficient CU + CP traits in childhood = a diagnosis of Conduct Disorder (CD) in youth. “Callous-unemotional traits are believed to be a childhood precursor to psychopathy, and among youth with conduct problems, they designate those showing a particularly severe, stable, and aggressive pattern of antisocial behavior.” Diagnosis of or qualification for Conduct Disorder in childhood is a diagnostic criteria for Antisocial Personality Disorder.

Taken from this research, The Measurement of Adult Pathological Demand Avoidance, two studies were performed which “examine the relationship between PDA traits, ASD traits, and other psychopathology dimensions, in a community sample of adults reporting self-identified psychopathology.” Liz O’Nions begins with noting that “Pathological (“extreme”) demand avoidance (PDA) involves obsessively avoiding routine demands, and extreme emotional variability. It is clinically linked to autism spectrum disorder (ASD).” The results of both studies were reported: “Study 1 found [self-report PDA screening tool to be] reliable, univariate, and correlated with negative affect, antagonism, disinhibition, psychoticism, and [ASD Screening] scores. Study 2…found low agreeableness, greater Emotional Instability, and higher scores on the full [ASD Screening] predicted [Pathological “extreme” Demand Avoidance]. PDA…is associated with extremes of personality.” The study further specified in its concluding discussion about the overlapping characteristics between ASD, PDA & CU/CP, and psychopathology: “it may be personality that differentiates how ASD traits are expressed, with more emotionally unstable and antagonistic persons with ASD expressing PDA-type qualities. Research will show whether persons with low emotional stability and antagonism may likewise present with PDA symptoms despite not having significant ASD features. In short, in community samples, it is possible that PDA captures general p-factor psychopathology features (Caspi et al. 2014). In the context of ASD, PDA may reflect a developmental consequence of anxiety surrounding routine demands emerging in response to ASD-related vulnerabilities (e.g. sensory sensitivities, anxiety about uncertainty, or other emotive stimuli).”

To summarize, the above research discussion characterizes PDA by naming: an obsessive need for control; non-compliance with routine demands; socially manipulative and shocking behavior; unpredictable shifts in mood; extreme outbursts when requests increase; passive avoidance; domineering behavior; comfort in pretending; lack of cooperation. 

What are the definitions of traits listed above in regard to PDA, that also overlap with ASPD?

Negative Affect – “affective instability has been defined as a dynamic process involving three components: extreme shifts in mood, exaggerated reactivity to environmental stimuli, and an ephemeral, fluctuating mood course (Trull, Solhan, Tragesser et al., 2008).” 

Antagonism –  “the low pole of agreeableness, references traits related to immorality, combativeness, grandiosity, callousness, and distrustfulness. It is a robust correlate of externalizing behaviors such as antisocial behavior, aggression, and substance use.”

Disinhibition – “orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences” (APA, 2013, p. 780).

Psychoticism – “a dimension of personality in Eysenck’s dimensions characterized by aggression, impulsivity, aloofness, and antisocial behavior, indicating a susceptibility to psychosis and psychopathic disorders (see antisocial personality disorder).”

Worth noting from here, “the Personality Inventory for DSM-5 (PID-5; Krueger et al. 2012) measures the five domains of maladaptive personality in the alternative model: Negative Affect, Detachment, Psychoticism, Antagonism, and Disinhibition, which partially correspond with the pathological “poles” of the FFM personality domains (Skodol et al. 2015).”

In other words, PDA is correlated with four out of five characteristics commonly associated with personality disorder criteria.

Why is it important to understand PDA in the context of personality correlates?

Similar to the advocacy and voices that support individuals on the autism spectrum, there are sympathetic support pages for PDA individuals, and parents of PDA children. The PDA Society of the UK even has a section on workplace adjustments for adult PDA. There are subsections of advice and support for parents, teens, siblings, children, etc. Unsurprisingly, there is no menu category of suggestions for spouses married to a PDA partner.

PDA can vary in levels of impairment. Not all individuals will struggle across settings to the same extent – it varies in severity. It can vary from routine resistance in regard to specific categorical “demands,” to deeply impairing. Sometimes employment and relationships are nearly impossible. Yet, being “super-maskers,” I find that many low-to-mid PDA individuals tend to stay regulated at work, but struggle most with symptoms at home. Family life, and marriage in general, is filled to the brim with direct and indirect expectations – all day, every day. It is an inherent part of human relationships – being responsible to one another, the relationships we choose, and the families we create. Obviously, chronic avoidance of demand perception in the marital and family home is extremely problematic over time.

PDA is not “just” conventional autism. It’s not “just” living with a brilliant, quirky, slightly awkward spouse who struggles with flexibility, theory of mind, and social-emotional reciprocity. It is not living with someone who expresses remorse and contrition when social confusion is lifted.

PDA is living with a spouse who, at any moment in time, will reflexively resist, oppose, thwart, defy, deny, withhold, withdraw or otherwise enact control – to make certain that a spouse’s “demand” is avoided. And will then often or even likely exhibit callous, unemotional, and uncaring responses to a distressed spouse or children. As noted above, there might be an observable pleasure in upsetting a spouse to maintain control. The spousal dynamic of PDA is a relentless maze for a neurotypical spouse to navigate, especially when it is an unacknowledged profile of an ASD diagnosis. True manipulation might indeed be happening, and yet…. how can that be true, if it’s autism? Many spouses who are under the impression that a diagnosis of autism precludes any ability to manipulate, are stuck in despairing confusion – questioning the diagnosis, or gaslighting themselves that surely problematic behavior isn’t manipulative, because… autism.

It’s important to validate neurotypical or allistic spouses that their experience with the presence of callous disregard, unemotional affect, oppositionality, shocking conduct, antagonism, impulsivity, highly reactive emotional lability – can FEEL AND LOOK like living with sociopathic behavior, even though PDA is not ASPD.

PDA advocates sometimes find grave offense at the notion that anxiety-driven behaviors could be mislabeled as psychopathic – since, primary psychopathy (associated with ASPD) presents with a low levels of anxiety. However, secondary psychopathy “is characterized by high anxiety and thought to develop in response to environmental adversity.” This very recent 2022 study examined the differential neurocognitive deficits between psychopathy and ASD, and “found a phenotypical overlap between secondary but not primary psychopathy with autistic traits.” Interestingly, this study also seemed to discover “secondary psychopathy showed differential neural deficits, with specific and so far, unreported deficits found at the level of sensory integrative processing. This sensory deficit could be specific to voice communication signal processing, given the specific complexity of auditory signals and the neural effort to decode social information from sounds. This sensory processing deficit could be a common factor with autistic traits, for which we also found a large overlap in terms of the personality phenotype with secondary psychopathy.”

We can have all the empathy in the world for how challenging it is to struggle with PDA as an individual. (Or ODD, CD, IED, DMDD, ASPD.) It is a genuine hardship to be flooded by dread in the face of demand, and act in ways that harm oneself and others. Though, the most complex PDA presentations that I’ve encountered tend to be among those who resist any self-confronting. They do not express hardship at wanting to resist demands; they generally have an outlook that resisting daily and/or meaningful requests from a spouse or child is normal and justified. Their sense of hardship rests in not being able to fully control other people, or act without accountability.

Oppositional Defiant Disorder is probably the most parallel diagnosis for PDA in the US among children (though, again, PDA is differentiated from ODD, and ODD is a childhood diagnosis). We know that ODD can lead to a Conduct Disorder diagnosis in adolescence – and if symptoms persist or worsen, potentially ASPD in adulthood. Criteria for ODD behavior is separated into: angry and irritable symptoms; argumentative and defiant behavior; and vindictiveness. If we consider those traits, even if PDA is not necessarily defiance (just as it is not ASPD), it sounds and possibly looks… very similar. Aspects of oppositionality in ASD are discussed here.

Suffering is suffering. Just as we recognize the suffering of PDAers (among those who desperately desire to learn coping skills, and articulate how difficult it is to feel such alarm and flooding in the face of demand) – we can equally have empathy for how extraordinarily confusing, harmful and devastating that PDA often is for partners. We can have empathy for how voiceless a spouse may become when every need, request or inquiry is treated with outbursts, silent stonewalling, distraction, delay, faux excuses, or weaponized incompetence (among many other avoidance techniques). We can have empathy for how isolating it is that PDA is inexplicable to family or friends – because how does one normalize daily rage that is provoked by things like… a reminder to eat breakfast, a request to pick up milk on the way home from work, or an expectation of cuddling on the couch? Nevermind more abstract and commitment-required demands, like… “can we work on our communication? Our relationship? Our sex life? Our affection? Our companionship…?”

The average spouse doesn’t desire to pour over the DSM-5 and consult with a clinical psychologist as to which differential diagnosis of highly disruptive and anti-social behavior best fits their spouse. It all… feels quite the same, regardless of which box is ticked. A spouse isn’t supposed to be a treating clinician who looks at research-based evidence for best intervention, anyway. What a spouse often DOES need is affirmation that yes, personality and behaviors that they observe and experience from a PDA spouse, are termed highly disruptive and anti-social for a reason. That the astronomical hardship of PDA behavior isn’t just imagined.

This post is intended to be an introduction to PDA, and will have a follow-up post to more closely examine the many ways in which PDA is expressed within and/or impacts neurodiverse relationships.

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