For both ADHD and autism, the criteria for the disorders were formed based on observations of boys. Firstly, because in those days only boys attended school. Secondly, because boys had more externalised symptoms than girls: something that could be seen from the outside. Hyperactivity, banging their heads against the wall, not answering the doctor’s questions can be seen from the outside. But the internalised criteria (racing thoughts, inner restlessness, inability to relax) were merely not taken into account and were not known about. Girls have more internalised symptoms – it’s harder to notice those, and they are less taken into account in diagnosis.
There have been some great studies of underdiagnosis of girls in recent decades. For example, the same cases of children with ADHD were read to school teachers with both girls’ and boys’ names. Where there were boy’s names, the teachers expressed a desire to refer the child to a psychologist, while the ‘girl’ cases were ignored. Another neat study was on autistic children, where researchers followed 15,000 twins. With the same problems, boys were diagnosed much more often than girls (Francesca Happe and colleagues).
The lack of a correct diagnosis has consequences:
Severely reduced self-esteem, even compared to men of the same neurotype
Difficulties in work and relationships
Increased risk of codependent relationships
Risk of comorbid disorders
Burnout and exhaustion from masking.
Features of ADHD in women
As mentioned above, there are more symptoms that are not visible to others. On the one hand, this is due to gender socialisation, women are more likely to be expected to suppress everything (you twitch inside and run in circles on the ceiling, but because of the habit of suppressing everything and sitting quietly, it is almost invisible from the outside). Or you get angry and boil inside, but you don’t express it on the outside). On the other hand, women are more likely to have the inattentive subtype of ADHD than the hyperactive subtype.
Women are more prone to comorbid anxiety and depression than men, so psychiatrists are more likely to attribute all women’s problems to anxiety and depression.
A tendency to perfectionism and comorbid obsessive-compulsive disorder can also complicate the diagnostic process.
Women with ADHD have fewer symptoms overall according to DSM criteria, but the same level of distress.
In addition, women tend to mask and suppress more, suffer more from emotion dysregulation, and the menstrual cycle also affects the manifestation of symptoms.
What ADHD in women may look like
Difficulties with time management, although women often have more pressures and demands on them than men.
Difficulties with organising themselves and the space around them.
Frequent feelings of low mood (not to the point of depression, but along the lines of ‘I must be missing something’).
A history of anxiety and depression.
Difficulty managing money.
Sensory overload (more common in women than men).
Somatic complaints such as headaches, migraines, stomach aches and nausea (also due to sensory overload).
Sleep problems.
High-risk behaviour – speeding, extreme sports, etc.
Tendency towards addictions.
Hyperactivity often manifests as self-harm or skin picking, nail biting, lip biting, hair pulling. This is not done as a punishment, but because it is the only thing available.
Features of autism in women
Girls tend to have less stereotypical behaviour, less specific, noticeable interests than boys. They may be interested in the same Barbies and ponies as neurotypical girls, but the immersion of interest will be more profound and specialised. For example, an autistic girl may be just as interested in a teen series as a neurotypical girl. But an autistic girl is more likely to know everything about the characters but nothing about the plot, for example. And show little interest in talking about anything beyond that.
What can a woman be diagnosed with instead of ASD? If ADHD is present, the diagnosis favours ADHD because it is easier to observe. The chances of being diagnosed with OCD or an eating disorder are high. People with ASD are selective about what they eat and follow strict rules – hence the inference of restrictive behaviour and, for example, anorexia (which can actually be comorbid with autism).
What autism in women may look like
A tendency to rely on other people to act and speak for you.
Dependency and co-dependency in relationships – because it’s generally unclear what to do with the outside world, and it’s easier to adapt with the help of someone else. Where an autistic boy won’t do anything, a girl will cop out, try by imitation, ask others to do it for her.
High sensory sensitivity.
The presence of passionate but limited interests.
Difficulty making and keeping friends.
Conversation limited to a few topics of interest.
A behaviour that appears outwardly shy, quiet and passive.
Problems controlling emotions.
High sensitivity to rejection.
Presence of symptoms of anxiety and co-occurring disorders in general.
And lastly, about masking
Masking is common in both autistic and ADHD women. Women are good at adjusting to high demands, but adjusting doesn’t mean adapting. Adaptation is exactly what doesn’t happen. A woman who is forced to participate in small talk at work doesn’t hate it any less, but she sees that others approve of her participation and suppresses her natural desire to leave immediately. And she can feign interest in colleagues’ holidays so well that others have no idea.
You may have guessed how much effort it takes to constantly check yourself and worry about the outcome. This leads to burnout, exhaustion, depression and relapse of all that can relapse.
This is why working on masking is as important a goal in therapy as, for example, working on sensory sensitivity.
Complex post-traumatic stress disorder is one of the youngest and most “high-profile” diagnoses in modern psychiatry. It does not yet exist in the United States and has only recently been officially recognised in the rest of the world, although it has been talked about since the 1980s. It’s often confused with borderline personality disorder, there’s a lot of debate about it, and myths are already forming around it.
Where does it all come from?
Before moving on to complex PTSD, a word or two should be said about PTSD in general.
Post-traumatic stress disorder is a diagnosis that owes its existence to the wars of the 20th century. In the First World War, the number of guns, the variety of weapons and the scale of warfare approached a level that the human psyche could not cope with.
European asylums were filled with veterans returning from the battlefield. They were terrified of their military uniforms, trembling, crying and struggling to stand on their feet.
Film had already been made and the notion of ethics in psychiatry had not yet been established, so history has preserved records of what it looked like. In those days, the diagnosis for veterans was “shell shock” or “war neurosis”.
The Second World War and the Vietnam War gave psychiatrists a better understanding of what happens to people who survive terrible events. The diagnosis of post-traumatic stress disorder began to take shape.
The qualifying details varied, but at the heart of PTSD, like the three whales, lay three symptoms:
A constant sense of threat that spills over into life. It’s like you’re sitting in your house in Wisconsin, eating soup, Vietnam in the past – and you feel like you’re going to be attacked from behind if you relax. Hence poor sleep, constant tension, constant fatigue, irritability, bouts of aggression.
Symptoms of re-experiencing, famous in the meme culture as Vietnamese flashbacks. For some, they look ‘classically’ like a sudden change of frame and a return to the trauma. Here you were mowing the lawn in your garden, a sharp noise is heard – and you see again a terrible accident in which you almost died, you are reliving everything you were experiencing – and it was just a car driving by, you are still in the middle of the lawn, trying to breathe, all sweaty and your heart is pounding. Some people have flashbacks without images – just feelings. Some have intrusive thoughts about what happened or their role in it – “It’s my fault that I survived”, “Could I have prevented it? What did I do wrong?”, “Why did this happen to me?” – these and similar thoughts can haunt them for years. For some, re-experiencing manifest not in reality but in dreams – in the form of nightmares.
Avoidance. Avoidance becomes second nature in PTSD. Anything that resembles people, things, events from the trauma, even thoughts and emotions, can bring back the past – and seem dangerous in itself. So there is a long list of things to stay away from. Crowds, military uniforms in the wardrobe, loud shouts, harsh noises, familiar smells – anything can become a threat. Even things that used to be an important part of life – like going with the family to watch fireworks on a holiday. This is how avoidance robs people of their lives. A bonus to avoidance is protective behaviour. That’s the name given to actions that are somehow designed to ward off a threat (in essence, it’s also avoidance, but less obvious). Going to the supermarket to do your shopping – and putting pepper spray in your bag, just in case. Going to a meeting with friends and putting a blister of sedatives in your pocket just in case – what if your emotions kick in and crush you? When you go out on the balcony for a smoke, you make several plans in your head about what you are going to do and how you are going to deal with an intruder. These are all examples of protective behaviour.
You may have noticed that all of the above examples refer to military actions, or at least stranger attacks and incidents. That’s how PTSD has been understood for decades. The idea that this diagnosis might have anything to do with children or women who have suffered domestic violence has been completely absent from all of this for quite some time.
And that’s where complex PTSD comes in
I chose these examples above for a reason. I would like to emphasise that the idea of the American researcher Judith Herman was not the most obvious for her time (it was the eighties of the last century): she studied how incest experiences affect children.
She found that children who had experienced sexual abuse by their parents had the same symptoms of PTSD as war veterans. But these weren’t the only symptoms. The children’s problems were more extensive; what had happened wasn’t just in their memories and reactions, it affected their personality.
Today, complex PTSD appears in the International Classification of Diseases (ICD-11 version) and its symptoms look like this:
The three PTSD symptoms I listed above (avoidance, re-experiencing, sense of threat) + three additional symptoms:
Problems with emotional regulation. Emotions are intensive, difficult to tolerate, can increase dramatically, there is a feeling that they can be destructive. Sometimes there is a constant emotional numbness in response to them. Sometimes emotions lead to impulsive, self-harming behaviour, suicidal thoughts. They lead to chaos in life or, on the contrary, to desperate attempts to control everything. To a desire to drown them out with addictions. Or simply – to a life of emotional pain.
Negative self-concept. Comes from and is related to trauma. Usually there is a lot of self-hatred and disgust, guilt (for what happened or in general – for everything), helplessness (at the moment of the trauma – and in general all the time), shame. Self-blame may not need to be justified in the moment – it simply haunts through many different contexts and situations.
Relationship problems. A person’s role in a relationship can go to two extremes. Some people try very hard to turn their partner into a saviour, relying completely on them and giving up their own subjectivity (“I can’t do anything without them”). Someone else, on the other hand, does not trust others, does not consider it safe to open up to people and to show feelings, so the relationship remains superficial (and ideally with people with whom nothing “serious” could happen).
Other common symptoms of cPTSD are:
Dissociation, which may occur in response to any threat or only in response to events that trigger the memory of the trauma.
Distorted perceptions of the abuser: the abuser may be seen as omnipotent, relationships with them may seem incredibly important or, conversely, the most important thing in life may seem to be getting revenge on them.
Suicidal thoughts and attempts.
Alcohol and drug abuse.
Symptoms of depression.
Psychotic symptoms – suspiciousness, paranoia, unusual or extremely intense ideas that have no connection with reality.
Physical health complaints.
Loss of meaning in life and faith – in religion or simply in one’s future.
Feelings of despair and hopelessness.
Symptoms of complex PTSD tend to be more persistent and severe than symptoms of regular PTSD.
Interesting fact: Judith Herman, who started it all, was American and worked in America. The USA has its own classification of psychiatric disorders, called the DSM, and unlike the global classification, it does not include complex PTSD. Meeting after meeting, American scientists agree that cPTSD is simply complicated PTSD and that there is no need for a separate diagnosis. Therefore, therapies for cPTSD in the US (e.g. DBT PE) are therapies for PTSD (well, how else could it be?).
Why does this happen?
For both PTSD and complex PTSD, diagnostic criterion A (i.e. where we start) is the presence of traumatic episodes. In cPTSD, these are either repeated traumatic episodes or a series of different traumatic events that are chained together in a person’s life. There is a myth that complex trauma only develops in those who have experienced such events in childhood – but this is not true. Trafficking, captivity or combat and other ongoing traumatic events can lead to cPTSD in adults.
To generalise, the ‘recipe’ for cPTSD looks something like this:
You are vulnerable: because you are a minor, or because you have no savings of your own, or because there is no one to stand up for you or protect you. You are dependent on abusive people in some way, or because, for example, your neurodiversity makes you less able to understand social cues.
You can’t just get out of the situation or somehow defend yourself in it, there is a sense of helplessness in the face of the threat.
The situation is prolonged or repetitive.
What you are facing can be described as an attack on your identity, your sense of dignity, your humanity, your freedom. There is a threat to your life, your safety, your physical integrity.
Here is a rough (not exhaustive!) list of things that give people complex PTSD:
Slavery
Prostitution
Imprisonment
Torture
Bullying
Ongoing sexual or physical violence
Repeated witnessing of violence against others
Child abuse or neglect
Most people with complex PTSD have a combination of several types of events: e.g. there was bullying at school, there was sexualised violence by a distant relative in the summer at the country house, there was physical violence at home against the mother.
Many (LOTS) of people with cPTSD believe that their trauma is not as traumatic as other people’s. Other people’s trauma is real and their own is nothing. But there really is no categorisation of the ‘severity of the cause of the injury’. Some people will recover from colony torture in a few months, while others will have painful flashbacks for decades because of what others would call “well, my dad hit me sometimes, it’s no big deal”.
In fact, the icing on the cake is that traumatic invalidation (being told that you made up all your experiences) leads to the same symptoms of trauma as all the above!
That’s why it’s important to look at the traumatic event – AND the symptoms.
Treatment path
There are many different approaches to complex PTSD therapy. But they have similar aims. These are:
Distinguishing between the present and the past. If you notice when the flashback started and realise that this is it, that then and now are not the same, some of the suffering goes away.
Change your attitude to the memories. So that they are no longer a source of threat, but simply a memory – of a very bad experience.
Changing your attitude to people, places and objects that are actually safe but frightening because they remind you of the trauma – this is about working with avoidance. To gradually bring back into your life things that seem important (but are unavailable because of avoidance).
Developing the ability to notice, name and regulate different emotional and physical states, and to understand what caused them.
To cultivate self-compassion, greater empathy, a reduction in self-critical thoughts
To learn to form close and healthy relationships
In the cognitive behavioural approach I work with, this is addressed through two strands of work:
Dialectical Behavioural Therapy skills training helps you learn how to better manage crises, regulate your own emotions, understand what is happening in the moment, manage your emotional states, and build healthier relationships with others.
The Prolonged Exposure Protocol has three objectives:
Changing attitudes towards memories – by revisiting them in a safe environment, clients gradually come to realise that memories are not dangerous, will not destroy them, are not threatening and gradually cease to evoke even strong emotions. What was once a nuisance becomes simply something that was and is gone.
Non-avoidance – people gradually learn, in a safe environment, to bring back into their lives what they would like to bring back into their lives, but is very frightening because of its association with trauma. Gradually, by approaching scary (but safe!) things in a measured way, it is possible to stop being afraid of them altogether – and to make one’s life more complete and meaningful.
Processing trauma-related emotions. By discussing traumatic events with the therapist, it is possible to gradually see them in a different light – perhaps realising for the first time that they are not to blame, that there is nothing to be ashamed of and nothing to hate oneself for. In this way, clients develop a healthier and more compassionate view of what has happened.
All this happens in sequence: first clients learn to regulate their states and cope with their emotions at least a little, and then they move on to work with the trauma. This is usually long-term therapy and takes about a year.
What else is important to know
Complex PTSD is rarely the only diagnosis, often there are other co-occurring disorders – anxiety, depression, sleep disorders, addictions, personality disorders and so on. All of these complicate diagnosis and impair quality of life and prognosis in therapy.
Both PTSD and cPTSD are disorders that are self-maintained. Trauma is self-sustaining through avoidance mechanisms. The more we avoid thoughts, memories, emotions, things that are safe but remind us of the trauma, the stronger the belief that the threat is real. This is why cPTSD rarely goes away on its own.
A stable self-image helps us to recognise more quickly and accurately what is important to us in the moment. It is the basis for self-confidence in difficult situations and helps us not to be destroyed by criticism or the stresses of life. It is the basis for a healthy self-esteem and the foundation for inner stability. An understanding of one’s self helps us to communicate with others and improves the quality of our lives.
What are the characteristics of the self-concept of autistic people?
Challenges of transitions
Autistic people have a much harder time with change than neurotypical people. And adolescence is probably the biggest change in a person’s life. Society, demands and the body change. At the same time, it is the time when the foundations of your own identity are being laid. Autistic people often face bullying, feelings of social inadequacy, social isolation and negative judgements from others during this time.
When everyone around you tells you how stupid, weird and wrong you are, it affects how you see yourself. As a result, many people with autism have a negative self-image.
Social challenges
Problems with understanding social interaction are the key symptom of ASD. They affect the way we perceive ourselves in many ways.
Our self-image is largely shaped by our experiences of interacting with people around us, and if these experiences are often perceived as unsuccessful, then it is more difficult to build a self-image in general, and it is particularly difficult to build a positive self-image.
Research shows that the higher the intelligence of autistic people, the higher the level of perceived social incompetence. And this incompetence is not always objectively confirmed (i.e. people around them see the situation differently). And the higher the level of perceived social incompetence, the less confidence they have in themselves to judge what is happening (“I am socially incompetent!”) and the more confidence they have in others. So autistic people may rely more on the feedback and judgements of others (because they understand better, they see better) and less on themselves in determining who they are.
A lack of understanding of social interactions may prevent them from understanding their problems with social interaction. At some level, a lack of understanding of socialisation reduces the ability to recognise that there is a fundamental problem. For example, autistic people may perceive themselves very differently from how others around them perceive them. And if there is no understanding of the problem, there is no way to change things.
For people with ASD, social life and interaction with others play a smaller role in their self-image than for neurotypical people. When describing their identity, autistic people talk less about social roles and relationships and more about what they normally do in life (knitting, hiking, working).
It is also thought that feelings of social inadequacy have a negative impact on perceptions of agency – the ability to influence one’s own life.
Difficulties with abstract thinking
Self-perception is to a large extent made up of abstract concepts. This means that not only do you need to understand what ‘introvert’, ‘feminine’ and ‘open-minded’ mean, but you also need to be able to try out such categories on yourself (crazy, yes). So many autistic people may
Lack the words to describe their identity
Not have the ability or skill to relate such words to their own experiences.
For autistic people it is particularly difficult to think abstractly about people.
Understanding mathematical concepts can be much easier than describing the personality traits of the person you are talking to. This is because mathematics has logic and concrete meaning, while these traits have only metaphors and vague feelings.
In particular, it is associated, for example, with the prevalence of gender dysphoria in people with ASD. Finally, gender is no less a simple social construct than phlegmatism. Firstly, it is not clear how to apply it to oneself, and secondly, it is not clear why to do so in the first place.
Difficulties with abstract, fuzzy ideas make it very difficult to form a self.
Rigid, black-and-white thinking
Rigid, inflexible thinking, problems with adapting beliefs to changing conditions mean that self-image can also be rather black and white, rigid and with little inherent potential for change.
Masking
Masking is what people with autism do in order to mimic society and be in line with expectations. There are many different problems with masking (to start with burnout), but in particular it interferes with the formation and maintenance of a sense of self. People who mask a lot tend to think that they have no identity – just a set of roles. Changing roles prevents the stability of the sense of self, it becomes contextual and therefore highly variable and fragmented. These fragments are usually taken from the personalities of the people around you with whom you want to bond and from whom you need acceptance.
And here’s another sad thought: if you think you need to disguise yourself, you’re signing up to not accepting who you are.
Alexithymia
We form our identity by observing our thoughts, behaviours and emotional responses. Without the ability to name our feelings, we have limited ability to analyse them.
Opinion on autism
For people diagnosed with autism, perceptions of autism contribute significantly to self-image. The more positive the perception of autism (more focus on benefits and less sense of helplessness), the higher the self-esteem and the better the self-image. Typically, those who tend to think better of themselves associate autism with giftedness, emotional stability and strength. In general, the more good autistic people find in autism, the more good they find in themselves.
Analytical mind
The mind and nervous system of autistic people are organised in such a way that we think analytically, piecing together the big picture piece by piece, not on the basis of intuition and fragmentary ideas, but on the basis of deep, unhurried analysis and logic. And the love of being alone provides plenty of time and opportunity for such introspection. So there is enormous potential for people with ASD to understand their own internal machinery with awareness and sensitivity.
Ideas on how to help yourself develop a sense of identity
Development of a theory of mind
Developing the ability to understand other people’s thoughts and feelings can help you understand yourself better. Social skills training can help with this, or simply regular and careful self-analysis of what is going on in communication and asking for feedback from other participants to check.
Expanding the vocabulary of personality trait terms
The development of a more varied vocabulary for the description of one’s own identity will help to shape it more clearly.
Developing emotional competence
The better you can understand and describe emotions, the more material you have to analyse and build your self-image. You can learn emotional literacy by keeping an emotional diary, for example.
Avoiding masking
Trying to imitate others and creating false identities has a negative impact on self-understanding. It is therefore important to work on finding your own authentic responses to the outside world gradually, gently and in a safe environment.
Developing awareness in general
The better you are at noticing your own thoughts and emotions and how they relate to your behaviour, the more you can draw conclusions about who you really are. Bottom line: meditation works, as do informal mindfulness practices.
Everyone has a unique sense of self that is shaped by our thoughts, feelings, memories and relationships. This self creates our individuality and sets us apart from everyone else. It is also the foundation upon which self-esteem is built. But what if our Self seems vague, elusive?
For some people (such as those with borderline personality disorder), finding a stable Self can be particularly challenging. But understanding how our brains work, and using specific strategies, can help us on this journey.
What is the Self?
Here’s the boring scientific answer: the sum of all the physical and psychological (thinking, emotional, motivational, social) characteristics that make a person unique.
To turn this phrase around, Self is about ….
How do I see my body and what does it say about me?
How do I interpret the facts of my biography? What does my story say about the kind of person I am?
How do I routinely react to external events?
What kinds of thoughts are typical of me?
What triggers my emotions and which ones?
What drives me? What is important to me? What do I aspire to?
How do I relate to others?
And on and on.
If you have rushed to answer the above questions in the hope of finally understanding yourself, I have bad news for you. Having separate, scattered answers is not the same as having a firm inner certainty about who I am.
For random facts to be transformed into a coherent and beautiful self-image, they need to be sprinkled with “magic dust” (as in Peter Pan!). And the magic dust in this case is the process of self-awareness.
What does self-awareness consist of?
Self-awareness is a complex cognitive process in which we turn our attention inward, analyse, integrate and store information about ourselves, and identify with this ‘Self.
If we try to break self-awareness down into the individual Lego pieces that make it up, we get:
Consciousness. Simply put, awareness of what is going on inside and outside of us. Always present to some degree while we are awake, it usually comes with the package.
Metacognitive thinking. This is the process of observing what you are thinking.The ability to notice and critically examine one’s own thoughts is no longer innate, but is specifically developed.
Autobiographical memory. This involves not only remembering past experiences, but also building relationships between different memories and how we manifested ourselves in them. Remembering your past experiences, as you might guess, is essential to having a stable view of your identity.
Self-reflection and mindfulness. This includes the ability to notice your emotions, physical sensations, behavioural responses, thought processes and how they all relate to each other.
A dash of neuroscience
The brain is conceptually divided into three parts: the reptilian (or lizard) brain, the limbic brain and the neocortex (i.e. the cerebral cortex). The reptilian brain is responsible for instinctive behaviour. The limbic system controls emotions. The neocortex is responsible for reasoning, introspection and awareness.
If we match the building blocks of our self-awareness to these parts, it’s clear that it’s the cortex – and its robust connections with other departments – that we need to understand ourselves.
The neocortex lags developmentally behind other parts of the brain, becoming a fully functional tool only between the ages of twenty and thirty. What does that mean? Well, it’s a relief if you’re under twenty: some of your difficulties in understanding yourself can easily (and rightly) be attributed to age and the rate of cortical development.
Let’s focus for a moment on autobiographical memory, which is seen as a proxy for identity integration. The posterior cingulate cortex and the left medial prefrontal cortex play a crucial role in its operation. Indeed, there are numerous articles on how these are the areas that may be underdeveloped or have developmental abnormalities in borderline personality disorder (BPD). The hippocampus and its surrounding areas are also important – and there are problems here too: in BPD, the connection between the cortex and the hippocampus are also affected. All in all, this means that people with borderline personality disorder have biologically based reasons for struggling to find themselves.
But it’s not just people with BPD who can have problems. And it is possible to help yourself find your identity in any condition, including BPD.
Ideas: How to build your own Self
Practice mindfulness.
Meditation and informal mindfulness practices (being in the moment, being open and paying attention to sensations, thoughts and emotions) can help you develop an observant attitude and become more aware of what’s going on inside you. And the better and more often you notice what’s going on inside you, the more material you have for identity construction.
Develop metacognitive thinking.
Noticing your own thoughts is taught in cognitive behavioural therapy, but you can do it to yourself. Analysing your own thought processes through observation and self-reflection can help you better understand how you arrive at decisions and reactions and, if you generalise, what drives you in general.
Improve autobiographical memory.
Recording and reflecting on significant life events can strengthen your connection with these memories. This gives you the material to generalise and gradually integrate the many individual episodes into the self.
If something causes us worry and anxiety, we tend to avoid it. Afraid of public speaking? You may never agree to them for various reasons. Worried about going out with a friend? You could say you’re ill and not go. The more we avoid, the scarier it becomes the next time we do the same thing. So gradually, by giving in to the urge to avoid again and again, we reinforce our belief that the danger is serious. So, little by little, avoidance steals our space to live. This is what happens with PTSD, social anxiety, obsessive-compulsive disorder, panic disorder, phobias – and more.
What is the treatment in such cases? Exposure.
Exposure therapy is a type of cognitive behavioural therapy (CBT). It helps people overcome anxiety by gradually exposing them to the things that make them anxious. This can be done in different ways:
Imaginal Exposure. This is where we describe in detail and visualise what is terrifying (e.g. contracting a deadly virus in the case of OCD or a history of trauma in the case of PTSD).
In vivo exposure. It involves encountering a frightening object or situation in real life (this could be a trip to a doctor’s office or a small-talk with a colleague).
Exposure using virtual reality. Using a VR helmet helps you to encounter frightening things in a safe and controlled environment (for example, being in the company of snakes or spiders).
Here is a simple example of exposure therapy in CBT:
A person with a fear of spiders (arachnophobia) might start by looking at pictures of spiders. Once he can do this without feeling too anxious, he might move on to watching videos of spiders. Finally, he may try to hold a spider in his hands.
The therapist provides support and guidance throughout the exposure process.
Another example:
A person with a fear of public speaking might start by speaking in front of a mirror. If he can do this without too much anxiety, he may move on to speaking in front of one person. Eventually he may try speaking in front of a small group of people.
There are two types of exposure:
Formal – when the therapist and client make a step-by-step plan of work.
Informal – when we approach the frightening thing as the opportunity arises, without a plan made in advance.
How can you use the exposure method on your own?
There’s a cool term exposure lifestyle that means you:
The first thing you do is learn to notice how your fear and anxiety manifest. What do you usually feel in your body when you feel anxious? What do you usually start to do in those moments? Some make a phone call, some amuse the people around them, some go to the fridge and so on. What thoughts do you have when you’re anxious?
Practice noticing when some everyday things make you feel anxious or fearful.
If the object or situation is safe, catch yourself wanting to avoid it – instead, approach it.
Repeat this at random moments, anywhere, anytime, as if your whole life is your training ground.
For example, walking past the coffee shop and thinking, “It would be awkward to go there alone. And you catch yourself in that thought – you turn towards the cafe and go in for a latte.
Exposure therapy is challenging and scary, but it’s very effective. And an exposure lifestyle can bring adventure, new stories and joy to your everyday life – from its courage.
Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in children, but it also affects adults. Symptoms include difficulty concentrating and staying on task, hyperactivity and problems with impulse control. ADHD is a chronic and debilitating condition. It affects many aspects of a person’s life, including academic and career success, relationships and daily life.
Research into strengths in people with ADHD is a very new area of research and there are few papers on it, but those that are available are very interesting. It’s important to note that having strengths does not diminish or erase the problems and difficulties people with ADHD face. Just because people with ADHD are particularly good in some areas of life does not mean that they do not have difficulties and do not need treatment.
Is it really necessary to talk about strengths?
There are several reasons why talking about the positive aspects is just as important as talking about the negative ones:
Not everyone is aware of their strengths. And this is crucial knowledge, both for self-esteem and for finding the right fit in life.
Understanding the strengths of people with ADHD is necessary for those around them: the more educators and HR professionals know about them, the more likely they are to treat them appropriately.
It also helps to de-stigmatise the condition.
Creativity, vibrancy and open-mindedness
Dutch scientist Martine Hoogman and her team are actively researching strengths in ADHD. Most of the research has been done on adults, and the participants have mostly been employed people in treatment. However, the number of strengths listed by each individual participant was independent of employment status and the presence of treatment.
Interestingly, the lists of positive traits were similar for male and female participants, but women mentioned more traits about adventurousness and risk-taking, while men mentioned more traits about humanism.
All the strengths mentioned in the study fell into five main clusters:
1. Creativity (most commonly mentioned): this includes imagination, resourcefulness, associative thinking and the ability to see non-obvious patterns. There are types of creative tasks that people with ADHD do particularly well. These include creative writing, visual arts and humour.
2. Being dynamic (second most popular): this included traits such as being energetic, active, enthusiastic, having an ‘inner motor’, a positive attitude and a tendency to seek novelty.
3. Flexibility: the cluster about spontaneity, openness, impulsiveness, a wide range of interests, ease in switching between tasks.
5. High level cognitive skills – attention span, multitasking, quick thinking, good memory, hyperfocus (ability to concentrate deeply on one thing), analytical thinking. If you suspected there was something odd about this cluster, you wouldn’t be wrong: many of the items mentioned (memory and attention, for example) are things that people with ADHD tend to struggle with. There is no clear answer as to why the same items fell into the strengths cluster. We could speculate that memory and attention problems only occur in some contexts and not in others, or only in some people, or – this could also be the case – the participants in the study were talking about wishful thinking rather than reality.
The participants also noted that some of the strengths were not related to the specificity of ADHD, but rather to the difficulties of living with it (having to persevere and learning to be more open-minded about different people).
Conclusion
An important factor related to the expression of positive traits is the severity of a person’s ADHD symptoms. Research has shown that the more severe the symptoms, the less people mention enthusiasm, perseverance, willingness to get involved and social skills. This is not surprising: when life is hard, there is less desire to socialise and be active. Hyperfocus, on the other hand, becomes even more hyperfocused as symptoms worsen.
It’s important to note that these studies are still quite small, and there aren’t many of them yet. In the past, thinking about strengths in people with psychiatric and neurodevelopmental conditions was not common.
It’s also worth adding again that having strengths does not mean that symptoms are absent or ‘unimportant’, nor does it negate the difficulties and suffering that people with ADHD face.
Further reading
Here are some studies to read if you want to explore this further (including one on strengths in autism!):
Everyone seems to know that autistic people don’t like to make eye contact and somehow don’t socialise much. Some people, moreover, know the “official” symptoms of autism – the ones that determine the diagnosis. And only the most meticulous and curious (and also autistic people themselves) know what else there is:
Non-obvious implications of the “official” symptoms, sometimes very unexpected ones
Symptoms, traits and syndromes that are not part of the main symptoms, but are still directly related to ASD.
Personal observations by autistic people themselves – those likely manifestations of ASD that scientists have not yet reached, but which are talked about at the level of personal stories and generalised experience.
I try to balance my texts between research and people’s personal experiences, so I’ll tell you about them all in turn!
Basic package
The “official” definition of autism (I refer to ICD-11) consists of just two symptoms – broad, rather vague and with a lot of implications:
Problems with social interaction (difficulty reading and responding to non-verbal cues, problems understanding and responding to social context, etc.)
Repetitive, rigid patterns of behaviour, interests and activities (repetitive movements, rigid thinking, difficulty adapting to new things, rigid routines, preoccupation with rules and rituals, and sensory sensitivities are all included).
These two criteria determine the diagnosis. The ICD also lists some symptoms and other disorders that are common in autistic people but are not necessary for a diagnosis. These include
Intellectual disability
Disorders of speech and language development
Developmental delays
The presence of anxiety and depressive disorders (and generally a high number of co-occurring mental disorders)
Self-injurious behaviour (such as banging one’s head on something)
Epilepsy and non-epileptic seizures
Catatonia (a condition in which a person has little or no response to the outside world)
Tuberous sclerosis (a rare genetic disorder that causes benign tumours)
Chromosomal and genetic abnormalities
Cerebral palsy (a group of disorders that affect movement and balance)
Neurofibromatosis (another genetic disorder that leads to the development of tumours).
Unexpected consequences
The two main ‘symptoms’ of ASD are actually so overarching that they can have a myriad of manifestations. Some are better known than others. Here are the ones that may not be obvious:
Sensory sensitivity is not necessarily oversensitivity. A person may just as well have low sensitivity to some sensory stimuli and be in search of additional sensory stimulation. There are autistic people who like spicy food, heavy music concerts and raves with flashbulbs. There are also those who can’t tolerate any of this.
Humans have not 5 but 8 senses: hearing, sight, smell, touch and taste, plus vestibular (sense of movement in space), proprioception (sense of the body in space) and interoception (sensations inside the body). The last three can also be hyper- or hyposensitive and can manifest unexpectedly. For example, dehydration can often occur in autistic people simply because thirst is something that should still be felt. Nausea from transport can last a lifetime because the vestibular system is too sensitive. Constant collisions with objects, furniture and doors are due to proprioception not working as it does in neurotypicals.
Difficulties in reading facial expressions and voice intonation can lead to two opposite manifestations: either a lack of facial expressions and weak intonation of speech in autistic individuals, or conversely, exaggerated facial expressions and vivid (but possibly inappropriate for listeners) intonation. This may be the same reason why people with hearing loss speak loudly: if you can’t hear yourself, you feel you have to work harder to make others hear you. If you feel that facial expressions are difficult to read, you may want to make it easier for others and convey the expression accurately.
Repetitive behaviours include echolalia and echopraxia. The former is the repetition of sounds and words after other people, film characters and singers, and the latter is the mirroring of body positions, which can also feel almost involuntary.
Among anxiety disorders, autistic people are more likely than neurotypicals to have selective mutism, a condition in which a person is unable to speak at certain times.
Little-known symptoms
One big problem with autism is that descriptions of symptoms, traits, states, and specifics are generally handled by people without autism.
Many of the symptoms of autism are things for which there often seem to be no words. There is no language that can adequately describe the experience of living with one type of nervous system to people with another type of nervous system.
You can’t just go to people and say: “I find it very disgusting to wear socks for some reason”. Those kinds of observations don’t generalise well and are rarely taken seriously by anyone. That’s why we have what we have:
Ideas about symptoms and related disorders that have made their way from clinical observations by psychologists and psychiatrists into studies, and scientists have concluded for sure that yes, these conditions are indeed related to autism (but it’s not for sure because almost everywhere there is minimal sampling and so-so study design).
Lots of everyday observations by autistic people themselves (yes, including the one about socks!) that no one has really studied in any special way.
Let’s talk about both in turn. Let’s start with the symptoms, disorders and characteristics that are most likely to be associated with autism – and which have been studied.
Gastrointestinal disorders. People with ASD often have GI disorders, including pain, diarrhoea and constipation, and heartburn.
As adults, there are higher risks of obesity, hypertension (i.e., high blood pressure), and diabetes.
Sleep problems. Many people with autism suffer from sleep disturbances. These can include difficulty laying down and falling asleep; repeated awakenings throughout the night; and difficulty returning to sleep after waking up.
One in five autistic people suffer from alexithymia. People with alexithymia have difficulty recognising, understanding and describing emotions.
Difficulty regulating emotions. Strong emotions that are hard to regulate are more common in autistic people than in neurotypicals.
Where there are strong emotions, there is often impulsive behaviour. This is also common in autistic people – it is also associated with sensory sensitivities and impaired executive functions.
Although synesthesia (the perception of signals from one sensory organ as signals from another) is not specific to autism, it is quite common in autistic people. Especially the form in which tactile sensations occur without physically touching the person. For example, looking at something can cause tactile sensations.
Problems with posture, different types of unusual gait (e.g. bouncy gait), coordination difficulties are also associated with ASD, and the neuroprocesses behind it are only just being studied.
Hyperlexia – unexpectedly advanced reading skills in children, far beyond what was expected at their age – is also common in autism.
A propensity for food allergies. About 11% of children with autism in one study were diagnosed with food allergies, compared to 4% of neurotypical children with food allergies.
A predisposition to joint hypermobility (this is a connective tissue disorder in which the ligaments are weaker and therefore the joints bend more than normal)
Menstrual cycle problems. Recent studies have shown that women with autism spectrum disorders are more likely to have problems such as irregular periods, unusually painful periods, and heavy menstrual bleeding.
Postural orthostatic tachycardia (this is when your heart rate increases abnormally after lying down and sitting or standing up, and there is evidence that it is also more common in autistic people).
Personal experiences
And finally, the last part is about personal observations of people with autism that they have shared (publicly, on Reddit). These are not research findings or even symptoms, but private stories from autistic people about what of their behaviours they think might also be related to autism. Perhaps some of this will be studied and described in articles in the future (and then it will go on one of the lists above). So!
A strange, atypical or fluctuating accent
Walking on your toes (not because it doesn’t work otherwise, but because it’s so much more comfortable-pleasant-better).
Belonging to fandoms
Hating drinking water.
Breathing through an open mouth.
Sitting in weird twisted poses
Looking down when walking
Uncomfortable walking ahead of other people, leading them
Voice is either too loud or too quiet
Unwillingness to wear socks (or unwillingness to live without them even a little bit)
Fear of losing balance
Hands against the chest all the time, aka raptor hands.
Autism has existed in nature throughout human history. By the measure of that history, even humanity as a whole has only recently begun to pay attention to how people are mentally organised. Figuring out how people who are different from the majority are organised is a huge task for the future. And it seems that in the case of autism, we are only at the very beginning of this journey. And if so, I would like to believe that at some point, individual observations made by specific people about their experiences will be taken seriously, studied, and will make more sense. And will help different people to better understand and respect each other’s needs (you have to believe in something, right?).
