Pathological Demand Avoidance (PDA) and anxiety are two interconnected yet distinct constructs that have gained significant attention in the context of autism. PDA is characterised by extreme avoidance of everyday demands, often driven by anxiety, and the lived experience of Autistic adults with a PDA profile has received little research attention. In this article, we explore the relationship between anxiety and PDA in autistic adults, examining their prevalence, underlying mechanisms, and implications for diagnosis and intervention, based on the most recent research.
Anxiety is prevalent in autistic adults, with studies indicating that approximately 20% of autistic adults experience anxiety disorders, compared to 8.7% in the general population (Nimmo-Smith et al., 2020), and 86% of autistic adults have daily problems with their experience of anxiety (Attwood, Evans and Lesko, 2014). The most common anxiety disorders among autistic adults include obsessive-compulsive disorder and phobic anxiety disorders (Nimmo-Smith et al., 2020). Anxiety in autistic adults is often linked to specific triggers such as sensory sensitivities, difficulties with social interactions, and challenges in coping with change (Gillott & Standen, 2007).
Sensory processing differences play a significant role in anxiety among autistic adults. Research suggests that sensory sensitivities can directly contribute to anxiety, as individuals may find specific sensory experiences overwhelming (Gaigg et al., 2023). This is particularly relevant in autistic adults, where sensory processing differences are more pronounced compared to non-autistic individuals (Mazurek et al., 2024).
Worry and intolerance of uncertainty are also critical factors in anxiety among autistic adults. Studies have shown that autistic adults experience higher levels of worry compared to non-autistic adults, often manifesting as a cycle of negative thoughts that impact daily life (Black & Clarke, 2023). Intolerance of uncertainty, or the difficulty in coping with uncertain situations, further exacerbates anxiety (Gaigg et al., 2023).
PDA is a behavioural profile often associated with autism, characterised by extreme avoidance of everyday demands. This avoidance is typically driven by anxiety, with individuals employing various strategies to avoid compliance with demands (O’Nions et al., 2014; Hoster, 2022).
The observable profile of PDA is characterised by extreme resistance to demands, including using social strategies, such as giving compliments and offering to help (O’Nions et al., 2014). Using social strategies to avoid complying differentiates the PDA profile from the typical autistic profile of demand avoidance (Newson et al, 2003). PDA behaviours have been distinguished from demand avoidance observed in conduct problems and people with callous-unemotional traits, by reward-based techniques, which are often effective in the latter, not being effective for people with a PDA profile (O’Nions et al., 2014). In addition, the PDAer will avoid activities they typically enjoy if these are perceived as demands.
Emotional symptoms in people with a PDA profile are particularly pronounced, with higher levels of emotional distress experienced compared to those who are autistic or have conduct problems (O’Nions et al., 2014). Adults with PDA experience significant anxiety and social dislocation, which can lead to isolation and difficulty accessing services (Kenny & Doyle, 2024).
Understanding the reasons behind the observable behaviour, in addition to the extreme emotional symptoms of PDA, allows specific interventions tailored to address the underlying anxiety driving the behaviours and the distress.
Anxiety in autistic adults differs from that in non-autistic adults in several key aspects. First, the triggers for anxiety are often more specific in autistic adults, with sensory sensitivities and difficulties with social interactions playing a more central role (Gaigg et al., 2023; Gillott & Standen, 2007). Second, the manifestation of anxiety may differ, with autistic adults often exhibiting more intense emotional reactivity and behavioural avoidance (Gillott & Standen, 2007).
While numerous studies of autistic children have explored PDA, its manifestation in adults is less studied and understood. However, research suggests that PDA behaviours persist into adulthood, with some adults continuing to exhibit extreme demand avoidance driven by anxiety (Johnson & Saunderson, 2023; Kenny & Doyle, 2024; White et al, 2022). The strategies employed by adults to avoid demands tend to become more sophisticated, but the underlying anxiety remains a driving force (Johnson & Saunderson, 2023).
PDA shares some behavioural features with other clinical populations, such as people with conduct problems and callous-unemotional traits, but it is distinct in its underlying mechanisms. While conduct problems are often associated with a lack of concern for others, PDA is driven by anxiety, a need to avoid demands (O’Nions et al., 2014), and perceived coercive control (Gillberg et al., 2024). This distinction is crucial for accurate recognition, support, and therapy.
The diagnosis of PDA in autistic adults is often challenging due to its overlap with other conditions such as autism and anxiety disorders. Some researchers suggest that PDA should be viewed as a behavioural profile rather than a distinct diagnostic entity, emphasising the need for a comprehensive assessment that considers autistic traits and anxiety (Kamp-Becker et al., 2023; Hoster, 2022).
Therapy to reduce distress for autistic adults with a PDA profile generally focuses on addressing the underlying anxiety driving the demand avoidance. Strategies such as reducing uncertainty, providing clear structure, and offering choices can help alleviate anxiety and reduce avoidance (Johnson & Saunderson, 2023; Kenny & Doyle, 2024). Additionally, therapies that assist with emotion regulation and understanding sensory needs can be beneficial in managing anxiety in autistic adults (Zecevic, 2023; Gaigg et al., 2023). Therapy must be adapted to emphasise flexibility and greater autonomy for the client. Modifying therapy to be relationship-focused and trauma-sensitive is helpful.
Autistic adults with a PDA profile often experience high levels of anxiety, which drives the extreme demand avoidance characteristic of PDA. Understanding these phenomena requires a comprehensive approach that considers both the unique experiences of autistic adults and the overlap with other clinical populations. By addressing the underlying anxiety and providing tailored interventions, we can improve the quality of life for autistic adults who feel trapped by their PDA.
We have created two half-day live webcasts exploring PDA in children, adolescents and adults:
PDA and Autism: An Introduction
The purpose of this training is to increase your understanding of PDA to assist you to recognise the profile your child, student or client, to increase your confidence in your role with these children and equip you with strategies to maximise positive outcomes.
We assume the knowledge presented in the first course and go deeper to explore strategies and how to best support the PDA-er and their family or partner.
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Dundon, R. (2021) PDA in the Therapy Room. JKP, London, UK.
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White, R., Livingston, L. A., Taylor, E. C., Close, S. A. D., Shah, P., & Callan, M. J. (2022). Understanding the Contributions of Trait Autism and Anxiety to Extreme Demand Avoidance in the Adult General Population. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-022-05469-3
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