Not all Social Difficulties are Autism

By: Camden Baucke MS LLP

There’s plenty of reasons someone might have difficulties managing social situations.

It could be fear, inexperience, or specific expectations that drive distress and increase avoidance, hypervigilance, and so on.

However, social media is currently overwhelmed with mental health misinformation, especially regarding autism – countless children and adults are claiming it is a potential root behind most social difficulties.

As a psychotherapist and researcher with expertise in social anxiety, I can tell you there are plenty of explanations for social difficulties other than autism.

Knowing those different explanations is key to determining what can change – autism is primarily biological, and it holds room for support, but not change.

However, there are several other disorders with social difficulties that can be treated, and they need to be labeled accurately if that’s going to happen.

In this article, I will describe what autism is, what it isn’t, and how to differentiate between autism and a range of other mental health disorders that include social difficulties.

Mental Health Misinformation

Social media is rife with misinformation about mental health.

A study from the University of East Anglia found that a majority of TikTok posts spread misinformation about autism as well as ADHD.

From a sample of 5,000 posts, 56% were misinformation.

From subsamples, 52% of ADHD content was misinformation, as well as 41% of autism content.

Additionally, they found that TikTok has the highest amount of mental health misinformation, especially with autism and ADHD versus other platforms.

A study by the Guardian found that more than half of the top 100 posts of TikTok mental health content were misinformation, with 14% found potentially harmful.

If you view it like a test, those are some failing grades.

As a mental health professional, It can be frustrating to see so much misinformation online – especially regarding social difficulties.

Issues with Autism Content

I tend to see autism misinformation have two things:

(1) What you’re experiencing, if not obviously autism, is somewhere on the spectrum.

(2) If you’re experiencing anything someone might consider “irregular“, it’s autism.

Obviously, this is just enough stigma and loose definitions to include just about any behavior as indicative of autism.

First of all, the term “autism spectrum” came into prevalence in the late 1900’s, and developed out of previous research on milder forms of autism, done by Leo Kanner, Hans Asperger, Lorna Wing, and so on.

The DSM-V, the manual for mental health disorders and their diagnostic criteria, has a section describing each threshold of the autism spectrum.

Autism has 3 levels of severity, making it a spectrum of intensity.

Level 1 – Requiring Support

• Trouble understand and following social rules
• Inflexible behavior
• Stressful transitions
• May need therapeutic intervention

Level 2 – Requiring Substantial Support

• Disruptive social behavior
• Obsessive interest in specific topics
• Observable distress with change
• May need accommodations

Level 3 – Requiring Very Substantial Support

• Communication deficits, possibly non-speaking
• Repetitive behaviors like rocking or spinning
• Extreme distress if forced to switch tasks
• May need structural support for their daily routine

In the DSM-V, each of these includes (1) social communication and (2) restricted/repetitive behavior.

Let me tell you how these form the basics of the diagnostic criteria for autism.

Autism – Diagnostic Criteria

Difficulties with Social Communication & Social Interaction

1. Difficulties with social-emotional reciprocity
2. Failure of back-and-forth conversation
3. Reduced sharing of interests, emotions, or affect
4. Failure to initiate or respond to social interactions
5. A lack of nonverbal communication – abnormal or absent physical or facial expressions
6. Difficulty understanding or making gestures
7. Abnormalities in eye contact
8. Difficulty adjusting behavior for different social contexts
9. Difficulty building, maintaining, and understanding relationships
10. Difficulty with shared play, shared imagination, making friends, and reduced interest in peers.

Restricted, Repetitive Pattern of Behaviors, Interests, or Activities

1. Repetitive motor movement, use of objects, or speech
   • Repetitive motor movements that reduce distress or don’t serve a function.
   • Disruptively lining up toys, flipping objects
   • Echolalia – automatic repetition of what you hear someone else saying
   • idiosyncratic phrases – statements used in social situations that only you understand, like an inside joke
2. Insistence on sameness, inflexible routines, or ritualized patterns of verbal and nonverbal behavior
   • Disruptive distress at small changes
   • Rigid thinking patterns
   • Difficulty with transitions
   • Repetitive greeting rituals
   • Extremely uniform routine
3. Highly restricted, fixated interests that are abnormal in intensity or focus.
   • Strong attachment to unusual objects
   • “circumscribed” and “perseverative” interests, meaning interests that are “restricted” and “repetitive from which one is unable to switch tasks“
4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory input of the environment
   • Indifference to pain or temperature
   • Adverse response to specific sounds or textures
   • Excessive smelling or touching of objects
   • Disruptive fascination with lights or movements

What also makes autism a spectrum is the assortment of symptoms that create unique presentations for each individual with this disorder.

For the record, even I as a therapist can not provide a firm diagnosis of autism in a speak-therapy setting.

A diagnosis of autism requires a specific assessment battery from mental health professionals like psychologists, psychometrists, and neuropsychologists who are trained to administer them.

Differential Diagnosis

Something TikTok seems to be missing is the concept of differential diagnosis – this is a step that mental health professionals take when diagnosing a set of symptoms.

It takes years of practice, advanced schooling, and advanced certifications to do so – so your average mental health influencer isn’t likely trained in this highly specific process.

The reason mental health professionals have to know the DSM inside and out is because we need to not only know symptoms, but the function and context in which they exist – it’s not as simple as checking off a box.

Let me go through the symptoms of autism I just gave you and provide some potential alternatives to a seemingly autistic behavior:

• A narcissistic personality might disrupt social-emotional reciprocity by disrupting back and forth conversation – giving too much.
• A victim with PTSD might be hypervigilant and struggle with back and forth conversation, struggling with social-emotional reciprocity.
• Someone with social anxiety who was bullied as a child might be reluctant to share their interests.
• Someone who grew up with abusive parents might be reluctant to share their emotions or affect in fear of retaliation.
• Someone depressed by negative core beliefs might struggle to initiate social interactions.
• Individuals with schizophrenia are known to have flat affects – no facial expressions at all.
• Individuals with social anxiety, who fear negative evaluation, will struggle with eye contact.
• People with borderline personality disorder struggle to sustain and build relationships.
• Abused or neglected children often have difficulty with making friends and shared play.
• Singing in the shower isn’t “stimming” to reduce distress, it is an expression when the body and mind are relaxed, eliciting positive emotions (not just relief from negative ones).
• Echolalia isn’t just repeating funny phrases you hear, and an inside joke might be mistakenly used with others if you expect them to know it too.
• Normal distress with small changes is not the same as disruptive distress with small changes.
• Rigid thinking patterns could also be rigid beliefs in most anxiety disorders as well as most depressive ones.
• An anxious desire for perfection might also make transitions difficult.
• We all have repetitive greeting rituals (handshake and hello in the USA), so the abnormality depends on the disruptive nature and context.
• Someone with obsessive-compulsive disorder (OCD) might form an extremely uniform routine to reduce distress.
• Liking trains, math, fantasy, or other stigmatized hobbies are not all restricted, repetitive, and create an inability to switch tasks.
• Additionally, a child who struggles to switch from stop playing video games might have an addiction with underlying depression and anxiety.
• Indifference to pain might indicate CIPA disease or emotional numbness from depression, grief, or PTSD.
• Adverse responses to sounds and textures could be misophonia, or normal discomfort when hearing nails on a chalkboard.
• A fascination with lights or movements must be disruptive and highly abnormal, otherwise everyone who enjoys fireworks has autism.

Crossovers

Autism is often defined by the distress, but most of its symptoms of distress overlap with other diagnoses.

It does not mean that everything is autism – autism is a specific neurological disorder with a genetic background and heritability connected to epigenetic outcomes of certain environments.

Autism includes distress that is anxious, depressive, or obsessive, but it shares those symptoms rather than being the same entity.

Autism might include social difficulties, but it shares those symptoms with social anxiety, narcissistic personality disorder, borderline personality disorder, obsessive-compulsive disorder, and a whole range of other disorders.

Essentially differential diagnosis is this:

(1) A person struggles to switch tasks – they have a personal history of perfectionism driven by abuse growing up.

(2) A person struggles to switch tasks – they have the biological status of autism.

(3) A person struggles to switch tasks – they’re chronically fatigued.

(4) A person struggles to switch tasks – they’re chronically fatigued and struggle with perfectionism.

(5) A person struggles to switch tasks – they have the biological status of autism and are chronically fatigued.

One isolated symptom can’t determine a singular disorder on its own – but put together a whole set of symptoms? That confusing nuance is why mental health professionals dedicate their lives to navigating it with years of training and practice.

When all these very specific disorders are thrown under the label of autism, including regular distress and behavior, it creates a massive problem.

The Dangers of Misdiagnosis

Autism is an epigenetic disorder, meaning that heritability and family history are primary causes.

Social anxiety is often not.

Major depression is often not.

Narcissistic personality disorder is often not.

Most disorders that create social difficulties have psychology behind them – trauma, beliefs, and patterns of thought.

We have evidence based practice and research-based treatment methods that can help – not to make you more “normal“, but to ease distress that has a treatable source.

What happens when you slap a label of autism or ADHD on it?

A treatable issue then is perceived as a neurological, genetic, concrete issue that can’t change.

What happens when you don’t treat treatable disorders? They continue to hurt or get worse.

Misinformation on social media is so destructive because it could convince people that they should identify as neurodivergent and autistic, but not address a history of trauma, abuse, neglect, or bullying creating treatable symptoms.

This is something most mental health professionals know – diagnoses are for treatment only.

Not everything is autism – and knowing the difference could mean someone being treated for pain that can be changed.

I believe that even promoting misinformation about autism could lead to people in pain not getting the appropriate treatment, leading to chronic or worsening symptoms.

If someone seeks treatment for strictly autism (when they have actually another disorder) then that self-diagnosis can delay them from meeting someone who can provide the treatment they truly need.

There is a cost to autism being plastered onto behaviors that represent other disorders or are not problematic at all.

Accidentally Creating Bias

The danger of misdiagnosed autism is that it can create bias for completely normal people and activities.

When it comes to social difficulties, there’s plenty of issues why someone might have them other than autism – a history of abuse, ridicule, bullying that created a belief that something is wrong with them.

Unfortunately, many of these individuals come to think they have autism, which serves as a rationale for why their bullies were right – they come to falsely believe they deserved their pain because they have a disorder that makes them “unaware“.

A narcissistic person might even hurt someone under the guise of themselves having “autism” – claiming they simply weren’t aware of how much they were harming others, all as a ploy to gain forgiveness and continue to break boundaries.

At the same time, children who escape isolating homes often have difficulties with adjusting to social situations.

Isolating homes can easily facilitate abuse, so an individual can go from an abusive home to a judgmental world that tells them their social experiences are indicative of autism.

Trauma from abuse and neglect goes untreated, and this person wanders into the real world already thinking something is permanently wrong with their social awareness.

In the end, proposing the idea that everything “abnormal” is autism can create bias and stigma for entire marginalized groups.

Anyone with a harmless hobby? If it’s too nerdy or geeky, it often gets labeled as autistic.

Anyone who can’t seem to fit into “normal” social situations? If you’re too unique and don’t conform it often gets labeled as autistic.

Of course there are communities more accepting of individuals with autism, but it’s different to associate certain communities with autism – that’s perceptual bias and potentially stigma.

It’s a bias because if hobbies aren’t intrusive, then they’re not symptomatic – if someone struggles to fit in, maybe that’s a problem with our social expectations, not someone’s brain.

No, I don’t believe everyone’s on the spectrum. Disorder means “to disturb the normal order“, so if everyone has autism, it’s not a disorder, because it wouldn’t have an order to be abnormal from.

Final Thoughts

Autism is a common tool for those who over pathologize behavior or misdiagnose other disorders.

It is a real and primarily biological disorder, and it can result in symptoms that overlap with other disorders that have their own unique causes.

Assessment for autism, as well as differential diagnosis, needs to be left to the professionals.

If you experience social difficulties, don’t jump to conclusions, self-diagnose, or perpetuate a stigma around the disorder or normal behavior.

Find a trained mental health professional and go from there.