Is social camouflaging associated with anxiety and depression in autistic adults?

Abstract

Background There is inconsistent evidence for a clear pattern of association between ‘camouflaging’ (strategies used to mask and/or compensate for autism characteristics during social interactions) and mental health. Methods This study explored the relationship between self-reported camouflaging and generalised anxiety, depression, and social anxiety in a large sample of autistic adults and, for the first time, explored the moderating effect of gender, in an online survey. Results Overall, camouflaging was associated with greater symptoms of generalised anxiety, depression, and social anxiety, although only to a small extent beyond the contribution of autistic traits and age. Camouflaging more strongly predicted generalised and social anxiety than depression. No interaction between camouflaging and gender was found. Limitations These results cannot be generalised to autistic people with intellectual disability, or autistic children and young people. The sample did not include sufficient numbers of non-binary people to run separate analyses; therefore, it is possible that camouflaging impacts mental health differently in this population. Conclusions The findings suggest that camouflaging is a risk factor for mental health problems in autistic adults without intellectual disability, regardless of gender. We also identified levels of camouflaging at which risk of mental health problems is highest, suggesting clinicians should be particularly aware of mental health problems in those who score at or above these levels.

Camouflaging in autism: A systematic review

“…Table 2 provides an overview of participant characteristics for participants with autism diagnoses or high autistic traits. There were four sets of studies in which samples were partially or fully duplicated (Hull et al, 2019;Hull, Lai, et al, 2020;Hull, Levy, et al, 2021;Jorgenson et al, 2020;Bernardin et al, 2021;Lai et al, 2017Lai et al, , 2019Livingston, Shah, & Happé, 2019;Livingston et al, 2020). In these instances, only information from one study (the study with the largest N) was counted when calculating aggregated participant characteristics.…”

“…Later studies quantifying both camouflaging and mental health constructs using validated measures have provided more consistent evidence suggesting that greater self-reported camouflaging (i.e., higher Total CAT-Q scores) is associated with increased neuroticism (Robinson et al, 2020); increased social anxiety, general anxiety, and depressive symptoms (Hull et al, 2019;Hull, Levy, et al, 2021); greater psychological distress (Beck et al, 2020); and decreased well-being (Hull et al, 2019; although see Perry et al, 2021). However, there was no evidence that the relationship between selfreported camouflaging and mental health outcomes was moderated by gender (Hull, Levy, et al, 2021).…”

“…Subsequent examination of each of these distinct aspects of camouflaging, related to both self-perceived engagement and observable behaviour change, is required in both autistic and non-autistic samples. Specific efforts should be made to include non-autistic samples who similarly experience social challenges (i.e., social anxiety) or stigma, to further the current conceptualisation of camouflaging and help in distinguishing autism specific elements of camouflaging (Lai et al, 2017(Lai et al, , 2021.…”

A systematic review on autistic people’s experiences of stigma and coping strategies

“…In contrast to research on other stigmatised identities showing that more disclosure correlates with improved mental health (Quinn et al, 2014), both disclosure and concealment were associated with poorer mental health among autistic individuals . Literature within and outside of this review has also demonstrated associations between camouflaging behaviours and depression, anxiety, stress, and lower psychological well-being among autistic people (Beck et al, 2020;Cage et al, 2018;Cage & Troxell-Whitman, 2019;Hull et al, 2021).…”

Supporting autistic doctors in primary care: challenging the myths and misconceptions

“…Stigma and unconscious bias contribute to poor mental health outcomes for autistic people. Camouflaging, or hiding the fact that one is autistic, is associated with increased anxiety, depression, 13 and suicidality. 14 Since the rates of mental illness and suicide are considerably higher among doctors than other professions, raising awareness of this hidden minority of autistic doctors is critical.…”