Polly's pages (aka 'Donna Williams')

Ever the arty Autie

Exposure Anxiety versus Pathological Demand Avoidance.


Aloof by Nature by Donna Williams Someone wrote to me about the differences between Exposure Anxiety (EA, as written about in the book, Exposure Anxiety; The Invisible Cage ) and Pathological Demand Avoidance (PDA). Here are my reflections on those differences:

Hi Donna,

A big thanks for all the emails that come my way – please keep me on the list, they are really useful. Having read ‘Exposure Anxiety’ now for the second time, would you agree that this is another term (all be it a more useful description) for Pathological Demand Avoidance? I would be interested to hear your view.

DONNA: Its a great question of course,

I’ve been asked this before. PDA doesn’t seem to respond well to usual education and treatment methods used with those with Autism and those with EA as a co-morbid condition with their Autism are in the same position.

This is from a PDA support group website…. www.pdacontact.org.uk


“Pathological Demand Avoidance Syndrome is a pervasive developmental disorder related to, but significantly different from, autism and Asperger syndrome. First identified as a separate syndrome at the University of Nottingham, research has continued at the Early Years Diagnostic Centre. Children with PDA would previously have been diagnosed as having ‘non-typical autism/Asperger’ or ‘pervasive developmental disorder not otherwise specified’; but it is important to diagnose them separately since they do not respond well to the educational and treatment methods that are helpful with autistic and Asperger children, and since appropriate guidelines for education and handling have been produced by the Early Years Diagnostic Centre specifically for children with PDA”.


DONNA: Here’s the diagnostic criteria for PDA below (quoted from the website: www.psychnet-uk.com/dsm_iv/pda.htm) .


“Individuals with PDA are typically socially manipulative with people,…”

DONNA: those with EA are not at all any more or less manipulative of others than anyone else… in fact they are generally so busy trying to trick their own compulsive avoidance, diversion, retaliation responses they get very little time to think about others as they are so damned busy just trying to function in basic ways… eat, dress, use the toilet, stay, go…

“…and therefore superficially socially skilled, which sets them apart from Autism and Asperger Syndrome”

DONNA: again, people with EA can be severely impaired in their social skills, especially where the interaction between EA and personhood becomes so demanding there is little ability left to focus on social skills.

“…The most central characteristic of people who have Pathological Demand Avoidance (PDA) is their obvious and obsessional avoidance of the ordinary demands of everyday life”.

DONNA: yes, this fits EA, they both share this, but one is voluntary, essentially ‘ego-syntonic’, meaning deriving from the self, the other is involuntary, essentailly ego-dystonic and those who type about their experiences with EA communicate they don’t at all mean or want to behave this way.

“People with PDA lack a clear and defined sense of self, “…

DONNA: here, EA is quite the opposite as those with EA who have used typed communication in spite of the condition have expressed a highly developed, yet trapped sense of self, probably because, like those with marked Cerebral Palsy, they know what’s happening isn’t ‘them’ but can’t change that.

“and hence do not view themselves as being responsible for their actions.”…

DONNA: one can have a personality disorder and not feel they are responsible for their actions but another person may have an impulse control disorder and also be not responsible for their actions… similarly with Tourette’s for example, … and EA is definitely the latter… yes, EA and PDA share that they don’t view themselves as responsible for their avoidant responses but one is having a psychological issue, the other a chemical one causing involuntary responses that can cause the person themselves extreme despair and entrapment. Avoidant Personality Disorder (the extreme of the sensitive personality) will cause similarly involuntary avoidance that is not a manipulative indulgence deriving from shallowness but deriving from an anxiety disorder they can’t chemically manage and is treated with antidepressants or mood levelers.

“Therefore, the person with PDA is highly motivated to avoid demands and is so able in this domain that they may even appear manipulative, as a variety of strategies are used with such determination toward the desired outcome of escaping demands.”…

DONNA: yes, I can see why they LOOK similar and can expect many with EA are misdiagnosed with PDA and many with PDA may be wrongly thought to have EA (or could have both) , but I would never say EA makes one HIGHLY MOTIVATED to avoid demands, because its not at all about volition or motivation. In fact EA involves the opposite where the stronger the desire and motivation is to do something the more it triggers the opposite response, so its like an involuntary fight-flight response gone mad.

Interestingly, EA occurs a lot more with those with tics and it may be EA is a combined product of the Sensitive-Avoidant personality combined with the associated state of Social Phobia and when in those who also have the energetic, hypomanic or manic states of bipolar or adrenaline addiction it gets its energetic drive, and the final straw may be that with the same high dopamine that reinforces addiction to one’s own chemistry highs there may be co-morbid OCD or Tourettes- both impulse control disorders… in other words, true EA as I know it may only occur when several conditions come together and certainly information overload issues of Autism will raise those stakes and keep EA high in these individuals).

I also feel that Reactive Attachment Disorder (RAD) could exacerbate EA and that one doesn’t need to be abused to develop RAD. Being face blind, having social emotional agnosia (inability to read facial expression, body language, intonation), auditory verbal agnosias and visual agnosias (meaning deafness, meaning blindness) and tactile agnosias (difficulty processing body feedback) are enough basis to significantly alter the usual course of bonding processes. Quite simply, those with RAD may have an already disturbed relationship to body, emotions and be at greater risk of social phobia and intimacy problems which could conceivably exacerbate a case of EA.

“Passive Early History in first year,”…

DONNA: here I’d say EA is one of those things that seems far more common in those who appear to have had their ‘Autism’ from birth. I’ve also had a number of letters from therapists remarking that EA seems almost ‘standard’ in those with Fragile X (a particular form of autism) though it occurs in those with other types and in some members of the general population. Rather than those with EA being ‘passive’, if you look at the early photos of children who developed severe EA, early on they still show signs of being overstimulated and avoidant in how they pull in with their limbs, in tensing and eye related behaviours.

“Continues to resist and avoid ordinary demands of life,”…

DONNA: many people with EA will try very hard to join in or comply but in the overstimulated state they are triggered into involuntary avoidance, diversion, retaliation responses… in fact what’s interesting with EA is you see constant tiny hints of the person continuing to wish and try in spite of years of failure because of impulse control problems.

“Surface sociability, but apparent lack of sense of social identity, pride or shame.”…

DONNA: PDA is not the same as EA here. I think any impulse control disorder that blocks simple direct interactions will interupt social identity and make pride or shame far less relevant than the pure effort to simply function, but many with EA who do type or communicate have an intact social identity that is internal where they have been unable to live it externally because of the EA.

“Lability of Mood, impulsive, led by need to control.”…

DONNA: people with EA are no more or less controlling than others but are perhaps so triggered into EA by a non-comprehending, directly confrontational and socially invasive environment that they have a great reason to need to keep that environment from triggering their EA and incidentally sabotaging what functioning they do have.

“Comfortable in role play and pretending.”…

DONNA: I don’t think anyone with chronic EA is ever comfortable and ‘pretending’ is stretching it re EA. Being driven to use self delusion and characterisations as a tool may be more to the point, and yes, extremely shy people may need to hide behind anything to function so if one of the conditions involved in EA is extreme sensitivity, then finding one can function better when hiding may be a useful tool. But this doesn’t make PDA the same as EA. Type with someone with EA and you will usually get someone strikingly geniune. In my view, the use of characterisation in EA is more akin to how stutters have used singing to get around their stuttering.

“Language delay, seems result of passivity.”…

DONNA: I see people with EA who are utterly exhausted by what they fight against. So far from passivity. A percentage who do speak do so in an indirectly confrontational manner, through adverts, songs, animal voices, cartoons etc… so not the same as that group which may have depression where language delay may be related to passivity. Most with EA are not at all passive but highly agitated and restless. I see them wander in and out of a room, pacing, unable to sit for any length of time or unable to get up in spite of great agitation sitting where they are… hardly passivity.

“Obsessive behaviour.”…

DONNA: Obsessive Compulsive Personality Disorder is about the desire to control but this is not OCD and both are common in those on the spectrum but not necessarily in the same people. It is my experience that EA seems to be very common not with those with Obsessive Compulsive Personality Disorder but in those with OCD and Tourette’s tics. OCD is more common in those with the Vigilant Personality trait- one which involves Solitary traits- not with the Conscientious/Cbsessive-Compulsive one. Obsessive Compulsive Personality is ‘ego-syntonic’ meaning the person identifies with that obsessive nature. OCD is ‘ego dystonic’ and those with OCD usually don’t enjoy this or see it as part of their ‘selfhood’ but something that distracts from or intrudes upon expression of their selfhood.

So its my hope that in pointing out the difference between EA and PDA that people might realise that whilst PDA is a related Autism Spectrum Condition but separate to Autism or Asperger’s that it is my experience that what I call Exposure Anxiety (EA) is a co-morbid disorder that can occur in people with Autism Spectrum Conditions, perhaps more common in those effected by co-morbid impulse control, anxiety and childhood bipolar disorders.

Thanks for your question. I do discuss this broadly in my upcoming book, The Jumbled Jigsaw, out soon with Jessica Kingsley Publishers.

I hope this has been some use.

Donna Williams *)

author, artist, singer-songwriter, screenwriter


Ever the arty autie.