Tag Archives: Attachment Disorder

Attachment Disorder vs. Autism: An Overview and My Personal Experience

I am currently reading the book A Guide to Mental Health Issues in Girls and Young Women on the Autism Spectrum by Judy Eaton. I’m only halfway through the second chapter and it’s so incredibly validating. The book talks about misdiagnosis and co-occurring diagnosis of many psychiatric conditions in autistic girls and young women. I can relate to so much of it.

One concept that I found resonated particularly with me was “secondary misdiagnosis”. This refers to a situation where, while a woman was diagnosed as autistic initially, somewhere along the way, her diagnostic records “disappear” and she is rediagnosed as something else. Yes, that’s me! The book has a UK-based focus and I have been told quite often that, in the NHS, your records automatically move where you go. This is not the case here in the Netherlands: you have to transfer them yourself. Apparently though, in the UK, records can disappear too.

In the second chapter, the author discusses misdiagnosis of autistic girls as having an attachment disorder, disruptive behavior disorder or (emerging) personality disorder. Today, I will talk about attachment disorders.

In August of 2016, I demanded an independent second opinion on my autism diagnosis, which my psychologst had removed, for the first time. My psychologist told me she’d set things in motion, but would have to consult with the brain injury unit’s psychiatrist first. After all, my having sustained a brain injury shortly after birth was her primary reason for removing my autism diagnosis. As she returned, the weirdest diagnostic process I’ve ever seen, emerged: she started negotiating diagnoses with me. She said she was willing to diagnose brain injury-related personality change instead of the personality disorder she’d initially diagnosed me with, generalized anxiety disorder and an attachment disorder. I took time to think and eventualy ignored the attahment disorder thing, while reluctantly agreeing to the rest. We still used DSM-IV, after all, where you have to have endured “pathogenic care” to be diagnosed with attachment disorder.

In DSM-5 and the newest edition of the ICD, which was published in 2016, your early childhood still has to have been less than ideal, but the criteria leave room for milder forms of less than optimal care, such as your parents not having been very nurturing. I guess in my case, even with perfect parents (which I don’t have), my premature birth and three months in the hospital would suffice for the current “inadequate or inconsistent care” criterion for reactive attachment disorder.

However, the criteria for RAD say that the child cannot be diagnosed with it if they have an autism spectrum disorder. I understand this doesn’t mean autistic children and adults do not have attachment issues, since I for one do. However, when someone is diagnosable with autism, they cannot be diagnosed with RAD too. In other words, my psychologist ought to have ruled out autism – which she did a pretty poor job of doing – before trying to label me with RAD.

There are several features of attachment disorder that overlap with autism and particularly with pathological demand avoidance. For example, children with attacchment disorder as well as those with PDA can be superficially charming (in order to get what they want), indiscriminately affectionate with unfamiliar adults and inaffectionate with primary caregivers. Both are often defiant or manipulative. They also both can be controlling or bossy. Children with RAD are however more likely to be cruel to animals or other people or destructive towards property. They often show a preoccupation with such things as fire, blood, death or gore. Autistic children as well as those with RAD may avoid eye contact, but RAD children do make eye contact particularly when lying.

Judy Eaton outlines several distinguishing features between autism and attachment disorder. In the ICD-10, the following are mentioned:


  • Children who have a reactive attachment disorder will have the underlying ability to react and respond socially.

  • When abnormal social reciprocity is noted in children with reactive attachment disorder, it will tend to improve significantly when the child is placed in a more nurturing environment.

  • Children with reactive attachment disorder do not display the types of unusual communication seen in children with autism.

  • Children with reactive attachment disorder do not have the unusual cognitive profile often observed in children with autism.

  • Children with reactive attachment disorder do not display the types of restricted interests or repetitive behaviours seen in children with autism.

I definitely see how I have attachment issues. I am usually more open to strangers than to my own parents. Particularly as a teen, I’d also direct most of my aggression towards my mother. I could also be quite defiant. I however also definitely have communication oddities, repetitive behaviors and restricted interests and an unusual cognitive profile. I never “recovered”, though that could be blamed on the fact that I lived with my apparently inadequate parents till I was nineteen. Or it could be that I’m autistic.

Pathological Demand Avoidance (PDA) Awareness Day: My Life with Possible PDA Traits

Today, May 15, is pathological demand avoidance syndrome (PDA) awarness day. Pathological demand avoidance is a subtype of autism characterized by extreme anxiety, a need to resist everyday demands and a need to be in control. Core features include:


  • Passive early history in the first year, avoiding ordinary demands and missing milestones.

  • Continuing to avoid demands, panic attacks if demands are escalated.

  • Surface sociability, but apparent lack of sense of social identity.

  • Lability of mood and impulsivity.

  • Comfortable in role play and pretending

  • Language delay, seemingly the result of passivity.

  • Obsessive behavior.

  • Neurological signs similar to those seen in autism.

When I first wrote about PDA, I wasn’t so sure I believed in its existence. I recognized and still recognize many features, but the condition isn’t recognized in the Netherlands, so I can never be sure whether I have it. Also, I doubted whether my behavior may be a normal reaction to being in an institutional environment for too long. However, when I read stories from adults with PDA or parents of children with PDA, I recognize a lot. I am going to write about this now.

Pathological demand avoidnance is an autism spectrum disorder that shares traits with oppositional defiant disorder and reactive attachment disorder. However, children with PDA are not willfully naughty. The only rule I routinely broke was the one about not stealing candy. Then again, doesn’t every child do that?

I was a quiet child. However, i could show aggression seemingly out of nowhere. I acted out particularly when my parents or sister wouldn’t do as I said. For example, even as a teen I had no clue when it was not appropriate to demand my parents do something for me and I’d get upset if they refused.

I was an early talker and quite sociable as a young child. For example, I’d shout “Hi!” at everyone we met in the streets. This is expected in the tiny village my husband and I live in now, but it is definitely abnormal in Rotterdam, where I lived as a child. I was comfortable – perhaps too comfortable – in social interactions with strangers. As I grew older, this got worse. This is what got me thinking I might have attachment issues.

I was very comfortalbe in pretend play, but on my own terms. Autistic children don’t tend to engage in pretend play with other children, but I did. I however dominated the play situation. I was always the one who thought out the scernarios we were going to play. I also made the rules of what was “proper” pretend play. For instance, my sister could not say “My doll said ___”, because after all she was acting out her doll.

Most of my life, I’ve been able to hold down a conversation, again as long as it’d go on my own terms. I tend to dominate conversations and make them about topics I want to discuss. When this happened at my diagnostic assessment, my parents said I wanted to make conversation about me all the time. This isn’t necessarily the case. For instance, yesterday a Christian nurse and a patient with his own set of religious beliefs were discussing religion. It wasn’t about me at all and I didn’t make it about me, but as soon as i jumped in, I tried to control the conversation.

The core feature that got me thinking about PDA as applying to me, is however my resistance to ordinary demands. This may be an oppositional behavior too, but in PDA, the need to resist demands is not out of defiance. It seems to be more a core need stemming sometiems from anxiety and sometimes from sensory issues. For example, children and adults with PDA might refuse to brush their teeth when asked, but this is commonly out of sensory defensiveness. They may refuse to do household chores out of anxiety. Interestingly, they may do certain tasks that create anxiety in them when they’re asked to do them by others, when they are on their own. I can do household chores much more easily when I am the one in control or when I’m on my own than when it’s someone else demanding I do them.

Children and adults with PDA are often described as Jekyll and Hyde. They can act perfectly normal as long as they’re in control and their anxiety isn’t provoked. However, when people make demands of them or situations or people don’t follow their rules, they have rapid mood swings. I definitely relate to this and often wonder whether it’s my autism or a borderline personality disorder trait.

Empathy and Expressing Emotions

In chapter three of the book Look Me in the Eye, John Elder Robison talks about empathy and the expression of emotion. He describes a situation in which an acquaintance informs him tht someone he doesn’t know has died. He smiles, being glad that he and his own family wouldn’t die in the same way and are safe for now. The acquintance responds furiously, because why would he smile at someone else’s death? Robison is regularly accused of psychopathy for similar lack of empathy. Then again, he has strong emotional reactions to soomething happening to his own family.

I can relate to what Robison describes, only to an even greater extent. He describes the thoughts he has when there’s a plane crash in Uzbekistan, as rational empathy: he’s aware that it’s sad that people are killed and knows that the victims’ families are grieving, but it doesn’t affect him personally. On the other hand, when his father had been in an accident, he was anxious and nervous and did care on a deeper emotional level. Then again, when his mother’s car was on fire, he immediately went to fix it.

These are three different kinds of responses: rational empathy with no emotional reaction, emotional empathy as in feeling personally touched, and emotional empathy with the urge to fix someone’s problems.

I for one don’t often experience a strong emotional response when something “big” happens. When my maternal grandfather had a brain bleed in 1995, I was worried because I’d had one myself. I didn’t realize that his brain bleed was very different, and I didn’t particularly feel any emotion when he died five days later. I did feel the need to care for my mother, who ran towards me for comfort at the funeral. This lack of actual emotional empathy was amplified when my maternal grandmother, to whom I had no emoitonal connection, died in 2007. I was in an emotional crisis two days before her death and called my parents, stammering only “I, I.” My father was extremely pissed, saying: “It isn’t about you. Your grandmother is dying don’t you know!” A few months later, I remember talking to my mother and, when she referred to “grandma”, asking which one./P>

In this sense, I’m more self-centered, possibly even selfish, than Robison. I honestly have never had an emotional response to someone dying. That is, I do sometimes feel touched when I realize people have passed away, but this seems unrelated to the events of their deaths. An online acquaintance died sometime in 2013, and I still have moments where my inner children are sad that they can’t talk to hers anymore. Then again, the emotional response is not strong.

It isn’t, in my opinion, a psychopathic tendency that drives me not to be touched by people’s deaths. I do feel sadness when other people are sad, even if it’s for a relatively minor reason. Rather, it seems to be that I’m captured by details more than by the bigger picture of someone having died. For example, when a fellow patient told us that he had been diagnosed with terminal cancer in late 2007, I smiled at the funny spin on a nurse’s name he made rather than reacting emotionally to his diagnosis.

The intersection of autism and borderline personality disorder, which is essentially an attachment disorder, is interesting here. It is probably an autistic tendency to be captured more by the details of an event than the bigger picture, as in the laughing at a pun when being informed someone has cancer. Then again, I do have strange attachments sometimes. I should technically care more about my grandma’s death than about an online friend kicking me off her mailing list, but the reaction was reversed. Is this selfishness? It could be, but then again, I too have strong emotional reactions to other people’s sadness, sometimes if they’re people I hardly know.