Pathological Demand Avoidance
6/13/23. I’m speaking at the American Family Therapy Academy in Baltimore next week on this issue. We will not make progress on helping neurodiverse couples as long as we offer diagnostic tchotchke to soothe the suffering neurotypical with an painfully incomplete, bullsh*t narrative of choice.… but it also does no honor to the neurodiverse partners lived experience…. Revised 3/21/24.
I do a great deal of work with neurodiverse couples, who I encourage to read widely and freely on neurodiversity and relationships.
The relatively new diagnostic term Pathological Demand Avoidance (PDA) was first brought to my attention by several of my neurotypical clients.
One wife read an essay describing PDA traits and thought she recognized some of her husbands quirky behavior and reported “I am experiencing some of this. Not the small requests (ex. picking up milk on the way home), but larger issues of communication and cooperation.”
What is Pathological Demand Avoidance?
Pathological Demand Avoidance (also known as Extreme Demand Avoidance) isn’t merely lazy reluctance when faced with tasks we’d rather not do. For some neurodiverse spouses with Extreme or Pathological Demand Avoidance, too many “bids” or requests from a partner can feel overwhelming and oppressive.
Elizabeth Newson first coined the term Pathological Demand Avoidance twenty years ago when she noticed what she called “demand avoidant behavior” in a group of children she was observing.
The problem I have as a couples therapist specially trained to work with neurodiverse couples, is that PDA is a diagnostic spittoon.
It’s not in the DSM, and there is very little research on the topic. Since that time, PDA has been reconceptualized as part of the autism spectrum. Despite the fact some researchers have suggested that non-autistic people can manifest PDA traits as an aspect of a personality disorder.
What are the traits regarding Pathological Demand Avoidance disorder, that are also sometimes found among the neurodiverse by neurotypical observers?
Negative Affect – “Affective instability has been defined as a dynamic process involving three components: extreme shifts in mood, exaggerated reactivity to environmental stimuli, and an ephemeral, fluctuating mood course (Trull, Solhan, Tragesser et al., 2008).”
Antagonism – “the low pole of agreeableness, references traits related to immorality, combativeness, grandiosity, callousness, and distrustfulness. It is a robust correlate of externalizing behaviors such as antisocial behavior, aggression, and substance use.”
Disinhibition – “orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences” (APA, 2013, p. 780).
Psychoticism – “a dimension of personality in Eysenck’s dimensions characterized by aggression, impulsivity, aloofness, and antisocial behavior, indicating a susceptibility to psychosis and psychopathic disorders (see antisocial personality disorder).”
PDA has been described as a syndrome, but it’s probably more widely recognized as a chronic behavioral pattern, or profile. My problem with the conception of PDA is that it requires teasing out between neurodiverse responses and personality disordered responses.
These 4 negative traits are rather large leaky buckets. From a neurodiverse perspective, they seem to be saturated in neurotypical hegemony. Who decides what is “extreme, fluctuating, ephemeral or exaggerated mean in an intimate relationship devoid of context? If a neurodiverse spouse is dysregulated are they… exaggerating?
For a science-based couples therapist like me, this differential diagnosis is the holy grail of treating PDA. So much damage has been done by incompetent therapists who too-often conflate a neurodiverse orientation with a personality disorder…yikes!
A robust and reflexive “No!” is calling card of Pathological Demand Avoidance… and the dashing of neurotypical norms…
Spouse with a PDA traits are motivated to avoid incurring everyday demands and expectations from their partner to an extreme extent. This demand avoidance is sometimes also accompanied by a sharp spike in anxiety.
What do we mean by a demand?
A “demand” is a request for engagement, action, or attention. It may direct or indirect, implied or clearly stated. a “demand” expectation, desire, or obligation. The term “demand” is inherently problematic… is it’s understood as a noun, or an adjective?
Here’s the problem. The neurotypical spouse making requests is not inherently “demanding” (i.e. possessing unusually high standards, and therefore not easily pleased ). The word “demand” is inherently problematic. Furthermore, is the neurotypical spouse relying too heavily on a “story” about their partner?
Any circumstance requiring a response from the PDA individual may create a felt sense of demand. While PDA is highly problematic, the degree of impairment can vary.
Not all spouses will struggle in similar circumstances to the same degree – Pathological Demand Avoidance varies in severity. It can show up as resistance to specific categories of “demands,” or it can be pervasive, and deeply damaging to the relationship.
It’s typical for partners with a low to middling set of PDA behaviors to successfully navigate expectations in the workplace, but struggle most often with PDA behaviors.
That’s the rub. A committed relationship is marinated in expectations – day in, and day out.
Teamwork and interdependence are the essence of family life – being responsible to the partners we choose to move through time with
We are always confronting and negotiating expectations…and we either make ongoing deposits or withdrawals in our partner’s emotional bank account.
a Pathological Demand Avoidant partner, may reactively resist, avoid, oppose, defy, deny, withhold, or otherwise withhold their collaboration. They may complain bitterly of being “controlled.”
Not only do they thwart their partner’s designs, they may even express surprisingly callous and dismissive feelings while doing so. In some cases, a major power struggle ensues.
Bad behavior that is not confronted, is bad behavior redux
Many spouses tread carefully out of respect for their partner’s neurodiversity are nevertheless flung into despairing confusion – questioning the diagnosis, or gaslighting themselves that this PDA behavior behavior isn’t really a power struggle.. they struggle to excuse the impact on their emotional needs out of respect for the fact their partner is neurodiverse.
We can have all the empathy in the world for how challenging it is to struggle with Pathological Demand Avoidance as an individual.
For some neurodiverse spouses, it is positively dreadful to experience a “demand.”
I get it, and I empathize. But if your goal is to improve your marriage with your neurotypical spouse, you’re going to be asked to confront your discomfort with their “demands” head on.
Whether you’re neurodiverse or just another unlucky bozo with such a sh*tty childhood that you wound up with an impressive personality disorder… listen up.
If you lack motivation to engage in family obligations or fail to offer an occasional helping, curious hand…you’ll eventually manage to deflect any important requests from your spouse or children. As they move through time, they will most likely emotionally exclude you from a felt sense of family.
If you’re uncomfortable when you’re not fully in control of other family members or you act without accountability toward them because you’d rather not explore your bad behavior, then you will weaken your family bonds and undermine your legacy. Good luck with that.
Narcissism or neurodiversity? The problem of pathological demand avoidance as an idea…
Pathological Demand Avoidance has emerged as a new descriptive diagnostic employed by a robustly neurotypical mental health regime.
Despite the fact that we are migrating away from notions of Asperger’s Syndrome, or high functioning autism, certain highly problematic behaviors manifested by the neurodiverse still manage to find neurotypical hegemony intact. Perhaps the most salient is the empire of marital disappointments that is now labeled “Pathological Demand Avoidance.”
The neurotypical diagnostic complaint is that PDA is particularly difficult to navigate in a neurodiverse relationship.
Marriage, as understood by neurotypicals, requires collaboration and emotional noticing, which, when mutual, leads to a congenial experience for both spouses.
A common complaint in neurodiverse couples therapy is that the neuro-diverse partner tends to avidly pursue independent interests, at the expense of a spouse’s (perhaps undeclared) needs.
The complaint is that a pattern of high-conflict neurodiverse revolves from what is described as the Neurodiverse partner Reactively resisting heeding and cooperating with their neurotypical partner.
Because this apparently selfish and inconsiderate behavior threatens a lifelong partnership, a neurodiverse couple may seek out couples therapy.
On-demand emotional connection?
“Demand” in the diagnostic sense here just refers to any circumstance requiring a response from the PDA individual. Notice that explanation was required because of the associations NT’s have to the word demand when used as a verb.
The Neurotypical hegemony slips in when we’re reminded that Pathological Demand Avoidance is not characterized by chores that require an unreasonable commitment of time, or any particularly unusual ability. When my neurotypical clients complain, it is mostly about how effortless and routine their “demands” are deemed to be.
What are some of the routine demands my neurotypical clients complain that are met with PDA?
Bill paying, Budgeting, car repair, shopping, taking out the trash, mowing the lawn, etc… but more impactfully, Pathological Demand Avoidance can degrade the expression of responsibilities, of maintaining an Intimate relationship.. such behaviors as starting a conversation, paying a compliment, expressing affection, initiating intimacy, having a date night, even parenting responsibilities, such as feeding, bathing, calming, overnight duties, interacting, nurturing, playing, schooling, chauffeuring children to activities, medical appointments, etc.
How do “routine demands” become a power struggle in a neurodiverse marriage?
The typical “story” that the neurotypical partner makes up is that the neurodiverse partner has a high tolerance for incomplete responsibilities.
Furthermore, the neurodiverse partner also makes up the story that the neurodiverse partner is deliberately withholding their support because they see saying NO as a power grab.
As Gottman reminds us, the mathematical ratio of negative to positive experiences establishes the level of the couples’ emotional bank account.
As in the case of untreated adult ADD, the neurotypical spouse becomes hypervigilant in managing the needs of the home, children and the relationship.
The NT spouse feels overwhelmed with both the practicalities of daily life, but also the subtle, but relentless labor of strategizing how to get the most cooperation from the ND spouse.
The combination of an increasingly resentful hypervigilance, colliding into the relentless resistance from the Neurodiverse partner’s demand avoidance.
Unfortunately, the neurotypical spouse is frequently caught in a web of rage, resentment, despair, and desperation.
One reason couples therapists are seeing more Pathological Demand Avoidance is that since the pandemic, the complexity of modern life has taken a toll.
A common complaint I hear from my neurodiverse clients is that they feel that their NT spouse was easy going early on in the relationship.
But easy going doesn’t mean devoid of expectations.
The ND spouse may come to associate the NT partner with an arousal state of perpetual threat.
From an NT perspective, a convenient “story” is that the ND spouse is more overwhelmed by life, due to the rising difficulty we’re all experiencing in satisfying the demands of daily life. – and possibly use this perception to justify increasingly avoidant behavior.
The Problem of the neurotypical love for stories
The interaction between a PDA spouse and an NT spouse often turns into an arid, adversarial emotional gridlock. ,
A neurotypical couples therapist would see the neurotypical spouse vacillate between a variety of approaches to gain cooperation, and the neurodiverse spouse may dig in and grow even more stubborn.
Such a therapist would also quickly inform us that most despairing bids for cooperation become a Pursue-withdraw dynamic. They may even suspect the ND spouse has a narcissistic personality disorder.
Our hapless couples therapist struggles to find common ground as the ND/ PDA complains how exhausting the needs are of the NT partner, who is like an old wooden bucket with a hole in the bottom, requiring a consistent flow of understanding, assistance, collaboration, agreement, reliability, security, and predictability, and of course… love and affection.
The therapist feels an alignment with the NT partner. Her requests make sense. Why does her husband see her needs in such a negative light?
J. Douglas Edwards once said “questions are the answer”
Here are 6 incongruent concepts curated from the lived experience of neurodiverse clients that are not found in any neurotypical stories and narratives about our couple: They are incongruent because they are not recognizable as part of a neurotypical lived experience.
Bandwidth / Special Interest / ND Meltdown States / Mindreading / Corrective Cognitive Experience / Transition Stress
I’ll discuss these issues in depth in upcoming posts.
At the AFTA conference, I’ll be leading a discussion among attendees about how narrative creation may be deconstructed to allow for new narratives that contain information and concepts about Neurodiverse lived experience, free of neurotypical hegemonic thinking…especially from well-meaning therapists and self-styled diagnosticians.
Be well, Stay kind, and Godspeed.
RESEARCH:
Butler, Emily. Reframing PDA: The Power of an Autistic Perspective. October 27, 2021.
Moore A. Pathological demand avoidance: What and who are being pathologised and in whose interests? Global Studies of Childhood. 2020;10(1):39-52. doi:10.1177/2043610619890070
National Autistic Society. PDA - A Guide for Autistic Adults.
O’Nions E, Christie P, Gould J, Viding E, Happé F. Development of the ‘extreme demand avoidance questionnaire’ (Eda-q): preliminary observations on a trait measure for pathological demand avoidance. J Child Psychol Psychiatr. 2014;55(7):758-768. doi:10.1111/jcpp.12149
O'Nions E, Viding E, Greven CU, Ronald A, Happé F. Pathological demand avoidance: exploring the behavioural profile. Autism. 2014 Jul;18(5):538-44. doi: 10.1177/1362361313481861. Epub 2013 Oct 8. PMID: 24104509.
White R, Livingston LA, Taylor EC, Close SAD, Shah P, Callan MJ. Understanding the Contributions of Trait Autism and Anxiety to Extreme Demand Avoidance in the Adult General Population. J Autism Dev Disord. 2022 Apr 18:1–9. doi: 10.1007/s10803-022-05469-3. Epub ahead of print. PMID: 35437676; PMCID: PMC9015283.
