The neurotypical mask. Psychopathology of camouflaging: from the origins to modern descriptions

The term camouflaging defines behavioral strategies as the subject applies to mask social difficulties or deficits. While present in general population, to date, social camouflaging is frequently linked to autism spectrum disorder (ASD) and subthreshold autistic traits (AT)^.  However, across centuries, psychiatrists focused on the phenomenon of a set of behaviors overlapping with the contemporary concept of social camouflaging, which was associated with obsolete diagnostic definitions, frequently referring to the presence of clinical pictures that seem to overlap with autistic dimension. In this perspective, we aimed to give a comprehensive description of camouflaging psychopatology, from the origins to modern definitions.

INTRODUCTION

According to modern Psychiatry the term camouflaging defines behavioral strategies the subject in the autism spectrum applies to mask social difficulties or deficit, becoming effectively invisible in social settings ¹. Many species have their own typical “camouflaging strategy,” adopted to cope with everyday life tasks. Among humans, camouflaging helps to cope with difficulties during social situations or hide behaviors considered socially unprofitable ^1-4. While neurotypical subjects may also engage in camouflaging improving their social appeal, for neurodivergent people, it often becomes a crucial tool to access better educational and employment opportunities, sustain friendships and romantic relations, and protect from bullying and social stigma ⁵. As a result, the individual may appear well-adapted, creating the illusion of an alignment between neuroatypical and neurotypical functioning ^1-2.

While the adoption of social camouflaging strategies could be present in general population as well as in several conditions such as social phobia, personality disorders, eating disorders and mood disorders, recent literature is focusing on the link between camouflaging, autism spectrum disorder (ASD) and subthreshold autistic traits (AT) ^1-2, ^6-11. Indeed, individuals with autism adopt cognitive and behavioral strategies in order to adapt to a predominantly neurotypical social world. Camouflaging is supposed to follow the distribution of AT among general population, linked in quality and quantity to the presence of autistic-like features. However, in the most severe forms of ASD the ability to camouflage disappears ^1,7,9. ASD patients may acquire over time and through relational failures, awareness of their deficits. In this perspective, they attempt to camouflage the difficulties in socio-emotional reciprocity through mimetic behaviors of adaptation, superficial and momentary adequacy ^{1-2, 12-14}. These manners improve during the formative years and become an integral part of the personality structure ^{1-2, 12-13}. In this framework, the imitation of others’ attitudes may hesitate in exaggerated features, abnormal expression of common gestures resulting in manneristic and inauthentic behaviors to others and to the subjects ^{1, 15-16}.

According to recent literature, Camouflaging seems to be particularly prevalent among females ^{2, 17-19}, often hindering the correct diagnosis of ASD in high functioning subjects ²⁰. Female autistic features seem to be less evident due to ASD women higher awareness of difficulties in social contexts and, as consequence, higher tendency and ability toward camouflaging ^1-2,12-13,21. In this framework, the imitations of neurotypical behaviors become crucial such as avoiding eye contact, suppressing public displays of stereotypies or rituals. Moreover, firm applications of learned social rules to handle interactions, and mimicking others’ nonverbal behaviors to react appropriately are commonly employed ^1,2.

However, the daily use of coping strategies requires deep cost in the life of ASD subjects. Indeed, under high-demanding social situations the effect of camouflaging breaks down, and several disorders may emerge such as anxiety, mood and eating disorders, till self-harming and suicidal behaviors ⁵, ^21-23. These symptoms reduce the ability to cope with real-world demands leading to an inner conflict ²¹. The mask of camouflaging needs continuous cognitive and emotive effort, leading to feelings of social overload and exhaustion, stress responses, fear to be discovered that may increase clinical expressions of anxiety and mood symptoms especially in ASD subjects ^{1, 23-24}.

Recent studies on camouflaging still provide few certainties and highlight the need to deeper investigation. On the other hand, what we now define as camouflaging had not escaped the keen descriptive eye of past psychiatrists, though associated with different, now obsolete, “diagnostic categories”. Clinicians, phenomenologists, and psychoanalysts all made fundamental contributions in this area.

MINKOWSKI, CLAUDE, AND THE LOSS OF VITAL CONTACT WITH REALITY

Eugène Minkowski, the Bleuler Russian-born student, in La Schizophrénie (1927–1953) conceptualized schizophrenia focusing instead on the pathological aspects of contact such as perceiving and feelings, becoming one of the earliest exponents of the phenomenological movement. In this perspective, he defined phenomenological concept of “schizoidia,” characterized by a tendency to withdraw and isolate oneself from the world against altered psychoesthetic balance, oscillating between hyperesthesia and affective anesthesia. Moreover, Minkowski also stressed the concept of “autism,” interpreted as a loss of vital contact with reality often due to excessive emotionality. The loss of this intimate contact with the environment leads to behavioral anomalies and other symptoms. The inability in establishing a lasting, permanent, normal contact with the external world requires these individuals to establish an appearance of social connection without being emotionally – and even sensorily – overwhelmed by the content of reality ²⁵.

In his now-forgotten work, Henri Claude described “marginal” or “poor” forms of schizophrenia that stood in contrast to the dramatic Kraepelinian syndromes anticipating what would later become borderline disorders. To Claude we owe the descriptions of schizomania a transition between schizoidia and schizophrenia, involving low levels of dissociation marked by ambivalence, eccentricity, impenetrability, and detachment that eventually “dries out” existence. Claude’s school anticipated a long series of clinical concepts, from Witzel’s latent schizophrenia to Conrad’s sub-apophanic schizophrenia, up to the long history of minor and marginal schizophrenia disorders. These clinical pictures emerge from an underlying schizoid organization of the personality characterized by shyness, hyper-emotionality, and hypersensitivity frequently deriving from childhood milder traumatic events ^26-27. According to Codet and Laforgue, these experiences may often result in the schizonoia a sort of “inversion of the capacity to love” that periodically distances the subject from others. In adulthood, outcomes typically take two manifestations: the “dreamers” (rêveurs) and the perpetually dissatisfied and sullen types (bodeurs). Both the clinical pictures may experience brief episodes of schizomania, including a break with reality, characterized by short-lived, acute psychotic episodes or catatonic symptoms such as stereotypies, perplexity, and blocking ²⁸.

Despite the now obsolete and largely forgotten terminology, the intuitions of Claude seem to have identified, through an heuristic approach, a clinical picture that could eventually overlap with autism spectrum symptomatology. Moreover, Claude explored the link between traumatic experiences, highlighting the role of stressful events in exacerbating symptoms and leading to more complex clinical pictures ascribable to post-traumatic stress disorder (PTSD) features ^1-2,29.

“AS IF” PERSONALITY BY HELENE DEUTSCH

The “As if” personality concept firstly presented at the Vienna Psychoanalytic Society in 1934 and later published in 1942 under the title “Emotional Development and Its Disturbances, with Special Reference to Schizophrenia.”, remains Helene Deutsch’s most well-known clinical contribution. According to Deutsch, there is continuity between the “as if” picture and impoverished psychotic forms, as well as schizoid personalities. The structuring of the core symptoms is due to a developmental deficit in early childhood including poor parental identifications and superego. Deutsch believed that although manifestations of the “as if” personality were relatively rare, they reflected universal experiences that lie at the border between normality and pathology. According to Deutsch description, the “As if” personalities give the observer “the inescapable impression that their entire way of being in life is somehow lacking in genuineness,” despite an outward appearance of “complete normality.” Even when these individuals engage in seemingly rich and varied emotional or friendly relations, they show lack of warmth and real feelings ³⁰.

The “as if” behaviors may resemble depersonalization states. However, in depersonalization, there is a subjective perception and suffering due to one’s estrangement from the self, the environment, and interpersonal relationships. Conversely, “as if” behaviors report purely imitative nature characterized by merely formal emotional expressions. Furthermore, any internal experience is entirely foreclosed. These subjects mold themselves on external worlds expectations. In terms of differential diagnosis, hysterical personalities show deep emotional and libidinal investment as well as emotional conflicts. These manifestations are weak or absent in “as if” personalities that report inauthentic reactions to abandonment, or no reaction at all, quickly replacing their “love object.” Moreover, they mask aggression with passivity, presenting “an air of artificial goodness” ³⁰.

A refined evolution of Deutsch’s conception can be found in the work of Argentine psychoanalyst José Bleger with his notion of “ambiguity” ³¹. Similarly, the phenomenon of “loss of natural self-evidence” as described by patient Anna Rau and made famous by Blankenburg’s report, as well as the pseudo-anorexia in “The Case of Ellen West” by Ludwig Binswanger, are clinically comparable to the “as if” concept.

CONCLUSIONS

Across centuries, psychiatrists focused on the phenomenon of a set of behaviors overlapping with the contemporary concept of social camouflaging, which was associated with now obsolete diagnostic definitions, frequently referring to the presence of clinical pictures that seem to overlap with autistic dimension ^25-26,30. To date, camouflaging can be found in ASD, in general population and eventually in other psychiatric disorders, following the continuous distribution of autistic traits ^1,7,10,32. In autistic subjects the lack of authenticity, and spontaneity in life often perceived by external observers may appear as an attempt to reduce or compensate social limitations and deficit in socio-emotional reciprocity ^1-4. As autistic traits are distributed along an increasing continuum of severity from general population to full-blown clinical conditions, camouflaging behaviors are associated in quantity and quality with autistic-like features ^12-13. In this perspective, both clinical and general population may show hyper-adaptive camouflaging strategies in social contexts often significantly correlated with psychological distress deriving from intense effort to maintain the mask of a well-adapted subject ^{1-2,12-13,21-23}.

As a result, the camouflaging phenomenon holds deep significance in terms of pharmacological treatments and therapy. The analysis of camouflaging requires extreme caution for the clinicians in identifying the coping strategies, though deficient, that the patient has developed over time in order to appear neurotypical and adapting to routine, avoiding greater suffering.

Every psychiatric patient keeps an own internal balance, which must be respected. The patient’s well-being must come before the ambition for complete recovery. Indeed, dysfunctional coping could be reduced when the subjects are able to build their own world, even if it represents a compromise with the demands of reality. These reflections open to challenging expectations for the clinicians that will need to be able to provide therapeutic support maintaining a fragile balance between the patient and the real-world requests.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.

Authors’ contributions

L.D.O. conceptualization; C. B., R.P.D.L. writing-original draft prepa-ration; L.D.O., B.C., R.P.D.L., B.N. writing—review and editing; L.D.O, B.C.: super-vision.