Feeling Pathologically Out of Control

It's finally time for me to talk about PDA, or Pathological Demand Avoidance. I have avoided this topic for a while because I felt like it might go away, but it's not, and I can't make it go away. I will note that this post is mainly geared toward an American audience since, as my clients tell me almost daily that Australia, the UK and most of Europe is already taking PDA more seriously than I am.

What it is

PDA is a pattern of behavior. This pattern appears to be especially noticeable in people with autism and related neurocognitive conditions. As the name suggests, such people will avoid situations where there are too many demands. PDA is sometimes used to explain people's chronic challenges with attending school, keeping a job, or having relationships.

What it is not

PDA is not a medical or a mental health condition.

Because PDA is real, but not a medical condition, I have had a hard time dealing with it. To that end, I have had to work on my own definitions and applications, and do so in a way my clients find useful. So, as a subjective term it is no use to me, but making it objective is extremely difficult.

Out of control

As far as I can tell this pattern of behavior (which includes more than just avoidance) happens when a person experiences a certain amount of the feeling of being out of control. Either people will avoid situations where they suspect this feeling will occur, or once they experience the feeling they will engage in behavior that gives them a greater sense of control. For instance, I suspect some of the teens I worked with who would lay under desks or argue with a teacher instead of engaging in expected classroom behavior were trying to regain a lost sense of control.

This behavior pattern is a problem for at least two reasons. First, behaviors that help people in such situations regain a sense of control, like asking excessive questions, isolating, or otherwise refusing direct commands are interpreted as oppositionality. Society is structured hierarchically, and first and foremost people are expected to comply with authority. Obedience to authority supersedes any feelings, opinions, or uncertainty. When my clients feel out of control and then appear to refuse to follow direct instructions and orders, they are labeled immediately and reliably as oppositional.

Second, in most situations there are seemingly obvious behaviors people can do to feel more in control, and my clients almost never do them. I know this because every teacher or police officer I talk to tells me they gave my client simple instructions that they refused to do.

Treatment

Since PDA is not a disorder, there is no treatment for it. However, psychologists and other clinicians have been "treating" this sense of feeling out of control since the beginning. For instance, "Social Stories," which has a somewhat dubious research history, is all about using pictures and narratives to give a person a better ability to anticipate, predict, and adapt to new situations. I have no data to support this but it would make sense that Social Stories, or similar interventions have decreased the behavior associated with PDA. Also, exposure, which is a treatment for anxiety, also likely decreases PDA behavior. Exposure would do this through experience with and practice of difficult situations. Knowing one can do it because they have already done it once should decrease the out of control feeling.

Learning how to tolerate the feeling of being out of control also has its merits. The reality is that all people have limited control. Tolerating the out of control feeling can only come, again, through continued exposure to that feeling. So, one might say that avoidance (the A in PDA) keeps the PDA behavior pattern prominent and in control. In short, this impulse to seek ultimate control through isolation or only engaging in heavily curated interactions and environments might need to be resisted by some people who see the PDA behavior pattern in themselves.

Summary

I think I understand what PDA is. If I do then I can say that PDA is not new, even if it's a clever term. I also think there's some danger is seeing it as something unique or distinct, or something to be diagnosed. If it is a response to the sense of feeling out of control, or a desire to feel more in control, then it is a very human experience. It is likely, however, that the situations an autistic person feels out of control might be distinct from those a neurotypical person feels out of control, even if the feeling is the same. We all seek a greater sense of control (it's called agency, or autonomy) and we all must submit to an authority outside of us and often more influential than us. Denying that authority exists, or resisting it to our detriment, can be pathological.