The Trauma-Autism Diagnostic Gray Zone: Adult Autism vs. C-PTSD
Friday, April 4, 2025. This is for Austin, My 10am on Thursdays.
In the past decade, a growing number of clinicians and researchers have begun wrestling with what many now call the “trauma-autism diagnostic gray zone.”
This refers to the complex clinical overlap between Developmental Trauma—especially complex PTSD or early relational trauma—and autism spectrum disorder (ASD).
Increasingly, families, therapists, and neurodivergent adults are raising concerns about missed diagnoses, misdiagnoses, or dual presentations that defy traditional diagnostic categories.
So how did we get here? And what does the research really say?
Shared Features, Different Origins
At the heart of the gray zone is this: trauma and autism can look strikingly similar, especially in children.
Many children with trauma histories exhibit:
Sensory sensitivities
Social withdrawal or flat affect
Emotional dysregulation
Repetitive or self-soothing behaviors
Difficulties with transitions or changes in routine
But these are also hallmark characteristics of autism (American Psychiatric Association [APA], 2022). The overlap can lead clinicians to confuse trauma responses for autistic traits, or vice versa.
Both trauma and autism affect the nervous system, especially in how folks process social, emotional, and sensory input (Porges, 2011). But while autism is considered a neurodevelopmental condition present from early life, developmental trauma often arises in response to chronic neglect, abuse, or instability in caregiving relationships (van der Kolk, 2014).
Competing Theories: What Causes the Overlap?
Trauma Mimics Autism
Some clinicians argue that many children showing autistic-like behaviors are actually exhibiting the effects of complex trauma.
This is particularly relevant in child welfare settings or with youth from high-adversity backgrounds (Spinazzola et al., 2021). In these cases, behaviors such as repetitive movements or emotional shut-down may reflect survival adaptations, not intrinsic differences in brain wiring.
For example, dissociation—a common trauma response—can resemble social detachment, flat affect, and emotional withdrawal, which are also present in autism (Lanius et al., 2014).
I have just been assigned a case in my public health clinic role of Austin, a 19 year old who has a bi-polar dad, a mom who went into a coma, while he was shuffled through and abused in various faster homes. He shows traits of both high-functioning autism and trauma, which I’ll have to map out as best I can in developing a treatment plan.
Autism Increases Trauma Vulnerability
Others argue that autistic folks are more vulnerable to trauma, not less. Social rejection, bullying, sensory overwhelm, and misattuned caregiving can all create cumulative trauma in autistic children (Kerns et al., 2015). In this view, trauma doesn’t mimic autism—it’s layered on top of it. I’m inclined to agree.
Studies suggest that youth on the autism spectrum experience higher rates of trauma exposure and are more likely to meet criteria for PTSD compared to neurotypical peers (Rumball, Happé, & Grey, 2020). However, because they may express distress in atypical ways—such as through meltdowns, shutdowns, or masking—these trauma symptoms are often overlooked, or misunderstood.
There’s True Comorbidity—and It’s Under-Recognized
Some researchers suggest that we stop thinking in terms of either/or. Instead, we should consider that many clients, particularly women and gender-diverse people, may be both autistic and trauma survivors, and that our current diagnostic systems lack the nuance to capture this dual presentation (Hull et al., 2020).
Indeed, autistic adults often report late diagnosis, having spent years in therapy for trauma, anxiety, or depression without anyone recognizing their unencountered neurodivergence was the underlying fountainhead of their suffering (Lai & Szatmari, 2020).
Diagnostic Challenges: The Role of Bias and Masking
The gray zone is compounded by gendered and cultural biases in both trauma and autism diagnosis.
Girls and women are more likely to mask autistic traits, often presenting as compliant, socially mimicking peers, or internalizing distress (Lai et al., 2015).
At the same time, clinicians may pathologize behavioral distress in racial and ethnic minority children as conduct disorder or trauma-related, rather than consider autism (Mandell et al., 2009).
Many trauma assessments are normed on neurotypical populations, leading to under-recognition of PTSD in autistic souls (Kerns et al., 2015).
These biases mean that who gets what diagnosis—and when—is shaped by systemic factors that go well beyond symptoms alone.
Emerging Approaches: Beyond Binary Thinking of Adult Autism vs. C-PTSD
I’m among a growing number of clinicians advocating for more integrative and contextual models. Rather than force-fitting clients into one category or another, they encourage nuanced formulations such as:
“Masked autism with trauma overlay”
“Neurodivergent PTSD”
“Trauma-expressed neurodivergence”
These terms are not official diagnoses but reflect an ongoing, sincere effort to validate the complexity of lived experience. They also emphasize the importance of nervous system safety, relational attunement, and neurodiversity-affirming care, regardless of formal labels (Ogden & Fisher, 2015).
Treatment Implications for Adult Autism vs. C-PTSD
Why does this matter? Because working with these sorts of clients, misdiagnosis can lead to ineffably ineffective or even harmful interventions.
A trauma-informed lens without neurodivergence awareness may interpret stimming as dysregulation and try to extinguish it.
A behavioral autism model may punish self-protective trauma responses that actually need co-regulation and repair.
Medication decisions, school accommodations, and therapy goals all hinge on the primary diagnosis—and getting it wrong can prolong suffering.
What’s needed is a developmentally-informed, cross-disciplinary approach that sees the whole person, including their history, nervous system profile, identity, and relational context.
Final Thoughts: Toward a More Compassionate Diagnostic Culture
The trauma-autism diagnostic gray zone reveals a deeper truth about modern mental health: our categories are imperfect, our tools incomplete, and our clients far more nuanced than our manuals allow.
Rather than choosing between trauma or autism, perhaps the more honest and ethical path is to ask better questions, stay open to complexity, and build systems that allow both diagnoses—and people—to be treated with dignity and precision.
Be Well, Stay Kind, and Godspeed.
REFERENCES:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing.
Hull, L., Mandy, W., & Petrides, K. V. (2020). Behavioural and cognitive sex/gender differences in autism spectrum condition and typically developing males and females. Autism, 24(6), 1280–1295. https://doi.org/10.1177/1362361320902840
Kerns, C. M., Newschaffer, C. J., & Berkowitz, S. J. (2015). Traumatic childhood events and autism spectrum disorder. Autism, 19(3), 314–323. https://doi.org/10.1177/1362361313508028
Lai, M.-C., & Szatmari, P. (2020). Sex and gender impacts on the behavioural presentation and recognition of autism. Current Opinion in Psychiatry, 33(2), 117–123. https://doi.org/10.1097/YCO.0000000000000575
Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child & Adolescent Psychiatry, 54(1), 11–24. https://doi.org/10.1016/j.jaac.2014.10.003
Lanius, R. A., Frewen, P. A., Vermetten, E., & Yehuda, R. (Eds.). (2014). Restoring the self in people with trauma-related disorders: A clinician’s guide. Routledge.
Mandell, D. S., Wiggins, L. D., Carpenter, L. A., et al. (2009). Racial/ethnic disparities in the identification of children with autism spectrum disorders. American Journal of Public Health, 99(3), 493–498. https://doi.org/10.2105/AJPH.2007.131243
Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: Interventions for trauma and attachment. W. W. Norton & Company.
Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W. W. Norton & Company.
Rumball, F., Happé, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: Risk of PTSD development following DSM‐5 and non‐DSM‐5 traumatic life events. Autism Research, 13(12), 2122–2132. https://doi.org/10.1002/aur.2306
Spinazzola, J., van der Kolk, B., & Ford, J. D. (2021). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 51(12), 508–515. https://doi.org/10.3928/00485713-20211108-01
van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.