An Examination of Perceived Stress and Emotion Regulation Challenges as Mediators of Associations Between Camouflaging and Internalizing Symptomatology

Background: Camouflaging involves the masking of autism traits, potentially creating an outer impression of “non-autisticness.” Although associations of camouflaging with anxiety and depression in autistic adults are widely reported, factors that mediate these associations are unclear. We examined two potential mediators of the association between camouflaging and anxiety/depression: perceived stress and emotion regulation (ER) challenges. Methods: Seven hundred eighty-seven autistic adults (18.2–78.2 years) recruited through Simons Powering Autism Research (SPARK) Research Match completed questionnaires, including the Camouflaging Autistic Traits Questionnaire (CAT-Q), and measures of autistic traits, depressive and anxious symptomatology, perceived stress, and ER challenges. Four moderated mediation models were tested. In all models the independent variable was CAT-Q total score, and the moderator variable was sex designated at birth. The dependent variable was depressive or anxious symptomatology, and the mediator variable was perceived stress or ER challenges. Results: We found that more camouflaging, increased ER challenges, and higher levels of perceived stress were associated with greater depressive and anxious symptomatology. We also found that perceived stress and ER challenges significantly mediated the associations between camouflaging and both depression and anxiety. In the model with perceived stress and anxiety, sex moderated the mediation, with females showing a stronger mediation. There was no significant moderation in any of the other models. Conclusion: We contextualize the findings within the broader literature on camouflaging as a response to stigma and other facets of minority stress. We discuss how the results of this study support the idea that the day-to-day stress of living in a neurotypical world, the cognitively demanding nature of camouflaging, and the constraints that camouflaging place on autistic people's behaviors in social contexts (e.g., contributing to suppressing ER strategies such as stimming), create a cycle that contributes to elevated rates of anxiety and depression in autistic people. Why is this an important issue? Camouflaging describes behaviors that can mask social differences. Camouflaging includes things such as “copying” other people's hand movements or facial expressions. Some autistic people say camouflaging feels like they are “pretending” to be someone they are not. Camouflaging is associated with depression and anxiety. We do not know exactly what other factors may be related to these associations between camouflaging and depression and anxiety. Autistic adults have high rates of depression and anxiety. It is important to understand factors that might make autistic adults more vulnerable to depression and anxiety. What was the purpose of this study? The purpose of this study was to look at possible factors related to associations between camouflaging and anxiety and depression. We looked at two factors: perceived stress and emotion regulation challenges. Perceived stress is how stressed a person feels in their day-to-day life. Emotion regulation is how a person handles their emotions across different situations. We looked at perceived stress and emotion regulation challenges for three main reasons. First, autistic adults report high levels of perceived stress and challenges with emotion regulation. Second, perceived stress and emotion regulation challenges are both associated with depression and anxiety in autistic people. Third, camouflaging is associated with increased stress in autistic people. What did the researchers do? We asked 787 autistic adults living in the United States to complete surveys. Participants answered questions about camouflaging. Participants rated their anxiety and depression. Participants reported on how stressed they felt and how they handled their emotions. We looked at associations between camouflaging and depression and anxiety. We also looked at whether different amounts of perceived stress or different challenges handling emotions were associated with camouflaging, depression, and anxiety. We tested whether all of these associations differed for autistic people designated male sex at birth relative to those designated female sex at birth. What were the results of the study? We found that more camouflaging, increased emotion regulation challenges, and higher levels of perceived stress were all associated with more depression and anxiety. We also found that perceived stress and emotion regulation challenges each significantly related to the associations between camouflaging and both depression and anxiety. For the most part, these associations did not differ for autistic people who were designated male sex at birth relative to those who were designated female sex at birth. What do these findings add to what is already known? These findings support the idea that the day-to-day stress of living in a neurotypical world play a part in elevated rates of anxiety and depression in autistic people. What are the potential weaknesses in the study? We collected information from autistic people at one point in time. This limits how we can interpret the associations we found. How will these findings help autistic adults now or in the future? These findings may help us to better understand why autistic adults are at risk for depression and anxiety. The findings may show us ways to improve the mental health of autistic adults.