What is Pain Masking?
Pain Masking in PDA: When Hiding Hurts
Contents
What We Talk About When We Talk About Masking
Pain Masking Is Not the Same as Social Masking
Why PDA Makes Pain Masking More Likely
Masking Pain From Yourself
The Post-Demand Crash and the Pain Reveal
The Medical Appointment Problem
What This Means for Our Support Group
Closing Thoughts
Sources
What We Talk About When We Talk About Masking
Most people in the PDA community have heard of masking. In autism and PDA spaces, it usually refers to hiding neurodivergent traits: suppressing stims, forcing eye contact, performing social ease that doesn't come naturally. That kind of masking is well-documented, widely discussed, and rightly recognized as exhausting and harmful over time.
But there is another kind of masking that gets far less attention, even though many of us live it every day.
Pain masking.
Not hiding that you are autistic or PDA. Hiding that you are in pain.
This article is about that: what it is, why PDA makes it more likely, and what we can do to support each other around it.
Pain Masking Is Not the Same as Social Masking
It is worth separating these two things clearly, because they look similar from the outside but come from different places internally.
Social masking in autism is often imposed: learned through years of being told, explicitly or implicitly, that your natural way of being is wrong. It is exhausting precisely because it goes against the grain.
Pain masking is different. For many PDA people, it is closer to instinct. Sally Cat, a well-known PDA writer and researcher, describes at least three different types of masking in the PDA experience, only one of which is the harmful imposed kind. The other forms, including pain-masking behaviour, are instinctive rather than learned. The PDA nervous system is highly prone to adrenal triggering. When that fight-or-flight response is activated, the body can and does suppress pain signals. Not as a conscious choice, but as a survival mechanism. Hide the injury so a predator does not see weakness. Hold it together so no one moves in.
For those of us with PDA, this instinct can be constantly running in the background, especially in high-demand environments, social situations, or any context where showing vulnerability might invite intervention from others.
And intervention, even caring intervention, can feel like a demand.
Why PDA Makes Pain Masking More Likely
For most people, showing pain invites support. You wince, someone notices, they offer help, you accept. Simple.
For someone with a PDA profile, that chain of events is more complicated. Showing pain invites others to take action on your behalf. That might mean being told to rest, being taken to a doctor, having your schedule changed, being asked repeatedly how you are feeling, or being made the subject of someone else's plan for your recovery. All of those things, however well-intentioned, arrive as demands.
The PDA nervous system registers demands as threats. Not metaphorically, but as actual threat signals, triggering the same anxiety and resistance response that makes ordinary tasks feel impossible.
So the logic, at a nervous system level, becomes: if I show pain, demands will follow. If demands follow, I will feel worse, not better. Therefore, do not show pain.
This is not a decision most PDA people consciously make. It is a pattern that develops over years, often starting in childhood, and by adulthood it can be so automatic that the person genuinely does not register how much pain they are in until they are somewhere safe, or until the body simply cannot hold it back any longer.
Masking Pain From Yourself
Pain masking in PDA is not only about what we hide from other people. Many of us also mask pain from ourselves.
The adrenaline that floods a PDA nervous system during high-demand periods is genuinely analgesic. It reduces the conscious experience of pain. This is why people can walk on a broken bone during a crisis, or not notice a significant injury until they sit down. For PDA people who are in near-constant low-level demand-response mode, this effect can be almost permanent.
Add to this the alexithymia that frequently co-occurs with autism and PDA: difficulty identifying and naming internal physical and emotional states. Research indicates that roughly half of all autistic individuals have significant alexithymic traits, far higher than the general population. In practical terms, this means that pain may register only as general unease, irritability, shutdown, or the need to be alone. It is not that the pain is not there. It is that the signals are not being interpreted accurately.
Research on autism and pain has found that autistic individuals often have difficulty recognizing and labeling their own physical sensations, making it genuinely hard to identify and communicate pain experiences accurately. Behavioural changes that would flag pain in a neurotypical person, like mood shifts, withdrawal, or increased meltdowns, are frequently attributed to autism itself, masking the underlying physical cause. Healthcare providers may also assume that behaviours expressing pain are simply autism-related behaviours, a pattern known as diagnostic overshadowing.
For PDA people, this is compounded further. The behaviours that might signal pain (shutting down, refusing to engage, needing to escape) look identical to the behaviours that signal demand overload. So everyone, including the person themselves, tends to read it as demand avoidance rather than as a body that is hurting and needs care.
The Post-Demand Crash and the Pain Reveal
Many PDA people will recognize this pattern even if they have never named it.
You hold everything together through a hard day, a difficult appointment, a social event, a stretch of sustained demands. You manage. You perform. You function. And then, when you finally get somewhere safe, somewhere low-demand, somewhere you can stop performing, the pain arrives.
Sometimes it is physical pain that was there all along and simply could not register while the nervous system was otherwise occupied. Sometimes it is the physical cost of the tension itself: headaches, muscle pain, exhaustion that goes beyond tiredness.
This is not a coincidence and it is not weakness. It is the body doing exactly what it needed to do to get through the demand-heavy period, and then releasing what it has been holding.
The problem is that this pattern makes it very difficult to connect cause and effect. If your knee hurts on Tuesday evening, but it was hurting since Monday morning and you only noticed it after the work meeting ended, it becomes hard to explain or track. Others may not believe the timeline. You may not fully trust your own timeline. And so the pain gets minimised, attributed to stress, and filed away.
The Medical Appointment Problem
Medical appointments are, for many PDA people, one of the highest-demand environments imaginable. You are expected to answer questions on a stranger's schedule, describe your symptoms accurately and concisely, follow instructions, use standardised pain scales that were not designed with neurodivergent nervous systems in mind, and do all of this in a setting where you have essentially no autonomy or control.
Research backs this up. Autistic adults consistently report that unpredictable wait times, sensory environments, communication differences, and provider assumptions create cascading barriers to care. Many report needing to mask in healthcare settings just to be taken seriously, which creates a painful bind: in order to receive help, you have to perform in ways that suppress the very signals you came to report.
The PDA response to that environment, for many people, is to mask. Not consciously. But the same nervous system response that masks pain in threatening or high-demand situations kicks in right there in the waiting room.
So the person who has been in significant pain for weeks walks into the appointment and presents as relatively fine. Their body language is composed. Their answers are measured. They may even downplay symptoms, not because they are lying but because the adrenaline of the appointment itself is masking what they came to report.
The clinician, seeing a person who does not appear to be in significant distress, may rate the complaint as low priority. The PDA person may leave without the care they needed. They may walk out feeling vaguely like they failed, or like they were not believed, or like the pain was perhaps not that bad after all.
And the cycle continues.
This dynamic is almost entirely absent from existing healthcare guidance on PDA, and from existing PDA community writing. It deserves to be named directly.
Ways To Show Support
If pain masking is this embedded in the PDA experience, then the way we check in with each other in our community matters.
A few things worth considering:
Asking about pain in low-demand ways. Direct questions can feel like demands, especially from someone whose nervous system is already on high alert. Instead of "are you in pain?" or "how bad is it?", lower-demand check-ins might sound like "how's your body been lately?" or simply offering presence without requiring a report.
Not reading shutdown as purely emotional. When someone in our community goes quiet, withdraws, or seems to be struggling, it is worth gently holding the possibility that there is physical pain involved, not just demand overload. The two are often happening at the same time.
Making it safe to disclose after the fact. Many of us only realize or admit we were in pain once we are past it. Creating space for that kind of delayed disclosure, without judgment, matters. "I was actually really struggling last week" deserves the same response whether it is said in the moment or three days later.
Supporting each other in medical settings. Having someone who understands PDA accompany you to appointments, or help you prepare what you want to say in advance, can reduce the demand load enough that the masking lessens slightly. Even writing down your pain history before the appointment, in your own words, in your own time, can help you present more accurately when you are there.
Trusting the crash. When someone in our community has a significant physical crash after a high-demand period, that is information. The body was holding something. It does not need to be immediately problem-solved: sometimes it just needs to be believed.
Closing Thoughts
Pain masking in PDA is not a quirk or an interesting footnote. For many of us, it is a pattern that has meant years of untreated or undertreated physical pain, medical encounters that left us feeling dismissed, and a persistent disconnection from what our own bodies are trying to tell us.
The existing writing on PDA masking barely touches this. The existing writing on autism and pain rarely centres the PDA profile. The existing writing on pain and healthcare almost never addresses what happens when the nervous system's demand-response is actively working against self-disclosure.
That gap is worth filling. Not just in articles, but in the way we show up for each other here.
If you recognized yourself in any part of this, you are not alone, and you are not making it up.
Sources
The following sources informed this article.
On PDA masking (the foundation for distinguishing pain masking from social masking)
Sally Cat — An Exploration of PDA Masking http://www.sallycatpda.co.uk/2024/05/an-exploration-of-pda-masking.html
Sally Cat — PDA Masking in Detail http://www.sallycatpda.co.uk/2021/10/pda-masking-in-detail.html
Neurodivergent Insights — What Is PDA in Autism? https://neurodivergentinsights.com/autism-pda-explained/
Reframing Autism — PDA and Autism: A Guide for Allies https://reframingautism.org.au/pathological-demand-avoidance-pda-and-autism-guide-for-allies/
On alexithymia and difficulty identifying physical sensations
Simply Psychology — Autism and Alexithymia: When Emotions Are Hard to Identify https://www.simplypsychology.org/autism-and-alexithymia.html
Neurodivergent Insights — Alexithymia in Autism and ADHD https://neurodivergentinsights.com/glossary/alexithymia/
Embrace Autism — Alexithymia and Autism Guide https://embrace-autism.com/alexithymia-and-autism-guide/
Cambridge Core — Investigating Alexithymia in Autism: A Systematic Review and Meta-Analysis (European Psychiatry, 2020) https://www.cambridge.org/core/journals/european-psychiatry/article/investigating-alexithymia-in-autism-a-systematic-review-and-metaanalysis/06F8AA96D03679353022A52E6ACE2F50
NIH / PMC — Alexithymia and Intolerance of Uncertainty Predict Somatic Symptoms in Autistic and Non-Autistic Adults https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10076343/
On autism, pain masking, and healthcare barriers
Neurodivergent Insights — The Double Empathy Problem in Medicine https://neurodivergentinsights.com/the-double-empathy-problem-in-medicine/
Autism Spectrum News — How Stigma Creates Invisible Barriers for Autistic Individuals in Healthcare https://autismspectrumnews.org/how-stigma-creates-invisible-barriers-for-autistic-individuals-in-healthcare/
NIH / PMC — I Am Afraid of Being Treated Badly If I Show It: Healthcare Accessibility and Autism Health Passports Among UK Autistic Adults https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11135756/
NIH / PMC — A Systematic Review of Barriers and Facilitators to Physical Healthcare Services for Autistic Adults https://pmc.ncbi.nlm.nih.gov/articles/PMC6647496/
Neurodiverse Counseling Services — Barriers to Healthcare and a Triple Empathy Problem: Adverse Outcomes for Autistic Adults https://www.neurodiversecounseling.com/counselor-education-resources/2024/9/19/barriers-to-healthcare-and-a-triple-empathy-problem-may-lead-to-adverse-outcomes-for-autistic-adults-a-qualitative-study-journal
NIH / PMC — Unmasking Compartment Syndrome in an Autistic Adolescent: Diagnostic Overshadowing and Pain Masking in Clinical Settings (Cureus, 2025) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12707551/