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This study will summarise the current emerging biopsychosocial factors for autistic individuals which can improve and/or maintain good physical, social and mental wellbeing.

There is a link between neurodevelopmental, physical and mental health conditions. Autism, which is a neurodevelopmental condition, will be the focus of this study. To be more specific, the relationship between trauma, camouflaging behavior, and chronic pain/fatigue conditions in Autism will be investigated. First, the literature shows that diagnosis of Autism in females is more difficult compared to males (Bargiela et al., 2016). Camouflaging behavior is one of the potential reasons for why less females get diagnosed with Autism. The detection of Autism in females becomes very difficult since they are more likely to engage in camouflaging behavior and to become experts in camouflaging (Baldwin and Costley, 2015). Therefore, it has been suggested that camouflaging behavior to appear more neurotypical should be included in the definition of the female autism phenotype (Holliday-Willey, 2014). Second, autistic people are more likely to be diagnosed with Post-traumatic Stress Disorder (PTSD) and complex PTSD. Autistic individuals, especially females, are more vulnerable to experiencing traumatic life events such as negative social events, and therefore have an increased risk for PTSD (Haruvi et al., 2020). In fact, autistic women are at risk for victimization by their partners including sexual abuse (Bigelow, 2011). Autistic people state that they use camouflaging strategies to achieve acceptance in personal and professional relationships, and to avoid possible traumatic events and harm (Hull et al., 2019). Therefore, these findings might suggest a relationship between PTSD and camouflaging. Lastly, chronic pain has been shown to be overrepresented in autistic people (Csecs et al., 2022), and those with PTSD (insert a reference which shows this). Chronic fatigue is more common in people diagnosed with PTSD (reference), and may be overrepresented in autistic individuals, although research is lacking. Chronic pain can be defined as a difficult physical condition where pain persists for more than three months (Blyth et al.,2001), while chronic fatigue can be defined as an extreme tiredness that lasts for at least six months (Yancey & Thomas, 2012). A large proportion of women who were diagnosed as autistic stated that they have chronic pain (Asztély et al., 2019). Likewise, PTSD is associated with chronic pain and fatigue (Roy-Byrne et al., 2004). Additionally, camouflaging might result in physical problems such as increased exhaustion and pain (Bradley et al., 2021). Based on these findings in the literature, the purpose of this study is to get a better understanding of the relationship between (PTSD), camouflaging behavior, and chronic pain/fatigue in Autism. To achieve this, a secondary data analysis using the relevant data from an already existing data set will be conducted.

The present study will be analysing data collected in a previous study. This data includes measures from a patient group with complex chronic conditions (CCCs), - Chronic pain (e.g., fibromyalgia) - Chronic fatigue (e.g., myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)) - Complex personality presentations (i.e., borderline/emotionally unstable personality disorder (BPD/EUPD), complex post-traumatic stress disorder (C-PTSD)) The present study will investigate a potential moderation relationship between autistic traits and increased rejection sensitivity (RS) in people with CCCs, using questionnaire measures of autistic traits (Ritvo Asperger and Autism Diagnostic Scale (RAADS; Ritvo et al., 2011); Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull et al., 2019), and rejection sensitivity (Rejection Sensitivity Adult Questionnaire (A-RSQ; Berenson et al., 2009).

Neurodivergence describes a set of neurodevelopmental conditions, such as Autism Spectrum Disorder (henceforth "Autism", Attention Deficit Hyperactivity Disorder, and Tourette's Syndrome. Neurodivergent people may think and perceive the world differently, interact with other people differently, and experience emotions in a unique way. We also know that being neurodivergent is linked with dramatically increased risks for mental and physical health conditions, where it is reported that up to 84% of neurodivergent adults suffer from poor health. Previous research from our group suggests that some patient populations, namely those with specific complex chronic conditions (CCCs) have especially high rates of "hidden", that is, undiagnosed neurodiversity. These complex chronic conditions include both physical and mental health conditions, specifically chronic pain and fatigue, and complex personality presentations (i.e., Borderline/Emotionally Intense/Emotionally Unstable Personality Disorder, Complex Posttraumatic stress disorder [C-PTSD]). This project aims to find out how many people with these complex chronic conditions meet criteria for autism or ADHD, and have associated traits. It is important to detect neurodivergence, and to adjust treatment and care options accordingly. Identifying the prevalence of neurodivergent traits in patients with CCCs is the first step in assessing commonalities in these populations, and ultimately finding targeted treatment opportunities. To do so, we recruited individuals with CCCs (diagnosis of chronic pain/fatigue and/or complex personality presentation), and individuals without CCCs. Participants were asked to fill out a survey that includes diagnostic screening questionnaires for autism and ADHD, and questionnaires assessing neurodivergent traits, such as masking/camouflaging behaviour, sensory sensitivities, rejection sensitivity, and dissociative experiences.

Loneliness is shown to have negative consequences for physical and mental health across cultures, lifespan, and clinical populations (for a recent review, see Quadt et al., 2020). The World Health Organization has declared loneliness a priority for researchers and care providers, given its potential adverse consequences, including depression (Cacioppo et al., 2010), anxiety (Anderson & Harvey, 1988), psychotic disorders (Lim et al., 2018), cardiovascular disease (Holt-Lunstad et al., 2015), chronic health conditions (Barlow et al., 2015), and immunological/inflammatory changes (Moieni et al., 2015). The surge of the Covid-19 pandemic and associated lockdown measures world-wide have added to the importance of understanding the potential consequences of feelings of loneliness. The term ‘loneliness’ can be quite elusive, being defined differently in everyday language, and also in academic research. It is often conceptualized as the actual or perceived absence of meaningful social interactions (Cacioppo et al., 2015; Weiss, 1973), although it is acknowledged that there is a qualitative difference between social isolation (number of social contacts) and feelings of loneliness (perceived lack of meaningful social contacts). Most standard self-report tools in loneliness research on adults ask how often a person feels lonely, or how many social contacts they have. Research has shown that it is the subjective experience of being distressed by loneliness that induces adverse health effects (Cacioppo et al., 2010; Matthews & Tye, 2019). It is therefore important for loneliness measures to explicitly pick up this dimension of loneliness and reliably distinguish feelings of distress associated with loneliness from chosen solitude that may not induce feelings of distress. The most commonly used loneliness measures to date touch on negative affect associated with loneliness through items such as “I have an unmet need for a close romantic relationship” (SELSA; DiTommaso & Spinner, 1993), “I miss having people around” (De Jong Gierveld Loneliness Scale; Gierveld & Tilburg, 2006), or “How often do you feel that your relationships with others are not meaningful?” (UCLA-LS; Russell, 1996). However, while it is assumed that this perceived lack of meaningful relationships will lead to distress, this may not always be the case. Similarly, populations believed to not be motivated for meaningful social interactions, such as autistic individuals (Chevallier et al., 2012), most likely actually feel distress at being lonely (Causton-Theoharis et al., 2009). Standard questionnaires about loneliness do not pick up these subtleties explicitly. We believe these to be of importance for detecting and distinguishing feeling states associated with loneliness. Therefore, the aim of this study is to modify the UCLA-LS, and add the question “How do you feel about this?” after each original item, with a unipolar 5 point Likert scale ranging from “Very bad” to “Very good”. These additional questions are designed to capture feelings of distress and contentment associated with loneliness (UCLA Loneliness, Distress and Contentment Scale; UCLA-LDC). In a large-scale survey, the goal is to assess the psychometric properties of a modified loneliness questionnaire, statistically test whether the added questions indeed assess the latent constructs of distress and contentment, and test whether they capture aspects of loneliness that multi-dimensional loneliness questionnaires, like the De Jong Gierveld Loneliness Scale, do not.