Unmasking the Truth: Understanding Masking in the Context of Neurodiversity

by | Oct 24, 2023 | Chronic Fatigue Syndrome, Depression, Home Page Display, Neurodiversity, Stress

Context of Neurodiversity

The Biological Cost of Masking: A Bottom-Up Functional Approach

Author: Rohan Smith | Functional Medicine Practitioner | Adelaide, SA

Quick Answer: What is the Impact of Masking on Health?

Masking is clinically associated with increased allostatic load—the cumulative physiological burden of chronic stress—and is linked to higher rates of anxiety, depression, and chronic fatigue (1, 2). Because masking relies on sustained top-down executive control, it is associated with increased energetic demand within the brain, particularly across stress-regulation and social cognition networks. Over time, this persistent stress activation may contribute to HPA axis dysregulation and neuro-inflammatory signalling, making gradual unmasking and physiological regulation important considerations in long-term recovery (3, 15).

The “Bottom-Up” Clinical Perspective

In functional medicine, a bottom-up approach focuses on addressing the biological foundations that support cognitive and emotional regulation, rather than targeting behavioural adaptation alone. When mitochondrial energy production is inefficient or the gut–brain axis is inflamed, the energetic and cognitive cost of sustained masking becomes increasingly difficult to maintain (4, 10). In clinical practice, we prioritise:

Cellular Foundations

Supporting adequate availability of micronutrients such as zinc, vitamin B6, and magnesium, which are involved in neurotransmitter synthesis and stress-response modulation (8, 11).

Autonomic Regulation

Interventions that support vagal tone and autonomic flexibility, helping shift the nervous system away from persistent sympathetic activation associated with social hyper-vigilance (12, 14).

Metabolic Efficiency

Identifying and addressing patterns of metabolic strain associated with prolonged cognitive effort and stress processing, particularly within prefrontal regulatory networks (5, 9).

The Consequences: From Social Camouflaging to Burnout

While masking may provide short-term social safety or occupational functioning, prolonged reliance on camouflaging behaviours is associated with several downstream physiological patterns:

Mitochondrial Stress Patterns

Chronic stress signalling may activate protective metabolic responses described in the Cell Danger Response model, in which cellular resources are preferentially allocated toward defence rather than optimal energy output (3, 13). This framework remains theoretical but is relevant in chronic stress states commonly seen in people seeking support for masking-related fatigue.

Neuroendocrine Strain

Persistent sympathetic dominance is associated with altered diurnal cortisol patterns and reduced stress resilience, rather than irreversible adrenal failure (7, 12).

Identity and Cognitive Load

The sustained cognitive effort required to maintain masking behaviours may reduce available capacity for self-reflection and interoceptive awareness, contributing to emotional exhaustion and identity strain (1, 6).

The Functional Medicine Edge: Assessing the Physiological Impact

Masking itself cannot be directly measured. Instead, functional medicine assessment focuses on downstream physiological patterns commonly associated with prolonged stress and burnout. When individuals report masking-related fatigue, evaluation may include:

Neurotransmitter Metabolite Patterns

Organic acids testing, such as the Mosaic Diagnostics Organic Acids Test (OAT), can assess metabolic by-products related to dopamine and serotonin pathways, which may be influenced by chronic stress exposure (10, 15).

Stress Hormone Rhythm Assessment

Evaluation of diurnal cortisol patterns to identify adaptive or maladaptive stress-response signalling.

Gut–Brain Axis Integrity

Assessment of intestinal permeability and microbiome balance, as gut-derived inflammatory signalling can contribute to sensory sensitivity and neuro-immune activation within the gut–brain axis (14).

Frequently Asked Questions (FAQ)

Is masking always a conscious choice?

No. For many neurodivergent individuals, masking develops as an automated protective strategy, often originating in childhood to reduce social threat or exclusion (1, 6).

How do I begin unmasking safely?

Unmasking is best approached as a gradual process of nervous system regulation, beginning with sensory safety, energy restoration, and physiological resilience rather than abrupt behavioural change (2, 12). This often overlaps with broader approaches to neurobiological stress regulation.

Can neurotypical individuals experience masking fatigue?

Yes. Although neurodivergent individuals may experience a higher neurological burden, anyone engaged in sustained self-suppression may accumulate allostatic load and burnout risk over time (7, 15).

Key Insights

  • Masking is associated with increased energetic and cognitive demand, rather than proven ATP depletion (5, 9).
  • A bottom-up approach prioritises physiological regulation to support mental capacity (4, 11).
  • Chronic camouflaging is increasingly recognised as a contributor to burnout and persistent fatigue patterns.
  • Functional testing helps map biological stress responses, informing personalised recovery strategies.

Support Your Authentic Self

Rebuilding energy begins with understanding the physiological toll of prolonged adaptation. At Elemental Health and Nutrition, care is grounded in neuro-affirming principles and a bottom-up functional approach to burnout recovery. When masking-related exhaustion affects health, targeted physiological assessment can help clarify appropriate next steps.

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References:

  1. Hull L, Petrides KV, Allison C, et al. “Putting on my best normal”: social camouflaging in adults on the autism spectrum. J Autism Dev Disord. 2017.
  2. Raymaker DM, Teo AR, Steckler NA, et al. “Having Beaten Every Trick in the Book”: autistic burnout in adult autistic people. Autism in Adulthood. 2020.
  3. Naviaux RK. Metabolic features of the cell danger response. Mitochondrion. 2014.
  4. Lord C, Brugha TS, Charman T, et al. Autism spectrum disorder. The Lancet. 2020.
  5. Miller D, Rees J, Pearson A. The costs of camouflaging: autistic burnout and mental health. J Autism Dev Disord. 2021.
  6. Cage E, Troxell-Whitman Z. Understanding the reasons, contexts and costs of camouflaging for autistic adults. J Autism Dev Disord. 2019.
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  8. Bjørklund G, Meguid NA, El-Bana MA, et al. The role of magnesium in autism spectrum disorder. Biol Trace Elem Res. 2020.
  9. Gaigg SB. The physiological correlates of clinical symptoms in autism spectrum disorder. Res Autism Spectr Disord. 2012.
  10. Rose S, Niyazov DM, Rossignol DA, et al. Mitochondrial dysfunction in autism spectrum disorder. CNS Neurosci Ther. 2018.
  11. Hyman SL, Levy SE, Myers SM. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020.
  12. Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic Journal of Medicine. 2009.
  13. Sinclair J, et al. Autistic burnout: a qualitative study of the phenomena. Autism. 2022.
  14. Cryan JF, O’Riordan KJ, Cowan CSM, et al. The microbiota-gut-brain axis. Physiol Rev. 2019.
  15. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet. 2020.