Autism Spectrum Disorder or Social Anxiety Disorder? A clinical and psychopathological approach to differential diagnosis

Abstract

Introduction: The increasing clinical recognition of autism spectrum disorder has improved access to diagnosis, but it has also increased the risk of automatically attributing social withdrawal, interpersonal discomfort, and sensory hypersensitivity to autism. Objective: To review, from a clinical and psychopathological perspective, the differential diagnosis between autism spectrum disorder and social anxiety disorder, emphasizing sensory processing, anxious dissociation, social cognition, camouflaging, and comorbidities. Method: Narrative review conducted according to SANRA (Scale for the Assessment of Narrative Review Articles) recommendations, based on a targeted search of PubMed/MEDLINE, clinical guidelines, institutional sources, scientific publisher databases, and reference works in psychiatry, psychopathology, and neurodevelopment. Search terms were combined around autism spectrum disorder, social anxiety disorder, social phobia, sensory processing, camouflaging, intolerance of uncertainty, alexithymia, differential diagnosis, and psychopathology. Results: Social anxiety disorder is mainly organized around fear of negative evaluation, anticipatory shame, hypervigilance, and avoidance. Autism involves persistent neurodevelopmental changes in social reciprocity, pragmatic communication, behavioral flexibility, and sensory processing. Similar symptoms, such as avoiding parties, reduced eye contact, or distress with noise, may arise from different mechanisms. Recent studies highlight intolerance of uncertainty, sensory hypersensitivity, alexithymia, emotion regulation, and social camouflaging as factors of clinical overlap. Conclusion: Differential diagnosis requires longitudinal developmental history, psychopathological examination, assessment of social cognition, family or school information, and clinical/pharmacological review. Standardized instruments should support, but not replace, clinical formulation. The main contribution is to propose a mechanistic and hierarchical framework to avoid rapid equivalences between nonspecific signs and diagnostic categories.