By Dr Robert Baylis, Consultant in Pain Medicine and Pain Medicine Expert Witness.
Neurodiversity is a natural variation in brain function (autism, ADHD, dyslexia, dyspraxia, Tourette syndrome), now a frequent clinical diagnosis. It alters how the nervous system processes pain, which is directly relevant to personal injury, clinical negligence, employment and disability claims and, on top of that, it changes how pain is shown, through masking. Understanding why requires taking the two apart in order: the underlying biology first, then the psychological layer of felt experience and expression it produces, and finally the social behaviour, masking, that sits on top of both.
Chronic Pain Is No Longer “Just” a Symptom
Chronic pain, lasting more than three months, is no longer seen simply as a symptom of underlying pathology. It is now recognised as a complex neurobiological response to multiple factors: biomedical, psychological and social. Neurodevelopmental differences may alter that pain experience at each of these levels, which is why this framework follows the same biopsychosocial sequence: biology, then psychology, then the social presentation that a legal audience actually observes.
This matters in practice because neurodivergent individuals show higher rates of chronic pain, diagnostic delay, increased disability, poorer level of function, increased healthcare use alongside difficulty with engagement, and associated mental health difficulties.
The Biology: Why Neurodivergent Nervous Systems Process Pain Differently
Some of the processes thought to underlie neurodivergence also appear to affect pain processing directly. Pain is a protective output influenced by sensory processing, emotions, expectations and previous experience – all of which are altered in neurodivergence.
Neurodivergent nervous systems differ in four recurring respects:
- Sensory amplification
- Interoceptive differences
- Executive dysfunction
- Autonomic dysregulation
Autism and Pain. In autism, pain presentation is affected by hypersensitivity or hyposensitivity, pain masking, difficulty describing symptoms, and sensory overload.
ADHD and Pain. In ADHD, relevant associations include altered dopamine, sleep disturbance, hypermobility, and higher rates of migraine, fibromyalgia and chronic back pain.
Common Co-Existing Conditions. A recognisable cluster of conditions co-exists more frequently in neurodivergent individuals: fibromyalgia, migraine, hypermobile Ehlers-Danlos Syndrome, POTS, IBS and chronic fatigue.
Sensory Processing and the Clinical Environment. Sensory processing can be altered by noise, light, touch and temperature. Busy clinical environments can worsen pain, a relevant factor when considering how a claimant presents during a formal medico-legal assessment.
The Psychology: Feeling Pain Differently, and Struggling to Describe It
These biological differences don’t just change how much pain is felt, they change whether it can be accurately felt, located and put into words at all. This is where interoception and alexithymia become central. They are distinct concepts but interact closely, and together they explain why neurodivergent claimants may feel pain differently, express it differently, and genuinely struggle to do either.
Interoception is the brain’s ability to perceive, interpret and respond to signals arising from within the body, including pain, hunger, thirst, heart rate, muscle tension, temperature, fatigue, breathlessness, bladder fullness and nausea.
Many autistic and ADHD individuals experience differences in interoceptive processing. This may mean they detect internal sensations later than other people, struggle to localise pain, misinterpret bodily sensations, have difficulty recognising increasing pain until it becomes severe, or find it difficult to distinguish between different bodily sensations. A patient may, for example, struggle to determine whether they are experiencing anxiety, muscle tension, gastrointestinal discomfort, migraine, fatigue or musculoskeletal pain, because the internal signals themselves are difficult to interpret. Good pain management relies on recognising early warning signs, and some neurodivergent patients may not recognise worsening pain until it becomes overwhelming, knowing something feels wrong without being able to explain where, when, how severe, or what type of pain it is. This can make clinical assessment more challenging.
Alexithymia literally means “no words for emotions.” It is characterised by difficulty recognising emotions, describing emotions, distinguishing emotional states from physical sensations, and interpreting bodily responses. It occurs more frequently in autistic populations than in the general population, although it is not unique to them.
Alexithymia matters because pain is never purely sensory, it involves emotional processing, attention, expectation, memory and threat perception. If someone cannot identify an emotional state, that state may instead be experienced as a physical symptom: “I feel terrible” rather than “I feel frightened” or “I feel overwhelmed.”
Because of this, patients may struggle to answer pain questionnaires, appear vague, provide inconsistent histories, find pain scales difficult, or have difficulty identifying triggers. This can mistakenly be interpreted as being a poor historian, exaggeration, malingering or somatisation, when in reality it reflects differences in emotional and interoceptive processing.
Traditional pain assessment often assumes patients can accurately report location, severity, quality, timing and triggers. Patients with interoceptive differences or alexithymia may genuinely struggle to provide this information. In medico-legal settings, communication difficulties may be mistaken for unreliability. Expert witnesses should consider whether interoceptive or alexithymic differences affect symptom reporting, rather than assuming inconsistency or lack of credibility.
Interoceptive differences and alexithymia do not mean that pain is less real or less severe. Instead, they can make pain harder to recognise, harder to describe, and therefore easier to underestimate.
The Social Layer: Masking
On top of these biological and psychological differences sits a further layer of behaviour: masking. This is how a claimant presents to the outside world, including, critically, in a single medico-legal consultation and it is where the gap between actual disability and observed disability widens further.
Masking, sometimes called camouflaging, is the conscious or unconscious suppression or compensation of natural neurodivergent behaviours in order to appear neurotypical. In practice this can include maintaining eye contact despite discomfort, rehearsing conversations in advance, copying social behaviours, smiling despite severe pain, minimising symptoms, avoiding asking for help, and continuing to work despite deteriorating health.
Neurodivergent people mask for a range of reasons: to avoid stigma, fear of discrimination, previous negative healthcare experiences, fear of not being believed, workplace pressures, cultural expectations, or simply a desire to appear “normal.”
Clinicians are trained to observe how a patient presents during a consultation. With neurodivergent patients, this can be misleading. Many autistic and ADHD adults have spent decades learning to imitate neurotypical behaviour, forcing eye contact, suppressing repetitive movements, rehearsing socially acceptable responses, and consciously hiding distress. The same strategy is often used to hide pain. A single consultation may represent the patient’s best performance rather than their usual level of functioning.
This has a direct bearing on credibility in medico-legal settings. Assumptions that should be avoided include: good eye contact meaning credible, working meaning not disabled, calm appearance meaning mild pain, and articulate meaning low functional impairment.
A more reliable assessment instead focuses on: recovery time after work, recovery time after appointments, energy expenditure, variable functioning, family observations, occupational adjustments, and longitudinal evidence. Appearance during a single consultation should never be used as the sole indicator of disability.
A robust assessment should consider day-to-day variability, functional capacity over a working week, the cumulative effect of masking, the recovery time required after ordinary activities, and evidence from employers, family members, occupational therapists and treating clinicians. A person who appears articulate, calm and professionally dressed during a one-hour assessment may still meet the legal definition of disability if they experience substantial and long-term impairment in everyday functioning. Masking can make disability invisible, but it does not make disability absent.
Bringing It Together: The Legal Perspective
Taken together – altered biological pain processing, a psychological layer that makes that pain harder to feel accurately and harder to describe, and a social layer of masking that actively conceals what remains, this has clear implications for litigation.
Employment Tribunals frequently encounter individuals who have maintained employment through extraordinary effort, only for that effort to be invisible in a single assessment. Personal injury claims may underestimate disability where the claimant appeared composed during examination. Clinical negligence cases may involve delayed diagnosis where symptoms were minimised by the patient. The Equality Act focuses on functional impact rather than outward appearance, and masking can create a substantial gap between observed presentation and actual disability that any assessment needs to account for.
Key Messages
- Neurodivergent processing differences can alter how pain is felt and interpreted at source – this is the starting point, not an afterthought.
- Interoception and alexithymia can make pain genuinely harder to recognise and describe. Treat vague or inconsistent reporting as a possible sign of this, not automatically as unreliability.
- Masking is a survival strategy with a real psychological cost, layered on top of the above – not a sign of a milder underlying condition.
- Assess function, not appearance: recovery time, energy expenditure, variable functioning, and longitudinal evidence over a single consultation.
- Believe pain. Masking can make disability invisible – it does not make it absent.
Conclusion
Neurodivergent claimants require an assessment approach that accounts for altered pain processing, interoceptive and sensory differences, atypical symptom description, and masking. Working through that sequence — biology, then psychology, then the social presentation it produces — rather than starting from how a claimant appears in the room, is the principle that should guide it.
Related Insights
Chronic Pain, Neurodiversity and the Courts, by Dr Jon Valentine
Chronic Pain Without Demonstrable Physical Pathology, by Dr Mike Sidery
Chronic Pain, FND, and the Brain, by Dr Mike Sidery
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FAQs
What is masking, and why does it matter for a medico-legal assessment?
Masking is the conscious or unconscious suppression of neurodivergent traits to appear neurotypical, including maintaining eye contact, minimising symptoms, or continuing to work despite deteriorating health. A single assessment may capture a claimant’s best performance rather than their usual level of functioning, so appearance during examination should never be used as the sole indicator of disability.
Why do neurodivergent claimants sometimes give inconsistent or vague accounts of their pain?
Interoceptive differences and alexithymia can make it genuinely difficult to detect, localise and describe internal sensations, including pain and emotional states. What can look like a poor historian, exaggeration or inconsistency often reflects differences in how the nervous system processes and communicates these signals, not unreliability.
Does a calm or composed presentation during an assessment mean a claimant is not significantly disabled?
No. A person who appears articulate, calm and professionally dressed during a one-hour assessment may still meet the legal definition of disability if they experience substantial and long-term impairment in everyday functioning. Recovery time after work or appointments, energy expenditure and family or occupational observations are more reliable indicators than presentation on the day.
What should an assessment focus on instead of appearance during the consultation?
Day-to-day variability, functional capacity over a working week, the cumulative effect of masking, recovery time after ordinary activities, and evidence from employers, family members, occupational therapists and treating clinicians.
What areas of litigation does this affect?
Employment Tribunal claims involving individuals who have maintained employment through extraordinary effort, personal injury claims where disability may be underestimated due to a composed presentation, and clinical negligence claims involving delayed diagnosis due to minimised symptoms.
