The Misdiagnosis of Autism as Depression

Join Dr. Regan for the third in this series on autism misdiagnosis. This episode focuses on the misdiagnosis of mood conditions for the autistic individual. Specifically bipolar disorder and depression are reviewed.  

Exhaustion in Autism: Balancing Momentum for Daily Activities

Recognizing Dysregulation on the Autism Spectrum: Fight, Flight, Freeze

Dr. Regan's Resources

New Course for Clinicians - Interventions in Autism: Helping Clients Stay Centered, Connect with Others, and Engage in Life

New Course for Clinicians: ASD Differential Diagnoses and Associated Characteristics

Book: Understanding Autism in Adults and Aging Adults, 2nd ed

Audiobook

Book: Understanding Autistic Behaviors

Autism in the Adult website homepage

Website Resources for Clinicians

Read the transcript here:

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Hello,

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this is Dr Theresa Regan.

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I'm glad you're joining us for today's episode of autism in the adult podcast.

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I am a neuropsychologist and the director and founder of a diagnostic autism clinic for adolescents through aging adults in central Illinois.

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I am an author,

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your podcast host, and the parent of a teen on the spectrum.

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You are joining us for the third episode in our series on misdiagnosis for those on the spectrum, and, at a very basic level,

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the diagnosis of autism is something that helps us distinguish whether the core emotions and behavioral patterns we see for an individual are the result of their neurology or the result of learning, life experiences, or willful behavior...

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that "this is a decision for me to respond this way."

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This is a really important starting point to understand the basis for the patterns that we experience or express.

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And this distinction helps us make good goals and use strategies that are most likely to help us reach the best outcomes for well being.

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Now,

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of course it would be too simplistic to say that a behavioral pattern could be the result entirely of neurology or experience.

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But because we often miss that neurology piece,

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I am highlighting it in this episode.

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Now,

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one of the things that happens for individuals who receive mental health diagnoses is that there's never even a starting point in the diagnostic process where neurology is invited into consideration into the differential.

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So the differential process is when we say,

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okay,

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these features could be present and these five diagnoses.

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Now we're going to do our detective work to figure out which diagnosis really matches this individual.

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If neurology is not in that process,

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of course,

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we're not going to find it,

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we're not looking for it,

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we're not looking at it.

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The assumption is that the experience of the individual stems from their life experience from their choices.

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Uh and that putting diagnoses into two categories of neurologic versus experiential.

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Um although it's not that simple,

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it is a starting point for the beginning framework.

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So,

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I want to raise this idea of neurology being considered in the diagnostic process as really an important place to start,

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because autism often is not considered as a possibility and the initial diagnostic process.

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Many autistic individuals on the spectrum,

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really,

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particularly adults, are given mental health diagnoses that may capture pieces of the picture.

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Um but that are not the best description of the person's overall pattern of experience and behavior,

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and also really missing the point of describing the neurology.

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Now,

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if you have not listened to the first episode in this series on misdiagnosis,

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please do that.

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The foundation for understanding each of these subsequent episodes is really in that first offering. The second episode covered misdiagnosis of personality disorders, and we specifically spent time talking about borderline personality and narcissistic personality.

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Now,

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today we are going to cover diagnoses that have to do with mood.

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So specifically including bipolar disorder and depression.

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Now,

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as in all the episodes in this series,

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we will not be discussing how to distinguish autism from mood conditions.

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This really is an important thing to understand because it's something that would require a skilled clinician to do with lots of training.

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Um it's really on a very individualized basis and it's beyond the scope of anyone podcast episode.

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We will,

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however,

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be covering why a mood diagnosis might be assigned to the autistic individual incorrectly while the autism diagnosis gets missed.

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I think that's an important thing that all of us can understand,

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"why does this happen."

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and then we can start discussions about this with our providers or family...

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so that we're really trying to get at that ability to start with the neurology included in the differential.

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So let's start with bipolar disorder.

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Now,

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at a basic level,

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bipolar describes things like manic episodes,

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lability of mood and emotional expression. 'Lability' 

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meaning that there's this quick change of emotional expression or these mood swings.

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Specifically,

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the following elements may be present in mania:

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inflated self esteem or grandiosity.

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So,

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feeling that the person really has a great knowledge,

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skill, and ability that other people don't.

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For some on the spectrum,

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there are qualities of categorical thinking,

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A love for facts and ideas and inventions, and difficulty understanding the perspectives of others.

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So,

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when these qualities are present,

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the individual may feel that their knowledge (particularly about their topics of greatest interest)... that their knowledge level or skill level is so exceptional that others really have a lot to learn from them... and as noted in the previous episode on personality,

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the individual on the spectrum with these characteristics might appear narcissistic or grandiose ... particularly regarding their

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particular interests.

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So let's say they love history and they dive in and perhaps they really...

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emphasize their skill level in this area and may feel that they are really well above people in their sphere...

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other people that they're interacting with. Another feature of mania that's recognizable to the clinician is a decreased need for sleep.

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So the person in the midst of a manic episode

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may be sleeping a lot less,

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may even stay up for a few days at a time.

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Sleep disturbance is a common characteristic in autism because the brain is in charge of sleep.

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So ... there is variability in what the sleep disturbance looks like for the autistic individual,

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including if it's present at all,

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but a common pattern for the autistic is this trouble falling asleep... very late

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sleeping,

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late waking, or sometimes even reversed sleep cycles.

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So I'm a person that goes to bed at two and wakes up at noon.

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There can even be at least seasons of time where this is an individual that will be up for two days at a time and just can't fall asleep for... three days.

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Sometimes they crash then from exhaustion and spend a lot of time in bed for a period before they're up and at it again.

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The decreased sleep,

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particularly if it's within a season of being even more difficult than usual for this individual...

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Again,

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staying up for days at a time...

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this can trigger concerns for mania in the individual who is actually on the autism spectrum.

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Another piece of mania that people can focus on when they meet someone on the spectrum (and again,

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miss that

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this could be part of autism) is increased talkativeness.

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So for the person with mania,

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they may have a very rapid speech pattern.

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They may not let the other person contribute to the conversation or slow down for the other person.

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It may be difficult to really follow.

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everything that's floating through their head and and coming out.

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so that the listener might feel lost in the case of mania.

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Now,

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for the person on the spectrum who loves to talk about really particular topics...

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they may dominate conversations without realizing it,

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or they may struggle to really understand when others need to stop or take a break or switch topics.

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They might resist talking about topics that they're not interested in.

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Perhaps where they're the listener and the other person is talking about things they enjoy,

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even though the autistic person really is not interested in that.

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And many people on the spectrum also feel like they have racing thoughts and it can be difficult to turn their brain off at night or when they have down time,

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that at least in seasons,

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racing thoughts can interfere with sleep,

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or they can't slow their thoughts down in order to pay attention to a class or a work project.

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And they may even dive deep into particular topics of interest to the extent that they seem obsessed with them in mania.

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You can picture the seasons of poor sleep,

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intense interest, racing thoughts,

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perhaps looking like a mania uh ... particularly if there's a season where these features are really emphasized, like...

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oh,

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I usually get a bit better sleep and now I'm just so into this topic,

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I've been up all night.

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The person with the mania may be distracted easily.

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So executive function...

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part of that is the ability to stay focused, to have flexible attention based on what's most important, to be able to concentrate well.

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Executive function is also an area of challenge for the autistic individual in some pattern.

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So the executive function difficulty for one person on the spectrum may look like distractibility.

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They may struggle with having too little attention for things that people want them to focus on,

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but also too much attention to other things that really capture their interest. Also within the bipolar realm,

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we can see this increase in goal directed activity or what's called psychomotor agitation,

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where,

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the person just can't stop...

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their motor is really running too high.

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The autistic individual who has a motor that's running too high.

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We call that dysregulation.

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And we talked about these concepts and issues when we focused on regulation.

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And one form of dysregulation in the neurologic sphere is when our internal motor is running too high...

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we're not centered in our activity level.

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And so this is an individual neurologically who may rock or pace or stay up all night researching fish tanks instead of sleeping.

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And this is dysregulation for the autistic individual that ...may look like a manic or a hypomanic episode.

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Another feature listed in the diagnostic manual for a manic episodes include engaging in activities that hold the potential for painful consequences.

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This would be things like ...purchasing lots of items,

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spending lots of money,

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for example.

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This characteristic may also be present for the autistic.

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If their executive function

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difficulty leads to poor planning of finances, and if their intense interests really lead to that hunger for more...

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"I want to add to my collection of interesting items,

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I want to add to my book series.

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I need to finish the series of things that I really love."

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Now... spending is not the only type of behavior that could lead to risk or consequences,

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but it's one example in this category of potentially risky activities.

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A characteristic of the bipolar individual may also be difficulty with emotional regulation which is called labile mood in bipolar ...where you have mood swings.

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So instead of being regulated,

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which again means centered with emotions,

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the individual with bipolar may experience difficulty with mood swings.

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So this ability to stay centered...

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and perhaps someone with dysregulation who has bipolar may become very upset or angry without much warning.

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Now,

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all individuals on the spectrum will struggle with emotional regulation.

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But the individual on the spectrum who leans toward externalized dysregulation...

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So "we let out all of this emotion"... a meltdown...

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this may be a person who rolls on the ground, or shouts, or throws

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things ... has crying spells.

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These are the external ...

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you know that... when they're dysregulated,

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it's very loud and noticeable.

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Well,

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this person on the spectrum who has externalized dysregulation,

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they are at risk of being misdiagnosed as bipolar.

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Now,

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the person who has quiet dysregulation... like I'm hiding,

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I'm retreating and withdrawing...

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That's the flight reaction.  Or... I'm frozen.

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I'm shut down.

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I've dissociated.

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This is the freeze reaction.

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These individuals on the spectrum are not likely to be diagnosed with bipolar.

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They may be diagnosed with other things like depression,

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which we'll talk about in a bit.

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So,

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one thing to remember is that the type of dysregulation for this specific autistic individual may influence what misdiagnoses they may be likely to receive.

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So someone with externalized fight reactions when dysregulated may look bipolar to a clinician who's not looking at the big neurologic picture.

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It is possible for an individual to have both bipolar and autism.

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However,

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most of the time that I see bipolar present,

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it's a misdiagnosis or it's assigned by clinicians who don't understand that emotional dysregulation is expected in autism,

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it doesn't need a separate label.

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Um,

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If the dysregulation is not explained by the autism diagnosis,

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then you also diagnose bipolar. And I think I've diagnosed both in about two of my clients out of nearly 550 assessments.

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So that could be particular to my clinic,

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but it does show you that really it's not a very common overlap,

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that most of the time when there's overlap there...

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just describing the fact that there's an externalized dysregulation when someone's overwhelmed.

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But that is to be expected. For the people that I did diagnose,

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I really was able to work with them over a long period of time and I could see acute episodes of mania that really were not typical for autism and were very different from their baseline of autistic dysregulation.

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Another thing to note is that medications typically are not going to change

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if the diagnosis switches from bipolar to autism.

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The medication choices tend to be symptom based and therefore not really dependent on the specific diagnosis as much as the presentation of the characteristics.

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So there may still be a mood stabilizer,

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for example,

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prescribed for someone who has difficulty 

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staying centered with emotions.

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Now,

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let's look at the diagnosis of depression,

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certainly the individual on the spectrum can have mood difficulties based on life struggles just as any human does.

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Um,

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in my experience,

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anxiety is much more inherent to the neurology of autism than depression,

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but depressed mood occurs secondary to struggles.

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Other characteristics that the autistic may have could be labeled as depression but appear to be a misdiagnosis ...

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trying to describe some neurologic characteristics.

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So if there's a misdiagnosis,

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what characteristics of autism would be likely misdiagnosed as part of a depressive episode or part of depression?

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Let's look at these examples.

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So,

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someone with a flat affect ...

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Affect is the emotions ... and in this case we're talking about emotions in the face and the voice.

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And for the individual on the spectrum,

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their neurology may be that there are muted expressions.

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There's a limited range of emotion that comes through the face and the voice so that there's a flatness or a lack of range in their nonverbal expression.

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And this can be part of what fits this criteria of nonverbal communication difficulties when there is not much emotional expression.

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Whether it's neurologic or not...

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another person may say,

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oh,

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this looks like the person is depressed.

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There could be this kind of hidden struggle inside,

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let's treat this person for depression,

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but this is an individual who says,

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gosh,

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I don't feel sad,

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I don't feel hopeless or helpless.

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I don't feel worthless.

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I don't feel discouraged.

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I feel fine,

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but people tell me I'm depressed.

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So I guess I must be...

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So that could be one person who's at risk for,

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misdiagnosis.

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And then of course the depression interventions,

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whether that's counseling or medication, are not going to change the neurology of that nonverbal expression.

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Also,

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there are a subset of individuals on the spectrum who struggle to consistently engage in things like self care...

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taking showers,

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brushing their teeth,

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wearing deodorant,

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eating regular...

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nutritious food,

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uh engaging in exercise,

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getting the sleep

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they need, cleaning the environment,

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working,

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engaging in relationships...

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If the individual rarely leaves the house,

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eats junk food,

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has a reversed sleep cycle,

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doesn't bathe,

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only plays video games...

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Others may conclude that this person is depressed,

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particularly if something in life has changed.

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For example,

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let's say the individual graduated from high school and really can't get going with life.

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The problem is that for the autistic individual,

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their neurology may struggle without structure and high school may have been that input that gave them a reason to get up in the morning, and to get going, and a place to go.

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And the removal of that structure could really lead to a loss of what we call behavioral momentum,

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which is neurologically based...

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creating their own structure and momentum (because of their neurology on the spectrum)...

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that can really be difficult.

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So, even in the absence of emotional struggle,

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you may see this real struggle to initiate behaviors and keep momentum for daily life.

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Now,

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speaking of momentum,

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the brain is in charge of this...

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The issue of getting started...

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let's get going with the task or behavior.

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Let's go,

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let's start,

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let's transition from a resting state to an active state.

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And in my book Understanding Autistic Behaviors,

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I have a chapter called The Physics of Behavior...

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just to explain these kinds of phenomenon where ... if we take the concept of inertia,

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for example,

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so this is a physics concept,

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that's something that is in a resting state

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tends to stay there unless there's energy put into moving it.

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So how do I get going from a resting state... from a stopped state?

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When the individual with autism is in a resting state,

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they may have difficulty getting going into a state of activity.

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Now,

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interestingly,

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the last section on mania describes the same difficulty of transitioning states,

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but this time it's in the opposite direction.

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So the brain should help us both start an activity and stop an activity depending on what's most meaningful,

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important, and healthy.

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Now.

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For the individual with autistic neurology,

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they may have difficulty neurologically doing this... so I can't get going, or when I'm going,

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I have not only momentum,

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but I'm accelerating and I can't stop.

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So,

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if you can't get going that can look like depression, and if you can't stop,

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that can look like mania ... and you can have these elements in the same person at different times.

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So the neurology has difficulty getting to the "just right state" of activity level. Fourth,

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and finally,

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the social withdrawal in autism can also be mistaken for depression.

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So the individual on the spectrum who is content to have alone time, to not leave the house for periods of time, to engage in solitary pursuits... may appear depressed to people who prefer a lot more social interaction and activity.

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Uh,

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So let's talk and visit and talk about our lives...

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Let's play games,

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Let's watch a movie.

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Let's have people over for dinner, and when the individual on the spectrum resists this level of interaction,

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others may wonder if there's a mood issue present and ... kind of at the root of this difficulty.

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So ...certain individuals on the spectrum can struggle significantly with depressed mood....

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But this section highlights,

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that depressed mood can also be misapplied ... and sometimes can prevent the person from getting a really accurate diagnosis of autism because there's this assumption that this must be depression. Now because we've talked about behavioral momentum and we've talked about getting going with activities.

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I'm going to link a few of our previous podcast series that cover these issues.

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I did a series on exhaustion in autism... and issues of gaining and keeping momentum for daily activities.

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This started in September of 2021, and I will put a link to that first episode.

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But there are a couple in that series

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you might want to review.

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I also did a series on dysregulation and autism... and what that can look like, and what to do to prevent dysregulation, to recover from dysregulation, and to recognize dysregulation...

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and that series started in January of 2022.

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I will also link the first episode down in the show notes.

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Thank you for joining me for this episode about mood and autism,

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and we are going to keep talking about this important subject of misdiagnosis in autism

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next time when we focus on anxiety based conditions,

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I hope you join me then.