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: 1 00:00:06,900 -- 00:00:07,470 Hello, 2 00:00:07,470 -- 00:00:09,420 this is Dr Theresa Regan. 3 00:00:09,430 -- 00:00:15,040 I'm glad you're joining us for today's episode of autism in the adult podcast. 4 00:00:15,050 -- 00:00:25,570 I am a neuropsychologist and the director and founder of a diagnostic autism clinic for adolescents through aging adults in central Illinois. 5 00:00:25,580 -- 00:00:26,940 I am an author, 6 00:00:26,940 -- 00:00:30,600 your podcast host, and the parent of a teen on the spectrum. 7 00:00:31,550 -- 00:00:41,780 You are joining us for the third episode in our series on misdiagnosis for those on the spectrum, and, at a very basic level, 8 00:00:41,790 -- 00:01:02,980 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... 9 00:01:02,990 -- 00:01:07,290 that "this is a decision for me to respond this way." 10 00:01:08,530 -- 00:01:15,470 This is a really important starting point to understand the basis for the patterns that we experience or express. 11 00:01:15,480 -- 00:01:24,730 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. 12 00:01:25,400 -- 00:01:25,820 Now, 13 00:01:25,820 -- 00:01:35,170 of course it would be too simplistic to say that a behavioral pattern could be the result entirely of neurology or experience. 14 00:01:35,180 -- 00:01:39,780 But because we often miss that neurology piece, 15 00:01:39,790 -- 00:01:42,280 I am highlighting it in this episode. 16 00:01:44,100 -- 00:01:44,390 Now, 17 00:01:44,390 -- 00:02:02,060 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. 18 00:02:02,070 -- 00:02:04,980 So the differential process is when we say, 19 00:02:04,990 -- 00:02:05,440 okay, 20 00:02:05,440 -- 00:02:10,040 these features could be present and these five diagnoses. 21 00:02:10,040 -- 00:02:18,090 Now we're going to do our detective work to figure out which diagnosis really matches this individual. 22 00:02:18,100 -- 00:02:21,170 If neurology is not in that process, 23 00:02:21,180 -- 00:02:22,010 of course, 24 00:02:22,010 -- 00:02:23,420 we're not going to find it, 25 00:02:23,430 -- 00:02:24,710 we're not looking for it, 26 00:02:24,710 -- 00:02:26,140 we're not looking at it. 27 00:02:28,140 -- 00:02:35,880 The assumption is that the experience of the individual stems from their life experience from their choices. 28 00:02:35,890 -- 00:02:43,440 Uh and that putting diagnoses into two categories of neurologic versus experiential. 29 00:02:43,450 -- 00:02:46,660 Um although it's not that simple, 30 00:02:46,670 -- 00:02:50,470 it is a starting point for the beginning framework. 31 00:02:50,480 -- 00:02:50,840 So, 32 00:02:50,840 -- 00:02:58,750 I want to raise this idea of neurology being considered in the diagnostic process as really an important place to start, 33 00:03:00,000 -- 00:03:06,830 because autism often is not considered as a possibility and the initial diagnostic process. 34 00:03:06,830 -- 00:03:09,640 Many autistic individuals on the spectrum, 35 00:03:09,640 -- 00:03:10,250 really, 36 00:03:10,260 -- 00:03:18,750 particularly adults, are given mental health diagnoses that may capture pieces of the picture. 37 00:03:19,140 -- 00:03:26,570 Um but that are not the best description of the person's overall pattern of experience and behavior, 38 00:03:26,570 -- 00:03:31,920 and also really missing the point of describing the neurology. 39 00:03:32,780 -- 00:03:33,180 Now, 40 00:03:33,180 -- 00:03:38,500 if you have not listened to the first episode in this series on misdiagnosis, 41 00:03:38,500 -- 00:03:40,070 please do that. 42 00:03:40,080 -- 00:03:59,860 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. 43 00:03:59,880 -- 00:04:00,360 Now, 44 00:04:00,360 -- 00:04:05,330 today we are going to cover diagnoses that have to do with mood. 45 00:04:05,370 -- 00:04:09,990 So specifically including bipolar disorder and depression. 46 00:04:11,250 -- 00:04:11,550 Now, 47 00:04:11,550 -- 00:04:13,970 as in all the episodes in this series, 48 00:04:13,970 -- 00:04:20,300 we will not be discussing how to distinguish autism from mood conditions. 49 00:04:20,310 -- 00:04:30,740 This really is an important thing to understand because it's something that would require a skilled clinician to do with lots of training. 50 00:04:30,750 -- 00:04:38,270 Um it's really on a very individualized basis and it's beyond the scope of anyone podcast episode. 51 00:04:39,030 -- 00:04:39,690 We will, 52 00:04:39,690 -- 00:04:40,280 however, 53 00:04:40,280 -- 00:04:52,160 be covering why a mood diagnosis might be assigned to the autistic individual incorrectly while the autism diagnosis gets missed. 54 00:04:52,170 -- 00:04:56,290 I think that's an important thing that all of us can understand, 55 00:04:56,290 -- 00:04:57,650 "why does this happen." 56 00:04:57,660 -- 00:05:03,290 and then we can start discussions about this with our providers or family... 57 00:05:03,490 -- 00:05:12,120 so that we're really trying to get at that ability to start with the neurology included in the differential. 58 00:05:13,970 -- 00:05:16,370 So let's start with bipolar disorder. 59 00:05:16,380 -- 00:05:16,940 Now, 60 00:05:16,940 -- 00:05:17,920 at a basic level, 61 00:05:17,920 -- 00:05:21,790 bipolar describes things like manic episodes, 62 00:05:21,800 -- 00:05:26,120 lability of mood and emotional expression. 'Lability' 63 00:05:26,120 -- 00:05:34,190 meaning that there's this quick change of emotional expression or these mood swings. 64 00:05:35,100 -- 00:05:36,210 Specifically, 65 00:05:36,210 -- 00:05:39,670 the following elements may be present in mania: 66 00:05:39,680 -- 00:05:43,560 inflated self esteem or grandiosity. 67 00:05:43,570 -- 00:05:44,010 So, 68 00:05:44,010 -- 00:05:48,050 feeling that the person really has a great knowledge, 69 00:05:48,050 -- 00:05:50,460 skill, and ability that other people don't. 70 00:05:50,990 -- 00:05:52,980 For some on the spectrum, 71 00:05:52,990 -- 00:05:56,600 there are qualities of categorical thinking, 72 00:05:56,610 -- 00:06:04,770 A love for facts and ideas and inventions, and difficulty understanding the perspectives of others. 73 00:06:04,780 -- 00:06:05,230 So, 74 00:06:05,230 -- 00:06:07,810 when these qualities are present, 75 00:06:07,820 -- 00:06:27,390 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, 76 00:06:27,400 -- 00:06:37,410 the individual on the spectrum with these characteristics might appear narcissistic or grandiose ... particularly regarding their 78 00:06:38,330 -- 00:06:39,930 particular interests. 79 00:06:39,930 -- 00:06:48,140 So let's say they love history and they dive in and perhaps they really... 80 00:06:48,150 -- 00:06:57,460 emphasize their skill level in this area and may feel that they are really well above people in their sphere... 81 00:06:57,470 -- 00:07:08,640 other people that they're interacting with. Another feature of mania that's recognizable to the clinician is a decreased need for sleep. 82 00:07:08,650 -- 00:07:12,580 So the person in the midst of a manic episode 83 00:07:12,590 -- 00:07:15,380 may be sleeping a lot less, 84 00:07:15,390 -- 00:07:18,660 may even stay up for a few days at a time. 85 00:07:19,550 -- 00:07:26,130 Sleep disturbance is a common characteristic in autism because the brain is in charge of sleep. 86 00:07:26,140 -- 00:07:33,350 So ... there is variability in what the sleep disturbance looks like for the autistic individual, 87 00:07:33,360 -- 00:07:35,840 including if it's present at all, 88 00:07:35,850 -- 00:07:43,080 but a common pattern for the autistic is this trouble falling asleep... very late 89 00:07:43,090 -- 00:07:44,180 sleeping, 90 00:07:44,190 -- 00:07:48,350 late waking, or sometimes even reversed sleep cycles. 91 00:07:48,350 -- 00:07:52,810 So I'm a person that goes to bed at two and wakes up at noon. 93 00:07:53,730 -- 00:08:03,670 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. 94 00:08:03,680 -- 00:08:13,580 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. 95 00:08:14,870 -- 00:08:16,110 The decreased sleep, 96 00:08:16,120 -- 00:08:23,140 particularly if it's within a season of being even more difficult than usual for this individual... 97 00:08:23,150 -- 00:08:23,690 Again, 98 00:08:23,690 -- 00:08:25,730 staying up for days at a time... 99 00:08:25,740 -- 00:08:32,930 this can trigger concerns for mania in the individual who is actually on the autism spectrum. 100 00:08:34,480 -- 00:08:43,840 Another piece of mania that people can focus on when they meet someone on the spectrum (and again, 101 00:08:43,840 -- 00:08:45,100 miss that 102 00:08:45,100 -- 00:08:48,830 this could be part of autism) is increased talkativeness. 103 00:08:49,920 -- 00:08:53,560 So for the person with mania, 104 00:08:53,570 -- 00:08:57,630 they may have a very rapid speech pattern. 105 00:08:57,640 -- 00:09:04,630 They may not let the other person contribute to the conversation or slow down for the other person. 106 00:09:04,640 -- 00:09:08,110 It may be difficult to really follow. 108 00:09:08,760 -- 00:09:14,010 everything that's floating through their head and and coming out. 110 00:09:14,450 -- 00:09:18,390 so that the listener might feel lost in the case of mania. 111 00:09:19,520 -- 00:09:20,000 Now, 112 00:09:20,000 -- 00:09:25,900 for the person on the spectrum who loves to talk about really particular topics... 114 00:09:27,000 -- 00:09:30,680 they may dominate conversations without realizing it, 115 00:09:30,690 -- 00:09:37,740 or they may struggle to really understand when others need to stop or take a break or switch topics. 116 00:09:37,750 -- 00:09:42,550 They might resist talking about topics that they're not interested in. 117 00:09:42,560 -- 00:09:50,470 Perhaps where they're the listener and the other person is talking about things they enjoy, 118 00:09:50,480 -- 00:09:55,580 even though the autistic person really is not interested in that. 119 00:09:57,080 -- 00:10:07,670 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, 120 00:10:07,680 -- 00:10:09,700 that at least in seasons, 121 00:10:09,710 -- 00:10:12,650 racing thoughts can interfere with sleep, 122 00:10:12,660 -- 00:10:21,530 or they can't slow their thoughts down in order to pay attention to a class or a work project. 123 00:10:22,520 -- 00:10:30,370 And they may even dive deep into particular topics of interest to the extent that they seem obsessed with them in mania. 125 00:10:32,950 -- 00:10:35,810 You can picture the seasons of poor sleep, 126 00:10:35,820 -- 00:10:38,270 intense interest, racing thoughts, 127 00:10:38,280 -- 00:10:50,290 perhaps looking like a mania uh ... particularly if there's a season where these features are really emphasized, like... 128 00:10:50,300 -- 00:10:50,530 oh, 129 00:10:50,530 -- 00:10:55,700 I usually get a bit better sleep and now I'm just so into this topic, 130 00:10:55,710 -- 00:10:57,790 I've been up all night. 131 00:11:00,510 -- 00:11:04,320 The person with the mania may be distracted easily. 132 00:11:04,330 -- 00:11:07,130 So executive function... 133 00:11:07,140 -- 00:11:17,730 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. 134 00:11:17,730 -- 00:11:24,830 Executive function is also an area of challenge for the autistic individual in some pattern. 135 00:11:25,640 -- 00:11:32,470 So the executive function difficulty for one person on the spectrum may look like distractibility. 136 00:11:33,980 -- 00:11:41,170 They may struggle with having too little attention for things that people want them to focus on, 137 00:11:41,180 -- 00:11:49,720 but also too much attention to other things that really capture their interest. Also within the bipolar realm, 138 00:11:49,730 -- 00:11:56,240 we can see this increase in goal directed activity or what's called psychomotor agitation, 139 00:11:56,240 -- 00:11:56,710 where, 141 00:11:57,300 -- 00:11:59,480 the person just can't stop... 142 00:11:59,480 -- 00:12:02,790 their motor is really running too high. 143 00:12:03,710 -- 00:12:08,500 The autistic individual who has a motor that's running too high. 144 00:12:08,510 -- 00:12:11,140 We call that dysregulation. 145 00:12:11,150 -- 00:12:17,020 And we talked about these concepts and issues when we focused on regulation. 146 00:12:17,030 -- 00:12:25,690 And one form of dysregulation in the neurologic sphere is when our internal motor is running too high... 147 00:12:25,700 -- 00:12:30,490 we're not centered in our activity level. 148 00:12:30,710 -- 00:12:40,720 And so this is an individual neurologically who may rock or pace or stay up all night researching fish tanks instead of sleeping. 149 00:12:41,520 -- 00:12:50,970 And this is dysregulation for the autistic individual that ...may look like a manic or a hypomanic episode. 150 00:12:52,390 -- 00:13:04,030 Another feature listed in the diagnostic manual for a manic episodes include engaging in activities that hold the potential for painful consequences. 151 00:13:04,040 -- 00:13:09,000 This would be things like ...purchasing lots of items, 152 00:13:09,000 -- 00:13:10,200 spending lots of money, 153 00:13:10,200 -- 00:13:11,440 for example. 154 00:13:13,190 -- 00:13:16,980 This characteristic may also be present for the autistic. 155 00:13:16,990 -- 00:13:18,680 If their executive function 156 00:13:18,680 -- 00:13:30,040 difficulty leads to poor planning of finances, and if their intense interests really lead to that hunger for more... 157 00:13:30,050 -- 00:13:33,600 "I want to add to my collection of interesting items, 158 00:13:33,600 -- 00:13:36,200 I want to add to my book series. 159 00:13:36,200 -- 00:13:40,190 I need to finish the series of things that I really love." 160 00:13:42,820 -- 00:13:48,480 Now... spending is not the only type of behavior that could lead to risk or consequences, 161 00:13:48,480 -- 00:13:53,800 but it's one example in this category of potentially risky activities. 162 00:13:55,100 -- 00:14:07,750 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. 163 00:14:07,760 -- 00:14:10,840 So instead of being regulated, 164 00:14:10,850 -- 00:14:16,100 which again means centered with emotions, 165 00:14:17,000 -- 00:14:23,060 the individual with bipolar may experience difficulty with mood swings. 166 00:14:23,070 -- 00:14:25,630 So this ability to stay centered... 168 00:14:27,620 -- 00:14:36,770 and perhaps someone with dysregulation who has bipolar may become very upset or angry without much warning. 169 00:14:38,670 -- 00:14:39,180 Now, 170 00:14:39,190 -- 00:14:44,450 all individuals on the spectrum will struggle with emotional regulation. 171 00:14:44,460 -- 00:14:50,810 But the individual on the spectrum who leans toward externalized dysregulation... 172 00:14:50,820 -- 00:14:55,880 So "we let out all of this emotion"... a meltdown... 173 00:14:55,890 -- 00:15:00,240 this may be a person who rolls on the ground, or shouts, or throws 174 00:15:00,240 -- 00:15:02,850 things ... has crying spells. 175 00:15:02,870 -- 00:15:04,960 These are the external ... 176 00:15:04,970 -- 00:15:07,160 you know that... when they're dysregulated, 177 00:15:07,170 -- 00:15:09,800 it's very loud and noticeable. 178 00:15:10,530 -- 00:15:11,060 Well, 179 00:15:11,060 -- 00:15:15,910 this person on the spectrum who has externalized dysregulation, 180 00:15:15,950 -- 00:15:20,010 they are at risk of being misdiagnosed as bipolar. 181 00:15:21,340 -- 00:15:21,640 Now, 182 00:15:21,640 -- 00:15:27,650 the person who has quiet dysregulation... like I'm hiding, 183 00:15:27,650 -- 00:15:30,230 I'm retreating and withdrawing... 184 00:15:30,240 -- 00:15:34,930 That's the flight reaction. Or... I'm frozen. 185 00:15:34,940 -- 00:15:36,000 I'm shut down. 186 00:15:36,000 -- 00:15:37,630 I've dissociated. 188 00:15:38,830 -- 00:15:40,940 This is the freeze reaction. 189 00:15:41,810 -- 00:15:47,990 These individuals on the spectrum are not likely to be diagnosed with bipolar. 190 00:15:48,050 -- 00:15:51,910 They may be diagnosed with other things like depression, 191 00:15:51,910 -- 00:15:53,540 which we'll talk about in a bit. 192 00:15:55,690 -- 00:15:56,040 So, 193 00:15:56,040 -- 00:16:10,430 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. 194 00:16:10,440 -- 00:16:22,290 So someone with externalized fight reactions when dysregulated may look bipolar to a clinician who's not looking at the big neurologic picture. 195 00:16:24,540 -- 00:16:29,980 It is possible for an individual to have both bipolar and autism. 196 00:16:29,980 -- 00:16:30,900 However, 197 00:16:30,910 -- 00:16:34,160 most of the time that I see bipolar present, 198 00:16:34,170 -- 00:16:43,230 it's a misdiagnosis or it's assigned by clinicians who don't understand that emotional dysregulation is expected in autism, 199 00:16:43,240 -- 00:16:46,260 it doesn't need a separate label. 200 00:16:47,070 -- 00:16:47,750 Um, 201 00:16:47,760 -- 00:16:53,940 If the dysregulation is not explained by the autism diagnosis, 202 00:16:53,950 -- 00:17:08,460 then you also diagnose bipolar. And I think I've diagnosed both in about two of my clients out of nearly 550 assessments. 204 00:17:09,500 -- 00:17:12,600 So that could be particular to my clinic, 205 00:17:12,610 -- 00:17:18,260 but it does show you that really it's not a very common overlap, 206 00:17:18,270 -- 00:17:21,170 that most of the time when there's overlap there... 207 00:17:21,170 -- 00:17:26,810 just describing the fact that there's an externalized dysregulation when someone's overwhelmed. 209 00:17:27,720 -- 00:17:33,830 But that is to be expected. For the people that I did diagnose, 210 00:17:33,840 -- 00:17:48,900 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. 211 00:17:49,870 -- 00:17:55,170 Another thing to note is that medications typically are not going to change 212 00:17:55,180 -- 00:17:59,560 if the diagnosis switches from bipolar to autism. 213 00:18:00,510 -- 00:18:12,740 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. 214 00:18:12,750 -- 00:18:16,630 So there may still be a mood stabilizer, 215 00:18:16,630 -- 00:18:17,730 for example, 216 00:18:17,740 -- 00:18:20,970 prescribed for someone who has difficulty 217 00:18:20,980 -- 00:18:23,400 staying centered with emotions. 218 00:18:24,620 -- 00:18:24,900 Now, 219 00:18:24,900 -- 00:18:27,530 let's look at the diagnosis of depression, 220 00:18:29,960 -- 00:18:38,360 certainly the individual on the spectrum can have mood difficulties based on life struggles just as any human does. 221 00:18:38,370 -- 00:18:39,190 Um, 222 00:18:39,190 -- 00:18:40,280 in my experience, 223 00:18:40,280 -- 00:18:46,400 anxiety is much more inherent to the neurology of autism than depression, 224 00:18:46,410 -- 00:18:50,360 but depressed mood occurs secondary to struggles. 225 00:18:51,440 -- 00:19:01,260 Other characteristics that the autistic may have could be labeled as depression but appear to be a misdiagnosis ... 226 00:19:01,270 -- 00:19:04,490 trying to describe some neurologic characteristics. 227 00:19:05,400 -- 00:19:08,140 So if there's a misdiagnosis, 228 00:19:08,140 -- 00:19:16,820 what characteristics of autism would be likely misdiagnosed as part of a depressive episode or part of depression? 229 00:19:17,450 -- 00:19:19,390 Let's look at these examples. 230 00:19:19,390 -- 00:19:19,980 So, 231 00:19:19,990 -- 00:19:22,760 someone with a flat affect ... 232 00:19:22,770 -- 00:19:29,730 Affect is the emotions ... and in this case we're talking about emotions in the face and the voice. 233 00:19:29,740 -- 00:19:33,010 And for the individual on the spectrum, 234 00:19:33,010 -- 00:19:39,510 their neurology may be that there are muted expressions. 235 00:19:39,520 -- 00:19:51,940 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. 236 00:19:51,940 -- 00:20:08,340 And this can be part of what fits this criteria of nonverbal communication difficulties when there is not much emotional expression. 237 00:20:08,350 -- 00:20:10,630 Whether it's neurologic or not... 238 00:20:10,640 -- 00:20:12,430 another person may say, 239 00:20:12,430 -- 00:20:12,850 oh, 240 00:20:12,850 -- 00:20:16,920 this looks like the person is depressed. 241 00:20:16,930 -- 00:20:21,990 There could be this kind of hidden struggle inside, 242 00:20:22,000 -- 00:20:24,750 let's treat this person for depression, 243 00:20:25,820 -- 00:20:28,050 but this is an individual who says, 244 00:20:28,050 -- 00:20:28,350 gosh, 245 00:20:28,350 -- 00:20:29,610 I don't feel sad, 246 00:20:29,620 -- 00:20:32,130 I don't feel hopeless or helpless. 247 00:20:32,140 -- 00:20:33,810 I don't feel worthless. 248 00:20:33,820 -- 00:20:35,750 I don't feel discouraged. 249 00:20:35,760 -- 00:20:37,100 I feel fine, 250 00:20:37,640 -- 00:20:39,920 but people tell me I'm depressed. 251 00:20:39,920 -- 00:20:41,720 So I guess I must be... 252 00:20:42,490 -- 00:20:46,010 So that could be one person who's at risk for, 253 00:20:46,020 -- 00:20:48,120 misdiagnosis. 254 00:20:48,120 -- 00:20:51,140 And then of course the depression interventions, 255 00:20:51,140 -- 00:20:59,200 whether that's counseling or medication, are not going to change the neurology of that nonverbal expression. 256 00:21:01,670 -- 00:21:02,890 Also, 257 00:21:02,900 -- 00:21:11,380 there are a subset of individuals on the spectrum who struggle to consistently engage in things like self care... 258 00:21:11,390 -- 00:21:12,930 taking showers, 259 00:21:12,940 -- 00:21:14,060 brushing their teeth, 260 00:21:14,060 -- 00:21:15,040 wearing deodorant, 261 00:21:15,050 -- 00:21:16,030 eating regular... 262 00:21:16,030 -- 00:21:17,280 nutritious food, 263 00:21:17,290 -- 00:21:20,310 uh engaging in exercise, 264 00:21:20,320 -- 00:21:21,270 getting the sleep 265 00:21:21,270 -- 00:21:23,390 they need, cleaning the environment, 266 00:21:23,400 -- 00:21:24,090 working, 267 00:21:24,090 -- 00:21:25,940 engaging in relationships... 268 00:21:26,760 -- 00:21:30,190 If the individual rarely leaves the house, 269 00:21:30,200 -- 00:21:31,450 eats junk food, 270 00:21:31,450 -- 00:21:32,960 has a reversed sleep cycle, 271 00:21:32,960 -- 00:21:34,120 doesn't bathe, 272 00:21:34,130 -- 00:21:36,140 only plays video games... 273 00:21:36,150 -- 00:21:39,710 Others may conclude that this person is depressed, 274 00:21:40,640 -- 00:21:43,880 particularly if something in life has changed. 275 00:21:43,890 -- 00:21:45,230 For example, 276 00:21:45,230 -- 00:21:50,540 let's say the individual graduated from high school and really can't get going with life. 277 00:21:53,150 -- 00:21:56,460 The problem is that for the autistic individual, 278 00:21:57,260 -- 00:22:10,330 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. 279 00:22:10,340 -- 00:22:19,140 And the removal of that structure could really lead to a loss of what we call behavioral momentum, 280 00:22:19,150 -- 00:22:22,430 which is neurologically based... 281 00:22:24,410 -- 00:22:30,470 creating their own structure and momentum (because of their neurology on the spectrum)... 282 00:22:30,470 -- 00:22:32,320 that can really be difficult. 283 00:22:32,330 -- 00:22:36,120 So, even in the absence of emotional struggle, 284 00:22:36,130 -- 00:22:45,550 you may see this real struggle to initiate behaviors and keep momentum for daily life. 285 00:22:49,700 -- 00:22:50,070 Now, 286 00:22:50,070 -- 00:22:51,580 speaking of momentum, 287 00:22:51,580 -- 00:22:54,760 the brain is in charge of this... 288 00:22:54,770 -- 00:22:58,420 The issue of getting started... 289 00:22:59,230 -- 00:23:02,570 let's get going with the task or behavior. 290 00:23:02,590 -- 00:23:03,740 Let's go, 291 00:23:03,740 -- 00:23:04,670 let's start, 292 00:23:04,680 -- 00:23:09,370 let's transition from a resting state to an active state. 293 00:23:09,380 -- 00:23:12,770 And in my book Understanding Autistic Behaviors, 294 00:23:12,780 -- 00:23:16,020 I have a chapter called The Physics of Behavior... 295 00:23:16,050 -- 00:23:23,150 just to explain these kinds of phenomenon where ... if we take the concept of inertia, 296 00:23:23,160 -- 00:23:24,510 for example, 297 00:23:24,520 -- 00:23:27,870 so this is a physics concept, 298 00:23:27,880 -- 00:23:30,360 that's something that is in a resting state 299 00:23:30,370 -- 00:23:35,330 tends to stay there unless there's energy put into moving it. 300 00:23:35,330 -- 00:23:43,160 So how do I get going from a resting state... from a stopped state? 301 00:23:43,750 -- 00:23:47,240 When the individual with autism is in a resting state, 302 00:23:48,140 -- 00:23:52,700 they may have difficulty getting going into a state of activity. 303 00:23:54,410 -- 00:23:54,790 Now, 304 00:23:54,790 -- 00:23:55,800 interestingly, 305 00:23:55,810 -- 00:24:01,650 the last section on mania describes the same difficulty of transitioning states, 306 00:24:01,650 -- 00:24:04,300 but this time it's in the opposite direction. 307 00:24:04,310 -- 00:24:14,450 So the brain should help us both start an activity and stop an activity depending on what's most meaningful, 308 00:24:14,450 -- 00:24:16,040 important, and healthy. 309 00:24:16,050 -- 00:24:16,520 Now. 310 00:24:16,520 -- 00:24:19,520 For the individual with autistic neurology, 311 00:24:19,520 -- 00:24:29,390 they may have difficulty neurologically doing this... so I can't get going, or when I'm going, 312 00:24:29,400 -- 00:24:31,690 I have not only momentum, 313 00:24:31,690 -- 00:24:35,090 but I'm accelerating and I can't stop. 314 00:24:35,720 -- 00:24:36,030 So, 315 00:24:36,030 -- 00:24:40,150 if you can't get going that can look like depression, and if you can't stop, 316 00:24:40,160 -- 00:24:47,300 that can look like mania ... and you can have these elements in the same person at different times. 317 00:24:47,310 -- 00:24:56,750 So the neurology has difficulty getting to the "just right state" of activity level. Fourth, 318 00:24:56,750 -- 00:24:58,000 and finally, 319 00:24:58,010 -- 00:25:02,970 the social withdrawal in autism can also be mistaken for depression. 320 00:25:02,980 -- 00:25:19,210 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. 321 00:25:20,060 -- 00:25:20,480 Uh, 322 00:25:20,490 -- 00:25:23,600 So let's talk and visit and talk about our lives... 323 00:25:23,610 -- 00:25:24,630 Let's play games, 324 00:25:24,630 -- 00:25:25,500 Let's watch a movie. 325 00:25:25,500 -- 00:25:33,060 Let's have people over for dinner, and when the individual on the spectrum resists this level of interaction, 326 00:25:33,070 -- 00:25:40,550 others may wonder if there's a mood issue present and ... kind of at the root of this difficulty. 327 00:25:42,590 -- 00:25:48,520 So ...certain individuals on the spectrum can struggle significantly with depressed mood.... 328 00:25:48,530 -- 00:25:51,260 But this section highlights, 330 00:25:51,680 -- 00:26:18,020 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. 331 00:26:18,960 -- 00:26:24,870 I'm going to link a few of our previous podcast series that cover these issues. 333 00:26:26,710 -- 00:26:35,190 I did a series on exhaustion in autism... and issues of gaining and keeping momentum for daily activities. 334 00:26:35,200 -- 00:26:41,430 This started in September of 2021, and I will put a link to that first episode. 335 00:26:41,440 -- 00:26:43,950 But there are a couple in that series 336 00:26:43,950 -- 00:26:45,510 you might want to review. 337 00:26:46,210 -- 00:27:00,880 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... 338 00:27:00,890 -- 00:27:05,130 and that series started in January of 2022. 339 00:27:05,140 -- 00:27:09,660 I will also link the first episode down in the show notes. 340 00:27:11,580 -- 00:27:16,020 Thank you for joining me for this episode about mood and autism, 341 00:27:16,030 -- 00:27:22,030 and we are going to keep talking about this important subject of misdiagnosis in autism 342 00:27:22,030 -- 00:27:26,600 next time when we focus on anxiety based conditions, 343 00:27:26,610 -- 00:27:28,020 I hope you join me then.

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