The problem of screening out autism with other conditions

Maybe you win, maybe you don’t

Here’s another little tidbit that corresponds with World Autism Awareness Week. It has to do with the woefully inadequate understandings the mainstream of autism, which are both caused by and correlate with missed and denied diagnoses.

The diagnostic criteria for Autism keep changing, over time. In fact, they can vary from country to country (USA uses DSM-V, but there are a number of other tools in use). And from clinician to clinician, depending on their familiarity and how current they are on the research, the likelihood / possibility of being diagnosed can vary in the extreme. You just never know, really, especially in the US, whether you’re going to be really seen and understood for the autistic person you are.

It can be a veritable crap-shoot, and if you end up talking with a clinician who’s more practiced in other areas (as I have been, a number of times), you can end up having your autistic issues conflated with other mental health issues. Borderline personality disorder. Bipolar. Depression. Panic-anxiety. PTSD. ADHD. Trauma residue. Oppositional defiance. You name it, it’s probably been diagnosed (and treated) before autism, any number of times.

Now, this is not to say that none of these ever occur with autism, or that they aren’t actually accurate diagnoses. Perhaps they are. But too often they can be used to screen out autism and discredit the patient / client’s point of view.

One of the elements of the DSM-V Autism diagnostic criteria is that

E.       These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.


Although this directive is fairly constrained, still there’s the idea that “disturbances [are] better explained by [another] disability”. And the fact of the matter is, a whole lot of other conditions can — on the surface — present similar to autism… unless the clinician is very familiar with “spectrum-y” symptoms and can tease them out from the haze of conflicting messages and indicators.

Autism is easy to miss, if people don’t know what to look for. Mental health issues and organic/structural conditions such as brain injury (including concussion/ stroke/TIA) or a developmental disorder can “disqualify” someone from an autism diagnosis, offering a more obvious explanation for why someone is behaving the way they are.

Co-occurring conditions may be heightened and the symptoms made all the more intolerable, thanks to the “intense world” of autism, and unless the issues that come with our distinct autistic neurotype are recognized, understood, and addressed, our other conditions will necessarily be further complicated, made more intense, and confront clinicians with a puzzling array of symptoms that just don’t make any sense — or seem made-up (to get attention, obtain drugs, etc.)

Autism-related fatigue can exacerbate all sorts of attentional and post-concussion-related behavioral issues (a tired brain is a cranky brain), possibly resulting in increased medication to offset the symptoms, while the underlying causes continue un-addressed. Sensory issues can repeatedly traumatize a person, spiking their PTSD, and resulting in more (and more) talk therapy designed to uncover supposedly deeply buried memories or emotions that are causing the stress… which in the case of autistic folks can actually exacerbate their stress, no matter how hard they try to comply and “get it right”. On the surface, it may look pretty cut-and-dried to the clinician, but they’re missing a critical substrate that sets the stage for ongoing issues, which may appear intractable.

This can end up confounding treatment and sending an autistic person down an extended medical/clinical “boondoggle”, filled with confusion and ill-chosen pharmaceutical and psychotherapeutic tactics. Ultimately, the autistic patient can end up zombied-out by their meds, or the clinician may give up, considering them a borderline Munchausen case, just looking for attention.

Now, if we consider that autism is a distinct neurotype, rather than a disorder, we can literally get the best of both worlds (so to speak). By understanding the context of autism, the experiential / physiological substrate of our overall condition, we can all factor in co-occurring conditions and gain a deeper understanding of not only how autism affects us, but the other condition(s) we’re dealing with.

Take my migraines, for example. I had daily sickening headaches, some of which had me doubled over in pain, for years and years. And yet, I didn’t fully realize how much they were affecting me until a few years ago. My PCP/GP and other healthcare providers thought it very strange that I would go for years saying, “I never get headaches,” and then suddenly announce that I always had a headache, and I had for years. It was literally not the sort of thing I wanted to think about, so I didn’t. I figured it was just how I was, just how my life was supposed to be. Not until I started talking to other people about it, did I realize that other people didn’t actually have headaches that intense on a daily, moment-by-moment basis.

Now, if you know a thing or two about pain perception and how variable it can be with autism, that may not seem so strange to you. And if you’re familiar with how we can block everything out of our attention when we’re locked onto an attentional target, it makes a lot more sense that I’d be in that situation. Additionally, knowing how … haywire … our sensory detection systems can be, as well as how overwhelming and wide-ranging our sensations can be, it would make sense that the sickening pain of a constant migraine would just blend in with the never-ending stream of unpleasant experiences that make up the background noise of my life.

But if you don’t know about wonky pain-perception, the autistic ability to block out unwanted stimuli, and the cacophony of sensory input a lot of us live with, I’d probably look like an attention-seeking exaggerator who’s just shown up for the drugs.

Of course, when I documented my headaches and presented my providers with the evidence of day after day of ever-present, continually morphing pain, there wasn’t much they could argue with. They could, however, give me strange looks and jump to the conclusion that there was something seriously wrong with me, if I went for years with this level of pain without telling anyone about it. Maybe some long-buried trauma from a horrific childhood… maybe a form of multiple-personality disorder… a recurring dissociative fugue state… better addressed through counseling than medical treatment.

Ultimately, I did get help for my headaches, and it’s been about a year since I last had a constant migraine. Last weekend, I had one for a few days, but it went away, as they now tend to do. But I can’t help but wonder — if my doctors had realized I was autistic and my spectrum-y issues blocked my ability to detect and interpret pain, would they possibly have asked me different questions, and might they possibly have taken a more pro-active approach in helping me identify and treat the conditions that were making my life a lot more complicated than it needed to be?

Personally, I think a working knowledge of autism and its “confounding” factors should be taught to clinicians, and that would clear up a ton of confusion. Also, by taking an inclusive, co-occurring approach that factors in the “substrate” of autism in the overall picture, we can truly appreciate the complexity and richness of the autism neurotype, and even gain greater insight into the intricacies of our co-occurring conditions (even the organic ones). Autism exaggerates a whole lot of sh*t, and we could learn a lot about any number of conditions if we studied the interplay of autism with co-occurring conditions.

  • Migraines
  • Depression
  • EDS
  • Stroke/concussion/other kinds of brain injury
  • PTSD
  • A wide range of mental illnesses
  • Injury recovery
  • [ Insert condition here ]

Rather than using these other conditions to deliberately rule out autism (or simply obscure it), let’s consider that autism might sometimes actually co-occur naturally and form the context for the experience. Diagnosis of autism needn’t be a damning prognosis. It can be a starting point to better understand.

But of course, first you have to be aware that it even exists, in all the forms it does.

And that’s not happening. Yet.

10 thoughts on “The problem of screening out autism with other conditions

  1. In my German autism ambulance, I had a friend getting screened and they said that he probably had depression and that he needed to be treated for depression first, before they will even try to diagnose autism with the argument “maybe all your problems come from the depression and not any autism”. This fails to see the big picture where depression may just be a side effect of that other perception of the world and heightened senses. He ended up not getting diagnosed and not getting treated for depression, because of schedule conflicts. He seems to do way better since he graduated school, just like I did back then and I got diagnosed in university. So, yeah, I think a lot of people get missed just because they get turned away instantly. That’s why I tried to hide my anxiety while in diagnosis process, so I wouldn’t get to hear that “it’s probably just social anxiety”, when I knew it wasn’t – luckily, my parents could provide insight into my childhood, so the diagnosticians could see that I was always autistic.

    Liked by 2 people

    1. VisualVox

      That’s fortunate that you’ve got your parents to back you up. And very prudent, to hide your anxiety. If they don’t know what they’re looking at, it can wreak havoc with your options.


    2. tahrey

      That’s just bananas… where did they think the social anxiety, and the depression it leads to, was coming from? I thought the German healthcare system was quite switched on and progressive until reading that…


  2. it’s infuriating that another thing that causes a lot of misdiagnoses is the autistic people’s assigned gender. so an aspie born with congenital femaleness? girls can’t be aspies, here take some epilepsy drugs and let’s write your chart full of bs…
    another problem: other coexisting issues. sight problems, hearing problems, sensory issues downplayed, language and cultural issues…
    funny how that cultural issue thing doesb’t get exported for NTs. take your typical high maintenance, extrovert female from USA and put them in Finland or Estonia. if she maintains her behaviors, she should be classified with something like bipolar only because the other persons around her do not behave in such emotional manner. they are taught to control and manage their emotions, not display them too much, and certainly not go talk to random strangers in a grocery store. when she’ll notice how different everyone else behaves from her, she probably will feel a bit annoyed and out of her place.
    on the same time we have a LOT of aspies that can’t get correct diagnoses
    because of things get explained away first:
    – using excuses of sight or hearing issues
    – language or culture as excuse
    – femaleness as an excuse
    and whatever.
    i’ve heard those all (although noone has tried the hearing for me. apart of tinnitus, i can hear well).
    and of course things can coexist. i’ve always had migraines. have had some concussions, sone ptsd (the multiple cause), eye surgeries and what not. offline i don’t openly advertise but i’ll gladly play all the cards i got. no shame in being an aspie – i’m technical and thorough, can control emotions very well and not be controlled by emotions. i see NTs weird in heir preferences to using veiled communication, euphenisms, communicating with facial expressions or tones of voice instead of conmunicating better. maybe… when someone scores as NT they should get some support and training and fixing instead.


    1. VisualVox

      It really is, isn’t it. I just listened to this the other day: And it speaks to many of your points. I fell between the cracks, in no small part, because I was never “from” the places I lived. First, I was a little white kid in a predominantly Black area… then I was the “city kid” in a rural, homogeneous white area… then I was the student from out-of-state… then I was the American in Europe (before Europe was nearly as united as it is now)… then I was the Protestant among Catholics, the gentile among Jews, the woman working amidst men. Always the outsider, which could easily account for my awkwardness, my difficulties understanding and being understood… the whole nine yards, if you will. And of course, if you’re diagnosed congenitally female, all you have to do to “pass” is keep quiet and do as you’re told. Easy peasy! Who would know, how much trouble you’re having?

      Dunno… the whole thing is screwy to me.

      I’m just glad I figured it out now, and I can do something with it.

      As a matter of fact, I’m actually really enjoying my whole autism “trip”. So long as I actually get to be autistic! That is completely awesome!

      Liked by 1 person

      1. VisualVox

        Ah yes – revenge. There are so many ways to exact it… Knowing where I am in the world (on this spectrum) has done wonders for my range of repertoire 😉

        Liked by 1 person

  3. Yep. I have the wonky tendency to screen out pain too. Sometimes I’ll even be walking funny and my wife will ask why. I have to stop and think and used to just say my back was stiff. No I realize it’s actually hurting. Sometimes anyway.

    I also used to say I never felt anxious about anything. That was never true, of course. I just screened out the constant level of anxiety I lived with every day and misidentified the spikes as something else. Which then leads my wife to note (correctly) that I never talked about anxiety before being diagnosed.

    I’m starting to realize just how much I screen out every moment. It’s been pretty eye-opening.

    Liked by 1 person

    1. VisualVox

      It is pretty amazing, isn’t it. The ability of the mind to just block things out is remarkable. The thing that gets me, is how that capacity is seen as pathological or a sign that something is wrong, rather than a sign that things are working right. I honestly have no idea how it would be to go through life untroubled by pain, anxiety, gut-wrenching fear, awkwardness, and a constant sense of doom. Fortunately, I can find the humor in it. I just don’t see the point in trying to eradicate them from my life. They’re background noise. That’s all. They don’t define me. I get on with it, in spite of it all. And my ability to screen it all out (or just accept it as what-is, since I’m prolly never going to get rid of it all) is the one thing (or is that two things?) I have going for me in this world.

      I’ve been an active stoic my entire life, and now I’m coming to realize just how true that really is.

      Frankly, it’s awesome. I kinda feel like a bullet-deflecting superhero sometimes – what brings others down can’t possibly hurt me. ‘Cause it’s been hurting me like hell for 51 years, and I’m still here.

      Ha. So there.

      Liked by 2 people

  4. tahrey

    My favourite potential explanation is that there is no one single condition that is “autism”, in the same way that a lot of other developmental, personality or mental health conditions/disorders are woefully poor labels for a lot of the people who bear them. They simply happen to be the aggregate of what the first cohort exhibited at the time the diagnosis was established and named, a long time ago in a rather less caring and well connected world.

    In reality, there’s a much greater multitude of contributing traits, each affecting a certain narrow part of your ability, personality, worldview/thought process, sensory function, etc, and whilst there are certain bands of them that happen to frequently occur together (possibly they all arise from a diversity of structure in a certain area of the brain, so a particular point-spread of altered development has an Area Of Effect on various different but physically colocated functions), which previous generations of doctors ascribed certain well-worn names to, it ain’t necessarily so, and they could well appear in much different combinations depending on the pattern of developmental variation, differences in exactly where each function is physically located, as well as environmental and experiential factors interacting with such.

    So really you have an inconveniently long and complicated laundry list of enhanced or typical abilities or disabilities, heightened/average/lowered sensory perceptiveness, and so on and so forth, which would produce a much better picture of the real you, and what you can and can’t do; a literal spectrum, if considered in terms of doing a spectral analysis of e.g. a star, or an unknown material in a lab. Bundling the most obvious (or the only tested-for) ones of those together and calling them, say, Autism, or OCD, is much like calling a star a “blue dwarf”. It only gives the vaguest, broad-categorisation, quick-reference idea of its characteristics and what it’s made of, and if you make a blind assumption of the deeper details based on that, you’ve got a good chance of being wrong even if you’re taking a well-researched average, because every single person’s combination of traits will differ, so what one person with the broad diagnosis can do easily, another will struggle with or fail, and vice versa…

    (a better comparison from my own recent learning would be the asteroids and dwarf planets of the solar system; it’s only really practical with current technology to, for more than a tiny fraction of the total population, record the average apparent brightness and how it changes cyclically as the body rotates, and plot its position and path through the sky, which then lets you calculate the actual overall brightness… and, if you have a reasonably advanced telescope, its approximate colour tone (using two to five fairly narrow wavebands)… from which you can make a very rough estimate of its size, composition, roundness and mass, partly by comparing it with other better known objects in the same or similar orbital and spectral families, for which typical value ranges have been determined and are routinely refined and updated as additional members are discovered and studied. But until you can score some much more detailed measurements with better instruments (including IR, radio-band, and preferably radar scopes, and maybe a proper spectrometer), perform stellar occultations, preferably find a clearly orbiting natural satellite, or best of all send a probe for a flyby, you can only give the result as a range, and even that can still be proven wrong once direct and detailed measurements of the object’s reflectivity, true colour, shape, size, and mass (derived from orbital components) are obtained.

    There have been some notable “surprises” before where entire hidden “interloper” families have turned up within the orbital area occupied by better known ones, and even some of the largest and most easily studied post-Plutonian bodies (and, heck, Pluto itself, within the last 10 years) have seen sudden massive revisions of their size up or down when the improved science has shown that they’re actually either extremely reflective (e.g. Eris, when it was found to basically be a small snowball, rather than a duller but more Earth-sized body, and to exhibit “beaming effects” where surface features occasionally concentrated more light back towards the sun – and thus, Earth – than was originally thought possible even for a perfect mirror), or unusually matte (e.g. Salacia, which is about the colour of charcoal or asphalt, and so wasn’t discovered until 2004, despite orbiting at a similar distance to Pluto and not being so much smaller than it; initially its dim appearance led to it being thought quite a lot smaller)… which might well be an allegory for someone scoring unusually high or low on an IQ test despite their other apparent disabilities or strengths. And there’s even the confounding example of (208996) 2003 AZ84, which is somewhere in the region of the usually assumed average reflectivity, but there are about as many conflicting estimates for the precise figure as there are astronomers who have studied it, with figures varying by 10~20% around the average, showing us that what you see can very much depend on at what time and how long you observe a thing, what equipment and methods you use, what particular aspects you include or ignore, and your own personal philosophy… (and when it comes to studying people, what feedback effect your method of study has on them) … when really you need to observe all known measurable traits for as long as possible, as non-invasively as possible, and with a completely open mind towards things being a long way removed from the expected main cohort.)

    tl;dr common condition labels are about as useful as the trim badges on the back of a car, in a range where almost everything is available as an option…


What do you think? Share your feedback - and feel free to share this post!

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.