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Adult ADHD from the board-certified PMHNP behind the YouTube channel Focus Path and the book The Process. Clinical perspective on medication, frameworks, and the conversations the internet hasn't been having.
Welcome back to Actually ADHD.
My name is Jonathan Murphy,
psychiatric nurse practitioner.
This podcast is sponsored by
the Focus Path YouTube channel.
You can go ahead and check that out
on YouTube at Focus Path Systems.
got 109 self-produced videos
on mental health topics
so let's jump into it
Today I wanted to talk about
autism spectrum disorder.
This is a neurodevelopmental disorder
that I've seen a lot over the years
because it often comes alongside ADHD
you hear about it a lot these days, and
I think that if there's one psychiatric
condition that I encounter that has
the greatest degree of confusion
surrounding or mystery surrounding,
it is autism spectrum disorder.
I've developed a strong read on autism
spectrum disorder, and at first I used
to say, " You need to get evaluated."
And then when patients would come back,
I'd say, "Okay, you got evaluated.
What'd you learn?"
And they'd say, "Not
much, and it's expensive."
So it's a diagnosis just like any
other diagnoses, anyone that uses the
DSM is licensed to, can diagnose it.
And yet a lot of clinicians are nervous
about it, and patients aren't sure
what it takes to get a diagnosis.
And getting a diagnosis is only
necessary when trying to access
something outside of the appointment,
access something outside of therapy.
, A diagnosis does not always need to
be documented for it to be something
that you apply to your life or an
individual applies to their life.
A diagnosis serves multiple purposes.
It serves many different groups at once.
But for the consumer or for you,
the individual, the diagnosis
is pertaining to your health.
So we are the ones that
need to be approving of the
diagnosis at the end of the day.
A diagnosis isn't
something we just accept.
A diagnosis is something that we carry
forth with us and we identify with,
provided that we have freedom to do so
That's the goal as a nurse practitioner
is to increase autonomy, help people
access and navigate these, these systems.
So I wanted to break down, what autism
looks like to me, and along the way, maybe
you'll hear yourself in it or someone
else And if you're a clinician, I would
encourage you to feel confident if you
have a good read, if because it is one
of the rare psychiatric diagnoses where
people just feel better by knowing it.
So if you just know this about yourself
and, it can really contextualize things in
an interesting way that's not gonna be the
case for anxiety or depression or bipolar.
But for autism spectrum disorder,
it can really just provide a lot
of instant access to strategies
that are gonna be helpful
So what is autism spectrum disorder?
The way I look at it is a fixed nervous
system difference or neurodevelopmental
difference, meaning it affects
your brain and it affects the way
that you perceive the world, your
sensory experience of the world.
So it affects the way we receive
information, and it affects
the way we process information
and the way we see the world.
So the presentations can vary
wildly, and I've learned to
delay judgment and to always be open to
the idea of autism being on the table if
it's not clear, because You'll know when
someone's better, and sometimes it can
take years to spot high-masking autism.
And I think there are two
separate categories of autism.
There's gonna be high-masking
autism, and then there's gonna
be autism spectrum disorder.
The difference between someone
with high-masking autism and autism
spectrum disorder is not necessarily
the external, how well they function
or how well they do in social
environments, how well they integrate.
It has to do with objective or observable,
by the clinician, signs of autism.
And These include a
monotonous tone and voice
The inflection of speech
expressive and receptive language
and intonation in speech.
You can hear a monotonous voice or
a voice that has a specific pattern,
but there's not a lot of range in it.
That was the first thing that cued me
into someone that might be on the autism
spectrum, is the way someone spoke.
But over the years, I've learned that
it's not necessary for a diagnosis.
It's just one of the signs
But ultimately, since we are social
creatures and much of our psychiatric
pathologies as adults are remnants of
dependency and periods of
developmental psychology where
we had to adapt to a group.
And group adaptation psychologically
can go very well or can be perceived
as one way when you're still under
development, and then when you're
grown and you're mature, you no longer
require dependent self-regulation.
So self-regulation
must occur under different terms.
This is why I say you gotta
regulate before you navigate
For anyone that's on the autism
spectrum, these are the things that I see
So when we're talking about
the sensory world, okay?
People on the autism spectrum, they're
typically going to be people who see
the world with their eyes, and then
perceive the world through thoughts and
thinking, and the integration of senses.
So it could be sense of touch,
sense of taste, sense of smell,
sounds too loud, lights too bright.
There's a heightened - sensitivity or
distress in processing multiple sensory
inputs just naturally at a baseline.
And there's a concrete cognitive
logical thought process that is very
much at the center of individual
perception and experience of the world.
Now, that concrete thought process sits
on top of and takes precedent over other
senses, even if they're uncomfortable.
So sensory sensitivity Things
weird to the touch, things taste
weird, specific preferences.
Sometimes people naturally accommodate
these and they figure out ways to
navigate it and reduce the distress.
But I would say the most common thing
is someone on the autism spectrum
is gonna experience this while at
the same time have the cognitive
capacity to say, " Oh, you know what?
I thought everyone was like this."
And the difference is no, because
normative neurodevelopment
is balanced in sensory perception
and integration of thoughts.
There's a felt sense of the world.
There's a sixth sense, if you will.
Our ability to perceive the environment
socially without much thought, so
you don't have to think about it.
So this is something that someone on
the autism spectrum really can't do
I talk about our natural social mode.
This usually has to do with cohesion
developmentally within a group.
Were we the fly on the wall?
Were we someone who
kept everyone together?
Someone on the autism spectrum
naturally are picking up on the
world through what they see and what
they perceive when they hear things.
Communication, typically very concrete,
black and white processing, little
nuance, taking people at face value,
difficulty reading intentions of other
people, so more likely to take people
at face value And because of this, more
prone to manipulation from people that
are looking to target other people, like
say a narcissistic personality disorder.
The interesting thing about autism
spectrum disorder is it's a different
baseline, so it's a lot more
narrow in terms of what types of
pathologies are gonna run downstream.
You're not gonna see the
same pathologies emerge
when they can't be conditioned.
We can only do things when we're
encountering things that are working.
We do something and then we do it so
much it's predictable, and then we
don't have to think about it anymore.
But since someone on the autism
spectrum is processing the world
differently and feels different because
of it, because there's an observable
outside world that remains confusing,
there's a mismatch between what
someone sees and what someone feels.
Now, there's another common mismatch
between people on the autism
spectrum and someone with normative
neurodevelopmental functioning.
That would be a mismatch between
internally felt sense of emotions.
I often hear that people on the autism
spectrum, they feel very, very deeply,
but that emotion is internalized
and it's not clear externally.
So it's an expressive mismatch, an
internalization of emotions and-
Decreased ability to express emotions
On The Focus Path YouTube channel,
I went into a theory of mine called
Developmental Reinforcement Theory,
where I developed a screener which
helped me identify eight distinct modes.
They're nervous system patterns that
we can get stuck in, and they're
distinct, and they're helpful for
me to understand how someone's gonna
move to that place of self-regulation.
Someone on the autism spectrum is most
likely to be a strategist, meaning
they're thinking a lot about the world
around them and perceiving it in terms of
thoughts, and doing so ultimately results
in social cohesion so that I'm gonna think
about it and then I'm gonna feel better.
I'm gonna think about it
and I'm gonna feel better.
So that also lends
itself to shutting down.
There's another mode called the
operator, and the operator would
be someone that is encountering
difficulty with vulnerability.
As children, we need to be emotionally
vulnerable, and we want to be
validated, and we need to be comforted.
If we're not able to be comforted,
then we need to stay regulated.
And how do we stay regulated?
Well, it's gonna have to
do with the group cohesion.
Is the environment a safer place
through a set of behaviors?
And someone on the autism spectrum
is gonna have a busy mind, but that
doesn't mean using that mind within
the relationship is gonna work.
In fact, it can fail oftentimes, and
people on the autism spectrum are
subject to bullying and scapegoating.
So then what will happen?
Well, maybe someone will
become what I call an operator.
This attachment pattern is what
I consider to be more avoidant.
So there's cohesion to a
group, but on the periphery.
And someone on the autism
spectrum's mind is gonna be busy.
They're gonna go and maybe
do things on their own.
Do things in the environment
that are predictable.
So the things are logical and make sense
that lead to a more harmonious environment
but I also think this can set the
stage for OCPD or obsessive-compulsive
personality disorder, essentially
where the belief systems or the
thoughts become very fixed and
reinforced and hard to break through
there's another survival
mode called the general.
The general is a protective strategy that
avoids emotional vulnerability through
agitation or aggression externalized.
It doesn't need to be anger.
It just needs to be felt
agitation or external frustration.
And sometimes you'll see patients on
the autism spectrum that although start
as a strategist, they are more likely
to become agitated and have difficulty
with moving past certain ideas and these
types sometimes are told that they're
getting upset and they don't realize
it because they're stuck in their head.
When you're stuck in your head, one
of the things that happens with your
nervous system is your mind can go.
So someone on the autism spectrum,
their mind's gonna be busy and they
can't tell they're dysregulated.
So what I like to say is you're not
gonna think your way out of this one.
And in terms of other people,
it's understanding that there
are other people in the world.
So for anyone, they need to learn how to
navigate the world around them, including
the social relationships around them.
And the way someone is gonna do that
is gonna be based on how they feel.
So it goes like this: someone on the
autism spectrum needs to know why they
feel the way they do how their mind
works, understand the bigger picture, and
really being able to break the pattern.
Maybe it's racing thoughts, maybe
it's not being able to let things go.
Whatever it takes to go, "Whoa, I'm
actually stressed out and dysregulated.
What I need to do is be by myself,
settle down, write, ask myself,
'How do I feel right now?'"
I'd say the biggest concern I have for
adults in the autism spectrum is being
able to stay in the job, stay in the
unstable marriage or relationship, stay in
the boiling water, and everyone says they
look fine and suddenly they're not fine.
And I think that's the piece where
the meltdowns and the dysregulation
comes in So having the awareness of
what emotions and sensory processing
and what the world is for you is
gonna help you understand you.
But the social skills training and
doing it right and this external
stuff, the need to belong, that
can exist alongside autism because
attachment is different than autism.
But autism is gonna explain the attachment
pattern within the individual or the
patient because you'd consider the
adaptation as nature plus nurture.
And then you have an individual that
is distressed and has attachment
issues, but they have autism.
Understanding how complex PTSD or
autism or ADHD separate is very useful.
But for people that are saying, "Oh,
it's a fashionable diagnosis, it's the
cool diagnosis, autism," well, you might
hear that online, but I would say that
the oddity is Many people on the autism
spectrum, high masking autism, many
folks won't identify with that groupthink
in this, um, sort of internet culture.
So I think we really have to do a
good job and separate what we see on
the internet from actual real life.
When we say, "Everyone's doing this
now," or, "What's the deal with this?"
It's like, is this happening in real life
or is this happening on the internet?
But autism spectrum disorder
doesn't require medicine.
And what is helpful to have, and I like
to advocate for, is accommodations.
I've had patients be maligned
because they weren't adhering to
unwritten social nuanced rules.
And I don't really see much of a
harm in it, in expanding the ability
to diagnose and understand autism.
I do not see the harm in it because
someone being on the autism spectrum
Just like ADHD, these are psychiatric
diagnoses So it's important that there
is no universal psychiatric experience.
There's a universal personal
experience, your experience, the
human experience, your truth.
So We need to understand
from the inside out.
So I wanna understand how
someone feels on the inside out.
The outside in might give you some clues,
but it's the inside out that matters most.
So if this resonates, social skills
training I think can be helpful to
a degree, let's say if there are
clearly problems with an ability
to adhere to social norms of, let's
say, etiquette or what have you.
However
We wanna make sure those social
problems aren't the result
of the environment first.
So we wanna ask, how are these
people actually treating me?
How do I feel?
Am I comfortable with this?
Because that's the goal,
is to identify that
you can self-regulate
And I think sometimes it can be very
interesting in terms of autism spectrum
disorder when someone is very social.
So autism and bipolar do come alongside
each other, but I would view it as more of
a manifestation of the ability for someone
with the autism spectrum to endure tons
of distress to the point where can occur.
It's just a manifest of the intensity
of the distress, the person's individual
capacity to fluctuate in mood.
But These are the folks typically that
respond well to medication intervention
and their mood can stabilize and often
does when the social circumstances
change and the environment changes and
the boundaries change a narcissistic
parent can do a lot of damage to someone
on the autism spectrum, and it's very
confusing, I think, and hard for someone
on the autism spectrum to develop
self-regulation when they've normalized
dysregulation across the social plane.
So in other words, being reinforced to
perform and be super social even though
it's not a natural tendency, or maybe
socially performing at a high level
and appearing one way while internally
being exceedingly bright and struggling
with the mental gymnastics it all takes.
So I just wanted to touch on that today.
I just had some interesting
observations about autism lately.
But there's also something called
sensory processing disorder, and I do
believe this is an interesting diagnosis.
It's more rare, but sometimes people just
have that social-emotional reciprocity.
It's really interesting 'cause
when you know, you know.
I've asked a couple
people, " maybe it's autism.
" , and kind of talk it over,
and I can just tell.
I just get that gut feeling
because I've always had that.
I can read the room as soon as I walk in.
And it's different between being able to
read the room and being able to read the
room and feeling activated or anxious.
That can be very elusive.
You feel like you're reading the room,
but you're actually just triggered.
You know you can read the room when
you walk in there and you're calm, and
you can understand how everything's
going, and you're just calm in the
social environment Someone on the autism
spectrum can do that, but they might not
understand how and why they're different.
And simply having the language to
understand yourself and stick up for
yourself and advocate for yourself and
set boundaries and remain emotionally
mature is the goal for all my adults.
And that's gonna do it for today.
This was another episode of Actually ADHD.
Once again, my name is Jonathan
Murphy, psychiatric nurse practitioner.
We'll talk to you later