Sam Porter
@PerinatalBirder
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#Neurodivergent NHS Consultant Perinatal Psychiatrist, birder, twitcher. Passionate about improving care and support for #autistic & #ADHD new mums/mums to be
SW Essex
Joined November 2018
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Here’s a thread I’ve written for psychiatrists to help them pick up recognise when their patients are autistic, because 1 in 5 are!
A recent study showed 1/5 of people referred to
#psychiatry
OPDs are
#actuallyautistic
. If your clinical experience is that this is much lower, you’re probably missing
#autism
in your patients. This 🧵 will explain why that’s a problem, why it happens, and how to stop 1/35
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I don’t mind people thinking autism and ADHD are overdiagnosed if they are able to tell me how much autism and ADHD there is supposed to be, explain why that’s the correct amount and show me evidence that diagnosis rates outstrip that
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@DrEricKuelker
I lived with a Christian guy at uni. All his friends were Christian. We also had a German guy. Do you know he found the two other Germans in the building and hung around with them a lot. People often end up with friends who are like them
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PIP assessors be like “If your house was on fire and you were lying down next to your open front door would you be able to drag yourself outside?”
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Remembering the time a psychologist suggested a patient couldn’t be autistic because she had… bonded with her baby…
Can anyone beat that?
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A recent study showed 1/5 of people referred to
#psychiatry
OPDs are
#actuallyautistic
. If your clinical experience is that this is much lower, you’re probably missing
#autism
in your patients. This 🧵 will explain why that’s a problem, why it happens, and how to stop 1/35
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@AdultingADHD
Just because I forget to do something I said I would doesn’t mean it wasn’t important for me. I’ve missed a job interview and a driving test because I forgot - I forget important things all the time.
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Really excited to be able to officially say that from October I’ll have a day a week to run a dedicated Perinatal Neurodivergence service offering:
Autism/ADHD assessments
Post diagnosis groups
ADHD meds titration/counselling
For pregnant women/new mums in BEH/C&I 🥳🥳🥳
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Here’s another 🧵 about
#autism
for medics after the popularity of my last one. This time I’ll look at some principles you should follow when prescribing for an autistic pt. My practice mainly involves psychotropes but these are principles that any specialist should follow 1/22
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If you don’t/won’t/can’t diagnose autism/adhd in your clinical practice you shouldn’t diagnose EUPD. If your reason is you don’t have the time then you don’t have time to be rigorous enough about PD diagnoses either. If lack of expertise - you lack the expertise to diagnose PD
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Something that doesn’t get mentioned in rise of autism diagnosis conversation. U.K. child mortality rate was 10x higher in 1950 than 2020. Autistic women have more obstetric comps, more prem babies, autistic kids have more asthma, allergies etc = More autistic kids are surviving
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Neither of them have any choice in this. So why was one mocked and one praised? Nociceptory response is not a moral virtue. If you wouldn’t force analgesia on a woman in labour who said she didn’t need any don’t deny it to one who does 😡 3/3
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An autistic pt of mine was mocked by her midwife for how much pain she was in during early labour “just wait until the real pain starts!”
Another was praised by her MW for “doing so well” & not having any analgesia. She didn’t understand the praise as “it just didn’t hurt” 1/3
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@Spug_D
@Trilla___G
@leakyfbaybeee
Somebody who killed somebody who raped them isn’t a threat to me because I’m not going to rape anybody. A rapist is a threat to lots of people. I would feel much safer in the presence of somebody who killed their abuser than in of an abuser.
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I’ve had this conversation many times:
- Might she be autistic?
- No I don’t think so
- Have you asked her about sensory processing issues, special interests, response to change, or taken a developmental history
- No
- So why don’t you think so?
- She doesn’t seem autistic
18/
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Could journos who want to write about the scandals around ADHD assessments start focussing on the following instead of misdiagnosis:
NHS waiting times
Diagnosis rates in girls
Diagnosis rates in black people
Diagnosis rates in poor people.
Cheers 👍
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“Function” can also mislead. We see the job & marriage. We don’t see that they depend on their partner to help them overcome the executive dysfunction that is ratcheted up by the amount of energy they expend on work, how they spend every evening recovering from the day 21/
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@AAWoodfields
@MrDavidScales
This is the problem with teachers setting school rules. They usually have minimal experience of the real world outside of a school. They left one and went back to one. The world has moved on. Schools haven’t.
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@The_Weed
Whenever I suggest that a patient might be autistic and a colleague says “oh no, they just had a lot of trauma in childhood” as if the “lot of trauma” doesn’t make it MORE likely they’re autistic my head hits the table so hard it could drive a nail into it.
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Most autistics knows they’re different to their fellow members of a species that alien field guides would describe as “aggressive and suspicious of the different” & so most of them learn to do a thing called masking. I one patient told me “eye contact’s easy - 3s off 3s on” 19/
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And whilst NTs get burnt out too, autistics and NTs get burnt out by different things, and autistics know the things that burn them out don’t burn most people out, and can often be self conscious about them, and don’t share them, because they’re used to them being trivialised 4/
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@ScrubSurvivors
I’ve always thought that men who insist women aren’t interested in sex are telling on themselves.
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First, there is a differential for depression in autistic people that is clinically very difficult to distinguish from depression but does not respond to antidepressants or therapy - burnout. If you don’t know your patient is autistic, you won’t consider the differential 3/
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If a patient tells you that they have read about it and they are convinced they are autistic then proceed with the assumption that they are. There are far more autistic people being jammed like square pegs into round holes than there are people pretending to be autistic 34/
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@KhadiDon
I diagnose autistics as part of my job. In my clinical experience people so far who self diagnose have universally been autistic following assessment.
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Thanks for making it this far. The main take homes are - always consider neurodivergence, look for it with your ears not your eyes and learn about autism by listening to autistics. 35/35
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The best way to learn about autism is to listen to/read lots of autistics talking about it - there’s lots out there, this article is a good start . Many autistics, hearing these stories, say things like “I thought I was the only person like that” 26/
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Her previous MSEs noted “good eye contact” which had been used against a previous question of autism, but there’s nothing “good” about having to constantly be counting to 3 whilst you’re trying to have a conversation. The CAT-Q tool can be helpful for uncovering masking 20/
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And “objectively” to the NT mind there is nothing going on that could be burning them out, so we assume they are depressed. I meet lots of autistics on antidepressants that they have been on for years, that haven’t really helped, but are hell to stop - started whilst burnout 5/
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It still helps to know that they’re autistic for treatment. Medication should be used carefully - start low, go slow is life-long advice for autistics - those patients who say they get unbearable side effects at very low doses (and you sometimes doubt) are often autistic 7/
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Should all prompt exploration of neurotype. When I listen to the presenting complaint I’m aware to phrases like “I’m fine when I’m alone” “I always feel overwhelmed” “I’m always exhausted” “I can’t be myself” “I haven’t been able to socialise since i stopped drinking” 24/
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One reason for missing it is bias. Autistic women/PoC are less likely to be recognised as such, creating an impression that people from these backgrounds are less likely to be autistic, & there’s a vicious circle. So set a high bar for convincing yourself women and POC are NT 11/
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So - how to find the 20%?
Begin at the referral >2/3 of: OCD, EUPD, (C)PTSD, GAD, IBS, ME, epilepsy, hEDS, multiple allergies/intolerances, atopy, Fibromyalgia, depression, DV, schizophrenia, severe PMS, social anxiety,eating disorder, ADHD, workplace bullying, alcoholism etc 23/
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Autistics regularly get misdiagnosed with things like EUPD, but even if it is not a misdiagnosis the patient could still be autistic. Trauma & autism go hand in hand, which is a huge thread tin itself, but if they have a history of trauma it is MORE likely they’re autistic 15/
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Both of these people would agree they have atypical pain responses. The 1st pt had previously told me that she seems to find similar experiences more painful (or the pain more unbearable) than other people. The 2nd says she’s only hurt by eye contact & unexpected touch 2/3
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@MaxMoriarty3
Way more ADHD is misdiagnosed as anxiety/depression that the other way around.
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@DrDave_99
@gretchemaben
@bnuckols
Yes I have to admit I read it without twigging the MD in the handle and thought “that’s a very medically knowledgable drug user” then spotted the MD and thought “oh no she’s still not fully with it and has just admitted using ketamine to the world” and then I thought “hang on…”
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Further, it should inform their overall care. Avoid last minute appointments as far as possible. Ask if they are comfortable with group work/video/home visits & only offer them if they are. Get the same staff to see them. Check each other’s understanding of plans proactively 8/
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Usually in an unhappy/abusive relationship/job, with recovery following the end of that situation. They may recognise this link, try to stop the meds for the first time, mistake withdrawal for relapse, and think “oh it was depression after all”. And even when it is depression 6/
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@rcpsych
@katehollowood
The really cool thing about borderline personality disorder is that once you know how to recognise Autism, ADHD and CPTSD you never have to diagnose it ever again.
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I follow these up & explore them. Some autistics struggle to articulate their feelings. I will often say something like “patients who have also described xyz sometimes tell me…” & then I will tell them how autistics describe burnout, masking, sensory processing issues etc 25/
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So, now we know why we need to pick up that somebody is autistic, we need to know how to do it, and to do that we need to know why we aren’t very good at it. Mostly it’s that we don’t even think of it. That one’s easy. 20% of new patients you see are autistic. Think about it. 9/
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The first question some people have is whether or not it even matters, a dermatologist doesn’t need to know if somebody is autistic or not to treat their psoriasis, so do you need to know if they’re autistic or not to treat their depression? Well, you do. For a few reasons 2/
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“Whilst I agree her childhood trauma does contribute significantly to a lot of the difficulties she has today, I don’t think ‘she’s not autistic, this is trauma’ fully explains her enormous collection of interesting stones or the fact she taught herself Tolkien’s elvish”
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But even when we are thinking about autism, and we’re conscious of bias, we can get thrown of the scent by either false reassurance - usually they were seen by CAMHS/SALT/EdPsych and not been picked up - or diagnostic overshadowing - they’ve already got a Dx of EUPD/CPTSD etc 12/
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Explore why they saw these professionals. You’ll probably find lots to support the fact that they are autistic, with the benefit of hindsight. The next trap to avoid is thinking that their personality disorder/mental illness/trauma “explains everything” 14/
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@commaficionado
It’s also a lot of undiagnosed autistics who have masked their whole lives without realising that’s what they were doing because being seen as weird was always their biggest fear until they had a kid, and then the fear transfers onto the child.
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@AnnMemmott
A lot of Fesshole is either autisitc people or people confessing to tormenting autisitc people
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@ScrubSurvivors
Imagine already being under investigation for sexism when you show this slide.
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With every patient. You can only pick it up if you’re thinking about it. But even when we are thinking about it, we can miss it. I’ve had a few patients that I’ve had for months, even years, & I’ve suddenly realised I’ve missed the wood for the trees. And I think about it 10/
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@mightbeautistic
That’s not true either. There are autistics who can happily lie, and see no problem with it. We are not all morally pure. There are autistics who are liars. There are autistic murderers, rapists, fraudsters, abusers etc too. We’re not all the same.
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Those that can are starting to get curious, and so I ask if we can do a questionnaire. I then do the AQ50 +/- the CAT-Q with them, using it explore aspects of autism as they come up - “you’re good at small talk, but you don’t like it?” “tell me more about noticing patterns” 28/
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1 - set aside plenty of time to discuss it. Many autistics struggle to make decisions, and can feel panicked if they feel being pushed towards a certain one. They will often want a lot of information before making a decision. If you don’t have the time to give them that info 3/
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@drjanaway
Don’t need a new term. We don’t need the construct at all. C-PTSD and/or neurodivergence amply explains literally every case I’ve ever come across. Why do you think ADHD/autism is more common in men and PD more common in women? Because medicine is sexist. Most PD is autism/adhd
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I used to fall into the trap myself. “If they were autistic it would have been picked up when they saw x”
But actually, if somebody you think might be autistic for saw eg SALT for speech delay I think that’s evidence in favour even if they weren’t recognised as autistic then 13/
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So, now we’re ready to recognise our autistic patients we need to know how to. Given the 20% prevalence in psychiatric new referrals, an argument for screening everybody could be made, but the AQ50 has a sensitivity of .8, meaning a -ve result shouldn’t stop us still thinking 22/
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So continue to think about autism in light of other diagnoses - as your management of them will be guided by it (see above). But even when we are really thinking about autism we still miss that people are autistic because we try to spot it with our eyes instead of our ears 16/
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I’ll then ask if I can ask some questions that may seem unrelated, but that will eventually have a point. I ask about things like sensory processing, special interests, feelings about change, I tell anecdotes about autistic friends, patients and family and ask if they relate 27/
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I’m not being funny but the reason we’ve got private adhd clinics of varying degrees of quality is because we’ve restricted adhd diagnosis to specialist clinics & have them do 3 hour assessments + collateral + write a novel for each patient and so nobody can get seen
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Now, I will admit, I do occasionally walk into a home, or see a patient walk in to a clinic and be a hit by a kind of “autistic gestalt” but far more commonly the thought that a patient might be autistic comes from something they say. And for autism, the history trumps MSE 17/
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Thanks again for making it this far. Please share if you found it helpful
#MedTwitter
#Psychiatry
#autistic
#actuallyautistic
22/22
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This is where having used real life people helps. I can tell the patient “all the people I’ve told you about, many of whose experiences you relate to have something in common so when I say what it is I want you to try to ignore everything you may have heard about it before” 30/
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@sarahditum
As a consultant psychiatrist who used to work in an NHS ADHD service and diagnoses ADHD regularly I have yet to come across a self-diagnosed patient that, after assessing them, haven’t met criteria. I see far more people with ADHD who have been misdiagnosed with something else
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@MichaelBaggs
I’d spent some time in a city where you had to press the buttons on the doors and I came back to London and was on a tube with a friend and pressed the button and he looked at me and said “stop it you look like a fucking tourist”
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By this time, the patients usually either say “do you think I’m autistic because I have wondered before” or “how do all these things connect”. The first group are easy, but the second group, who don’t necessarily know much about autism, can be resistant when it is suggested 29/
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My little boy just told me he wanted me to tell me about a man called
@MichaelRosenYes
because he’s so funny. He says I will laugh a lot at “don’t”. I’m looking forward to reading him some of the poems I liked when I was his age 😂
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And if, after spending time reading about it, the patient really feels that they are autistic, & you don’t feel able to formally diagnose them, not because you doubt the diagnosis but because you’re “not a specialist”, don’t wait years for the assessment to make adjustments 33/
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Most patients are perplexed at first, some are even offended, (I remind them of the many friends and family members I had referred to, and told them that if I think they are autistic they should take it as a compliment, which usually gets over). But most want to discuss it 31/
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@AxhDefi
Ok it’s very simple give me the prevalence of ADHD, explain why that’s correct and compare it to your data (not your sense) of what proportion of people are being diagnosed with it.
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Then they will look for it elsewhere, maybe online or in the leaflet - and if they don’t like what they read they may not take it due to concerns you may have been able to alleviate. Autistics can get focussed on details, and this can irritate people interacting with them 4/
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@JJpixies
When I suspect a patient might be an undiagnosed autistic one of the questions I ask as I’m exploring it is “do you ever avoid the news because you get so affected by sad news that it affects your mood and/or gets in the way of your life?”
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They will be able to pick up if you are irritated, and their concern will not be alleviated, and they will feel unlistened to. Where you can, give people time to make decisions, I will offer anybody on the fence some written info and ask them to email our team in a week or so 5/
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@drphiliplee1
I’ve been to a lot of parties thrown by Filipino friends and so far the only vegetarian option I’ve seen on offer has been plain boiled rice.
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They hadn’t even taken ibuprofen for a headache but she gets accused of drug seeking when she is finally so crippled by endometriosis that she needs opiates despite “relatively little extrauterine endometrial tissue”. There are wider issues of misogyny here of course 16/
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It’s a major scandal in this country that many CAMHS teams restrict access to Autism/ADHD assessments to people referred by schools - ie organisations that are financially incentivised to ignore autism and adhd and staffed by people who know nothing about them.
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They feel symptomatic when slightly hypo/hyper - screen them. And if one mushroom, or a leaf of coriander, or a pinch of chilli or scrape of ginger can overwhelm a dish, and slight distortions or an internal norm have big effects - maybe a low dose of 💊 can have big se’s? 12/
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Atypical sensory processing and acuity is part of the dsm criteria for autism, and this can often be pronounced. A pt’s dad secretly put 1 🍄 in a pot of stew “to test her” after 1 sip she refused to eat anymore as 🍄 flavour overwhelmed. A pal can ID a 🐦 flying towards us 10/
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@elsalwilliams
Whenever i teach people about autism (in a very neurodivergence affirmatory way) I’m always upset at how many people were clearly hearing it all for the very first time, despite having plenty of previous education and training.
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3 have completely shut it down and we left it, but 8 months later 1 brought it up & I’ve just diagnosed her. The majority have agreed to be sent the some articles, read about it, & explore it more if they wanted to. So far every patient has wanted an assessment afterwards 32/
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And then they become aware that they get a reputation for “always having side’s” as if that was somehow a failing on their part. And you know some of those patients - so screen them for autism next time you see them. Because those se’s are real, even at tiny doses 9/
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Before any of us can see that there is a bird at all, but when it gets close enough - he’s always right. Many autistics also have a very tight comfort range - one patient says she is freezing when it’s <19/66 and roasting when it’s >23/72 those T1DMs w v tight control because 11/
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Which brings us on to 2 - believe them about side effects. Many autistics have told me this story about 💊. They start 💊A at a very low dose and notice they get itchy 🦶 . They weren’t told this was an se so they read the leaflet, and sure enough it’s there. So they see a dr 7/
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@jamesldowns
So much this. It makes me so annoyed that when I diagnose an autistic patient I write 7 sides of A4 and if possible talk to their parents, or nobody will accept the diagnosis. But the same person given a diagnosis of EUPD by a trainee whilst in crisis cannot shake that at all.
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So if a patient has pain “disproportionate” to the pathology, consider screening them for autism before wondering if they’re addicted to codeine.
Then once there is a medication strategy everybody is happy with: 5 - make sure they can take the 💊 as prescribed 19/
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@MonarchAnd
@sohosquad
Yeah. Fire your biggest star and champion to preserve the feelings of a wrestler who was out injured for nine months without being missed at all and a tag team who get the name of a superior team they’re trying to bury chanted at them during their identical matches.
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Introducing my six year old to some old wrestling.
@TheJimCornette
comes out. “Who’s that daddy?” “That’s the man who sometime starts speaking when we start the car and before I can turn it off sometimes he says words that you’re not allowed to say”
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How they experience their symptoms. Which brings me on to 4 - believe them about their treatment response. This is most relevant when it comes to pain - especially pain that is “disproportionate to the pathology” so many autistic women have cried to me about how in 20 years 15/
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@dickandtinasson
@helen_barnowl
@ElshadKarbasi
What country do you work in where they make doctors who don’t know anything about autism?
I want to make sure I don’t require any healthcare there.
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Autistics are more likely to have physical and mental health diagnoses, and are therefore more likely to be on 💊, and so it’s important that we can manage them appropriately. The principles I’ll outline are basically just good medical care, with some special considerations 2/
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Here’s a 🧵 I’ve long wanted to write combining my major interests of birdwatching and autism. Birdwatching, like trainspotting/ philately, is a stereotypical “autistic” activity, & my experience is that many birders have numerous autistic traits, & this I why I think that is 1/
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