Diagnosing Autism in Psychiatry: It’s Giving ‘You Don’t Look Autistic'

Autism has long been boxed into a narrow stereotype—white, male, socially awkward, obsessed with trains. But what about the autistic people who don’t fit that mold? The girl who made it to adulthood without a diagnosis because she was “just shy”? The high-achieving professional who burns out repeatedly but is told they’re just anxious? The Black kid who gets labeled as “defiant” instead of supported? The adult who spent years self-medicating with alcohol or drugs because they were never given the right framework to understand themselves?

In this episode of Brain Trash, we’re breaking down the DSM’s diagnostic criteria for autism, point by point, and exposing just how many people slip through the cracks. We’ll dig into how sensory sensitivities, social differences, and repetitive behaviors manifest in ways that aren’t always obvious—especially in those who mask or were forced to adapt from a young age. From hyper-empathy to burnout, camouflaging to substance use, we’ll explore the many ways autism can present that the DSM fails to capture, and why this misunderstanding has real, harmful consequences.

If you’re a clinician who works in mental health or you’re a person who questioned neurodivergence to your provider only to get shot down because you don’t “look” autistic, then you better have a seat and pop on your headphones.  Don’t miss our deep dive into how the DSM leads clinicians to the stereotypical presentations. Subscribe and leave any questions or thoughts!

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Transcript

Maria: When people think of autism, they picture a kid who loves trains, maybe doesn’t make eye contact, maybe even some sort of, like, a quirky genius—amazing at music, something like that.

But what if I told you that autism doesn’t always look like that? What if it means that you get exhausted after you’re socializing, and you still enjoyed socializing when you were doing it? Or what if it means that you are repeating the same song over and over in the car the entire drive or watching the same three comfort shows for years?

Today, we’re diving into the unexpected and overlooked—but valid—ways that autism can show up for people, especially adults, women, and people who’ve masked their whole lives. So if you’ve ever wondered, “Is this autism or is this just sort of a TikTok fad?” Stick around, because this episode might change how you view neurodivergence.

Tabitha: So, if we look through the DSM criteria when it comes to, like, autism spectrum disorder, right, we can kind of go through how each one is more nuanced than what the words say and maybe talk a little bit more about what that looks like.

Um, so in their first Criterion A, it says: “Persistent deficits in social communication and social interaction across multiple contexts as manifested by the following, currently or by history. Examples are illustrative, not exhaustive. See text.”

That, just right there, tells you, like, “Hey, we’re saying a lot of things, but also, it can be a lot of other things.” And this is why it’s important for us to kind of research, listen, go through the different nuances so that we know what that means—that they’re just illustrations. And that’s all that—there are other options.

So, the first one is: “Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation, to reduced sharing of interest, emotions, or affect, to failure to initiate or respond to social interactions.”

So it’s, like, a really broad range of how somebody interacts socially. And it also, like anything else, requires context because as a practitioner, you’re looking at this going, “Oh, this seems like an abnormal social approach.” But are we basing that off of what is truly abnormal, what we think is abnormal, or what’s different from the way that we socialize, right?

So, there’s a lot of things that you have to assess about yourself in order to understand what an abnormal social approach even is—what reciprocity should or should not look like—all of these things.

So, even if somebody appears as if they are back-and-forth conversing with you, is there a point in time where they are potentially thinking a lot about how they are giving you that reciprocity, right?

Is there a moment of pause where you’re not sure—“Are they gonna say something?” But then they say something, and it’s totally normal, so you’re like, “Oh no, they’re not socially awkward. They just needed a moment to think about that thing.”

This can look different ways in different people. And it’s not always just, “Oh hey, I’m really socially awkward, and it’s very obvious,” right? It’s not always like that. This can all happen internally, inside of somebody’s brain. If you don’t ask them the questions of what happens inside of their mind when they socialize, we may not ever get to a place where we feel there is any abnormal socializing going on.

Maria: And I think this is like if you back up to, like, even what happens before the social interaction. So, a lot of people are rehearsing social interactions. They have scripts about what to say. They know, like, the, “Hey, how are you? What’s up? What’s going on?” And that sounds very fluid and very normal because it’s rehearsed and it’s scripted.

And then sometimes people have lists in their phone about, like, “What are the things to talk about if there is a silence?” So it feels like they’re very extroverted and comfortable to socialize with. It doesn’t feel awkward because they’ve essentially, like, created this demeanor or this personality that is able to thrive in a social situation, but that comes with a lot of research, and that can be really exhausting for people.

And that’s what a lot of people do mean by, like, “masking,” right? Like, as you said, like, internally, there’s, like, so much stuff going on of, like, “Okay, now they stopped talking. What do I say next? Like, how do I respond to that?” Like, just analyzing every single aspect of that conversation in order to maintain it. And that’s, like, a lot of work.

Tabitha: Well, not even just what they’re saying, but also, you know, what their bodies are doing—and that comes a little bit later in the conversation. But, like, that’s just one aspect of the planning that goes into socializing for somebody who is highly masking.

And I’ve even had people tell me that they, like—they’ll go on, like, ChatGPT and they—

Maria: Yes!

Tabitha: To take a statement and make it more, you know, social or more diplomatic if it’s a work setting. Or, like, they’ll have other people or resources and tools help them with this scripting because they can’t figure it—

Because they can’t figure it—

Like, if you really think about the amount of time that takes up out of somebody’s life, out of their day, and why it’s like, “Oh, this event isn’t until 7 PM, but I need to spend all day prepping for it, and so my whole day is shot because I have a one-hour meeting at 7 PM.” It’s like, that’s exhausting.

Maria: Accurate.

Yeah, and then sometimes it’s like, even some people are too blunt, and, like, we could just assume that they’re assholes, but, like, they’re not an asshole. They’re just blunt. And that’s how they navigate social conversations.

But we’re not ever, like, backtracking and thinking about, “Maybe they’re autistic, and that’s why they’re answering in this way.”

Um, or, like, “Why are they continuously, like, asking for more information about my questions?” Again, that’s like—they’re not understanding the typical social interaction, and they need more information, right?

Tabitha: Well, and also, I find that highly masking people are typically pretty humorous.

Maria: Yes.

Tabitha: So it may cover for that awkwardness or that, like, “Oh, they seem like an asshole,” by, like, following it up with, like, a self-deprecating joke or—

Maria: Yup, sarcasm.

Tabitha: You know, something where it even furthermore helps to make other people comfortable with the awkwardness, even though the person experiencing it is so fucking uncomfy, right?

Maria: Accurate, accurate.

So, the next one: “Deficits in nonverbal communicative behaviors for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication, abnormalities in eye contact and body language, or deficits in understanding and use of gestures, to lack of facial expressions and nonverbal communication.”

So again, like, range.

As you said—range, right? Like, it doesn’t mean that you are just not having facial expressions. It could also mean that they are exaggerated—like, you could be watching anime and then using those facial expressions in things.

So you might have somebody, like a kid—I’ve seen this before—kids who love anime, and, like, if they’re surprised or excited about something, they do the jaw drop, so they’re, like, thinking that their jaw is actually dropping, and that’s, like, what they’re imagining is how they’re showing it, right? Um, but that’s, like, a huge indicator. What else? What else you got for that?

Tabitha: Well, and I think a lot of this too—like, with the body language, right? There’s a lot of thought that goes into, “What does it mean if I cross my arms? Do they think I’m mad? Maybe let me put them down by my sides. No, wait, they look like a robot.”

This also happens with eye contact too, right? Like you said before, it’s not always that, “Oh, I can’t make eye contact, or my eye contact is really avoidant, and then I awkwardly look at you, and then walk away again.” Right?

In somebody who has really well thought out these things about themselves throughout their whole life, a lot of it’s gonna be like, “Okay, now, I’m still looking at them and making that eye contact, and I’m gonna—okay, I’m back now.” You know?

Like, really thinking about, “Don’t make it weird for them, so make sure that this meets the context of the conversation I’m having.” And this may be rehearsed ahead of time, and maybe something that’s just, like, at the forefront of somebody’s mind during a conversation. It may be something that changes based on the other person’s form of eye contact, right?

So kind of, um, mimicking what other people are doing in that setting—like, what is the right amount of eye contact to make or not make? And that may not always come across as awkward to you, especially if they are mimicking your eye contact as a practitioner.

It’s—I’m not gonna say, “Oh, that’s awkward that they’re doing that,” if they’re just doing what I’m doing. Which, sometimes, I like to look out the window ‘cause there’s, like, fun stuff out there, right? So if they look away, I’m gonna be like, “Oh, that’s totally normal ‘cause they do it like I do it.”

Maria: Yep.

Or, like, they’re, like, looking right into your eyes, like into the depths of your soul, because they literally think, like, “I was told that I had to have eye contact growing up, so, like, let me look into your eyeballs.” But then, like, there’s always, like, the conscious thinking of, “How much should I be blinking?”

But, you know, as a practitioner, we need to, like, be asking about the background of what is happening behind these social conversations and, like, these social interactions. It’s a big deal. 

Tabitha: Just because the surface looks one way doesn’t mean that there’s not an entire shit show dumpster fire happening inside of somebody’s brain.

Maria: Exactly. And, like, even with, like, nonverbal communication—like, how do you sit in an appointment? Like, I’m over here sitting cross-legged, right? I can’t sit in any sort of a professional environment with my legs down. I’m cross-legged, I’m on the floor, I’m, like, you know, kind of, like, hunched over sometimes.

And those are some of, like, the weird abnormal things—“abnormal”—we see too that we’re like—

Oh, not necessarily like sitting straight up in a chair, having a normal conversation. Like, things can look a little bit more, um, stiff sometimes—or sometimes not.

Tabitha: When I get a lot of descriptors from people about how uncomfy it feels to just, like, be inside of a body—right? And so, this can also impact that body language aspect of, like, trying to practice and find things that are, like, comfortable enough but look okay to other people so they’re not weird, right?

Like, I can’t sit on the floor during a board meeting, um, but I can, you know, curl my foot up under my bum during a board meeting and then maybe, like, you know, find ways to get a little bit more comfy. But it’s not necessarily going to be ideal, but it can still be shown to other people as, like, kind of normal.

Maria: I like how you refer to the body as a “meat suit.” And I think that is, like, a great thing. Like, do you feel like your body is a meat suit? Like, are you just kind of manipulating the meat to, kind of, like, slap it around a little bit and, like, stay comfortable? And that’s, like, a really uncomfortable costume kind of thing?

Tabitha: Yeah, like, just essentially like, “How do I make the Play-Doh meat suit look like the other people’s meat suits in this room so that they think I belong here and I’m not, you know, fucking weird,” for lack of a better way to describe it, you know?

And this is a common experience that people have when it comes to, um, especially, like, Level 1 autism, where you’re, like, really, really focused on how to maintain normalcy or whatever. 

Maria: How do I not out myself kind of thing—that I’m weird and that I’m different than everyone else?

Accurate.

Third thing would be: “Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviors to various social contexts, to difficulties in sharing imaginative play, or making friends, to the absence of interest in peers.”

What you got for your take?

Tabitha: There’s—there’s a lot to unpack there. Especially if we’re talking specifically about, like, adults, women, people who have, you know, trauma, right? There are things that cause somebody to behave differently in social settings.

And depending on, like, how you are socialized growing up too, like, what types of contacts were you made to be appearing comfortable in, right? So when you’re developing these relationships, especially as a girl, right, you see other people like, “Ooh, we are playing dolls, and we are into fashion, and into these things that, like—” really make no fucking sense to me.

Because I’m like, “Mewtwo is floating on a rock in space, why do we care?” Right? But being able to learn, “How do I kind of navigate this?” But then not fully feeling sameness—like, sameness to others in those settings. And trying to kind of come to terms with what that means.

That imaginative play piece—I think that you talk a lot about that in a way that’s awesome, but, like, it can look imaginative, but it’s about these realistic things. What do you think about that?

Maria: So yeah, like, my daughter is a prime example, where I kept telling myself, like, “No, she can’t be autistic. She does so much pretend play.”

But the pretend play was like, “I’m playing doctor. This is the stethoscope, right? Like, I’m gonna check the heart now.” And all of her imaginative play comes from shows. So, like, it’s all rescue situations.

So she’s always rescuing a car that’s stuck on top of a building, or something like that, and the cars are doing it, and they’re rescuing each other. And, like, they’re talking to each other, and it seems to be imaginative, but then I started noticing that a lot of it is scripts from shows she was watching.

And she’s using, like, different parts from shows to make up this “pretend play.” So it feels pretend, but there’s no dragons appearing or, like, anything that she hasn’t seen before. Like, nothing is stemming directly from her imagination—it’s all stemming from things she’s seen.

And it might be play around, like, “I’m gonna play doctor ‘cause I just went to the doctor.” Or, “I’m gonna play work. I see my mommy working all the time.” Things like that.

So even, like, in pretend play, a lot of the time it goes to the point of, like, people are setting up their dollhouses or setting up a scene, and then they just look at it and they’re like, “Mmhmm.” And then they move on to the next thing.

Whereas somebody who’s neurotypical would actually continue the play. Once that’s set up, they would continue doing the pretend play.

But people who are autistic just set it up and leave it there ‘cause they’re satisfied, or they might be, like, lining things up in a specific way and kind of checking it out, being like, “Yeah.” And then they’re doing imagination and kind of talking in their head, but it’s not coming out into the play anymore.

It’s just kind of like, “Okay, I put the scenario in my head, and it’s here now.”

So, I think that’s where girls get misdiagnosed a lot because, well, they pretend play, but do they? Right?

Or, like, even in the ATOS, right? Like, when we did the ATOS of my daughter—blowing out birthday candles—she's seen birthday candles, she's done blowing out candles, so yes, that's a realistic situation where she can pretend to blow out candles because that’s criteria.

Does that mean she pretend plays? No. She still doesn't get it. That's a realistic scenario. That doesn't count.

Tabitha: Right.

Yeah, there's no piece of imagination being used for something that you have a real context to draw from, right?

Maria: Right.

Tabitha: And I think this goes into adulthood in terms of relationships too—like the social aspect of interacting with other people, or, you know, a version of play that happens in adulthood, right? Being at a party, socializing with other people.

Like, people oftentimes have either, you know, no big interest in this, or in the moment, it feels really fun, but afterward, there's a lot of nitpicking, like, “Why did I hold my body in that way? How come I didn't say it this way? Was that weird that I did it that way?” And then not wanting to, like, reach out and ask all your friends, “Hey, was it weird when I did that one hand movement? Did everybody think my hand looked really big? Disproportionate to my body?”

These are not the things that we assume other people are thinking about when they are at some type of fun social gathering, right? 

Maria: And that's not social anxiety, and that's kind of where the difference is.

Yeah, it's like, social anxiety isn’t nitpicking everything that you did wrong and kind of misinterpreting how other people interpreted it, basically.

Um, and even, like, with relationships and romance, that kind of comes in with getting obsessive about your partner, or thinking you have to people please, and not understanding how to maintain relationships. Or, you know, if you get into a fight with a partner, you might just think like, “The relationship's over,” and just pack up their things and be like, “Okay, I guess we're broken up now.”

‘Cause you just don’t understand. And you can develop some sort of, like, abandonment trauma about that if you don’t see those things coming.

So, there’s a lot of weird, nuanced ways in relationships. I feel like that's pretty endless.

Tabitha: Well, and yeah, I think too, this is a great example of how this can be important for clinicians to know, even if you're not gonna be diagnosing autism. Like, it's important to know that these things are common in autism so that if somebody's, like, checking a bunch of boxes for borderline personality disorder—

Maria: Yep.

Tabitha: Just because there's a history of unstable relationships doesn't necessarily mean that it's based out of this, like, personality disorder. It may be based out of a much larger web of fuckery happening in this person's brain every time that they are trying to get close or be more intimate with another human being, you know?

Maria: It looks like fearing abandonment because they can't keep friends. And that’s why they can’t keep friends since childhood. This isn’t, like, an adult, trauma-developed thing. This is like, “I could never, ever, keep friends. What’s wrong with me?”

So—of course, I’m gonna be fearing that, and like, of course, I’m very reactive with social situations, and of course, they're triggering. Because it’s traumatic.

Tabitha: Well, if you ask somebody, “Are these relationships abruptly ended because of something you did?” Right? If you're thinking of, like, borderline-type of stuff, like, “Oh, were you being dramatic and you just were like, ‘We're not friends anymore’”—

The person might say, “Yes. It's because of something I did.” But if you go ask the friend that they just, like—or the boyfriend that they left, right? They might say, “Yeah, one day, like, she just left, and it was so weird because, like, I thought we were fine, and I just never heard from her again.”

And so, it wasn’t a big dramatic thing—it was just a misinterpretation of that social cue.

Maria: So many of those, and I feel like that could get pushed as borderline so often.

That’s so true. That’s like where the borderline disparity happens, I feel like.

Tabitha: Mmhmm.

And think about the ways that impacts somebody to be told, “You have borderline,” versus, “Hey, this is an autistic trait, let’s dig more into that,” you know?

Maria: Yeah.

Like, there are a lot of people who say, “But I don’t have trauma, but I think I have borderline.” That would make me question, like, “Hmm, genetics, hmm,” you know what I mean? Like, is there autism somewhere in here?

The sprinkles of maybe.

Tabitha: Yeah.

Maria: Alright, next up we have B—so: “Restricted and repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history.”

And again, examples are not exhaustive, right?

So, first one: Repetitive motor movements, use of objects, speech. So things like simple motor stereotypes.

Is it stereotypes? Am I saying it right? I think. I hope I am.

I jack up words, and then I get corrected on TikTok all the time.

So, lining up toys, flipping objects, echolalia, idiosyncratic phrases—those kinds of things.

Echolalia is probably one of the most common ones, and I think people automatically assume it means, like, “Oh, it’s that little boy who’s running around quoting things,” or, “I just said that, and now he’s repeating it for half an hour.” But they’re missing the subtleties.

Sometimes, when you’re talking to an adult, they repeat things—but not even out loud. They’re repeating it in their head, and then they will answer you. Or palilalia, which isn’t even listed in here, is when you say something, and, for instance, my daughter does this a lot—she would say, “The train is coming… the train is coming…” so she’s repeating herself. It’s kind of like a version of echolalia.

And then it can be internal too, right?

Tabitha: Yeah, it can be, like, you know, hearing that same line in a song over and over in your brain—and then you have to listen to the song to get it out of your brain.

Now, obviously, that’s something that, like, could be a million different things, but if we’re asking enough questions, this is how we start to help people identify, “What is it that’s causing this thing that I’m experiencing that’s making me feel distressed sometimes or just really confused by how my brain works?”

Obviously, a lot of the repetitive motor movements—the most stereotyped thing that we think about is, you know, historically, like what you were talking about at the beginning, right?

Kids who are just really into trains, and having these big, stimming behaviors that are repetitive, right?

Maria: Lining up the trains.

Tabitha: Yeah, it’s not necessarily going to look like that, especially for people who have either had to mask, or have learned to mask, or are going to find ways to fit in so that they can function—especially as adults, right?

And so, some of these repetitive motor movements might not even be things that you see—it might be moving your toes inside of your shoes, 

Maria: Crossing your toes, applying pressure on your fingers. Yeah, cheek biting is a favorite over here.

Tabitha: Cheek biting, tapping on things in a way that seems like, “Oh yeah, I’m really into music and rhythms,” but actually, it’s scratching that itch of, “I need to repeat these things to get that sensory feedback, tactile feedback—all of these things.”

Maria: Yeah. And then, um, with that too—a lot of people don’t talk about the idiosyncratic phrases, but that one is kind of like, these are self-created expressions, right? So, like, they’re different than common meanings.

For example, my daughter uses, “Green means go,” and she does this when we’re in traffic. For the longest time, I used to just be like, “No, it’s red. The light is red.” And I didn’t understand that she was just mentioning that we were in traffic—and that was just her way to mention it.

So now, I understand—I’m like, “Oh yes, we’re in traffic.” But for a long time, I just didn’t understand.

So sometimes, people are kind of just giving these phrases where you’re like, “What? What’s the relevance?” Or, like, it might have some relevance, and you just think they’re joking, so you laugh it off. But those phrases can kind of pop in and out of places too.

So, that’s important to be assessing.

And then, like, what do girls do for repetitive behaviors—like, lining things up, right? Lining up pencils, and getting irritated if somebody takes them out. Lining up colors in a certain way.

Or in grocery stores, if they’re in the checkout line—fixing things.

OCD? Or is it autism?

That’s kind of your jam too.

Tabitha: Yeah, well, and that’s like when we get to this next one here:

“Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal and nonverbal behavior. Extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, needing to take the same route, or eat the same food every day.”

Like, just like anything else in mental health—these things can be more than one thing. And so, being able to identify some of this in a way that’s more nuanced allows us to search for meaningful answers—not just an answer to put in a chart to bill insurance, right?

Yeah, all of that—the ritualized things. Routines. Needing the sameness. It has to be done this way.

This can all be OCD as well. This could also be ADHD, right?

If I need things to be in the same place every time, or else I’ll forget them or lose them—

Maria: Right.

Tabitha: That can be a whole other basket of symptoms. 

Maria: Is it a system somebody's made just to cope, right?

Tabitha: And so, figuring out what is the reasoning behind this behavior—Can I get this person or somebody who knows them really well to describe why this happens for them?

If I need that routine because this is just the way that it is, this is just the way that makes sense—

Like, it just works this way.

This is how I do my laundry because this is what I was taught, and this is what works for me.

And this is what works for me.

We can even look at that and say, “Oh well.” You know, there are certain aspects of that kind of behavior where, if you have a routine that's not distressing to you but maybe makes other people frustrated, you could even say, “Oh, is this obsessive-compulsive personality disorder?”

Maria:  Right. Yeah. Being particular, kind of thing.

Tabitha: Being able to really look at each of these pieces and say, What is it? Is it because this is just that rigid sameness routine piece of autism? Or is there another aspect to it?

Right, and is there other criteria also? Because it's not just saying, Oh, this is this one thing, and that means you have autism. It's like when we go down all of these, and we're able to look at all of them to say, Do we meet enough of these? to say, Hey, this might be autism.

Maria: Yeah, that's a good point.

And then, like, people think—I think it's so rigid sometimes that it can't be messed with, um, but they're like, Do you have a routine that you follow every day?

It doesn't necessarily mean that autistic people are following a routine. It might be that they just watch the same show before they go to bed every night or, like, they read the same book over and over and over again, um, or they're just listening to the same song for, you know, a three-hour car ride, and they're pumped up by it—it's kind of like a form of stimming in a way.

It's just kind of regulating you, right?

The transition thing too, like—

“But you're transitioning fine.”

And it's like, “How much effort goes into transitioning for me? Being dry to wet? Getting into a shower? Do I need to mentally prep myself to go do that transition?” Like, what about the transition from eating to not eating, you know?

There are just, like, all these weird little nuanced things that people think like, “Transition must mean, like, getting up in the morning and going to work. Home to work. Home to school.” But sometimes, it's like, “Bed to not bed. Bed to up. What is that transition like? Is it hard to get out of bed?”

Depression? Autism?

Tabitha: Right.

Maria: You know?

Tabitha: Well, and I think also with, like, the greeting rituals and stuff—I mean, is it a ritual because if I don't say goodbye to you in a certain way, I feel like you might die, and then we are never gonna talk again, and it'll be my fault because I didn’t say it that way?

That would fall more in our OCD bucket, right?

But if it's like, I've been socialized by the people in my life that when we are leaving a setting, I say, “Bye, I hope you have a nice day.” And if you don't say that back to me, it's like, “But wait, you aren't following the script.”

And it feels really rigid and routine, like that is, like, a, “Hey, this is our greeting ritual or our goodbye ritual.” If someone doesn’t follow that script with me, it can be really confusing, frustrating, overstimulating, or understimulating, right?

Maria: Feeling like that person hates you—and then overthinking it, kind of thing.

Tabitha: Yeah, yeah.

They definitely hate you if they didn’t follow the script. Yeah.

Maria: They're mad at me, like—they're not, like, you know, communicating back. Like my daughter, who wants to play with this boy, and he told—I told her, no, because he's autistic, and he just didn't want to play with her.

So he's being too blunt, and she's like, “Why? Why does he hate me?” And I’m like, “Buddy, I'm so sorry, I know you—”

Tabitha: Finally made an attempt.

Maria: She's like, “We have the same script, we do, Mom! We rehearse this all the time, and you always say yes!”

And it’s like, Man, I guess I gotta—I gotta mix that up.

I mean…

Tabitha:  Start throwing new scripts in there.

Maria: Gonna make some new scripts over here for social situations, but yeah.

It kinda—it kinda runs into that. The greeting ritual one is interesting, or like, Do I always shake a hand kind of thing, um, do I not know what to do with rituals because I don’t usually hug, and then people want to hug, and I’m like, “What do I do that’s different?” And you kind of freak out internally because someone’s trying to hug you all of a sudden.

Tabitha: Can't relate at all. Never.

Maria: Not like I had to prep—

Not like we had to prep our office manager not to hug you, and she was so concerned.

She’s a hugger. She’s like, “What do I do?”

Tabitha: Listen, I like a hug—if I know what kind of hug is coming my way and what I’m supposed to do in response, okay?

Is this… Are we a deep hug?

Is this, like, a side hug? What—it—what is happening?

Maria: You don’t wanna hug wrong back. That would—that would be bad.

Tabitha: I mean, yeah, obviously. I need to know what to expect.

Maria: Oh my God.

Tabitha: I can practice the script.

Maria: But we don’t seem autistic.

Tabitha: No. Not at all.

Maria: No. Don’t worry, guys, we don’t relate to any of this.

Maria: Alright, next up, we have, um…

“Highly fixated, restricted interests that are abnormal in intensity or focus—so, strong attachment or preoccupation with unusual objects, circumscribed or different kinds of interests.”

So…
 
 Tabitha: oh yeah…

Maria: One of the big things I’ve noticed with this is, like, sometimes stuffed animals—people can have an unusual attachment to stuffed animals.

And this is wildly common for autistic people.

Maria: So, being like, “My stuffed animal has feelings. I don't want them to feel left out.” Or like, “Let me make a social media for my stuffed animal.”

And like, they have feelings, and they have, like, their own friends and things like that.

Or feeling like your car has feelings. My daughter seems to think that our car has feelings—she’s always asking how he feels.

“Did you miss me?” She kisses him, you know, all of the things.

But also—a car girl for the restricted interests.

Tabitha: Yeah, well, and I think these can be things that are also really celebrated aspects of people.

And so, it doesn’t feel like—I think a lot of times, when we use the train example, right, it’s like, “Oh, this is a really nerdy thing that somebody’s way too into and like spending too much time on.”

But it can also be something that’s really positive—that brings them a lot of, you know, career success or just patient success, right?

If somebody’s able to get really deeply into something and know a lot about it—

Maria: Tech.

Tabitha: For example—it can be a good thing about them.

Yeah, and so, I think we look at this as, “What’s your thing? What are you into that’s like wasting your time or is silly to me or whatever?”

But these restricted, fixated interests can also be really positive things too. And then, we aren’t always looking for stuff like that.

Because I think a lot of what we learn—especially in psychiatry—is, “How are we gonna fix this problem for this person?”

Maria: Exactly.

Tabitha: This isn’t always a problem.

Maria: Yeah, exactly.

Tabitha: And sometimes, it is their profession, right?

Maria: Like, my thing is to nerd out on psychiatry—like, that is literally what I love. I love psychology, all of it—sociology, social justice—but like, those things are just conversational things and things in current events.

But literally—that’s all I wanna do.

I wanna read non-fiction books about these things, and that’s all I’m interested in. And that’s all I really wanna talk about.

So, when people wanna have superficial conversations, I’m like, “But what about all these bigger things?”

But like, nobody’s gonna ask me that if I go in for an autism evaluation. They’re gonna say—

“Do you have any, like, special collections of things?”

I don’t know, really. I don’t know.

“Do you have any fixated interest on, like, trains or anything?”

Not any objects.

So, it’s different, right?

Tabitha: Yeah, well, it’s things that we may not even realize are those things, right?

Like, I had a family member that collected yogurt tops in the drawer of the bathroom, right?

This is not a normal behavior.

But it’s also not something that you’re gonna be like—

“Oh, is your special interest collecting yogurt tops in the drawer of your bathroom as a child?”

Maria:  Would not be an example, right?

Tabitha:  It’s just—

Maria: It’s so obscure, like, you wouldn’t think to ask. And honestly, like, it’s so normal to them that they wouldn’t think to answer.

Tabitha: Yeah.

Maria: Like, they’re like, “So?”

Tabitha: I think they did.

Maria: Yeah, it’s just normal.

Like, “Doesn’t everyone collect things?” That kind of thing?

Tabitha: I think too, if we look at, like, all of the—there’s a lot of jokes about it, but, like, tons of undiagnosed autistic boomers that have, like, hoarder houses that have collections of all types of shit.

Maria: Dude, that’s so accurate.

Tabitha: It’s just like, “Oh, they’re really… um… I don’t even know.”

They—they have special things that they like a lot.

The China cabinet, right? Like, 

Maria: it’s just the China cabinet.

You know, all the expensive China that makes no sense—that is untouched because you can’t touch it.

It’s in its place.

Tabitha: We’ve never used it.

Maria: Yeah, actually.

All the little quirky things where they have, like, old-school dolls, and it’s like—

“Just ‘cause they were old when I was a child, and they’re all lined up.”

Tabitha: Or, like, a whole shitload of tchotchkes that are, like, inside—like, size order, color order.

Maria: Yes, dude. And, like, I think some of it too is, like—um, what was I gonna say? Celebrities.

It’s, like, another thing that, like, young girls or even adults get really into, and they’re, like, collecting fan things.

Uh, I don’t know—football or basketball or sports could be a huge one that’s missed.

Because it’s like, “No, they’re just a sports fan.” And it’s like, “No, they’re fucking obsessive about it.”

Tabitha: Every single stat of every single player—height, weight, position, what teams they’ve been on, who was the greatest in that position ever, what their record was last season, and in the 17 seasons before that.

Maria: And they’re, like, info dropping on you, and you just are kind of like, “I don’t understand any of this.”

And they don’t even notice—they’re just, like, continuously info dropping—like, so excited, right?

Tabitha: This is also so socially acceptable, right?

And if you look at—like, I don’t know about you, but if anybody in your life has a TikTok algorithm that’s like, “Here’s all these sports people that talk about sports.”

Like, these people are making really good money talking about sports. And so, again, it can be a really positive thing for them.

And especially if it’s something that’s socially acceptable to really, like, nerd the fuck out on.

That doesn't seem nerdy to other people ‘cause of sports. And we're bros, and bros love sports.

Maria: Accurate.

Tabitha: Or, like, some sort of weird-ass nerding out on brains, or trains, or anime—

Maria: Or singers and stuff like that. Oh, like, "She's just into pop stars or, like, you know, Taylor Swift or whatever it is." And it’s like, "Yeah, but, like, when you’re that deep into it and it’s, like, your whole life, when does it kind of cross into autism territory?" Right?

Tabitha: Oh yeah, and I think it’s a whole—you have to look at all of the things combined, right? ‘Cause you can be non-autistic and be obsessed with Taylor Swift or whatever, right?

Tabitha: Or the NFL.

Tabitha:  Or the NFL, right? But how many of these other criteria are we, like, hitting?

Tabitha: Yep. Without a doubt, you know?

Maria: And, like, one of the big ones, I think, is the sensory issue. So, I’ll give that one to you.

Tabitha: Oh yeah. So, like, hyper or hypo reactivity to sensory input or unusual interests in sensory aspects of the environment. Like, apparent indifference to pain or temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascinations with lights or movement—now again, I think when you hear all of those things, it’s a very, like, stereotyped version of these things, but there’s so much that goes into this.

Another big plug for, like, occupational therapy in this regard.

Maria: Yeah

Tabitha: Because a lot of these things are things that we don’t necessarily notice about ourselves unless somebody helps to point it out, right? If your body has always felt this way with specific stimuli or—

Uh, one of the things that they’ll look at too is, like, interoception, right? Like, how much do I recognize about what’s happening inside of my body? Do I know when I have to pee, or am I just, like, all of a sudden, "Oh my gosh, I haven’t peed all day—I have to pee!" Right?

Maria: Also, these kids end up later potty trained. So, like, as an adult, you should ask your parent when you got potty trained ‘cause, you know, might be some insight there.

And also, like, emotional regulation—you ask them about emotions or just anything like hunger, "I don’t know" is always the answer.

And they feel pressured by those questions because they literally don’t know. They don’t understand hunger. So sometimes we get overeating, and sometimes we get diagnosed with eating disorders because, again, we’re not recognizing hunger. So we just don’t eat.

And then it’s restricted on what we’re eating, so we’re like, "Well, they’re restricting," but it’s like, "No, they literally have, like, three safe foods."

Tabitha: Yeah, this can also happen with, like, the way that clothing feels on your skin. And you may not recognize, like, "Oh, when I wear, you know, really tight jeans, it makes me feel trapped and irritable and all of these things." And so somebody may present as "Oh, they’re super irritable, and they have this, like, mood disorder going on," but then if they’re wearing sweatpants, they don’t display any of that, right?

Helping somebody identify what it is that’s actually kind of the trends and why they feel the way that they do. And is that something internally in their body, or a response to an external stimuli, or a lack of response to external stimuli?

Maria: Yeah, and I think that’s where we get, like, a lot of NPs and people who don’t necessarily understand the sensory stuff. And they kind of, like, bring it back to, "Well, you know, if you’re bothered by loud noises, you’re covering your ears as a kid."

But what does that look like in an adult? That looks like irritability, kind of as you said.

Like, pain processing—what does it look like if you get hurt? Are you, like, thinking that you broke your toe ‘cause you stubbed it every single time you’re falling over? Or do you just get bruises everywhere ‘cause you don’t notice and you’re, like, super clumsy?

Are you, like, uh, going outside when it’s, like, super cold out, not wearing a jacket ‘cause you just don’t feel cold? That’s the thing. Or, like, feeling overheated or too cold at everything, so you’re constantly bundling up.

But there’s just so many, like, weird little nuanced things that, like, people aren’t looking at the variations.

Yeah. Um, clothing, as you said, like, is a really big one. Tags—it’s kind of, like, the most common one. 

Tabitha: Sock seams—oh my gosh, there’s so many people talking about sock seams.

Maria: Yep. Or just, like, how do they fit? Like, do I break, uh, holes into my shoes because I’m, like, constantly, like, stimming with my toes and breaking holes into them? And I hate socks because of it?

Tabitha: Or, like, do you walk around barefoot, or do you always have socks on?

Maria: Right. Or shoes—like, some people can’t take their shoes off ‘cause it’s weird.

Tabitha: Yeah, yeah. And there’s a lot of variation and nuance to that, right?

‘Cause it’s not always about what it feels like on your skin—more so, what kind of tactile input is it giving you? Does it feel better if there’s, like, something holding your meat suit together on your feet? Right?

Maria: Uh, the deep pressure on the meat suit, right?

Tabitha: Again, this can overlap with some of that more, like, OCD stuff. "Do I not want the contamination of something being on my foot and my skin from, you know, outside, or whatever, so I wear a sock or a shoe?"

Or is it more that, you know, either sensory—I don’t like what it feels like when carpet touches—

my toes. Or do I want something that’s, like, holding it together, you know?

Maria: The sticky thing too is like something on OCD questionnaires—like if you don’t like sticky things, but that’s often a sensory issue. Um, it’s like, "I don’t wanna touch things that are sticky," or "I crave it," one or the other.

Um, so that’s a big thing. 

Tabitha: A lot of times what I hear from people is, like, "Yes, I hate loud noises—unless I choose what the noise is, like my music."

Maria: Yeah.

Tabitha: "Unless it’s a certain type of slime that I really like or a certain type of texture," you know? And so, it’s not always, like, "Oh yeah, I hate these specific textures." It’s—"Sometimes I hate it, and sometimes I don’t, and this is why."

Maria: So, for the most part, we covered all of the criteria and some of the unconventional ways that things can show up.

Some of the things that we did not mention would be empathy and demonstration of empathy. So, looking at hyper-empathy occurring—a lot of clinicians assume that if you experience empathy, then you cannot be autistic.

But there’s kind of, like, a spectrum on that too, where people can experience none. There’s people who experience it but don’t know how to show it, so they come across as cold, right? But they just don’t even know how to feel it, recognize the feeling, or express it.

And then there’s the people who have hyper-empathy. And there is a study on this from Sheffield in the UK that looks at the experiences of autistic women and kind of descriptors of empathy. And there are people who describe feeling, like, physical pain, overwhelmed with anger, grief, a deep sad feeling.

"It feels like my innards are being twisted."

So, there is a level of empathy that can occur that can be actually crippling. And that can be kind of a way that social interactions are perceived that, again, isn’t neurotypical standard—that we’re not often talking about.

The other thing is, uh, looking at queer and trans folks—how gender presents.

So, we get a lot of, like, uh, people who don’t want to dress in gender normative ways and kind of, like, questioning gender norms. And if you imagine, like, all of the social thought and effort that goes into following and understanding gender norms, that can be really hard for somebody who’s neurodivergent.

So, we often see that there’s a large population who are trans, who are non-binary, who are asexual, um, and that whole spectrum is much more common. And I think more easily explored for people who don’t necessarily fall in with, uh, the social norms, right?

So, I think, overall, a lot of the criteria is just kind of missed and misunderstood because we’re taking it too literally ourselves, right?

We’re like, "Well, they understand sarcasm," but, you know, maybe we’re just taking questions too literally—so literally that we’re answering them incorrectly.

So, like, when they look at the ADOS scores—the ADOS is an "evidence-based" tool that helps us diagnose autism. It’s actually a "gold standard".

But, like, there was a study out of MIT that looked at autistic people, right? They found that about 80% of men that they were looking at—already diagnosed with autism—met criteria for ADOS to be diagnosed with autism. But only half of the women did.

So, where—what are the symptoms of the other ones that are being excluded in this? And how many diagnoses are being missed? Right. And, like, what’s the impact of that?

Tabitha: Yes, there is a lot of new information that we are learning over time. And when this comes out, it looks very sensationalized because of the way that we disseminate information now, right?

And so, we run into some of the stigma that gets kind of perpetuated by these things. But really, the underlying importance of all of this—and finding tools that are more, you know, specific due to different presentations—is that the time that somebody is diagnosed is so, so crucial to the outcomes that they experience in life.

Right? If you are consistently thinking, "Oh my God, there’s something wrong with me," but nobody’s telling you, like, "Hey, this actually is fitting criteria for this thing, and we have an explanation, and there’s ways to support yourself,"—

If you’re having that internal presentation, basically, the messaging that you get about it is whatever you tell yourself. And a lot of times, that includes a shitload of shame—like, constant spiraling, "Why am I like this?"

All of these things that can lead people to have really shitty outcomes, right?

Substance use disorders are huge.

Maria: Yeah. 

Tabitha: Being, you know, perpetually treated for depression, low self-esteem, self-deprecating thoughts, anxieties—all of this without an actual explanation of, "How can I best support myself?"

‘Cause, again, it’s not even something that needs to be fixed. It’s something where we need to shift our awareness of how we function so that we can shape our world to fit the way that our brain thinks instead of trying to make it the way that it’s supposed to be.

And so, being able to identify these things in, you know, younger humans that are born in female bodies in a way that is meaningful enough to diagnose and give explanations is so important.

And I’m—a huge part of me is, like, just waiting for some type of gold standard that includes something other than what we are historically used to.

Because that's not doing anybody a service other than people who present exactly like the DSM says—without any imagination outside of that box that they give.

Maria: Yeah.

And, uh, let's stop looking at the DSM like the Bible ‘cause—let’s be honest—it’s trash. And, uh, we don’t have enough research, and, like, what are we gonna do, right? Like, we’re just literally kind of, like, clinically flowing through it and trying to, like, hear people where they’re at and understand people where they’re at.

Like, it makes so much sense, but I’m with you. Um, early diagnosis like—

Tabitha: Illustrative and not exhaustive.

This makes way too much room for interpretation and way too much room for provider bias to be in there, right? And that just, again, perpetuates that same shit over and over.

Maria: All the bias, dude. All the bias. I’m with you.

So, uh, that’s a wrap for today’s episode of Brain Trash.

We just pretty much scratched the surface of, kind of, like, how autism can present for people and how it’s overlooked and how provider bias can get in the way and, uh, impair somebody’s ability to have a strong, thorough assessment for autism that is fair to them and representative of their lived experience, right?

So, if any of this hit home for you—if you’re rethinking how you see autism, if you wanna take a deeper dive into learning more about neurodivergence, and, like, start questioning your own stigma, we’d like to hear your thoughts.

Drop a comment if you’re watching on YouTube. You know—go ahead and hit subscribe, follow us for our next episode.

If you’re on TikTok, you can follow me @dr.mariaingalla there. Let us know what resonated with you.

And if you’re a clinician, honestly, like—really please—start challenging yourself to look beyond the stereotypes because, like, there are so many different nuanced presentations, and we need to start having awareness to look at those to provide better care for people and more validating care for people.

So, make sure you’re subscribed—don’t miss any future episodes.

If you’re here for Brain Trash, the deep dives, the drama, how much the DSM sucks, all of it—just to validate your own weirdness—like, we’re here for it.

So, we appreciate you. Until next time—keep questioning, keep learning, and, um, remember that, like, you’re not broken. It’s probably just that the system’s really fucked up.

So, thanks, guys.