“I think I may be autistic”

“I think I have ADHD”

As generalists, whose training may have contained little about neurodiversity, we might wonder how to best manage a consultation that starts this way, and how to support our patients during what is likely to be a long wait for a definitive diagnosis. This uncertainty can be made harder by the fact that neurodivergent people may have difficulties in their social interaction, some of which may be interpreted as rudeness and can make clinicians feel uncomfortable, such as:

• overexplaining
• being emotional during conversations
• fidgeting
• interrupting.

The neurodiversity movement is a social, political, and human rights movement led by neurodivergent people, with the goal of acceptance. Mainstream understanding of this area is recent and so it is normal to feel conflicted and challenged in your own perceptions when having these conversations.

When a patient comes to see the GP it is usually because they are struggling, either physically, socially or emotionally. Neurodivergent people often have difficulties in all three areas, made worse by associated mental health difficulties. Alongside symptoms listed in the DSM-5, neurodivergent people also often experience emotional dysregulation. GPs often focus on the result (depression, anxiety) rather than addressing the underlying cause (neurodivergence).  

Neurodiversity not only affects mental health, but is also linked to a significant increase in the risk of some physical illnesses^1,2,3,4. Neurodivergent patients may consult more often about physical health conditions such as chronic pain, fibromyalgia, chronic fatigue, insomnia, reflux, auto immune disease, respiratory illness, hypermobility, female hormonal issues and atopy. The nature of emotional dysregulation means that they may get more overwhelmed by the challenges of ill-health than neurotypical people. This can include coping with chronic conditions, dealing with disability and pain and the practical and financial issues around the administrative burden of requesting adjustments and accessing financial support. Burnout may result.

A GP may reasonably wonder what we can do, in the limited amount of time available. We do not have to be experts in neurodiversity to be able to help this subset of patients – there is much that we can do within usual holistic primary care.

Some examples are as follows:

• Understand some basics about autism and ADHD – if your knowledge is lacking in this area, consider it as a PDP at your next appraisal. Be aware that there is significant stigma in this area and do not assume that your patient is looking for secondary gain, which is known to be uncommon.
• Listen with compassion, validate experiences, use kindness freely and often.  
• Know that these are not ‘vanity’, ‘trendy’ or ‘fashionable’ diagnoses; make it clear to your patient that you understand that neurodivergent struggles are real, and that a “get over it approach” causes harm.  Not everyone needs medication, but most will benefit from strategies and education for long term management.
• Identify resources which are neurodivergent affirmative or created by people with lived experience of neurodiversity – national examples include ADHD UK and the National Autistic Society. There may also be local peer support groups to which the patient may be signposted as well as charities and responsible information websites; support your social prescribing link worker to do so. Be clear in what the NHS can and can’t offer, and the timescale for help that is available.
• Be proactive as well as reactive – consider whether patients in whom anxiety and depression is not improving may be as a result of neurodivergence. Reframing "heartsink" patients and viewing them through a neurodivergent lens can lead to greater understanding.
• Manage physical illness. Many of the physical illnesses associated with neurodiversity are not obvious on investigation (e.g. IBS and hypermobility) – patients can therefore labelled as ‘functional’, or as having a low pain threshold or psychosomatic symptoms. Understand that their symptoms may well need management which may include physical therapy, medication and lifestyle change.
• Educate the patient on self-management where appropriate; remember that what may seem obvious to a neurotypical person may not be to someone who is neurodivergent, in spite of previous academic achievements.
• When in doubt, discuss the pros and cons of an official diagnosis with the patient and refer for a full assessment.

In summary, consultations with neurodivergent people can be difficult and different, but when patients are validated in their experience, managed with knowledge and compassion and given clear explanations, these can be some of the most rewarding patient contacts for a GP.

References:

1. Garcia-Argibay M, du Rietz E, Lu Y et al. The role of ADHD genetic risk in mid-to-late life somatic health conditions. Transl Psychiatry. 2022 Apr 11;12(1):152.
2. Zhang L, Reif A, Du Rietz E et al. Comedication and Polypharmacy With ADHD Medications in Adults: A Swedish Nationwide Study. J Atten Disord. 2021 Sep;25(11):1519-1528.
3. Al-Beltagi M. Autism medical comorbidities. World J Clin Pediatr. 2021 May 9;10(3):15-28.
4. Khachadourian V, Mahjani B, Sandin S et al. Comorbidities in autism spectrum disorder and their etiologies. Transl Psychiatry. 2023 Feb 25;13(1):71.