Psychiatry & Psychotherapy Podcast - The Autism Wave with Dr. Cummings

Episode Date: November 2, 2022

In today's episode of the podcast, we are joined by Dr. Michael Cummings to discuss the most recent and popular diagnosis wave of individuals believing they may have autism, which has become a recent TikTok phenomenon. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign in, take the test, and the certification is emailed to you in seconds. Dr. Cummings and Dr. Pudor have no conflicts of interest to announce. Let's start the show. All right, welcome back to the podcast.

I'm joined today with Dr. Michael Cummings, and today we will be talking about autism spectrum disorder, and we'll be talking about some overlap with different diagnostic categories. When I posted on this on my Instagram, I got a ton of interest in this topic. I think there have been a couple sensations in, TikTok that I've been following for a while. One is on tick disorders, another autism, and a third on multiple personality disorder. And from what I can tell, it's influencing people to contemplate,

do they have this diagnosis? Do they have any one of these diagnoses, you know, like diagnose I? So, for example, with tick disorder, there are people who are gaining large amounts of popularity on TikTok talking about this and there's been articles talking about how there's people showing up to clinic with potential tick disorder but it's it's not presenting in the classical sense it's somewhat manufactured have you have you heard have you seen those articles dr covings yes i have um and i'm frankly i've been in psychiatry long enough to know that diagnoses do undergo periods of popularity, the general population will become interested in them that often then results in an increase in people who are indeed validly wondering, well, do I have this, or at least some

aspect of it? And they often then turn to mental health professionals essentially to ask that diagnostic question. One of the limitations that you and I have talked about a number of times in psychiatry is that our diagnostic nomenclature is imprecise, although we have now the DSM-5. Essentially, and it does improve agreement about diagnosis, but it is based on essentially on essentially clustering symptoms together and then saying, well, if something is a cluster, then it's an illness. Of course, the problem with that is there is often a great deal.

overlap of symptoms or features among diagnoses. Right. And so, you know, I think maybe 20 years ago, there was this hope that, like, genetic studies would show, you know, this specific diagnosis has these gene mutations. What have they found instead? Instead, they found that most major mental illnesses are polygenic in origin,

meaning there are a number of risk genes involved in the ideology of the illness in association with various environmental exposures that may alter either the brain's development or the brain's functioning. And consequently, it's, and I think in psychiatry, it's never going to be as simple as

you have a single point mutation on a gene, and that results in a given mental illness. Yeah, it's like there's, it's complex, right? There's so many factors that go into someone developing a diagnosis or having, I think, better than saying a diagnosis is a symptom of cluster of symptoms which are distressing and difficult in their life. So tell me a little bit about autism. Is there genetic links with autism? Or environmental links?

What do you? There are both genetic and environmental links all over it in its clearly diagnosed form, which is a childhood disease, one of the developmental diseases. It is very genetically driven and of concern. It's been getting more common, such that I think the last statistic I read on this, it was estimated that one in eight 87 male children would be liable to a diagnosis of autistic spectrum disorder. Those cases, however, are relatively easy to diagnose in that there is initially a major failure in terms of language development, interpersonal interaction, often with very clear clinical signs and symptoms, I think, where you're seeing something currently in the popular press and on TikTok that is of interest is like most illnesses, autistic spectrum disorders run the range from subclinical, meaning the

person doesn't actually have a disorder, but they have some features, to severe illness where the person is mentally retarded and requires lifelong institutionalization. the interest in the general population has been more in those people who either have subclinical or mild autism what used to be called Asperger's disease where they may have some abnormalities and language function they don't quite speak fluently the way everyone else does they may have difficulty making social connections or understanding the emotions of other persons they themselves may be either hypo or hyper responsive to environmental sounds or lights or noises, and they may be prone to some degree of mood liability and occasionally to psychomotor agitation and acting out.

And that can overlap, of course, with a number of other things, you know, and diagnosis, including personality disorders. mood disorders, and so forth. And I think that's where the confusion comes from is people are often distressed and say, well, I have something. What is it? And because of, particularly in the Internet age, something will gain notoriety and popularity, and then people start wondering, understandably, well, could this be what I have? Yeah.

So, okay, I think it might be worthwhile to kind of go into some of those diagnostic criteria a little bit more and talk about, like, what is a higher functioning person who has autism spectrum disorder look like? Talk to me about, like, the sort of narrow interests that someone like that might have. Yeah. Often they have a propensity. to become preoccupied with a very narrow range of interests, to have very limited social interaction with other people. Often if they do interact with other people, they clearly don't understand the social interaction. They often have difficulty with some abstract language concepts.

They may be kind of prone to be unempathetic, unable to make an empathetic connection with other. people and may at times be either emotionally withdrawn or if distressed emotionally labile. People can be quite high functioning, you know, in autistic spectrum disorder, the more severe end, people are often intellectually disabled. I think probably one of the prototypical individuals who demonstrated intelligence and talent, who is also kind of. clearly autistic, was the individual Temple Grandin, who, when she was growing up, could not permit herself to be hugged by other people, for example. It would send her into a panic.

She would become preoccupied with something and spend hours or days, just thinking about it and working on that. I actually had an opportunity to talk with her and being quite intelligent. she understood that she is different from other people and said, well, if you ask a typical person to imagine a church steeple, most people will make up a prototypical church steeple in their head out of the elements of, well, what does a church steeple look like? She said she can't do that. Instead, she remembers every church steeple she's ever seen, but she can't synthesize that into an abstract form. So just for those of you who don't know, Mary Tumpto-Grandin was the person who, I think, developed how they slaughter cows at this point with the kind of the turning, like they turn in so they don't get to watch the cow in front of them be slaughtered. Yes.

Is that the person I'm thinking of? Yes, that is her. Indeed, the slaughterhouses hired her to basically walk through one of their slaughterhouses because she could actually look at the slaughterhouse from the cow's point of view, a minor reflection or something that most people would ignore,

she would fixate on it and say, well, that's going to panic the cow. And so she was able to help them design essentially more humane slaughterhouses. Yeah. People with autism, they have intact affective empathy. They have lower than average cognitive empathy. And so affective empathy is the ability to feel into someone's experience. And so my autistic patients, even if they're maybe less verbal or nonverbal, I've had a number still that are nonverbal, you know, maybe one or two words at a time, these patients will feel into their parents' anger or parents' emotionality and start stemming or start having repetitive behavior or start getting riled up themselves because their affective empathy is intact.

cognitive empathy is the ability to put towards someone else's experience your own experience. So they're not very good at that. And so they can come off as narcissistic or, you know, kind of not able to empathize. But they feel other people's stuff. They just don't have words to put to it. They don't have the ability to relay it. Yeah. Very much so.

they can often internally identify with what the other person is feeling. But if you ask them to describe what the other person is feeling, they're at a complete loss. Right. Someone who's more narcissistic or psychopathic, they have low affective empathy. So they don't necessarily feel into another's experience. So they could have normal cognitive empathy because they've learned how to put words to it. They've learned how to read people. and describe it.

Yeah, in particular, the psychopaths are quite talented, usually at reading other people. That's often how they manipulate them, but they don't have any affective empathy toward them. Okay, I think it might be helpful to read some of these responses that I got once I posted. So I posted, let me see if I can read what I post so that you guys can have some context. Okay, I've seen several patients with clear-cut borderline personality disorder come in saying they have autism, and that is the core of their issues. I have real autistic patients as well. I have high-functioning autistic patients, but a history of chronic SI cutting self-harm affect regulation issues is likely borderline personality disorder. Two years ago, I saw autism influences popping up more and more on TikTok, borderline personality disorder. order was borderline personality disorder, then it was bipolar, and it changes over and over.

Really, borderline personality disorder is, in my mind, an issue of affect regulation. So that's what I put, and then here's some of the responses I got. I have so many patients self-identifying, self-diagnosing autism when they really have personality disorders and are trying to validate why they feel so disconnected and struggle socially. It has led to some challenging and enlightening conversations. I'd love to see an episode on this. As a school, oh go ahead. You have some thoughts. I was going to say, yeah, I can understand, you know, probably of all the diagnoses out there other than some of the paraphylic diagnoses, borderline personality disorder has such a connotation history of being pejorative.

I'm not surprised that people who've been given the diagnosis would like something else as a diagnosis. I certainly don't blame them for that. In fact, I agree very much with the ICD-11 rather than the DSM-5 in this and that they have renamed it mood dysregulation disorder because that does appear to be the heart of what we call borderline personality disorder, although it doesn't border on anything, as far as I can tell. That's not to say, though, that somebody with borderline or narcissistic or avoidant or schizotypal or schizoid personality disorder may not have autistic features as part of their makeup. And I think that gets into the overlap in these things.

In fact, there are people out there who argue that our whole, system of categorical personality disorders is the wrong way to think about personality and personality functioning. That is, there is a camp who would very much favor a dimensional analysis of personality. Okay. Yeah, I hear you. I think, you know, there is some overlap, like when I started looking at studies of autism and personality disorders. The strongest overlap is actually in cluster A and in OCPD, like those, the cluster A being like the schizetiposci. Yes. And then obsessive, compulsive personality disorder. Those are the ones that statistically have the strongest link. Okay, here's another person's comment. As a school psychologist, autism seems to be a coveted category of disabilities.

saying your child has autism sounds a lot better than saying your child has emotional disturbance. There's way more funding and resources for people identified as autism. Way less in ED. Autism seems to be on the rise, but I think there is a misdiagnosis identification. You know, you can get from the state quite a bit of funding for a diagnosis of autism because, you know, people need quite a bit of treatment resources. and do you see that as a driver in the increase in the diagnosis? I think that's one of several.

I think there is actually looking at several careful epidemiologic studies. There actually has been a real increase in the rates of autism. However, I think beyond that, there is also for both social acceptability, having a support network and support organizations, and for funding reasons, people may indeed be drawn to the diagnosis. As I said, I've been around long enough. I've lived through periods when every child was thought to have ADHD,

every child was thought to be bipolar, every child was fill in the blank. And I think autism is going through something, of that process currently? This is another comment, and this I think gets at one of my concerns. And I'll state my concern before I read the comment. My concern is that if the child does have affect regulation issues, borderline personality disorder, there are treatments that are effective.

And I think if there's a mis-diagnosis or maybe not seeing it, then there might be this kind of permanence in the mind of the patient or the family members. It's just going to be this way, right, without the ability to make a change. Yes, and although we do have psychosocial treatments for autism and some pharmacologic agents that are used to treat specific target symptoms, by and large, we don't have an effective treatment for, autistic spectrum disorder. Okay, here's the comment. In a lot of ways, I agree.

And I think a big part of this is patients with borderline person or feeling like they have no control, so it is much safer to find a diagnosis that is not perceived as their fault to themselves or a lot of people in the medical community. It also takes the anxiety and pressure of having to do anything about it off because it's autism spectrum disorder, and I can't do anything about that. It's like swinging hard to the radical acceptance side

of the core dialectical behavioral therapy without having to balance it out with the need to change. So what this comment means to me and why I think it's so important is, number one, Dr. Cummings and I do not think that borderline personality disorder is something you should blame on a person. I think that that is stigma that is incorrectly put on the person. Would you like to say anything on that? Yeah, I agree very much with that. That's one of the reasons I

dislike the nomenclature the way it currently stands is the name, the label itself, has become highly pejorative. I've heard mental health professionals make the statement, oh, they're just just borderline. Well, they may meet the diagnostic criteria for borderline personality disorder, but this is a disorder like any other. They did not create the mood liability that often drives them and makes their life difficult, often miserable. And the person is right. There are effective treatments for borderline personality disorder, primarily dialectical behavior, therapy, although there are other forms of cognitive behavioral therapy that can be beneficial

as well. And of course, for psychotic episodes, antipsychotics do work. Mood stabilizers do or can decrease mood liability, mood intensity. We certainly don't have a cure for it, but we do have treatments that will benefit these individuals. Yeah. And, you know, there's partial programs that really do work, and intensive therapy really does work. There's Gundersen's approach that works. There's mentalization-based therapy, transference-focused therapy, schema-focused therapy, dialectical behavioral therapy.

You know, there's a lot of different therapies that have been shown to be effective. You know, when they put one of these against another, they do about the same. and Dr. Cummings was on here for a prior podcast, and if you haven't listened to that on Borderline Persadage, go go check that out. It was with Dr. Pro as well. And we talked about how a lot of these affect regulation issues start from like the first couple weeks of life. And there seems to be a temperamental inborn propensity

along with trauma that leads to this issue. it's not like these people are choosing to have the affect regulation issues. You want to say anything else on that? Yeah, indeed, we previously talked about the strong and chest study in which they looked at infants at six hours of age and basically looked at them in approach avoidance settings and indeed those who were the most affectively reactive turned out in later life to be those who had all of the person who later had a borderline personality disorder diagnosis came out of that group. And it would certainly be unfair to say that at six hours of age, they had caused

their own illness. Yeah, here's another comment. Okay, so this is, someone on Instagram said this to my post. My 12-year-old patient today said, I hope I'm diagnosed with autism so that everyone will take me seriously and I don't feel so bad about the weird things I do. And what I said is notice how this diagnosis can increase perceived empathy with your peers or with your teachers. And whenever you have something like that in a culture, you're going to have more of it. You know, if you have something that increases empathy in other people, if you have this issue, you will have more people wanting that label,

especially if they're distressed, and especially if they're going through really hard things. It's like, I want people to understand me and to give me compassion. It's like, of course they do. Of course they want that. So. Yeah, it's very understandable. I mean, I think everyone, if they are in distress,

is hoping that others will have empathy for their plight. Yep. And so when we think about patients with autism who maybe were not diagnosed, that may, you know, I think some of the people who probably really do have autism that were not diagnosed, I think when they learn about this is what it's like for a person with autism, maybe without some of the IQ issues and the developmental, you know, verbal issues, I think it can give them a sense of inner compassion, which can be, helpful for them and maybe make sense of some of the reasons why they've struggled. In a similar way, someone with just pure affect regulation issues, hopefully we'll find treatments that will help them and understanding of it as well. But, okay, getting back to this idea of diagnosis overlap, when you think about autism, do you see it as a neurodevelopmental issue that starts,

like at what age does it start in your mind? Autism appears to start, frankly, prior to birth. The best biological understanding we have of it is that normally the brain develops in a very sequential pattern of, well, first putting the neurons in place, neurons becoming interconnected initially with more connections than would be advisable, serviceable.

So we actually spend part of our time as the brain matures pruning away or letting atrophy those connections that don't work very well, don't fit very well. That process seems to be mistimed in autism so that the number of interconnections among neurons, and the cortex in particular is excessive. That may be one of the reasons that these people are prone to preoccupation,

and in some cases may be what was historically called, somewhat pejoratively, idiot savants, more recently just called savants, that is they may occasionally come up with a configuration among those neurons that can do things that normal people can't do, look at a bunch of matches thrown on the ground and tell you virtually instantaneously how many matches there are or calculate for you what day of the week it will be in 50 plus years on a certain

date in their head. Things are well beyond the capability of normal people. Most of those non-standard configurations are not beneficial, but occasionally one is. Yeah. And I don't know if you heard this Saturday Night Live. I think Elon Musk was telling the truth, but he said he thought that he had autism spectrum disorder. I don't know if you've heard that or if you've thought about that. I've heard that. I frankly don't know if I understand Elon Musk well enough to make a comment. Who does know Elon Musk that well? one thing that I've thought about is like what happens to someone who is incredibly intelligent at a young age and then they notice things that maybe they shouldn't notice for that age you know it's like they pick up things that maybe they shouldn't even pick up and I've observed a couple of these children as my

as my kids get older you know we have friends and stuff with similar age kids and it's one girl in particular I think it's like like she had like almost like a teenage capacity to absorb what was going on and and picked up stuff before she should have really picked it up and like how that influences her trajectory. I've ever thought about that? I know you're... Yes. In fact, one of the issues that comes up in regard to gifted children in general, particularly if they are in a. academic settings promoted beyond their age group is these are these are kids and young adults who clearly have a superior intellectual understanding of the world they picked up on things other people didn't but that often places them in a very socially distressing circumstance of being

as intellectually developed as the people around them but not being as emotionally or socially developed as the people around them. And that's often a significant burden for such individuals. Yeah. Or it's like imagine everyone your age is thinking about, you know, something that a normal person that age should be thinking about. But you're like thinking about things a couple years ahead. It can be a very lonely or isolating experience.

Yes. I wonder if these types of people are sometimes then putting themselves into criteria or having unique problems that other kids wouldn't have, you know, or like they have maybe the inability to emotionally regulate this information. Yeah, it's often very emotionally difficult for them and socially, because they often then have difficulty communicating, with their peers because they and their peer are not truly at the same stage of development. And many ways, that kind of parallels what happens to people with autism, intuitively, emotionally,

the autistic spectrum individual may grasp what's happening emotionally in someone else, but they can't put it into words, which also means they can't put it into thoughts, which is a severe handicap if you're trying to communicate with others. Yeah. So, okay, what advice would you give to clinicians then who may be having a patient coming in that is saying that they're autistic?

Like, what advice would you give them in terms of how to go about making that diagnosis or if that diagnosis is helpful to be made? Yeah, well, I think first, you know, when anyone coming in, I'm always very cautious when somebody comes in and says, I have X, my initial response to that is always to say,

well, before we start with the labels, tell me what problems you're having, and then we go through getting a good description of those, and then tell me the history of this. When did it begin? Was it abrupt? Was it slow? How has it developed?

Is it sporadic? Is it cyclic? And over time, of course, what I'm doing is developing a profile of signs and symptoms as well as the longitudinal history of their difficulty before I want to rush to a diagnostic hypothesis. And in particular, in the neurodevelopmental disorders, this is an excellent area where if you have an association with good child neuropsychologist, some of the test, in this area can be exceedingly helpful in terms of arriving at a diagnosis.

You know, a very carefully considered diagnosis before you begin pursuing treatment, because I think something you said earlier is very important. The whole reason we make diagnoses is to try to match the person to what's likely to be the most effective treatment options we have. Rushing into that or accepting a label with, testing at first really puts the person at risk of not receiving the help and the treatment they may need. Yeah. Which, I mean, it's the same thing when someone comes in and says, I have bipolar.

I am thinking to myself, do they really have bipolar? Okay, let me get the full history. Let me hear about their manic episodes. Let me hear about, like, how they came to this point. Because if they're not bipolar, maybe they should, consider, you know, classes of medication that I would not consider if they were bipolar. I wouldn't consider like SSRIs or SNRIs if they had true bipolar. And so for that reason, I'm going to be discriminant. Now, with autism spectrum disorder, if someone truly has autism

spectrum disorder, how would that treatment differ in your mind than if they, you said earlier, there's not that many treatments for that? And I think you've said, You've said in prior episodes like SSRIs don't seem to work for people with autism spectrum disorder. No, they don't. Some of the things like the alpha two agonists and very low dose dopamine antagonists like risperidone at very low doses may help with some of the target symptoms. there is no good pharmacologic way to address the condition itself. However, there are psychosocial support treatments and trainings, behavioral therapies, that are very much designed to assist the autistic individual to function better.

Doesn't cure them of autism, but they can become a more functional. autistic person versus say if I have somebody who comes in and it turns out they would like to be autistic but in truth they really suffer from mood dysregulation disorder aka borderline personality disorder that pulls up a different set of pharmacologic options and it pulls up things like cognitive behavioral therapy and dialectical behavioral therapy a different approach is to try to help the person function better. I think it might be worth going through some of the personality disorders and how you would differentiate if they have autism versus if they have this personality disorder. Maybe let's start with schizoid personality disorder.

The hallmark of schizoid personality disorder is somebody who feels disconnected from others. and isn't especially bothered by that. I've had a few schizoid patients who, when I talked with them about other people, they lacked the inability to verbalize what other people were feeling. They had both cognitive and affective awareness in terms of empathy, but in essence they didn't feel that need for, connection the way most people do.

And part of this comes down to getting to know the person well enough to be able to delve into those areas to try to figure out what they do or don't have. And usually what you'll find is that, yeah, they may have some things that overlap, but they're missing some critical elements that might be more typical, for example, of autism. Okay. How about schizetipple personality disorder? The classically eccentric individual who doesn't quite fit the social norms. But again, they, although they don't fit the social norms, they typically don't have things like the preoccupation,

the limited range of interests, or a deficit in cognitive empathy. Their response to the world is, is often odd, but it's not because they don't have those particular features as part of their ability. Okay, it's less common, but paranoid personality disorder. How would you differentiate that? Well, at least most of the autistic individuals I've met are not paranoid. They may be, in some cases, frightened by other people.

or actually panicked by other people if the other person is, appears aggressive or allowed. The hallmark of paranoid personality disorder, though, is to see essentially conspiracies under every rock. And although they may start with what sounds like a reasonable suspicion, if you let them talk, the suspicion tends to expand both in terms of level of important. and geographically as well, even if it does not reach delusional levels, somehow everyone is sort of against them. I've not gotten the impression that most autistic people feel that others are against them. They may not understand other people very well,

but they're not focused on the idea that, oh, this person is plotting to harm me. How about borderline precise order? I think there are some things shared by borderline. personality disorder and autistic individuals. It certainly is true, I think, because of their own affective liability that borderlines often have difficulty establishing stable relationships. But that's not the same difficulty that autistic individuals have in connecting. Usually the borderline actually connects very well, often intensely, initially with idealization

and then later with devaluation, but it's a roller coaster ride with affective responses, but the connection is intense. And then you have the other features like the brief psychotic episodes and dissociation. Those are things that don't tend to show up in autism.

Yeah. Usually people with Borodon and Precise or do not have issues with the non-verbal communication and like someone with autism might and people with borderline and precise surgery not typically show the narrow interests, repetition, insistence on sameness

that characterize autism spectrum disorders. No, indeed. I've had a number of borderline patients over the years who were, if anything, somewhat hyperverbal. I'm reminded of the quote from the Shrek movie when the princess says, oh, a talking donkey. And Shrek remarks, well, the magic isn't, and getting him to talk, the magic isn't getting him to shut up. Okay, yeah.

So, let's see, we talked before about antisocial personality disorder is really, or, you know, psychopathy has an issue with, affective empathy, whereas autism spectrum disorder has an issue with cognitive empathy. And so adults with autism spectrum disorder can seem unempathic, but they feel into other people's experience.

Yes. And you can often see the response in them and that they, if someone else is distressed, they often become exceedingly emotionally distressed and agitated, but they can't put it into words as to why they are behaviorally presenting that way. A narcissistic personality disorder can seem like autism spectrum disorder. I mean, someone who's autistic can seem a little bit narcissistic, especially if they're insisting or correcting other people's errors, lecturing other people on, you know,

their particular area of fascination or deep profound curiosity. Is there anything that would help you differentiate? Yeah, the narcissistic individual is, again, does not have difficulty connecting with other people, but their nature of the relationship and narcissism is, it's all about me, not about you. because the narcissist typically sees other people as objects to be used

whereas the autistic individual has a genuine emotional connection to other people they just don't have the language to express it right do you like someone who's narcissistic first are you know

with the full spectrum of the disorder may be art maybe superficially able to read people but they their empathy or their sort of

their empathy is lacking and so they're gearing their world to really support their own movement forward and as long as you are a part of them moving forward they are happy to have you be part of their Oh they're often

yeah and they're often quite ingratiating at the initial part of a relationship while they're trying to figure out if you're something or someone who will be useful for them. Yeah. Okay, how about obsessive-compulsive personality disorder? That one often phenotypically

is somewhat often the most difficult to distinguish because indeed the preoccupation and singular focus that you see in autism can look very much like the obsessive-compulsive personality. disorder in the sense that both can become incredibly preoccupied with details and want to narrow their interest into a very narrow range. The obsessive-compulsive personality disorder, though, often seems more interested in then imposing their rigidity and their preoccupation on other people to much greater extent.

than autistic individuals do. If you were trying to work with somebody with obsessive, compulsive disorder, it can be very difficult because they can't, often can't grasp the big picture because they're entirely focused on the details. The other thing is they don't lack the ability to connect with other people, and they don't lack the ability to put things into words. You know, I think one of the things I always come back to is

autism was originally described as a language developmental disorder. And almost all individuals with autism have as a central feature that inability to put things into words. Yeah, so someone with OCPD will have psychological defenses of intellectualization, rationalization, you know, so they have maybe distressing emotions, and then instead of wanting to feel them, they want to pontificate about ideas. And this is a good coping mechanism for them. They may be very orderly, very detail-oriented. You know, they make great accountants, great billers, great people that need to be very meticulous. They can be very perfectionistic. They can be inflexible about things like morality, they can have some rigidity, some stubbornness.

I also think there's a big link between OCPD and conscientiousness. Most of the personality disorders are linked to low conscientiousness, but OCPD is uniquely linked to high conscientiousness. And so, you know, if you are in a world where, you know, people, you know, people, are very driven, people are very motivated, you know, part of conscientious is achievement striving is, you know, people with high achievement striving, you know, doctors, right, lawyers, people and business owners, sometimes they can have more of the OCPD traits and these will serve them well to get through and jump through a bunch of the hoops needed to, you know, obtain their medical

degree or become a lawyer, so on and so forth. Yeah, I think, you know, and this brings us back to something about, well, that I think is very important. What's the difference between personality and personality disorder? Essentially, the difference is, I think, flexibility. All of us have a variety of aspects to our personalities. If we are healthy, it means we can shift which aspect is. is most prominent based on circumstances, on the context. The people with personality disorders,

whether you consider them dimensionally or categorically, in some ways what is giving them difficulty is they're unable to make those shifts, unable to exhibit that flexibility. The person with OCPD has a very difficult time being detail-oriented when they're doing their accounting, but then loosening up and being more free if they're at a social engagement where, you know, paying attention to are all of the napkins lined up is not the most important thing to be attending to.

So, okay, there's a lot of sort of fixed rigidity in someone with autism spectrum. disorder. So let's say you have two people with more of the high functioning forms of these disorders, OCPD and autism spectrum disorder. I guess like how would you how would you differentiate it? If it's not the verbal issues that's leading to the autism. Oh, if the person with the autistic spectrum disorder largely has intact linguistic abilities. I think the other thing that is still missing in the autistic individual is the ability to intellectually understand the emotional experience of other people. If you can get the OCPD person to stop long enough from attending to details to think about what somebody else is feeling,

they don't have a deficit in that area. Yeah, I think this is obviously a tougher thing. And there can be overlap, right? You could have both. Yes. So it's not always one or the other. Yeah, well, yeah. Unfortunately, nature is not so kind

that it says you can only have one type of problem or one illness. Okay. Which puts back on us, something we touched on before. rather than initially dealing in labels, we need to very carefully construct the history and the symptom and sign profile of the individual patient, one, to try to figure out what is really getting

in the way of their life, and two, to arrive at the most accurate diagnosis we can. And I say most accurate because I think we're, since we're still dealing with a syndromic nomenclature, none of our diagnoses is perfectly accurate because we're likely talking about related clusters of things. Yeah, I prefer to not lean into labels too much in my own personal practice of patients.

There are some patients I've been treating for years. I don't think we've ever talked about diagnostic things, partially because when you get to know someone individually, it's almost like they're so complex. It's like their personality has gone beyond a specific. It's like, yeah, I think there's a more, I take a more dimensional approach of like, okay, this person's high openness or high conscientiousness.

And these places are, or I see them, like, like to see things as like adaptive. Like this is somehow serving them in an adaptive way and not necessarily think about, like, oh, this person is this diagnosis, which can sometimes be a little bit difficult if that's what they come in and that's what they really want. If they really want a diagnosis, I may explore why or help me understand like what having the diagnosis will allow you to do or like what would that, what role would that serve Yeah. It's perfectly valid. I think to ask the question, well, why is the diagnosis so important to you?

Yeah. And then, of course, sometimes I use the diagnosis to kind of think about what treatments research-wise have been effective. Yeah. Or if, you know, if they have schizophrenia or bipolar, it's like, okay, I need to start, I need to think about medications that would help those specific diseases. Yeah. And, well, frankly, that's a whole. whole reason I'm interested in diagnosis as a psychopharmacologist is to match the label that best fits with the evidence-based treatments for that. Right. Beyond that, I don't see diagnosis as serving all that much of a purpose. I do understand that for some patients, when I've asked that question, often it comes down to,

well, I'm looking for validation that I have something that is real. At which point I would say, I think it's really hard that you are struggling and you really want to excel in these domains of your life. And here's some potential things that will help you excel. and if we can focus on them, I think it'll make a big difference. There are the occasional patients that want a diagnosis to, you know,

move into chronic disability or, you know, and partial programs are great to keep people functional and to move people out of a chronic dysfunction. I mean, I do have some patients who are autistic who will never have a job. They're usually more of the non-pharmes, verbal, you know, patients who will need help from their parents for the rest of their life. There's no doubt that they will need that.

So I'm careful to want, I'm careful to not want to put someone in a box where it chronically disables them if they don't need to be in that box. Right. Which gets to the issue of, I think one of the other sub-reasons for making an accurate diagnosis This is, of course, for yourself, to get an, whether you tell it to the patient or not, is to get an accurate sense of likely prognosis. And to think about what kind of support or supports this person will need going forward. Yeah.

Okay. So we've talked about differentials. Are there any other differentials that you think would be worthy to kind of include in here? I know we haven't hit on every diagnostic criteria, which is fine. I think the, well, the other categories, you know, the other developmental disorders, I think always come up for consideration. And people who, particularly in child clinics, present with elements that may be autism. it's always important to rule out other reasons for those disturbances. Is the person actually suffering from an intellectual disability?

Are they, you know, is this somebody who's developing a REITS syndrome? You know, I don't work in that area, so I'm certainly not an expert in diagnosing the range of developmental disorders. but of course for somebody presenting in early childhood, that sort of very careful evaluation is vital to picking the treatment course that will give them the best possible trajectory. Yeah. I think that's who it comes down to is like what is the best possible trajectory that we can help someone with and using all of our wisdom

and all the things that we possibly can do to help a person get from where they are to where they want to go. And I think that's, I think it comes into that question you said earlier of like, okay, what is this person coming in with that they want change or they want ameliorated or how do they want, like, what is their goal? Yeah. Well, indeed, I always make the, well,

I've made the, make the assumption that if they and other people are perfectly happy with them as they are, they're not going to be coming to see me. Yeah, absolutely. So, like, what is their biggest pain point? And then how do we get them moving towards that? And how do we walk with them? And I have a lot of respect for therapists and psychiatrists

who are seeing people for a long time trying to get them to that place where they want to go. I think it's much easier to be like a one-time, sweep in and say, okay, here's the, here's your brain scan, here's what you need to do, and then no follow-up, it's a lot harder to walk with someone and to try to help them get to that point. Yes, indeed. One of my own soapboxes is, I think too much of modern medicine is very divided into momentary contacts. I think there is, um, a reason to miss

the sort of long-term physician, not necessarily psychiatrists, but just long-term physician, who works with somebody across years, decades? Yeah, beautiful. Well, Dr. Cummings, thank you for coming on having this conversation. I'm sure that

I get a number of messages almost daily asking for more Dr. Cummings. And I'm very happy to bring you on and to have this conversation. So thank you so much. Oh, you're certainly welcomed. All right. We will leave it there for today.