Can a Neurotypical Be Misdiagnosed with Autism?

You know that an autistic person can be misdiagnosed with something else, but what about the reverse: a neurotypical being misdiagnosed with autism?

It’s pretty well-heard-of: Autistic people, especially women, being misdiagnosed with any of the following: social anxiety, social pragmatic disorder, general anxiety, bipolar disorder, depression or ADHD.

Though an autistic person can have another condition such as ADHD or OCD (obsessive compulsive disorder), the problem is when the ASD gets missed by the assessor.

But what about a neurotypical (NT) who’s told he or she has autism spectrum disorder – but actually doesn’t have it?

There are autistic people, whose first evaluation denied the ASD diagnosis, but whose second evaluation by a different examiner resulted in an ASD diagnosis.

Likewise, it’s possible that an NT who’s diagnosed autistic, might be diagnosed with something else by a second examiner.

This is all because autism spectrum disorder has no biomarker such as a blood test.

The diagnosis is based on the evaluator’s impression, various tasks during the assessment, a personal history given by the patient, answers to questionnaires and, when possible, feedback from family members.

Neurotypical Person Being Misdiagnosed with Autism

The person who’s actually neurotypical (no biomarker for that, either), but is given an ASD diagnosis, will reveal autistic traits during an evaluation, and will answer some questions on an intake form the way an autistic person would. But they could still be neurotypical.

“Diagnosing autism is tough,” says Dr. Meghan T. Lee, clinical neuropsychologist and practice owner, Horizon Neuropsychological Services in Colorado.

“It may be the case that a person has social communication/interaction weaknesses without restricted interests/repetitive behaviors, in which case social (pragmatic) communication disorder is more appropriate.

“Conversely, a person can have restricted interests/repetitive behaviors without social communication weaknesses, in which case obsessive compulsive disorder or a tic disorder should be considered.”

However, when the patient has both social deficits and restricted interests/repetitive behaviors since childhood, this duo makes a very strong case for ASD.

What is a restricted interest?

It’s an intense interest in a specific topic. The intensity is greater than what would be expected in the typical person with the same interest. The degree of interest may even be obsessive.

A tipoff that it’s excessive is that the person frequently wants to talk about the subject, especially at inappropriate times or with people who clearly do not share the interest.

Secondly, the topic is often part of a whole rather than the whole.

For instance, an autistic person may be fascinated by seizures caused by getting hit in the head, but not seizures in general, such as from epilepsy, brain tumors or adverse drug reactions, plus treatments for seizures.

However, the intense interest may also be of the whole, such as an extreme fascination with a particular movie and anything related to it.

What is a repetitive behavior?

©Lorra Garrick

In autism, this is called stimming – short for self-stimulating behavior. The “stimulation” here refers entirely to self-regulating, calming or soothing behavior.

Common stims include rocking while seated, hand flapping, spinning, swaying while standing, twirling hair, bouncing a leg up and down, and tapping one’s fingertips together, among so many others such as using fidget “toys” like handheld spinners, and biting or sucking on sleeves or collars.

The difference between stimming and an OCD behavior is that stimming is often subconscious, such as rocking or teeth clicking while doing computer work.

Whereas in OCD, a repetitive behavior is done consciously because the individual believes that it will either bring good luck or prevent something bad from happening, such as ritualistically tapping their leg eight times every time they start their car – to avoid an accident.

Stimming is done for emotional regulation, particularly during stress or anxious moments, eager moments, habit, and for some autists, because it just feels good or relaxing.

OCD behavior is typically done under some level of duress, such as repeatedly getting out of bed at night to make sure the stove was turned off.

Significant Impact

“It is also the case that a person’s social pragmatics are intact, but there are still difficulties facilitating social interactions with others, in which case a clinician should assess for mood and personality disorders,” says Dr. Lee.

“There are also quirky individuals out there who, for all intents and purposes, exhibit symptoms of autism, but the symptoms do not have a significant impact on their everyday life. When this occurs, a diagnosis is not warranted.”

Though some autistic people have no support needs (they are 100 percent independent), this doesn’t mean their autism never had a significant impact on their everyday life.

Since ASD is a social communication disorder, its first and foremost impact is on interaction with people.

It’s certainly a significant impact when an autistic person either doesn’t think friendships are important; wants friends but can’t make them, or, they can make friends but can’t keep them.

It’s very significant when, no matter what group they’ve ever been a part of throughout their life, they never fit in nor felt a sense of belonging, often rubbing people the wrong way or being perceived as rude without these intentions.

“A child may be extremely bright yet still struggle in a traditional classroom setting due to social communication/interaction challenges that interfere with their ability to interact with teachers and peers,” says Dr. Lee.

They’re the student whom many teachers dislike despite being well-behaved. They’re the kid most other kids think is one of the “weirdest.”

Dr. Lee also explains, “An adult may perform their job function well but fail to maintain a job for a significant period of time due to their social communication/interaction challenges impacting their ability to get along with coworkers and supervisors.”

This will make life quite difficult, no matter how adept this individual is at self-care, navigating unexpected situations and living independently.

“Lastly, it is important to note that individuals on the spectrum can sometimes have different sensory perceptions than the neurotypical population, which can be misinterpreted as hallucinations,” says Dr. Lee.

“As such, it’s important for the clinician to not over-pathologize these sensory experiences and misdiagnose a psychotic disorder like schizophrenia, particularly when there has not been a regression in adaptive functioning, an increase or emergence of the symptoms (rather than being longstanding), or impairment in reality testing.

“Bipolar disorder is another big one. Individuals on the spectrum can become consumed by their restricted interests [e.g., excessive interest in caverns] and lose track of time or their outside responsibilities, which mimics a manic or hypomanic episode, particularly when loss of sleep or increase in passion is present.

“In conclusion, it is imperative that a clinician conducts a thorough clinical interview with the patient and collateral interview(s) with a family member or friend (preferably multiple if available), review historical data and review the comprehensive neuropsychological profile.”