Thread by @PerinatalBirder

Here’s another 🧵 about #autism for medics after the popularity of my last one. This time I’ll look at some principles you should follow when prescribing for an autistic pt. My practice mainly involves psychotropes but these are principles that any specialist should follow 1/22

Autistics are more likely to have physical and mental health diagnoses, and are therefore more likely to be on 💊, and so it’s important that we can manage them appropriately. The principles I’ll outline are basically just good medical care, with some special considerations 2/

1 - set aside plenty of time to discuss it. Many autistics struggle to make decisions, and can feel panicked if they feel being pushed towards a certain one. They will often want a lot of information before making a decision. If you don’t have the time to give them that info 3/

Then they will look for it elsewhere, maybe online or in the leaflet - and if they don’t like what they read they may not take it due to concerns you may have been able to alleviate. Autistics can get focussed on details, and this can irritate people interacting with them 4/

They will be able to pick up if you are irritated, and their concern will not be alleviated, and they will feel unlistened to. Where you can, give people time to make decisions, I will offer anybody on the fence some written info and ask them to email our team in a week or so 5/

And let us know if they want to start or not. This won’t always be possible and won’t always be necessary, but where it is it’s worth doing. The relief that rushes knee some patients’ faces when I suggest it is obvious - because autistics often have a complex history w 💊 6/

Which brings us on to 2 - believe them about side effects. Many autistics have told me this story about 💊. They start 💊A at a very low dose and notice they get itchy 🦶 . They weren’t told this was an se so they read the leaflet, and sure enough it’s there. So they see a dr 7/

Who tells them that they’ve probably read the leaflet and given themselves the idea that a slight itch was a side effect, and now their 🦶 are always itchy because they’re worrying about it - after all, they do “have a history of anxiety” because this dose is too low for se’s 8/

And then they become aware that they get a reputation for “always having side’s” as if that was somehow a failing on their part. And you know some of those patients - so screen them for autism next time you see them. Because those se’s are real, even at tiny doses 9/

Atypical sensory processing and acuity is part of the dsm criteria for autism, and this can often be pronounced. A pt’s dad secretly put 1 🍄 in a pot of stew “to test her” after 1 sip she refused to eat anymore as 🍄 flavour overwhelmed. A pal can ID a 🐦 flying towards us 10/

Before any of us can see that there is a bird at all, but when it gets close enough - he’s always right. Many autistics also have a very tight comfort range - one patient says she is freezing when it’s <19/66 and roasting when it’s >23/72 those T1DMs w v tight control because 11/

They feel symptomatic when slightly hypo/hyper - screen them. And if one mushroom, or a leaf of coriander, or a pinch of chilli or scrape of ginger can overwhelm a dish, and slight distortions or an internal norm have big effects - maybe a low dose of 💊 can have big se’s? 12/

Which leads me on to 3 - Start low and go slow, but be prepared to need high doses to see an effect at times. I told a patient recently to tell her other specialists to prescribe to her like she was 85. Low doses, slow increments, avoid polypharmacy. But also bear in mind 13/

That atypical sensory acuity can go both ways. One pt told me she dumps 🌶 sauce over all her food because it’s the only way she can taste anything. Some autistics will be hyposensitive to 💊 and need higher doses to achieve an effect & remember sensory issues also affect 14/

How they experience their symptoms. Which brings me on to 4 - believe them about their treatment response. This is most relevant when it comes to pain - especially pain that is “disproportionate to the pathology” so many autistic women have cried to me about how in 20 years 15/

They hadn’t even taken ibuprofen for a headache but she gets accused of drug seeking when she is finally so crippled by endometriosis that she needs opiates despite “relatively little extrauterine endometrial tissue”. There are wider issues of misogyny here of course 16/

And many NT women have similar issues, it’s just the most common example I see - but it could equally be mild joint degradation or mild inflammation somewhere causing “disproportionate pain”. I have a pt won’t visit her home country because she is so sensitive to touch that 17/

A 🪰landing on her feels like needles in her skin. She knows that’s “disproportionate”, but it doesn’t mean she doesn’t get woken up in the night if there’s a hole in the 🦟 net and something lands on her. There’s no reason for nociception to be the only sense w/o divergence 18/

So if a patient has pain “disproportionate” to the pathology, consider screening them for autism before wondering if they’re addicted to codeine.
Then once there is a medication strategy everybody is happy with: 5 - make sure they can take the 💊 as prescribed 19/

Complex regimens may not suit people with executive dysfunction, pills may be so unpleasant to swallow so as to prevent adherence, advice around taking with/without food may be hard to follow for some individuals 20/

Think of solutions - do 4 small 250mg tabs go down easier than 1 big 1g tab? Can you write clear instructions for complex regimens? Could you even prescribe a liquid now and then, if swallowing tablets is really distressing? 21/

Thanks again for making it this far. Please share if you found it helpful
#MedTwitter
#Psychiatry
#autistic
#actuallyautistic 22/22

How did “over” autocorrect to “knee”?!