When examining the differentiation of an Anxiety Disorder and an Autism Spectrum Disorder, it is again pertinent to look closely at the social communication weaknesses and restricted repetitive behaviors. Does an individual struggle with social communication, avoid situations and complete routines or rituals because of anxiety, because of ASD, or could it be both? An individual with an ASD who does not suffer from anxiety may avoid social situations because of a lack of interest in social interaction . Conversely, he or she may enjoy social interactions, but deficits in social communication will have some impact on his or her ability to read social cues, interpret the perspective of others, and engage in reciprocal social interaction at an age appropriate level. Many individuals with ASD do not have co-occurring anxiety. Anywhere from 16 to 89 % of individuals who have ASD do not meet criteria for an Anxiety Disorder (Cervantes et al., 2013).

An individual who has Social Anxiety and not ASD will likely have very different behavior at home with siblings, family members, or close friends (playing cooperatively, making eye contact, initiating joint attention, conversing reciprocally) than he or she in a social setting like at school or at a party. This individual will fear embarrassment or rejection and try to avoid certain settings that may lead to these experiences. If forced into social settings, an anxious individual may freeze, cling to a parent, fail to speak, or throw a tantrum. An individual with an ASD is more likely to wander alone, ignore others, play independently, or misread nonverbal and social cues of others leading to disagreements or challenges. An individual with ASD will have some level of social communication challenges across settings, while an individual with an anxiety disorder should be able to interact appropriately in the absence of fear and anxiety. In the clinic evaluation setting, individuals who warm up considerably, show a marked change in eye contact, conversation, and engagement (social communication) over time, and who have insight into their own anxiety are likely to be diagnosed with an anxiety disorder, rather than ASD.

OCD can be more challenging to differentiate and is often diagnosed instead of autism in children with Autism Spectrum Disorders by practitioners who are not familiar with ASD. OCD is intrusive and unwanted thoughts or images causing marked anxiety followed by repetitive behaviors aimed at preventing or reducing anxiety . Those with ASD who have specialized interests in dinosaurs, trucks, trash, the solar system, or WWII and subsequently have routines based around their interests enjoy talking about these topics. Individuals report they like completing routines related to the topic. A child with ASD who lines up his or her cars does this because he or she likes to line up and look at the cars, not to reduce anxiety. A child with ASD may throw tantrum or demonstrate rigidity when prevented from completing such a routine, but the point of the routine is not to reduce anxiety. This is very important to differentiate during the assessment process. Westphal, Kober, Voos, and Volkmar (2014) put it well when they reported “… the obsessions and compulsions that occur with OCD are generally egodystonic , at odds with the idealized self-image a person may have. The circumscribed interests and rituals that accompany ASD, on the other hand, tend to be egosyntonic, in harmony with the subject’s self-image” (p. 294).

Can an individual with ASD develop OCD? Yes. However, individuals who complete their repetitive routines and rituals because they want to, and are not trying to decrease or prevent anxiety, do not have OCD.

A Specific Phobia, Gene ralized Anxiety Disorder, Separation Anxiety Disorder, and OCD can co-occur with Autism Spectrum Disorders. It can be challenging at times to make the comorbid diagnosis of anxiety, however, because of limited emotional insight in individuals with autism. Trammell, Wilczynski, Dale, and McIntosh (2013)) states that symptoms of anxiety are very common in ASD, but an anxiety disorder is only diagnosed if anxiety has a significant impact on an individual’s daily functioning.

Clinically, the authors of this text find that anxiety commonly co-occurs in untreated Autism Spectrum Disorders. Bright individuals often overlooked for assessment until late elementary school, middle school, or at times even high school often present with significant symptoms of anxiety or depression based on a realization that they are different from peers and an inability to establish meaningful relationships. Worry about school performance, social situations, and peer rejection are common. In these cases, anxiety may or may not be reported on rating scales by the individual but frequently anxiety is evident in an individual’s presentation, his or her stories, projective measures, and parent and teacher questionnaires. A child may deny symptoms when asked directly, but he or she may hyperventilate as questions become difficult or cry when a task does not come easily. A child may need frequent contact with a parent or even require a parent to be present at all times. It is important to determine whether anxiety is present because treating these symptoms can make a huge difference to the individual. Psychotherapy combined with a social skills group and at times medication management can help a struggling child, adolescent, or adult regain footing and find success socially, academically, and/or occupationally. It is important to note that anxiety is readily contagious and so a child with very anxious parents is more likely to exhibit symptoms than a child whose careg ivers are psychologically more stable.

Determining whether an Autism Spectrum Disorder, Mood Disorder, or both are impacting social communication can be challenging, particularly in adolescents and adults. A process of identifying all symptoms that are pathologic and then examining these in the context of mood and autism is recommended. In adults, symptoms of withdrawal and interpersonal impairment are associated with both Depression and Autism Spectrum Disorders (Trammell et al., 2013). In the context of ASD, these impairments are secondary to challenges initiating conversation, taking others’ perspectives and understanding relationship dynamics. It can be challenging when assessing a depressed adult or adolescent to determine whether ASD is present. It can also be difficult to differentiate between withdrawal, lack of eye contact, and lack of conversational reciprocity in ASD and these symptoms in Depression. Assessing for the presence of pathologic symptoms that only occur in ASD like stereotyped language, repetitive behaviors or interests, lack of creativity, and insight into the nature of relationships can help make a differential diagnosis. An individual with severe depression may present with impaired conversation skills, nonverbal skills, and even impaired emotional awareness. The same individual who does not have ASD should be able to describe what a friend is and discuss the nature of social relationships. An individual with ASD would likely have more difficulty discussing these or might sound as if he or she were reciting a definition from a textbook.

Stereotyped language and repetitive behaviors cannot be subsumed under depression or explained in the context of a Mood Disorder; thus these are pathologic symptoms that must be explained with another diagnosis. Creative ADOS-2 tasks like “Telling a Story from a Book” or “Description of a Picture” (discussing the cartoon map) can provide a nice arena to evaluate for stereotyped or repetitive language. Individuals who list states and capitols, remark on the size of the cartoon figures in relation to states, or provide an exhaustive list of cheeses produced in Wisconsin are exhibiting pathologic symptoms not associated with depression. An individual who exhibits no pathologic symptoms outside of those associated with a Mood Disorder, and has appropriate social reciprocity, would be diagnosed with the corresponding Mood Disorder and not ASD. With adequate treatment of an individual’s depression, it may be advised to reevaluate for ASD. This may be recommended if an individual was so withdrawn that little language or conversation was offered. Conversely, an individual who does not report sadness, presents as neutral or incongruent in mood and affect, and who has impairments in social communication and poor reciprocity may have ASD alone, given his or her tendency to withdraw and avoid social interaction.

In children, when considering mood and autism, often tasks of creativity in play can aide in differentiating. A depressed child may exhibit depression symptoms or share emotions during play. For example, a child who acts out a scenario involving multiple character deaths and then demonstrates mourning and honoring these individuals with appropriate mood and affect usually does not have autism. Children who demonstrate the ability to symbolically represent characters in play, understand emotions, take another character’s perspective, and express complex emotions generally do not meet criteria for ASD, but might indeed for a mood disorder. Character play that is immature, unreasonably violent or careless, not well-integrated, and lacking perspective taking may signal ASD.

While emotional disturbance and difficulty regulating emotions are not core features of ASD, mood disturbances are surprisingly common in individuals diagnosed with Autism Spectrum Disorders (Mazefsky et al., 2013). Lehnhardt et al. report that when patients are diagnosed later with ASD, they are diagnosed with Depressive disorders in 53 % of cases (2013). The DSM-5 indicates the importance of determining whether mood symptoms such as irritability or temper outbursts occur in the context of ASD. An example for ASD would be when the tantrums occur in response to a routine being disturbed. Alternately, a child who meets full criteria for ASD and also exhibits crying, irritability, suicidal statements, and reports a lack of friendship and acceptance among peers may receive a diagnosis of depression in addition to ASD. When a child is overly active, has racing thoughts, and exhibits periods of grandiosity, pressured speech, flight of ideas, and engages in dangerous behavior in addition to having an Autism Spectrum Disorder, he or she may have a comorbid Bipolar Disorder . As with Anxiety Disorders, there may be a common ideology between Bipolar and ASD. Those with DMDD often have irritability and tantrums not related to the ASD symptoms, but do not have the elevated mood symptoms that would be consistent with Bipolar.

As individuals with ASD often have poor emotional insight, researchers suggest it is important to evaluate mood criteria with observable behaviors. While scales like the Beck Depression Inventory (BDI) may not be elevated, property destruction, aggression, or self-injury may be behavioral equivalents of depression (Witwer & Lecavalier, 2010). Researchers suggest that excessive giddiness, an increase in talking, and excessive noisemaking may be behavioral equivalents for mania. Witwer and Lecavalier (2010) note the importance of assessing these behavioral symptoms that may signal a mood disorder with multiple methods. This hypothesized use of behavioral indicators alone, rather than requiring self-report indicators for mood disorders, has not been validated to date. When evaluating children, it can be most useful to consider parent and teacher rating scales of emotions and compare these to self-report. The “frozen profile” termed by Helena Huckabee PhD, BCBA-D, suggests that often children with autism report fewer emotional symptoms than average. When individuals present with this profile, it suggests that the self-reporter does not have appropriate insight into his or her own emotions and is unlikely to adequately assess these internal emotional experiences. Taken together, it is recommended that clinicians consider self-report with caution, utilizing clinical judgment, observable behaviors, and rating scales from multiple sources to diagnose a mood disorder comorbid with ASD.

A study of emotion dysregulation in children and adolescents with ASD evaluated the use of various cognitive techniques including cognitive reappraisal and emotion suppression in those with and without autism. Individuals with ASD who had solid problem-solving and emotion-regulation skills benefitted equally from the use of cognitive strategies in regulating their emotions. While no significant difference was found in problem-solving, avoidance, and relaxation skills, Samson, Hardan, Podell, Phillips, and Gross (2014) found those with ASD suppressed emotions more frequently and were less likely to engage in cognitive reappraisal. Cognitive reappraisal involves modifying thoughts about an event so that the emotional response is altered. When prompted to do this, individuals with ASD had more difficulty using the strategy; however, when taught to generate cognitive reappraisals, individuals with ASD benefitted equally from using them. This study indicates that explicit teaching of skills for emotion regulation can benefit those with ASD. These researched differences in emotion regulation and suppression for those with ASD are perhaps a contributor to greater mood symptoms (Lehnhardt et al., 2013; Samson et al., 2014).

In order to differentiate between Bipolar or Depression With Psychotic Features or a diagnosis on the Schizophrenia Spectrum and ASD, it is crucial to fully understand what is a Delusion or Hallucination and what is stereotyped language or a repetitive behavior or interest. The DSM-5 states on p. 105 “These (ASDs) may also have symptoms resembling a psychotic episode but are distinguished by their respective deficits in social interaction with repetitive and restricted behaviors and other cognitive and communication deficits.” As prominent Delusions or Hallucinations must be present, making a differential diagnosis or a comorbid diagnosis involves understanding these features. “Delusions are fixed beliefs not amendable to change in light of conflicting evidence” (APA, 2013 p. 87). The degree of conviction in light of evidence that contradicts differentiates a Delusion from a strong belief. Themes can be persecutory (belief that one will be harmed), referential (belief that comments or cues are directed at oneself), somatic (regarding health), religious, grandiose (belief that the individual possesses exceptional abilities, wealth etc.), erotomanic (false belief that another is in love with the individual), Nihilistic (belief that a major catastrophe will occur), and bizarre (implausible and not culturally understandable) (APA, 2013). “Hallucinations are perception-like experiences that occur without an external stimulus” (APA, 2013 p. 87). These can occur in any sensory modality. The DSM-5 notes that auditory hallucinations are most common in the Schizophrenia Spectrum. These are voices distinct from an individual’s thoughts.

A client told one of the authors of this text “An air conditioner used to talk to me and tell me I was a bad person.” This client presented with diagnoses of psychosis and ASD, having had developmental delays and an early diagnosis of autism. This client did not have a perseverative interest in air conditioners and did not quote books or movies with relative themes. If in fact air conditioners were a restricted interest, this would indicate ASD is the appropriate diagnosis, rather than psychosis. She seemed to respond well to her antipsychotic medication and at the time was “in full remission” of symptoms.

Another client presented with significant stereotyped language around Star Wars movies, speaking of “Jedi Mind Tricks,” “Light-sabers,” and quoting sections of dialogue from Star Wars movies and books. This client expressed his frustration through the use of Star Wars analogies “I’m like Darth Mal in this scenario!” While professionals in the past had reported psychosis, this individual was presenting with restricted repetitive interests associated with autism. When pressed, he understood that Star Wars was a creation of a writer, producer, and director and could provide extensive historical information on the making of the series including set, score, and actors. In this case, Star Wars was a restricted interest and stereotyped language included quotes and reenactments. The client offered at one time that he really wished fictional characters were real because he understood them and knew in those scenarios what was going to happen next. These characters provided predictability and routine as well as entertainment. He remarked that real people were not so predictable. This client was not presenting with a grandiose delusion , but rather his symptoms occurred in the context of autism.

Hallucinations can be challenging for an individual with ASD to distinguish from a thought. At times, children express concerns about “hearing voices” and describe an internal dialogue or conscience. For example, “I shouldn’t have a cookie, mom said to wait until after dinner” is an internal thought process and not a hallucination. Providers considering rating scale data like the BASC-2 self-report must clarify with the child what is meant by “I hear things that others cannot hear” when a child says “often” or “almost always.” The literal nature of many children with ASD often leads to an elevation in scales and requires clarification.

Two other features of psychosis include negative symptoms, like diminished emotional expression and disorganized or abnormal motor behavior. These symptoms could be confused with restricted repetitive behaviors and nonverbal communication deficits . Diminished emotional expression occurring in psychotic disorders could easily be confused with flat or restricted affect or mood and affect incongruence. Those with ASD may have less varied facial expression, use fewer gestures, and avoid eye contact. They also may have unusual motor behaviors. Lord et al. (2000) suggested that when differentiating ASD from Schizophrenia, while this can be challenging, those with ASD have less reciprocal communication, use more stereotyped language, and demonstrate poorer rapport and fewer social responses (Trammell et al., 2013). Lord suggests evaluating directed facial expressions and shared enjoyment in differentiating the two (Trammell et al., 2013).

Because onset of Schizophrenia prior to adolescence is rare, the age of onset can be a very useful factor in differentiating Schizophrenia from ASD (APA, 2013; Lehnhardt et al., 2013). On average, Schizophrenia has onset in the mid-twenties for males and late-twenties for females. Autism Spectrum Disorders are evident much earlier. Taking a detailed history of an adult presenting for an evaluation can help to determine whether symptoms have been present across the lifespan or are later to onset. Less than 1 % of the population will be diagnosed with Schizophrenia (APA, 2013, p. 102).