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Creating Autistic Suffering: The AuDHD Burnout to Psychosis Cycle- A deeper look

This article was co-authored by Tanya Adkin and David Gray-Hammond

Monotropism is a theory of autism. It is used interchangeably as a theory and also a trait that describes a style of attention. It suggests that Autistic people tend to have singular but highly detailed tunnels of attention, as opposed to spreading their attentional resources across multiple subjects (Murray, Lesser & Lawson, 2005). It has succeeded where other theories have failed by offering an explanation for every element of Autistic experience. In this sense monotropism is the only universal theory of autism.

One could consider it the “engine” of Autistic experience. Whereby every other part of Autistic experience can be traced back to monotropism in some way. It is at the core of our experience.

Emerging research is showing that both Autistic and ADHD people strongly identify with many aspects of monotropism as a way of describing their experience (Murray & Hallett, 2023). More on this can be found at this virtual presentation. It comes as no surprise then that monotropism is of significant importance to those who identify as both Autistic and ADHD, termed AuDHD.

Psychotic phenomena is another shared experience for many Autistic and/or ADHD people. 34.8% of formally identified Autistic people have experienced psychosis with up to 60% of Schizophrenic people also showed traits of autism (Ribolsi et al, 2022), In terms of the cross-over with ADHD, 47% of those diagnosed with childhood onset of schizophrenia experienced attention differences and hyperactivity in childhood, and in a sample size of 100 adults with psychosis, 32% reported attentional differences in childhood (Levy et al, 2015).

From this we can see that there is a significant overlap between the AuDHD experience and psychotic phenomena. When we look at this through the lens of monotropism, it begins to make more sense.

Monotropic Split

Monotropic split refers to a very specific type of attentional trauma experienced by monotropic people who are regularly exceeding their attentional resources (Adkin, 2022) in an effort to meet the demands of living in a world designed for non-monotropic (polytropic) people. It inevitably leads to burnout.

Atypical Burnout

Autistic burnout refers to a state of exhaustion created by using up all of your internal resources.

“Autistic burnout is often used by autistic adults to describe a state of incapacitation, exhaustion, and distress in every area of life. Informally, autistic adults describe how burnout has cost them jobs, friends, activities, independence, mental and physical health, and pushed them to suicidal behavior.”

Raymaker et al (2020)

Because Autistic burnout is described as a state of exhaustion, one would assume, that for many Autistic people observationally it can look like depression, and as such tools are being developed to differentiate between the two. However, exhaustion does not always mean that you are bed-bound, observably tired, and, indeed, displaying observable traits of depression. Many people with depression do not fit typical criteria, which is then referred to as high-functioning depression (useful!).

This is likely because the medical model has some sort of obsession with observable, diagnosable, traits. Many Autistic people are unable to stop and burnout. This may be because they are also ADHD, they may have interoceptive differences resulting in alexithymia and a lack of recognition of tiredness. They may simply have to work or raise children.

This may look like meerkatting and hypomanic behaviour (Adkin & Gray-Hammond, 2023) in addition to loss of skills and reduced tolerance to stimulus (Raymaker et al, 2020).


Lovingly dubbed “meerkat mode” by Tanya due to the heightened state of vigilance and arousal it presents, it involves constantly looking for danger and threat. It is more than hyper-arousal, Tanya believes that it is actually an overwhelmed monotropic person desperately looking for a hook into a monotropic flow-state.

This is not just sensory hyper-arousal, it is the tendency of monotropic minds to seek out a natural and consuming flow-state to aid recovery from burnout and/or monotropic split. Because of the heightened sensory-arousal and adrenal response that comes with it, monotropic flow becomes difficult to access, leading into monotropic spiral.

Monotropic Spiral

Tanya’s original concept of Monotropic spiral results from the inertia of monotropic flow. It may involve obsessive-compulsive type occurrences of rumination about a particular subject of experience that pulls the person deeper and deeper into an all-consuming monotropic spiral. Associative thinking that starts connecting this to anything and everything, seemingly like an ever increasing black-hole (Adkin & Gray-Hammond, 2023; Gray-Hammond & Adkin, 2023).

This can lead to the development of apparent loss of insight into ones own mental state and reality as described by the general population.

Psychotic Phenomena

Monotropic spiral is not psychosis. It is rather the vehicle that carries the person into psychotic phenomena, and maintains its inertia. Much like a star collapsing on itself, the resultant black-hole sucks in everything in its vicinity and is all-consuming.

A person experiencing monotropic spiral may lose insight and their sense of Self, compounded by a decoupling from shared reality. People can experience hallucinatory events, especially when alexithymic, making it difficult to differentiate between external sound and one’s own internal monologue. We can experience paranoia and rejection sensitive dysphoria to the point of delusion, it’s unclear where the line between this and fully fledged psychosis lies. We can also experience catatonic events and extreme lability of our mood, ranging from suicidally depressed to overtly manic and elated.

This may be why criteria for conditions such as schizophrenia and bipolar are so frequently met in the psychiatrists office. In a world that traumatises us by design, these phenomena may not be as atypical as we are led to believe.

Concluding thoughts

Are we looking at three separate occurrence that commonly happen together, within an observational model? Or are we looking at chronically stressed and burned out monotropic people, that due to the infinite possible interactions with an individual person’s environment, may observationally appear distinctively different?

Perhaps then we should stop thinking in terms of:

Autistic person + Environment = Outcome

instead considering:

Monotropic person + Environment = Outcome

Chronic stress or stressful life events have long been studied as a key contributing factor for the onset of psychotic phenomena (Philips et al, 2007) but the occurrence and impact of stress for monotropic people is vastly different, but it is not yet widely understood. This is because of the lack of training and rampant neuronormativity in mental health services (Gray-Hammond & Adkin, 2022); the antidote to which is neurodivergence competence (Gray-Hammond & Adkin, 2023).

Instead, we keep throwing money in the wrong direction and leaning on carcerative care to make the problem go away. If we can’t see it, it doesn’t exist, right? Seems to us like we should just fix the environment. Maybe that’s our “rigid” black and white thinking.


Adkin, T. (2022) What is Monotropic Split?

Adkin, T. & Gray-Hammond, D. (2023) Creating Autistic Suffering: What is atypical burnout?

Gray-Hammond, D. & Adkin, T. (2023) Creating Autistic Suffering: CAMHS kills kids.

Gray-Hammond, D. & Adkin, T. (2022) Creating Autistic Suffering: Neuronormativity in mental health treatment.

Gray-Hammond, D. & Adkin, T. (2023) Creating Autistic Suffering: Autistic safety and neurodivergence competency.

Levy, E., Traicu, A., Iyer, S., Malla, A., & Joober, R. (2015). Psychotic disorders comorbid with attention-deficit hyperactivity disorder: an important knowledge gap. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 60(3 Suppl 2), S48.

Murray, F. & Hallett, S. (2023) ADHD and monotropism.

Murray, D., Lesser, M., & Lawson, W. (2005). Attention, monotropism and the diagnostic criteria for autism. Autism, 9(2), 139-156.

Phillips, L. J., Francey, S. M., Edwards, J., & McMurray, N. (2007). Stress and psychosis: towards the development of new models of investigation. Clinical psychology review, 27(3), 307-317.

Raymaker, D. M., Teo, A. R., Steckler, N. A., Lentz, B., Scharer, M., Delos Santos, A., … & Nicolaidis, C. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: Defining autistic burnout. Autism in adulthood, 2(2), 132-143.

Ribolsi, M., Fiori Nastro, F., Pelle, M., Medici, C., Sacchetto, S., Lisi, G., … & Di Lorenzo, G. (2022). Recognizing psychosis in autism spectrum disorder. Frontiers in Psychiatry13, 768586.

Creating Autistic Suffering: What is Atypical Burnout?

This article was co-authored by Tanya Adkin and David Gray-Hammond

The literature around Autistic burnout is in it’s infancy with regards to academic papers, most of what exists comes from lived experience and blogs written by Autistic people themselves. The first academic paper on Autistic burnout was written by Raymaker et al (2020).

This paper describes Autistic burnout as:

“Autistic burnout is a syndrome conceptualized as resulting from chronic life stress and a mismatch of expectations and abilities without adequate supports. It is characterized by pervasive, long-term (typically 3+ months) exhaustion, loss of function, and reduced tolerance to stimulus.”

Raymaker et al, 2020

The following image from the paper shows how life stressors and barriers to support culminate in the outcome of burnout for Autistic people.

Typically the Autistic person in question will still have multiple demands in their life that require cognitive resources, despite having little to no resources left to give. Life goes on, as they say.

Burnout is widely understood and reported to be misdiagnosed in Autistic people as depression (Raymaker et al, 2020). This isn’t without basis; burnout can look like stereotypical features of depression such as not being able to attend to day-to-day life and losing one’s enthusiasm for things that used to be enjoyable. People experiencing burnout can struggle to get out of bed, although this is not necessarily a defining feature.

We are moving towards a measurement of Autistic burnout, although it is still in it’s very early stages. Papers such as Arnold et al (2023) suggest looking at things like issues with memory, emotional numbness, and difficulty communicating; all of which are usually taken as features of depression. It’s easy to see where the difficulty in differentiating arises.

The key difference in our opinion is that while burnout can lead to depression, it does not start there, and is rarely responsive to typical treatments for depression. Autistic burnout starts with monotropic split (Adkin, 2022) over a sustained period of time. Burnout recovery can take months or even years, and the recommended course of action is usually to remove as many demands as possible, and recharge through interest-led activities.

As Autistic people, we naturally live as demand free as possible. We do this because whether we are aware of it or not, we have to account for the distribution of our cognitive resources.

So, what happens if we can’t stop?

There are many reasons that an Autistic person may not be able to stop and recover; we may not be able to sense our exhaustion (due to interoceptive differences), masking (it may not be safe to practice authentic expression, it may not even be conscious), responsibilities such as child care, work, and home management. We may have co-occurring ADHD.

What we should try and remember is that burnout is not necessarily a set of observable traits that conform to a checklist. It literally is the result of going into an energy deficit on a regular basis.

Atypical Burnout

The use of the word atypical is not to create a neat category for an observable form of burnout. What we are referring to is burnout that might look different to the typical “depressive” understanding. In our experience it is not at all rare or atypical. We come across this time and again.

What atypical burnout can look like is being stuck in a hyper-aroused state, Tanya often affectionately dubs this as “meerkat-mode”, she describes a meerkat-type nervousness, constantly on the look out for danger, unable to focus and self-regulate creating the need for constant co-regulation with another person, and a fear of being left alone. This is sometimes misinterpreted as attachment disorder because of the childs perceived over-attachment to a parent or safe person. We often see this type of response from children and young people in traumatic school environments for extended periods of time.

This is usually accompanied by significant changes in sensory needs, especially interoception. This can result in a loss of sense of self, and reports of voice hearing. Individuals in this state appear to struggle to differentiate between our own thoughts and something external to their own being. This may be related to the high rates of occurrence of psychosis amongst Autistic people (Varcin et al, 2022).

It would be important at this point to mention monotropic spiral. We may internalise beliefs that seem negative and/or delusional in nature. We can seem stuck in a loop that drags us deeper into these internalised notions.

Rituals and routines can become more pronounced and seemingly compulsive, this is usually in an effort to create some attentional resource and ease an overloaded monotropic neurology.

There is a growing under-current in various circles questioning the validity of the diagnosis of Emotionally Unstable Personality Disorder (formerly known as Borderline Personality Disorder). We know that this is commonly misdiagnosed in Autistic people (Fusar-Poli et al, 2022). We also know that there is a huge amount of sexism involved in the identification of EUPD; women out-number men 3 to 1 in the diagnosis of EUPD (Bjorkland, 2006).

When we reverse that lens, men out-number women 4 to 1 in the formal identification of autism (Rynkiewicz, 2016). Considering the high co-occurence of ADHD and EUPD (Philipsen, 2006) and the well-known co-occurrence of autism and ADHD; is it possible that we might be looking in the wrong direction? Could many of these people be experiencing a protracted, atypical, Autistic burnout?

Or is it just a big coincidence?


Adkin, T. (2022) What is monotropic split? Emergent Divergence

Arnold, S. R., Higgins, J. M., Weise, J., Desai, A., Pellicano, E., & Trollor, J. N. (2023). Towards the measurement of autistic burnout. Autism, 13623613221147401.1

Bjorklund, P. (2006). No man’s land: Gender bias and social constructivism in the diagnosis of borderline personality disorder. Issues in mental health nursing, 27(1), 3-23.

Fusar-Poli, L., Brondino, N., Politi, P., & Aguglia, E. (2022). Missed diagnoses and misdiagnoses of adults with autism spectrum disorder. European archives of psychiatry and clinical neuroscience, 272(2), 187-198.

Philipsen, A. (2006). Differential diagnosis and comorbidity of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults. European archives of psychiatry and clinical neuroscience, 256, i42-i46.

Raymaker, D. M., Teo, A. R., Steckler, N. A., Lentz, B., Scharer, M., Delos Santos, A., … & Nicolaidis, C. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: Defining autistic burnout. Autism in adulthood, 2(2), 132-143.

Rynkiewicz, A. (2016). Autism spectrum disorders in females. Sex/gender differences in clinical manifestation and co-existing psychopathology (Doctoral dissertation, PhD Dissertation. Retrieved from Medical University of Gdansk Bibliography Database 2016).

Varcin, K. J., Herniman, S. E., Lin, A., Chen, Y., Perry, Y., Pugh, C., … & Wood, S. J. (2022). Occurrence of psychosis and bipolar disorder in adults with autism: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 134, 104543.

Mask on, Mask off: How the common understanding of Autistic masking is creating another mask

This post was authored by Tanya Adkin

Over the years I’ve been privileged enough to play a part in the discovery journey of what must be hundreds of Autistic people. One of the questions I am frequently asked about masking is “how do I unmask?”, as if there is a more authentic version of themselves that exists below the layers of neuronormative conditioning and the traumas that come with that.

My answer is often received as quite shocking. You don’t unmask. Not consciously, at least.

Masking tends to be commonly understood (thanks to some really interesting literature) as a choice. Almost as if when somebody suggests that we are Autistic, or we come to that realisation, we can begin to remove parts of ourselves that we deem “inauthentic” or “forced”, but where is the roadmap that tells us which parts are inauthentic or forced? How do we know what is the mask and what is us?

Autistic masking (also referred to in the literature as camouflaging, compensation, and most recently “adaptive morphing”) is the conscious or unconscious suppression of natural responses and adoption of alternatives across a range of domains including social interaction, sensory experience, cognition, movement, and behavior.

Pearson & Rose, 2021

To sum up the above quote, while we can consciously choose to conceal authentic Autistic expression as a way to avoid stigma; masking is also an unconscious projection of acceptability in an effort to avoid traumatic situations that arise from our differences. Projecting acceptability does not just mean pretending to appear more neurotypical.

Much like water, we take the shape of our container. To put it another way, we don’t choose the form that our masking takes, the environments we exist within often choose it for us. This is why many Autistic people experience internalised ableism, the environment of neuronormative society teaches us that we are broken and unworthy.

These attitudes are taught to us from the moment we commence education. Schools that give out attendance rewards, and punish children and families that struggle to engage, usually because of unmet needs or disability.

Gray-Hammond & Adkin, 2021

This feeds back into Beardon’s Golden equation:

Autism + Environment = Outcome

It stands to reason then that if you have been unconsciously masking for a significant amount of time in order to protect yourself due to previously traumatic experiences, you may not even be aware of the ways in which you conceal yourself. Traumatic experiences for an Autistic person are unavoidable (Gray-Hammond & Adkin, 2021), therefore an unconscious response to said trauma in the form of projecting acceptability is also unavoidable.

50% of Autistic people are alexithymic (Kinnaird et al, 2019). Which means that we have difficulties reading, interpreting, or even feeling our emotions. Emotions are an internal sense, this sense is called interoception. When we talk about alexithymia what we are talking about is interoceptive differences specifically related to our experiences of emotion. If we have interoceptive differences, how are we supposed to know which internal authentic expressions we are unconsciously masking?

I posit that masking is one of the most authentically Autistic expressions. It’s been argued that not all Autistic people mask, what we actually know is that all people mask, regardless of their neurology. This has been called many different things, from “using a telelphone voice” to code switching. All of us mask, it’s a human experience. For monotropic people, who cannot perform neurotypicality as comfortably as a polytropic person might, the taxation on one’s attentional resources can be huge. This then leads to monotropic split (Adkin, 2022), burnout, potential suicidality, and mental health concerns.

If all humans mask to some degree then so do all Autistic people. We need to get rid of the notion that masking is appearing more neurotypical. This may not be achievable for everyone. There are often phrases thrown around such as “high-masking” or “unable to mask”. To me this is repackaging of functioning labels. Truth be told if we are basing our analysis of somebody’s ability to mask on how neurotypical they appear, we are missing the entire point of an unconscious trauma response.

If cognitively privileged Autistic people are unable to articulate the beginnings and ends of an unconscious mask, then who are we to impose our own unconscious masking onto another. We are reinforcing neuronormative and ableist stereotypes by assuming that all masking is about performing neurotypicality, and that neurotypicality is something we should emulate.

When we discover our Autistic identity, our environment changes. The vessel in which we exist is changing shape, so therefore so are we. This could be the literature, the information absorbed in google searches, the attitudes around us (such as those of Autistic advocates). It could reinforce negative views of ourselves.

What people are really asking is not how to unmask, but “how do I behave more Autistically?”

The unconscious masking is so ingrained into us that the assumption is often “if I behave Autistically, things will be better”. Which in its own way is a conscious expression of masking in order to avoid the traumas which masking created in the first place. It follows a cycle of imposter sydrome. Doubting one’s identity, because you don’t flap your hands, or because you are considered “sociable”. I am not ashamed to admit that I have been formally identified twice because of this.

We share commonality but when you’ve met one Autistic person, you have met one Autistic person. Our life experiences (like it or not) shape who we are. The concept of unmasking can oftentimes (in my experience) create somewhat of a secondary identity crisis. You unconsciously consider yourself not neurotypical enough, but also not Autistic enough. Further from this, we can see exaggerated expressions of the Autistic Self as a way to project acceptability within the new environment in which we now exist. Also, as a way to deter potentially harmful environmental interference.

We become angry, and rightfully so. We may notice that we have been too passive, we are given a licence to lean into stereotypical Autistic expression. There is nothing wrong with that. One could say that we try on the Autistic mask because this is how we have been conditioned to behave.

It is still very much an unconscious projection of acceptability in order to keep oneself safe. So therefore, we do not unmask in the way that many think we do; we do not peel of our face to leave by the bedside at night time. You are already authentically Autistic.

It takes time, but what we can do is become more aware of our environments and reframe our own experiences thus far, which eventually, hopefully, leads us to exist in a way that is least taxing on our internal resources but also keeps us safe.


Adkin, T (2022) What is monotropic split? Emergent Divergence.

Gray-Hammond, D & Adkin, T (2021) Creating Autistic Suffering: Ableism and Discrimination. Emergent Divergence.

Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80-89.

Pearson, A., & Rose, K. (2021). A conceptual analysis of autistic masking: Understanding the narrative of stigma and the illusion of choice. Autism in Adulthood, 3(1), 52-60.

Guest Post: What is monotropic split?

This guest post was authored by Tanya Adkin

“At any one moment, the amount of attention an individual can give is limited”
(Murray et al., 2005)

So, what happens when a monotropic mind is forced to live in a polytropic way?

A monotropic individual focuses more detailed attention over fewer attention streams than a polytropic (non-Autistic) individual. When they are forced into environments where they must perform like a polytropic person, the amount of attention to detail they apply to multiple attention streams doesn’t decrease, all that happens is the monotropic mind experiences trauma by being pushed into trying to give more attention than any individual can cognitively give.

I call this monotropic split. The monotropic mind is having to split its attention and give more mental energy and attention than it has available to be able to withstand the environment it is in and remain safe.

When we think of an Autistic person experiencing overwhelm, we are thinking of a monotropic mind taking on more than it can process and creating meltdown or shutdown. Therefore, experiencing monotropic split is the cause of meltdown or shutdown.
When we think of an Autistic person who masks, “copes” and “gets by” which eventually leads to burnout or mental health crisis, we are again thinking of a monotropic mind being forced to perform in a way that traumatises its processing capabilities. This is monotropic split causing trauma, burnout, or mental health crisis.

When we think of a child stuck in a constant state of hyperarousal, looking out for danger because they are being put through a school system that forces them to perform polytropic tricks. Monotropic split and the subsequent cognitive trauma is the cause of the constant hyperarousal.

Autistic demand avoidance is a result of monotropic split because the Autistic person simply has been working in a state of attention hyperactivity for so long that they cannot tolerate any demand as that would re-traumatise their already overstretched attention capacity, so therefore they avoid the demand.

Monotropic split is something that every Autistic person experiences to varying degrees as a result of existing in an unaccommodating world.

Autism + Environment = Outcome.
(Beardon, 2019)

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