Progress Note: ASD Assessment Discussion

Date: 14/05/2024

Reason for Assessment

• GP referral for suspected Autism Spectrum Disorder (ASD) following lifelong difficulties with social communication and sensory processing.
• Patient-requested assessment due to escalating occupational burnout and difficulty maintaining interpersonal relationships.

Mental Health

• Present mental health concerns: Generalized anxiety, social exhaustion, and low mood secondary to workplace sensory overload.
• Earlier mental health difficulties: Treated for mixed anxiety and depressive disorder in university (2018); completed 12 sessions of CBT with partial benefit.
• History of self-harm or harming other people: History of superficial cutting in adolescence (ceased age 17). Denies any history of aggression or harm to others.
• Psychiatric hospitalisations: Nil.
• Current medication: sertraline (Lustral®) 100 mg PO OD.

Social History

• Living arrangements: Lives alone in a rented one-bedroom flat; manages ADLs independently.
• Social interactions: Limited social network; communicates primarily with two online friends via text. Finds face-to-face group settings overwhelming.
• Occupation: Data analyst at a financial firm for the past 3 years.
• Work preferences: Strongly prefers remote working with written briefs; struggles with open-plan office noise and unscheduled video calls.

ASD-related Observations

• Social interactions: Reduced eye contact throughout the interview. Flat affect and monotonous prosody. Difficulty with reciprocal small talk, though articulate when discussing structured topics.
• Sensory sensitivities: Severe hypersensitivity to fluorescent lighting and background hums (wears noise-cancelling headphones daily). Tactile defensiveness regarding clothing tags and synthetic fabrics.
• Cognitive processing: Literal interpretation of idioms; strong preference for unambiguous, direct communication. High attention to detail.
• Behaviour: Subtle repetitive hand-rubbing noted when discussing anxiety-provoking topics.
• Interests: Intense, circumscribed interest in 19th-century railway logistics and timetables; spends 3–4 hours daily cataloguing historical routes.
• Routine: Rigid adherence to daily schedules and meal plans. Experiences significant distress and shutdowns when travel routes or work tasks are altered without notice.

Family History

• Maternal uncle diagnosed with Asperger's syndrome.
• Mother has a history of recurrent depressive disorder.
• Younger brother diagnosed with ADHD.

Risk Assessment

• Risk to self: Low. Denies current suicidal ideation, intent, or plans. No recent DSH. Identifies flatmate's cat and personal projects as protective factors.
• Risk to others: Low. No forensic history, violent ideation, or intent.

Plan

• Proceed to formal multi-disciplinary ASD diagnostic assessment (ADOS-2 and ADI-R).
• Send informant developmental history questionnaire to patient's mother (consent obtained).
• Continue sertraline 100 mg PO OD via GP.
• Provide letter supporting workplace adjustments (remote working allocation and quiet workspace).
• Follow-up appointment scheduled in 6 weeks at 10:00 to review developmental questionnaires.