Autism & Misdiagnosed Anxiety
In therapeutic treatment, it is not uncommon for a person to spend years in treatment for anxiety or depression before the root cause, neurodivergence, is identified. In one dataset of autistic women, more than 82 percent had already been diagnosed with depression or anxiety, and more than three-quarters of them received that diagnosis first, an average of over thirteen years before their autism was finally recognized (Brown et al., 2019, International Society for Autism Research). It is evidence of a system that treats the symptoms but fails to delve deeper.
Diagnostic overshadowing is when a person's traits and behaviors get fully absorbed into one diagnosis, usually the one with a faster path to treatment, while the condition actually driving them goes unaddressed (Gupta & Gupta, 2023). For neurodivergence, it most often means the anxiety or the depression gets the prescription and the protocol, while the neurodivergence itself, the actual source of the distress, remains unseen.
The Treatment Logic Is Backwards
A systematic review and meta-analysis of adults with autism spectrum disorder found a pooled prevalence of 27 percent for current anxiety disorder and 42 percent across the lifetime, with 23 percent for current depressive disorder and 37 percent across the lifetime (Hollocks et al., 2019). The problem is that clinicians stop at addressing the symptoms but fail to deal with the issue underneath. Standard first-line approaches, selective serotonin reuptake inhibitors (SSRIs) and conventional cognitive behavioral therapy, were developed and validated in neurotypical populations and do not always reliably transfer. Autistic patients are more likely to experience behavioral activation side effects from SSRIs, including agitation and insomnia, and unmodified cognitive behavioral therapy (CBT) shows weaker outcomes than CBT that has been specifically adapted to autistic cognition and communication (Gupta & Gupta, 2023). Treating the anxiety symptom with a tool built for a different nervous system is a mismatch dressed up as treatment.
Why This Is Reductive, Not Just Incomplete
Neurodivergence, at the neural level, is a difference in how the brain integrates information across regions. The theory of frontal-posterior underconnectivity describes autism as involving reduced long-range communication between frontal and posterior brain networks, alongside denser short-range connections within more local regions (Just et al., 2012). In plain terms, the autistic brain often processes pieces of information with real precision while struggling to integrate those pieces into a coordinated, efficient whole. Attention, language, sensory input,
social inference, and executive control do not always talk to each other as fluidly as they do in a neurotypical brain.
Anxiety and depression are frequently what it feels like from the inside to live, unsupported, with that integration gap: a nervous system working harder than it should have to, in environments that assume a kind of effortless cross-domain processing the autistic brain is challenged to do. Treating the anxiety without ever mapping that underlying integration profile does not change the conditions producing the distress in the first place. Hence the established loop: neurodivergent people cycle through SSRIs, generic talk therapy, and renewed diagnoses of treatment-resistant depression without ever improving at the level that matters.
Masking Makes the Case Even Harder to Miss
Paradoxically, part of what gets lost when clinicians treat only the anxiety is the reason the anxiety is there. A large and growing body of research on autistic masking, the conscious or learned suppression of autistic traits to appear neurotypical, links sustained camouflaging to anxiety, depression, exhaustion, and a significantly elevated risk of suicidal thoughts and behavior, a risk that persists even after accounting for depression and anxiety on their own (Cassidy et al., 2018). In other words, camouflaging independently predicts distress.
The anxiety is frequently downstream of the unaddressed autism, not a separate, parallel condition. A clinician who treats anxiety and neglects masking in the first place is treating a symptom of a system that was never given the chance to be understood, let alone supported.
What Integration Looks Like in Practice
None of this means anxiety and depression care should be abandoned, just that it should sit inside a bigger picture. A comprehensive neuropsychological evaluation exists precisely to build that bigger picture: mapping how attention, memory, processing speed, sensory regulation, social cognition, and executive function actually function together in a specific person, rather than treating a mood symptom in isolation from the cognitive architecture producing it.
That integrated profile changes what treatment looks like. It identifies whether anxiety is being driven by sensory overload, by the chronic cognitive load of masking, by executive function demands that outstrip the person's working memory, or by some combination unique to that individual, and it allows targeted intervention and treatment to address those actual mechanisms rather than the mood symptom they produce. It is the difference between prescribing an SSRI because the chart says "anxiety" and building a support plan because the evaluation says precisely where that anxiety is coming from.
A neurodivergent person who spends over a decade being treated for depression before anyone looks at the underlying problem is the malignancy of our fragmented system. One prescriber for the mood symptom, one diagnosis code, no integrated map of how that person's brain actually processes the world. The research is consistent that this approach is not just incomplete. It can actively miss the mechanism driving the distress for years, while a more serious risk, including suicidality, quietly compounds underneath it (Cassidy et al., 2018).
A comprehensive neuropsychological evaluation with Dr. Bonnee Price-Linden is built to prevent exactly that gap: a single, integrated picture of how a person's cognitive, sensory, and emotional systems function together, so that care addresses the actual source of distress rather than
the symptom that happened to get noticed first. Linden Neuropsychological Services serves families in New Jersey, New York, and Florida, with telehealth available across PSYPACT participating states. Schedule an evaluation today and get a picture of the whole person, not just the symptom in front of you.
If you or someone you know is struggling with thoughts of suicide, the 988 Suicide & Crisis Lifeline is available by call or text, 24 hours a day.
Sources
Brown, C. M., Fuller-Tyszkiewicz, M., Krug, I., & Stokes, M. A. (2019). Diagnostic overshadowing in autistic women [Conference presentation]. International Society for Autism Research (INSAR) 2019 Annual Meeting.
https://insar.confex.com/insar/2019/webprogram/Paper29860.html
Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults. Molecular Autism, 9, Article 42. https://doi.org/10.1186/s13229-018-0226-4
Gupta, N., & Gupta, M. (2023). Diagnostic overshadowing in high-functioning autism: Mirtazapine, buspirone, and modified cognitive behavioral therapy (CBT) as treatment options. Cureus. https://doi.org/10.7759/cureus.39446
Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: A systematic review and meta-analysis. Psychological Medicine, 49(4), 559–572. https://doi.org/10.1017/S0033291718002283
Just, M. A., Keller, T. A., Malave, V. L., Kana, R. K., & Varma, S. (2012). Autism as a neural systems disorder: A theory of frontal-posterior underconnectivity. Neuroscience & Biobehavioral Reviews, 36(4), 1292–1313. https://doi.org/10.1016/j.neubiorev.2012.02.007
