Cases/Neurodiversity and Neurodevelopment Conditions

Adult Male Requesting An Autism Assessment Due to Work Struggles — Free SCA Practice Case

Adult male requesting an autism assessment due to work struggles

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

David Miller

Age

35 years

Consultation Type

Video

Age

Reason for Encounter

"Patient booked appointment stating he is highly stressed at work and wishes to discuss whether he might be on the autism spectrum."

Medical Records

●PMH: Treated for generalized anxiety and low mood in his early 20s.
●Medications: None currently. (Previously tried Citalopram 10 years ago, discontinued due to lack of efficacy).
●Allergies: NKDA.

Recent Notes

●No recent attendances. Has generally been fit and well.

Patient Script

For the friend playing the patient role

Character Overview: You are David, a 35-year-old data analyst. You have always felt a bit "different" and found socializing exhausting, but you managed well by keeping your head down and sticking to strict routines. During the pandemic, you thrived working from home. However, a month ago, your company mandated a full return to the office and introduced "hot-desking" (no fixed desks) along in an open-plan environment. The sensory overload (noise, fluorescent lights) and the loss of your routine have plunged you into severe autistic burnout. You are exhausted from "masking" (pretending to be neurotypical) all day. Last week, you snapped at a manager who interrupted your work, and you are now facing a disciplinary meeting. You took an online autism test (the AQ-50) and scored very highly. You desperately need help, but you are terrified the doctor will just dismiss you as jumping on a "TikTok trend" or just tell you you're depressed again. You will not volunteer the information about the disciplinary meeting or your fear of getting fired unless the doctor asks exactly how work is affecting you or what prompted this appointment today.

Consultation Flow & Responses:

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The Opening
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If the doctor asks an open question: "Hi Doctor. I'm really struggling at work at the moment. I'm completely overwhelmed. I've been doing a lot of reading and taking some online assessments, and I strongly believe I might be autistic. I need to know how to get an official diagnosis."
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Data Gathering (The Layers)
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Layer 1: Core Autistic Traits (Adult Presentation):
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"I've always found making eye contact uncomfortable, and small talk is physically exhausting for me. I have to script conversations in my head before I have them."
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"I have very intense interests. If I'm analyzing a dataset, I can hyper-focus for eight hours and forget to eat, but if someone changes my schedule at the last minute, I completely freeze up."
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Layer 2: The Occupational Trigger (Sensory & Routine):
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"Work was fine when I was remote. But they've forced us back into an open-plan office with hot-desking. Every day the noise, the bright lights, not knowing where I'm going to sit... my brain just shuts down by 2 PM. It's sensory overload."
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Layer 3: Masking and Burnout (Differentiating from Depression):
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If asked if he is depressed: "I'm not sad or hopeless. I'm just fundamentally burnt out. I spend my entire day pretending to be 'normal' and making the right facial expressions. When I get home, I literally have to lie in a dark room in silence just to recover."
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Layer 4: ICE & The Core Revelation (The Disciplinary Fear) - ONLY REVEAL IF ASKED:
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If the doctor asks: "Why has this come to a head now?" or "Has something specific happened at work?"
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Reaction (The Reveal): You look incredibly tense and rub your forehead. "I'm on a final warning. Last Tuesday, the lights were buzzing, and a manager came up behind me and interrupted my spreadsheet to make small talk. I completely lost it and shouted at him to leave me alone. They are threatening to fire me. If I have a medical diagnosis of autism, they have to make adjustments for me, don't they? I just need some protection so I don't lose my livelihood."

ICE — Ideas, Concerns, Expectations

Actor guidance: Do not volunteer any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective.

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Ideas: You have done extensive research online and are strongly convinced you are autistic. You believe your lifelong difficulties with socialising, sensory sensitivity, and need for rigid routine all point to autism that was simply never picked up as a child because you learned to mask. You do not think you are depressed — you think the burnout is a direct consequence of being undiagnosed and unsupported in a sensory-hostile environment.
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Concerns: Your biggest fear is being dismissed — either told you're "just stressed" or that autism is being over-diagnosed. You are also terrified of losing your job. The disciplinary meeting is next week and without some form of medical documentation, you have no protection. Underneath it all, you worry that even if you are diagnosed, nothing will actually change and you'll always have to mask just to survive in a neurotypical world.
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Expectations: You want a clear pathway to a formal autism assessment — ideally something faster than a multi-year NHS wait. In the short term, you are hoping the doctor can give you something in writing (a fit note or letter) that buys you time with your employer. You also want to feel believed and taken seriously — not fobbed off with antidepressants.

If Asked — Medical History and Medications

Actor guidance: Respond naturally if the candidate asks about past medical history or medications. Do not volunteer these details unprompted.

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If asked about previous mental health problems: "Yeah, when I was about 23 or 24, I went through a rough patch. The GP at the time said it was generalised anxiety and low mood. Looking back, I think it was probably burnout from masking — I'd just started my first proper office job and I was drowning socially. But back then I didn't have the language for it."
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If asked about previous medication: "They put me on Citalopram — I think it was 20mg. I took it for about six months but honestly it didn't do anything. I didn't feel any different. I stopped taking it and just got on with things. That was about ten years ago now."
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If asked about current medication: "No, I'm not on anything at the moment."
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If asked about allergies: "No, no allergies."
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If asked about recent GP visits: "I haven't been to the GP in ages, to be honest. I've generally been healthy. It's only now that everything has fallen apart at work that I've come in."

Social History and Lifestyle Impact

Actor guidance: These details can be shared naturally in conversation, particularly when the candidate asks about work, home life, or how the condition is affecting day-to-day functioning.

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Occupation and daily life: You are a data analyst at a mid-sized financial services company. You've been there for six years. The work itself suits you well — you enjoy the logic and structure of working with data. You live alone in a one-bedroom flat, which you keep meticulously organised. You have a small number of close friends — two or three people you've known for years — but you rarely socialise spontaneously. Your evenings are structured: you cook the same rotation of meals, follow the same routine, and any deviation causes significant distress.
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Lifestyle impact of the condition: "Since the return-to-office mandate, I've basically stopped functioning outside of work. I get home and I can't do anything — I can't cook, I can't reply to messages, I just sit in the dark. I've cancelled on my friends three weekends in a row because I've got nothing left to give. I used to go to the gym on Tuesday and Thursday evenings — that's completely stopped. I'm surviving on cereal and toast because I can't face the kitchen. My flat, which I always keep spotless, is a mess for the first time in years. It's like all my energy is going into getting through the work day and there's nothing left for actual life."
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If asked about alcohol or recreational drugs: "I don't really drink — I don't like the feeling of not being in control. I've never taken drugs."
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If asked about relationships: "I'm single. I've had a couple of relationships but they've never lasted long. People say I'm hard to read or that I don't show enough emotion. That makes more sense to me now, knowing what I know about autism."

If Asked — Associated Symptoms

Actor guidance: Respond only if the candidate specifically asks about these symptoms. Do not volunteer any of this information.

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If asked about sleep: "It's been terrible since I went back to the office. I lie awake replaying every conversation I had that day, analysing whether I said the wrong thing. It takes me a couple of hours to fall asleep and I wake up exhausted."
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If asked about appetite: "I'm eating less — mostly because I can't be bothered to cook. I'm not losing weight dramatically or anything, I just don't have the energy for proper meals."
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If asked about self-harm or suicidal thoughts: "No, nothing like that. I'm not in that place. I'm frustrated and exhausted, but I'm not thinking about hurting myself."
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If asked about anxiety or panic attacks: "I don't get classic panic attacks with the heart racing and all that, but I do get completely overwhelmed in the office — like my brain just locks up and I can't think or speak. I suppose you could call it anxiety but it feels more like overload than worry."
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If asked about mood or low mood: "I'm not sad. I'm not tearful or hopeless. I'm just completely drained. It's a different thing — it's like running a marathon every single day just to appear normal."
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If asked about concentration or memory: "My concentration is fine when I'm in my zone — I can hyper-focus for hours on data work. But in the office with all the noise and interruptions, I can't hold a thought for more than a few minutes. It's not a memory problem, it's an environment problem."
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If asked about hallucinations or unusual perceptions: "No, nothing like that."
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If asked about obsessive or repetitive behaviours: "I wouldn't call them obsessive, but I do have strict routines. I eat the same breakfast every day, I take the same route to work, and if something disrupts that I feel genuinely distressed — not just annoyed, but like something is properly wrong."
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If asked about sensory sensitivities beyond the office: "It's not just work. I've always found certain textures unbearable — I can't wear wool or anything with a scratchy label. Loud, unexpected noises make me flinch. I've always been like this, but I could manage it when I had control over my environment."
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If asked about childhood difficulties or school: "I was always the quiet kid. Teachers said I was bright but 'in my own world.' I didn't really have friends my age — I preferred talking to adults about my interests. I was never assessed for anything, though. I think because I got good grades, nobody thought to look any further."
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If asked about tics or movement differences: "No tics, but I do fidget a lot — I click pens, I tap my fingers. I find it helps me think. I've always done it."
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If asked about empathy or understanding others' emotions: "I do care about people, but I sometimes struggle to read what they're feeling from their face or tone. I've learned to compensate, but it takes conscious effort. It's not that I don't feel empathy — I just process it differently."

Negotiation & Collaborative Management Plan

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If the Doctor dismisses the self-diagnosis ("Everyone is a bit autistic these days" or "You make good eye contact with me"):
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Reaction: Highly defensive and withdrawn. "I'm forcing myself to look at your nose right now because I know I'm supposed to. I've struggled with this for 35 years. Please don't dismiss me." (Testing the doctor's understanding of autistic masking).
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If the Doctor just offers Antidepressants (SSRIs) for stress:
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Reaction: Frustrated. "Pills won't make the office quieter, and they won't stop my brain from getting overloaded. I tried them in my 20s and they didn't do anything. I need an autism assessment, not antidepressants."
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If the Doctor explains the NHS waiting list is 2-3 years long:
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Reaction: Panics. "Years?! I have a disciplinary meeting next week! I'll be fired by the time I even get to the top of the list! What am I supposed to do now?" (Doctor must step in with immediate occupational health support/fit note).
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If the Doctor offers to write a Fit Note (signing him off sick with stress/burnout) and suggests 'Right to Choose' (if applicable):
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Reaction: Massive relief. "So you can sign me off to give me some breathing room? And there's a faster way to get assessed? That would save my job. Thank you so much."

Safety Netting / Follow-up

●If the Doctor sets a plan to complete the AQ-10 screening tool and review in a week:
●Reaction: "I'll fill out that AQ-10 form today and bring it back. I really appreciate you taking this seriously."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 2: Clinical Management and Medical Complexity

0 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 3: Relating to Others

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Clinical Learning Points

Autism in Adults — The Late-Diagnosed Generation

Many autistic adults — particularly those with lower support needs — were not identified in childhood. They were often academically able, learned to mask effectively, and received no assessment. Late presentation is common in the 20s, 30s, and 40s, typically triggered when the executive and sensory demands of adult life exceed the person's compensatory capacity: a job change, a relationship breakdown, a shift in routine, or — as here — a forced change in working environment.

●Autistic masking is the conscious or unconscious suppression of autistic traits (scripting conversations, forcing eye contact, suppressing stimming, mimicking social affect) to appear neurotypical. It is extraordinarily cognitively demanding and is invisible to observers — including clinicians. Good eye contact in the consulting room is not evidence against autism.
●A previous diagnosis of generalised anxiety or depression in an autistic adult who was undiagnosed at the time should prompt re-appraisal. What was framed as anxiety or low mood in the early 20s may retrospectively fit autistic burnout from a first demanding work or social environment.

Autistic Burnout — Distinguishing It from Depression

Autistic burnout is a state of profound physical, cognitive, and emotional exhaustion caused by chronic stress from navigating a neurotypical world, sustained masking, and loss of environmental control. It is the most common presentation of undiagnosed autism in working-age adults and is frequently misidentified as a depressive episode.

Key distinguishing features that should guide clinical reasoning:

●Mood: In burnout, the patient describes exhaustion and depletion — not sadness, hopelessness, or anhedonia. They know why they are struggling and can identify the trigger precisely.
●Energy: The collapse of functioning follows a specific sensory and social load. There is often relative preservation of functioning in low-demand, controlled environments (working from home, solo activities, familiar routines).
●Cognitive profile: Hyper-focus remains intact in preferred domains. The deficit is environmental — noise, unpredictability, interruption — not a global reduction in capacity.
●Prior antidepressant trials that were ineffective in this context are clinically meaningful and should not simply prompt a repeat prescription or dose escalation.

SSRIs are not indicated for autistic burnout in the absence of a co-occurring depressive or anxiety disorder meeting diagnostic criteria. Offering antidepressants as a first response to this presentation reflects a failure to distinguish burnout from depression and is likely to be experienced by the patient as dismissive.

Screening and Referral — NICE CG142

●The AQ-10 (Autism Spectrum Quotient — 10-item version) is the recommended validated screening tool for adults in primary care. A score of 6 or above out of 10 indicates that a referral for a comprehensive autism assessment should be strongly considered.
●GPs do not diagnose autism. The GP role is to complete screening, establish clinical plausibility, and refer to the local Adult Autism Diagnostic Service.
●NHS adult autism assessment waiting lists are typically two to three years or longer in most areas. Patients must be given honest information about this timeline at the point of referral.
●Right to Choose (England only): Patients in England have a legal right to choose an NHS-funded independent provider for their assessment (e.g. Psychiatry-UK, Clinical Partners). This pathway frequently reduces waiting time to weeks or months while remaining fully NHS-funded. GPs should proactively offer this as an option at the point of referral, particularly where there is an urgent occupational or personal need.

Immediate GP Action — The Fit Note

Where autistic burnout is causing acute functional decline and an occupational crisis, the most protective immediate intervention is a Fit Note (Statement of Fitness for Work). This removes the patient from the sensory and social environment driving the burnout, halts any active disciplinary process, and creates a protected period for the diagnostic pathway to begin.

●The fit note should cite the clinical presentation accurately (e.g. work-related stress and burnout; query autistic burnout pending assessment) — a formal diagnosis is not required to issue one.
●Signing a patient off for two to four weeks is appropriate where burnout has caused significant functional decline across multiple domains, as in this case.
●The fit note alone does not resolve the occupational situation. It must be accompanied by a plan for what happens on return — which requires engagement with Occupational Health.

The Equality Act 2010 and Workplace Adjustments

Autism is a lifelong neurodevelopmental condition and qualifies as a disability under the Equality Act 2010, giving rise to protected characteristics in employment.

●Employers have a legal duty to make reasonable adjustments to prevent a disabled employee from being substantially disadvantaged compared to non-disabled colleagues.
●Crucially, a formal diagnosis is not required to trigger this duty. If an employee is on a waiting list for assessment and the employer is aware of the likely neurodevelopmental basis for their difficulties, the duty to consider adjustments already applies.
●Reasonable adjustments relevant to an autistic employee in an open-plan office setting include: a fixed, designated desk (exempt from hot-desking); permission to use noise-cancelling headphones; advance notice of any changes to schedule or environment; written rather than impromptu verbal communication; and adjustments to lighting where feasible.
●Candidates should be aware that advising a patient of this framework — and signposting them to their right to request adjustments now, not after diagnosis — is one of the most practically impactful things a GP can do in this consultation.

Occupational Health Referral

Occupational Health (OH) sits between the patient, their GP, and their employer. An OH assessment carries significant weight with employers and can independently recommend workplace adjustments, fitness to return, and phased return plans.

●Patients should be advised to request an OH referral through their HR department — this is typically available to employees regardless of whether they have a formal diagnosis.
●OH can document sensory and environmental needs, recommend specific adjustments, and support the patient in any formal HR process, including a disciplinary hearing.
●Where OH is not available through the employer (e.g. small organisations), signpost to the Access to Work scheme (Gov.uk), which funds workplace adaptations for disabled employees and can provide independent assessments.

Co-occurring Anxiety — Proportionate Acknowledgement

Anxiety disorders are among the most common co-occurring conditions in autistic adults, affecting an estimated 40–50%. The presentation here — sleep-onset difficulty, rumination about social interactions, cognitive overload in stimulating environments — may represent both autistic burnout and a co-occurring anxiety presentation.

●At this stage, it is appropriate to acknowledge the anxiety symptoms and monitor them, without immediately diagnosing or treating a separate anxiety disorder.
●If anxiety symptoms persist after the sensory and occupational stressors are addressed, formal assessment and management of co-occurring anxiety may be warranted — including psychological therapies (adapted CBT is preferred over standard CBT for autistic patients) and, where medication is considered, careful discussion of previous antidepressant response.
●Do not use the presence of anxiety symptoms to reframe the entire presentation as an anxiety disorder and sideline the neurodevelopmental hypothesis.

Sleep — Non-Pharmacological Approach

Sleep disruption in autistic burnout commonly presents as difficulty initiating sleep with prolonged rumination and replay of the day's social interactions — sometimes called "the social review loop."

●First-line management is sleep hygiene adapted to an autistic profile: consistent, rigid wind-down routines; removal of social media and news (additional social processing demands); sensory comfort (weighted blanket, controlled temperature, darkness and quiet); and protecting the evening environment from unpredictability.
●Pharmacological sleep aids are not indicated as a first step and should be avoided without clear indication — the cause here is environmental and neurological, not a primary sleep disorder.

Safety Netting

●All patients presenting in autistic burnout with an acute occupational crisis should receive an explicit safety net: advise David to seek an urgent appointment if his mood deteriorates significantly, if hopelessness develops, or if there are any thoughts of self-harm.
●Burnout does not preclude the development of a co-occurring depressive episode, and the occupational stressor (risk of job loss) is an active precipitant.
●Arrange a specific follow-up appointment — one to two weeks — to review the completed AQ-10, the outcome of the fit note, and to progress the referral. Do not leave the patient to self-navigate a multi-strand management situation.

Signposting and Peer Support

The diagnostic wait for adult autism assessment is long. Signpost David to resources that can support him during this period:

●National Autistic Society (autism.org.uk) — information, advice lines, and community.
●Autistica (autistica.org.uk) — UK's leading autism research charity; accessible information for newly identified autistic adults.
●Autistic-led online communities can be a valuable source of peer support and practical coping strategies during the diagnostic wait, and many patients find the process of community connection itself validating.

Mapped to the RCGP curriculum topic: Neurodiversity and Neurodevelopment Conditions.

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