Understanding neurodivergence

Our stance: the diagnosis as the beginning of an understanding

For us an assessment is not a search for a defect, but an attempt to understand, together with you, how you perceive, think and feel — and what it costs you day by day to manage in a world that takes little account of it.

Many adults come to us after years of feeling “somehow different” without having a language for it. Not infrequently depression, anxiety or exhaustion had been treated while the thing itself remained unrecognised: a particular way of experiencing stimuli, relationships and one’s own inner world. People with autism spectrum disorder (ASD) and with ADHD have the same feelings, wishes and longings as anyone else — they often suffer because the environment makes little sense to them, is overwhelmingly loud or unpredictable. Withdrawal, shielding from stimuli or constant tension are then not quirks, but understandable answers to fear and flooding.

As we see it, ASD and ADHD are first of all ways of being in the world — a spectrum of modes of experience with their own strengths and with real burdens, which we take seriously. What is treated, where that is wanted, is the burden — not the mode. A careful diagnosis can bring great relief: it reorders one’s own life story, replaces years of self-reproach with understanding, and makes it intelligible why so much in life has taken so much strength. It is not a label but a key.

What is best evidenced here is at the same time what brings most people to us: loneliness. And to a considerable extent it arises not within the person but at the boundary between them and their surroundings — where two modes of experience regularly miss each other. That is more than a consoling formulation: it shifts the question from “what is wrong with me?” to “where exactly does it get lost between me and the others?” — and the second question can be answered.

Our treatment stance follows from this. Where support is wanted, we work within a reliable, continuous and predictable frame at getting to know the inner experience and understanding the fears behind it — rather than merely training behaviour. In this we stand in the tradition of psychoanalytic work with autistic modes of experience: founded by Frances Tustin and carried on by Geneviève Haag into the most precise description we have of how a body image is built up — and in what order it reassembles when a treatment takes hold. For today’s technique Esther Bick, Anne Alvarez, Judith Mitrani and Thomas Ogden are added, and for the present Joshua Durban. The aim of this work is never to change the person, but to let them unfold — in their own way. For ADHD we follow the psychodynamic line from Marianne Leuzinger-Bohleber and Michael Günter to Stephen B. Bernstein and Francine Conway, who have written this work forward expressly for adulthood: it understands restlessness and distractibility not as unwillingness but as the expression of an overloaded inner apparatus, to which the treatment seeks to give room for thinking.

How matters stand with the evidence for this, we say openly. Controlled studies of psychodynamic treatment of adults with ASD or ADHD do not exist. What does exist, however, is more than the purely paediatric literature often assumed. For ADHD, a small but very precise adult literature has grown up alongside it — papers on the adult patient with ADHD in treatment, and a symposium of its own in which shame is described as the central affect, together with the experience that the usual interpretive interventions largely fail to carry here: what is needed first is something developmental rather than something uncovering. For ASD in adulthood there are carefully documented single courses of treatment — the longest extending over fourteen years — and papers on what Cohler and Weiner called the “inner fortress” of the adult patient. We do not make a virtue of this state of affairs, but an obligation: we document the course of treatment and measure it, instead of relying on impression.

And a word on how we handle the knowledge we rely on. In this field identity, market and science currently overlap, and anyone looking around finds two camps that barely read each other. We do not take one side in these disputes in order to be rid of the other. Our rule is simple: explain nothing away, inflate nothing. Where the research carries, we say so. Where a widespread term promises more than the data support, we say that too — even when it has become a self-description for many people. That is not directed against those people. It is only meant to prevent an experience that is real from being built on a term that cannot carry it.

With us, therefore, the diagnosis is not an end point but a beginning: the beginning of a better understanding of yourself and — if you wish — of a treatment that deepens that understanding.

A psychometric assessment answers more than the question “ADHD or ASD — yes or no”. It makes connections visible that often look like separate problems in daily life and are not. Five examples:

Stimuli. Over- and under-sensitivity do not exclude each other; they often occur in the same person, in different senses or at different times. Knowing this about yourself explains why “more quiet” alone sometimes does not help — and why a silent room and a need to move are not a contradiction.

Feelings. Many neurodivergent adults notice inner states late — tension, hunger, exhaustion. An assessment can show whether the difficulty lies more in perceiving or more in naming feelings. That is not an academic distinction: it helps decide where a treatment can begin.

Body. Physical complaints without a clear finding — exhaustion, pain, digestion, sleep — are often linked, in neurodivergent people, to how the body is perceived: too late, too vaguely, or only when nothing else is possible. The assessment can make the interplay of body perception, emotion recognition and symptom burden visible — and help to weigh how much of it belongs to medical work-up and how much to one’s own perception. It does not replace a physical examination.

Adaptation and its price. Years of covering over one’s own way of being can now be asked about. The report places how much energy this adaptation costs — and why it often does not bring the connection hoped for.

Look-alikes. Autistic traits, the after-effects of trauma and personality disorders resemble each other in many single features; misdiagnoses in both directions are common. The assessment therefore never relies on a single questionnaire, but on the pattern of several, differently obtained indications.

Where the limits lie: A score on its own is not a diagnosis, and a diagnosis is not a promise of treatment. That holds more strictly than it sounds — it is the point our review of the measures keeps arriving at: specificity does not arise from a single value. Not from a screening questionnaire, not from a measure of adaptation, not from a measure of exhaustion. What carries weight is the agreement of several independently obtained views — and the last of those views is always the conversation. What follows from a set of findings is decided by you — together with the person who treats you. How the assessment proceeds and what it costs is set out on the page ADHD and autism spectrum assessment.

Anyone reading about neurodivergence online soon meets three terms that seem to explain everything. All three name experiences many people recognise at once. And with all three the distance between what the term promises and what can be measured is greater than the popular literature concedes. We think both can be said — and that they should be said before anyone founds their self-understanding on them.

Masking and camouflaging. What is meant is the effortful covering of autistic traits: preparing conversations, copying tone and facial expression, spending the evening going over it afterwards, keeping an inner monitor running at all times. This exists, and it costs. The common questionnaire for it measures reliably — but whether it measures what its name claims is disputed: its scores are bound up with social anxiety about as closely as with ASD. More revealing is a look at the subscales. If one recalculates from the published figures where autistic and non-autistic respondents actually differ, the part that separates them least is precisely the one closest to the popular image — concealment in the narrow sense, the controlling of face and voice. Very many people do that. Two other components, by contrast, separate clearly: the laborious working-out of social techniques that come to others by themselves, and the giving up of parts of oneself in order not to cause friction. What distinguishes neurodivergent adults, then, is not self-control — it is the effort of belonging. For the assessment this means: we do not look at the total score, but at which component carries it.

Autistic burnout. What is meant is a collapse following an increase in social demands — not following a loss: deep, persistent exhaustion, heightened sensitivity to stimuli, temporary loss of familiar everyday abilities. There is by now a carefully examined measure for it which distinguishes reliably between people with and without current exhaustion. The same instrument, however, correlates highly with measures of depression — in one study no less closely than the exhaustion measures agree among themselves. At the level of experience those affected do describe the difference — the exhaustion feels less “suffocating” than a depression. At the level of measurement the two cannot yet be cleanly separated. Autistic burnout is not a recognised diagnosis; there are no prevalence figures, no evidenced stages, no treatment protocol. Why the distinction nevertheless matters shows in the consequences: if such a state is treated as a depression and the person is advised to become more active and to see more people, exactly that can deepen the exhaustion — it is more of what used her up. If it is understood as the exhaustion of a compensatory effort, the path leads the other way: protection from stimuli, fewer demands, permission to pause. Both readings are defensible. Which one applies is decided not by a questionnaire but by the course, by the trigger, and by the question whether joy has been lost altogether or only the strength to produce it.

Rejection sensitive dysphoria (RSD). What is meant is an extreme, bodily experienced sensitivity to rejection, traded online with self-tests, stage models and treatment advice. Here the examination has run behind the dissemination, not the other way round: the term comes from the clinical observation of a single practitioner and travelled first into podcasts, websites and self-help books. The first scientific paper on it appeared in 2024 — a case series of four people. There is no examined measure, no larger sample, and no demonstration that RSD can be separated at all from emotion regulation, social anxiety and depressive vulnerability to hurt; the term has no place in the classification systems. It names an experience many people with ADHD describe as real and tormenting — and it is, scientifically speaking, a construct in the making. We take the experience seriously. As evidence we do not use the term.

Three times the same figure, which is why it stands here: a measure that reliably indicates something, without its being settled what. That is no reason to mistrust the experiences. It is a reason not to fasten any of these experiences to a single number.

ADHD is frequently treated with medication, and many people experience a marked improvement with it. The scientific basis for this is, however, thinner than the matter-of-factness of prescribing suggests. The Cochrane Collaboration — the strictest independent review procedure medicine has — has summarised the studies of extended-release methylphenidate in adults: 24 studies with a good 5,000 participants. Symptom scores improve. Cochrane rates the trustworthiness of these results as “very low” for all endpoints. The reasons are methodological: the studies lasted eight weeks on average, blinding is effectively undone by the noticeable effect, measurement is by questionnaire, and industry had a financial part in nine out of ten participants analysed. To this comes a point that matters especially for our patients: 19 of 21 studies excluded people with further mental illness, and just as many preferentially enrolled people who had already responded well to stimulants. What was studied was therefore largely not the situation in which the question arises in daily life — adults with long-standing depression, anxiety or exhaustion as a rule did not appear in these studies. The authors themselves state that their review is likely to overestimate benefit and underestimate harm.

From this it does not follow, in our view, that medication does not work. “Very low trustworthiness” is a statement about the quality of the studies, not about the efficacy of the drug. What follows is: we know less certainly than we would like — especially over longer periods. That is not an argument against treatment, but an argument for careful indication in the individual case.

And that indication expressly includes medication. The clinical benefit is, in our experience, considerable; in some people it is the precondition for anything else becoming possible at all. For psychotherapeutic, and particularly psychoanalytic, work the same holds in the other direction: its benefit is clinically well attested and harder to capture in short randomised trials than the matter deserves. Whoever invokes the uncertainty of the evidence against the one must keep it in mind for the other. We do both — and this symmetry matters more to us than any positioning: the standard we apply to medication is the same one we apply to our own work.

In practice this means: with us the question of medication is not a matter of belief but a weighing — what is the aim, what the alternative, what the price, and what does the course show. We measure that course with validated instruments instead of relying on impression. And when something does not work, we say so.

Sources: Cochrane reviews CD012857 (extended-release methylphenidate in adults) and CD009885 (methylphenidate in children and adolescents), available through the Cochrane Library.

Neurodivergence shapes not only one’s own experience but also partnerships — often without either partner knowing what is actually happening. The recurring argument is rarely about what it appears to be about. She tells him something that matters to her and receives a factual question instead of a response; she does not feel meant, and over the years comes to feel she is talking to a wall. He listens closely and tries to help by understanding the problem; that the factual question arrives as coldness he does not understand — he was paying attention, after all.

Both versions are true. They describe the same event from two sides of a boundary at which two modes of experience fail to meet. She reads attentiveness off emotional resonance; he shows attentiveness by taking the problem seriously. Neither has less empathy than the other. What is fateful is that each side turns the misunderstanding into a character trait of the other: “he reacts differently from what I expect” becomes “he is cold”; “she wants something I cannot deliver” becomes “nothing is ever enough for her”. Both sentences feel like years of experience — they have been confirmed a hundred times over. Only what is confirmed each time is the same boundary, not the other’s character. And because both are trying hard to do better, the effect intensifies: he tries to understand the problem even more precisely, she to show her need even more clearly. Both do more of what does not arrive with the other.

The research supports this mutual reading — and supports it with measure. A large, pre-registered study from 2025 showed that knowing about each other — simply that the diagnosis is known — improves communication throughout. It did not, however, confirm what is often claimed alongside it: that mixed couples exchange information worse in general. The robust core is: the friction is mutual, and knowing about each other helps. We say no more than that, because no more is evidenced.

To this comes what arrives in daily life as withdrawal and usually is none. Whoever spends years on the effort of belonging is used up by the evening; at home, where it is no longer necessary, exhaustion, irritability and a need for silence show themselves. Often one’s own limits are noticed too late as well — overload frequently becomes apparent only once it has arrived: as a sudden cancellation, as withdrawal, as a “shutdown”. To partners this easily looks like indifference or rejection. It has nothing to do with it.

In couple therapy where neurodivergence is involved, the first concern is therefore that both understand how the neurodivergent partner perceives, communicates and recovers — and the other way round. On that basis, withdrawal and closeness, communication and spaces for recovery can be negotiated so that both have a place. Couple therapy is not a benefit of statutory or private health insurance; this service is therefore for self-payers. The cost per session corresponds to that of an acute session with findings (about €165). Appointments via Doctolib or by email.

We work according to the current state of research — and record when we last examined it. What stands on this page is the state of September 2026. Where the evidence is clear we say so; where it is not, likewise. If it changes, we change our position and write it here. We apply the same standard to our own work: we measure the course of treatment with validated instruments instead of relying on impression, and we check every statement we make here against the original paper — not against its summary.