Logan, age 15, asks for “autism testing” because he states he is “neuro-atypical.” You do not see symptoms of autism and wonder whether his self-diagnosis is the result of social contagion. What should you do?

In social contagion, information, behaviors, ideas, and emotions spread through a social group like a contagious disease. Adolescents are particularly susceptible as they navigate self-identity and the desire to fit in. Social contagion has been documented in schools, neighborhoods, families, and adolescent therapy groups (Christakis NA and Fowler JH, Stat Med 2013;32(4):556–577).

Sources of social contagion

There are numerous paths to social contagion. Here are five common ones:

• In-person conversations (eg, memories of an event altered through social interaction)
• Nonverbal behavior of emotionally expressive individuals in the same room (eg, a person silently crying during group therapy)
• Behaviors of individuals living in close proximity (eg, disordered eating habits spreading through a dorm)
• Conversations among a social network, for good or ill (eg, choir members influencing each other not to use drugs, or football teammates encouraging alcohol use)
• Social media with broad, public reach (eg, a popular influencer discussing “everyone’s ADD”)

Social media

Most teens report positive social media experiences, such as providing support for isolated or distressed adolescents, or promoting connections with peers facing similar problems (www.tinyurl.com/mr262pwv). However, some platforms reinforce harmful behaviors, such as disordered eating, self-mutilation, and suicidality (Martínez V et al, Curr Opin Psychiatry 2023;36(3):237–242).

Social media is a vector of contagion, an echo chamber that reinforces beliefs and behaviors even when the content is harmful. Platforms can glamorize or provide misleading information about mental health conditions. Normal adolescent moods and behaviors may be misrepresented online as pathological (Haltigan JD et al, Compr Psychiatry 2023;121:152362). Teens may believe their diagnosis is fixed and untreatable, or they may believe typical struggles are not valid without an accompanying diagnosis.

Social contagion phenomena

Social contagion exhibits a variety of clinical presentations.

Functional tic-like behaviors (FTLBs)

Social contagion has been linked to a surge in youth with FTLBs in the US and Europe (Haltigan et al, 2023). FTLBs are complex and begin abruptly. Patients may hit themselves or others, describing these movements as involuntary, often after seeing the movements on TikTok (www.tinyurl.com/7frjkuxb). Most patients with FTLBs are adolescent females, a key TikTok demographic (Haltigan et al, 2023).

Self-diagnosis

“#Autism” videos on TikTok have amassed 11.5 billion views (Aragon-­Guevara D et al, J Autism Dev Disord 2023; Epub ahead of print). Other social media focuses on dissociative identity disorder, bipolar disorder, and ADHD. A 2023 study of 1,600 possible cases of social contagion of “rapid-­onset gender dysphoria” was retracted because the people examined in the survey had not consented to participating (Diaz S and Bailey JM, Arch Sex Behav 2023;52(8):3577).

Suicide

Some research suggests that social contagion can precipitate suicide clusters in groups of teens who are from the same geographical area or share a social network (Niederkrotenthaler T et al, BMJ 2020;368:m575). These clusters are also linked to celebrity suicides and shows such as “13 Reasons Why” (see CCPR March/April 2019; www.tinyurl.com/3v65umux).

During your conversations with Logan, he shares his fascination with an online “autism influencer” who enthuses about the magic of neurodivergence.

How to identify and manage social contagion and self-diagnosis

How do we work with a teen when their self-diagnosis appears inaccurate? How do we differentiate accurate diagnosis from social contagion? What should we do when a teen requests medication for a self-diagnosis? Here are some suggestions.

Connect and validate

• Validate the patient’s experience (eg, feeling left out, feeling different).
• Explore the patient’s knowledge about the condition: “Tell me your thoughts about it.”
• If the condition is linked to a specific community, find out what the community offers the patient: “Help me understand how this community helps you.”

Build a shared agenda

Use the patient’s goals in a shared plan for assessment and care. For example, “What would you like to get out of today’s visit?” “What do you want to change/make better?”

Assess the patient

• Conduct a thorough assessment with a differential diagnosis.
• Identify positive symptoms and pertinent negatives (absence of typical symptoms for a diagnosis).
• Assess for comorbid conditions (eg, mood, anxiety, psychotic disorders) that may underlie symptoms.

Example language: “You felt like you were dissociating. Can you tell me more about what that experience was like? What was going on around you when this was happening?”

Provide a safe space

Ask nonjudgmental questions about lived experiences. For example, “What were you feeling when your parents told you they didn’t believe in multiple personalities?”

Logan is sad. His tells you that his girlfriend broke up with him and that he has “no friends.” Logan’s parents report that he talks during class and doesn’t turn in assignments. They have not seen problems with social communication, restricted interests, or sensory processing.

Obtain collateral history

Talk to parents, teachers, and others. Here are clues that a patient may be describing online content and not lived experience:

• Rare conditions
• Sudden onset
• Inability to provide real-life examples of symptoms
• Misuse of medical jargon (eg, “I was manic” to describe anger)
• Reporting of similar diagnoses among online friends/peers

Logan reports that the autistic influencer helped him see his own “social deficits.” He says that he “stims” and that he’s sad because he “masks” at school. While he says he has no friends there, he states that he now has “neurodivergent” friends online.

Remain empathetic

• Avoid debating the patient’s interpretation of events.
• Be factual about the clinical impression but de-emphasize labels while acknowledging distress.
• Use specific therapy or medication when clinically indicated by clear ­diagnosis.
• Learn about the patient’s social media ­interactions. Example language: “Which websites do you like? Do you worry about how to help your online friends?”

Facilitate connections with peers

• Help the teen connect with “live” peers through meaningful activities. Ask about their interests and provide information about opportunities to connect in person with peers who share their passions.
• Help parents address barriers to in-person engagement (eg, time, transportation, and reassurance that extracurricular activities will improve the patient’s academic interest rather than interfere with their grades).

You learn that Logan enjoys music. You encourage him to explore the music opportunities offered for teenagers at his local community center to build social experience and alleviate loneliness.

Provide resources

Provide information to patients and their parents about psychiatric diagnoses. Example language: “The mood shifts you are describing are consistent with emotional dysregulation rather than the mania that occurs in bipolar disorder. Let me explain the difference...”

Conduct risk assessment

• Check for thoughts of self-harm or suicide.
• Monitor at-risk teens as soon as a community becomes aware of a suicide. Schools need standing protocols for responding to student suicide to prevent cluster suicides.
• Treat co-occurring conditions as you normally would with therapy and/or medication.

You acknowledge with Logan and his parents that his breakup was difficult, and you see signs of depression. You explain your finding of ADHD and how social challenges with ADHD can look like autism. You note that internet self-assessment can be incomplete and request ADHD rating scales from Logan’s parents and teachers. You recommend psychotherapy for depression and social guidance. You will continue to explore concerns about autism and refer him as indicated for additional diagnostic assessment.

CARLAT VERDICT