The meltdown pathway: A multidisciplinary account of autistic meltdowns

Psychol Rev. 2025 May 5. doi: 10.1037/rev0000543. Online ahead of print.

ABSTRACT

Autistic meltdowns are fits of intense frustration and often physical violence elicited by sensory and cognitive stressors. Despite the high prevalence of meltdowns among autistic individuals, the neural mechanisms that underlie this response are not yet well understood. This has thus far hampered progress toward a dedicated therapeutic intervention-beyond traditional medications-that limits their frequency and severity. Here, we aim to initiate an interdisciplinary dialogue on the etiology of sensory meltdowns. In doing so, we frame meltdowns as a consequence of underlying chronic hypervigilance and acute hyperreactivity to objectively benign stressors driven by differences in the insular cortex-a multimodal integration hub that adapts autonomic state and behavior to meet environmental demands. We first discuss meltdowns through the lens of neurophysiology and argue that intrainsular hypoconnectivity engenders vagal withdrawal and sympathetic hyperarousal in autism, driving chronic hypervigilance and reducing the threshold of stressors those with autism can tolerate before experiencing a meltdown. Next, we turn to neuropsychology and present evidence that meltdowns reflect a difference in how contextual evidence, particularly social cues, is integrated when acutely assessing ambiguous signs of danger in the environment-a process termed neuroception. Finally, we build on contemporary predictive coding accounts of autism to argue that meltdowns may be ultimately driven by differences in sensory attenuation and coherent deep inference within the interoceptive hierarchy, possibly linked to oxytocin deficiency during infancy. Throughout, we synthesize each perspective to construct a multidisciplinary, insula-based model of meltdowns. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

PMID:40323827 | DOI:10.1037/rev0000543