By Dr Michelle Garnett and Prof Tony Attwood
Being able to determine the difference between clinical depression and autism is a skill that requires not only a good knowledge of both autism and depression, but also how depression presents in an autistic person. Some of the signs of a clinical depression, for example, decreased use of nonverbal communication, social withdrawal and a reduced number of interests, are also common in the presentation of an autistic person. These features of autism can potentially camouflage depression in autistic adults leading to inaccurate diagnosis, known as diagnostic overshadowing, and hence possible poorer support and therapy options. In this blog we describe our own findings, based on a combined 80 years of clinical experience, to assist health professionals to determine whether their autistic adult client is depressed. It is our hope that autistic adults and those who love them will also find this information helpful.
Change in the special interest
The special interest of the autistic person is often associated with pleasure and the acquisition of knowledge on an intellectually stimulating topic. However, when an autistic person becomes depressed, the interest can become morbid, and the person may become preoccupied with aspects of death, perhaps almost obsessively watching movies that have a theme of despair and death. The reason for the change in the focus of the interest to the macabre appears mystifying, but is the person’s attempt to intellectually explore and understand deep negative inner emotions and express confusion, sadness and uncertainty about his or her personal circumstances. The morbid interest can be ‘a cry for help’, and an attempt to understand intense sadness and despair without having to engage in social interactions and conversation that needs the ability to be articulate and insightful with regard to inner thoughts and feelings. Parents, partners and clinicians may need to look beyond the focus of the interest and recognize a mood disorder that is being expressed in an unconventional way.
An indication of a very deep depression in an autistic person is the loss of all enthusiasm for what was their special interest. Topics that once fired the person with passion, animating their conversation, creating energy, and causing immense pleasure and relaxation, can lose value. When experiencing this deep expression of depression, the person is no longer interested in talking about favourite topics; aviation, entomology, second world war tanks, Egyptology or whatever else previously captured their interest no longer acts as an effective antidepressant. Even the best-loved, most established interest may not have sufficient power to alleviate a very severe depression.
Anger as an expression of depression
Anger in an autistic person may actually be a sign of depression. We have found that autistic people of all ages have described the functional use of anger to achieve solitude. When an autistic person is sad or anxious, they typically do not crave intimacy and connection with another person. Yet, if they express sadness, for example through crying, this is exactly what they tend to receive, by way of a close hug or close attention. They can quickly learn not to cry (someone will ‘squeeze’ you and how will that help you feel better), but instead yell or punch a wall, so that people will leave them alone. An autistic person will often feel safer when alone and have time without interruption or distraction to process experiences and emotions.
Another characteristic of autism is to have an explosion of destructive anger to ‘cleanse the system’, ‘clear the air’ or to ‘reboot the emotion computer’. As one adult said ‘It’s a bit like wanting to vomit, knowing you will feel ill until you actually throw up. You get it over and done with and feel better. Getting it out of your system.’ Thus, a means of recovery or repair for negative emotions is to discharge those feelings in an explosion of aggressive energy. A metaphor is having a severe and chronic headache and the explosion is a form of Panadol (Tylanol) that quickly alleviates the pain. In psychological terms, the explosion is a powerful negative reinforcer and can become the person’s preferred effective treatment for increasingly intolerable feelings of depression.
Thus, while we recognize that one of the typical key signs of chronic depression is lethargy and self-blame, psychologists also recognize that depression can be expressed as agitation and blame of others rather than oneself, using the term ‘externalized agitated depression’. The person goes into ‘attack mode’ and is perceived as aggressive, but the underlying emotion is actually low self-worth and depression.
An autistic person may demonstrate many problems with anger and impulse control when feeling depressed, for example, yelling for no apparent reason, throwing plates or a chair or punching a wall. These behaviours may be an expression of their depression, that is, their feelings of helplessness and hopelessness about themselves, the world or their future and rather than ‘surrendering’ to the depression, go into ‘attack mode’, becoming violent against a world (or people) that may not express acceptance and respect.
The autistic person may not have a wide range of innate tools to communicate their true feelings as they arise; thus, these emotions may only be communicated once they are extreme, and expressed in a way that lacks precision and subtlety. Most autistic people are not ‘wired’ to express emotion in conventional or subtle ways.
In alexithymia, the circuitry in the brain that is responsible for helping people to find words for their thoughts, feelings and bodily sensations is not working as efficiently as would be expected, such that the person has a limited vocabulary of precise and subtle words for their emotions. As a seven-year-old autistic child said, “I need a language for my worries”. Alexithymia is a psychological construct to describe people who experience difficulty identifying and describing their emotional states and often occurs in autistic people. As Heather, an autistic astrophysicist, said, ‘I do not understand why you need all those words for different emotions! I have two emotions: “OK” and “mad”.’
This insightful statement raises a question: if somebody has only two words for their emotions, do they still experience the full range of emotions? The answer is yes. An emotion has four parts: thinking, behaviour, physiology and the subjective experience, or the feeling, of the emotion. People who experience alexithymia have difficulty with labelling, which is, knowing the word or words to describe the feeling clearly and precisely. They will still experience the thinking, behaviour, and physiology of that emotion, but have great difficulty communicating that feeling in conversational speech. This is important to know, because autistic person may say that they are not depressed, but their thought patterns, behaviour and physiology will tell a different story.
Autistic women in particular and autistic men are known to frequently ‘wear a mask’ to hide their true feelings and their true self from others, for fear of rejection. Masking emotions is a very intelligent and constructive coping mechanism but can lead to intense loneliness and depression. As a autistic woman said, ‘I have done such a great job at pretending to be normal that nobody really believes I have autism.’ ‘Masking or ‘faking it’ can create a temporary, but appealing ‘cure’. As much as the autistic person may mask autism, they can also mask their depression, desperately trying to appear that they are managing their life and do not need help.
The cost of masking the real self and depression in order to be accepted and liked can create a chronic sense of concealed alienation and feelings of personal defectiveness. It is exhausting to lead a double life, significantly contributing to feeling depressed.
Suppression of emotions
Recent research has discovered that autistic are most likely to utilize the coping mechanism of suppression for strong emotions, including depression, rather than other coping strategies such as seeking support or putting the problem in perspective. Suppression of painful emotions can hide the symptoms of depression so effectively that the person ‘slips under the radar’ and does not receive the help they so desperately need. Unfortunately, the painful emotions do not go away, but instead intensify and elongate the depressive episode, and can also cumulate and lead to intermittent ‘depression attacks.’
In instances of intense depression and deep despair, some people consider suicide as a means of ending their pain. This plan may be carefully considered over days or weeks.
However, in some autistic people there is a difference in the way they come to this decision. They may experience we have termed a ‘depression attack’. Suddenly, without any warning signs to themselves and others, they experience intense, catastrophic despair and make a spur-of-the-moment dramatic decision to end their life.
These out-of-the-blue, extremely intense, emotions are recognized in clinical practice, most often in association with an anxiety disorder and occurring in the form of the panic attacks. The feeling of intense anxiety is sudden, overwhelming, and unanticipated. Another example of an out-of-the blue, extremely intense emotion is the rage attack, where the person ‘flies off the handle’ and safety becomes the primary concern as the person expresses their rage physically through throwing items, yelling, hitting, shoving, or kicking. The rage attack has also been called a ‘meltdown.’
Depression attacks are similar, in the sense that there is no prior warning. The overwhelming despair may occur as a catastrophic emotional overreaction to what appears to be a relatively innocuous negative experience, such as making a minor mistake, being late or being teased. However, there may have been a backlog or build-up of despair over a long time that was not cognitively recognized by the autistic person or others. This final, simple event or trigger releases the pressure that has been building for so long. The cap could not stay on the bottle any longer. The resulting conspicuous despair is very deep and genuine, and entirely unanticipated by the autistic person and others. There may subsequently be an impulsive action, such as jumping from a bridge, resulting in serious injury or death. Friends, family or colleagues who have been with the person immediately prior to this depression attack may not have identified any obvious signs that such an action was imminent.
We know that, should the person resist or be distracted from the impulse to act dramatically, the unanticipated, deep despair passes. Remarkably, in a short time it gives way to a more balanced emotional state.
Suicidal thoughts and actions
Recent research studies and reviews indicate that thoughts of suicide occur in 66 per cent of autistic adults. In contrast, the rate of such thoughts in the general population is 16 per cent Research studies also indicate that 35 per cent of autistic adults have in their lives planned or attempted suicide. The actual suicide rate is unknown but could be at least 7 per cent. Thus, the majority of autistic adults have had thoughts of suicide, and around one in three have actually planned or attempted suicide at least once in their lives. A consequence for the clinician is to explore any suicidal ideation and/or plan with their autistic adult clients. The risks are higher for this population.
Some autistic people have considerable difficulty expressing subtle or complex emotions in their face, body or tone of voice, not because they mask or suppress emotions, but because of a difference in the way their brain works. The circuitry in the brain responsible for the expression of emotion through the face, body and voice is working slightly differently in Autism, and is an expression of emotional dyskinesia or a reduced range of emotional expression in the face and body language. This mind/body disconnection results in some of the features commonly observed in autism, including a facial expression that has been described as a ‘wooden mask,’ a paucity of gesture, and a monotonic tone of voice. However, because the person does not look or sound distressed, there can be a lack of recognition of that person’s feelings and access to support and increasing feelings of alienation and depression may occur. As one autistic woman put it, ‘People at school thought it was okay to bully and taunt me. They interpreted my lack of visible emotional expression as lack of feelings, they truly believed that I was not hurt by the taunts and severe bullying.’ Unfortunately, it is still a common myth that autistic people do not have feelings because of a lack of subtle variation in facial expressions.
In this blog we have described various ways in which depression may be overshadowed by autism to assist clinicians to assess for depression accurately when seeing an autistic adult. Depression may present differently as a change in the special interests, as anger, or may be intentionally masked with the use of camouflaging, or unintentionally masked because of alexithymia, emotional dyskinesia or the use of avoidance and suppression as coping mechanisms. Depression attacks and suicidal ideation are common signs of an underlying depression is autism and need to be assessed.
Where to from here?
To learn more about how to recognise autism and commonly co-occurring conditions and differential diagnoses we encourage you to attend our upcoming Masterclass: Diagnosis and Therapy for Autistic Adults on 8th and 9th September 2022. You may attend live in Sydney CBD or via live webcast.
LIVE WEBCAST And Live In Sydney: Masterclass – Diagnosis And Therapy For Autistic Adults – 8 & 9 September 2022
We also recommend our self-help book for anyone experiencing mild to moderate depression. We wrote the book based on our clinical experience treating depression in autistic adolescents and adults. We recommend using the book with a psychologist, coach, counsellor or mentor.
Exploring Depression, and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger’s Syndrome [ASD-Level 1] by Tony Attwood and Michelle Garnett, published by Jessica Kingsley Publishers, Web: www.jkp.com