By Dr Michelle S. Garnett & Prof Tony Attwood
Autistic adults appear especially vulnerable to feeling depressed, with about one in three adolescents and two out of three autistic adults having experienced at least one episode of severe depression in their life. More adults than adolescents may experience clinical depression because the reasons for depression in autistic adults may intensify during the adult years. The following descriptions about why autistic adults can become depressed are also relevant for adolescents. This is the second part of a two-part series on depression in autistic adults.
The reasons autistic adults become depressed
Self-reflection and self-disclosure
An autistic adult may have considerable difficulty recognizing, defining, conceptualizing and disclosing through speech, his or her inner feelings to parents, partner and/or peers, preferring to resolve thoughts and feelings in solitude. He or she may avoid conversation about negative feelings and experiences and try to resolve the depression by subjective thought or by using the special interest as a thought blocker. People not on the autism spectrum (neurotypicals) generally recognize that another person may provide a more objective opinion and comforting validation of emotions, act as an emotional restorative and be able to suggest an alternative explanation and reaction. An autistic adult may discover these possibilities for themselves, but only when they are open to new learning and can trust again.
Some people can easily recall the good times and anticipate that similarly good times will be part of their future. This style of thinking can be an effective antidote to pessimistic or depressive thoughts. Autistic adults may have difficulty experiencing and remembering times of happiness and joy, other than the excitement associated with aspects of the special interest and anticipate a life-long continuity of feeling sad.
Emotion repair mechanisms
Usually, family and friends of someone who is feeling depressed may be able to temporarily halt, and to a certain extent alleviate, the depressed mood by words and gestures of compassion, reassurance and affection. They may be able to distract or elevate the mood of the person who is depressed by initiating enjoyable social experiences, or using humour, thus providing an infusion of happiness. Autistic adults can have considerable difficulty resonating with, or being infused by, the happiness of others. Thus, some emotional rescue strategies used by family members or friends may be less effective for an autistic person; they are more likely to try to solve personal issues by themselves, finding affection, compassion and others’ optimism less effective emotional restoratives.
There may be one person within the family who takes primary or exclusive responsibility for emotion repair when the autistic family member is feeling depressed. The dynamics of this relationship may be of concern with an over-reliance on one person who may become exhausted or exasperated by their role and there can be the development of a mutual dependency.
Awareness of warning signs of a developing depression
Another characteristic of autistic adults is a ‘disconnection’ between mind and body, such that the person does not seem to be aware of the internal physical and psychological signals of deepening sadness, such as depleting energy levels; or psychological warning signs or cues, such as increasing pessimism. One example of this is the case of a teenager who was recounting at the clinic his experiences of being bullied at school that morning. As he told the story, tears were welling in his eyes. As tears were about to cascade down his cheeks and were clearly visible to his mother and to us, his mother handed him a tissue. He looked at it in amazement and asked, ‘How did you know I was going to cry?’
One of the characteristics of autism can be a delay in emotional processing time. An example is a conversation with an autistic woman who was describing an experience she had recently. As she was talking, with a voice that did not convey any specific emotion, tears started to stream down her cheeks. Michelle asked her why she was crying and she replied that she did not know the reason, but after about two hours she would be able to process the events, thoughts and feelings and provide an explanation. This characteristic delay in emotional processing time can explain why an autistic adult may have difficulty giving an instantaneous reason for having (or not having) a particular emotion, perhaps honestly replying to the question “How are/were you feeling?” with “I don’t know”, which means “I am still processing and analysing my feelings. Thus, there can be a considerable delay in the expression of some emotions, such as grief.
As the autistic person is often the last person to recognize the signs of sadness or depression; these may have to be pointed out by others, with comments such as, ‘You seem especially quite self-critical today, I wonder if you are feeling depressed?’ Alternatively, it is helpful to assist the person to develop a list of behaviours that occur when they are depressed, so that they can recognise their own depression through self-observation of what they do. For example, for one autistic woman we worked with, these behaviours included not tidying up or cleaning the house for a week, not showering for over 3 days and not going to the supermarket to purchase fresh food. Without being able to perceive the early warning signs of deepening depression themselves, the autistic adult cannot take action, and is thus susceptible to the depression becoming deeper.
Vulnerability to extreme, intense emotions
In instances of intense depression and deep despair, some people – both neurotypical and autistic adults – may consider suicide as a means of ending their pain. This plan may be carefully considered over days or weeks.
However, in some autistic adults there is a difference in the way they come to this decision. They may experience what can be 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.
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 autistic adult 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. 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. For this reason, this programme includes strategies to help create a safety plan in the event of a depression attack.
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.
Where to find more information
We have written a self-help book for depressed autistic adolescents and adults with the intention of saving lives. The above information is taken directly from one of the book chapters. Subsequent chapters outline a 10-Step Programme for recovery from depression. The programme is best undertaken with a Mentor who could be a health professional such as a counsellor or clinical psychologist, or a parent, partner or family friend.
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
If you are an autistic adult or supporting an autistic adult, we can highly recommend our one-day course: Exploring Depression: Training in a CBT Programme for Depressed and Autistic Adults and Adolescents.