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Key points
- People with autism are more likely to experience depression and anxiety than are neurotypical people.
- Fatalistic thinking and withdrawal from special interests can signal depression in autistic people.
- Psychotherapy strategies such as RO-DBT and ACT are among several treatment options.
Over the years, I have met dozens of individuals with autism who have shared with me experiences of their special interests losing their sparkle, or of a strong focus on work, while recreation suffered. Some of these experiences fall under the umbrella of what has been termed "autistic burnout"—the toll which masking autistic traits and performing in a world designed for neurotypical people can take on well-being (Raymaker et al, 2020).
Yet, for some, there seems to be something a bit different. I see patterns resembling that of major depression with a few tweaks.
Research shows that autistic adults are significantly more likely to experience a mental health diagnosis than those without-particularly major depression and anxiety disorders (Joshi et al, 2013). In addition, within the Joshi study, those in the autistic group showed more impairment from these conditions than neurotypical peers.
The emotional needs of autistic individuals often go unmet, and it is reasonable to ask whether depression and anxiety show up differently among the autistic and how psychotherapy ought to accommodate these differences.
Radically-Open Dialectical Behavioral Therapy (RO-DBT)
Radically-Open Dialectical Behavioral Therapy (RO-DBT) is an intervention that seeks to assist individuals living with what the creator terms "over-controlled" traits in areas related to psychological health. Within the treatment manual, the creator, Thomas Lynch, director of the Radically Open Institute, cites that overcontrol is a common pattern among autistic people (Lynch, 2018). With this in mind, the presentation (and treatment) of depression and anxiety can show up differently in autistic people.
5 Symptoms of Anxiety and Depression
What follows are five ways that depression and anxiety appear in this group of neurodivergent people.
1. Keeping Up with Work, but Less with Fun or Self-Care: Within RO-DBT, a "task" orientation and strong devotion to work is viewed as hallmarks of an overcontrolled personality style. In addition, the preference for routine and black-and-white thinking that sometimes accompany autism set autistic people up to have a greater likeliness to complete tasks they have committed to—including work tasks.
I have met several Autistic individuals experiencing depression who remain highly successful in the workplace, but show a decline in areas deemed as "non-essential"—things like recreation, keeping a space clean, or personal hygiene.
2. Loss of Interest in Special Interests: An intense, sometimes legendary focus on special interests is often associated with autism. These special interests can be specific, such as a particular animal, video game, or anime series. Any decrease in engagement with these pursuits should be considered a red flag for autistic mental health.
3. Fatalistic Thinking: Within RO-DBT, a fatalistic mind state is associated with a sense of surrender. Thoughts that things are awful, and will always be so, lead to a sense of hopelessness. I have noticed this mind state both in my neurotypical and neurodivergent clients.
For most, this fatalistic thinking follows an overwhelming experience and often changes once the person can step back, rest, and re-evaluate the situation. For autistic clients I have met experiencing depression, fatalistic thinking tends to appear more frequently and longer lasting. It is more fixed in nature, which makes sense, given the black-and-white thinking patterns associated with autism.
4. Perfectionism: Rule-governed thinking and behavior are characteristic of both an overcontrolled style and autism. When highly stressed, I have noticed a pattern of autistic individuals taking stronger attempts to perfect these rules, often leading to self-criticism. In the extreme, there is worrying overcontrolled-coping strategies, such as eating disorders. This could account for the high comorbidity between autism and eating disorders, particularly Anorexia Nervosa (Koch et al, 2015). Of interest, anorexia nervosa is also correlated with an overcontrolled style (Lynch, 2018).
5. Increased Social Withdrawal: Autism has generally been regarded to be associated with social withdrawal. Still, many autistic individuals share that they do feel socially engaged within circumstances that are welcoming to their neurodivergent needs. Increased distancing, or further extraction from one’s usual social spaces, may indicate increased anxiety and depression.
Closing Thoughts
If you are autistic, love someone who is, or are a professional caring for the emotional and social needs of neurodivergent people, know that co-occurring mental health challenges are common in this population. Autistic people sometimes experience these things differently when compared to their neurotypical peers making recognition more tricky. With this in mind, receiving care from clinicians with an understanding of neurodiversity is essential.
Psychotherapy strategies that account for these differences such as RO-DBT, or which draw on cognitive flexibility like Acceptance and Commitment Therapy (ACT) are among several available treatment options. Changes within someone's social and work environments toward a neurodiversity-affirming space may be relevant. With validation, empowerment, and support, Autistic individuals can thrive and work through associated mental health challenges.
References
Joshi, G., Wozniak, J., Petty, C., Martelon, M. K., Fried, R., Bolfek, A., & Biederman, J. (2013). Psychiatric comorbidity and functioning in a clinically referred population of adults with autism spectrum disorders: a comparative study. Journal of autism and developmental disorders, 43, 1314-1325.
Koch, S. V., Larsen, J. T., Mouridsen, S. E., Bentz, M., Petersen, L., Bulik, C., & Plessen, K. J. (2015). Autism spectrum disorder in individuals with anorexia nervosa and in their first-and second-degree relatives: Danish nationwide register-based cohort-study. The British Journal of Psychiatry, 206(5), 401-407.
Lynch, T. R. (2018). Radically open dialectical behavior therapy: Theory and practice for treating disorders of overcontrol. New Harbinger Publications.
Raymaker, D. M., Teo, A. R., Steckler, N. A., Lentz, B., Scharer, M., Delos Santos, A., .& Nicolaidis, C. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: Defining autistic burnout. Autism in adulthood, 2(2), 132-143.
