Depression’s new face:
Among the general population, most people who become suicidal are depressed. That’s true among people with autism too4. And because people with autism have high rates of depression, it’s not surprising that they are frequently suicidal.
Still, traditional screens for depression may miss the emotional experience of people with autism. In Baron-Cohen’s study, suicidality was far more common than depression as it is usually diagnosed. Although 66 percent of the participants reported having suicidal thoughts, less than half as many reported feelings of depression.
That’s not because they don’t have those feelings, however. “They may not be able to access or have the vocabulary to describe their emotional state,” says Baron-Cohen. This condition, called alexithymia, is common in people with autism.
Yet if clinicians listen closely, they may hear clues — albeit not the usual ones. People with autism may be unlikely to describe themselves as depressed, but “they will explain their emotional pain in idiosyncratic ways,” says Lainhart.
One clinician recalls an individual with autism who was so deeply sad and hopeless that he described himself as “now darkness.” Another said she constantly thought that the time had come for her leave this planet, in search of another galaxy where she would fit in better and find a friend.
The way people with autism think may itself make them more vulnerable to suicidality. For example, they often don’t think to reach out to others when they are upset: Asking for help is, after all, a social skill.
They also tend to have rigid, inflexible thinking, so once suicide enters their mind, it may stay there. Gotham and her colleagues have found that patterns of repetitive thought contribute to depression in people with autism. “I think that there could be something similar going on with suicidality,” she says.
People with autism often struggle to imagine the thoughts and feelings of others, including their own future selves. As a result, they may have trouble believing they will ever feel better. They can also easily become overwhelmed by the small but complex problems of everyday life and respond with extreme thoughts or statements.
In the study of children with anxiety and high-functioning autism, researchers found that the children sometimes made suicidal threats for attention or to escape from an unpleasant situation. “Often it was a reaction to some limit being set or placed on the child,” says study leader Eric Storch, professor of pediatrics, psychology and psychiatry at the University of South Florida in Tampa. For example, a parent might announce that it’s time to stop playing video games, and a child might throw a tantrum, lose control and say that he is going to kill himself.
Regardless of the intent, parents and clinicians should take threats of suicide from people with autism seriously. “It’s their best attempt to raise a red flag saying that they need help,” says Lainhart.
Storch and his colleagues are developing a program for suicidal teens with autism based on a similar one for those with Tourette syndrome. The next step for Baron-Cohen’s group is simple but unusual: The researchers plan to ask people from the Asperger syndrome clinic what would help them.
“We just have to be a little bit cautious not to jump to solutions that are off-the-shelf,” Baron-Cohen says. For example, telephone crisis lines are often recommended for suicidally depressed people — but because of their social deficits, people with autism may be unlikely to call.
Since her daughter’s diagnosis, Kathy Marshack has oriented her psychotherapy practice to help families who have a child or parent on the autism spectrum.
“At the time, it was frightening to me that Bianca was suicidal,” Marshack says. But looking back, she says, her daughter probably lacked the empathy to recognize the effect her pleas about wanting to die would have on her mother. “She was in such pain,” Marshack says. “She was trying to say, ‘I feel helpless.’”