Same but Different: How Autistic Adults Describe Depressive Symptoms and Their Alignment with DSM-5-TR Criteria

Abstract

Background:

Autistic adults experience disproportionately high rates of depression, yet Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text rev. (DSM-5-TR) diagnostic criterion descriptions may not fully reflect their lived experiences, impacting opportunities for identification and support. Autism-related differences, such as alexithymia, interoception, cognitive styles, and sensory processing, may influence how autistic adults perceive, experience, and describe depression. This study examines whether autistic adults’ descriptions of depressive symptoms align with, or diverge from, DSM-5-TR criteria descriptions, to inform more accurate diagnostic practices.

Methods:

We conducted an exploratory qualitative study with 109 autistic adults and 13 caregivers, who reported on the autistic adult they support. Participants described depressive symptoms relative to their typical autistic baseline via an online survey (n = 112) or semi-structured interview (n = 10). Using direct content analysis, we identified symptoms consistent with DSM-5-TR symptom descriptions, and through inductive analysis, we identified additional features outside DSM-5-TR criteria.

Results:

Participants described depressive symptoms that both aligned with and diverged from DSM-5-TR descriptors. Participants often expressed depressed mood as anger or irritability, or as emotional numbness. Anhedonia involved a loss of enjoyment in deep interests (autistic anhedonia), a source of emotional regulation. They described fatigue as a pervasive physical heaviness and reported depression attacks, characterized by sudden, overwhelming suicidal ideation. Participants described depression as influencing autistic characteristics, including variations in sensory sensitivities, stronger insistence on sameness and routine, changes in hyperfocus within deep interests, and self-injurious behavior. They also reported that emotional awareness and expression difficulties, alongside heightened sensitivity and dysregulation, intensify during depression.

Conclusion:

Autistic adults described depressive symptoms, which we coded against DSM-5-TR criteria, and while most symptom descriptions aligned with DSM-5-TR criteria, some differed in form or expression. For some, reports suggested a bidirectional relationship between autistic characteristics and depression. Further understanding of autistic adults’ depressive symptoms is critical to improving diagnostic accuracy and guiding the design of autism-informed assessment tools.

Community Brief

Why was this study done?

Depression is common in autistic adults, but assessment typically relies on diagnostic criteria and screening measures developed for non-autistic populations and not well validated for autistic adults. This can contribute to missed or delayed recognition when presentations differ from expected symptom descriptions.

What was the purpose of this study?

This study aimed to understand how autistic adults describe their depressive symptoms and whether their descriptions align with or differ from the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text rev. (DSM-5-TR).

What did the researchers do?

We conducted an online survey and interviews with 109 autistic adults and 13 caregivers who reported on an autistic adult they support. Participants described how depression affected their emotions, thoughts, behaviors, and daily life. We analyzed their responses to identify common themes.

What were the results of this study?

Autistic adults reported many depressive symptoms that aligned with DSM-5-TR criteria, but also described some differences:

Depressed mood often felt like anger, irritability or emotional numbness rather than sadness.

Anhedonia (loss of pleasure) often meant losing emotional connection and joy in deep and focused interests, which are usually an important source of emotional regulation. Some people described continuing their interests, but without the same enjoyment.

Fatigue felt like physical heaviness rather than general tiredness.

Although broadly consistent with DSM-5-TR concentration and indecisiveness criteria, participants often described executive-function impacts (task initiation, time management) and disrupted hyperfocus.

Depression attacks, which they described as sudden, intense suicidal thoughts with a sense of losing control.

Depression-related variations in autistic characteristics, such as fluctuations in sensory sensitivities, increased repetitive behaviors, and self-injurious behavior.

What do these findings add to what was already known?

This study provides new insights into how autistic adults describe depressive symptoms and how these descriptions align with DSM-5-TR criteria. Current diagnostic tools may not fully capture these symptom expressions, potentially leading to misdiagnosis or delays in receiving support.

What are potential weaknesses in this study?

This study relied on self-reported diagnoses and participants’ recall of symptoms, which may affect accuracy. Autistic adults with intellectual disability and people from diverse backgrounds were underrepresented, which limits generalizability.

How will these findings help autistic people now or in the future?

These findings provide a greater understanding of how depressive symptoms may be expressed and described by autistic adults, which may support recognition of depression-related change. By comparing lived descriptions with DSM-5-TR symptom criteria, the study indicates that many symptoms align with these criteria but may be expressed in ways that differ from how they are described in DSM-5-TR. This includes depressed mood expressed as irritability, anger, or emotional numbness, and autistic anhedonia, where deep and focused interests may be maintained while felt enjoyment or emotional connection is reduced. The results can inform autism-informed assessment prompts and guide the development of assessment tools that better capture autistic presentations, reducing missed or incorrect diagnoses and supporting timely access to care.