Same But Different: How Autistic Adults Experience and Describe Depression and Their Alignment with DSM-5 Criteria

ABSTRACTBackgroundAutistic adults experience high rates of depression, yet the DSM-5-TR criteria may not fully represent their experiences. Differences in alexithymia, interoception, and sensory processing may influence how autistic adults experience and describe depression. This study examines whether autistic adults' depressive experiences align with or differ from DSM-5-TR criteria to inform diagnostic understanding.MethodsWe used an exploratory qualitative design. A total of 109 autistic adults and 13 caregivers who reported on an autistic adult they support participated. Participants described depressive experiences relative to their usual autistic baseline through an online survey (n = 112) or a semi-structured interview (n = 10). Researchers applied direct content analysis to identify DSM-5-TR-aligned symptoms and used inductive analysis to identify additional experiences.Results Participants met DSM-5-TR depression criteria, but autism-related differences may influence symptom expression. Depressed mood presented as emotional emptiness or numbness. Anhedonia involves a loss of enjoyment in deep or focused interests, a key source of emotional regulation. Fatigue felt like physical heaviness and appetite changes included restrictive eating patterns. Task initiation, time management, and hyperfocus difficulties occurred but did not appear in DSM-5-TR. Participants described "Depression attacks"—sudden, overwhelming suicidal ideation with a loss of control. Additionally, depression may influence autistic characteristics, including fluctuations in sensory sensitivities and repetitive behaviours during depressive episodes. Autistic adults reported difficulties with emotional regulation, meltdowns and shutdowns, suggesting depressive episodes exacerbate challenges in emotional and sensory modulation.ConclusionAutistic adults often meet DSM-5-TR depression criteria, but their symptom expression may differ, which can complicate diagnosis. Autism may influence how autistic adults experience depression, while depression may influence autistic characteristics. Standard diagnostic frameworks often fail to account for these bidirectional effects, increasing the risk of inaccurate diagnosis. Recognising these interactions can improve diagnostic accuracy and guide the development of autism-relevant assessment tools.