Introduction
Suicide is the leading cause of death for young people aged between 20 and 34 years in the UK (ONS
2015). Understanding and preventing suicide is highly complex and challenging, involving a combination of biological, environmental and psychological factors (Townsend
2019; O’Connor and Nock
2014; Walter and Pridmore
2012; World Health Organization
2012). There is little research into what drives the associations between autistic traits with suicidal thoughts and behaviours, to help inform new suicide prevention strategies (Cassidy and Rodgers
2017). To address this knowledge gap, research has started to explore the applicability of suicide theories developed for the general population to autistic people,
1 and also how such theories could incorporate new psychological constructs to increase our understanding of suicide in the general population (Cassidy, in press; Pelton and Cassidy
2017). Developing suicide theory to better understand associations between autism and autistic traits with suicidal thoughts and behaviours could benefit our understanding, prediction and ultimately prevention of suicide in both autistic and non-autistic people (Cassidy, in press).
Autistic traits are preferences and behaviours characteristic of autism that are normally distributed in the general population (Baron-Cohen et al.
2001). The number of self-reported autistic traits tend to be higher in family members of autistic people, suggesting a broader autism phenotype (Constantino and Todd
2005; Piven et al.
1997). People with high autistic traits can experience similar difficulties to people diagnosed as autistic, such as in social and communication skills, adapting to change, and sensory hyper-sensitivity (Hannant et al.
2016; Robertson and Simmons
2013; Baron-Cohen et al.
2001; Piven et al.
1997). People with high autistic traits are also significantly more likely to meet criteria for a clinical diagnosis of autism (Baghdadli et al.
2017; Wigham et al.
2019; Ruzich et al.
2015). Autistic traits are frequently explored in the context of understanding increased vulnerability in autistic and non-autistic people, particularly given that many adults remain undiagnosed (Lai and Baron-Cohen
2015) or are misdiagnosed with other conditions (Au-Yeung et al.
2018). For example, autistic traits have been associated with increased vulnerability to traumatic life events (Griffiths et al.
2019), social problem-solving ability and depression (Jackson and Dritschel
2016).
Research shows that self-reported autistic traits are associated with suicidal thoughts and behaviours (Cassidy et al.
2018c; Pelton and Cassidy
2017; Paquette-Smith et al.
2014; Takara and Kondo
2014; Cassidy et al.
2014), and 40% of adults who have attempted suicide meet the cut-off for clinical concern on a validated autism screening instrument (Richards et al.
2019). Suicide theories developed for the general population stress the importance of difficulties commonly experienced by autistic people and those with high autistic traits in the formation of suicidal intent. For example, the Interpersonal Psychological Theory of Suicide (IPTS) (Van Orden et al.
2010) argues that thwarted belongingness (
I am alone) and perceived burdensomeness (
I am a burden) are both required in order to experience suicidal desire. In autistic adults, self-reported loneliness (an indicator of thwarted belonging) and lack of social support (an indicator of perceived burdensomeness) each predicted suicidal thoughts through depression (Hedley et al
2018; Hedley et al.
2017). Self-reported autistic traits in a non-clinical young adult sample were associated with suicidal thoughts and behaviours through thwarted belonging and perceived burdensomeness (Pelton and Cassidy
2017). This suggests that the IPTS could help explain
why autistic people and those with high autistic traits are more likely to experience suicidal thoughts and suicidal behaviours.
However, research suggests that autistic people experience and define constructs such as quality of life (McConachie et al.
2018) or depression (Stewart et al.
2006) differently to the general population, which can affect the measurement properties of tools designed for other groups (Cassidy et al.
2018a,
b; Wigham and McConachie
2014). Consistent with these concerns, the association between depression with the constructs of the IPTS was weakest in those with the highest levels of autistic traits (Pelton and Cassidy
2017). One interpretation of this result, is that perhaps the constructs of the IPTS, as defined in the general population, might not apply as strongly to those with high autistic traits. Therefore it is important to explore whether there are other autism relevant constructs which could be added to the model.
One potentially relevant factor, and previously unexplored in suicide research, is camouflaging one’s autistic traits, in order to ‘fit in’ in social situations. Social camouflaging was originally described by autistic people, who report actively attempting to mask and compensate for their autistic traits in social situations, in an attempt to fit in better with others socially (Allely
2019; Livingston et al.
2019; Cage and Troxell-Whitman
2019; Lai et al.
2017; Hull et al.
2017). Hull et al. (
2019) developed the Camouflaging Autistic Traits Questionnaire (CAT-Q), to capture the extent to which both autistic and non-autistic adults engage in three aspects of social camouflaging: (1) “compensation” for autism-related difficulties in social situations, such as using scripts and copying others from carefully watching other people; (2) “masking” one’s autistic characteristics, by constantly monitoring one’s own behaviours (e.g., eye contact, facial expression, gesture) to present a non-autistic persona to others; and (3) “assimilation”, which captures behavioural strategies used to fit in better with others (e.g., forcing oneself to interact by putting on a performance and pretending). Hull et al. (
2019) found that social camouflaging was significantly associated with poor mental health and well-being, consistent with a range of previous research (Cage and Troxell-Whitman
2019; Livingston et al.
2019; Allely
2019; Leedham et al.
2019; Au-Yeung et al.
2018; Camm-Crosbie et al.
2018; Cassidy et al.
2018c; Bargiela et al.
2016; Rynkiewicz et al.
2016; Rutherford et al.
2016).
Camouflaging may be particularly relevant to the IPTS, given associations with suicidality (Cassidy et al.
2018c), and feeling a lack of acceptance in society (Cage et al.
2018) which indicates thwarted belongingness. Therefore, we hypothesised that people with high levels of autistic traits will be more likely to camouflage these traits in social situations, increasing risk of feelings of thwarted belonging and thus suicidal thoughts and behaviours. We also hypothesise that camouflaging will be more strongly associated with feelings of thwarted belonging compared to perceived burdensomeness. Given that the assimilation subscale of the CAT-Q represents key aspects more relevant to thwarted belonging (i.e., not feeling that social interactions are natural or genuine), we also hypothesise that the assimilation subscale of the CAT-Q would be more strongly associated with suicidality through thwarted belonging compared to the full camouflaging scale.
Discussion
The current study explored whether people with high autistic traits attempt to camouflage these traits in social situations, resulting in increased feelings of thwarted belonging, and in turn suicidal thoughts and behaviours, as predicted by the IPTS (Van Orden et al.
2010). Results from the current study support this hypothesis. The association between self-reported autistic traits with lifetime suicidal thoughts and behaviours was significantly mediated by camouflaging and thwarted belonging. Interestingly, the only non-significant path was between camouflaging and lifetime suicidal thoughts and behaviours. This suggests that camouflaging was indirectly associated with suicidal thoughts and behaviours through thwarted belonging. Camouflaging was not similarly associated with perceived burdensomeness, which significantly mediated the association between self-reported autistic traits and lifetime suicidal thoughts and behaviours.
These findings are consistent with the predictions of the IPTS (Van Orden et al.
2010) and findings from previous research. Specifically, previous studies have also shown that people with high autistic traits tend to camouflage these traits to ‘fit in’ in social situations (Hull et al.
2019), with negative consequences for mental health in autistic and non-autistic people (Hull et al.
2019), and suicidal thoughts and behaviours in autistic people (Cassidy et al.
2018c). The IPTS predicts that stable barriers to meaningful social participation lead to feelings of thwarted belonging, and subsequently suicidal intent (Van Orden et al.
2010). Previous research showed that a stable barrier to social participation (autistic traits) was significantly associated with thwarted belonging and subsequently suicidality (Pelton and Cassidy
2017). Results from the current study bring together these findings, showing that the path from autistic traits to suicidality is driven by camouflaging one’s autistic traits leading to feelings of thwarted belonging.
In line with our hypotheses, results also suggest that there is a particular component of camouflaging that is more strongly associated with thwarted belonging—assimilation. The assimilation subscale of the camouflaging scale (CAT-Q), explained significant additional variance in thwarted belonging, after controlling for age, gender, depression, anxiety and autistic traits. However, the camouflaging total score did not similarly account for significant additional variance in thwarted belonging after controlling for these factors. The association between autistic traits and lifetime suicidal thoughts and behaviours was also significantly mediated by assimilation and thwarted belonging, suggesting that those with high autistic traits, tend to try and assimilate into social situations, which results in feelings of thwarted belonging and subsequently lifetime suicidal thoughts and behaviours. The strength of the mediating effect for assimilation was larger than that for the camouflaging scale total score. The assimilation component of camouflaging therefore appears to tap into key areas which are more relevant to the construct of thwarted belonging, particularly feelings that social interactions are not natural or genuine, as you need to pretend or put on an act in social situations (Hull et al.
2019). Masking and compensation however tap into behavioural strategies and general reputation management (Hull et al.
2019), which are likely less relevant to thwarted belonging as conceptualised in the IPTS. Assimilation could therefore be considered to be a more stable barrier to achieving meaningful social connections, and thus feelings of thwarted belonging as outlined in the IPTS (Van Orden et al.
2010).
An interesting area for further study, is how specific social camouflaging is to autism, or whether this phenomenon is also present in other groups. Given that our sample did not comprise autistic people, perhaps associations between assimilation and thwarted belonging are driven by trying not to stand out from the crowd more generally, rather than camouflaging autistic traits per se. Self-reported autistic traits measured by the AQ accurately distinguish over 80% of autistic and non-autistic people (Baron-Cohen et al
2001) and predict who will later go on to obtain a diagnosis of autism (Woodbury-Smith et al
2005). However, self-reported autistic traits are also elevated in a number of other groups, such as those with psychosis (Upthegrove et al
2018) and borderline personality disorder (Dudas et al
2017). Hence, some have argued that the AQ does not specifically measure autistic traits, but more general social skills and social interest, regardless of the underlying condition (Lugnegård et al.
2015). Therefore, it is possible that camouflaging could also occur in other groups which have difficulty in assimilating into social situations, as well as those with high autistic traits or diagnosed autistic. This could be explored in future research by replicating associations between assimilation and thwarted belonging in autistic people and those from other groups (e.g., anxiety, depression, psychosis, BPD).
Results may have implications for current suicide theory, future research and clinical practice. Autism research has traditionally been plagued by the unhelpful assumption that autistic people are socially unmotivated, contrary to the testimony of autistic people (Jaswal and Acktar
2018). This has led to research exploring deficits in autistic people’s ability to accurately interpret the thoughts and feelings of non-autistic people, and clinical interventions to improve the social and communication skills of autistic people (Jaswal and Aktar
2018). However, a growing body of research is consistently showing the negative consequences of camouflaging autistic traits in social situations, demonstrating the well-intentioned but potentially damaging consequences of this traditional approach (Mitchell et al.
2019). Therefore, we must be cautious in encouraging autistic people and those with high autistic traits to modify their behaviour to fit in in social situations, and instead focus on making society more accommodating of the unique social and communication style of autistic people.
A new approach to understanding social cognition in autistic and non-autistic people is gaining empirical support. Research is showing that difficulties in social interaction between autistic and non-autistic people are two way, evidencing a ‘double empathy problem’ (Milton
2012). For example, non-autistic people have difficulty interpreting the behaviour and intentions of autistic people (Sheppard et al.
2016), which can also lead non-autistic people to rate autistic people less favourably (Alkhaldi et al.
2019). Hence, future interventions could focus on helping non-autistic people to more effectively interact with autistic people. Reducing emphasis and pressure for autistic people and those with high autistic traits to camouflage their ‘true self’ could even help prevent risk of developing mental health problems, suicidal thoughts and suicidal behaviours (Mitchell et al.
2019), and create a more useful and accurate understanding of autism that values the unique social and communication style of autistic people (Jaswal and Aktar
2018).
Our results also have implications for current suicide theory, which has not tended to include constructs relevant to autism or autistic traits, given that high rates of suicidality were not recognised in autistic people until relatively recently (Richa et al.
2014; Segers and Rawana
2014; Cassidy et al.
2014) and suicide in autism remains an under-researched area (Hedley and Uljarevic
2018; Zahid and Upthegrove
2017; Cassidy and Rodgers
2017). However, the results add to a growing body of evidence showing that autistic traits, and camouflaging autistic traits, are important risk markers for suicidal thoughts and behaviours in autistic and non-autistic people, through the constructs of the IPTS. Previous research showed that associations between depression with thwarted belonging and perceived burden were reduced at high levels of autistic traits (Pelton and Cassidy
2017), indicating that perhaps the constructs of the IPTS, as they are currently conceptualised in the general population, may not be as relevant to autism. Research is showing that constructs such as quality of life (McConachie et al.
2018) and depression (Ghaziuddin et al.
2002; Stewart et al.
2006) might be different in autistic people, with a need for new adapted measures to better capture and identify these constructs in autism (Cassidy et al.
2018b,
c; Gotham et al.
2015; Wigham and McConachie
2014). Current research is therefore exploring whether the constructs of the IPTS are similarly associated with suicidal thoughts and behaviours in autistic compared non-autistic people. Another important avenue to explore will be whether thwarted belongingness and perceived burdensomeness are conceptualised the same way in autistic and non-autistic people, or whether additional autism relevant constructs (such as social camouflaging), need to be considered in relevant aspects of the model.
The current study has a number of limitations. Self-report measures of autistic traits, camouflaging, depression, anxiety, thwarted belonging and perceived burden were utilised in the current study. However, all measures have good evidence in support of their measurement properties from previous research (Hull et al.
2019; Ruzich et al.
2015; Hoekstra et al.
2011; Spitzer et al.
2006; Kroenke et al.
2001; Osman et al.
2001; Van Orden et al.
2012). Although analyses adjusted for age, sex, current depression and anxiety, additional potentially important covariates, such as socio-economic status, were not controlled for. A majority of the sample consisted of female undergraduate students. This limits the generalizability of results to the wider general population, and possibly the autistic population which has historically consisted of more males being diagnosed autistic than females (Dworzynski et al.
2012). However, autism is likely under-diagnosed in females (Dworzynski et al.
2012), in part due to camouflaging one’s autistic traits (Leedham et al.
2019; Bargiela et al.
2016; Rynkiewicz et al.
2016; Rutherford et al.
2016). Autistic females without co-occurring intellectual disability are more at risk of dying by suicide than non-autistic females (Kirby et al.
2019; Hirvikoski et al.
2016). Hence, it is important to understand why females with high autistic traits might be more likely to experience suicidal thoughts and behaviours, and the role of camouflaging in this increased risk. This study was cross-sectional, and therefore results show associations, and direction of causation cannot be confirmed.
In conclusion, results replicate and expand previous findings, showing associations between autistic traits and social camouflaging with suicidal thoughts and behaviours in autistic and non-autistic people. For the first time, results suggest that people with high autistic traits in the general population, tend to camouflage these traits in social situations, which may increase feelings of thwarted belonging and in turn risk of suicidal thoughts and behaviours. These results are consistent with the IPTS, and expand and increase the applicability of this theory to understanding and predicting suicidal thoughts and behaviours in both autistic and non-autistic people.
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