A lack of empathy is often erroneously described as a defining characteristic of autism spectrum disorder, leading to speculation about children on the spectrum developing antisocial personality disorders in adulthood.
“Autistic people and psychopaths are almost the opposite of each other…” This remark, made by Professor Baron-Cohen during an interview for the Autism Parenting Summit (September 2022) is enlightening and may be especially relevant to parents of autistic kids pondering possible links between antisocial personality disorder and autism.
Prof. Baron-Cohen shared this opinion while answering questions about his book The Pattern Seekers: How Autism Drives Human Invention. He spoke about empathy and how those with autism spectrum disorders may struggle with cognitive empathy but not affective empathy.
Affective empathy, illustrated through appropriate responses to the thoughts and feelings of others, is intact in those with autism, according to Prof. Baron-Cohen. Some autistic people may struggle to read facial expressions and gestures, but once they know someone is in distress they will most likely respond and act with the appropriate care.
Cognitive empathy, explained in the interview as putting yourself in someone else’s shoes, or taking their perspective, is often an area of difficulty in autism spectrum disorder. In contrast, a psychopath may excel in this area, because reading the minds of others is often necessary to manipulate. This is why autism may be thought of as the opposite of psychopathy—the difficulty in understanding the minds of others would make it tough for someone on the spectrum to manipulate and deceive.
The struggle with social communication and interaction is probably the reason autism is sometimes wrongly linked to antisocial personality disorder. That is not to say that antisocial personality disorder and autism can’t co-occur in an individual; rather, it’s important to realize the two conditions are distinct and not related to one another.
Autistic and psychopathic traits may however overlap, which is why it is important for parents to know the differences between autism and personality disorders. While psychopathy bears traits of various personality disorders, it is important to note that not every person diagnosed with antisocial personality disorder is a psychopath (Abdalla-Filho & Völlm, 2020).
Personality or autistic disorder?
Autism is a developmental disorder characterized by persistent impairments in social communication and restricted/repetitive behaviors or interests. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) includes specific criteria for autism, including the requirement that symptoms should be present from early on, even if full manifestation only occurs later.
Antisocial personality disorder (ASPD) on the other hand, is a mental health condition that is not diagnosable in childhood. Before a child reaches adulthood, a diagnosis of conduct disorder is necessary—before the age of 15—which could then convert to ASPD if antisocial behaviors persist (Black, 2015).
The DSM-5 criteria for ASPD includes:
- A pervading pattern disregarding and violating the rights of others from the age of 15 years (three or more indications of such behavior should be apparent, such as failure to conform to social norms, disregard for the safety of self and/or others, impulsivity, and aggressiveness/irritability)
- A diagnosis of ASPD is only possible after the patient reaches the age of 18
- Before reaching adulthood the presence of a conduct disorder should be evident (typically appearing before the age of 15)
- The symptoms or appearance of antisocial behavior should not occur only as a result of schizophrenia or bipolar disorder
Looking at the criteria and characteristics of ASPD, a picture of wilful exploitation, violation, and manipulation of the rights of others (with no remorse) emerges. The manifestation is distressing as we are conditioned to follow social norms; generally people want their social image to reflect that which is desirable and acceptable by others.
Moreover, as humans we seem to have an innate desire to belong, to connect; we crave approval and act accordingly—to be accepted in our communities. Antisocial behavior seems at odds with such desires, and raises questions about the reasons behind such deviations from social norms.
Although the genetic influence and heredity of antisocial behavior has been established (Baker et al., 2006) research also shows greater adverse childhood experiences may be associated with an ASPD diagnosis. The link between sexual abuse and a diagnosis of ASPD is not surprising, one can imagine the development of hostility to authority when caretakers are responsible for such distress (DeLisi et al., 2019).
Conversely, while trying not to generalize, a definite pattern of desiring to fit in socially emerged in the many conversations I’ve had with individuals on the spectrum. In fact, most autistic people I’ve interviewed spoke of a deep need for connection and belonging. Because of communication and sensory struggles, social interactions may be challenging, but despite such struggles, a desire to connect with others means many autistic individuals often mask their symptoms simply to conform to social norms.
In an attempt to foster friendships autistic children may force themselves to maintain eye contact, despite experiencing severe physical discomfort. This is but one example where socially acceptable behavior is adopted not to deceive, but due to a genuine desire to conform to neurotypical norms to gain social acceptance.
An area which would benefit from further research is the possible link between abuse of autistic individuals and whether this contributes to the risk of personality disorders. We do know children with autism are at a heightened risk for maltreatment and this may lead to increased aggressiveness (McDonnell et al., 2019). The long-term effects of such maltreatment and the implications for personality disorder development in ASD deserves further investigation.
Overlapping symptoms and comorbidity
Aggression may be used as an example to illustrate how autism and ASPD symptoms overlap. It could also show how an overlapping characteristic or behavior is motivated differently.
Aggressive and violent behavior in ASD and ASPD
Aggression in early adolescence may predict ASPD (Whipp et al., 2019). Research also shows prevalence of aggressive behavior in children and adolescents on the spectrum is high, with some studies reporting 68% of participants demonstrating aggression to a caregiver (Kanne & Mazurek, 2011). This kind of antisocial behavior is an area where autism spectrum disorder (ASD) may overlap with ASPD.
It is important to look at the reason for the behavior, especially when following therapists advice that all behavior is communication. If prevalence of aggression is especially high in autistic kids with more social communication problems (Kanne & Mazurek, 2011) one could speculate about aggression as a form of expressing pain, discomfort or sensory stimuli experienced as threatening.
Speculating about the reasons for aggression in ASD does not alleviate the hardship the behavior bestows upon families and individuals themselves—aggression is often expressed in a self-injurious manner—in fact, aggression is often listed as one of the most distressing challenges ASD families experience. Encouragingly, families report addressing aggression with some success with intervention targeting underlying problems like sleep disturbances and gastrointestinal issues.
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Aggression in ASPD may be motivated differently, with some experts providing reasons like impulsivity and substance abuse as motivating aggressive behavior. If a child is genetically predisposed to personality or conduct disorders and grows up in a chaotic, abusive environment it may not be surprising that as an adult they demonstrate violent and aggressive behavior. Such behavior may be exacerbated while under the influence of alcohol or other substances—interestingly in some countries almost half of all violent crimes involve alcohol intoxication (van Amsterdam et al., 2020).
Comorbidity of ASD and ASPD
Not only do symptoms of the two distinct conditions overlap, a dual diagnosis of autism and ASPD may be common in forensic settings (Carthy & Murphy, 2021). Such a dual diagnosis is difficult to assess because:
- a lack of clinical guidance on the assessment of those who present with both personality disorders and ASD
- establishing the sensitivity of diagnostic tools like the Autism Diagnostic Observation Schedule (ADOS) and the International Personality Disorder Examination (IPDE) in those with comorbid ASD and ASPD still needs to be undertaken (Carthy & Murphy, 2021)
A definite difference
Equating the social interaction deficits in autism with an antisocial personality disorder is inaccurate and it may be harmful, adding to the stigma experienced by those with neurodevelopmental conditions. Perhaps the solution is to adopt a solution suggested by research: by accurately diagnosing the type of empathetic deficit, psychopathy or ASPD could be differentiated from autistic disorders (Hansman-Wijnands & Hummelen, 2006).
Afterall, as the researchers (Hansman-Wijnands & Hummelen, 2006) explained, the “innocent” inability to take the perspective of another, often found in autistic individuals, differs substantially from the psychopathic trait of insensitivity, the inability to feel with another.
Abdalla-Filho, E., & Völlm, B. (2020). Does every psychopath have an antisocial personality disorder?. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 42(3), 241–242. https://doi.org/10.1590/1516-4446-2019-0762.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.
Baker, L. A., Bezdjian, S., & Raine, A. (2006). BEHAVIORAL GENETICS: THE SCIENCE OF ANTISOCIAL BEHAVIOR. Law and contemporary problems, 69(1-2), 7–46.
Black D. W. (2015). The Natural History of Antisocial Personality Disorder. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 60(7), 309–314. https://doi.org/10.1177/070674371506000703.
Carthy, E., & Murphy, D. (2021). Comorbid Autism Spectrum Disorder and Antisocial Personality Disorder in Forensic Settings. The journal of the American Academy of Psychiatry and the Law, 49(4), 462–469. https://doi.org/10.29158/JAAPL.210101-21.
DeLisi, M., Drury, A. J., & Elbert, M. J. (2019). The etiology of antisocial personality disorder: The differential roles of adverse childhood experiences and childhood psychopathology. Comprehensive psychiatry, 92, 1–6. https://doi.org/10.1016/j.comppsych.2019.04.001.
Hansman-Wijnands, M. A., & Hummelen, J. W. (2006). Differentiële diagnostiek van psychopathie en autismespectrumstoornissen bij volwassenen [Differential diagnosis of psychopathy and autism spectrum disorders in adults. Empathic deficit as a core symptom]. Tijdschrift voor psychiatrie, 48(8), 627–636.
Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: prevalence and risk factors. Journal of autism and developmental disorders, 41(7), 926–937. https://doi.org/10.1007/s10803-010-1118-4.
McDonnell, C. G., Boan, A. D., Bradley, C. C., Seay, K. D., Charles, J. M., & Carpenter, L. A. (2019). Child maltreatment in autism spectrum disorder and intellectual disability: results from a population-based sample. Journal of child psychology and psychiatry, and allied disciplines, 60(5), 576–584. https://doi.org/10.1111/jcpp.12993.
van Amsterdam, J. G. C., Ramaekers, J. G., Verkes, R.-J., Kuypers, K. P. C., Goudriaan, A. E., & van den Brink, W. (2020). Alcohol- and drug-related public violence in Europe. European Journal of Criminology, 17(6), 806–825. https://doi.org/10.1177/1477370819828324
Whipp, A. M., Korhonen, T., Raevuori, A., Heikkilä, K., Pulkkinen, L., Rose, R. J., Kaprio, J., & Vuoksimaa, E. (2019). Early adolescent aggression predicts antisocial personality disorder in young adults: a population-based study. European child & adolescent psychiatry, 28(3), 341–350. https://doi.org/10.1007/s00787-018-1198-9.