ASD I PD
ASD I PD
ASD I PD
WJ P Psychiatry
Submit a Manuscript: https://www.f6publishing.com World J Psychiatr 2021 December 19; 11(12): 1366-1386
SYSTEMATIC REVIEWS
Camilla Rinaldi, Margherita Attanasio, Marco Valenti, Monica Mazza, Roberto Keller
ORCID number: Camilla Rinaldi Camilla Rinaldi, Roberto Keller, Adult Autism Center, Department of Mental Health, ASL Città
0000000268739827; Margherita di Torino, Turin 10138, Italy
Attanasio 0000-0002-4571-3173;
Marco Valenti 0000-0001-9043-3456; Margherita Attanasio, Marco Valenti, Monica Mazza, Department of Applied Clinical Sciences and
Monica Mazza 0000-0003-4050- Biotechnology, University of L’Aquila, L’Aquila 67100, Italy
2243; Roberto Keller 0000-0002-
6873-9827. Margherita Attanasio, Marco Valenti, Monica Mazza, Regional Centre for Autism, Abruzzo
Region Health System, L’Aquila 67100, Italy
Author contributions: Rinaldi C
wrote the paper and collected and Corresponding author: Roberto Keller, MD, Chief Doctor, Adult Autism Center, Department of
interpreted the data; Attanasio M Mental Health, ASL Città di Torino, Local Health Unit, Cso Francia 73, Turin 10138, Italy.
incorporated changes during the [email protected]
course of review and edited the
paper; Valenti M and Mazza M
reviewed and critically revised the Abstract
paper; Keller R conceived, BACKGROUND
supervised and reviewed the study Differential diagnosis, comorbidities and overlaps with other psychiatric
and finalized the manuscript. All disorders are common among adults with autism spectrum disorder (ASD), but
authors read and approved the clinical assessments often omit screening for personality disorders (PD), which are
final manuscript. especially common in individuals with high-functioning ASD where there is less
need for support.
Conflict-of-interest statement: The
authors declare no conflict of AIM
interests for this article. To summarize the research findings on PD in adults with ASD and without
intellectual disability, focusing on comorbidity and differential diagnosis.
PRISMA 2009 Checklist statement:
The authors have read the PRISMA METHODS
2009 Checklist, and the manuscript PubMed searches were performed using the key words “Asperger’s Syndrome”,
was prepared and revised “Autism”, “Personality”, “Personality disorder” and “comorbidity” in order to
according to the PRISMA 2009 identify relevant articles published in English. Grey literature was identified
Checklist. through searching Google Scholar. The literature reviews and reference sections of
selected papers were also examined for additional potential studies. The search
Country/Territory of origin: Italy was restricted to studies published up to April 2020. This review is based on the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.
Specialty type: Psychiatry
RESULTS
Provenance and peer review:
The search found 22 studies carried out on ASD adults without intellectual
Invited article; Externally peer
disability that met the inclusion criteria: 16 evaluated personality profiles or PD in
reviewed.
ASD (comorbidity), five compared ASD and PD (differential diagnosis) and one
Peer-review model: Single blind
performed both tasks. There were significant differences in the methodological
Peer-review report’s scientific approaches, including the ASD diagnostic instruments and personality measures.
quality classification Cluster A and cluster C PD are the most frequent co-occurring PD, but
overlapping features should be considered. Data on differential diagnosis were
Grade A (Excellent): 0
only found with cluster A and cluster B PD.
Grade B (Very good): 0
Grade C (Good): C, C CONCLUSION
Grade D (Fair): 0 ASD in high-functioning adults is associated with a distinct personality profile
Grade E (Poor): 0 even if variability exists. Further studies are needed to explore the complex
relationship between ASD and PD.
Open-Access: This article is an
open-access article that was
selected by an in-house editor and Key Words: Autism spectrum disorder; Asperger’s Syndrome; Personality disorder;
fully peer-reviewed by external Adulthood; Comorbidity; Differential diagnosis
reviewers. It is distributed in
accordance with the Creative ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to Core Tip: Differential diagnosis, comorbidities and overlaps with other psychiatric
distribute, remix, adapt, build disorders are common among adults with autism spectrum disorder (ASD). Findings of
upon this work non-commercially, most studies support that ASD in high-functioning adults is associated with a distinct
and license their derivative works personality profile even if variability exists. Cluster A and cluster C personality
on different terms, provided the disorders (PD) are the most frequent co-occurring PD in ASD, but overlapping features
original work is properly cited and should be considered.
the use is non-commercial. See: htt
p://creativecommons.org/License
s/by-nc/4.0/ Citation: Rinaldi C, Attanasio M, Valenti M, Mazza M, Keller R. Autism spectrum disorder and
personality disorders: Comorbidity and differential diagnosis. World J Psychiatr 2021; 11(12):
Received: February 17, 2021 1366-1386
Peer-review started: February 17, URL: https://www.wjgnet.com/2220-3206/full/v11/i12/1366.htm
2021 DOI: https://dx.doi.org/10.5498/wjp.v11.i12.1366
First decision: May 13, 2021
Revised: May 26, 2021
Accepted: November 24, 2021
Article in press: November 24, 2021
Published online: December 19,
INTRODUCTION
2021 Autism spectrum disorder (ASD) is a neurodevelopmental disorder with an early
onset and a genetic component. ASD is characterized by deficits in socio-emotional
P-Reviewer: Li Q, Wei EH reciprocity, by impaired verbal and non-verbal communication skills, and by an
S-Editor: Wang LL inability to develop and maintain adequate social relationships with peers, and is
L-Editor: A associated with the presence of repetitive verbal and motor behaviours, restricted
P-Editor: Wang LL patterns of interest, the need for an unchanging (or at least predictable and stable)
environment and hypo- or hypersensitivity to sensory inputs. The onset of clinical
symptoms occurs during the early years of life[1].
The severity of ASD symptoms, intellectual functioning, age at diagnosis and
psychiatric comorbidity have been shown to account for heterogeneity in clinical
presentation, functioning and outcome[2-4].
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition[1], classifies
three levels of ASD functioning. Level 1, which requires support, is the best
functioning and includes the previous definitions of high-functioning ASD (a term
commonly used in clinical practice) and Asperger’s syndrome (AS), the closest to
neurotypical functioning[1]. ASD level 1 may not have been diagnosed in adulthood
and may also have been misdiagnosed as a psychiatric disorder[5,6]. Late-diagnosed
individuals show higher levels of co-occurring psychiatric conditions, potentially
related to the long-term stress in adaptation to daily life in society[7].
The most common coexisting psychiatric disorders in subjects with ASD include
attention deficit hyperactivity disorder (ADHD)[8], obsessive–compulsive disorder[9,
10], psychosis[11-13] and mood and anxiety disorders[14-16]. It is possible that adults
with ASD level 1 are vulnerable to such disorders[17], in part because of their greater
insight into their deficits[18] and greater sensitivity to discrimination[19].
The high frequency of co-occurring disorders and the development of learnt or
camouflaging strategies[20] make it difficult to diagnose ASD in adults, especially in
women[21,22]. Misdiagnosis, differential diagnoses, comorbidities and overlapping
behaviour with other psychiatric diagnoses, as well as personality disorders (PD),
should be considered[23]. While these patients are usually screened for the presence of
Axis I disorders, Axis II comorbidities are less often evaluated in this sample of
patients[15]. However, in a recent survey Keller et al[24] found a PD comorbidity in
ASD in 24% of the sample.
PD are enduring and pervasive patterns of inner experience and behaviour that
deviate markedly from the expectations of the individual’s culture, resulting in
distress and impairment[1]. Both PD and ASD are life-long and egosyntonic disorders.
There is a growing interest in exploring the complex relationship between ASD and
PD, because a better understanding of this topic may enhance the diagnostic process
and also inform targeted interventions.
The purpose of this review is to summarize the research findings on PD in adults
with ASD, focusing on comorbidity and differential diagnosis.
RESULTS
Figure 1 shows a PRISMA flow diagram of the systematic research process. The
database search yielded a total of 6936 articles. Three additional records were
identified through other techniques (ancestry method, grey literature searches and
expert consultation). Following the removal of duplicates, 5808 articles remained for
screening.
Upon screening of the records, a further 5735 articles were excluded for a variety of
reasons, including a focus on different research topics or a failure to satisfy the
inclusion criteria. Thus, the full texts of 74 articles were assessed, 22 of which qualified
for inclusion.
In order to perform a better analysis, the studies were grouped into two main
classes: Those examining personality or PD in ASD adults using categorical and
dimensional models (comorbidity); and those comparing ASD with PD on personality
traits or psychological functioning (differential diagnosis). In addition, one study[26]
performed both tasks.
The characteristics of the studies included in this review are summarized in Table 1.
Seven reviews on psychiatric comorbidity/differential diagnosis of adults with ASD
that also referred to PD were found[5,27-32], but only two papers were specifically
focused on PD[33,34].
Anckarsäter et al Neuropsychiatric Clinic in Sweden To describe PD in relations to ADHD and ASD symptoms One sample t - test Non-specific symptoms may be
[47], 2006 overselected
Ketelaars et al Center of Expertise for Autism in Netherlands To explore difference between patients with mild ASD and patients without ASD Χ2 test Small sample size
[43], 2008 in term of AQ scores and psychiatric comorbidity
Rydén and Psychiatric setting (tertiary unit) in Sweden To characterize psychiatric patients with ASD in regard to demographical factors, Fisher exact test; t- Not ADOS/ADI-R for assessing ASD; A
Bejerot[40], 2008 psychiatric comorbidity and personality traits and compare the ASD group with a test; Kruskal-Wallis naturalistic study
psychiatric control group; to compare differences of personality traits between test
females and males in the ASD group.
Hofvander et al Neuropsychiatric Hospital in France NeuropsychiatricClinic To describe the clinical presentation and psychosocial outcome of a group of Χ2 test Lack of comparison group; Two studies
[14], 2009 in Sweden normal intelligence adults with ASD sites; Prevalence of comorbid psychiatric
conditions may be overestimated
Sizoo et al[49], Two diagnostic centers specialized for adult patients with To test whether adults with ASD or ADHD have distinct personality profiles, to One sample t-test The clinically based diagnostic procedures;
2009 developmental disorders in Netherlands assess how personality profiles in these groups differed by SUD status The absence of a psychiatric control group;
All participants were diagnosed in
adulthood
Geurts and Tertiary psychiatric unit from diagnosing ASD in Netherlands To draw the pathway to a diagnosis for adults referred to ASD assessment Mann-Whitney U Retrospective chart study; Not standardized
Jansen[44], 2011 tests; Kruskal-Wallis clinical interviews for assessing axis I and
tests; Χ2 test axis II diagnosis
Kanai et al[59], University Hospital in Japan To examine the clinical characteristics of adults with AS Spearman’s rank Small sample size
2011 correlation coefficient
Kanai et al[67], University Hospital in Japan To examine the clinical characteristics of adults with AS Mann-Whitney U test Small sample size
2011
Lugnegård et al Neuropsychiatric clinics in Sweden To explore the presence of PD in young adults with AS Χ2 test Small sample size
[38], 2012
Schriber et al Local recruitment by physicians, psychologists, speech and To compare self-reports of Big Five personality traits in adults with ASD to those Independent sample t Small sample size
[55], 2014 language pathologists, occupational therapists, advocacy of typically developing adults. -test
groups, regional centers, ASD support groups in United
States
Hesselmark et al Tertiary psychiatric unit for diagnosing ASD; a community To test validity and reliability of self-report data using the NEO-PI-R in adults with Independent sample t Small sample size
[62], 2015 based facility for ASD; a website for ASD ASD -test
Strunz et al[26], Department of Psychiatry at a University Hospital in To identify personality traits in adults with ASD and to differentiate them from MANOVA Selection bias (BPD and NPD were
2015 Germany patients with NPD, BPD and NCC inpatients, while ASD were outpatients)
Helles et al[52], Neuropsychiatric Centre in Sweden To examine temperament and character in males who were diagnosed with AS in t-test; Kruskal-Wallis Only men with AS
2016 childhood and followed prospectively over almost two decades H testDunn’s post hoc
test
Schwartzman et On line recruitment United States To assess and compare personality traits of adults with and without elevated ASD Independent sample t Online administration of self-report
al[56], 2016 traits using; the Five Factor Model of personality -test questionnaires; Sample was not
representative of adult population with
ASD
Vuijk et al[51], Expertise Centre for Autism in Netherland To investigated temperament and character dimensions of men with ASD by t-test Only men with ASD
2018 individual case matching to a comparison group.
Ozonoff et al University Child and Adolescent specialized clinic in United To explore personality and psychopathology in adult with ASD Independent sample Small sample size
[65], 2005 States t-test
López-Pérez et al Four different mental health institutions in Spain To examine use of different interpersonal ER strategies in BPD and AS compared ANOVA Self-reports of interpersonal ER; ToM was
[95], 2017 to normative control participants not assessed
Dudas et al[92], CARD, online responders to a website To compare ASC, BPD, and comorbid patients in terms of autistic traits, empathy, ANOVA Diagnosis was based on self-report of
2017 and systemizing patients
Murphy[100], High security psychiatric care in UK To compare the ToM performance of three forensic patient groups (AS, Kruskal-Wallis H test No control for the potential influence of
2006 Schizophrenia and PD patients) medication on cognitive functioning
Stanfield et al Clinical and support services in Scotland; Nonpsychotic To compare Social Cognition in ASD and SPD using functional magnetic resonance Kruskal- Wallis tests Small sample size
[87], 2017 people who had previously participated in the EHRS of imaging (fMRI).
schizophrenia
Booules-Katri et Patients and relatives of schizophrenia patients attending To compare the ToM performance of a group of HFA and SSPD with a matched t-test SSPD sample consisted of non-clinical
al[84], 2019 psychiatric service at a hospital in Spain; Public HC group individuals
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ADHD: Attention deficit hyperactivity disorder; ADI-R: Autism diagnostic interview - revised; ADOS: Autism diagnostic observation schedule-generic; AQ: Autism quotient; AS: Asperger Syndrome; ASC: Autism spectrum condition;
ASD: Autism spectrum disorder; BPD: Borderline personality disorder; Er: emotion regulation; HC: Health control; HFA: High-functioning autism; NCC: Non-clinical controls; NEO-PI-R: NEO personality inventory revised; NPD:
Narcissistic personality disorder; PD: Personality disorder; SPD: Schizotypal personality disorder; SSPD: Schizotypal-schizoid personality disorder; SUD: Substance use disorder; ToM: Theory of mind.
the criteria for at least one PD: primarily obsessive–compulsive (32%), avoidant (25%)
and schizoid PD (21%). Concerning cluster B PD, rates of comorbidity were low, but
antisocial disorder was common in the pervasive developmental disorder subgroup. A
high number of patients (35%) had more than two PD. The prevalence of PD did not
differ between genders, with the exception of schizoid PD, which was significantly
more common among women.
Lugnegård et al[38] reported that 48% of a sample of 54 young adults with AS
fulfilled the criteria for a cluster A or cluster C PD diagnosis. This evidence was in line
with Gillberg and Billstedt’s review[27] reporting no cluster B PD comorbidity in this
sample of patients. It is surprising that paranoid and dependent PD diagnoses were
not found. There was a significant difference in PD prevalence between genders: 65%
in males versus 32% in females. Patients with AS and a concomitant PD showed more
marked autistic features according to the autism spectrum quotient (AQ)[39].
Similarly, no cluster B PD comorbidity was found by Strunz et al[26]. In research
examining personality pathology in ASD compared to specific PD, 45% of ASD
patients met the criteria for an Axis II PD diagnosis. In particular, 36% of ASD patients
Table 2 Summary of included studies exploring comorbid personality disorders diagnosis (according to DSM-IV) in autism spectrum
disorder patients
Rydén and Bejerot[40], n = 84 (5 autistic disorder, 51 AS, 28 SCID-I, WAIS III, ASSQ, SCID-II screen; SPP > 40%
2008 PDD-NOS); 37% comorbid ADHD ASDI, ASRS, MADRS,Y-
BOCS, GAF, CGI-S,
WRAADDS
Hofvander et al[14], 2009 n = 117 (5 autistic disorder, 62 AS, WAIS-R or WAIS-IIISCID-I, SCID-II 62%
50 PDD-NOS) ASDI
Strunz et al[26], 2015 n = 59 (49 AS, 10 HFA) ADOS, ADI-R, MINI, SCID- SCID-II 45%
I, DAPP-BQ,NEO-PI-R
Geurts and Jansen[44], n = 105 (27 autistic disorder, 28 AS, Former DSM-IV Axis I Former DSM-IV Axis II 15%
2011 50 PDD- NOS); 34% of sample with diagnosis reported diagnosis reported
intellectual disability
Anckarsäter et al[47], 2006 n = 174 subjects with childhood SCID-I, ASDI, Y-BOCS; SCID- II 75%
onset neuropsychiatric disorder (47 ASHFAQ, TCI
ASD, 27 ASD+ADHD, 81 ADHD,
19 other diagnosis)
ADHD: Attention deficit hyperactivity disorder; ADI-R: Autism Diagnostic interview-revised; ADOS: Autism diagnostic observation schedule-generic; AS:
Asperger syndrome; ASD: Autism spectrum disorder; ASDI: Asperger syndrome diagnostic interview; ASHFAQ: Asperger syndrome and high-
functioning autism screening questionnaire; ASRS: Adult ADHD self-report scale; ASSQ: Autism spectrum disorder in adults screening questionnaire;
ASDI: Asperger syndrome diagnostic interview; AQ: Autism spectrum quotient; CGI-S: Clinical global impression severity of illness; DAPP-BQ:
Dimensional assessment of personality pathology; DISCOS-11: Diagnostic interview for social an communication disorder; GAF: Global assessment of
functioning; HFA: High-functioning autism; IPDE: International personality disorder examination; MADRS: Montgomery asberg depression rating scale;
MINI: Mini international neuropsychiatric interview; NEO-PI-R: Neo personality inventory revised; PDD-NOS: Pervasive developmental disorder not
otherwise specified; SCAN-2.1: Schedules for clinical assessment in neuropsychiatry; SCID-I: Structured clinical interview for DSM-IV axis I disorders;
SCID-II: Structured clinical interview for DSM-IV personality disorders; SPP: Swedish universities scales of personality; TCI: Temperament and character
inventory; Y-BOCS: Yale -brown obsessive compulsive scale; WAIS-R: Wechsler adult intelligence scale-revised; WAIS-III: Wechsler adult intelligence
scale-III; WRAADDS: Wender-reimherr adult attention deficit disorder scale.
met the criteria for schizoid PD, 17% for obsessive–compulsive PD and 2% for
avoidant and paranoid PD diagnoses.
These findings are in line with those reported by Rydén and Bejerot[40]. They
assessed adults with ASD having no intellectual disability using the structured clinical
interview for DSM-IV (SCID-II) screen[41] and the Swedish Universities Scales of
Personality[42]. Avoidant and schizotypal personality traits were more common in
patients with ASD compared to the control group (patients without ASD). Patients
with ASD scored higher on detachment and stress susceptibility and had a median of
four PD compared to two in the control group. More than 40% of the ASD group
reached the cut-off score for avoidant, borderline and obsessive–compulsive PD, more
than a third had depressive, schizotypal, schizoid and narcissistic PD and at least 25%
reached the cut-off for paranoid and passive-aggressive PD. Females with ASD scored
significantly higher than males on borderline and passive-aggressive traits.
In a pilot study on adults with mild ASD, Ketelaars et al[43] found partial or
complete PD, assessed by the IPDE[37], in more than half of the sample. Schizoid and
avoidance were the most frequent PD. There were no significant differences in the
pattern of Axis II comorbidity between the ASD and the non-ASD patients.
Instead, in a retrospective chart study[44] on adults screened for ASD, only 15% of
ASD patients had a lifetime PD diagnosis. This lower comorbidity is probably due to
the fact that one third of the patient group had an intellectual disability. People with
autism and an intellectual disability were less likely to receive a diagnosis of PD[45,
46].
In a study on Temperament Character Inventory (TCI) profiles in ASD and ADHD
[47], the presence of PD was assessed with the SCID-II in a subgroup of patients with
childhood onset of a neuropsychiatric disorder: 75% of the sample met the criteria for
at least one PD. Specific PD prevalences are presented in Table 3.
Table 3 Specific personality disorders (Structured clinical interview for DSM-IV axis II diagnosis) prevalence in autism spectrum
disorder samples
PD Lugnegård et al[38], 2012 Hofvander et al[14], 2009 Anckarsäter et al[47], 2006 Strunz et al[26], 2015
Paranoid 0% 19% 25.5 % ASD; 25.9% ASD + ADHD 2%
Histrionic 0% 0% 0% 0%
PD: Personality disorders; ASD: Autism spectrum disorder; ADHD: Attention deficit hyperactivity disorder.
Figure 1 Preferred reporting items for systematic reviews and meta-analyses flow diagram of the systematic research process.
Table 4 Summary of studies using temperament character inventory to evaluate personality in adults with autism spectrum disorder
Personality
Ref. Participants Comparison group Measures Results
measures
Anckarsäter et n = 113 (6 autistic disorder, 46 Age and sex matched SCID-I; ASDI; Y- TCI; SCID-II Lower NS, RD, SD, C; Higher HA;
al[47], 2006 AS, 66 Atypical Autism); group BOCS; ASHFAQ; Cluster A and Cluster C PD were
47ASD+ADHD 66 ASD TCI common
Soderstrom et n = 31 AS Age and sex matched WAIS-III TCI Higher HA ST; Lower NS, RD, SD, C
al[50], 2002 group
Sizoo et al[49], n = 75 (53 without SUD, 8 n = 657 NC ADI-R; ADOS; VTCI Higher HA, ST; Lower RD, SD, C;
2009 with past SUD, 14 with DSM-IV criteria Lower NS and RD for ASD without
current SUD) checklists; WAIS-III SUD; Higher P for subgroups with
current or past SUD
Vuijk et al[51], n = 66 (15 ASD, 25 AS, 26 Matched comparison TCI Higher HA, lower NS, RD, SD, C
2018 PDD-NOS) group (age, education,
marital status)
C: Cooperativeness; HA: Harm avoidance; NC: Neurotypical controls; NS: Novelty Seeking; P: Persistence; RD: Reward dependence; SD: Self-directedness;
ST: Self-transcendence; SUD: Substance use disorder; SUD: No history of SUD; VTCI: Short version of temperament character inventory.
[47].
In the sample of AS patients included in another TCI study[50], the obsessional type
of PD was the most frequent, followed by the passive-dependent, explosive and
passive-aggressive types.
The TCI profiles differed somewhat when ASD was combined with a comorbid
disorder such as ADHD[47] or substance abuse[49]. When ASD was comorbid with
ADHD this was associated with higher levels of novelty seeking, whereas when ASD
was comorbid with substance abuse this was associated with a higher degree of
persistence and a lower degree of self-directedness compared to ASD patients without
the comorbidity.
There was also some evidence indicating an association between temperament and
character dimensions and long-term ASD diagnostic stability and psychiatric
comorbidity. In a longitudinal cohort study by Helles et al[52], the TCI was used to
assess 40 males who were diagnosed with AS in childhood and followed prospectively
over almost two decades. Three distinct temperament and character profiles emerged.
Those no longer meeting the criteria for ASD had high reward dependence. It is also
interesting to note that in another study[50] 35.5% of the sample had reward
dependence scores above the general population mean, suggesting that a subgroup of
individuals with AS desire closer social interaction than they are able to establish. The
participants with a stable ASD diagnosis and no current psychiatric comorbidity (‘ASD
pure group’) were characterized by lower novelty seeking and higher harm avoidance
compared with normative data; however, compared to the other groups harm
avoidance was lower than for the ‘ASD plus group’ (those with a stable ASD diagnosis
and psychiatric comorbidity), which showed elevated harm avoidance and low self-
directedness and cooperativeness. In the ASD plus group, comorbidity disorders were
depression, anxiety disorder and/or ADHD.
Vuijk et al[51] performed a re-analysis of scores on the TCI administered to a sample
of 66 ASD men by individual case matching. Compared to the general population,
patients with ASD scored significantly higher on the scale for harm avoidance, and
lower on novelty seeking, reward dependence, self-directedness, and cooperativeness.
These findings confirmed the results emerging from their previous research published
in Dutch[53].
Table 5 Summary of studies measuring big five personality traits in adults with autism spectrum disorder
Comparison Personality
Ref. Partecipants Measures Results
group trait measures
Schwartzman et n = 364 adults with n = 464 adults with RAADS-R IPIP-NEO-120 Neuroticism was positively correlated with ASD symptomatology; Extraversion, openness to experience, conscientiousness, and
al[56], 2016 elevated ASD traits lower ASD traits agreeableness were negatively correlated with ASD; About 70% of the variance in RAADS-R scores accounted for by the IPIP-NEO-120
facets. A great variability in personality traits emerged in the elevated ASD traits group with four distinct clusters of FFM personality
types
Schriber et al n = 37 ASD (29% HFA, n = 42 NC WAIS; BFI Higher Neuroticism Lower Openness to experience, Conscientiousness, Extraversion, Agreeableness
[55], 2014 57% AS, 14% PDD- ADOS G
NOS)
Kanai et al[67], n = 64 AS n = 65 NC AQ; HADS; NEO-FFI AQ, HADS, and L-SAS were significantly higher in AS than in control. Higher Neuroticism, Lower Extraversion, Agreeableness,
2011 L-SAS Conscientiousness AQ correlated with the subscale scores of HADS and NEO-FFI in AS
Strunz et al[26], n = 59 ASD(83% AS, n = 62 NPD,80 BPD, SCID- NEO-PI-R; On the NEO-PI-R: Conscientiousness: NCC = ASD > BPD and NPD Neuroticism: NCC < ASD = NPD < BPD; Extraversion: ASD < BPD,
2015 17% HFA) 106 NC I/MINI DAPP BQ; SCID- NPD, NCCOpenness for experience: ASD < NCC, BPD, NPDAgreeableness: ASD = BPD and NPD > NCCOn the DAPP-BQ:
II Inhibitedness: ASD = BPD > NCC and NPD Dissocial Behaviour: NCC = ASD < BPD and NPD; Emotional dysregulation: NCC < ASD =
NPD < BPD Compulsivity: ASD > BPD, NPD, NCC
Hesselmark et al n = 48 ASD n = 53 NC MINI NEOPI-R Satisfactory internal consistency of the NEOPI-R. Neuroticism correlated with psychiatric comorbidity in ASD group
[62], 2015
BFI: Big five inventory; L-SAS: Liebowitz social anxiety scale; HADS: Hospital anxiety and depression scale; IPIP-NEO-120: International personality item pool representation of the NEO-PI-R; NEO-PI-R: Neo personality inventory revised.
personality differences were confirmed when controlling for age, gender and self- and
parent reports. The findings indicated that the personality profile distinguished
between ASD and neurotypical controls but did not significantly distinguish severity
symptoms between individuals with ASD.
In another study, Schwartzman et al[56] compared adults with and without ASD
using the International Personality Item Pool Representation of the NEO-PI-R (IPIP-
NEO-120) as a trait measure. The IPIP-NEO-120, following the full-length version of
the NEO[57,58], consists of 24 items per factor and 4 items per facet for a total of 120
items. The Big Five facets accounted for 70% of the variance in autism trait scores
measured with the Ritvo Autism Asperger’s Diagnostic Scale Revised (RAADS-R)[59].
Neuroticism correlated positively with autism symptom severity, whereas
extraversion, openness to experience, agreeableness and conscientiousness correlated
negatively with autism symptom severity.
The clinical characteristics of AS adults, including depression, anxiety and
personality (NEO Five-Factor Inventory, NEO-FFI)[57], were examined by Kanai et al
[59]. The AQ[39], Hospital Anxiety and Depression Scale (HADS)[60], Liebowitz Social
Anxiety Scale (L-SAS)[61] and neuroticism scores were significantly higher in adults
with AS than in controls, whereas the extraversion, agreeableness and conscien-
tiousness scores were significantly lower. The total score of the AQ correlated with the
anxiety subscale score of the HADS and the extraversion, openness and conscien-
tiousness subscale scores of the NEO-FFI in adults with AS, but not in the controls.
Strunz et al[26] assessed personality traits using the NEO-PI-R[62] and personality
pathology using the Dimensional Assessment of Personality Pathology (DAPP-BQ)[63,
64] in four samples of adults: ASD, narcissistic PD, borderline PD and non-clinical
controls. Personality traits and personality pathology specific to ASD could be
identified: ASD individuals, when compared to non-clinical controls, showed
significantly higher scores on the NEO-PI-R neuroticism and DAPP-BQ emotional
dysregulation dimensions and lower agreeableness scores; ASD individuals had
significantly lower scores on the NEO-PI-R extraversion and openness to experience
scales and significantly higher scores on the DAPP-BQ inhibitedness and compulsivity
scales, relative to all other groups.
Moreover, individuals with ASD scored significantly higher than all other groups
on the NEO-PI-R straightforwardness (frankness in expression) subscale. The results of
the comparison with PD will be described later as differential diagnosis features.
Table 6 Summary of studies using different assessment measures to evaluate personality in adults with autism spectrum disorder
Personality
Ref. Participants Comparison group Measures Results
measures
Ozonoff et n = 20 HFA 24 NC (age, intelligence WAIS-R MMPI-2 Higher Depression, Social Introversion, Social Discomfort,
al[65], 2005 and gender matched Repression and PSY-5 scale Introversion
college students)
Kanai et al n = 55 AS 57 NC WAIS-R SPQEPQ SPQ: AS>NC; SPQ subscale scores (unusual perceptual
[59], 2011 experiences, odd behaviour, and suspiciousness) were correlated
with total scores of the AQ in the AS group; Higher ‘Neuroticism’
and ‘Psychoticism’; Lower ‘Extraversion’ and ‘Lie’
EPQ: Eysenck personality questionnaire; MMPI-2: Minnesota multiphasic personality inventory; SPQ: Schizotypal personality questionnaire.
between affective and cognitive ToM components when compared with the SSPD
patients; and the SSPD individuals scored significantly lower on cognitive than
affective ToM tasks.
Stanfield et al[87] compared SC in ASD and schizotypal PD (SPD) using functional
magnetic resonance imaging (fMRI). In the Ekman 60-Faces Test and the social
judgement task there were no significant differences between the ASD, the SPD and
the comorbid groups on any measure. All groups had similar patterns of impairment
in the SC tests and few differences in clinical symptoms, but clear differences were
seen between the ASD and SPD groups using fMRI during the social judgement task.
Hyperactivation in SPD compared to ASD was found in the amygdala and the
cerebellum. The fMRI findings for the comorbid group showed differences compared
to the ASD group and similarities with the SPD group. The findings supported the
hypo- and hyper-mentalizing theory of ASD and schizophrenia, highlighting the
difficulty and importance of considering SPD as a differential diagnosis for ASD.
Table 7 Studies comparing autism spectrum disorder patients with personality disorders patients on different assessment measures
López-Pérez 30 AS 30 BPD60 matched NC SCID-ISCID-IIEmotion regulation of others and Affect improvement: BPD = AS < NNC; Affect worsening: BPD = AS = NNC; Affect improvement > affect
et al[95], self (two scales: extrinsic affect improvement, worsening in BPD e NCC; Affect improvement = affect worsening in ASD; Adaptive interpersonal
2017 extrinsic affect worsening)Interpersonal emotion strategies (attention deployment, cognitive change) ASD < BPD and NNC; Maladaptive interpersonal
management strategies (expressive suppression) ASD > BPD and control.
Dudas et al 624 ASD 23 BPD; 16 ASD+ BPD; 2081 NC AQ; EQ; SQR; SCID-II AQ: NC < BPD = ASC < ASC+BPD; EQ:NC = BPD > ASC = ASC+BPD; SQR NC < BPD = ASC = ASC+BPD
[92], 2017
Murphy 39 AS; Male forensic 39 PD (antisocial and/or WAIS-R; ToM measures IQ PD = AS > SC; AS and SC performed worse on two ToM measures (the Revised Eyes Task and the
[100]2006 patients detained in high borderline)39 SC with positive second order mental representation stories)
security psychiatric care symptoms detained in high
security psychiatric care
Stanfield et 28 ASD 21 SPD; 10 CM; 33 NC ADOS-G; SCID-II; PANSS; WAISsocial judgment SPD = CM = ASD < controls on social judgment task and Ekman 60-Faces Test; on positive symptoms: ASD
al[87], 2017 taskEkmann 60 facies task; fRMI task of social < SPD = CM; on negative symptoms ASD = SPD > CM; fRMI: hyperactivation in SPD and CM group
judgement compared to ASD was found in the amygdala and the cerebellum
Booules- 35 HFA SSPD (n = 30) and a NC (n = 36) O-LIFE questionnaire; SCID-I; SCID-II; ADI-R; HFA showed greater impairment and no dissociation between affective and cognitive ToM components;
Katri et al ADOS; WAIS-III; ToM test SSPD scored significantly lower on cognitive than affective ToM test
[84], 2019
BPD: Borderline personality disorder; CM: Comorbid group (SPD+ASD); EQ: Empathy quotient; NPD: Narcissistic personality disorder; O-LIFE questionnaire: Short version of the Oxford-Liverpool Inventory of Feelings and Experiences
questionnaire; PANSS: Positive and negative syndrome scale; NC: Non clinical control group; SQR: Systemizing quotient revised; SSPD: Schizotypal-schizoid personality disorder; ToM: Theory of mind.
In BPD, higher levels of neuroticism, extraversion and openness for experience but
less conscientiousness and the same level of agreeableness were found on the NEO-PI-
R scores. The study also found, using the DAPP-BQ, more emotional dysregulation
and dissocial behaviour and less inhibition and compulsivity in BPD patients
compared with ASD patients. On the three inhibitedness subscales, no differences
were reported. Even if the underlying causes social avoidance differed between BPD
and ASD (social skill deficit in ASD versus fear of rejection in BPD), ASD individuals
scored lower on the NEO-PI-R openness to experience dimension but significantly
higher on the ideas (intellectual curiosity) subscale than BPD patients.
In relation to the difference between autism and narcissism, ASD patients’ scores on
the NEO-PI-R modesty and compliance subscales were comparable to non-clinical
control subjects. Moreover, patients with ASD and non-clinical controls had similar
scores on the DAPP-BQ narcissism subscale.
DISCUSSION
Examining personality in adults with ASD has only become the focus of research in
recent years. The current review provides a literature summary of how personality
and PD have been studied in high-functioning adults with ASD, focusing on two
clinical issues.
The first issue for clinicians evaluating personality in ASD adult patients is to
determine whether personality traits are part of the same autistic phenomenology or
rather represent different categorical factors (comorbidity). The findings of studies
focused on PD comorbidity suggested that approximately 50% of individuals with
ASD fulfilled the diagnostic criteria for at least one PD.
The prevalence of PD comorbidity seemed to vary, increasing in samples of patients
with other Axis I disorders, especially ADHD, and decreasing in mixed samples with
intellectual disabilities. The most common comorbid PD belong to cluster A or cluster
C (schizoid, schizotypal, obsessive–compulsive and avoidance PD). High rates of
patients with more than one PD were found using the SCID-II. This suggests the utility
of completing an assessment with other instruments to answer the question: ‘True
comorbidity or overlapping features?’[5]. Phenotypic similarities between high-
functioning ASD and both schizoid/schizotypal and obsessive–compulsive PD have
been noted, but the available data are sparse, so this could be a diagnostic challenge
for clinicians[105,106]. An additional PD to an ASD diagnosis could be considered
‘true comorbidity’ if it gives relevant information for understanding patient
functioning and for developing more specific treatments.
In most of the studies reviewed, the personality of adults with ASD was assessed in
order to identify a specific profile differing from that of neurotypical controls. Big Five
personality traits and the TCI dimensions are the most commonly used taxonomy for
measuring personality in adults with ASD. The findings of these studies support the
hypothesis that ASD in adults is associated with a distinct personality profile that is
not equivalent to an ASD diagnosis or to a specific PD.
Regarding the Big Five traits, these patients have been shown in all the studies
reviewed to be higher in neuroticism and lower in extraversion and agreeableness, and
also in most of the studies to be lower in openness to experience and conscien-
tiousness. At the same time, ASD characteristics are statistically independent of the Big
Five personality traits in clinical samples.
Adults with ASD have repeatedly been shown to have a distinct temperament and
character compared to neurotypical controls. Concerning the TCI dimensions, lower
scores on the character dimensions of self-directedness and cooperativeness indicated
a possible personality psychopathology[107,108]. Moreover, ASD was associated with
high harm avoidance, low reward dependence, low novelty seeking and high self-
transcendence. High harm avoidance reflects pessimism and shyness, and also state-
dependent anxiety. Low reward dependence indicates impairments in social
sensitivity, attachment capacity and adaptability. In individuals with an immature
character structure, high self-transcendence may lead to disregard for the basic
realities of human interaction and social responsibilities.
As regards other personality measures, such as the EPQ and MMPI-2, the emerging
profile reflected social isolation, interpersonal difficulties and psychotic-like
symptoms.
In summary, the overall profile of personality traits and dimensions in ASD puts
individuals at risk for other psychiatric disorders and lower functioning, even if
variability exists.
Individuals with autism that are not diagnosed in childhood may have a high level
of stress in trying to find a lifestyle to survive in a world that is difficult to understand;
thus, building their personality with this level of chronic stress could be a trigger for
creating a PD. Nevertheless, the neuropsychiatric dysfunctions associated with ASD
permit considerable variation in personality. It has been suggested that personality
mediates the relationship between autistic symptoms and well-being[109,110].
Exploring personality could provide a more comprehensive picture of adults with
ASD, characterizing them through their individual strengths and weaknesses. It could
advance the understanding of heterogeneity within patients and help in the
development of more specific interventions. Treatment of PD comorbidity in adults
with ASD is still in its infancy, but specific programmes have started to be developed
[111].
The second critical issue is differentiating ASD patients from PD patients in clinical
samples when searching for an ASD diagnosis. High-functioning ASD patients are
frequently misdiagnosed with PD, and few studies were found on differential
diagnosis between ASD and PD.
SC deficits could be useful for distinguishing ASD from PD, especially borderline
and antisocial PD[112]. Gender could cause specific patterns of PD comorbidity and
increase the risk of misdiagnosis, especially in women[14,113]; it has been suggested
that some women with BPD have undiagnosed ASD.
Concerning the difference between autism and narcissism, individuals with ASD
may appear egocentric because of a limited awareness of when it is appropriate to
compliment oneself and when it is not. Nevertheless, ASD patients were found to be
comparable to non-clinical controls on scales measuring narcissism in the only
available investigation on this topic[26].
Differences in ToM abilities between ASD and cluster A PD have also been found,
but functional neuroimaging may be better than SC testing for discriminating between
autism and schizophrenia spectrum disorders[87].
Findings on differential diagnosis should be replicated and investigations should be
extended to compare ASD patients with cluster C PD patients too.
Differential diagnosis should be based on clinical examination and a very careful
history investigation of the first years of development, the first social relationships
with other children and adolescents, changes of lifestyle during development and
clinical symptoms of ASD in the first years of life.
Interviews such as the Autism Diagnostic Interview–Revised (ADI-R)[114] could
help the clinician to collect the first symptoms of ASD. Personality assessment could
help in confirming the diagnosis, but has to be used carefully by an expert clinician
who knows the ASD cognitive style in order to avoid misunderstandings.
The findings of all the studies included in this review were based on self-reporting
questionnaires or structured interviews that collected information only from the
patients. This raises concerns about how a person with autism can read and
understand the complex questions in a self-report test: individuals with autism could
have difficulties in understanding the real meaning because of their literal way of
reading a text. Nevertheless, studies have supported the validity of self-report in
adults with ASD without intellectual disability[55,62].
CONCLUSION
This review provides a summary of the main findings in the literature regarding PD in
adults with high-functioning ASD without intellectual disability. The aim of the
review is to improve knowledge of the complex relationship between ASD and PD.
Among the limitations of this review is the exclusion of studies looking for autistic
traits in patients with PD or in non-clinical populations, which may be informative for
giving a better understanding of overlapping features, as the question of commonality
as opposed to comorbidity is not yet resolved. Furthermore, our research was
conducted extensively on PubMed only. Future works should be conducted by
ARTICLE HIGHLIGHTS
Research background
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by
persistent deficits in social communication and social interaction, as well as restricted,
repetitive and stereotyped patterns of behaviour. Individuals with high-functioning
ASD are more likely to be diagnosed in adulthood, probably due to the development
of learnt or camouflaging strategies that make it much harder to identify the
underlying difficulties. Late-diagnosed individuals report higher levels of co-occurring
psychiatric disorders or misdiagnosis, because some features of ASD can overlap with
symptoms of other psychiatric conditions as well as personality disorders (PD). In
recent years there has been a growing interest in exploring the complex relationship
between ASD and PD, especially for features that overlap with cluster A and cluster C
PD.
Research motivation
Consideration of the relationship between PD and ASD, with a focus on differential
diagnosis and comorbidity, can lead to a better understanding of this complex topic
and can improve the diagnostic process as well as supporting the creation of targeted
interventions.
Research objectives
To summarize the research findings on ASD and PD in adulthood, focusing on
comorbidity and differential diagnosis.
Research methods
The guidelines of the Preferred Reporting Items for Systematic Review and Meta-
Analyses (PRISMA) were followed in the present review. A comprehensive literature
search was performed through PubMed, including only studies published in the
English language and performed on adults without intellectual disability. The research
included studies published up to April 2020.
Research results
The current review provides a literature summary of how personality and PD have
been studied in high-functioning adults with ASD. The findings show that approx-
imately 50% of individuals with ASD fulfilled the diagnostic criteria for at least one
PD. The most common comorbid PD belong to cluster A or cluster C (schizoid,
schizotypal, obsessive–compulsive and avoidance PD). High-functioning ASD patients
are frequently misdiagnosed with PD, but only a few studies have been conducted on
differential diagnosis. Furthermore, there were significant differences in methodo-
logical approaches, including ASD diagnostic instruments and personality measures.
Research conclusions
ASD in high-functioning adults is associated with a distinct personality profile even if
variability exists. Cluster A and cluster C PD are the most frequent co-occurring PD,
but overlapping features should be considered. Exploring personality could provide
greater understanding of adults with ASD by identifying strengths and weaknesses,
and could give relevant information for the development of specific and individual
treatments.
Research perspectives
Further studies are needed to explore the relationship between ASD and PD,
especially on differential diagnosis. It would be useful to explore the relationship
between PD and ASD from a longitudinal perspective, take in account individual’s life
and development history.
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