ASD I PD

Download as pdf or txt
Download as pdf or txt
You are on page 1of 22

World Journal of

WJ P Psychiatry
Submit a Manuscript: https://www.f6publishing.com World J Psychiatr 2021 December 19; 11(12): 1366-1386

DOI: 10.5498/wjp.v11.i12.1366 ISSN 2220-3206 (online)

SYSTEMATIC REVIEWS

Autism spectrum disorder and personality disorders: Comorbidity


and differential diagnosis

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

WJP https://www.wjgnet.com 1366 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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

WJP https://www.wjgnet.com 1367 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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.

MATERIALS AND METHODS


The present review adhered to the standards set out in the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guidelines[25]. A systematic
review of the literature was performed through PubMed, using combinations of the
following search terms: Asperger’s Syndrome or/Autism + Personality/Personality
disorder or + comorbidity. The search was restricted to studies published up to April
2020. Grey literature was identified through searching Google Scholar. The literature
reviews and reference sections of selected papers were also examined for additional
potential studies. All records that remained following the removal of duplicates were
screened for the inclusion criteria.
Studies were included in this review if they examined PD (as a comorbid or differ-
ential diagnosis) in ASD samples. Only studies published in the English language and
performed on adults without intellectual disability were selected. In studies for which
IQ data were not reported, the participants had to be diagnosed with AS or high-
functioning autism (HFA)/ASD level 1. Investigations carried out on non-clinical
samples were excluded. Studies evaluating autistic traits in PD patients were also
excluded. There were no restrictions made for the geographical region or setting of the
study.

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].

Personality disorders as comorbid diagnosis


Among studies exploring personality features in ASD, only a few assessed PD as a
categorical diagnosis using the Structured Clinical Interview for DSM-IV Axis II
Disorders (SCID-II)[35,36] or the International Personality Disorder Examination
(IPDE)[37] (see Table 2). As autistic traits overlap with aspects of several PD,
dimensional measures were preferred to assess personality in adults with ASD.

Structured Clinical Interview for DSM-IV


A study[14] carried out on 117 patients with ASD found that 62% of the sample met

WJP https://www.wjgnet.com 1368 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

Table 1 Description of the studies included in the systematic review

Ref. Setting Aim Statistical methods Limitations


Soderstrom et al NeuropsychiatricClinic in Sweden To study the personality characteristics of adults with AS One sample t-test Small sample size
[50], 2002

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

WJP https://www.wjgnet.com 1369 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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
advertisements

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

WJP https://www.wjgnet.com 1370 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

Table 2 Summary of included studies exploring comorbid personality disorders diagnosis (according to DSM-IV) in autism spectrum
disorder patients

PD assessment PD Prevalence (at least


Ref. Participants Measures
instrument one PD)
Ketelaars et al[43], 2008 n = 15 (4 AS, 10 PDD-NOS, 1 HFA) AQ, SCAN-2.1 IPDE > 50%

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

Lugnegård et al[38], 2012 n = 54 (AS) WAIS-III, DISCOS-11AQ SCID-II or a structured 48%


DSM-IV-based clinical
interview

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.

WJP https://www.wjgnet.com 1371 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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%

Schizoid 26% 13% 31.9% ASD; 22.2% ASD + ADHD 36%

Schizotypal 2% 21% 23.4% ASD; 11.1% ASD + ADHD 0%

Antisocial 0% 3% 0% ASD; 18.5% ASD + ADHD 0%

Histrionic 0% 0% 0% 0%

Borderline 0% 9% 10.6% ASD; 14.8% ASD + ADHD 0%

Narcissistic 0% 3% 6.4%ASD; 3.7% ASD + ADHD 0%

Avoidant 13% 25% 34% ASD; 11.1% ASD + ADHD 2%

Obsessive-compulsive 19% 32% 42.6% ASD; 29.6% ASD + ADHD 17%

Dependent 0% 5% 8.5% ASD; 22.2% ASD + ADHD 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.

Temperament and character inventory


Studies using the temperament and character inventory (TCI) to evaluate personality
in patients with ASD are presented in Table 4[48]. Four TCI studies on adults with
ASD[47,49-51] found low scores on the character dimensions of self-directedness and
cooperativeness. Moreover, ASD was associated with high harm avoidance, low
reward dependence, low novelty seeking and high self-transcendence. The high level
of rare answer scores also reflects the oddity and social insensitivity inherent in the
self-descriptions of subjects with ASD[50,52]. Cluster A and cluster C PD were more
common in patients with ASD assessed with the TCI and confirmed with the SCID-II

WJP https://www.wjgnet.com 1372 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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)

Helles et al n = 40 AS Within comparison GAFWAIS-IIIASDI; TCI Higher RD in no longer ASD; Higher


[52], 2016 group (no longer BDI; ASRS HA, lower NS in ASD pure; Higher
ASD/ASD pure/ASD HA, lower C, SD in ASD plus
plus)

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].

Big five personality traits


In Table 5 a summary of studies measuring the Big Five personality traits[54] in ASD
patients is presented.
Schriber et al[55] investigated personality differences between ASD adults and
neurotypical control adults using self-reports of the Big Five personality traits.
Individuals with ASD were more neurotic, and less extraverted, agreeable,
conscientious and open to experience, than neurotypical controls. The same

WJP https://www.wjgnet.com 1373 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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-

WJP https://www.wjgnet.com 1374 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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.

Minnesota multiphasic personality inventory


Table 6 shows a summary of studies using other assessment measures to evaluate
personality in ASD.
Only one study[65] explored personality in HFA by administering the minnesota
multiphasic personality inventory (MMPI-2)[66]. The ASD sample had higher scores
on the L (Lie) validity scale, Clinical Scale Depression (D) and Social Introversion (Si),
Content Scale Social Discomfort (SOD), Supplementary Scale Repression (R) and
Personality Psychopathology Five (PSY-5) Introversion (INTR) scales than a matched
sample of college students.
In ASD, sample comorbidity conditions were major depression, anxiety disorder
and ADHD. The MMPI-2 profile reflected social isolation, interpersonal difficulties,
depressed mood and coping deficits. This study also found medium-sized group
differences from the control sample and elevations in 30%-40% of the ASD group on
Scale 8 (Schizophrenia). These results could be related to psychotic symptoms but also
to social alienation and general maladjustment. A high rate of elevation (30%) on the L
scale reflects a desire to present a favourable impression and is quite unusual in this
sample of patients.

Eysenck personality questionnaire


Kanai et al[67] examined 112 adults with AS using the eysenck personality
questionnaire (EPQ)[68] and the Schizotypal Personality Questionnaire (SPQ)[69].
Patients scored higher than controls on the SPQ, higher on the neuroticism and
psychoticism scores of the EPQ and lower on the extraversion and lie scores of the
EPQ. The SPQ subscale scores (unusual perceptual experiences, odd behaviour and
suspiciousness) were correlated with the total scores of the AQ in AS.

Personality disorders as differential diagnosis


In the literature investigating the relationship between PD and ASD, differential
diagnosis is less explored than comorbidity. Studies comparing individuals with ASD
or PD on different assessment measures are shown in Table 7, and each PD cluster is
described in terms of differential diagnosis with ASD.

Cluster A personality disorders


Autism and schizophrenia spectrum disorders are classified separately in the DSM-5,
but empirical findings suggest that these two disorders share overlapping features[70-
72]. In clinical practice the most common difficulties are in the differential diagnosis of
adults with ASD from those suffering from schizoid or schizotypal PD[29,73]. It is
suggested that attention should be paid to the developmental history of the person, the
prodrome and onset of the condition, its course and the absence of positive symptoms
[74].
Social cognition (SC) deficits are points of overlap between ASD and schizophrenia
spectrum disorders. SC includes cognitive mechanisms involved in the processing and
interpretation of the social world[75-79]. Most studies on this topic directly examined
patients with autism and schizophrenia[80-83] rather than schizoid or schizotypal
patients. Only two studies meeting the inclusion criteria were found.
Booules-Katri et al[84] investigated differences in Theory of Mind (ToM), a main
component of SC, which refers to the ability to understand the emotional and mental
states of other people[75,78,79,85,86]. They used three advanced ToM tests in 35
patients with HFA, 30 patients with schizotypal-schizoid PD (SSPD) and 36 healthy
controls: individuals with HFA showed worse performance and no dissociation

WJP https://www.wjgnet.com 1375 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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.

Cluster B personality disorders


In recent years there has been a growing interest in investigating deficits in SC, given
the symptomatic overlap between autistic spectrum conditions and borderline PD
(BPD)[88-91].
An investigation[92] into the difference and overlap between ASD and BPD was
performed by evaluating autistic traits and empathizing and systemizing abilities in
four samples: ASD, BPD, comorbid ASD+BPD and controls.
Similar to BPD, ASD patients scored higher than controls on the AQ[39] and the
Systemizing Quotient-Revised (SQ-R)[93] but had lower empathizing abilities
measured with the Empathy Quotient (EQ)[94]. The major limitations of this study
were that diagnosis was based on the patients’ self-reports, and that there was a
preponderance of females in the BPD and control samples. The results support the
view that some females with BPD have undiagnosed ASD.
In another study[95], 30 BPD, 30 AS and 60 matched control participants were
compared on interpersonal emotion regulation strategies. Both patients with AS and
those with BPD engaged less than the controls in interpersonal affect improvement.
No differences were found for affect worsening. Individuals with AS did not differ in
affect improvement and worsening, tending to generally engage less in interpersonal
emotion regulation. Instead, individuals with AS reported using less adaptive
(attention deployment, cognitive change) and more maladaptive (expressive
suppression) interpersonal emotion regulation strategies compared to individuals with
BPD and controls.
Differential diagnosis between ASD and narcissistic PD (NPD) may also be difficult.
NPD was found to be one of the most prevalent PD in a help-seeking population of
adults with suspicion of autism without intellectual disability in whom autism could
be excluded[96]. Attwood[97] suggested that individuals with ASD, especially those
with superior intellectual abilities, may overcompensate for feelings of inadequacy in
social situations by becoming arrogant and egocentric.
Strunz et al[26] compared BPD, NPD and ASD on personality traits (NEO-PI-R) and
personality pathology (DAPP-BQ), reporting different profiles. Adults with ASD had
significantly higher scores on the NEO-PI-R conscientiousness dimension and
significantly lower scores on the DAPP-BQ dissocial behaviour dimension than BPD
and NPD patients. On the corresponding DAPP-BQ compulsivity scale, adults with
ASD had significantly higher scores than all other groups.

WJP https://www.wjgnet.com 1376 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

Table 7 Studies comparing autism spectrum disorder patients with personality disorders patients on different assessment measures

Ref. Participants Comparison group Measures Results


Strunz et al 59 ASD (83% AS, 17% 62 NPD, 80 BPD, 106 NC NEO-PI-R; DAPP BQ; SCID-I/MINI; SCID-II On the NEO-PI-R: Conscientiousness: NCC = ASD > BPD and NPD; Neuroticism: NCC < ASD = NPD <
[26], 2015 HFA) BPD; Extraversion: ASD < BPD, NPD, NCC; Openness for experience: ASD < NCC, BPD, NPD;
Agreeableness: ASD = BPD and NPD > NCC; on the DAPP-BQ; Inhibitedness: ASD = BPD > NCC and
NPD; Dissocial Behaviour: NCC = ASD < BPD and NPD; Emotional dysregulation: NCC < ASD = NPD <
BPD; Compulsivity: ASD > BPD, NPD, NCC

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.

WJP https://www.wjgnet.com 1377 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

With regard to differential diagnosis with antisocial PD, different empathic


dysfunctions in psychopathy and autism have been found[98,99]. Only one study[100]
compared the ToM performances of forensic AS, schizophrenia and PD patients. In the
PD group there were individuals with dissocial PD and/or BPD, diagnosed by expert
clinicians. Patients were male and detained in high security psychiatric care. The
results suggested that the AS and SC groups performed worse than the PD patients on
the revised eyes task[101] and the second-order mental representation stories. The AS
and PD groups did not differ on the Wechsler Adult Intelligence Scale full-scale IQ but
both scored more highly than the SC group.

Cluster C personality disorders


It is well known that the phenomenology of obsessive–compulsive PD shows
similarities to that of ASD[102], so misdiagnosis of ASD as anankastic PD is possible. It
is suggested to consider first whether an individual has an underlying autism
spectrum condition before diagnosing obsessive-compulsive PD[103]. In ASD,
repetitive patterns of behaviour, in particular the pursuit of circumscribed interests,
are often associated with pleasure and mastery rather than egodystonicity. Gadelkarim
et al[104] suggested that in obsessive–compulsive patients the presence of
obsessive–compulsive PD should alert one to the possible recognition of ASD.
No studies comparing ASD patients with cluster C PD patients met the inclusion
criteria.

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

WJP https://www.wjgnet.com 1378 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

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

WJP https://www.wjgnet.com 1379 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

optimizing retrieval strategies and also including studies concerning adolescents.


Another area little examined is the role of age in modulating the relationship between
PD and ASD[115,116]. Longitudinal research on personality and ASD may clarify
whether the relationship between personality and ASD increases in adulthood, as has
been suggested[55].

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.

WJP https://www.wjgnet.com 1380 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

REFERENCES
1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-
5®). Arlington, VA, 2013 [DOI: 10.1176/appi.books.9780890425596.x00diagnosticclassification]
2 Howlin P, Moss P. Adults with autism spectrum disorders. Can J Psychiatry 2012; 57: 275-283
[PMID: 22546059 DOI: 10.1177/070674371205700502]
3 Marriage S, Wolverton A, Marriage K. Autism spectrum disorder grown up: a chart review of adult
functioning. J Can Acad Child Adolesc Psychiatry 2009; 18: 322-328 [PMID: 19881941]
4 Seltzer MM, Shattuck P, Abbeduto L, Greenberg JS. Trajectory of development in adolescents and
adults with autism. Ment Retard Dev Disabil Res Rev 2004; 10: 234-247 [PMID: 15666341 DOI:
10.1002/mrdd.20038]
5 Lai MC, Baron-Cohen S. Identifying the lost generation of adults with autism spectrum conditions.
Lancet Psychiatry 2015; 2: 1013-1027 [PMID: 26544750 DOI: 10.1016/S2215-0366(15)00277-1]
6 Luciano CC, Keller R, Politi P, Aguglia E, Magnano F, Burti L, Muraro F, Aresi A, Damiani S,
Berardi D. Misdiagnosis of high function autism spectrum disorders in adults: an Italian case series.
Autism 2014; 4: 131 [DOI: 10.4172/2165-7890.1000131]
7 Mattila ML, Hurtig T, Haapsamo H, Jussila K, Kuusikko-Gauffin S, Kielinen M, Linna SL, Ebeling
H, Bloigu R, Joskitt L, Pauls DL, Moilanen I. Comorbid psychiatric disorders associated with
Asperger syndrome/high-functioning autism: a community- and clinic-based study. J Autism Dev
Disord 2010; 40: 1080-1093 [PMID: 20177765 DOI: 10.1007/s10803-010-0958-2]
8 Antshel KM, Russo N. Autism Spectrum Disorders and ADHD: Overlapping Phenomenology,
Diagnostic Issues, and Treatment Considerations. Curr Psychiatry Rep 2019; 21: 34 [PMID:
30903299 DOI: 10.1007/s11920-019-1020-5]
9 Postorino V, Kerns CM, Vivanti G, Bradshaw J, Siracusano M, Mazzone L. Anxiety Disorders and
Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder. Curr Psychiatry
Rep 2017; 19: 92 [PMID: 29082426 DOI: 10.1007/s11920-017-0846-y]
10 Russell AJ, Mataix-Cols D, Anson M, Murphy DG. Obsessions and compulsions in Asperger
syndrome and high-functioning autism. Br J Psychiatry 2005; 186: 525-528 [PMID: 15928364 DOI:
10.1192/bjp.186.6.525]
11 Bertelli MO, Piva Merli M, Bradley E, Keller R, Varrucciu N, Del Furia C, Panocchia N. The
diagnostic boundary between autism spectrum disorder, intellectual developmental disorder and
schizophrenia spectrum disorders. Advances in Mental Health and Intellectual Disabilities 2015; 9:
243-264 [DOI: 10.1108/amhid-05-2015-0024]
12 Cauda F, Costa T, Nani A, Fava L, Palermo S, Bianco F, Duca S, Tatu K, Keller R. Are
schizophrenia, autistic, and obsessive spectrum disorders dissociable on the basis of neuroimaging
morphological findings? Autism Res 2017; 10: 1079-1095 [PMID: 28339164 DOI:
10.1002/aur.1759]
13 Cochran DM, Dvir Y, Frazier JA. "Autism-plus" spectrum disorders: intersection with psychosis
and the schizophrenia spectrum. Child Adolesc Psychiatr Clin N Am 2013; 22: 609-627 [PMID:
24012076 DOI: 10.1016/j.chc.2013.04.005]
14 Hofvander B, Delorme R, Chaste P, Nydén A, Wentz E, Ståhlberg O, Herbrecht E, Stopin A,
Anckarsäter H, Gillberg C, Råstam M, Leboyer M. Psychiatric and psychosocial problems in adults
with normal-intelligence autism spectrum disorders. BMC Psychiatry 2009; 9: 35 [PMID: 19515234
DOI: 10.1186/1471-244X-9-35]
15 Lai MC, Kassee C, Besney R, Bonato S, Hull L, Mandy W, Szatmari P, Ameis SH. Prevalence of
co-occurring mental health diagnoses in the autism population: a systematic review and meta-
analysis. Lancet Psychiatry 2019; 6: 819-829 [PMID: 31447415 DOI:
10.1016/S2215-0366(19)30289-5]
16 Lever AG, Geurts HM. Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged,
and Older Adults with Autism Spectrum Disorder. J Autism Dev Disord 2016; 46: 1916-1930
[PMID: 26861713 DOI: 10.1007/s10803-016-2722-8]
17 Roy M, Prox-Vagedes V, Ohlmeier MD, Dillo W. Beyond childhood: psychiatric comorbidities and
social background of adults with Asperger syndrome. Psychiatr Danub 2015; 27: 50-59 [PMID:
25751431]
18 Hedley D, Uljarević M, Foley KR, Richdale A, Trollor J. Risk and protective factors underlying
depression and suicidal ideation in Autism Spectrum Disorder. Depress Anxiety 2018; 35: 648-657
[PMID: 29659141 DOI: 10.1002/da.22759]
19 Cassidy S, Bradley L, Shaw R, Baron-Cohen S. Risk markers for suicidality in autistic adults. Mol
Autism 2018; 9: 42 [PMID: 30083306 DOI: 10.1186/s13229-018-0226-4]
20 Hull L, Petrides KV, Allison C, Smith P, Baron-Cohen S, Lai MC, Mandy W. "Putting on My Best
Normal": Social Camouflaging in Adults with Autism Spectrum Conditions. J Autism Dev Disord
2017; 47: 2519-2534 [PMID: 28527095 DOI: 10.1007/s10803-017-3166-5]
21 Baron-Cohen S. Empathizing, systemizing, and the extreme male brain theory of autism. Prog
Brain Res 2010; 186: 167-175 [PMID: 21094892 DOI: 10.1016/B978-0-444-53630-3.00011-7]
22 Rynkiewicz A, Janas-Kozik M, Słopień A. Girls and women with autism. Psychiatr Pol 2019; 53:
737-752 [PMID: 31760407 DOI: 10.12740/PP/OnlineFirst/95098]
23 Matson JL, Williams LW. Differential diagnosis and comorbidity: distinguishing autism from other
mental health issues. Neuropsychiatry 2013; 3: 233-243 [DOI: 10.2217/npy.13.1]
24 Keller R, Chieregato S, Bari S, Castaldo R, Rutto F, Chiocchetti A, Dianzani U. Autism in

WJP https://www.wjgnet.com 1381 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

Adulthood: Clinical and Demographic Characteristics of a Cohort of Five Hundred Persons with
Autism Analyzed by a Novel Multistep Network Model. Brain Sci 2020; 10 [PMID: 32630229 DOI:
10.3390/brainsci10070416]
25 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097
[PMID: 19621072 DOI: 10.1371/journal.pmed.1000097]
26 Strunz S, Westphal L, Ritter K, Heuser I, Dziobek I, Roepke S. Personality Pathology of Adults
With Autism Spectrum Disorder Without Accompanying Intellectual Impairment in Comparison to
Adults With Personality Disorders. J Autism Dev Disord 2015; 45: 4026-4038 [PMID: 25022250
DOI: 10.1007/s10803-014-2183-x]
27 Gillberg C, Billstedt E. Autism and Asperger syndrome: coexistence with other clinical disorders.
Acta Psychiatr Scand 2000; 102: 321-330 [PMID: 11098802 DOI:
10.1034/j.1600-0447.2000.102005321.x]
28 Lehnhardt FG, Gawronski A, Pfeiffer K, Kockler H, Schilbach L, Vogeley K. The investigation
and differential diagnosis of Asperger syndrome in adults. Dtsch Arztebl Int 2013; 110: 755-763
[PMID: 24290364 DOI: 10.3238/arztebl.2013.0755]
29 Roy M, Dillo W, Emrich HM, Ohlmeier MD. Asperger's syndrome in adulthood. Dtsch Arztebl Int
2009; 106: 59-64 [PMID: 19562011 DOI: 10.3238/arztebl.2009.0059]
30 Shaltout E, Al-Dewik N, Samara M, Morsi H, Khattab A. Psychological comorbidities in autism
spectrum disorders. In: Essa MM, Qoronfleh MW. Personalized food intervention and therapy for
autism spectrum disorder management. Switzerland AG: Springer Nature 2020; 24: 163-191 [PMID:
32006360 DOI: 10.1007/978-3-030-30402-7_6]
31 Vannucchi G, Masi G, Toni C, Dell'Osso L, Marazziti D, Perugi G. Clinical features, developmental
course, and psychiatric comorbidity of adult autism spectrum disorders. CNS Spectr 2014; 19: 157-
164 [PMID: 24352005 DOI: 10.1017/S1092852913000941]
32 Woodbury-Smith MR, Volkmar FR. Asperger syndrome. Eur Child Adolesc Psychiatry 2009; 18:
2-11 [PMID: 18563474 DOI: 10.1007/s00787-008-0701-0]
33 Lodi-Smith J, Rodgers JD, Cunningham SA, Lopata C, Thomeer ML. Meta-analysis of Big Five
personality traits in autism spectrum disorder. Autism 2019; 23: 556-565 [PMID: 29676605 DOI:
10.1177/1362361318766571]
34 Vuijk R, Deen M, Sizoo B, Arntz A. Temperament, character, and personality disorders in adults
with autism spectrum disorder: a systematic literature review and meta-analysis. Rev J Autism Dev
Disord 2018; 5: 176-197 [DOI: 10.1007/s40489-018-0131-y]
35 First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured clinical interview for
DSM-IV Axis I disorders—clinician version (SCID-CV). Washington DC: American Psychiatric
Association, 1997 [DOI: 10.1002/brb3.1894/v1/decision1]
36 First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured clinical interview for
DSM-IV axis II personality disorders (SCID-II). Washington DC: American Psychiatric Association,
1997 [DOI: 10.1521/pedi.1995.9.2.83]
37 Loranger AW, Sartorius N, Andreoli A, Berger P, Buchheim P, Channabasavanna SM, Coid B,
Dahl A, Diekstra RF, Ferguson B. The International Personality Disorder Examination. The World
Health Organization/Alcohol, Drug Abuse, and Mental Health Administration international pilot
study of personality disorders. Arch Gen Psychiatry 1994; 51: 215-224 [PMID: 8122958 DOI:
10.1001/archpsyc.1994.03950030051005]
38 Lugnegård T, Hallerbäck MU, Gillberg C. Personality disorders and autism spectrum disorders:
what are the connections? Compr Psychiatry 2012; 53: 333-340 [PMID: 21821235 DOI:
10.1016/j.comppsych.2011.05.014]
39 Baron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E. The autism-spectrum quotient
(AQ): evidence from Asperger syndrome/high-functioning autism, males and females, scientists and
mathematicians. J Autism Dev Disord 2001; 31: 5-17 [PMID: 11439754 DOI:
10.1023/a:1005653411471]
40 Rydén E, Bejerot S. Autism spectrum disorders in an adult psychiatric population. A naturalistic
cross-sectional controlled study. Clin Neuropsychiatry 2008; 5: 13-21 [DOI:
10.1186/2040-2392-4-49]
41 Ekselius L, Lindström E, von Knorring L, Bodlund O, Kullgren G. SCID II interviews and the SCID
Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R. Acta Psychiatr
Scand 1994; 90: 120-123 [PMID: 7976457 DOI: 10.1111/j.1600-0447.1994.tb01566.x]
42 Gustavsson JP, Bergman H, Edman G, Ekselius L, von Knorring L, Linder J. Swedish universities
Scales of Personality (SSP): construction, internal consistency and normative data. Acta Psychiatr
Scand 2000; 102: 217-225 [PMID: 11008858 DOI: 10.1034/j.1600-0447.2000.102003217.x]
43 Ketelaars C, Horwitz E, Sytema S, Bos J, Wiersma D, Minderaa R, Hartman CA. Brief report:
adults with mild autism spectrum disorders (ASD): scores on the autism spectrum quotient (AQ) and
comorbid psychopathology. J Autism Dev Disord 2008; 38: 176-180 [PMID: 17385086 DOI:
10.1007/s10803-007-0358-4]
44 Geurts HM, Jansen MD. A retrospective chart study: the pathway to a diagnosis for adults referred
for ASD assessment. Autism 2012; 16: 299-305 [PMID: 21949003 DOI:
10.1177/1362361311421775]
45 Ghaziuddin M. Mental health aspects of autism and Asperger syndrome. Philadelphia PA: Jessica
Kingsley Publishers, 2005 [DOI: 10.7748/mhp.9.3.35.s30]

WJP https://www.wjgnet.com 1382 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

46 Tsakanikos E, Costello H, Holt G, Bouras N, Sturmey P, Newton T. Psychopathology in adults with


autism and intellectual disability. J Autism Dev Disord 2006; 36: 1123-1129 [PMID: 16855878 DOI:
10.1007/s10803-006-0149-3]
47 Anckarsäter H, Stahlberg O, Larson T, Hakansson C, Jutblad SB, Niklasson L, Nydén A, Wentz E,
Westergren S, Cloninger CR, Gillberg C, Rastam M. The impact of ADHD and autism spectrum
disorders on temperament, character, and personality development. Am J Psychiatry 2006; 163:
1239-1244 [PMID: 16816230 DOI: 10.1176/appi.ajp.163.7.1239]
48 Cloninger CR, Przybeck T, Svrakic DM, Wetzel RD. The Temperament and Character Inventory
(TCI): A Guide to its Development and Use. Washington University: Center for Psychobiology of
Personality, 1997 [DOI: 10.1037/t03902-000]
49 Sizoo B, van den Brink W, Gorissen van Eenige M, van der Gaag RJ. Personality characteristics of
adults with autism spectrum disorders or attention deficit hyperactivity disorder with and without
substance use disorders. J Nerv Ment Dis 2009; 197: 450-454 [PMID: 19525746 DOI:
10.1097/NMD.0b013e3181a61dd0]
50 Soderstrom H, Rastam M, Gillberg C. Temperament and character in adults with Asperger
syndrome. Autism 2002; 6: 287-297 [PMID: 12212919 DOI: 10.1177/1362361302006003006]
51 Vuijk R, de Nijs PFA, Deen M, Vitale S, Simons-Sprong M, Hengeveld MW. Temperament and
character in men with autism spectrum disorder: A reanalysis of scores on the Temperament and
Character Inventory by individual case matching. Contemp Clin Trials Commun 2018; 12: 55-59
[PMID: 30259003 DOI: 10.1016/j.conctc.2018.09.002]
52 Helles A, Wallinius M, Gillberg IC, Gillberg C, Billstedt E. Asperger syndrome in childhood -
personality dimensions in adult life: temperament, character and outcome trajectories. BJPsych Open
2016; 2: 210-216 [PMID: 27703778 DOI: 10.1192/bjpo.bp.116.002741]
53 Vuijk R, de Nijs PF, Vitale SG, Simons-Sprong M, Hengeveld MW. Personality traits in adults with
autism spectrum disorders measured by means of the Temperament and Character Inventory.
Tijdschr Psychiatr 2012; 54: 699-707 [PMID: 22893535]
54 John OP, Naumann LP, Soto CJ. Paradigm shift to the integrative Big Five trait taxonomy. In:
John OP, Robins RW, Pervin LA. Handbook of Personality: Theory and Research. New York:
Guildford Press, 2008: pp.114-158. [DOI: 10.1080/10478401003648732]
55 Schriber RA, Robins RW, Solomon M. Personality and self-insight in individuals with autism
spectrum disorder. J Pers Soc Psychol 2014; 106: 112-130 [PMID: 24377361 DOI:
10.1037/a0034950]
56 Schwartzman BC, Wood JJ, Kapp SK. Can the Five Factor Model of Personality Account for the
Variability of Autism Symptom Expression? J Autism Dev Disord 2016; 46: 253-272 [PMID:
26319256 DOI: 10.1007/s10803-015-2571-x]
57 Costa PT, McCrae RR. Revised NEO personality inventory (NEO-PI-R) and NEO five-factor
Inventory (NEO-FFI) professional manual. Odessa: Psychological Assessment Resources, 1992
[DOI: 10.4135/9781849200479.n9]
58 Ritvo RA, Ritvo ER, Guthrie D, Ritvo MJ, Hufnagel DH, McMahon W, Tonge B, Mataix-Cols D,
Jassi A, Attwood T, Eloff J. The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R): a
scale to assist the diagnosis of Autism Spectrum Disorder in adults: an international validation study.
J Autism Dev Disord 2011; 41: 1076-1089 [PMID: 21086033 DOI: 10.1007/s10803-010-1133-5]
59 Kanai C, Iwanami A, Hashimoto R, Ohta H, Tani M, Yamada T, Kato N. Clinical characterization
of adults with Asperger’s syndrome assessed by self-report questionnaires based on depression,
anxiety, and personality. Res Autism Spectr Disord 2011; 5: 1451-1458 [DOI:
10.1016/j.rasd.2011.02.005]
60 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:
361-370 [PMID: 6880820 DOI: 10.1111/j.1600-0447.1983.tb09716.x]
61 Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1987; 22: 141-173 [PMID: 2885745
DOI: 10.1159/000414022]
62 Hesselmark E, Eriksson JM, Westerlund J, Bejerot S. Autism Spectrum Disorders and Self-reports:
Testing Validity and Reliability Using the NEO-PI-R. J Autism Dev Disord 2015; 45: 1156-1166
[PMID: 25326256 DOI: 10.1007/s10803-014-2275-7]
63 Livesley WJ. Trait and behavioral prototypes of personality disorder. Am J Psychiatry 1986; 143:
728-732 [PMID: 3717394 DOI: 10.1176/ajp.143.6.728]
64 Livesley WJ. A systematic approach to the delineation of personality disorders. Am J Psychiatry
1987; 144: 772-777 [PMID: 3591999 DOI: 10.1176/ajp.144.6.772]
65 Ozonoff S, Garcia N, Clark E, Lainhart JE. MMPI-2 personality profiles of high-functioning adults
with autism spectrum disorders. Assessment 2005; 12: 86-95 [PMID: 15695746 DOI:
10.1177/1073191104273132]
66 Butcher JN, Graham JR, Ben-Porath YS, Tellegen A, Dahlstrom WG, Kraemer B. Minnesota
Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration, scoring, and
interpretation (Rev. ed.). Minneapolis: University of Minnesota Press, 2001 [DOI:
10.1037/t15120-000]
67 Kanai C, Iwanami A, Ohta H, Yamasue H, Matsushima E, Yokoi H, Shinohara K, Kato N. Clinical
characteristics of adults with Asperger’s syndrome assessed with self-report questionnaires. Res
Autism Spectr Disord 2011; 5: 185-190 [DOI: 10.1016/j.rasd.2010.03.008]
68 Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Questionnaire. London: Hodder
and Stoughton, 1975 [DOI: 10.1037/t05462-000]

WJP https://www.wjgnet.com 1383 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

69 Raine A. The SPQ: a scale for the assessment of schizotypal personality based on DSM-III-R
criteria. Schizophr Bull 1991; 17: 555-564 [PMID: 1805349 DOI: 10.1093/schbul/17.4.555]
70 Biamino E, Di Gregorio E, Belligni EF, Keller R, Riberi E, Gandione M, Calcia A, Mancini C,
Giorgio E, Cavalieri S, Pappi P, Talarico F, Fea AM, De Rubeis S, Cirillo Silengo M, Ferrero GB,
Brusco A. A novel 3q29 deletion associated with autism, intellectual disability, psychiatric disorders,
and obesity. Am J Med Genet B Neuropsychiatr Genet 2016; 171B: 290-299 [PMID: 26620927 DOI:
10.1002/ajmg.b.32406]
71 Cauda F, Nani A, Costa T, Palermo S, Tatu K, Manuello J, Duca S, Fox PT, Keller R. The
morphometric co-atrophy networking of schizophrenia, autistic and obsessive spectrum disorders.
Hum Brain Mapp 2018; 39: 1898-1928 [PMID: 29349864 DOI: 10.1002/hbm.23952]
72 Naito K, Matsui Y, Maeda K, Tanaka K. Evaluation of the validity of the Autism Spectrum Quotient
(AQ) in differentiating high-functioning autistic spectrum disorder from schizophrenia. Kobe J Med
Sci 2010; 56: E116-E124 [PMID: 21063152]
73 Wolff S. Schizoid personality in childhood: The links with Asperger syndrome, schizophrenia
spectrum disorders, and elective mutism. In: Schopler E, Mesibov GB, Kunce LJ. Asperger
syndrome or high-functioning autism? New York: Plenum, 1998: 123-142 [DOI:
10.1007/978-1-4615-5369-4_7]
74 Keller R, Piedimonte A, Bianco F, Bari S, Cauda F. Diagnostic Characteristics of Psychosis and
Autism Spectrum Disorder in Adolescence and Adulthood. A Case Series. Autism Open Access
2015; 6: 159 [DOI: 10.4172/2165-7890.1000159]
75 Mazza M, Lucci G, Pacitti F, Pino MC, Mariano M, Casacchia M, Roncone R. Could schizophrenic
subjects improve their social cognition abilities only with observation and imitation of social
situations? Neuropsychol Rehabil 2010; 20: 675-703 [PMID: 20714969 DOI:
10.1080/09602011.2010.486284]
76 Bishop-Fitzpatrick L, Mazefsky CA, Eack SM, Minshew NJ. Correlates of Social Functioning in
Autism Spectrum Disorder: The Role of Social Cognition. Res Autism Spectr Disord 2017; 35: 25-34
[PMID: 28839456 DOI: 10.1016/j.rasd.2016.11.013]
77 Pino MC, Mazza M, Mariano M, Peretti S, Dimitriou D, Masedu F, Valenti M, Franco F. Simple
Mindreading Abilities Predict Complex Theory of Mind: Developmental Delay in Autism Spectrum
Disorders. J Autism Dev Disord 2017; 47: 2743-2756 [PMID: 28597142 DOI:
10.1007/s10803-017-3194-1]
78 Pino MC, Masedu F, Vagnetti R, Attanasio M, Di Giovanni C, Valenti M, Mazza M. Validity of
Social Cognition Measures in the Clinical Services for Autism Spectrum Disorder. Front Psychol
2020; 11: 4 [PMID: 32116882 DOI: 10.3389/fpsyg.2020.00004]
79 Pino MC, Vagnetti R, Masedu F, Attanasio M, Tiberti S, Valenti M, Mazza M. Mapping the
Network of Social Cognition Domains in Children With Autism Spectrum Disorder Through Graph
Analysis. Front Psychiatry 2020; 11: 579339 [PMID: 33192721 DOI: 10.3389/fpsyt.2020.579339]
80 Bölte S, Poustka F. The recognition of facial affect in autistic and schizophrenic subjects and their
first-degree relatives. Psychol Med 2003; 33: 907-915 [PMID: 12877405 DOI:
10.1017/s0033291703007438]
81 Ozguven HD, Oner O, Baskak B, Oktem F, Olmez S, Munir K. Theory of Mind in Schizophrenia
and Asperger's Syndrome: Relationship with Negative Symptoms. Klinik Psikofarmakol Bulteni
2010; 20: 5-13 [PMID: 25584026 DOI: 10.1080/10177833.2010.11790628]
82 Tin LNW, Lui SSY, Ho KKY, Hung KSY, Wang Y, Yeung HKH, Wong TY, Lam SM, Chan RCK,
Cheung EFC. High-functioning autism patients share similar but more severe impairments in verbal
theory of mind than schizophrenia patients. Psychol Med 2018; 48: 1264-1273 [PMID: 28920569
DOI: 10.1017/S0033291717002690]
83 Pinkham AE, Morrison KE, Penn DL, Harvey PD, Kelsven S, Ludwig K, Sasson NJ.
Comprehensive comparison of social cognitive performance in autism spectrum disorder and
schizophrenia. Psychol Med 2020; 50: 2557-2565 [PMID: 31576783 DOI:
10.1017/S0033291719002708]
84 Booules-Katri TM, Pedreño C, Navarro JB, Pamias M, Obiols JE. Theory of Mind (ToM)
Performance in High Functioning Autism (HFA) and Schizotypal-Schizoid Personality Disorders
(SSPD) Patients. J Autism Dev Disord 2019; 49: 3376-3386 [PMID: 31104261 DOI:
10.1007/s10803-019-04058-1]
85 Mazza M, Pino MC, Mariano M, Tempesta D, Ferrara M, De Berardis D, Masedu F, Valenti M.
Affective and cognitive empathy in adolescents with autism spectrum disorder. Front Hum Neurosci
2014; 8: 791 [PMID: 25339889 DOI: 10.3389/fnhum.2014.00791]
86 Mazza M, Mariano M, Peretti S, Masedu F, Pino MC, Valenti M. The Role of Theory of Mind on
Social Information Processing in Children With Autism Spectrum Disorders: A Mediation Analysis.
J Autism Dev Disord 2017; 47: 1369-1379 [PMID: 28213839 DOI: 10.1007/s10803-017-3069-5]
87 Stanfield AC, Philip RCM, Whalley H, Romaniuk L, Hall J, Johnstone EC, Lawrie SM.
Dissociation of Brain Activation in Autism and Schizotypal Personality Disorder During Social
Judgments. Schizophr Bull 2017; 43: 1220-1228 [PMID: 29088456 DOI: 10.1093/schbul/sbx083]
88 Colle L, Gabbatore I, Riberi E, Borroz E, Bosco FM, Keller R. Mindreading abilities and borderline
personality disorder: A comprehensive assessment using the Theory of Mind Assessment Scale.
Psychiatry Res 2019; 272: 609-617 [PMID: 30616131 DOI: 10.1016/j.psychres.2018.12.102]
89 Dziobek I, Preissler S, Grozdanovic Z, Heuser I, Heekeren HR, Roepke S. Neuronal correlates of
altered empathy and social cognition in borderline personality disorder. Neuroimage 2011; 57: 539-

WJP https://www.wjgnet.com 1384 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

548 [PMID: 21586330 DOI: 10.1016/j.neuroimage.2011.05.005]


90 Preißler S, Dziobek I, Ritter K, Heekeren HR, Roepke S. Social Cognition in Borderline Personality
Disorder: Evidence for Disturbed Recognition of the Emotions, Thoughts, and Intentions of others.
Front Behav Neurosci 2010; 4: 182 [PMID: 21151817 DOI: 10.3389/fnbeh.2010.00182]
91 Roepke S, Vater A, Preißler S, Heekeren HR, Dziobek I. Social cognition in borderline personality
disorder. Front Neurosci 2012; 6: 195 [PMID: 23335877 DOI: 10.3389/fnins.2012.00195]
92 Dudas RB, Lovejoy C, Cassidy S, Allison C, Smith P, Baron-Cohen S. The overlap between autistic
spectrum conditions and borderline personality disorder. PLoS One 2017; 12: e0184447 [PMID:
28886113 DOI: 10.1371/journal.pone.0184447]
93 Baron-Cohen S, Richler J, Bisarya D, Gurunathan N, Wheelwright S. The systemizing quotient: an
investigation of adults with Asperger syndrome or high-functioning autism, and normal sex
differences. Philos Trans R Soc Lond B Biol Sci 2003; 358: 361-374 [PMID: 12639333 DOI:
10.1098/rstb.2002.1206]
94 Baron-Cohen S, Wheelwright S. The empathy quotient: an investigation of adults with Asperger
syndrome or high functioning autism, and normal sex differences. J Autism Dev Disord 2004; 34:
163-175 [PMID: 15162935 DOI: 10.1023/b:jadd.0000022607.19833.00]
95 López-Pérez B, Ambrona T, Gummerum M. Interpersonal emotion regulation in Asperger's
syndrome and borderline personality disorder. Br J Clin Psychol 2017; 56: 103-113 [PMID:
27990657 DOI: 10.1111/bjc.12124]
96 Strunz S, Dziobek I, Roepke S. [Comorbid psychiatric disorders and differential diagnosis of
patients with autism spectrum disorder without intellectual disability]. Psychother Psychosom Med
Psychol 2014; 64: 206-213 [PMID: 24234289 DOI: 10.1055/s-0033-1358708]
97 Attwood T. The Complete Guide to Asperger’s Syndrome. London: Jessica Kingsley Publishers,
2007 [DOI: 10.1177/13591045080130021008]
98 Blair RJ. Fine cuts of empathy and the amygdala: dissociable deficits in psychopathy and autism. Q
J Exp Psychol (Hove) 2008; 61: 157-170 [PMID: 18038346 DOI: 10.1080/17470210701508855]
99 Hansman-Wijnands MA, Hummelen JW. Differential diagnosis of psychopathy and autism
spectrum disorders in adults. Empathic deficit as a core symptom. Tijdschr Psychiatr 2006; 48: 627-
636 [PMID: 16958304]
100 Murphy D. Theory of mind in Asperger's syndrome, schizophrenia and personality disordered
forensic patients. Cogn Neuropsychiatry 2006; 11: 99-111 [PMID: 16537236 DOI:
10.1080/13546800444000182]
101 Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I. The "Reading the Mind in the Eyes" Test
revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning
autism. J Child Psychol Psychiatry 2001; 42: 241-251 [PMID: 11280420]
102 Cath DC, Ran N, Smit JH, van Balkom AJ, Comijs HC. Symptom overlap between autism spectrum
disorder, generalized social anxiety disorder and obsessive-compulsive disorder in adults: a
preliminary case-controlled study. Psychopathology 2008; 41: 101-110 [PMID: 18033980 DOI:
10.1159/000111555]
103 Fitzgerald M. Misdiagnosis of Asperger syndrome as anankastic personality disorder. Autism 2002;
6: 435 [PMID: 12540134 DOI: 10.1177/1362361302006004010]
104 Gadelkarim W, Shahper S, Reid J, Wikramanayake M, Kaur S, Kolli S, Osman S, Fineberg NA.
Overlap of obsessive-compulsive personality disorder and autism spectrum disorder traits among
OCD outpatients: an exploratory study. Int J Psychiatry Clin Pract 2019; 23: 297-306 [PMID:
31375037 DOI: 10.1080/13651501.2019.1638939]
105 Arduino GM, Keller R. Il ritiro sociale nei disturbi dello spettro autistico. Modelli clinici e
trattamento. In: Procacci M, Semerari A. Ritiro sociale: psicologia e clinica. Trento: Erickson, 2019:
207-230 [DOI: 10.3280/qpc47-2020oa11213]
106 Keller R, Bari S. Psychosis and ASD. In: Keller R. Psychopathology in Adolescents and Adults
with Autism Spectrum Disorders. Springer, 2019: 51-65 [DOI: 10.1007/978-3-030-26276-1_4]
107 Cloninger CR. A practical way to diagnosis personality disorder: a proposal. J Pers Disord 2000;
14: 99-108 [PMID: 10897461 DOI: 10.1521/pedi.2000.14.2.99]
108 Svrakic DM, Whitehead C, Przybeck TR, Cloninger CR. Differential diagnosis of personality
disorders by the seven-factor model of temperament and character. Arch Gen Psychiatry 1993; 50:
991-999 [PMID: 8250685 DOI: 10.1001/archpsyc.1993.01820240075009]
109 Rodgers JD, Lodi-Smith J, Hill PL, Spain SM, Lopata C, Thomeer ML. Brief Report: Personality
Mediates the Relationship between Autism Quotient and Well-Being: A Conceptual Replication
using Self-Report. J Autism Dev Disord 2018; 48: 307-315 [PMID: 28918443 DOI:
10.1007/s10803-017-3290-2]
110 Suh J, Orinstein A, Barton M, Chen CM, Eigsti IM, Ramirez-Esparza N, Fein D. Ratings of Broader
Autism Phenotype and Personality Traits in Optimal Outcomes from Autism Spectrum Disorder. J
Autism Dev Disord 2016; 46: 3505-3518 [PMID: 27538964 DOI: 10.1007/s10803-016-2868-4]
111 Vuijk R, Arntz A. Schema therapy as treatment for adults with autism spectrum disorder and
comorbid personality disorder: Protocol of a multiple-baseline case series study testing cognitive-
behavioral and experiential interventions. Contemp Clin Trials Commun 2017; 5: 80-85 [PMID:
29740624 DOI: 10.1016/j.conctc.2017.01.001]
112 Baron-Cohen S. The science of evil: on empathy and the origins of cruelty. Old Saybrook CT:
Tantor Media Inc, 2011 [DOI: 10.12775/pch.2014.019]
113 Rydén G, Rydén E, Hetta J. Borderline personality disorder and Autism Spectrum Disorder in

WJP https://www.wjgnet.com 1385 December 19, 2021 Volume 11 Issue 12


Rinaldi C et al. Autism spectrum disorder and personality disorders

females. A cross-sectional study. Clin Neuropsychiatry 2008; 5: 22-30 [DOI:


10.1097/yco.0000000000000318]
114 Lord C, Rutter M, Le Couteur A. Autism Diagnostic Interview-Revised: a revised version of a
diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J
Autism Dev Disord 1994; 24: 659-685 [PMID: 7814313 DOI: 10.1007/BF02172145]
115 Supekar K, Iyer T, Menon V. The influence of sex and age on prevalence rates of comorbid
conditions in autism. Autism Res 2017; 10: 778-789 [PMID: 28188687 DOI: 10.1002/aur.1741]
116 Wise EA, Smith MD, Rabins PV. Aging and Autism Spectrum Disorder: A Naturalistic,
Longitudinal Study of the Comorbidities and Behavioral and Neuropsychiatric Symptoms in Adults
with ASD. J Autism Dev Disord 2017; 47: 1708-1715 [PMID: 28303420 DOI:
10.1007/s10803-017-3095-3]

WJP https://www.wjgnet.com 1386 December 19, 2021 Volume 11 Issue 12


Published by Baishideng Publishing Group Inc
7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
Telephone: +1-925-3991568
E-mail: [email protected]
Help Desk: https://www.f6publishing.com/helpdesk
https://www.wjgnet.com

© 2021 Baishideng Publishing Group Inc. All rights reserved.

You might also like