Personality Disorders and ASD

  • Francesca De Cagna
  • Edoardo Squillari
  • Matteo Rocchetti
  • Laura Fusar-Poli


Autism spectrum disorder (ASD) in adolescence and adulthood is frequently difficult to discriminate from personality disorders (PD), a group of conditions that could present with similar symptomatology. For instance, PD belonging to cluster A (i.e., schizoid or schizotypal) share with high-functioning ASD the presence of odd behaviors and social withdrawal, while cluster B PD may present dysregulation in emotional expressivity, as well as self-injurious behaviors (i.e., borderline) and empathic behaviors (i.e., antisocial); finally, cluster C PD may again share a certain level of social avoidance (i.e., avoidant PD) or sameness (i.e., obsessive-compulsive PD). The assessment of PD in the low-functioning part of the spectrum may be even more difficult and few tools are available for their identification. Literature also reports that PD can be present also in comorbidity with ASD. In conclusion, during ASD assessment in adulthood it is always important to consider PD, both for differential diagnosis and for better treatment planning.


  1. 1.
    Millon T. Toward a new personology: an evolutionary model. Oxford: Wiley; 1990.Google Scholar
  2. 2.
    Roberts BW. Back to the future: personality and assessment and personality development. J Res Personality. 2009;43(2):137–45.CrossRefGoogle Scholar
  3. 3.
    Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50(12):975–90.PubMedCrossRefGoogle Scholar
  4. 4.
    Strelau J. The concept and status of trait in research on temperament. Eur J Personality. 2001;15(4):311–25.CrossRefGoogle Scholar
  5. 5.
    Cloninger CR, Bayon C, Svrakic DM. Measurement of temperament and character in mood disorders: a model of fundamental states as personality types. J Affect Disord. 1998;51(1):21–32.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Millon T. On the history and future study of personality and its disorders. Annu Rev Clin Psychol. 2012;8(1):1–19.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Kerekes N, Brandstrom S, Lundstrom S, Rastam M, Nilsson T, Anckarsater H. ADHD, autism spectrum disorder, temperament, and character: phenotypical associations and etiology in a Swedish childhood twin study. Compr Psychiatry. 2013;54(8):1140–7.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Kraepelin E. Dementia praecox and paraphrenia. Edinburgh: Livingstone; 1919.Google Scholar
  9. 9.
    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(8):699–707.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Poustka L, Bender F, Bock M, Bolte S, Mohler E, Banaschewski T, et al. Personality and social responsiveness in autism spectrum disorders and attention deficit/hyperactivity disorder. Z Kinder Jugendpsychiatr Psychother. 2011;39(2):133–41.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    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(3):556–65.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Roy M, Retzer A, Sikabofori T. Personality development and intellectual disability. Curr Opin Psychiatry. 2015;28(1):35–9.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Pridding A, Procter NG. A systematic review of personality disorder amongst people with intellectual disability with implications for the mental health nurse practitioner. J Clin Nurs. 2008;17(21):2811–9.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Harris J. Time to make up your mind: why choosing is difficult. Br J Learn Disabil. 2003;31(1):3–8.CrossRefGoogle Scholar
  15. 15.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). Arlington, VA: American Psychiatric; 2013.CrossRefGoogle Scholar
  16. 16.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Arlington, VA: American Psychiatric; 2000.Google Scholar
  17. 17.
    Alexander R, Cooray S. Diagnosis of personality disorders in learning disability. Br J Psychiatry. 2003;182:S28–31.CrossRefGoogle Scholar
  18. 18.
    Dosen A, Day K. In: Došen A, Day K, editors. Treating mental illness and behavior disorders in children and adults with mental retardation. Arlington, VA: American Psychiatric Pub; 2001. xv, 561-xv, p.Google Scholar
  19. 19.
    Royal College of Psychiatrists. DC-LD: diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation. London: Gaskell; 2001.Google Scholar
  20. 20.
    Barnhill J, Cooper SA, Fletcher RJ. Diagnostic manual–intellectual disability 2 (DM-ID): a textbook of diagnosis of mental disorders in persons with intellectual disability. New York: National Association for the Dually Diagnosed; 2007.Google Scholar
  21. 21.
    Bertelli M, Scuticchio D, Ferrandi A, Lassi S, Mango F, Ciavatta C, et al. Reliability and validity of the SPAID-G checklist for detecting psychiatric disorders in adults with intellectual disability. Res Dev Disabil. 2012;33(2):382–90.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Bertelli MO, Piva Merli M, Bradley E, Keller R, Varrucciu N, Del Furia C, et al. The diagnostic boundary between autism spectrum disorder, intellectual developmental disorder and schizophrenia spectrum disorders. Adv Mental Health Intell Disabil. 2015;9(5):243–64.CrossRefGoogle Scholar
  23. 23.
    Wolf JM, Ventola P. Assessment and treatment planning in adults with autism spectrum disorders. In: Volkmar FR, Reichow B, McPartland JC, editors. Adolescents and adults with autism spectrum disorders. New York: Springer; 2014. p. 283–98.CrossRefGoogle Scholar
  24. 24.
    Fusar-Poli L, Brondino N, Rocchetti M, Panisi C, Provenzani U, Damiani S, et al. Diagnosing ASD in adults without ID: accuracy of the ADOS-2 and the ADI-R. J Autism Dev Disord. 2017;47(11):3370–9.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Volkmar FR, Paul R, Rogers SJ, Pelphrey KA. Handbook of autism and pervasive developmental disorders, assessment, interventions, and policy. New York: Wiley; 2014.Google Scholar
  26. 26.
    Howlin P, Moss P. Adults with autism spectrum disorders. Can J Psychiatry. 2012;57(5):275–83.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Lai M-C, Lombardo MV, Baron-Cohen S. Autism. Lancet. 2014;383(9920):896–910.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Lugo-Marín J, Magán-Maganto M, Rivero-Santana A, Cuellar-Pompa L, Alviani M, Jenaro-Rio C, et al. Prevalence of psychiatric disorders in adults with autism spectrum disorder: a systematic review and meta-analysis. Res Autism Spectr Disord. 2019;59:22–33.CrossRefGoogle Scholar
  29. 29.
    Lugnegard T, Hallerback MU, Gillberg C. Personality disorders and autism spectrum disorders: what are the connections? Compr Psychiatry. 2012;53(4):333–40.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Hofvander B, Delorme R, Chaste P, Nyden A, Wentz E, Stahlberg O, et al. Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders. BMC Psychiatry. 2009;9:35.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Anckarsater H, Stahlberg O, Larson T, Hakansson C, Jutblad SB, Niklasson L, et al. The impact of ADHD and autism spectrum disorders on temperament, character, and personality development. Am J Psychiatry. 2006;163(7):1239–44.PubMedCrossRefGoogle Scholar
  32. 32.
    Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rossler A, Schultze-Lutter F, et al. The psychosis high-risk state: a comprehensive state-of-the-art review. JAMA Psychiatry. 2013;70(1):107–20.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Bleuler E. Dementia praecox, oder Gruppe der Schizophrenien. Leipzig: F. Deuticke; 1911.Google Scholar
  34. 34.
    Parnas J, Bovet P. Autism in schizophrenia revisited. Compr Psychiatry. 1991;32(1):7–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Minkowski E. La schizophrénie: psychopathologie des schizoïdes et des schizophrènes. Paris: Payot; 1927.Google Scholar
  36. 36.
    Minkowski E. Le Temps vécu: études phénoménologiques et psychopathologiques. Paris: J. L. L. L. d’Artrey; 1933.Google Scholar
  37. 37.
    Parnas J, Bovet P, Zahavi D. Schizophrenic autism: clinical phenomenology and pathogenetic implications. World Psychiatry. 2002;1(3):131–6.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Pilowsky T, Yirmiya N, Arbelle S, Mozes T. Theory of mind abilities of children with schizophrenia, children with autism, and normally developing children. Schizophr Res. 2000;42(2):145–55.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Solomon M, Olsen E, Niendam T, Ragland JD, Yoon J, Minzenberg M, et al. From lumping to splitting and back again: atypical social and language development in individuals with clinical-high-risk for psychosis, first episode schizophrenia, and autism spectrum disorders. Schizophr Res. 2011;131(1–3):146–51.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Craddock N, Owen MJ. The Kraepelinian dichotomy—going, going... but still not gone. Br J Psychiatry. 2010;196(2):92–5.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Hurst RM, Nelson-Gray RO, Mitchell JT, Kwapil TR. The relationship of Asperger’s characteristics and schizotypal personality traits in a non-clinical adult sample. J Autism Dev Disord. 2007;37(9):1711–20.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Spek AA, Wouters SGM. Autism and schizophrenia in high functioning adults: behavioral differences and overlap. Res Autism Spectr Disord. 2010;4(4):709–17.CrossRefGoogle Scholar
  43. 43.
    Konstantareas MM, Hewitt T. Autistic disorder and schizophrenia: diagnostic overlaps. J Autism Dev Disord. 2001;31(1):19–28.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Dinsdale NL, Hurd PL, Wakabayashi A, Elliot M, Crespi BJ. How are autism and schizotypy related? Evidence from a non-clinical population. PLoS One. 2013;8(5):e63316.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Volkmar FR, Cohen DJ. Comorbid association of autism and schizophrenia. Am J Psychiatry. 1991;148(12):1705–7.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Rutter M. Autism research: prospects and priorities. J Autism Dev Disord. 1996;26(2):257–75.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    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(1):5–17.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Raine A. The SPQ: a scale for the assessment of schizotypal personality based on DSM-III-R criteria. Schizophr Bull. 1991;17(4):555–64.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Barneveld PS, Pieterse J, de Sonneville L, van Rijn S, Lahuis B, van Engeland H, et al. Overlap of autistic and schizotypal traits in adolescents with autism spectrum disorders. Schizophr Res. 2011;126(1–3):231–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Russell-Smith SN, Maybery MT, Bayliss DMJP. Relationships between autistic-like and schizotypy traits: an analysis using the Autism Spectrum Quotient and Oxford-Liverpool Inventory of feelings and experiences. Personal Individ Differ. 2011;51(2):128–32.CrossRefGoogle Scholar
  51. 51.
    Crespi B, Badcock C. Psychosis and autism as diametrical disorders of the social brain. Behav Brain Sci. 2008;31(3):241–61; discussion 61-320.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Del Giudice M, Angeleri R, Brizio A, Elena MR. The evolution of autistic-like and schizotypal traits: a sexual selection hypothesis. Front Psychol. 2010;1:41.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Blackshaw AJ, Kinderman P, Hare DJ, Hatton C. Theory of mind, causal attribution and paranoia in Asperger syndrome. Autism. 2001;5(2):147–63.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Mottron L, Soulieres I, Menard E. Elements of a clinical differential diagnosis between Asperger syndrome and the schizoid/paranoid personality. Sante Ment Que. 2007;32(1):367–75.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Korzekwa MI, Dell PF, Links PS, Thabane L, Webb SP. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Compr Psychiatry. 2008;49(4):380–6.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453–61.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Mitchell AE, Dickens GL, Picchioni MM. Facial emotion processing in borderline personality disorder: a systematic review and meta-analysis. Neuropsychol Rev. 2014;24(2):166–84.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Dell'Osso L, Cremone IM, Carpita B, Fagiolini A, Massimetti G, Bossini L, et al. Correlates of autistic traits among patients with borderline personality disorder. Compr Psychiatry. 2018;83:7–11.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Gergely G. The development of teleological versus mentalizing observational learning strategies in infancy. Bull Menninger Clin. 2003;67(2):113–31.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Morandotti N, Brondino N, Merelli A, Boldrini A, De Vidovich GZ, Ricciardo S, et al. The Italian version of the reflective functioning questionnaire: validity data for adults and its association with severity of borderline personality disorder. PLoS One. 2018;13(11):e0206433.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Bateman A, Fonagy P. Psychotherapy for borderline personality disorder: mentalization-based treatment. Oxford: Oxford University Press; 2004.CrossRefGoogle Scholar
  62. 62.
    Frith U, Frith CD. Development and neurophysiology of mentalizing. Philos Trans R Soc Lond B Biol Sci. 2003;358(1431):459–73.PubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Rydén G, Rydén E, Hetta J. Borderline personality disorder and autism spectrum disorder in females—a cross-sectional study. Clin Neuropsychiatry. 2008;22(1).Google Scholar
  64. 64.
    Nanchen K, Brodfuehrer A, Heinrichs M, Philipsen A, van Elst LT, Matthies S. Autistic traits in patients with borderline personality disorder. Z Psychiatr Psychol Psychother. 2016;64(4):247.Google Scholar
  65. 65.
    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(9):e0184447.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Chabrol H, Raynal P. The co-occurrence of autistic traits and borderline personality disorder traits is associated to increased suicidal ideation in nonclinical young adults. Compr Psychiatry. 2018;82:141–3.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Miller JD, Campbell WK, Pilkonis PA. Narcissistic personality disorder: relations with distress and functional impairment. Compr Psychiatry. 2007;48(2):170–7.PubMedPubMedCentralCrossRefGoogle Scholar
  68. 68.
    Dziobek I, Rogers K, Fleck S, Bahnemann M, Heekeren HR, Wolf OT, et al. Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the multifaceted empathy test (MET). J Autism Dev Disord. 2008;38(3):464–73.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Ritter K, Dziobek I, Preissler S, Ruter A, Vater A, Fydrich T, et al. Lack of empathy in patients with narcissistic personality disorder. Psychiatry Res. 2011;187(1–2):241–7.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    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(12):4026–38.PubMedCrossRefGoogle Scholar
  71. 71.
    Walsh A, Wu HH. Differentiating antisocial personality disorder, psychopathy, and sociopathy: evolutionary, genetic, neurological, and sociological considerations. Crim Justice Stud. 2008;21(2):135–52.CrossRefGoogle Scholar
  72. 72.
    Asperger H. Die “Autistischen Psychopathen” im Kindesalter. Eur Arch Psychiatry Clin Neurosci. 1944;117(1):76–136.Google Scholar
  73. 73.
    Frith U. Asperger and his syndrome. In: Autism and Asperger syndrome, vol. 14. New York: Cambridge University Press; 1991. p. 1–36.CrossRefGoogle Scholar
  74. 74.
    Blair RJR. Fine cuts of empathy and the amygdala: dissociable deficits in psychopathy and autism. Q J Exp Psychol. 2008;61(1):157–70.CrossRefGoogle Scholar
  75. 75.
    Baron-Cohen S, Leslie AM, Frith U. Does the autistic child have a “theory of mind”? Cognition. 1985;21(1):37–46.PubMedCrossRefGoogle Scholar
  76. 76.
    Rogers K, Dziobek I, Hassenstab J, Wolf OT, Convit A. Who cares? Revisiting empathy in Asperger syndrome. J Autism Dev Disord. 2007;37(4):709–15.PubMedCrossRefGoogle Scholar
  77. 77.
    Rogers J, Viding E, Blair RJ, Frith U, Happe F. Autism spectrum disorder and psychopathy: shared cognitive underpinnings or double hit? Psychol Med. 2006;36(12):1789–98.PubMedCrossRefGoogle Scholar
  78. 78.
    Frick PJ, White SF. Research review: the importance of callous-unemotional traits for developmental models of aggressive and antisocial behavior. J Child Psychol Psychiatry. 2008;49(4):359–75.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Kimonis ER, Fanti KA, Frick PJ, Moffitt TE, Essau C, Bijttebier P, et al. Using self-reported callous-unemotional traits to cross-nationally assess the DSM-5 ‘With Limited Prosocial Emotions’ specifier. J Child Psychol Psychiatry. 2015;56(11):1249–61.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    King C, Murphy GH. A systematic review of people with autism spectrum disorder and the criminal justice system. J Autism Dev Disord. 2014;44(11):2717–33.PubMedCrossRefPubMedCentralGoogle Scholar
  81. 81.
    Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156(10):1563–9.PubMedCrossRefPubMedCentralGoogle Scholar
  82. 82.
    Vuijk R, Deen M, Sizoo B, et al. 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(2):176–97.CrossRefGoogle Scholar
  83. 83.
    Anckarsäter H, Stahlberg O, Larson T, Hakansson C, Jutblad SB, Niklasson L, et al. The impact of ADHD and autism spectrum disorders on temperament, character, and personality development. Am J Psychiatry. 2006;163(7):1239–44.PubMedCrossRefPubMedCentralGoogle Scholar
  84. 84.
    Ketelaars C, Horwitz E, Sytema S, Bos J, Wiersma D, Minderaa R, et al. 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(1):176–80.PubMedCrossRefPubMedCentralGoogle Scholar
  85. 85.
    Fitzgerald M. Misdiagnosis of Asperger syndrome as anankastic personality disorder. Autism. 2002;6(4):435.PubMedCrossRefPubMedCentralGoogle Scholar
  86. 86.
    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(45):755–63.PubMedPubMedCentralGoogle Scholar
  87. 87.
    Paul JD. The vacuum of the mind: a self-report on the phenomenology of autistic, obsessive-compulsive, and depressive comorbidity. Schizophr Bull. 2015;41(6):1207–10.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Francesca De Cagna
    • 1
  • Edoardo Squillari
    • 1
  • Matteo Rocchetti
    • 1
  • Laura Fusar-Poli
    • 2
  1. 1.Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly
  2. 2.Department of Clinical and Experimental Medicine, Section of PsychiatryUniversity of CataniaCataniaItaly

Personalised recommendations