Clinical reflections on the intersections of autism and personality development

Think twice before diagnosing an autistic individual with personality disorders

When the clinical profiles of what we now conceptualize as autism were first described, many characteristics were already seen as part of the child’s personality. For example, Hans Asperger stated in his 1944 Die ‘Autistischen Psychopathen’ im Kindesalter paper that he aimed

to report on a personality disorder already manifest in childhood . . . The literature on personality types certainly includes those who show similarities to the autistic personality . . . above all, the introverted personality described by C. G. Jung. In the description of the introvert, in particular, there is much that is reminiscent of the children described here . . . However, none of the authors mentioned has anything to say about the behaviour of their particular personality types in childhood. (pp. 87–90) (Asperger, 1944/1991).

Sula Wolff in her 1995 book, Loners: The Life Path of Unusual Children argued that

From the start, it has been my belief that the children I called ‘schizoid’ were showing in their early years the personality characteristics previously identified as schizoid mainly in adult people . . . Like Asperger, I considered the condition to be innate, not due to life experiences . . . I found the condition to be very stable over time . . . While we found continuity of characteristic personality traits in almost all our schizoid children, a number of them did not have these traits in any severe or handicapping form in later life. (pp. 123–124) (Wolff, 1995).

These historical accounts allude to the idea that autistic/neurodivergent ways of being do intersect with personality development, but this idea has not been incorporated into the modern conceptualization of general personality structure (e.g. the Five-Factor Model) or clinical categories (e.g. the personality disorder constructs). Consequently, current rates of DSM-based clusters A and C personality disorder diagnoses are high in autistic adults (Rinaldi et al., 2021). Such superficial overlap prompts the calls for careful differentiation based on the clinical gestalt, measurement clarification, and critical thought about the limitations and problems of current diagnostic systems to avoid mis- or over-diagnosis (Lai & Baron-Cohen, 2015; Lugnegård et al., 2012), such as with obsessive-compulsive/anankastic (Fitzgerald, 2002), avoidant (Lugnegård et al., 2012), borderline (May et al., 2021), antisocial (Carthy & Murphy, 2021), schizotypal (Poletti & Raballo, 2020), or schizoid (Cook et al., 2020) personality traits, difficulty, or disorders.

Anckarsäter and colleagues point out that depending on their training and theoretical framework, a clinician may diagnose a neurodivergent individual with a ‘primary’ personality disorder, especially when seen in adulthood; even if this is a ‘correct’ diagnosis by phenomenology, it is unclear the extent to which the personality disorder diagnosis helps understand the challenges the individual encounters (Anckarsäter et al., 2006). Nonetheless, personality-related clinical information can be helpful for depicting the life experiences of the autistic person (Lugnegård et al., 2012), and an autistic/neurodivergent person can still develop a personality disorder. Hence, when it comes to assessing for autism versus personality disorders/difficulty/traits, the diagnostician must be cautious about checklist-type practice and go beyond behaviour-based differential diagnosis. To avoid misunderstanding and misdiagnosis, we also need to ground the diagnostic formulation by acknowledging (1) the questionable construct validity of certain modern personality disorder diagnoses in autistic/neurodivergent individuals and (2) that autistic/neurodivergent ways of being are entwined with the individual’s personality development.

Consider how autistic/neurodivergent ways of being shape personality development: what is known and what is not yet understood

Elucidating how the autistic/neurodivergent ways of being intersect with personality development can be more helpful than assigning a personality disorder/trait label. On average, autistic people tend to show lower openness, conscientiousness, extraversion, agreeableness, and emotional stability than non-autistic people on the Big Five personality traits (Lodi-Smith et al., 2019). Understanding this tendency while being mindful of the large variability of the Big Five traits among autistic individuals and their independence to autistic characteristics (Lodi-Smith et al., 2019) may help understand the variable life outcomes of autistic people. Clarifying the developmental relationships between autism and personality ensures that autistic people are well understood and supported as early as possible.

Personality as an umbrella term includes components that are developmentally linked, from temperament, object relations, character, identity, ethical value systems, to cognitive potential (Kernberg, 2018). Autistic/neurodivergent characteristics are present from early in life and thus intersect with all these components. Most research to date examines temperament. Temperament characterizes biologically driven individual differences early in life regarding affectivity/emotionality, sociability, and self-regulation (Chetcuti et al., 2019). On average, autistic children demonstrate higher negative affectivity, lower sociability and self-regulation than neurotypical children or children with other diagnoses (Chetcuti et al., 2021). Temperament may signal individual differences in autistic children that have developmental relevance to adaptation, mental health, and well-being outcomes (Chetcuti et al., 2020; Helles et al., 2016), which is supported by increasing longitudinal studies (Chetcuti et al., 2021; Konke et al., 2022; Lee et al., 2020; Narvekar et al., 2022). But there are still many knowledge gaps, especially regarding (1) how variability in temperament reflects and interacts with neurodivergent early-stage sensory-motor processing and later neurocognitive modifiers (e.g. executive attention and social engagement) (Johnson et al., 2021); (2) how these early individual characteristics enriched by autism/neurodivergence interact with the social and physical environments to shape subsequent personality components across development (i.e. attachment, early affective memory and relations with significant others, habitual behavioural patterns, self-identity, and later value systems and cognitive features) (Kernberg, 2018); (3) how the person-environment fit at different stages of development affects wellbeing and can be understood through relevant models (e.g. the impact of invalidating environments (Linehan, 1993), consequent difficulties with mentalization (Fonagy & Luyten, 2009), and the influences of bidirectional differences in communication style highlighted by the double empathy problem (Milton, 2012)); and (4) how the autism-enriched personality organization corresponds to current taxonomy of personality structure and conceptualization of the dimensional versus categorical accounts of autism and constructs like the broader autism phenotype (Dell’Osso et al., 2016).

Practically, what is needed but under-developed is to integrate these developmental and ecological systems understandings of personality development to (1) inform clinical formulation and support for the autistic person (e.g. adjusting trauma-informed care or dialectical behavioural therapy skills teaching considering an autism-enriched temperament profile, modifying cognitive behavioural therapy considering the value systems and thinking style of an autistic person) as in the case of improving mental health care for autistic people (Mandy, 2022); and (2) actively re-shape the environments to enhance ‘goodness of fit’ (Lai et al., 2020)—akin to the lessons learnt from temperament research on adjusting the compatibility between an individual’s temperament and how the environment treats the individual to facilitate their personal and career goals (Chess & Thomas, 1991).

Clinicians should critically reflect on the current nosology of psychiatry and scrutinize checklist-type diagnostic practice and differential diagnosis when it comes to the intersections of autism and personality. Meanwhile, our field needs more longitudinal research to delineate the developmental relationships between autism/neurodivergence and personality components, to improve diagnostic conceptual clarity for clinicians. With these reflections, we are then able to train ourselves and the next generation of clinicians to ponder deeper on the clinical formulation when it comes to supporting neurodivergent individuals and the environmental contexts.