Autistic traitsand psychopathy may appear to overlap due to difficulties in social communication and emotion recognition common in both conditions.
However, this superficial similarity has led to theharmful myththat autistic people lackempathy.
In reality, autistic individuals often experience deep empathy but may express it differently than neurotypical people expect.
While autistic people might struggle with cognitive empathy (understanding others’ perspectives), they often have intact or even heightened affective empathy (sharing others’ emotions).
The misconception stems from traditional empathy measures failing to capture the unique ways autistic people experience and express empathy, highlighting the need for more nuanced understanding and assessment methods.
Key Points
Rationale
This systematic review aimed to synthesize research on the relationship between autism and psychopathy in order to better understand how these constructs interact and manifest when co-occurring.
The rationale for this study stems from growing interest in the overlap between autism and psychopathy, particularly given their shared difficulties with empathy and social cognition, albeit through different underlying mechanisms (Blair, 2008).
Prior research has established that while aggression is not a core symptom of autism, rates of aggressive behavior in autistic children and adolescents range from 25-53% (Hill et al., 2014; Mazurek et al., 2013).
Clarifying these issues is critical for developing appropriate interventions and care pathways, especially for those who encounter the criminal justice system.
Method
Thissystematic reviewwas conducted according to PRISMA guidelines and registered with PROSPERO (registration CRD42023413672).
Databases searched included PsychINFO, CINAHL Ultimate, and Medline Ultimate. Google Scholar was also searched and backward searching of identified papers was completed.
Grey literature was searched throughwww.opengrey.eu. Searches were conducted in March-April 2023.
Search strategy and terms
Key terms were searched using English and American terminology, spelling, and truncation. Search categories included:
Autism:“Autism Spectrum Disorder” OR Autis* OR ASD OR ASC OR Asperger* OR “Pervasive Developmental Disorder/condition” OR “neurodevelopmental disorder” OR Kanner*
Psychopathy:psychopathy OR psychopathic OR psychopath* OR “CU traits” OR “callous unemotional”
Terms were combined using “AND”. Searches were restricted to title only with “NOT psychopathology” in title/abstract to improve relevance.
Inclusion and exclusion criteria
Inclusion criteria:
Exclusion criteria:
No restrictions were placed on study design or date.
Statistical measures
Quality assessment was performed using the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies for most studies, and the Checklist for Cohort Studies for one longitudinal study.
Results
Study characteristics:
36 studies met inclusion criteria. 22 studies recruited children and 14 recruited adults. Studies were conducted across 11 Western countries. Sample sizes ranged from 7 to several thousand.
A total of 12,115 children were included across studies (6,654 males, 5,461 females). Of these, 746 had primary diagnoses of autism/autistic traits and 319 had conduct problems/CUTs/psychopathic traits.
For adults, 1,888 participants were included (1,133 males, 752 females, 3 non-binary). 163 adults had autism diagnoses/traits and 80 had psychopathic traits.
Measurement:
Studies used a variety of measures to assess autism and psychopathy/CUTs. Common autism measures included the ADOS, ADI-R, AQ, SCQ, and SRS.
For psychopathy/CUTs, the ICU was frequently used in children, while adult studies often used self-report measures like the PPI-R.
However, no measures have been validated specifically for assessing psychopathy in autistic populations.
Prevalence and relationship:
Estimates of CUTs/psychopathy prevalence in autistic individuals ranged from 22-56% across studies, compared to ~4.5% in the general population.
Most studies found positive correlations between autistic and psychopathic traits, particularly in children (r = 0.40-0.60). Correlations were generally weaker or non-significant in adults.
Empathy profiles:
Multiple studies found distinct empathy profiles for autism vs psychopathy.
In adults, psychopathy was associated with diminished affective empathy and intact cognitive empathy, while autism showed the inverse pattern.
In children, autism was consistently linked to cognitive empathy deficits with intact affective empathy. Findings on empathy in children with CUTs/psychopathy were mixed.
Emotion recognition:
Both autism and psychopathy were associated with emotion recognition difficulties, particularly for fear and sadness.
Some evidence suggested these deficits persisted when the conditions co-occurred. Eye gaze patterns differed, with cueing to the eyes improving fear recognition in children with CUTs but worsening overall emotion recognition in children with autistic traits.
Neural correlates:
Limited neuroimaging studies found atypical neural responses during empathy and emotion processing tasks in both autism and psychopathy but with distinct patterns of activation.
Co-occurrence:
Few studies directly examined co-occurring autism and psychopathy. Some evidence supported the “double hit” hypothesis of additional impairments, but findings were inconsistent.
One study found enhanced conflict monitoring skills in autistic children with high CUTs.
Insight
This systematic review attempts to synthesize research on the relationship between autism and psychopathy, but it’s crucial to approach its findings with caution.
The higher reported prevalence of CUTs/psychopathy in autistic individuals compared to the general population is a finding that requires careful interpretation. It may reflect true comorbidity in some cases, but could also result from measurement issues, phenotypic overlap between constructs, or misinterpretation of autistic traits.
A critical insight from this review is the recognition of distinct empathy profiles in autism versus psychopathy.
However, it’s essential to understand that traditional empathy measures may not accurately capture the unique ways autistic individuals experience and express empathy.
Issues such as reliance on outward expressions of empathy, the impact of alexithymia on self-reported empathy, and the context-dependent nature of empathy expression in autism are not always accounted for in standardized measures.
They may also show different levels of empathy depending on the situation or their relationship to the person involved, factors often overlooked in research settings.
Additionally, motor differences or atypical facial expressions in autism could be misinterpreted as lack of empathy when using traditional observational measures.
The finding that cueing attention to the eyes has opposite effects on fear recognition in autism versus CUTs is intriguing and suggests distinct underlying mechanisms for social information processing.
This highlights the importance of considering the unique cognitive and perceptual experiences of autistic individuals when interpreting social behavior.
The weaker relationship between autistic and psychopathic traits in adults compared to children warrants further investigation. This could reflect true developmental changes, measurement issues, or a combination of both.
It underscores the need for longitudinal research and the development of more nuanced, autism-specific measures for assessing both empathy and psychopathic traits across the lifespan.
It’s crucial to emphasize that this research does not suggest that autistic individuals are more likely to be psychopathic.
Rather, it highlights the complex nature of empathy and social cognition in autism, and the significant challenges in accurately measuring these constructs.
Future research should focus on developing more appropriate assessment tools that can capture the unique ways autistic individuals experience and express empathy, as well as distinguishing between true psychopathic traits and features of autism that may superficially resemble them.
Ultimately, this review underscores the need for a more nuanced understanding of social and emotional processing in autism, free from the constraints of neurotypical expectations and measurement approaches.
It calls for a shift towards research methods that can better capture the diverse ways empathy and social connection may manifest in autistic individuals.
Strengths
The study had several methodological strengths:
Limitations
Several limitations should be considered when interpreting the results:
These limitations highlight the need for more standardized, cross-cultural research on autism and psychopathy across diverse age groups and genders.
Longitudinal studies and the development of psychopathy measures validated for autistic populations are particularly important next steps.
Implications
The findings of this review have several important implications:
Clinical practice:
The higher prevalence of CUTs/psychopathy in autistic individuals suggests clinicians should routinely screen for these traits when assessing autistic patients, particularly those with behavioral difficulties.
Conversely, considering autistic traits in individuals with psychopathy may be warranted. Treatment approaches may need to be tailored when autism and psychopathy co-occur, given their distinct empathy profiles and potential additive impairments.
Forensic settings:
The complex relationship between autism, psychopathy, and criminal behavior highlighted in this review emphasizes the need for nuanced assessment in forensic contexts.
Autistic individuals may be at risk of misclassification if psychopathic traits are not considered separately.
Intervention development:
The distinct patterns of empathy and emotion recognition deficits in autism versus psychopathy suggest that interventions targeting these skills may need to be condition-specific.
For example, interventions focusing on eye gaze may have different effects in autistic versus psychopathic individuals.
Research:
This review underscores the need for more targeted research on co-occurring autism and psychopathy, including longitudinal studies tracking developmental trajectories.
Developing and validating psychopathy measures for autistic populations is a critical priority.
Ethical considerations:
The potential stigma associated with both autism and psychopathy necessitates careful communication of research findings in this area.
It is crucial to emphasize the heterogeneity within both conditions and avoid overgeneralization.
Policy:
The complex relationship between these conditions and criminal behavior highlights the need for specialized training for law enforcement and judicial personnel in recognizing and appropriately responding to individuals with autism and/or psychopathy.
References
Primary reference
Maguire, K., Warman, H., Blumenfeld, F., & Langdon, P. E. (2024). The relationship between psychopathy and autism: a systematic review and narrative synthesis.Frontiers in Psychiatry,15, 1375170.https://doi.org/10.3389/fpsyt.2024.1375170
Other references
Blair, R. J. R. (2008). Fine cuts of empathy and the amygdala: dissociable deficits in psychopathy and autism.Quarterly journal of experimental psychology,61(1), 157-170.https://doi.org/10.1080/17470210701508855
Collins, J., Horton, K., Gale-St. Ives, E., Murphy, G., & Barnoux, M. (2023). A systematic review of autistic people and the criminal justice system: an update of king and murphy (2014).Journal of Autism and Developmental Disorders,53(8), 3151-3179.https://doi.org/10.1007/s10803-022-05590-3
Hare, R. D. (1991). The Hare Psychopathy Checklist-Revised.Multi-Health Systems.
Hare, R. D. (1999). Psychopathy as a risk factor for violence.Psychiatric quarterly,70, 181-197.https://doi.org/10.1023/A:1022094925150
Hill, A. P., Zuckerman, K. E., Hagen, A. D., Kriz, D. J., Duvall, S. W., Van Santen, J., … & Fombonne, E. (2014). Aggressive behavior problems in children with autism spectrum disorders: Prevalence and correlates in a large clinical sample.Research in autism spectrum disorders,8(9), 1121-1133.https://doi.org/10.1016/j.rasd.2014.05.006
Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013). Physical aggression in children and adolescents with autism spectrum disorders.Research in Autism Spectrum Disorders,7(3), 455-465.https://doi.org/10.1016/j.rasd.2012.11.004
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., … & Duffy, S. (2006). Guidance on the conduct of narrative synthesis in systematic reviews.A product from the ESRC methods programme Version,1(1), b92.
Rogers, J., Viding, E., Blair, R. J., Frith, U. T. A., & Happe, F. (2006). Autism spectrum disorder and psychopathy: shared cognitive underpinnings or double hit?.Psychological medicine,36(12), 1789-1798.
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Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
