Autistic traits and 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 the harmful myth that autistic people lack empathy.
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.
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
Key Points
- The study aimed to examine the relationship between autism and psychopathy, but faced significant challenges in measurement and interpretation of results.
- While some studies reported a higher prevalence of callous-unemotional traits (CUTs) and psychopathy in autistic individuals compared to the general population, these findings must be interpreted cautiously due to measurement issues.
- Both autism and psychopathy are associated with differences in empathy, but the nature of these differences and how they’re measured is complex and often misunderstood.
- Traditional measures of empathy may not accurately capture the unique ways autistic individuals experience and express empathy, leading to potential mischaracterization of their empathic abilities.
- Emotion recognition difficulties are observed in both autism and psychopathy, but the underlying reasons may differ significantly between the two conditions.
- Eye gaze patterns differ between autism and psychopathy, suggesting distinct underlying mechanisms for social information processing.
- The relationship between autism and psychopathy traits appears more complex in children compared to adults, potentially due to developmental factors and measurement challenges.
- While this research provides new insights, it is limited by inconsistent methodologies, small sample sizes in some cases, and a lack of autism-specific measures for empathy and psychopathy.
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).
This has led to increased focus on potential links between autism and psychopathy. Psychopathy is characterized by shallow emotional responses, lack of empathy or remorse, callousness, and poor behavioral control (Cleckley, 1941; Hare, 1991). It is strongly associated with criminal behavior and recidivism (Hare, 1999).
However, the relationship between autism and criminality is less clear. A systematic review by Collins et al. (2022) found widely varying rates of criminality among autistic individuals across studies (0.2-62.8%) and concluded there was little evidence of increased crime risk, though methodological limitations were noted.
Rogers et al. (2006) proposed the “double hit” hypothesis, suggesting that some autistic individuals may show additional empathy impairments best explained by co-occurring psychopathy. However, research directly examining the interaction between autism and psychopathy has been limited.
This systematic review therefore aimed to address this gap by synthesizing existing research to: 1) elucidate the relationship between psychopathy and autism, and 2) describe the clinical manifestation when both constructs co-occur.
Clarifying these issues is critical for developing appropriate interventions and care pathways, especially for those who encounter the criminal justice system.
Method
This systematic review was 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 through www.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:
- Studies investigating the relationship between symptoms/traits/characteristics of psychopathy/CUTs and ASD
- Clinical or non-clinical samples
- Articles in English
- Peer-reviewed articles or grey literature
Exclusion criteria:
- Review articles, editorials, book chapters
- Articles focused on antisocial personality disorder/conduct disorder without considering CUTs/psychopathy or relationship to ASD
No restrictions were placed on study design or date.
Article selection was completed independently by two reviewers, with 100% agreement. Data extraction was conducted by the first author, with 30% checked by a second reviewer (88% agreement).
Statistical measures
Due to the heterogeneity of included studies, a narrative synthesis approach was used following guidance by Popay et al. (2006). No meta-analysis was conducted.
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.
For instance, an autistic individual might feel deep empathy but express it in ways that are not typically recognized by standard assessments.
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:
- Comprehensive search strategy using multiple databases and including grey literature
- Adherence to PRISMA guidelines for systematic reviews
- Independent screening and data extraction by multiple reviewers
- Quality assessment of included studies using standardized tools
- Inclusion of a broad range of study designs and populations (children and adults, clinical and community samples)
- Consideration of both autism and psychopathy as dimensional traits rather than only categorical diagnoses
- Narrative synthesis approach allowing for integration of heterogeneous studies
Limitations
Several limitations should be considered when interpreting the results:
- Heterogeneity in methodologies, measures, and populations across studies made direct comparisons challenging
- Many studies relied on self-report measures of psychopathy, which may be less reliable in individuals who lack insight or tend to manipulate
- Lack of validated measures for assessing psychopathy in autistic populations
- Most studies were conducted in Western countries, limiting generalizability to other cultural contexts
- Limited research on females and adults, with a predominance of studies on male children
- Few studies directly examined co-occurring autism and psychopathy, limiting conclusions about their interaction
- Potential publication bias favoring significant findings
- Inability to conduct meta-analysis due to study heterogeneity
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
Cleckley, H. (1941). The mask of sanity; an attempt to reinterpret the so-called psychopathic personality. Mosby.
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.
Keep Learning
Below are some Socratic questions for discussion in a college class:
- How might cultural factors influence the relationship between autism and psychopathy? What cross-cultural research is needed?
- Given the distinct empathy profiles in autism versus psychopathy, how might this impact moral decision-making in individuals with these conditions? How could this be ethically studied?
- What are the potential risks and benefits of screening for psychopathic traits in autistic populations? How should clinicians approach this sensitively?
- How might the co-occurrence of autism and psychopathy impact an individual’s ability to form relationships or function in social/occupational settings? What supports might be beneficial?
- Given the measurement challenges highlighted in this review, what novel approaches could be developed to assess psychopathy in autistic individuals more accurately?
- How might early intervention for empathy and emotion recognition skills in childhood impact the developmental trajectory of individuals with autism, psychopathy, or both? What ethical considerations are involved in such interventions?
- What neurobiological mechanisms might underlie the distinct empathy profiles observed in autism versus psychopathy? How could advanced neuroimaging techniques contribute to our understanding?
- How should the criminal justice system adapt to better accommodate the unique needs and characteristics of individuals with co-occurring autism and psychopathy?
