Okay, esteemed colleagues, my name is Sam Vaknin and I'm a professor of psychology in Southern Federal University, Rostov-on-Don in Russia, and a professor of finance and professor of psychology in the global outreach program of SIAS-CIAPS, Center for International Advanced and Professional Studies. Apologies for this long introduction, it's obligatory by my contractor.
Today we are going to discuss the differences between autism spectrum disorder and certain personality disorders, especially narcissistic personality disorder.
Why do we need to discuss this at all? Ostensibly, these are two different families of disorders. They're not on the same axis in the Diagnostic and Statistical Manual.
Well, we need to discuss the differences because autism spectrum disorders are very often misdiagnosed as personality disorders.
Now we are all acquainted with Asperger's disorder.
Asperger's disorder was described by regrettably a pro-Nazi Viennese doctor, but this is a misattribution. The first person to describe autism much more accurately than Asperger was actually Bleuler, the Swiss doctor in the 19th century, long before Asperger. Still, for some oblivious reason, Asperger got the credit and there was a disorder named after him, Asperger's disorder.
The Diagnostic and Statistical Manual, Edition 5 in 2013, renamed Asperger's disorder and now it's called autism spectrum disorder level one.
At any rate, this is the historical background, but what used to be called Asperger's disorder is often misdiagnosed as narcissistic personality disorder.
The first mistake is that Asperger's disorder can be diagnosed as early as age three, while narcissistic personality disorder should never be diagnosed before the end of adolescence and early young adulthood.
Pathological narcissism is not pathological when it occurs in children and when it occurs in adolescence. Narcissism generally is very healthy in these two phases of separation and individuation when we acquire identity, when we differentiate roles, when we learn how to be what we later become. Learning to become, taking on the world, exploring our environment, assuming risks, this requires grandiosity. It requires narcissism. It's healthy narcissism underlies a regulated sense of self-esteem, self-confidence and a sense of self-worth.
So, pathological narcissism cannot be diagnosed and should not be diagnosed before late adolescence at the earliest, but Asperger and other autistic spectrum disorders can safely be diagnosed even at age three.
Despite the fact that we find autism spectrum disorder among children age three, four, five, six, this misdiagnosis is all pervasive.
Let us try to generate a few pointers as to the differential diagnosis between the two.
The Asperger's disordered patient is self-centered, exactly like the narcissist. He is engrossed in a narrow range of interests and activities, social and occupational interactions with the autistic patient are severely hampered, conversational skills, the give and take of verbal intercourse. These are primitive, rudimentary, very basic.
The Asperger's patient's body language, eye to eye gaze, body posture, facial expressions and micro expressions, this is all constricted and artificial. It's a little like the patient is imitating, not really acting or behaving. And this is very typical in other personality disorders, in personality disorders, schizoid personality disorder, schizotypal personality disorder and yes, narcissistic personality disorder.
Nonverbal cues are virtually absent. Their interpretation in others is lacking. The autistic patient cannot properly identify, spot, detect, social cues, sexual cues, behavioral cues and grossly misinterpret other people's body language and even other people's verbiage, things they say.
Now, all of this is common to the narcissist and to the autistic patient. And it raises the issue of a chicken and egg.
From a very, very early age, from the age of three or four, the autistic patient is rejected, rejected sometimes by his or her own parents, by family, by peers, by teachers, by role models.
This rejection is perceived as abandonment. It challenges the formation of object constancy. It elevates the level of anxiety in the patient.
So many patients with autistic spectrum disorders develop narcissistic defenses. They defend against an environment which they perceive to be frustrating and hostile by essentially becoming narcissist.
It's an open question whether in autistic patients, narcissism, pathological narcissism is not actually a defense and aimed as a positive adaptation to survive in an environment which is largely rejection, rejecting and hostile.
Despite this, it must be emphasized that the aspergers patient has very little in common with the personality disorder patients. Aspergers and personality pathologies have little in common. Autism spectrum disorder is misdiagnosed as personality disorders we said it before.
And we also describe the similarities and yet the gulf between autism and pathological narcissism is vast, clinically speaking.
The narcissist, for example, switches between social agility and gregariousness and social impairment, schizoid mode. And these switches are voluntary. They're utterly controllable. They are choices. Also defiance, reactance, antisocial behaviors are choices. Everything the narcissist does, each and every one of his behaviors, these are choices. His social dysfunctioning is the outcome of conscious, conscious, deliberate, premeditated, haughtiness and the reluctance to invest scarce mental energy in cultivating relationships with inferior and unworthy others.
As far as the narcissist is concerned, everyone is inferior to him. Everyone is not worthy of his cosmically precious time and resources.
It's not the case with the autistic patient.
When the narcissist is confronted with potential sources of narcissistic supply, attention, adulation, admiration, the narcissist easily switches, regains his social skills. He becomes charming. He becomes sociable. He suddenly loves people. He suddenly love bombs them, grooms them. He tries to convert them into long-term sources of supply.
The autistic patient has no access, no recourse to such behavior. Even when the autistic patient decides to become sociable, decides to socialize, to have fun, to have good time, to court, to flirt, to engage in any social interaction, his social skills are so massively impaired his inability to read social cues is irredeemably dysfunctional that he simply can't do it.
The narcissist can choose to be pro-social and communal. The autistic patient cannot. Never mind how hard he wished he could, he cannot.
Many narcissists reach the highest ranks of their community. They become pillars of the community, of the church. They become chief executive officers of Fortune 500 companies. They head voluntary organizations, multinationals. They become famous actors, politicians, you know, they make it. They are very, very adept at the social game. They're very accomplished.
Most of the time, narcissists function flawlessly though the inevitable blow-ups and the grating extortion of narcissistic supply usually put an end to the narcissist's career and social liaisons sooner or later. Still, the narcissist is socially functional.
The autistic patient is manifestly not, determinately not functional.
He is not anti-social. The autistic patient is not anti-social. He is simply a-social.
The narcissist switches, fluctuates, pendulates between being over-social and being anti-social.
The autistic patient often wants to be accepted socially. He wants to have friends. He wants to get married. He wants to be sexually active. He wants to sire offspring. The autistic patient just doesn't have a clue how to go about it.
The affect of the autistic patient is limited.
His initiative, for instance, to share his experiences with his nearest and dearest or in a different setting to engage in flirting and seduction and foreplay, he doesn't know. He's clueless. He's thwarted by his own deficiencies and inadequacies. The ability of the autistic patient to divulge his emotions. This ability is tilted. He is incapable of reciprocating.
He is largely unaware of the wishes, needs, feelings, signaling of his interlocutors or counterparties. He's like a blind person in a colorful environment.
So inevitably, autistic patients are perceived by others as called eccentric, insensitive, indifferent, repulsive, exploitative, haunting, arrogant or emotionally absent.
That's how people describe autistic patients. And this description is identical to the description of the narcissist.
But phenomenologically, they are the same. Aetiologically, they are not.
The reasons the etiology of narcissism has nothing to do with the etiology of autism spectrum disorders. That the autistic person and the narcissist behave the same means nothing because their inner landscape couldn't be more different.
To avoid the pain of rejection, autistic patients confine themselves to solitary activities. But unlike the schizoid patient, this is not by choice. They hate it. They don't want it. They feel inadequate. They feel humiliated by their own repeated recurrent failure to engage, to integrate, to interact.
And so they constrict the world. The autistic patient limits their world to a single topic, a single hobby, a single person. And they dive into this with a greatest all consuming intensity, almost compulsively, almost obsessively, excluding all other matters and everyone else.
Avoiding the world, constricting life, becoming a laser, a laser beam focused on a single topic, mathematics, physics, whatever it is. That's a form of pain aversion. It's a form of hurt control, regulation of emotions, which would otherwise overwhelm the autistic patient.
He would experience emotional dysregulation akin, for example, to the borderline patient.
And so while the narcissist avoids pain, also avoids pain, by excluding, devaluing, and discarding other people, the autistic patient achieves the same result, avoiding pain, by withdrawing and by passionately incorporating himself in his universe and introducing into this universe only one or two people, one or two subjects of interest.
The narcissist goes out into the world in order to somehow establish his superiority, somehow integrate in a hierarchy of dominance and relative positioning being at the top. He regards everyone with contempt and disdain as inferior, not worthy of him.
The autistic patient also withdraws from the world, but not because he regards other people as inferior and contemptible. He withdraws from the world because it's very painful for him to be in the world.
So he minimizes his world. He is a tiny universe with one or two people he trusts, usually family members, and one or two topics he is engaged in. And in this sense, he again looks exactly like the schizoid patient, but the etiology is very different.
The schizoid loves, loves his existence. He is emotionally invested. He's cathected in his existence. He likes to be alone. He likes solitary activities. He hates people. He hates the presence of people in his life, the schizoid.
With the schizoid, it is a choice. Almost one could say an alternative lifestyle. Not so with the autistic patient. The autistic patient does this because he has no choice.
And so while the narcissist avoids pain by hurting others, the autistic patient avoids pain by hurting himself.
The use of language is another differentiating factor. The narcissist is a skilled communicator. He uses language as an instrument to obtain narcissistic supply, attention, adulation, admiration. Or he uses language as a weapon to obliterate his so-called enemies.
He's a bit paranoid with the persecutory delusions, or to humiliate people sadistically, put them in their place, or to establish a hierarchy of dominance.
And he uses language to punish, to penalize discarded resources and sources of supply. And people who had, in his mind at least, betrayed him somehow.
Cerebral narcissists, intellectual narcissists, narcissists who derive narcissistic supply by displaying their intellect and intelligence - these kinds of narcissists derive the supply from the consummate use that they make of their verbosity, of their control and mastery of the language.
It's not the same with the autistic patient. The autistic patient has a very complicated relationship with language. The autistic patient can be equally verbose. Anyone who came across an autistic patient knows that they can suddenly launch themselves into a six-hour monologue and you can't stop them.
So he can be verbose. Or he can be taciturn. He can be silent and there's no way to draw him out on other occasions.
But the difference between the narcissist and the autistic patient is that the autistic patient's monologues, the rare instances that he opens up and talks and discusses anything, they are all focused on his topics.
And these are very few topics, usually one. And so they are tediously repetitive.
The autistic patient is unlikely to obey conversational rules in etiquette. For example, he's not likely to let other people speak in turn. And the autistic patient is unable to decipher nonverbal cues and gestures or to monitor his own misbehavior on such occasions.
Narcissists are completely different. Although narcissists are also inconsiderate in conversation and also engage in tirades and diatribes and monologues and they're also, you know, pectoring and preaching and they're the same in this sense, like the autistic patients.
But they have a wide range of topics. They adapt the topic to the interlocutor in order to impress the interlocutor and convert him into a source of attention, adulation, admiration, a source of narcissistic supply. So their range is much bigger.
And when they are confronted with certain situations and with certain people, they can be good listeners or they can imitate or emulate good listening, which the autistic patient absolutely can not do. The narcissist is a good listener when he finds himself with someone who can serve a source of narcissistic supply or any potential intimate partner. Then he's the sublime supreme listener. And the narcissist deciphers conversational cues, including nonverbal body language cues, much better than the autistic patient.
Patients with most personality disorders are skilled communicators and manipulators of language. In some personality disorders, antisocial, narcissistic, histrionic, paranoid, the patient's linguistic skills far surpass the average. They are very superior. The narcissist, for instance, owns language as an instrument and uses it to obtain supply, as I said.
So he needs to have an enormous vocabulary. So he needs to have an enormous vocabulary. He needs to combine words in ways that will resonate. He needs to be poetic, if you wish. It's a consummate use. It's innate loquaciousness. It's the main tool to obtain what they need.
In contrast, the asperger's patient can't do this. He can't accomplish this intimate relationship with language. At a presenting session, when the autistic patient comes to diagnosis and therapy, vs. when the narcissist comes to diagnosis and therapy, there are so many immediate cues, immediate signs, the use of language, the range of topics, the orientation, goal orientation, yes or no, the social constriction, permanent social constriction, the ability to be charming, and all these immediately separate the narcissist from the autistic patient.
Now, many autistic patients, as I said, had developed pathological narcissism, secondary narcissism, as a defense against a world they perceive to be very hurtful, very wounding.
But this is a veneer. It's what we call an overlay in clinical terms. And it can be easily pierced and penetrated with a few pinpointed questions.
A good diagnostician should never misdiagnose autism spectrum disorders, as personality disorders, and vice versa. If he does, he is ignorant, inexperienced, and insufficiently versed in literature, even literature that is 60 or 70 years ago. This is not new literature.
I encourage practitioners to hone their skills with differential diagnosis, because misdiagnosing an autistic patient as a narcissist could have dire consequences for the patient. Misdiagnosing a narcissist as an autistic patient would be a waste of the patient's time and your time.
Get to work. Learn the differences.