High-functioning Autism: Psychopathy? Narcissism?

I need a humongous glass of wine to get through this topic.

The topic today is high-functioning autism.

Are these people psychopaths? Are they narcissists?

What the heck happened to Asperger's syndrome? And how do we view autism today after the massive revision in the Diagnostic and Statistical Manual, Edition 5, 2013?

Let's start with observations.

Many of you who had come across people with autism spectrum disorders described them as somewhat antisocial, somewhat psychopathic, a lot grandiose and entitled and narcissistic. Many people say he's not a narcissist, he has Asperger's syndrome, or he's not a psychopath, he's a high-functioning autist.

Or the other way around, he's not autistic, he's actually a psychopath.

This is a huge confusion in the field. And by the way, this confusion extends not only to you, the layman, but to my colleagues, professors of psychology, to therapists, to psychologists, everywhere.

And this is the autistic moment to tell you, my name is Sam Vaknin, and I'm the author of Malignant Self-La, Narcissism Revisited, and I'm a professor of psychology.

Okay, shavoshim, let's get to business. And business is not as usual.

Let's start with the most cutting-edge, bleeding-edge knowledge we have.

Nothing begins to emerge as a kind of global feature, global trait, possibly global behavior or global cognitive deficit in a variety of disorders.

Just yesterday, I made a video regarding a new study which supports Theodore Millon's view, and more modestly, my view of narcissism as compensatory.

Grandiose narcissists are actually psychopaths, said the study.

You may wish to watch yesterday's video to understand what am I talking about?

Psychopathy is almost indistinguishable from grandiose narcissism.

But people with borderline personality disorder, classic borderline, also become secondary psychopaths or primary psychopaths under conditions of stress when they feel rejected, humiliated, and abandoned. That's why I came up with a new diagnosis which I'm proposing, which is a hybrid between primary psychopathy and borderline, and that is covert borderline.

Psychopathy is a very strong feature of borderline. One of the self-states of the borderline woman is a psychopath. I'm saying woman because we have studies only about the psychopathic self-state in women.

Mysteriously, no one bothered to study men in relation to this.

So, psychopathy, borderline, narcissism, they're all interlinked, which is one of the main reasons I'm proposing to eliminate all these distinctions and to come up with a single personality disorder with various overlays, manifestations, and emphases.

But what about autism?

Let me start by saying we have no idea what causes autism. We have a perfect idea what doesn't cause autism. Vaccines do not cause autism. This is discredited research, discredited research, which had been withdrawn in disgrace by the authors and the journals that had published it. It was fake. It was wrong. There's no connection, correlation, causation, anything whatsoever to do between vaccines and autism.

However, we don't know what causes autism. We suspect that genetics may be hereditary, maybe some abnormalities in the brain. We are not sure. We can demonstrate pretty conclusively using functional magnetic resonance, PET, and other methodologies. We can demonstrate that people with autism spectrum disorders have abnormal brain activity patterns, mainly abnormal blood flow, and various areas of the brain are activated in the wrong sequence at the wrong time and with the wrong stimuli.

So something's wrong with the brain of the artist, but something is wrong with the brain of the psychopath.

Psychopaths have severe brain abnormalities. For example, when it comes to white matter, to multi-unit activity, to activity in the brain, to activated areas, they don't respond, for example, to emotional photography or photography displaying all kinds of stressful situations. Their brains do not process fear. Even their skin conductors, the skin conductors of psychopaths are different. They don't sweat it, so to speak. Their heartbeat is not heightened. They don't develop tachycardia. They don't react. Their bodies don't react to situations of fear and terror.

So something is very fundamentally different in the brain and the body of the psychopath, same as it is in the brain and the body of the autistic person.

Now, we are trying to map the abnormalities in the brain of the autistic person to the abnormalities in the brain of the psychopath. And to complicate matters further, there are abnormalities in the brain of the borderline, and there are very strong indications that both borderline and psychopathy have a hereditary component. They're somehow inherited. We can't prove it, but there are strong indications.

If you have first degree or second degree relatives with borderline and psychopathy, you are likely to develop borderline and psychopathy to a much higher degree, four or five times higher. To some extent, this is the case with autism.

So we are beginning to see similarities in the transmissibility of this disorder across generations, and in the fact that the brains of these people are abnormal.

What about the behavior?

There are quite a few studies actually linking high-functioning autism and criminal behavior. Several studies have shown that features associated with high-functioning autism increase the probability of engaging in criminal behavior. Of course, criminal behavior is one of the diagnostic criteria for antisocial personality disorder, aka psychopathy in extreme cases.

So there is a lot of thrust. There's a lot of effort doing research in this area. We don't know why people with high-functioning autism, and in a minute I will define high-functioning autism. We don't know why people with this variant of concern of autism are the ones who commit crimes well way and above the statistical average in the general population. We don't know, and that's why we are conducting the studies and the research.

We think maybe it has to do with a lack of empathy.

Another thing linking high-functioning autism and psychopathy, and narcissism of course, is a lack of empathy.

Later in this video lecture, I'm going to discuss the connection between autism and narcissism, and why they're very difficult to tell apart.

And so there's a lack of empathy. There's also social naivete, inability to decipher, properly interpret, embed in a context, social cues. And when you don't understand people, when you don't understand what they mean, what they want to say, what they're communicating, you may end up doing things which are stressful and distressful. You may end up actually committing crimes without meaning to do so.

So there is a question here of mens rea and actus reus. In other words, does the autistic person mean, does he mean to be violent?

Because most autistic crimes are violent, actually. They involve violence. Does he mean to be violent? Or is he just flailing and thrashing about because he doesn't understand where he is and what people are trying to tell him, which is very disorienting and very frightening? Is he in panic? Or is he a hardwired, hardcore criminal owing to a lack of empathy?

And so another very interesting feature is that both psychopathy and borderline, but not narcissism and not autism, both psychopathy and borderline, remit in midlife and late life. After the age of 40, 45, depending on the study, 50% of people with borderline personality disorder lose the diagnosis spontaneously.

There's hope for borderline. Borderline is a very hopeful disorder because it's treated very effectively with DBT, with medication, and it remits spontaneously. I would give my right arm for this to happen to me because narcissism is hopeless. Hopeless.

Now, the same happens with psychopaths, believe it or not. Psychopathy, antisocial features of the personality, remit and literally disappear late in life. Late in life could be 50, 45, sometimes 60, but always disappear. The psychopath ceases to be a psychopath when he reaches the second half of his life, which is a very, very hopeful message. Something unites and links the borderline with the psychopath on a biological, cerebral, neurological level, clearly.

It's not the same for narcissism and autistic spectrum disorders, especially high functioning autism. That's why I'm going to analyze the connection between these two things, these two disorders a bit later.

Now, of course, in psychopathy, we distinguish between primary psychopathy and secondary psychopathy the same way we distinguish between grandiose or phallic narcissist and covert or vulnerable or shy or fragile narcissist. There's no such distinction in borderline.

The construct of shy or quiet borderline failed the test of clinical studies and trials. There's no proof that it exists. However, it does exist in narcissism and it does exist to some extent in psychopathy, where we have primary and secondary psychopath.

The behaviors of the primary and secondary psychopath are the same, but the secondary psychopath has emotions.

Imagine psychopath with emotions. It's like reckoning with empathy and impossibility, but it exists.

Secondary psychopathy involves emotions, especially dysregulated emotions, strangely, a little like borderline, and it involves empathy.

No wonder the borderline patient, when she is exposed to stress, humiliation, rejection, and abandonment, real or imagined or anticipated, she becomes a secondary psychopath. She cannot become a primary psychopath because she has emotions and empathy, so she becomes a secondary psychopath and displays the full panoply, full range of behaviors of a psychopath, but with empathy and emotion.

Okay, let me read to you an excerpt from an article, which I'll refer to later, which gives an overview of autism spectrum disorder. Autism spectrum disorders are neurodevelopmental disorders that comprise a heterogeneous group of conditions, which are characterized by impairments in social interaction and communication, as well as repetitive and stereotyped interests and behaviors. Reported prevalence rates have risen markedly in recent decades. There is up to 1% lifetime prevalence, with more and more adults being diagnosed with autism spectrum disorder.

It is assumed that the male to female ratio is between 3 and 4 to 1, although nearly half, and there exists particular gender differences in autism spectrum disorders, although nearly half of individuals with autism spectrum disorders are not intellectually impaired and have normal cognitive language skills, such as individuals with high functioning autism or Asperger's syndrome.

The social interaction and communication deficits and difficulties in seeing the perspective of others, so the social interaction and communication deficits, the difficulties in seeing the perspective of other people, and intuitively understanding nonverbal social cues, these put together constitute hidden barriers to the development of romantic and sexual relationships.

Sexuality related problems can arise, especially at the start of puberty, a time when the development of the autism spectrum disorder individuals' social skills cannot keep up with increasing social demands, and the challenges of forming romantic and sexual relationships become particularly apparent.

Now, before we jump into the issue of what is high-functioning autism, a warning.

High-functioning autism is not a clinical construct accepted in academe, among scholars, in the Diagnostic and Statistical Manual, or even in the more advanced, conceptually more advanced, international classification of disorders.

So it is a kind of phrase that clinicians use very frequently, but has no foundation in clinical research and studies. It's anecdotal. It results from observations, self-reporting, and reporting by family members.

Many scholars and many autism rights activists, they disagree with the categorization of high-functioning, low-functioning. They disagree because the functioning of a typical person with autism fluctuates. One day, this person is high-functioning. The next day, for whatever reason, this person is very low-functioning.

So you can't look at someone with autistic spectrum disorder and say, oh, this guy is consistently high-functioning, because there will be many days when he will be low-functioning. And what about medium-functioning people? Where do you categorize them? Aren't they the majority?

We don't know. We don't know because we don't use the construct of high-functioning.

High-functioning autism is usually reserved for people who have diagnosed autism spectrum disorder, but no intellectual impairment, no intellectual problem. They can speak. They can read. They can write. They can handle basic life skills. They can eat by themselves, get dressed by themselves. They can live independently, and many of them attain positions, you know, their professionals and so on.

Starting in the 1990s, we began to have a more nuanced and subtle view of autism spectrum disorders. We began to recognize high-functioning autism, Asperger's disorder, or wrongly called Asperger's syndrome.

And these are people who actually function in society. They have families. They have jobs. Everything.

In 2013, the American Psychiatric Association decided to get rid of all this mess, and they created a single diagnostic group called Autism Spectrum Disorder. That's it. ASD. No Asperger's. No, nothing.

There's a single diagnosis of this level one ASD, which corresponds roughly to Asperger's disorder. But there's only one diagnosis.

Of course, there are different levels of functioning, different levels of empathy, different levels of deciphering social cues, different levels of social behavior, etc. There's a spectrum. That's why it's called autism spectrum disorders, but it's a single diagnosis.

And so people with high-functioning autism, exactly like everyone else with autism spectrum disorders, they are very bad in social interaction and communication. All manner of social interaction and communication, including later in life, dating, job interviews, holding a job, a career.

Now this from the outside may look like social anxiety or like avoidant personality disorder. This is the reactive side. The autistic person tries to integrate, tries to interact, tries to be long, tries to be accepted, tries to be loved, tries to become a part of a peer group and keeps being rejected, keeps being shunned.

And so she develops or he develops social anxiety and avoidant behaviors. These are secondary and reactive artifacts of the initial rejection by everyone around the autistic person.

They don't read social cues. They find it extremely difficult to make friends, let alone date. And they get very stressed in social situations because they anticipate rejection and they shut down. They don't make eye contact. They don't make small talk. People on the spectrum who are high-functioning, they're very rigid. They're very structure and order oriented. They make lists, for example, or they go through robotic routines, wine at 330, like me. So they're very, very kind of predictable. They're machine-like and they have repetitive and restrictive habits. And very often people find them very order because they're very compulsive and insistent on these habits, on these procedures, on these routines. They're devoted to them and they become very dysregulated, very anxious if they can't carry out these routines at the prescribed time and usually in a prescribed location. And people find it extremely bizarre.

So people with autism spectrum disorder sometimes are misdiagnosed as schizotypal personality disorder. There's a wide range of functioning in school and at work. Some actually do very well at school. Others get overwhelmed, can't concentrate. Some hold a job. Other finds it's very hard, very difficult to hold a job.

It all depends and that's why high-functioning, low-functioning, middle-functioning sounds a bit strained, sounds a bit, sounds a bit wrong. Even for someone on the spectrum who can do a lot, who is very functional, the commonality among everyone diagnosed with ASD is underdeveloped social skills, which is one hell of a barrier, makes it extremely difficult.

So if one has to summarize what is high-functioning, what's high-functioning autism, it's trouble with social interaction, impaired communication, restricted interests, restricted interests and repetitive behavior. This leads to social isolation, employment problems, family stress, bullying by others, self-harm. That's where it begins to be difficult to distinguish autism spectrum disorder from borderline personality disorder.

And so the thing that sets high-functioning autists apart is there's no intellectual disability. There are deficits in communication and emotion, recognition, cognition, expression, social interaction, yes, but no intellectual disability.

And in this sense, high-functioning autism is actually level one autism spectrum disorder, which used to be called Asperger's syndrome or Asperger's disorder more precisely.

And so in all these cases, including high-functioning autism, there had been a significant delay in the developmental path.

Now, in Asperger's syndrome, level one Asperger's disorder, what used to be called Asperger's disorder, in high-functioning autism, there was no language delay. They began to use language on time. There is language delay, speech delay, language skills delay among other types of autists, people who are low-functioning, have low-functioning autism.

These people start to talk at age three and later.

So it's a distinguishing feature. Language skills, high-functioning autists have no problem with language.

And there are other differences.

People with high-functioning autism have a lower verbal reasoning ability. People with Asperger's disorder have a higher verbal reasoning skill than people with high-functioning autism. People with high-functioning autism have better visual and spatial skills, higher performance IQ than people with Asperger. People with HFA, high-functioning, they don't have deviating locomotion, clumsiness. They're not clumsy. People with Asperger's are. People with FHA have problems functioning independently more often than Asperger's. People with FHA, high-functioning autism, they're curious. They have interest in many, many things. People with Asperger's have limited and restricted interests. People with Asperger's are better at empathizing with another person. People with HFA almost completely lack empathy and in decent resemble very strongly narcissists and psychopaths.

And so autism spectrum disorder, low-functioning, high-functioning, always includes, and almost always is diagnosed with anxiety. Anxiety is very commonly occurring mental health symptoms in high-functioning autism.

And the reason I'm mentioning it is anxiety is a hallmark of psychopathy and a hallmark of borderline. And remember, borderline and psychopathy are two brain disorders and both of them, in both cases, there's a very high comorbidity of anxiety disorders and depressive disorders, which is exactly the case in high-functioning autism, but not the case with other types of autism. There are other comorbidities and they include bipolar disorder, obsessive compulsive disorder. This is the number one comorbidity. The link between high-functioning autism and obsessive compulsive disorder is very strong.

And it seems that in both cases, there is a problem with serotonin in the brain. There's also ADHD. There's also Tourette's syndrome. Now, ADHD is intimately linked to narcissism. I encourage you to watch the relevant videos, I think one or two on my channel, but there's no intellectual disability in high-functioning autism.

Okay. And there are no differences in sexuality between high-functioning autism people and normal people, healthy control, as they're called. I refer you to the article Sexuality in Autism, Hypersexual and Paraphilic Behavior in Women and Men with High-functioning Autism Spectrum Disorder, published in the academic journal Dialogues in Clinical Neuroscience, December 2017. I think it was volume 19.

The short and the long of it, that there is no difference. There's no difference in sexuality between high-functioning autism, the normal population, more or less.

So before we go to narcissism, what do we have? We have strong similarities in behavior between psychopathy and HFA, high-functioning autism. We have a lack of empathy. We have brain artifacts or brain abnormalities. We have criminal behavior, including violent behavior, which indicatesof course a lack of impulse control and defiance and recklessness. We have inability to decipher social cues, which doesn't sit well with psychopathy.

Psychopaths have cold empathy. They're actually excellent at deciphering social cues, and that's why psychopaths are very good con artists.

We have dysfunctional social life, including problems with dating and so on and so forth, not sex, dating, social interactions.

Psychopaths usually don't have this. They're very skillful in social settings. Many of them are gregarious and charming. They're manipulative. They're good people. They're good with people. They're not good people. They're good with people.

So it would seem on the face of it that artificially, when you look from the outside, you see someone who is cold, detached, lacks empathy, goal-oriented, even to the point of compulsiveness, a bit criminal or antisocial.

And you say to yourself, this guy is psychopathic.

It could be a person with high-functioning autism.

The critical elements, the critical differential diagnosis or differential factors I mentioned.

So go deeper. Don't make snap judgments.

What about autism and especially Asperger's syndrome, Asperger's disorder? What about Asperger's disorder and narcissism?

Asperger's disorder, to repeat for the ninth time, was renamed in the Diagnostic and Statistical Manual Edition 5 as autistic spectrum disorder level one. And it is often misdiagnosed as narcissistic personality disorder, though it is evident as early as age three, which narcissism is not.

Pathological narcissism cannot be safely diagnosed prior to adolescence. And I would even say late adolescence, because adolescents are narcissistic, babies are narcissistic. You can't diagnose narcissism, pathological narcissism, in young people.

But you can, of course, diagnose Asperger's disorder in someone who is age three.

So here's the first difference between the two.

In both cases, narcissism and Asperger's, the patient is self-centered, engrossed in a narrow range of interests and activities.

Social and occupational interactions are severely hampered, and conversational skills, give and take, or verbal intercourse are primitive.

The Asperger's patient body language, eye to eye gaze, body posture, facial expressions, the body language is constricted, artificial, and it is very reminiscent of the narcissist body language, which is hot and superior.

Nonverbal cues are virtually absent, and the interpretation of nonverbal cues in other people is lacking solely against something very common to narcissists and Asperger's.

And yet, the gulf between Asperger's and pathological narcissism is vast.

The narcissist switches between social agility and social impairment, and he does this voluntarily.

The narcissist chooses to retreat into a schizoid phase, or to become gregarious and charming.

The narcissist's social dysfunctioning is the outcome of conscious haughtiness and the reluctance to invest scarce mental energy in cultivating relationships with people who are deemed inferior and unworthy.

When the narcissist is confronted with potential sources of narcissistic supply, however, he easily regains his social skills, his charm, and his sociability.

Many narcissists reach the highest levels and runs of their community, church, firm, voluntary organization.

Most of the time, narcissists are high-functioning. They 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, the narcissist always ends badly.

But until then, he functions perfectly.

The Asperger's patient often wants to be accepted socially, wants to have friends, wants to get married, to be sexually active, to sire or offspring. He just doesn't have a clue how to go about it. His affect is limited. His emotional repertoire is limited. His initiative, for instance, to share his experiences with his nearest and dearest or to engage in foreplay during sex, the initiative is thwarted. His ability to divulge his emotions. This ability is tilted in the Asperger's.

The Asperger is incapable of reciprocating, is largely unaware of the wishes, needs and feelings of his interlocutors or counterparties.

Inevitably, Asperger's patients are perceived by other people to be called eccentric, insensitive, indifferent, repulsive, exploitative or emotionally absent.

To avoid the pain of rejection, they confine themselves to solitary activities.

But unlike the schizoid, they don't do this by choice.

And also unlike the narcissist, the Asperger's patient limits his world to a single topic, single hobby or person, and he dives in with the greatest all-consuming intensity, excluding all other matters and everyone else.

It is a form of hurt control, pain control, pain regulation, if you wish.

And so while the narcissist avoids pain by excluding, by devaluing, by discarding other people, the Asperger's patient achieves the same result by withdrawing, by avoiding, by passionately incorporating in his universe only one or two people and one or two subjects of interest.

Both narcissist and Asperger's patients are prone to react with depression, to perceived slights and injuries.

But the Asperger patient is far more at risk of self-harm and suicide resembling very much the borderline.

The use of language is another differentiating factor.

The narcissist is a skilled communicator. The narcissist uses language as an instrument, a weapon, if you wish, to obtain narcissistic supply, to obliterate his enemies and discarded sources.

Cerebral narcissists derive narcissistic supply from the consummate use they make of their innate verbosity.

Just look at me. So the same with the Asperger's patient. Asperger's patient is equally verbose at times and taciturn on other occasions, but his topics are few.

And so he's tediously repetitive. The Asperger's patient is unlikely to obey conversational rules and etiquette. For example, he's unlikely to let other people speak in turn. And the Asperger's patient also is unable to decipher nonverbal cues and gestures and to monitor his own misbehavior on such occasions.

Narcissists are similarly inconsiderate, but only towards those who cannot possibly serve as sources of supply.

I want to make a comment about refrigerator mothers.

The concept of refrigerator mothers has been long debunked. It's ranked nonsense. Autism is a brain disorder. It is not linked to bad parenting.

But a dead, a dead mother to use Andrei Green's phrase, 1978, a dead mother, narcissistic mother, absent mother, selfish mother, she can cause her autistic child to defend himself by developing narcissism. In other words, a bad mother can push the autistic child, the congenitally autistic child with a brain disorder to become a narcissist.

ADHD has been intimately linked to the precursors in children of adult narcissism and psychopathy. These precursors are conduct disorder and oppositional Defiant Disorder.

So a bad, dead, cold mother, a refrigerator mother, fosters in the autistic child, narcissistic defenses, and in her other children, attention deficits, hyperactivity, and antisocial behavior. These dysfunctions make it difficult for the child to translate his or her reflexive empathy into a mentalizing theory of mind.

In other words, the child cannot, because of these deficits, the child cannot understand other people. This process is called mentalization. He cannot understand other people.

Early childhood abuse and trauma, therefore, inhibit the development of a mature form of empathy with cognitive and emotional components.

There are three problems with raising awareness and educating people about autism spectrum disorders.

We don't know the etiology of autism, what causes it, and whether the brain abnormalities often observed in autistic patients cause the autism or are caused by the autism or are merely correlated or effectuated by a third common factor. We don't know.

Number two, autism is a family of disorders which have little in common with each other. Some autistic persons are high functioning and accomplished, as I mentioned. Others, self-harm, are hypersensitive to stimuli or noncommunicative.

And number three, the long discredited aforementioned refrigerator mother theory blamed emotionally unavailable dead or frigid mothers for the pathogenesis of autism in their children. And these deterred parents from seeking help. The mother was terrified should she be blamed for her child's autism.

The ignorance, taboos, stigma, biases, prejudices, and lack of evidence-based theories and practices that pervade mental health apply even more so, or maximally even, to autism.

I would recommend, I'll give you now a reading list.

McDowell-Maxson, the image of the mother's eye, autism and early narcissistic injury in behavioral and brain sciences. And James Robert Brannon, Pervasive Development Disorder, Asperger's syndrome.

Autism spectrum disorder is one, amazingly, one of the least explored areas. The numerous studies, a lot of interest, a lot of money sloshing around, but we are very far from understanding it. We're very far from even realizing whether it's a single clinical entity or a family of disorders that just artificially resemble each other.

And so clearly, it's easy to confuse autism spectrum disorders with narcissism, as I've just demonstrated. It's equally easy to confuse it with psychopathy. Don't make this mistake.