Narcissistic Personality Disorder And Autism
Overview
This study explores the relationship between Autism Spectrum Disorders (ASD) and Narcissistic Personality Disorder (NPD), focusing on the dimensions of narcissistic vulnerability and grandiosity. Both ASD and NPD pose challenges in diagnosis due to shared characteristics, such as pervasive traits, lifelong duration, ego-syntonic features, and difficulties in forming and maintaining interpersonal relationships. Despite low co-diagnosis rates based on categorical criteria (0%–6.4%), clinical practice often faces diagnostic uncertainties.
The research involved 87 adults diagnosed with ASD without intellectual disabilities, utilizing the Pathological Narcissism Inventory-52 Items (PNI-52) to assess narcissistic vulnerability and grandiosity dimensions. Comparison of mean scores with normative data revealed that individuals with ASD scored significantly higher than neurotypical controls in the Total Score and Vulnerable Narcissism subscale but not in Grandiose Narcissism subscales. Demographic factors did not impact these results. Vulnerable narcissism demonstrated a significant association with the “Ritvo Autism and Asperger Diagnostic Scale – Revised” subscale Social Relatedness.
These findings suggest a potentially higher comorbidity rate between ASD and NPD, especially concerning vulnerable narcissism, which may not be adequately captured by DSM-5 criteria focused on the grandiose dimension. The study discusses potential links between ASD phenomenology and vulnerable narcissism, exploring the role of personality dimensions such as neuroticism. Additionally, it considers the potential mediating role of narcissistic vulnerability in internalizing symptoms (e.g., anxiety, depression) among individuals with ASD.
In summary, the research indicates that adults with ASD, despite not exhibiting differences in grandiose narcissism, show elevated scores in vulnerable narcissism compared to neurotypical controls. This highlights the need for a nuanced understanding of the interplay between ASD and NPD dimensions, emphasizing the potential role of vulnerable narcissism in explaining the comorbidity and internalizing symptoms observed in individuals with ASD.
Introduction
This study delves into the intricate interplay between personality disorders (PD), personality as a normative feature, and their interaction with concomitant mental conditions. It particularly focuses on Autism Spectrum Disorders (ASD), which share commonalities with PD in terms of pervasiveness, lifelong duration, ego-syntonic traits, and challenges in interpersonal relationships. Notably, individuals with ASD without intellectual disabilities often seek psychiatric help in young adulthood, coinciding with the onset period for PD.
Existing data indicates a significant co-occurrence rate of ASD without intellectual disabilities and at least one PD, with Cluster A and Cluster C PDs (Schizoid, Paranoid, Obsessive-Compulsive, and Avoidant) being most prevalent. However, Cluster B PDs, especially Narcissistic Personality Disorder (NPD), are minimally diagnosed in comorbidity with ASD. While categorical models have reported low overlap between ASD and NPD, clinical suspicions often arise during initial assessments due to perceived behavioral similarities, challenging the differential diagnosis.
This study distinguishes between narcissistic grandiosity and vulnerability, two distinct phenotypes proposed by Pincus et al. (2009). Grandiosity involves traits associated with NPD, such as arrogance, lack of empathy, and grandiose fantasies, while vulnerability includes hypersensitivity to criticism, social avoidance, perfectionism, and shame. The debate persists on whether these phenotypes represent extremes on the same continuum or distinct personality types.
Notably, sensory processing sensitivity, a trait in individuals with ASD, has been linked to vulnerable narcissism. This study aims to fill a gap by investigating both grandiose and vulnerable narcissism in adults with ASD without intellectual disabilities, offering insights into hidden comorbidities and potentially explaining internalizing symptoms reported by this population.
In conclusion, the research aims to contribute valuable information for clinicians by exploring the nuanced dimensions of narcissistic traits in individuals with ASD. Understanding both grandiose and vulnerable narcissism could aid in differential diagnosis and shed light on potential comorbidities, enhancing the efficacy of clinical interventions.
Methods
The study involved eighty-seven adults diagnosed with Autism Spectrum Disorder without intellectual disabilities (ASD-WID), recruited from the tertiary level neuropsychiatric clinic of ASST Santi Paolo e Carlo in Milan, Italy. The diagnosis was conducted by a psychiatrist and a psychologist following DSM-5 criteria, and further confirmed using Module 4 of the Autism Diagnostic Observation Schedule—2nd version (ADOS-2). Exclusion criteria included age below 18, intellectual disabilities (IQ < 75), and an inability to understand task instructions.
Participants provided written informed consent and had the right to withdraw from the study at any time. The study received approval from the local Ethics Committee.
The procedure began with collecting sociodemographic information. Participants then completed various questionnaires, including the Autism Spectrum Quotient (AQ) to measure autistic traits, the Ritvo Autism and Asperger Diagnostic Scale Revised (RAADS-R) for supporting ASD diagnosis, the Empathy Quotient (EQ) assessing cognitive and affective empathy, and the Pathological Narcissism Inventory-52 Items (PNI-52) to explore levels of narcissistic grandiosity and vulnerability. The Italian version of the PNI-52, developed by Fossati and Borroni in 2018, was utilized in the study.
Statistical Analysis
Statistical analyses for the study were conducted using SPSS 27, with a significance level set at α = 0.05 for two-tailed tests. Initial assessments included the Kolmogorov–Smirnov test to confirm the normal distribution of continuous variables. Descriptive statistics were then calculated for sociodemographic and clinical information in both samples.
A series of t-tests for independent samples compared the Pathological Narcissism Inventory-52 Items (PNI-52) Total Score and subscales of the ASD sample with normative data from Fossati and Borroni’s study in 2018. The normative data involved 1487 Italian adults.
To explore the impact of sociodemographic and psychometric variables on PNI-52 scores, additional t-tests for independent samples were conducted to compare differences between men and women diagnosed with ASD. Non-binary participants and those who did not disclose their gender identity were excluded due to low sample size. Results of t-tests were reported considering Levene’s test for homogeneity of variance.
Pearson’s correlational analysis was employed to identify associations between PNI-52 scores and various factors, including participants’ age, IQ, Autism Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale Revised (RAADS-R), and Empathy Quotient (EQ). To address multiple comparisons, the significance threshold was set at p < 0.001.
Finally, following Fossati et al. (2017), the study used the score reported by Fossati and Borroni (2018) as the 90th percentile of the PNI-52 Total Score (2.7308) to identify individuals with ASD potentially at risk of pathological narcissism, representing the highest 10% of the population.
Results
The mean age of the study sample was 30.6 years (±10.08), with 46% male participants, 46% female participants, 5.7% identifying as non-binary, and 2.3% choosing not to disclose their gender. The mean Intelligent Quotient (IQ) based on the Wechsler Adult Intelligence Scale—Fourth Edition (WAIS-IV) was 108.78 (±16.04). Participants’ mean scores were 33.07 (±7.96) on the Autism Spectrum Quotient (AQ), 142.75 (±43.14) on the Ritvo Autism and Asperger Diagnostic Scale Revised (RAADS-R), and 25.62 (±12.09) on the Empathy Quotient (EQ).
Regarding the Pathological Narcissism Inventory-52 Items (PNI-52), individuals with Autism Spectrum Disorder (ASD) scored significantly higher than the normative population in the Total Score (t = 6.81, df = 1571, p < 0.001) and specific subscales: Vulnerable narcissism (t = 9.31, df = 1571, p < 0.001), Contingent self-esteem (t = 10.50, df = 1572, p < 0.001), Hiding the self (t = 8.19, df = 1572, p < 0.001), Grandiose fantasy (t = 5.73, df = 1572, p < 0.001), Devaluation (t = 7.54, df = 1572, p < 0.001), and Entitlement rage (t = 4.96, df = 1572, p < 0.001). Conversely, they scored significantly lower on the Exploitative subscale (t = -2.33, df = 1572, p = 0.020). No significant differences were observed in the subscales Grandiose narcissism and Self-sacrificing self-enhancement (p > 0.05).
The study found no gender-based effects, with no significant differences between men and women. Age and IQ showed no significant correlations with any PNI-52 scales or subscales (all p > 0.05). Positive correlations were identified between RAADS-R Total Score and PNI-52 subscales Vulnerable narcissism (r = 0.369, p < 0.001) and Entitlement rage (r = 0.359, p < 0.001), as well as between RAADS-R subscale Social Relatedness and PNI-52 subscales Vulnerable narcissism (r = 0.364, p < 0.001) and Entitlement rage (r = 0.374, p < 0.001).
In conclusion, 28.7% of individuals with ASD scored above the score indicative of the 90th percentile in the normative population, suggesting a potential risk of pathological narcissism according to the criteria established by Fossati et al. (2017).
Conclusion
The objective of this study was to evaluate narcissistic dimensions, utilizing the PNI-52, in a cohort of 87 adults diagnosed with Autism Spectrum Disorder (ASD) without intellectual disabilities. The findings revealed that individuals with ASD scored significantly higher than the normative population on the PNI-52 Total Score, with notable distinctions observed in the vulnerable narcissism dimension rather than grandiose narcissism. Existing literature on the co-occurrence of Narcissistic Personality Disorder (NPD) and ASD has reported limited comorbidity rates, possibly attributed to the predominant focus on grandiose psychological experiences within the DSM nosography.
Unlike prior studies that utilized instruments emphasizing grandiosity, this research employed the PNI-52, specifically designed to discern the two primary dimensions of NPD. Results suggested that the elevated mean score in the ASD population was predominantly driven by the vulnerable component of narcissistic psychopathology. Remarkably, this study stands as the first to directly assess vulnerable narcissism in an ASD population, addressing a gap in current scientific understanding.
The investigation hypothesized a potential link between ASD phenomenology and vulnerable narcissism through the commonality of basic personality traits, particularly neuroticism. While this study did not directly assess basic personality traits or compare ASD subjects with NPD patients, it builds on prior findings indicating similar levels of neuroticism in both groups, supporting the proposed hypothesis.
Concerning PNI-52 subscales, ASD participants scored higher on vulnerability dimension subscales (Contingent self-esteem, Hiding the self, Devaluation, and Entitlement rage) and exhibited conflicting tendencies in grandiose dimension subscales (Exploitative, Self-sacrificing self-enhancement, and Grandiose Fantasy). The lack of correlation between PNI-52 scales and IQ levels or age, along with no gender differences, suggests clarity in the findings.
Correlation analyses revealed a positive association between RAADS-R scores, especially Social Relatedness, and PNI-52 subscales Vulnerable Narcissism and Entitlement rage. This connection, particularly in Social Relatedness, suggests that challenges in social and interpersonal contact may overlap with narcissistic vulnerability and autism phenomenology.
Importantly, 28.7% of the ASD sample scored above the 90th percentile of the normative population on the PNI-52, indicating a potential risk of pathological narcissism. The study acknowledges limitations, including sample size discrepancies and the use of a self-report tool not yet validated for ASD.
In conclusion, this study identified an increased expression of vulnerable narcissistic traits in adults with ASD without intellectual disabilities. The findings prompt inquiries into the interplay between autism, narcissism, and neuroticism, emphasizing the need for further research to confirm and expand upon these results. The ultimate goal is to inform specific diagnostic and therapeutic interventions tailored to the unique characteristics of individuals with ASD in clinical practice.
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