Narcissistic Personality Disorder and Autism (2):

Challenges in diagnosing

Diagnosing Narcissistic Personality Disorder (NPD) can be difficult as individuals with this disorder often resist admitting any flaws or seeking help. Their inflated ego and lack of insight into their behaviour can make diagnosis a challenge.

On the other hand, diagnosing ASD can be complex due to its wide range of symptoms, varying presentations, and overlaps with other conditions. ASDs without intellectual disability are often diagnosed late in life. Little is known about co-occurring psychiatric disorders and differential diagnosis of autism in adulthood, particularly with regard to personality disorders (Strunz, Dziobek, Roepke 2014). 

Differential diagnosis 

Although NPD and ASD possess commonalities, they differ significantly in crucial diagnostic features. For instance, while NPD is characterized by an inflated, yet fragile, sense of self-worth, some individuals with ASD typically lack the self-awareness necessary for exhibiting narcissistic behaviours. Moreover, individuals with NPD often seek admiration and validation from others, whereas those with ASD are notable for their indifference towards social approval, often displaying an absence of the desire to please. E.g.:

“I am not ambitious because I do not seek to hold a particular rank in an organisation; to me those are empty honors. Using [my] internal standards… I want to do the work that is up to my level of capability, and which I feel essential to the mission of the organization… Those who are competitive and ambitious put a high premium on ‘coming out on top’. They seek out situations in which they can do this… As such, they become confronters, and actually relish confrontations” (Schneider with AS 1999).

Furthermore, individuals with NPD tend to manipulate and exploit others, utilizing charm and charismatic behaviour to meet their egocentric needs. In contrast, individuals with ASD may unintentionally exhibit behaviour that disturbs harmonious social interactions due to their restricted understanding of social expectations and norms.

The challenge lies in the absence of definitive biological markers and medical tests for identifying ASD or NPD. The symptoms exhibited by individuals with these conditions, such as difficulties in social interaction, communication, rigidity of thought, and sensory sensitivities, can be unreliable and misleading, leading to potential misdiagnosis.

For example, individuals with NPD often have problems communicating with others because their ‘genius’ is not recognised. They may interpret interactions as personal ‘attacks on their integrity’ and cannot stop ‘me-me-me thinking’ (rigidity of thought patterns) – thus they can be misdiagnosed with autism.

On the other hand, adults with ASD/1 (Asperger syndrome) may come across as egocentric due to a limited awareness of when it is appropriate to compliment oneself and when it is not (Strunz et al. 2015). Attwood (2007) suggested that AS individuals, especially those with superior intellectual abilities, may overcompensate for feelings of inadequacy in social situation by becoming arrogant and egocentric.

And another thing: All people have narcissistic traits. Individuals with ASD (without NPD) were found to be comparable to non-autistic controls on scales measuring narcissism. However, levels of neuroticism and emotional dysregulations are similar between NPD and ASD population and, in both cases, are more pronounced than nonclinical controls (Strunz et al. 2015).

Misdiagnosis

Sometimes NPD can be misdiagnosed as autism and vice versa (especially in adults). For example, one of the most prevalent differential diagnoses in a sample of adults (without intellectual disability) who sought autism specific clinical diagnostics or who were referred with a presumed diagnosis of autistic disorder was NPD. (Along with NPD, other prevalent diagnoses were: depression, social phobia, paranoid, avoidant disorder). In only 50% of the group the autism diagnosis was confirmed, 36% of them fulfilled also criteria for psychiatric disorders (Strunz, Dziobek, Roepke 2014). 

The problem is, not many people want the label of NPD, and when an opportunity arises to jump under an autism spectrum umbrella, they immediately catch it. As there is a (very unfortunate) trend: quite a few self-diagnosed “autistic” individuals with NPD have grasped the badge of autism with both hands, proudly announcing ‘we, autistics’ and starting the fight against any negative comment against their ‘autism’:

“don’t you dare to say anything about treatments, interventions, etc. – ‘we, autistics’ are perfect the way we are; any expression of opposing views are ‘unethical’, etc.

Having “borrowed” the diagnosis, they then re-define ‘autism’ to suit themselves, e.g.:

“We, autistics, have neither sensory problems nor sensory distortions. In this aspect, we are not different from NTs” or “Trying to treat problems of autistics is violation of our human rights!”

Another “autistic researcher” claimed that

it’s wrong to class as autistic those people who perceive the world differently, and not those “people who have autistic behaviour but see the world in the same way as the general population [i.e.,] people diagnosed as autistic according to the conventional definition of autism [‘surface behaviours’].

They expect and demand others (both autistic and non-autistic individuals) to change their views on the condition and to accommodate the environment to their (“superior”) differences. Any suggestion that there may be deficits/ dysfunction/ problems in autism send them to the state of rage – “How dare you to call us, autistics, rotten?! Apologise!”

Any attempt to make them see autism from the perspectives of other (both nonverbal and verbal) autistics and their parents is in vain – they accuse whoever disagrees with them in low standards, unethical behaviour, defamation of their character, and demand an apology.

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Highlighting the importance of a correct distinction between ASD and NPD, Strunz et al. (2014) showed that, in a population of adult help-seekers in which ASD without intellectual disability was suspected and then ruled out.

The overlapping symptoms and complexities of ASD and NPD underscore the importance of thorough evaluation and consideration of individual differences to avoid misdiagnosis and ensure appropriate treatment and support.