- Autism is a complicated diagnosis. Social deficits and emotional detachment alone shouldn't lead to a conclusion of autism.
- Schizoid Personality Disorder is based in social-emotional detachment, mimicking Criterion A requirements of autism.
- Looking beyond the social-emotional detachment can help tell the two apart, as autism includes other components.
- Though the conditions share symptoms, they require different interventions.
April is Autism Awareness month. Awareness implies being able to recognize the condition, and recognizing a condition means it must be differentiated from others. Unfortunately, Autism-Spectrum Disorders (ASD) are yet another diagnosis to have fallen prey to pop psychology, which tends to simplify this complicated condition to "social awkwardness."
Popular culture understandings of psychology have a way of working into clinical practice, and new practitioners, or ones who have not done their diagnostic homework, may make a knee-jerk diagnosis simply relying on "what sounds familiar” or what they're comfortable with because of familiarity in what is termed diagnosis bias. The truth is, many psychiatric diagnoses (e.g., some personality disorders, social anxiety, and trauma) can account for "social awkwardness."
Being a popular diagnosis often renders ASD a "go-to" of choice for this item, and we are left with a startling influx of ASD diagnoses. In 2020, the Centers for Disease Control (CDC) noted that in the year 2000, cases were 1 in 150, and in 2016 were 1 in 54. Considering this rapid influx in conjunction with the “fad diagnosis” phenomenon in ASD (Frances, 2013), it can be safely suspected that at least some cases are false positives.
For example, I recently met someone who was told their child has ASD because they scored poorly in social ability and relation on a standardized measurement. The evaluator didn't take into account the child has no other symptoms or history aligning with ASD, nor the fact they have severe ADHD. People with ADHD might appear "socially awkward" because they frequently interrupt, and “space out” while interacting if they have a penchant for inattention, and miss social cues for the same reason.
Dialing it back
While gaining an exact sense of false positives would be difficult, a campaign for awareness of the importance of differentiation is important to reduce false positives engendered by heightened awareness. Some readers may ask why it matters so long as the “social awkwardness” is treated. The answer is that many disorders share symptoms, but that doesn’t mean they’re treated alike, as written about in Avoidant Personality or Social Phobia?.
Proper diagnosis allows us to conceptualize the nature of symptoms, understand their purpose and what they’re rooted in, which drives proper treatment. For example, if the aforementioned child's ADHD symptoms made socializing troublesome, then therapy focus would be refining social ability despite the restless and inattention. In a nutshell, those with ADHD understand socializing, but need to learn how to pay attention for better social interactions.
In ASD, however, socialization must be taught, including exposing them to the value of socializing and expansive guidance in developing social skills.
The ASD chameleon
Readers now understand the possibility of false diagnosis and the importance of very careful diagnostic consideration. The diagnosis perhaps most camouflaged, at first glance, as ASD is Schizoid Personality Disorder (White et al., 2017; Wolff, 2017; Boules-Katri et al., 2019). This is especially true when it comes to “high functioning” Autism (Cook et al., 2020; Wolff, 2017).
Millon (2011) wrote that Jung described the Schizoid Personality as:
They are mostly inaccessible, hard to understand…they neither shine nor reveal themselves…Their outward demeanor…is inconspicuous…with no desire to affect others, to impress, influence, or change them in any way…
A more objective understanding of Jung’s description that’s in line with current diagnostic criteria is that someone with Schizoid Personality Disorder, (SPD) exhibits, “…detachment from social relationships and a restricted range of expression of emotions in interpersonal settings…” (American Psychiatric Association [APA], 2013). Further:
- There is little to no desire for any personal relationships and their only closeness is usually with first-degree relatives.
- They appear detached, perhaps emotionally-cold, and/or even aloof.
- There is a preference for solitary work/activities, and generally have few, if any interests like hobbies.
This said, it's not unheard of for those with SPD to develop some personal relationships, even romantically. However, according to SPD expert Elinor Greenberg, Ph.D., these tend to be “partial relationships” where the other is somehow kept at a safe distance (Howard, 2020).
Greenberg and Millon (2011) also report that people with SPD tend to have early histories that were lacking parental warmth and good communication, along with possibly more traumatic incidents that lead to detachment defenses. As flat as they may seem, it's deceptive, as anyone who has worked with SPD will explain that anxiety runs below the surface, particularly in terms of interpersonal experiences.
The differences of ASD
It’s easy to see how, at first glance, the above encapsulation can lead to a knee-jerk consideration of ASD due to some remarkably similar features. However, those with SPD don’t exhibit the following items, at least some of which must also be present to assign an ASD diagnosis (APA, 2013):
- Meaningless, repetitious behaviors called stereotypes, such as body rocking, tic-like motions, or even self-injurious actions like head banging.
- Repetitious self-soothing behavior such as hugging oneself or petting objects of certain tactile characteristics.
- Concrete thought processes (i.e., asking “what’s up?” generates a glance to the sky).
- Highly fixated/perseverative interests, sometimes with unusual things, for example pieces and parts of objects.
- Sensory-integration difficulties, such avoiding certain foods or clothing because of texture, or significant adverse reactions to particular sounds or levels of brightness.
- Fixation with routine/ritualized patterns. Oftentimes straying from the routine can initiate a “meltdown.”
- Developmental delays or deterioration in previously learned social and language skills.
Interestingly, some researchers have discovered that there is a correlation between ASD and SPD. For example, Barlow & Durand (2015) note that some researchers have discovered it’s not unusual that people with SPD have an Autistic child. In this vein, they explain it has therefore been suggested that perhaps one path to ASD is a biological mechanism triggered by early learning and problems with interpersonal relationships.
It’s easy to see how interpersonal reservations can be modeled by a parent with SPD, and without interpersonal exchange, it is hard to cultivate emotions. The observations herein beg the question if perhaps ASD and SPD exist on a continuum.
Regardless of relationship, it is poor practice to err towards ASD without thorough evaluation, as there are treatment implications. For instance, SPD treatment requires social skill building, exploring the language of emotions, learning to be expressive, and how to enhance life by engaging in meaningful activities and experience pleasure.
On the other hand, it’s not unusual for providers to refer people they deem Autistic to specialized programming. Such programming would be too intensive for SPD and much of it irrelevant. This would likely lead to dropping out and creating a bad opinion of mental health care providers because they felt demoralized by someone believing they required such intensive interventions. As one can imagine, those with SPD are not quick to enter treatment, and we can’t afford to lose opportunities to help them lead better lives when they do.
For those interested in learning more about similarities between ASD and SPD, there is the book Loners by Sula Wolff, MD. Readers interested in treatment for SPD may find Borderline, Narcissistic, and Schizoid Adaptations by Elinor Greenberg, Ph.D., helpful.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Barlow & Durand (2015). Abnormal psychology: An integrative approach (7th ed). Cengage Learning.
Booules-Katri, T. M., Pedreño C, Navarro, J. B., Pamias, M., & Obiols, J. E. (2019). Theory of mind (tom) performance in high functioning autism (hfa) and schizotypal-schizoid personality disorders (sspd) patients. Journal of Autism and Developmental Disorders, 49(8), 3376–3386. https://doi.org/10.1007/s10803-019-04058-1
Cook, Michal Lauren MSW; Zhang, Yi MS; Constantino, John N. MD On the Continuity Between Autistic and Schizoid Personality Disorder Trait Burden, The Journal of Nervous and Mental Disease: February 2020 - Volume 208 - Issue 2 - p 94-100 doi: 10.1097/NMD.0000000000001105
Frances, A. (2013). Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. Morrow.
Howard, G. [Host]. (2020, September 1). What is schizoid personality disorder? [Audio Podcast]. Psych Central. https://www.gabehoward.com/schizoid-personality-disorder-psych-central-…
Millon, T. (2011). Disorders of personality (3rd ed). Wiley.
Sagar, J.V. (2010). Asperger's syndrome. Andrha Pradesh Journal of Psychological Medicine, 11, 12-13.
White, S. G., Meloy, J. R., Mohandie, K., & Kienlen, K. (2017). Autism spectrum disorder and violence: Threat assessment issues. Journal of Threat Assessment and Management, 4(3), 144–163. https://doi-org.baypath.idm.oclc.org/10.1037/tam0000089
Wolff, S. (2017). Loners: The life path of unusual children. Routledge.