Do autism and psychopathy co-occur? A systematic review and clinical discussion

Background: Although the prevalence is unknown, psychopathy can be a possible co-occurring condition associated with autism especially among forensic populations. However, the relationship between these two conditions remains poorly understood.

Aims: To carry out a systematic review of the available literature exploring the relationship between autism and psychopathy.

Methods: A systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using terms for autism and psychopathy to search the literature databases Scopus, Pubmed, Web of Science, ASSIA, APA Psych Info, Medline and EMBASE from 1980 to March 2024. For inclusion, we required that a recognised measure of autism and psychopathy or associated features of the latter had been used.

Results: Of the 4230 potential articles identified, 37 met the selection criteria. Insufficient and inconsistent methodologies for data pooling meant that a narrative analysis was used. Although there is some overlap, four broad themes emerged relating to (1) assessment and frequency of co-occurrence, (2) behavioural and neurophysiological expressions of empathy, (3) behavioural contagion effects, mirroring, mimicry and other linking mechanisms and (4) emotional face perception and theory of mind characteristics. Within these areas there are some specific differences between the two conditions. However, the research to date examining the relationship between autism and psychopathy has mostly been with children and males, carried out with non-clinical non-forensic populations, as well as using self-report measures and parental ratings. Prior research has also largely focused on looking for differences between these conditions rather than co-occurrence.

Conclusion: This review outlines a case for considering autism and psychopathy as distinct, but potentially co-occurring conditions and highlights the need for more research into how the two conditions interact with clinical populations. There also appears to be a need for guidelines on when and how to assess psychopathy with autistic individuals and a better understanding of the therapeutic needs and factors influencing the long-term outcomes of autistic individuals who may also present with co-occurring psychopathy.