Emerging Personality Pathology in Adolescents With Autism Spectrum Disorder: Clinical Correlates and Assessment Implications

Vollständiger Abstract

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The link between neurodevelopmental and psychiatric conditions is increasingly recognized in developmental psychiatry, yet the relationship between Autism Spectrum Disorder (ASD) and Personality Disorders (PDs) remains underexplored in adolescence. Dysfunctional personality traits (DPT) may emerge in individuals with ASD, especially when diagnosis is delayed and comorbidities occur. This study assessed 79 adolescents (mean age = 15.15 ± 1.50; 45.6% females) with ASD without intellectual disability using a multimodal protocol (Autism Diagnostic Observation Schedule–Second Edition [ADOS-2], Autism Diagnostic Interview-Revised [ADI-R], Wechsler Intelligence Scale for Children–Fourth Edition [WISC-IV]/Wechsler Adult Intelligence Scale–Fourth Edition [WAIS-IV], Structured Clinical Interview for DSM-5 Personality Disorders [SCID-5-PD], Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Version [K-SADS-PL], standardized questionnaires). Analyses examined associations between DPT, psychiatric comorbidities, clinical severity, and functioning. DPTs were identified in 64.5% of participants, more frequently in females (75.0%) than males (48.9%). A prior ASD diagnosis was missing in 62%, particularly among females (odds ratio [OR] = 2.86, p = .030). Cluster A traits were most common (38.0%), notably Schizoid (22.8%), followed by Cluster B (24.1%), with Borderline traits markedly higher in females (22.2% vs. 2.3%, p = .006) and Cluster C (20.3%). DPTs were associated with lower functioning (Children’s Global Assessment Scale [CGAS], p = .037) and higher clinical severity (Clinical Global Impression [CGI], p < .019), also after False Discovery Rate (FDR) correction. Findings indicate that DPTs are highly prevalent yet often unrecognized in adolescents with ASD and are associated with greater comorbidity and poorer psychosocial outcomes. Early, developmentally informed assessment is crucial to identify risks and guide tailored interventions. Lay Abstract Autism Spectrum Disorder (ASD) is a neurodevelopmental condition that affects social communication, behavior, and sensory processing. Some autistic adolescents may also show emerging maladaptive personality traits or early features of personality pathology. However, the relationship between ASD and personality disorders has been studied far less than other mental health conditions, especially during adolescence, a key developmental stage. This study included 79 adolescents with ASD without intellectual disability, with an average age of 15 years. Nearly half of the participants were female. Each adolescent completed a comprehensive clinical assessment, including standardized tools for autism diagnosis, psychiatric diagnostic interviews, cognitive testing, and questionnaires on emotional and behavioral functioning. We found that almost two-thirds of participants showed dysfunctional personality traits (DPTs). These traits were more common in females than males. In addition, many adolescents had not received an autism diagnosis before entering the study, and missed or delayed diagnosis was especially frequent among females. This is consistent with growing evidence that autism in girls may be less easily recognized, particularly when symptoms are masked or present differently from traditional expectations. The most common personality patterns involved social withdrawal, emotional detachment, and limited interest in close relationships. Other adolescents showed traits linked to emotional dysregulation, impulsivity, anxiety, perfectionism, or a strong need for control. Adolescents with DPTs also showed greater overall clinical severity and lower psychosocial functioning in everyday life, including difficulties with peers, family relationships, and school adjustment. These findings suggest that emerging personality pathology is common but often overlooked in autistic adolescents. If autism is identified late, emotional and interpersonal difficulties may become more complex over time. Clinicians should assess autistic traits, co-occurring psychiatric symptoms, and maladaptive personality features together, using a developmentally informed approach. Earlier and more accurate recognition may support personalized interventions, reduce distress, and improve outcomes during the transition to adulthood.