Autistics have lower empathy?

Research from 2019 indicates autistic people have lower empathy in correlation with autistic traits, even after accounting for alexithymia!^[1]Trait Autism is a Better Predictor of Empathy than Alexithymia (Shah et al., 2019) But do we really?

The short answer is, “It depends”. The long answer is that it’s complex. With the short answer out of the way, let’s do the long one now.

The research

Research from 2019 from Punit Shah and Lucy Anne Livingston et al. suggests that autism—more so than alexithymia—is predictive of low empathy.^[2]Trait Autism is a Better Predictor of Empathy than Alexithymia (Shah et al., 2019) The abstract of the research reads:

Multiple regression analyses showed that both trait autism and alexithymia were uniquely associated with atypical empathy, but dominance analysis found that trait autism, compared to alexithymia, was a more important predictor of atypical cognitive, affective, and overall empathy.

And the conclusion:

Together, these findings indicate that atypical empathy
in ASD is not simply due to co-occurring alexithymia.

And to clarify, alexithymia itself does not decrease one’s ability to empathize directly. As you can read in the post below, cognitive alexithymia (which is what autistic people tend to have^[3]The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder (Berthoz & Hill, 2005)) can limit your ability to identify and describe feelings, as well as your ability to identify facial expressions. Together, these difficulties can lead to a lower theory of mind, which in turn can affect whether we are likely to show empathy in particular situations.

Alexithymia & autism guide

I will discuss the specific results of the research in a moment. First, let’s look at what this study did differently from previous studies on autism, empathy, and alexithymia.

Clarifying autistic empathy

You might ask yourself why this study from 2019 is credible, since many autistic people indicate that at least their affective empathy is intact or even elevated, and that’s also what research from 2017 shows.^[4]The Empathy Imbalance Hypothesis of Autism: A Theoretical Approach to Cognitive and Emotional Empathy in Autistic Development (Smith, 2017) I think that is definitely the case, but it’s also true that different studies revealed different findings regarding autism and empathy. But generally, we see the following trends in the research literature:

• Research generally indicates that cognitive—not affective—empathy is lower in autism.^[5]Dissociation between cognitive and affective empathy in youth with Asperger Syndrome (Rueda, Fernández-Berrocal & Baron-Cohen, 2014)
• Research from recent years has highlighted the role of trait alexithymia in autism.
• Since we see elevated rates of alexithymia in autism, it’s argued that where lower empathy and different emotional processing is observed in autism, it’s due to co-occurring alexithymia.^[6]Empathic brain responses in insula are modulated by levels of alexithymia but not autism (Bird et al., 2010)

But there are several issues with other studies:^[7]Trait Autism is a Better Predictor of Empathy than Alexithymia (Shah et al., 2019)

• The tests that are often used to measure empathy—the Interpersonal Reactivity Index (IRI) ^[8]Measuring individual differences in empathy: Evidence for a multidimensional approach (Davis, 1983) and the Empathy Quotient (EQ)—were not designed to distinguish between cognitive and affective empathy.
• Few studies have used appropriate analyses to investigate cognitive and affective empathy in autism, and properly distinguish between them.^[9]The effects of repetitive transcranial magnetic stimulation on empathy: a systematic review and meta-analysis (Yang, Khalifa & Völlm, 2017) Often either cognitive or affective empathy and its relationship to autism (and alexithymia) is studied, without accounting for the other. This is problematic because affective and cognitive empathy are correlated, and used together in social situations.^[10]On the interaction of social affect and cognition: empathy, compassion and theory of mind (Preckel, Kanske & Singer, 2018)
• Many studies feature methodological issues, such as using very small sample sizes that lack sufficient statistical power to test the associations of trait autism and alexithymia,^[11]Interoceptive Impairments Do Not Lie at the Heart of Autism or Alexithymia (Nicholson et al., 2018) and using poorly matched samples. Specifically, the prevalence of alexithymia is much lower in neurotypical populations (5% vs 50+%^[12]Investigating alexithymia in autism: A systematic review and meta-analysis (Kinnaird, Stewart & Tchanturia, 2020)), so matching groups for alexithymia is potentially problematic.

So the reason that this 2019 study could be more credible is that it avoided these problems; the researchers used two large community samples drawn from the general population, and took measures of trait autism and alexithymia, rather than trying to match a neurotypical control group to an autistic sample. To measure empathy, they used the Toronto Alexithymia Scale (TAS-20) and the Questionnaire of Cognitive and Affective Empathy (QCAE).

NB: One counter-argument though is that although the QCAE may be better suited to differentiate cognitive and affective empathy from each other, it’s not at all clear it measures either component accurately in autism. It may very well be that neurotypical biases are present in the questionnaire, making it an imperfect tool to measure empathy in autism. This is an issue in earlier papers and instruments on empathy as well. So although the 2019 paper improves on many factors of earlier research, note that this paper is far from conclusive.

With that out of the way, let’s talk more about their results, and whether they match the autistic experience.

Results

The results of the study showed that:

• Autism and alexithymia were both significant predictors of:
  • Lower overall empathy.
  • Lower cognitive empathy (after accounting for affective empathy).
• Yet alexithymia was associated with higher affective empathy (after accounting for cognitive empathy).

The table below shows the different correlations. As you can see, both autism and alexithymia are negatively correlated with cognitive, affective, and overall empathy. But let’s look at how much.

Cognitive empathy

As you might expect, both autism and alexithymia have an influence on cognitive empathy. The study shows that the greater the autistic and alexithymic traits, the lower your cognitive empathy tends to be, and the two are 26% correlated. Autism has a marginally greater negative effect on cognitive empathy than alexithymia, as it’s 28% correlated.

Affective empathy

Autism has a negligible negative effect on affective empathy, as they are 0.004% correlated. But interestingly, the presence of alexitymia has a positive influence on affective/emotional empathy (correlation: 13%). That is a pretty big finding! Remember, 40–65%^[13]The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder (Berthoz & Hill, 2005)^[14]Brief report: cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives (Hill et al., 2004) of autistic people have alexithymia—or even as high as 70%.^[15]Measuring the effects of alexithymia on perception of emotional vocalizations in autistic spectrum disorder and typical development (Heaton, 2012)

I got really excited about these results, because I think this is what accounts for all those autistic people who report having more affective empathy than neurotypicals. Previous research already found affective empathy to be intact or even elevated in autism.^[16]The Empathy Imbalance Hypothesis of Autism: A Theoretical Approach to Cognitive and Emotional Empathy in Autistic Development (Smith, 2017) But now that effect has been traced to alexithymia, not autism.

I don’t think this paper has the final answers on this topic. The authors of the study also highlight limitations with their study, and directions for future research. Longitudinal research is required to examine whether differences in emotional processing and empathy in autism is a cause or consequence of alexithymia or other co-occurring traits.

In time, we will get a better picture of autistic empathy, and elucidate the role of alexithymia in autism.

For more information on autism and empathy, have a look at:

Autism & empathy