Social Peculiarity: A Primer for Counselors

Social peculiarity is frequently observed in clients with mental health and substance abuse disorders. However, it lacks a consensus definition and is not a well-delineated clinical entity or syndrome with an established set of descriptive diagnostic criteria. 

Some mental health clinicians would argue that, while social peculiarity is difficult to define, they know it when they see it. However, a case can also be made that clinically significant social peculiarity is often in the eye of the beholder, and cannot be easily distinguished, in its milder and more subtle forms, from normal variation in eccentric or idiosyncratic behavior, social awkwardness or anxiety, and interpersonal or communication abilities and skills (Gnaulati, 2013).  

Evaluation of social peculiarity can be influenced by multiple factors: the role and perspective of the observer such as a parent, teacher, counselor, psychotherapist; evolving sociocultural norms or values regarding what is considered socially appropriate, competent, and effective behavior in different settings; the situational context of the client (including the clinical assessment setting); and the limitations of existing tests to measure this somewhat elusive construct. Premature labeling of persons, as “socially peculiar,” by counselors and other mental health practitioners, may result in stigma and other unintended negative, iatrogenic effects.

Milder cases of clinically relevant social peculiarity may go undiagnosed for many years and only become evident in circumstances or phases of life which involve a markedly increased demand for social competence. Comorbid psychoeducational and psychiatric conditions may also mask socially peculiarity. Additionally, individuals can “age out” of conspicuous signs or symptoms of social peculiarity over the course of their development, which may contribute to diagnostic uncertainty (Pollak, 2010).

Working Definition  

For the purpose of this discussion, social peculiarity refers to physical appearance, atypical experiences, unusual perceptions and odd beliefs as well as patterns of thinking and behavior which consistently evoke considerable discomfort or consternation among a broad range of observers including significant others. Evidence of social peculiarity is reliably present in most, if not all, interpersonal situations. It is not well explained by sociocultural, linguistic, gender, racial, ethnic or religious differences, situational influences and stressors or the normative difficulties in interpersonal functioning and social competence seen in persons with DSM-5 defined Intellectual Developmental Disorder (Westphal & Mukherjee, 2014).  

Furthermore, assessment of social peculiarity as clearly maladaptive and warranting formal evaluation and intervention would depend on several factors: the degree and severity of the person’s subjective distress and motivation for treatment, presence and magnitude of psychoeducational and psychiatric comorbidity, impairment in everyday functioning (and other “quality of life” considerations) as well as the impact of the person’s peculiar thinking and behavior on the attitudes and feelings of significant others.

Relevant Constructs    

Since the 1980s, increased attention has been paid to the biopsychosocial substrates of emotional intelligence, social cognition, theory of mind, executive functioning, and most recently personal intelligence (Baron-Cohen, Tager-Flusberg, & Lombardo, 2013; Chan, Shum, Toulopoulou, & Chen, 2008; Joseph & Newman, 2010; Mayer, 2014). These are overlapping constructs related to social competence including the capacity for empathy, perspective taking, and reciprocal interaction. Therefore, they are highly germane to a better understanding of social peculiarity. Individuals with difficulties falling within these domains frequently present with an admixture of anomalies in appearance, perception, belief structure, cognition, and social relatedness despite often having at least average level cognitive or intellectual functioning (Myles et al., 2007). 

Over this same time period, there has also been considerable interest in Asperger’s disorder—subsumed within the broader diagnosis of autism spectrum disorder with the advent of the DSM-5—and other “neurosocial” disorders. These conditions involve impaired functioning referable to deficits in social perception and verbal or nonverbal communication skills, notably the understanding and use of social cues to adaptively navigate a range of interpersonal situations across the lifespan. Clients with these syndromes are typically deemed as socially peculiar by most observers.

Psychoeducational/Psychiatric Comorbidity  

Individuals who are considered socially peculiar, particularly persons with “lifelong eccentricity”  (Tantam, 1988), are at heightened risk for psychoeducational and psychiatric comorbidity including attentional, learning, anxiety, mood, psychotic, and other disorders (Mazzone, Ruta, & Reale, 2012). In addition, they have an increased susceptibility to a range of adverse outcomes. These include problems with attachment and intimacy, social isolation or withdrawal, and anger as well as impaired self-esteem and elevated rates of self-harm. Legal difficulties, limited educational or vocational attainment, and problems managing the demands of independent living   are also common among this population (Mazzone et al., 2012; Tantam, 1988).  

These daunting challenges are compounded by the negative reactions of others: anxiety or fear, social avoidance or distancing, and bullying or harassment (Corrigan, 2004; Smith & Cashwell, 2011). Early identification of maladaptive social peculiarity by counselors and others in the mental health community may, however, serve to mitigate one or more of these undesirable outcomes.

The DSM-5    

The DSM-5 includes references to odd, eccentric, and unusual beliefs, thinking, and behavior—often coupled with increased suspiciousness, constricted affect, and social isolation—as characterizing some persons with mental health conditions. Still, social peculiarity is not cited as a defining feature of any DSM-5 diagnosis except for schizotypal personality disorder and is not included as one of many specifiers. The latter are descriptive features which provide a more nuanced picture of an individual’s clinical presentation and status. 

However, based on the DSM-5 diagnostic criteria for autism spectrum disorder, even persons with mild symptoms who fall within this spectrum would be considered socially peculiar. This includes Criterion A: “persistent deficits in social communication and social interaction across multiple contexts” and Criterion B: “restricted, repetitive patterns of behavior, interests and activities” (American Psychiatric Association, 2013). Along similar lines, the DSM-5 criteria for the new neurodevelopmental diagnosis—social (pragmatic) communication disorder—will almost certainly, in the years ahead, result in an appreciable proportion of individuals with this designation being perceived as socially peculiar. This includes Criterion A: “persistent difficulties in the social use of verbal and nonverbal communication” and Criterion B: “the deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement or occupational performance, individually or in combination” (American Psychatric Association, 2013). 

The DSM-5 carried over the categorical diagnostic classification of personality disorders outlined in its predecessor, the DSM-IV. This includes the so-called “Cluster A” personality disorders: schizoid, schizotypal, and paranoid subtypes. This triad continues to be defined as involving eccentric appearance, experiences, perceptions, beliefs, thinking, and behavior. This contrasts with “Cluster B” personality disorders which are characterized by dramatic, emotional, and erratic patterns or traits and “Cluster C” personality disorders, which are distinguished by anxious, fearful, and frequently inhibited patterns or traits.  

In the DSM-5, the diagnosis of “personality change due to a another medical condition”—included in the DSM-IV within the grouping “mental disorders due to a general medical condition”—has been subsumed within the larger category of personality disorders. As is the case with Cluster A diagnoses, some of the criteria for this syndrome substantially increases the probability that some persons with this diagnosis would be deemed socially peculiar.

The DSM-5 disorders listed below also increase the likelihood that persons with diagnoses within these broad categories would be considered socially peculiar: 

 

• Schizophrenia spectrum and other psychotic disorders
• Bipolar and related disorders
• Depressive disorders
• Obsessive-compulsive and related disorders
• Trauma and stressor-related disorders such as reactive attachment disorder and disinhibited social engagement disorder
• Somatic symptom and related disorders, such as conversion disorder
• Dissociative disorders, such as dissociative identity disorder
• Neurocognitive disorders like minor and major frontotemporal neurocognitive disorder-behavioral variant 
• Substance-related and addictive disorders

 

In addition, many persons are likely to be viewed as socially peculiar who meet criteria for two of the “conditions for further study” included in the DSM-5, specifically attenuated psychosis syndrome and neurobehavioral impairment associated with prenatal alcohol exposure.

As well, certain specifiers within the DSM-5 would appear to increase the likelihood of a person being perceived as socially peculiar. These include catatonic, melancholic, and psychotic features in cases of mood disorder and behavioral disturbance for persons diagnosed with neurocognitive disorders. Specifiers that pertain to level of severity and degree of insight into symptoms also influence whether individuals with one or more DSM-5 diagnoses are considered socially peculiar.

Other Clinical Syndromes  

Social peculiarity has also been cited as a defining feature of neurodevelopmental conditions that, to date, have not been well validated and have not been formally included in the DSM-5 as recognized diagnoses or listed as conditions warranting further study. This includes the diagnosis of nonverbal learning disorder (NVLD) which, in most clinical accounts, overlaps in its symptomatology with DSM-5-defined autism spectrum disorder, social (pragmatic) communication disorder, and mathematics learning disorder (Delgado, Wassenaar, & Strauss, 2011).

A number of neurogenetic disorders are nearly always associated with social peculiarity. These include: fragile X, velocardiofacial syndrome, Turner’s syndrome, and Williams syndrome to name a few (Feinstein & Singh, 2007; Mazzocco & Ross, 2007). These conditions involve cognitive and neuropsychological dysfunction, learning problems, and elevated rates of DSM-5-defined intellectual developmental disorder. Some people with these developmental disabilities also meet criteria for DSM-5-defined autism spectrum disorder. In cases meeting criteria for intellectual developmental disorder social peculiarity is typically disproportionately severe relative to expectation for the degree of cognitive disability.

Issues Relevant to Perceived Social Peculiarity     

The broad DSM-5 groupings, cited above, can involve clinical presentations which would be assessed as odd, eccentric, strange, and sometimes bizarre by most observers depending on the nature and severity of the symptom profile in a given case. However, when a person is highly symptomatic with one or more of these conditions, it can be difficult to separate “state” from  “trait” with respect to the issue of social peculiarity as many individuals would not relate in ways considered socially peculiar when they are having few, if any, of the symptoms related to their diagnosis. Other individuals, however, would likely continue to be viewed as socially peculiar due to underlying cluster A personality patterns and/or their neurodevelopmental status.      

Baseline personality patterns and traits, level of cognitive and intellectual functioning, and type of specifiers, including level of severity and degree of insight into symptoms, may serve as moderator variables with respect to a person being considered socially peculiar who has one or more DSM-5 diagnoses. As one example, a young adult with intact cognitive and intellectual functioning, a generally unremarkable premorbid baseline, and mild symptoms of schizophrenia with relatively well-preserved insight is less likely to be deemed socially peculiar than a cognitively compromised peer with significant preexisting adjustment problems, a more severe course of symptoms—including both negative and positive psychotic symptoms—and persistently impaired insight. Persons with schizotypal personality disorder can be expected to appear socially peculiar even when their condition is relatively mild. Individuals with mildly severe schizoid or paranoid personality disorder, though, may or may not be considered socially peculiar depending on the setting as well as the duration and depth of contact including when seen for clinical assessment.

Differential Diagnosis  

The age range/phase of life onset, the type of onset together with the typical, longitudinal course- trajectory of behavioral patterns and symptoms of social peculiarity can help with DSM-5 differential diagnosis as reviewed below.  

Age Range or Phase of Life Onset  

 

• Early to Middle Childhood: autism spectrum disorder
• Middle Childhood to Early Adolescence: social (pragmatic) communication disorder 
• Later Adolescence to Young Adulthood: most other DSM-5 categories cited above  
• Middle to Advanced Age: minor and major neurocognitive disorders with behavioral disturbance 

 

 

Type of Onset  

 

Insidious or acute onset social peculiarity is highly suspicious for mental status change, referable to substance misuse and/or medical factors.

 

Course  

 

Social peculiarity is likely to gradually improve through the young adult years for some individuals with neurodevelopmental conditions like autism spectrum disorder and social communication disorder. It can be expected to wax and wane in psychotic disorders and other conditions that can be treatment responsive. Social peculiarity is likely to remain relatively stable in clients with cluster A personality disorders or who have a diagnosis of personality change due to a medical condition. Progression is the rule for neurocognitive disorders like the behavioral variant of minor or major frontotemporal neurocognitive disorder. Recurrent, but reversible, social peculiarity can be observed in some clients with substance- related and addictive disorders.

 

Rating Scale Assessment  

There are no well-validated rating scales for the assessment of social peculiarity per se, which are appropriate for clinical use. There are also no scales to assess social peculiarity specifically pertaining to acute, insidious or late-onset.  

Most rating scales germane to the evaluation of this construct were developed to assess neurodevelopmental disorders in children, adolescents, and young adults, notably Asperger’s disorder and stable, long-term maladaptive personality patterns like schizotypal personality disorder (Raine & Benishay, 1995; Stoesz, Montgomery, Smart, & Hellsten, 2011).

Additionally, there are no rating scales which include a self-report and informant version. Moreover, none of these tests have been shown to be superior to others for detection of neurodevelopmental and neuropsychiatric conditions associated with social peculiarity. Therefore, no measure should be considered a “gold standard” instrument. Furthermore, these screening tests are not “stand alone” measures, and should only be employed as adjunctive tools to supplement data gathering based on record review, the family and personal history provided by the client and responsible others, and findings gleaned from the mental status examination and the evolving counseling relationship. Persons screening positive on these tests would need further evaluation based on the probability of later being diagnosed with the targeted clinical syndrome (Stoesz et al., 2011).

Rating scales can be helpful in establishing the presence, relative severity, and pervasiveness of symptoms together with the degree of distress, insight, and functional impairment associated with social peculiarity (Campbell, 2005). These assessment tools may be particularly useful for counselors in “grey cases,” which involve suspected mild or attenuated features of social peculiarity. They may also serve as a hedge against both the under- and over-identification of clinically significant social peculiarity. These instruments can also assist in parsing out the relative contribution of neurodevelopmental influences, like autism spectrum disorder, from the acute or chronic symptomatology of psychotic disorders and other conditions which typically have a later-onset, but which are also highly associated with social peculiarity.

Assets  

These tests are easy to complete due to their brevity and modest reading comprehension demands. Most instruments can be completed in less than fifteen minutes, although some can take as long as an hour to finish. They are easily managed by respondents with an early high school reading level. Scoring and interpretation are relatively straightforward based on cut-off scores and/or a global composite index score indicating the probability of having the assessed condition.  

Most of these screening measures have satisfactory content validity—the items and subscales adhere closely to descriptions in the clinical and research literature including criteria in DSM-IV. For some of these scales, item selection was also based on the clinical experience of the authors, the opinions of expert judges, and/or the content from related scales.  

Common features include the following subscales for:

• Perceptual cognitive-psycholinguistic anomalies
• Problems with interpersonal relatedness and pragmatic language skills, including problems with socio-emotional reciprocity
• Idiosyncratic or circumscribed interests
• Disorganized thinking and behavioral patterns
• Social discomfort or anxiety and atypical sensory-motor development or functioning

 

Limitations  

The development of most of these instruments was based on the DSM-IV constructs and criteria. In the case of scales designed for the assessment of Asperger’s disorder, this includes the categorical distinction made in the DSM-IV between Asperger’s disorder and autism disorder. The separation of these two neurodevelopmental conditions has been eliminated in the DSM-5 as a “distinction without a difference” with respect to diagnostic validity (King, Veenstra-Vanderweele, & Lord, 2013).

Some of these screening tests have been normed on relatively small samples. In some cases, the test manuals lack independent diagnoses of the target syndrome, have limited, if any, data pertaining to level of general cognitive and intellectual functioning of the normative groups, and have sparse information on reliability (Campbell, 2005;  Stoesz et al., 2011). 

Most manuals include some evidence for construct validity including adequate to satisfactory ability to discriminate individuals with mild autistic behaviors or symptoms from normal controls as well as some clinical groups, including people with attention deficit disorder, learning disorders, and histories of behavioral problems. However, they do not contain supporting information pertaining to ability to differentiate Asperger’s disorder and related diagnoses, notably high functioning autism, from groups with similar descriptive features like schizoid and schizotypal personality disorder and attenuated psychosis syndrome or prodromal psychosis.  The manuals of some tests lack data pertaining to sensitivity-specificity. In this case, sensitivity means the probability that a person with the targeted condition will screen positive, while specificity refers to the probability that a person who does not have the targeted condition will screen negative while others contain accuracy “hit rates” which fall below acceptable standards. Other screening tests, however, have impressive sensitivity-specificity values in support of clinical utility (Ritvo et al., 2011).      

 

Several rating scales are commercially available for the evaluation of Asperger’s disorder:

• Asperger’s Syndrome Diagnostic Scale (ASDS)
• Gilliam Asperger’s Disorder Scale (GADS)
• Krug Asperger’s Disorder Index (KADI)

 

These screening measures are based on third party perspectives and do not include a self-report format. Most include normative data through late adolescence into the early twenties, and arguably are not suitable for use with clients who are middle-aged or elderly.  

There are also self-report instruments—authored by highly regarded researchers on autism spectrum disorder who have appeared in peer-reviewed publications—which can be employed by counselors with clients aged eighteen and over: Autism Spectrum Quotient (ASQ) (Woodbury-Smith, Robinson, Wheelwright, & Baron-Cohen, 2005) and the Ritvo Autism Asperger Diagnostic Scale, Revised (RAADS-R) (Ritvo et al., 2011).  The ASQ is primarily designed to identify attenuated-mild autistic traits. The RAADS-R was developed as a diagnostic instrument to formally screen for mild autistic disorder.  

Both of these screening tests were normed on individuals with average to above average cognitive or intellectual functioning, and high school level and above educations. Therefore, these scales are likely not appropriate for persons with known or suspected below average cognitive or intellectual ability and/or limited formal education.  

There are a number of self-report scales in the literature for the assessment of prodromal psychosis or attenuated psychosis syndrome (Daneault & Stip, 2013). The Prodromal Psychosis Scale is one of the more promising of these instruments. The sixteen-item scale—the shortest version developed to date—has been shown to have good sensitivity and specificity in a large sample of help-seeking young adults aged eighteen years and older. It predicted ultra-high risk status for conversion to psychosis as well as the longest version, a ninety-two-item scale (Ising et al., 2012). This abbreviated version of the scale retains a number of items pertaining to perceptual aberrations and unusual thought content; symptoms which would contribute to respondents being considered socially peculiar who exceed the cutoff—that is, screen positive for suspected prodromal psychosis or attenuated psychosis syndrome.

Broad-Band Assessment Instruments  

Counselors can also avail themselves of commercially available broad-band measures of socioemotional, personality, and executive functioning which, depending on the content of the instrument, contain scales pertaining to behavioral patterns and symptoms germane to the assessment of social peculiarity: atypical thinking, hypervigilance, behavioral rigidity, resistance to change, negative affectivity (anxiety/depression), social detachment or isolation, and deficits in social competence including self-monitoring and problems with socio-emotional reciprocity.   

These tests are more time-intensive to administer and score than the rating scales previously cited—they also require additional study and training. Therefore, they are generally not suitable to supplement history and clinical interview when conducting intake evaluations, especially in busy practice settings. One or more of the following tests can be helpful as part of a more extended evaluation. Most involve level C qualifications for purchase, which usually requires a minimum of a master’s degree in counseling.  

• Behavior Rating Inventory of Executive Function (BRIEF)
• Behavior Assessment System for Children-2 (BASC-2)
• Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
• Millon Clinical Multiaxial Inventory-III (MCMI-III)
• Personality Assessment Inventory (PAI) and the Personality Assessment Inventory-Adolescent (PAI-A)

 

Indications for Additional Diagnostic Assessment  

Medical evaluation—to include, as appropriate, substance abuse assessment—is indicated in some cases of social peculiarity. These cases involve acute onset or recurrent acute onset or offset, repeated exacerbations or gradual worsening over time. Medical evaluation should also be considered when social peculiarity arises de novo in middle age or late life, especially in the absence of psychosocial stressors and/or a clear worsening of baseline psychiatric difficulties, which satisfactorily explain the onset and course of symptoms (Pollak & Miller, 2011).  

There is a strong evidence base for neuropsychological dysfunction among some persons with clinically significant social peculiarity which can have important implications for diagnosis, treatment planning, and prognosis (Ambery, Russell, Perry, Morris, & Murphy, 2006; Fusar-Poli et al., 2012). Therefore, cognitive or neuropsychological testing should be considered particularly for clients with early- or late-onset social peculiarity, insidious changes in demeanor, and/or who might benefit from a trial of cognitive rehabilitation to develop compensatory strategies for their information processing problems (Schwarz, Roskos, & Grossberg, 2014).

Suggestions for Future Research  

A standardized definition of social peculiarity would help to guide clinical assessment and research investigation of this construct. Ideally, a set of agreed-upon clinical criteria should be established by a committee comprised of representatives from all of the mental health professional groups.

Data is needed on the incidence and prevalence of social peculiarity across clinical syndromes. Proposed text revisions of the DSM-5 should identify those syndromes for which social peculiarity may be a necessary criterion for diagnosis or an associated feature. As well, the designation of social peculiarity as a specifier ought to be considered for future text revisions.

The clinical perspectives previously cited regarding factors which may influence the perception of social peculiarity require research support and validation.

Research is also needed to improve the psychometric properties of screening measures currently in use. This would include expansion of norms across the adult age range, co-norming of self-report and informant versions of these scales, item revisions in line with DSM-5 criteria, and additional studies to bolster claims of reliability and validity. More specifically, studies would be helpful which compare the accuracy or hit rates of these tests and whether sensitivity-specificity can be enhanced by combining two or more current measures or via the development of new measures (Stoesz et al., 2011).   

Social peculiarity is probably not a unitary construct. Improvements in the psychometric adequacy of existing tests, together with the development of new screening instruments, may allow for delineation of possible subtypes of social peculiarity which are relatively specific to certain clinical syndromes and, perhaps, differentially responsive to particular interventions. Screening tests with a stronger psychometric foundation would also bolster the usefulness of these instruments—as pre- and postmeasures—in studies on strategies to strengthen adaptive skills and overall social competence and help to extend the evidence base in this area (Kopelowicz, Liberman, & Zarate, 2006; Rao, Beidel, & Murray, 2008). Research is also needed on factors which may impact treatment planning and outcome including early versus late identification, recognition, etiology, and psychological or neuropsychological test profile.

Social peculiarity is frequently observed in clients in mental health care and is associated with a number of adverse consequences and outcomes. Evaluation and treatment planning can benefit by knowledge pertaining to the phase of life and type of onset as well as the longitudinal course of behavioral features and symptoms.   

Despite their limitations, enhanced recognition of maladaptive social peculiarity can be facilitated by the judicious use of self-report and informant-based rating scales to supplement record reviews, interviews with clients and responsible others as well as information gleaned from the mental status and the client-counselor relationship. Some clients may need referral for medical evaluation—to include substance abuse assessment—and/or cognitive or neuropsychological testing to further clarify their clinical status and intervention needs. 

 

 

 

References  

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Campbell, J. M. (2005). Diagnostic assessment of Asperger’s disorder: A review of five third- party rating scales. Journal of Autism and Developmental Disorders, 35(1), 25–35.

 

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