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Autism Misdiagnosis: Borderline Personality Disorder

Updated: Nov 19, 2022

Autism is often "off the diagnostic radar," particularly for professionals serving adults. As a result, certain symptom clusters (e.g., emotional reactivity, difficulty with relationships) get labeled with a diagnosis while the big picture diagnosis is missing.

In the case of borderline personality disorder, the criteria include several things likely to be present for autism spectrum disorder including difficulty with a sense of stable identity, problems making and maintaining long term relationships, concerns about abandonment (e.g., not sure if the relationship is stable; wanting to be connected to a supportive other and worry abut being left), self-harm behaviors (e.g., cutting, suicidal gestures, banging or hitting the self, etc), and strong fluctuations in mood (difficulty staying emotionally even and recovering from emotional swings).

If you are familiar with autism characteristics, you know that many of these are frequently present in autism spectrum disorder. The ASD idividual will have difficulty with stable relationships and a sense of identity, emotional and behavioral regulation (fight, flight, freeze reactions), and behaviors that may cause harm or injury (skin picking, cutting, banging the self, etc).

How do we avoid misdiagnoses?

1. Put Autism in the Differential

One giant leap forward would be for autism to end up in the differential. What does this mean? When a professional considers diagnoses, s/he will usually have a list of possible diagnoses (differentials) and then narrow them down. We are at the point in our international culture where autism is RARELY on the differential at all.

2. Stereotyped Behaviors and Neurologic Abilities in Social Skills

Autism includes symptoms/characteristics not found in borderline personality disorder. These include the last four criteria: repetitive, stereotyped movements, use of objects, and/or speech; inflexibility of behavior and thought, ritualistic behaviors, concrete thinking; intense interests and/or attachment to objects, and sensory processing symptoms (under-reactivity, over-reactivity, or fascination). At times, the self-injury behaviors in autism relate to the stereotyped behaviors or sensory behaviors (or alternatively to socially naive behavior). Dissociative episodes and trauma histories are common in both BPD and autism.

In addition, although the borderline personality individual will struggle with relationships, the actual BPD criteria do not suggest that s/he lacks the neurologic ability to show reciprocity, interpret and express nonverbals, and understand relationships.

3. Different Recommendations

Understand that the two diagnoses will have different recommendations. For example, for the ASD individual, one should look at using sensory inputs to assist with dysregulated behavior, attend to the neurologic strengths and challenges with social communications, and be aware of self-harm behaviors related to stereotyped expressions of stress. Any counseling approaches for BPD that rely on self-awareness and introspection of internal states may have neurologic imitations for the ASD individual.

Additional Listening: Autism in the Adult podcast, Autism and Misdiagnosis: Personality Disorders

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