I-RAP
Improving Recognition and Understanding of Autism and Personality Disorder
Information about autism and personality disorder
1. Highlights
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Most people diagnosed with borderline personality disorder are women or people assigned female at birth (AFAB). Autism can look different in women/AFAB people, which can lead to it being missed or misdiagnosed as personality disorder..
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Autism and borderline personality disorder can appear similar. For example, both may be characterised by emotion dysregulation and self-harm. This could lead to autism being misdiagnosed as borderline personality disorder.
2. Further Information:
2. Further Information
You can discover detailed information through the three sub-sections listed below:
1. Gender stereotypes and autism in women and people assigned female at birth.
2. Possible overlaps between autism and personality disorder
3. The trauma of being autistic in a neurotypical world.
1. Gender stereotypes and autism in women and people assigned female at birth.
Autism has stereotypically been viewed as a male diagnosis [1]. A growing body of research shows that autism in women and people assigned female at birth may be more common than thought and often goes undetected [2, 3, 4]. (When we say “assigned female at birth” or “AFAB” we mean a person whose was assigned as female by medical professionals when they were born, even if the person then later realised they had a non-female or non-cis gender ).
Under-recognition of autism in women/ AFAB people has been attributed in part to the so-called “female phenotype” of autism. This is the idea that autism can present differently/ look different in women and AFAB people. Autistic females/AFAB people often strongly desire social relationships with others [5] and learn how to use “social camouflaging” or “masking” to disguise their autistic traits during social interactions [3, 6, 7, 8, 9]. The Autism Diagnostic Observation Schedule (ADOS) is an autism assessment tool that involves observation of a person’s social communication by a trained clinician. This way of making an assessment may underestimate autistic traits in women/AFAB people who have learnt to mask [3]. Additionally, autistic women/AFAB people may demonstrate lower levels of repetitive behaviour and restricted interests than men [10], or may show less unusual and more socially-focused interests that are not detected in current male-oriented assessment tools [3, 7, 8, 11]. It has since been suggested that this presentation can also be characteristic of men/people assigned male at birth, albeit less commonly, and also of autistic people with non-binary gender identities. For this reason it could be better named an “internalised” presentation of autism rather than relating it specifically to gender [12].
Conversely, potentially partly due to gender biases [13, 14, 15], at least 75% of people diagnosed with borderline personality disorder are women/AFAB [16]. This occurs despite borderline personality disorder features being equally common in men/people assigned male at birth in the general population [16, 17]. Thus, failure to recognise the “female” or “internalised” presentation of autism, alongside gender biases which stereotype autism as a “male” diagnosis and borderline personality disorder as a “female” diagnosis, could be one of the reasons why autism is missed in some women/AFAB people given a diagnosis of personality disorder.
2. Possible overlaps between autism and personality disorder
In their paper, the “Lost Generation of Autistic Adults”, Meng-Chuan Lai and Simon Baron-Cohen outline how symptoms of mental health conditions can sometimes overshadow autism - i.e. make it harder for mental health clinicians to realise that a person is actually autistic [2]. Autistic people are more likely to experience a wide range of mental health conditions than non-autistic people, including depression and anxiety [18, 19]. Mental health clinicians sometimes don’t realise that autism – and the difficulties associated with being autistic in a neurotypical world – are underlying these mental health difficulties. This is particularly the case when someone has a less obvious or more “internalised” presentation of autism. Autistic females/AFAB people are more likely than autistic males/AMAB people to have a range of mental health diagnoses, especially when they have been diagnosed with autism later in life [20].
Similarly, if someone is given a diagnosis of a personality disorder, this may make it harder for mental health clinicians to realise that they are actually autistic, because their behaviours, experiences and mental distress are interpreted by clinicians as being related to “personality disorder” rather than autism.
When it is realised that a person who has been given a personality disorder diagnosis is actually autistic, one conundrum is whether the personality disorder diagnosis is still valid and sits alongside the autism (known as “comorbidity”), or whether the personality disorder was a misdiagnosis all along. People that hold strong views that the personality disorder construct is wrong (see the Criticisms of the idea of personality disorder section) would argue that personality disorder is always an incorrect/invalid diagnosis in any case; encapsulated in the #autismnotpd hash tag on X ("Twitter") [21, 22]. However, currently ICD-11 and DSM-V allow for a person to hold both diagnoses at the same time. In reality sometimes the personality disorder diagnosis is acknowledged to be a misdiagnosis and revoked, but often it is seen as a co-existing diagnosis and remains on the person’s medical record [18].
Meng-Chuan Lai and Baron-Cohen [2] describe various ways in which, sometimes, an autistic person’s behaviour and experiences can look similar to various types of “personality disorder”, leading to misdiagnosis. In these instances, the personality disorder is a misdiagnosis because the person’s behaviour and experiences are better explained by autism. In 2020, Chris Gordon and colleagues wrote a more detailed paper outlining what, based on their clinical experience and the limited existing research on this topic, they believed to be the main similarities and differences between autism and borderline personality disorder, with suggestions that clinicians may find helpful [23].
When we planned the I-RAP project in 2020, we carried out our own literature review and we spoke to our panel of autistic people who had previously been diagnosed with a personality disorder to understand their experiences of similarities and differences between the two diagnoses. We identified potential similarities and differences in five areas: Emotions, Behaviour, Cognition, Identity and Interpersonal interactions. For example, both autistic people and people meeting diagnostic criteria for borderline personality disorder have been shown to experience intense emotions more readily than people without these diagnoses, and to experience difficulties in regulating their emotions, sometimes alongside self-harm [2, 24, 25, 26, 27, 28, 29]. Given that self-harm and emotional instability are diagnostic criteria for borderline personality disorder, this similarity could lead to autistic people being misdiagnosed with this [2]. However, there are likely to be some differences in what typically triggers emotional dysregulation. For example, an autistic person might be more distressed by sensory or cognitive overload, or by changes in routine and environment, than a non-autistic person [30, 31]. We looked at similarities and differences in detail as part of our research. For more information, see What did we do – Study 3.
Some other excellent resources, published subsequently from a lived experience perspective alongside rejection of the personality disorder construct, are Wren Aves’ blog on this topic [21] and Jay Watt’s paper [22].
3. The trauma of being autistic in a neurotypical world.
Autistic people are vulnerable to experiencing trauma on multiple fronts. Autistic people may experience rejection from their peers, the school system and even family members as they grow up [32], and are highly likely to experience bullying [33]. Consequently they may experience a lifetime of feeling that they do not fit in with others, that they are different or somehow wrong. Being misunderstood by society and the world around them can leave them struggling to make sense of themselves. Autistic people can also be vulnerable to exploitation and abuse by others due to their isolation and exclusion from society, and due to difficulties in navigating neurotypical social interactions and reading other people’s intentions [34]. Not only are autistic people more likely than non-autistic people to experience trauma, they are also more likely than non-autistic people to develop post-traumatic stress symptoms following traumatic experiences [35]. Since trauma is strongly associated with developing the coping strategies and internal experiences characteristic of borderline personality disorder [36], this may explain why some autistic people meet diagnostic criteria for BPD.
3. References
[1] Fombonne, E. (2005) Epidemiological studies of pervasive developmental disorder. In: Volkmar F, Paul R, Klin A, Cohen D, eds. Handbook of Autism and Pervasive Developmental Disorders. HobokenNJ: Wiley. pp 42–69. [2] Lai, M. C., & Baron-Cohen, S. (2015). Identifying the lost generation of adults with autism spectrum conditions. The Lancet Psychiatry, 2(11), 1013-1027. [3] Lai M.C., Lombardo MV, Pasco G, Ruigrok ANV, Wheelwright SJ, et al. (2011) A Behavioral Comparison of Male and Female Adults with High Functioning Autism Spectrum Conditions. PLoS ONE 6(6): e20835. doi:10.1371/journal.pone.0020835 [4] Sun X, Allison C, Auyeung B, Baron-Cohen S, Brayne C. (2014). Parental concerns, socioeconomic status, and the risk of autism spectrum conditions in a population-based study. Research in Developmental Disabilities. 35(12):3678–3688. [5] Sedgewick, F., Hill, V., Yates, R. et al. (2016). Gender differences in the social motivation and friendship experiences of autistic and non-autistic adolescents. Journal of Autism and Developmental Disorders, 46(4), 1297–1306. [6] Attwood, T. (2007). The complete guide to Asperger’s syndrome. London: Jessica Kingsley. [7] Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: An investigation of the female autism phenotype. Journal of Autism and Developmental Disorders. [8] Hull, L., Petrides, K.V., Allison, C., Smith, P., Baron‑Cohen, S., Lai, M-C., Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal of Autism and Developmental Disorders, 47, 2519-2534. [9] Hull, L., Petrides, K.V., Mandy, W. (2020). The Female Autism Phenotype and Camouflaging: a Narrative Review. Review Journal of Autism and Developmental Disorders, 7, 306-317. [10] Wilson, C. E., Murphy, C. M., McAlonan, G., Robertson, D. M., Spain, D., Hayward, H., et al. (2016). Does sex influence the diagnostic evaluation of autism spectrum disorder in adults? Autism, 20(7), 808–819. [11] Gould, J., Ashton-Smith, J. (2011).Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum. Good Autism Practice (GAP), 12(1), 34–41. [12] Henderson, D., Wayland, S., White, J. (2023). Is This Autism?: A Guide for Clinicians and Everyone Else. Routledge: Abingdon, UK. [13] Becker, D., & Lamb, S. (1994). Sex bias in the diagnosis of borderline personality disorder and posttraumatic stress disorder. Professional Psychology: Research and Practice, 25(1), 55–61. [14] Braamhorst W, Lobbestael J, Emons WH, Arntz A, Witteman CL, Bekker MH (2015). Sex Bias in Classifying Borderline and Narcissistic Personality Disorder. Journal of Nervous and Mental Disease;203(10):804‐808. [15] Shaw, C., & Proctor, G. (2005). I. Women at the margins: A critique of the diagnosis of borderline personality disorder. Feminism & Psychology, 15, 483–490. [16] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. [17] Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., Dawson, D. A., Pulay, A. J., Pickering, R. P., & Ruan, W. J. (2008). Prevalence, correlates, disability,and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry, 69(4), 533–545. [18] Lai, M. C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The lancet. Psychiatry, 6(10), 819–829. https://doi.org/10.1016/S2215-0366(19)30289-5 [19] Kentrou, V., Oostervink, M., Scheeren, A. M., & Begeer, S. (2021). Stability of co-occurring psychiatric diagnoses in autistic men and women. Research in Autism Spectrum Disorders, 82, 101736. [20] Rødgaard, E-M, Jensen, K, Miskowiak, KW, Mottron, L. (2021). Autism comorbidities show elevated female-to-male odds ratios and are associated with the age of first autism diagnosis. Acta Psychiatrica Scandinavica; 144: 475– 486. [21] Aves, W. (2022). #AutismNotPD: Borderline Personality Disorder Vs. Autism Spectrum Disorder. https://www.psychiatryisdrivingmemad.co.uk/post/autismnotpd-borderline-personality-disorder-vs-autism-spectrum-disorder [22] Watts, J. (2023). Engendering misunderstanding: autism and borderline personality disorder. International Journal of Psychiatry in Clinical Practice, 27(3), 316-317. [23] Gordon, C., Lewis, M., Knight, D., Salter, E. (2020). Differentiating between borderline personality disorder and autism spectrum disorder. Mental Health Practice, doi: 10.7748/mhp.2020.e1456 [24] Carpenter, R.W., Trull, T.J. (2013). Components of Emotion Dysregulation in Borderline Personality Disorder: A Review. Current Psychiatry Reports 15, 335. [25] Mazefsky, C. A., Pelphrey, K. A., & Dahl, R. E. (2012). The need for a broader approach to emotion regulation research in autism. Child Development Perspectives, 6(1), 92–97 [26] Moseley, R.L., Gregory, N.J., Smith, P., Allison, C., Baron-Cohen, S. (2019). A ‘choice’, an ‘addiction’, a ‘way out of the lost’: exploring self-injury in autistic people without intellectual disability. Molecular Autism, 10(18). [27] Samson AC, Phillips JM, Parker KJ, Shah S, Gross JJ, Hardan AY. (2014). Emotion dysregulation and the core features of autism spectrum disorder. Journal of Autism and Developmental Disorders, 44(7):1766‐1772. [28] Snir, A., Rafaeli, E., Gadassi, R., Berenson, K., & Downey, G. (2015). Explicit and inferred motives for nonsuicidal self-injurious acts and urges in borderline and avoidant personality disorders. Personality Disorders: Theory, Research, and Treatment, 6(3), 267–277. [29] Weiss, J.A., Thomson, K. and Chan, L. (2014), Emotion regulation measurement in individuals with ASD. Autism Research, 7: 629-648. [30] Black, K.R., Stevenson, R.A., Segers, M., NCube, B.L., Sun, S.Z., Phillip-Muller, A., Bebko, J.M., Barense, M.D., Ferber, S.. (2017). Linking Anxiety and Insistence on Sameness in Autistic Children: The Role of Sensory Hypersensitivity. Journal of Autism and Developmental Disorders, 47, 2459–2470. [31] Kapp, S. K. (2020). Autistic community and the neurodiversity movement: Stories from the frontline. Springer Nature. [32] Feldman, M., Hamsho, N., Blacher, J., Carter, A. S., & Eisenhower, A. (2022). Predicting peer acceptance and peer rejection for autistic children. Psychology in the Schools, 59(11), 2159-2182. [33] Humphrey, N., & Hebron, J. (2015). Bullying of children and adolescents with autism spectrum conditions: A ‘state of the field’review. International Journal of Inclusive Education, 19(8), 845-862. [34] Cazalis, F., Reyes, E., Leduc, S., & Gourion, D. (2022). Evidence that nine autistic women out of ten have been victims of sexual violence. Frontiers in behavioral neuroscience, 16, 852203. [35] Rumball, F., Happé, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: Risk of PTSD development following DSM‐5 and non‐DSM‐5 traumatic life events. Autism Research, 13(12), 2122-2132. [36] Porter, C., Palmier‐Claus, J., Branitsky, A., Mansell, W., Warwick, H., & Varese, F. (2020). Childhood adversity and borderline personality disorder: a meta‐analysis. Acta Psychiatrica Scandinavica, 141(1).
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