By Professor Tony Attwood and Dr. Michelle Garnett.
Autism in females has historically been under-diagnosed due to a lack of professional understanding about what has been labelled ‘the female phenotype’ of autism (Allely, 2019) and is now known as the camouflaging subtype, or the internalised presentation of autism. We now know that this subtype is strongly associated with experiencing mental health issues, such as anxiety and depression. How did mental health professionals make sense of the experience of autistic women without understanding camouflaged autism? From our clinical experience we know that a proportion of them were misdiagnosed with borderline personality disorder (BPD) and their autism was missed. Some women will meet diagnostic criteria for BPD but may be autistic. In this article we will describe the diagnostic criteria of BPD, how an autistic adult’s behaviour and abilities can resemble BPD, how to distinguish between BPD and autism, and avenues for therapy and support.
Diagnostic Criteria for BPD
The diagnostic criteria for BPD according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revised (APA, 2022), are:
- Frantic efforts to avoid real or imagined abandonment
- Unstable and intense interpersonal relationships with extremes of idealization and devaluation
- Identity disturbance, unstable self-image or sense of self
- Impulsivity in areas that are potentially self-damaging
- Recurrent suicidal behaviour, gestures, threats and self-mutilating behaviour
- Affective instability due to a marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms
A diagnosis of BPD is confirmed when the clinician identifies five or more of these nine criteria. BPD is rarely diagnosed in childhood but may become apparent during adolescence and adulthood.
The prevalence of BPD in the general population is between 1% and 2% and occurs equally in males and females (Lenzenweger et al., 2007). However, in practice 75% of adults diagnosed with BPD are female due to gender biases for this diagnosis (Grant et al., 2008). Clinicians have more recently described BPD as emotionally unstable personality disorder (EUPD) due to the term ‘borderline’ being largely misunderstood in the community and because emotional instability is a key feature of the profile of abilities of BPD.
As clinicians, we recognise that autism and BPD share many features, including social and emotional regulation difficulties and overlapping symptom profiles (Allely et al., 2003). The prevalence of BPD in a sample of autistic adults has been estimated at 4%, with the prevalence of Autism in BPD at 3% (May et al., 2021). However, our clinical experience is that BPD is overdiagnosed in autistic women. A likely possibility for overdiagnosis of BPD is the relatively new understanding about the internalised profile of autism, which means that many diagnosticians who see women have not been trained to recognise autism when it is camouflaged. Autistic traits are thus interpreted to represent the BPD diagnosis. We will now explore how an autistic adult may develop characteristics that resemble each of the diagnostic criteria for BPD.
Frantic efforts to avoid real or imagined abandonment
Autism is associated with difficulties with making and maintaining friendships and relationships. Unfortunately, when friendships and relationships are achieved, the non-autistic friend or partner may end the friendship or relationship, and the autistic person is confused about why and feels rejected and abandoned. When this has occurred several times, there can be an anticipation of abandonment and oversensitivity to any signs of rejection.
Unstable and intense interpersonal relationships with extremes of idealization and devaluation
Many autistic adults have difficulty intuitively determining the intensity and reciprocity of engagement in a friendship or relationship. Autistic girls have often had a history of intense and exclusive single friendships, with one friend being the centre of the autistic girl’s social and emotional life and becoming idealized. Unfortunately, there can be a risk of ‘wearing their welcome out’ and being perceived as controlling and possessive, contributing to the other person abandoning the friendship or relationship.
The autistic person may expect high standards of loyalty and exclusivity. When these are not met, it can be difficult for the autistic person to appreciate the other person’s perspectives and needs, with a tendency for ‘black and white’ thinking and a limited ability to negotiate and compromise. The friendship or relationship may have extremes of idealization and devaluation.
Identity disturbance, unstable self-image or sense of self
We have recognized that many autistic adolescents and adults have difficulty with self-identity, especially if they have camouflaged their autism and become a ‘chameleon’ in social situations. They have difficulty conceptualizing and expressing their authentic self. During a diagnostic assessment, when we ask an autistic adult ‘Who are you?’ there can be a long pause for reflection, and the reply, ‘I know who I am expected to be, but I don’t know who I really am, that is why I am here’.
Impulsivity in areas that are potentially self-damaging
Autism and ADHD co-occur in up to 70% of autistic adults (Rong et al., 2021). One of the characteristics of ADHD is impulsivity. This will affect daily life for an adult in areas such as spending, driving and sex. Another factor is that an autistic adolescent or young adult may be rejected by risk-averse peers but accepted by those who are notorious risk-takers in terms of criminal activities and substance abuse (Cumin et al., 2022).
Recurrent suicidal behaviour, gestures, threats and self-mutilating behaviour
Autism is associated with low mood (Attwood et al., 2014), clinical depression, suicidal ideation and self-harm (Blanchard et al., 2022; Halloran et al., 2022; Moseley et al., 2022). Non-suicidal self-injury (NSSI) is recognized as a transdiagnostic clinical feature for BPD and Autism Spectrum Disorder (McQuaid et al., 2023).
Affective instability due to a marked reactivity of mood
Emotion dysregulation is common in both conditions. However, in BPD, emotional instability tends to be a reaction to interpersonal stressors and, in autism, to being overwhelmed by social and sensory experiences, change and uncertainty.
Chronic feelings of emptiness
For both conditions, a sense of emptiness may be due to struggles connecting with other people and also feeling disconnected to the authentic self. Adults with BDP may only feel fully alive when interacting with another person, but empty and ‘dead’ when they are alone. We find that if an adult is autistic, they can long for solitude and not experience feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger
As clinicians, we are often asked by the parents and family members of an autistic person or the autistic person themselves how the autistic person can perceive the external and internal indicators of increasing agitation and regulate and reduce the expression of intense anger.
Transient, stress-related paranoid ideation or severe dissociative symptoms
Autistic adults can develop paranoid ideation due to persecution from being bullied, teased and humiliated during childhood and adolescence and overhearing derogatory comments about themselves due to having exceptional hearing. They can also experience confusion in understanding the subtleties of social interaction, social rules, and the intentions of others and make an erroneous or accurate assumption that someone’s intention was malicious.
An autistic person’s history of situational mutism, developing a chameleon-like personality to achieve social acceptance, and experiencing trauma could be considered indicative of dissociative disorders. The developmental history of both BPD and autistic adults can include evidence of all forms of trauma (Dodds, 2021; Golan et al., 2022).
Differential diagnosis
As described above, BPD and autism share resemblances (Cumin et al., 2022), and it is important that the diagnostic clinician explores the different underlying factors for each of the diagnostic criteria for BPD and developmental history to differentiate between the two conditions (McQuaid et al., 2023).
An autistic person’s developmental history will be characterized by a lack of social understanding from an early age, past and current sensory sensitivity, absorbing interests that are unusual in focus or intensity, and seeking and enjoying solitude. There may be unusual aspects of language in terms of prosody, pedantry, and pragmatics, extreme distress at small changes in routine, and a need for consistency and predictability in daily life. Emotional meltdowns may have occurred since early childhood, especially when experiencing social and sensory overload.
However, an autistic person who achieves social acceptance by camouflaging their autism may not disclose such characteristics in a diagnostic assessment. Having a second opinion from someone who knows the authentic person behind the mask can be important, as well as using screening instruments to determine if the person uses camouflaging in their daily life (Hull et al., 2019).
BPD is associated with having few signs of difficulties with social communication when in a period of emotional stability, wanting to be with others, and an intolerance of being alone. Socializing with others can be perceived as energizing, while socializing is often energy-depleting for an autistic person who often re-energises in solitude.
There may be differences in cognitive and emotional empathy, with autism associated with cognitive empathy deficits and emotional empathy sensitivity. Adults with BPD tend to have intact cognitive and emotional empathy, except when they feel highly distressed. At these times they can act without empathy but feel very remorseful later. Communication of emotions can be very different, where those with BPD may be able to explain how they are feeling with relative ease and varied vocabulary, while autistic adults often find verbalization of emotions difficult due to alexithymia (Cummin et al., 2022). BPD can also be associated with excessive disclosure of feelings and personal history (Gordon et al., 2020).
The BPD profile is becoming understood now as emerging in response to complex trauma, in the context of a genetic vulnerability for the condition. Many of the diagnostic features of autism are also seen in individuals with complex trauma backgrounds. The diagnostic assessment will require an exploration of whether trauma has occurred during childhood, and if any autistic abilities and behaviour were evident prior to trauma.
There are those who have both BPD and are autistic. The two conditions are not mutually exclusive (Gordon et al., 2020). A study by Dudas et al. (2017) noted that out of 38 women with BPD, almost half scored above the cut-off of the Autism Quotient, a screening instrument designed to identify the characteristics of autism in adults. There is research to show that the combination can contribute to more frequent suicide attempts (Ryden et al., 2008) which gives an additional reason to screen for autism in those who have or are being assessed for BPD.
Considerations for Therapy and Support
Three recommended therapies for BPD are Dialectical Behaviour Therapy (DBT), Schema Therapy and Mentalization-based treatment (MBT). There is evidence for the effectiveness of all three therapies for autistic adults. A recent study by Huntjens et al. (2024) confirmed the effectiveness and safety of DBT for suicidal ideation and behaviour in autistic adults. Schema Therapy has also been modified for autistic adults (Bullus, 2019) and MBT (Kramer et al., 2021). Thus, the therapies known to be effective for BPD may well be effective for addressing the intense emotional distress and dysregulation that some autistic adults experience. However, there is need to adjust therapy and support to accommodate aspects of autism, such as understanding group dynamics and expectations, a different learning profile, coping with changes in thinking and behaviour, alexithymia, and sensory sensitivity (Attwood & Scarpa, 2013).
In summary, we consider that it is important for a person to know if they are autistic or not, if they have a BPD profile. If the person is autistic, discovery of autism allows a more accurate appraisal of themselves and their past experiences, leading to the possibility of processing the past, including trauma, with more understanding and precision, as well as being able to discover the authentic self, one’s own neurotribe and design a life that is fulfilling and happiness-creating for an autistic person.
Where to from here:
We have created a half-day course for Autistic Women that will be live webcast on Friday 6th September. We describe the strengths and abilities commonly experienced by autistic women, as well as key challenges, including self-understanding, developing an authentic self, navigating the workplace, executive function, including ADHD, developing relationships whilst staying true to oneself, self-advocacy and issues of mental health including anxiety, depression, autistic burnout and eating disorders. Our presentation is based on recent relevant research and our combined 80 years of experience in autism. We discuss autism in females aged 17+.
References
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APA (2022) Diagnostic and Statistical Manual of Mental Disorders-5 Text Revision. American Psychiatric Association.
Attwood, Evans and Lesko (2014) Been There. Done That. Try This! An Aspie’s Guide to Life on Earth, Jessica Kingsly Publishers
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