Studies have discovered that some individuals with autism spectrum disorder (ASD) also present with a form of personality disorder. Of the various forms of personality disorders, borderline personality disorder (BPD) and autism as a combination seem to be the most prevalent.
Autism spectrum disorder (ASD) is not a personality disorder in itself. ASD is characterized by persistent difficulties in social communication and interaction, as well as repetitive/restrictive interests and behaviors. The difficulty with social etiquette is particularly highlighted as some individuals find challenges with social approach to conversation, difficulties integrating communication etiquettes, difficulty making eye contact, and difficulty understanding and using gestures. Autism is a heterogeneous condition given the variety in experiences across the spectrum.
Borderline personality disorder is a condition characterized by impairments in interpersonal functioning, and mostly includes experiencing emotions intensely. Because of this, many individuals with BPD experience emotional dysregulation.
Due to the rise in interest and research, in this article, we’ll look at what borderline personality disorder is, break down the difference between BPD and ASD, and explore the existing overlap between the two. The article also aims to answer whether some autistic individuals are misdiagnosed with BPS.
What is borderline personality disorder?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), borderline personality disorder (BPD) is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
As a broad understanding, BPD is characterized by impairments in interpersonal functioning i.e. poor empathy and difficulties with trust and intimacy. BPS also tends to include personality traits such as disinhibition and antagonism and impulsivity. Individuals with BPD typically experience emotions intensely and their emotions can last some time after a triggering event has occurred i.e. it is harder to establish emotional stability.
As stated in the DSM-5, below are the symptoms of BPD:
1. Intense fear of abandonment by friends and family
“Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior…)”
2. Unstable personal relationships also sometimes known as “splitting”
“A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.”
3. Self-image problems which affect moods, values, opinions, goals and relationships:
“Identity disturbance: markedly and persistently unstable self-image or sense of self.”
4. Impulsiveness and frequent mood swings:
“Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)…”
5. Self-harming behavior
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.”
6. Periods of intense depressed mood, irritability or anxiety
“Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.)”
7. Chronic feelings of emptiness”
8. “Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).”
9. “Transient, stress-related paranoid ideation or severe dissociative symptoms.”
Similarities between borderline personality disorder and autism
The result of a study by Dudas, et al. (2017) when comparing the empathy between BPD and ASD found that empathy in both conditions were low. The symptomatology of BPD and autism spectrum disorder have been found to overlap with one another. Some common traits include difficulties in social cognition such as reading the emotion of others
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Another overlap includes the symptoms of self-harm where in the case of individuals with autism, self-harm is due to sensory overload (in some cases), while with individuals with BPD, self-harm is due to interpersonal conflict and emotional dysregulation.
Overlap in empathy
This overlap seems the most prominent. When we dive into the subject of empathy, we find that there’s two critical constructs, namely: cognitive empathy and affective empathy. Affective empathy means the ability to recognize and perceive the feelings and emotions of others, and sharing that experience. Whereas cognitive empathy allows one to understand another person’s perspective by adopting his/her point of view.
In both autism and BPD, the theory of mind (ToM) is looked at. The ToM is the ability to perceive and interpret the mental states/emotions of others and predict the related behavior. The theory of mind informs one’s ability to empathize with another, most especially related to cognitive empathy.
When we look at the overlap between ASD and BPD in terms of empathy, we find that due to the lack of emotional regulation in BPD, this leads to an altered ability to empathize, most especially within the construct of cognitive empathy. In ASD, the same can be said where the empathy scale between affective empathy and cognitive empathy do not seem balanced. In both cases, these symptoms are a result of difficulties in social and interpersonal interaction.
Are autistic people being misdiagnosed with borderline personality disorder?
It is possible to diagnose an individual with both autism spectrum disorder (ASD) and borderline personality disorder (BPD). Often for such a diagnosis, the risk of suicide is increased due to the symptoms and distress caused by this comorbidity; therefore highlighting the importance of appropriate and accurate diagnosis.
Chabrol, et al. (2018) mentioned a study that discovered “15% of 41 female patients with BPD fulfilled criteria for ASD”. Chabrol, et al. also adds individuals with both undiagnosed and diagnosed comorbidity of BPD and ASD experienced more frequent suicide attempts, negative self-image, and lower global functioning.
It is not clear whether autistic people are being misdiagnosed with BPD but rather that there’s sufficient evidence to consider a diagnosis of both these conditions to rule out any possibility of comorbidity or co-occurrence. Accurate diagnosis is essential as, if symptoms of both ASD and BPD are left untreated it could pose a risk should it be found to be comorbid.
It is unknown whether some autistic children are being misdiagnosed with BPD but it is evident that these two conditions can co-occur. It is important for parents to consider consulting with a qualified practitioner should there be concern that their autistic child or children show symptoms of borderline personality disorder.
As always, prevention is better than cure, therefore, if it is suspected that there’s any possibility of an autistic child also presenting with BPD, prompt diagnosis is required to receive adequate treatment and prevent the risk associated with carrying both diagnoses due to the mental health challenges that arise.
Borderline Personality Disorder. National Alliance on Mental Illnesshttps://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Borderline-Personality-Disorder
Chabrol, H., & Raynal, P. (2018). The co-occurrence of autistic traits and borderline personality disorder traits is associated with increased suicidal ideation in nonclinical young adults. Comprehensive psychiatry, 82, 141–143. https://doi.org/10.1016/j.comppsych.2018.02.006
Dudas, R. B., Lovejoy, C., Cassidy, S., Allison, C., Smith, P., & Baron-Cohen, S. (2017). The overlap between autistic spectrum conditions and borderline personality disorder. PloS one, 12(9), e0184447. https://doi.org/10.1371/journal.pone.0184447
Vegni, N., D’Ardia, C., & Torregiani, G. (2021). Empathy, Mentalization, and Theory of Mind in Borderline Personality Disorder: Possible Overlap With Autism Spectrum Disorders. Frontiers in psychology, 12, 626353. https://doi.org/10.3389/fpsyg.2021.626353