Misdiagnosed: BPD or Autism Spectrum Disorder (ASD)?

After a recent blog that I posted regarding Borderline Personality Disorder (BPD) and the common obstacles to treatment, I received an email from a reader. In this email, it was noted that being misdiagnosed with BPD rather than with their actual diagnosis, Autism Spectrum Disorder (ASD), led to years of misguided and damaging treatment for a disorder they did not have. In the past several years, increasing attention has been given to the symptom overlap between these two distinct disorders and reasons why the misdiagnosis of women is more likely to occur.

Are There Shared Symptoms Between BPD and ASD?

The primary challenge for those diagnosed with ASD revolves around social communication. It is a neurodevelopmental disorder that has been identified as occurring at three levels of severity that reflect increasing difficulty in successful social connection (Dell’Osso et al., 2023). Emotional dysregulation is also a common trait among those diagnosed with ASD which can lead to outbursts and flares of temper when frustrated or angry or it may lead to withdrawal from others and the presence of depressive symptoms. This may be related to their heightened sensory sensitivity or the intensity at which they experience their emotions. Another potentially confounding symptom is engagement in repetitive behavior that includes self-harming activities, such as suicidality, cutting, hair pulling, or hand hitting (Blanchard et al., 2021). In fact, people diagnosed with ASD have a likelihood of self-harm and suicidality three times higher than the general population.

With BPD, emotional regulation can also be extremely challenging as individuals diagnosed with BPD frequently exhibit extreme mood swings and anger outbursts. A person with BPD also typically has extreme fears of abandonment and the tendency to misread innocuous comments or facial expressions as signs of disapproval, rejection, or insult by others. Impulsiveness is another trait common to the BPD diagnosis and this impulsiveness can lead to self-harming behaviors. Around 60-70% of individuals with BPD attempt suicide during their lives and 10% die of suicide (Goodman et al., 2012).

Who Is More Likely to Be Misdiagnosed?

Women are less likely to be accurately diagnosed with ASD during their childhoods, adolescence, or adulthood and are often misdiagnosed with BPD or other disorders before they receive an ASD diagnosis. One possible explanation is that young girls learn early about the importance of “fitting in” and getting along with others (Dell’Osso, 2023). This focus on social interaction may encourage them to camouflage their autism symptoms so that they don’t stand out. Overall, males with ASD have poorer social skills and more social difficulties than their female peers. Another surprising reason that diagnoses of ASD may be missed is that the restrictive interests that are common to those with ASD may include a focus on food and diet. This focus mirrors Anorexia nervosa symptoms, which are more frequently exhibited by females, and that may be the diagnosis that is made with ASD going undetected. Females also tend to have higher linguistic skills than males and are more easily able to express their thoughts and feelings, which may delay accurate diagnosis.

What Symptoms Lead to the BPD Misdiagnosis?

One of the symptoms that is most likely to lead to a misdiagnosis is self-harm, so clinicians should also explore the motivation for self-harm expressed by the client (Powell et al., 2024). This behavior may be used as a coping method by those with ASD to mitigate unease regarding sensory issues, change, or uncertainty; with individuals with BPD, it is more likely to be motivated by issues related to their relationships. Further, when individuals with ASD spend time alone, this may be experienced as pleasurable, whereas those with BPD often experience fears of abandonment when they are alone. There are also similarities in these two groups’ ability to experience empathy or understand another’s perspective. In addition, the emotional dysregulation that is expressed by females with ASD can be mistaken for BPD as can the lack of quality friendships.

When an Accurate ASD Diagnosis Is Delayed

One of the most significant problems in making an inaccurate diagnosis is that the treatment for BPD is inappropriate for those with ASD and vice versa. For those with BPD, psychotherapeutic treatment is beneficial, as it provides support for developing healthy relationships, awareness of and changing of one’s thoughts and behaviors, and emotional stability. A standard treatment protocol for managing BPD is Dialectical Behavior Therapy (DBT), which is designed to help clients regulate their emotions and enhance their social and interpersonal skills. DBT is not designed for those with ASD, and the real needs of these clients go unmet. Medication prescribed to treat symptoms of BPD can be deleterious to someone with ASD. The stigma of a BPD diagnosis has also been noted as a harmful by-product of an incorrect diagnosis of ASD.

ASD treatment goals tend to revolve around improved communication, sensory integration, and functioning effectively in daily life. A behavior-focused approach is used rather than a psychotherapeutic approach, although Cognitive Behavioral Therapy (CBT) might be appropriate for some issues. Medication isn’t prescribed for ASD, although co-occurring disorders might require medication.

Being misdiagnosed results in delayed treatment for the individual’s actual diagnosis and this lack of congruence between treatment and symptoms can lead to increased withdrawal from others and blaming oneself for not “getting better” when the treatment doesn’t match the diagnosis. Traumatization can result when those with ASD are required to follow protocols that do not take into account the ways in which ASD manifests and the sensory sensitivities associated with it. If you are concerned that you might have been misdiagnosed, seek out another practitioner for a second opinion. Being given the right diagnosis can change the course of one's life for the better.

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