BPD and autism

Untangling borderline personality disorder (BPD) and autism spectrum disorder (ASD)

Clinical psychologist and autism assessment specialist

This post was written by Dr Laura Eid, clinical psychologist and autism assessment specialist at The Oak Tree Practice

Kylie (name changed), aged 27, was diagnosed with borderline personality disorder (BPD). She described herself as extremely sensitive to criticism and everyday stressors and felt a sense of hopelessness about her future and the possibility of happiness. To her, instability seemed to define not just her internal world but also the way others perceived her, and she felt trapped.

But while she believed her personality made it difficult to sustain meaningful relationships and connect with others, she felt that the diagnosis of BPD fell short in capturing the complexity of her lived reality and offered little assistance in her journey. For her, the diagnosis seemed to miss the mark.

Throughout our therapy sessions then, Kylie and I thoroughly explored her experiences, attempting to grasp her perspective on the diagnosis and uncover any overlooked aspects. Following comprehensive assessments, it became evident that ASD provided a more fitting framework for understanding Kylie's unique journey.

BPD vs. autism: Are they very different?

Autism and borderline personality disorder are distinct mental health conditions in the DSM-5. BPD is a personality disorder characterized by unstable emotions, impulsive behavior, and an unstable sense of self. ASD is a neurological and developmental disorder that involves challenges in social skills, repetitive behaviors, speech and nonverbal communication.

However, upon closer examination, there is a BPD and autism overlap since since these two conditions share features which can lead to misdiagnosis in some cases. Both feature a difficulty with social interaction, interpersonal skills and maintaining relationships. Individuals with either BPD or ASD tend to exhibit low empathy. They are also more likely to self-harm.

One of the primary challenges in distinguishing between BPD and ASD lies in their overlapping symptoms. For example, difficulties in emotion regulation are a hallmark of BPD but they can also occur in autism. Similarly, repetitive behaviors, a characteristic feature of autism, can sometimes be mistaken for impulsivity seen in BPD. Furthermore, individuals with BPD may exhibit rigid thinking patterns and intense interests such as those seen in autism. Conversely, autistic individuals may develop coping mechanisms that mimic the apparent emotional instability observed in BPD.

Person in mirror without a reflection

So why is this important? 

Misdiagnosis or overlooking one condition in favor of the other can have significant consequences on individual’s beliefs about themselves as well as treatment options. Misattributing BPD traits to ASD, for instance, may lead to inadequate support for emotional regulation challenges. Conversely, focusing solely on autism-related challenges may neglect the emotional needs of individuals with BPD.

Differential diagnosis, conducted by mental health professionals, is essential for untangling these diagnostic dilemmas. This process involves thorough assessment, including comprehensive interviews, observation, and consideration of developmental history. Collaboration between clinicians specializing in BPD and ASD can provide a holistic understanding of an individual's presentation, facilitating accurate diagnosis and tailored interventions.

Once a clear diagnosis is established, tailored interventions can be implemented to address the unique needs of individuals with BPD and ASD. For BPD, dialectical behavior therapy (DBT) has shown efficacy in improving emotion regulation and interpersonal skills. Meanwhile, therapies for autism often focus on enhancing social communication, sensory integration and adaptive functioning.

Read more: Seeking Therapy: Options and considerations for autistic adults

Recognizing the overlap between BPD and autism also opens doors to integrated approaches that address common underlying mechanisms. For instance, therapies targeting emotional dysregulation may benefit individuals with both conditions, although it is crucial to tailor the intervention to specific needs and goals.

Can you have BPD and autism?

It's worth mentioning that meeting diagnostic criteria for both ASD and BPD simultaneously, which a diagnosing clinician would call a 'comorbidity,' is possible. However, while there is research that suggests the co-occurrence of BPD and ASD is not uncommon, more studies need to be done to find out the prevalence. Regardless, it's crucial to evaluate each condition independently to confirm whether both contribute to the current challenges, rather than attributing them solely to one or the other.

What should you do if you think you got an autism or borderline personality disorder misdiagnosis?

Seeking a second opinion is vital if you suspect a misdiagnosis of either BPD or ASD. It provides an opportunity to gain a deeper understanding of your experiences and find a label that resonates with you. While some find validation in receiving a diagnosis, others prefer to focus on treating their symptoms without labels.

It's worth noting that women and girls are more prone to misdiagnosis, partly due to camouflaging behaviors—strategies used to conceal symptoms. These behaviors can complicate diagnosis and highlight the importance of thorough assessment by qualified professionals.

For Kylie, the realization that her struggles might be attributed to ASD was incredibly affirming and provided a sense of validation. It resonated with her deeply, offering a framework that aligned more closely with her lived experiences.

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