Autism in the Adult Autism and Misdiagnosis: Personality Disorders
Join Dr. Regan for the second in this series on autism misdiagnosis. This episode focuses on how often and why autism may be misdiagnosed as a personality disorder. Although there are 10 personality disorders outlined in the DSM-5, Dr. Regan focuses on two in this episode: borderline personality and narcissistic personality.
Netherlands study of over 1000 autistic individuals
Norway case study Borderline Personality Disorder misdiagnosis
Recognizing dysregulation on the autism spectrum: podcast episode
Dr. Regan's Resources
New Course for Clinicians: ASD Differential Diagnoses and Associated Characteristics
Book: Understanding Autism in Adults and Aging Adults, 2nd ed
Book: Understanding Autistic Behaviors
Autism in the Adult website homepage
Website Resources for Clinicians
Read the episode transcript --
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Hello everyone.
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This is Dr Theresa Regan joining you for the podcast,
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autism in the adult.
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I am a neuropsychologist.
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I specialize in understanding how the brain impacts personality emotions,
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behavior and thinking skills.
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I'm a certified autism specialist and the director of an adult diagnostic autism clinic in central Illinois and I'm the parent of a child on the spectrum.
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You are joining us for the second episode of a series we're doing on misdiagnosis for those who are on the autism spectrum.
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If you did not listen to the first episode,
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I really encourage you to do that.
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There are foundational things that I think will really be illuminating and that I'm not going to be repeating in this episode.
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For today's episode,
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we're going to focus about when the misdiagnosis has to do with the category of personality disorders.
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Now,
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personality disorders originally really focused on the impact of the environment and early life experiences and parenting and the development of the personality structure.
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And when I was in graduate school back in the 90s there was a focus on the fact that there were some studies coming out suggesting that some of the personality disorder categories actually had some influence in genetics.
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So this was through adoptive studies and looking at the personality traits of adopted Children as compared to their biological parents.
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So that at the time was actually news because the personality theories that dominated the literature had a lot to do with parenting and that personality was a learned experientially based um long term way of interacting with the world.
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Now today a lot of the literature explaining that personality disorders are likely caused by multifactorial issues.
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So issues of biochemistry and genetics and experience are more prominent.
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So the original foundations of personality disorders being in that theory about early life experiences and of course autism being in the category of physically based in the neurology of the individual and really impacted by the genetic code.
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There are three clusters of personality disorders,
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cluster a, b, and c.
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And there are a total of 10 conditions listed in the current diagnostic manual.
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So what will the scope of our discussion today be about as regards personality disorders and autism?
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What will not happen in this episode is that you will not be able to distinguish autism from personality disorders at the end of the episode,
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that's really not in the scope of what we can focus on.
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And it takes an expert clinician with many years of training and study to do that well.
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But what we are going to focus on is why this happens and how often it seems to happen.
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So why does this misdiagnosis occur?
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And and how many people does that impact?
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As you probably know,
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a lot of the literature about autism focuses on early childhood and development.
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And more of the literature is beginning to focus on autism across the lifespan.
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And there are some articles out there about autism and misdiagnosis And what you'll see when you look for them is that these are often scattered internationally.
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So,
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the first article that I want to talk about actually was published last year 2021 and it came from the Netherlands.
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And I have a link in the show notes if you'd like to read more about it.
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So,
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this article was based in their national health system.
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They have a database of individuals who are on the autism spectrum.
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And then they contacted individuals to ask them about their diagnostic history.
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They surveyed a 1019 adults in this way,
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and it was very nearly an even split between males and females.
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And what they found was that about 50% of the 1019 adults reported that they had previous mental health diagnoses prior to being diagnosed with autism,
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They report that 63% of the females and 37% of the males had a previous diagnosis.
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Females had more previous diagnoses than males.
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So they had a larger number of diagnoses on their list in the mental health area.
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And this suggests that men in their sample were more likely to be diagnosed correctly the first time rather than carrying incorrect mental health diagnoses.
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Now,
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the top categories in their list of frequently misdiagnosed
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conditions for the autistic were mood disorders.
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And it didn't specifically say,
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I'm assuming this may include depression and bipolar.
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and then the second category was personality disorder.
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So,
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26% of the total sample had a history of mood disorder diagnosis and 20% had a history of personality disorders.
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They also asked the individuals who did have previous diagnoses.
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So that was 512 people out of the 1019,
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if any of their previous diagnoses were then removed from their list once autism was diagnosed.
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So this is really getting at that phenomenon of misdiagnosis,
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where,
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oh,
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now that we know that what we're actually looking at here is autism.
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What diagnoses,
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if any,
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might we removed from the list
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...these were misdiagnoses. Of the 512 participants who did have a previous diagnosis,
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382 reported that one or more of the diagnoses were removed once autism was diagnosed.
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So that's 75% of the participants who did have a history of diagnosis.
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And the authors also report this as 38% of the total sample of 1,019.
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I'm not sure that this is as meaningful because of course,
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people who did not have a prior diagnosis would not report that a diagnosis was removed.
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So,
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to me,
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it makes the most sense to to show that half the people had at least one previous mental health diagnoses.
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And of these participants,
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75% reported that at least one of the diagnoses were removed,
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then,
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once autism was diagnosed. And personality disorders were the most frequent of the diagnoses that were removed and that's the category that we'll be speaking about today,
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I'm gonna look at two other articles before we keep going.
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Uh there is an article that came out of Italy in March of 2022 and it had a much smaller sample size that was only 161 individuals and only 47 were females.
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So I don't feel like it's quite as representative.
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Probably not something that we can generalize as much from.
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But one thing that was interesting that they found was that the age,
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the median age of first evaluation by a mental health professional for these individuals was age 13.
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And then there was a gap of averaging about 11 years before any autism evaluation was even performed or considered.
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So,
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these individuals had presented with some distress or having some struggle 11 years prior to the consideration of autism in that diagnostic arena for the differential. In their sample,
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a third of participants had never received a psychiatric diagnosis prior to autism diagnosis.
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So two thirds of their sample did have a history of mental health diagnoses.
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The next article we're going to focus on is about borderline personality disorder, and I did want to focus on that for today's episode.
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In addition to narcissistic personality.
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Now,
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these are the two personality disorders that I see most often in my clinic as misdiagnoses for the autism spectrum,
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But really I have seen all 10 of them listed incorrectly for the autistic in the past,
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but let's take a look at borderline personality and talk about why
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there may be a misdiagnosis of this condition.
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So the concept of borderline personality refers to a constellation of characteristics and one of the prime characteristics has to do with difficulty connecting appropriately in relationships.
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So it says a pattern of unstable and intense interpersonal relationships characterized by extremes.
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Um and also these efforts to avoid abandonment and relationships. What we can see for the autistic is that often there is this desire to connect with the supportive other ... that I do want to be connected.
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I want to be in a relationship.
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And of course,
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there can be difficulties in that connection,
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particularly when they're trying to maintain this relationship over time.
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Now,
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that is not to say that the autistic individual doesn't have close relationships,
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but there may be some history of dissatisfaction with the ability to connect or feeling like the relationships didn't work out,
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Maybe the person isn't quite sure why or what happened.
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So this area of difficulty maintaining relationships may overlap in someone's concept...
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and if you did listen to the first episode of the series,
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it's kind of like looking at what's right in front of you without seeing the big autistic picture.
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You can see that if someone is trying to interact with a client who has a history of relationships that have not been maintained over time,
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that there can be perhaps the question of whether borderline should be in the differential... in addition to that there can be this element in borderline of chronic feelings of emptiness and also just identity disturbance.
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Like I don't really know who I am or I feel like I'm different people when I'm with various groups or I have an unstable self image or sense of self.
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So for the autistic that can be present in the sense that it can be difficult to um delve into the internal world.
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Like what am I feeling?
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What,
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what is going on inside of me?
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How do people perceive me?
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What is their evaluation of me?
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How would people describe me?
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What's going on in the core of myself scanning the internal for what's going on in my internal world and the world of the other person that I'm with.
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That's part of a neurologic ability called Theory of Mind,
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where we can scan and have this um exploration of what's inside me and then we can have a theory of what's in the mind of the other.
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So,
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you can see again,
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if you are a clinician or diagnostician and you hear these explanations of having difficulty uh knowing who you are or feeling like you're different people in various groups.
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This of course,
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can have to do with the masking and autism.
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You can see how that one piece may trigger someone to think about a borderline personality.
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There also is this characteristic lability of mood and emotions.
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So by that,
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I just mean that this kind of roller coaster of intense emotions.
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Um so it talks about um difficulty controlling anger,
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frequent displays of temper,
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constant anger,
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recurrent physical fights for the individual on the spectrum who has dis regulation that looks external realized.
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So,
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if you've listened to the dysegulation series, and I'll put a link in the show notes,
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you'll know that for that...
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Everyone on the autism spectrum will have difficulty feeling centered with their emotions and behavior.
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And that is called dysregulation.
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And that's neurologically based for the autistic... and for some people,
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this regulation is very quiet.
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It's this shutting down.
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It could be a disassociative episode which can also occur in borderline.
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It can be a very quiet withdrawal.
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I'm going to my room,
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I'm quitting this relationship,
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I can't make it to work.
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Um but it can also be this externalized reaction,
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this explosive reaction,
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a meltdown,
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a crying
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spell... shaking.
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And for people who have that externalized reaction,
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this can look like borderline to a clinician who's not looking at the big neurologic picture.
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And finally,
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one of the aspects of borderline personality can be this recurrent self harm behavior or impulsive,
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self damaging behavior.
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You can get elements of that on the autism spectrum in the sense of ... it would not be unusual for clients to in the midst of their dysregulation to do things like hitting themselves or biting themselves,
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cutting themselves,
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banging their head.
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Um,
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and that is part of,
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of dysregulation for the autistic.
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Um,
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and so there are certainly differences in borderline personality as compared to autism,
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in this dynamic of when dysregulation occurs.
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Uh,
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and also what you don't see in the borderline is the broader neurologic picture.
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So,
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these sensory elements,
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these stereotyped behaviors.
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Again,
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we're not going to end on a note where people know how to distinguish the two conditions,
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but I do want you to have a sense of why this occurs.
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Why does this mistake happen where someone looks at pieces of an individual and their history and comes up with borderline instead of autism.
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This article that I do want to share is actually a case study of a gentleman who had been diagnosed with borderline personality and then was correctly diagnosed with autism.
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And the link is in the show notes,
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this article was published in Norway In February of 2022 and I'll just read you some elements that I think are important.
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The patient received treatment for borderline personality disorder without any observable improvement in his difficulties for several years.
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And that's end,
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quote.
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The authors note that the case highlights the need for mental health professionals to have the quote knowledge necessary to recognize and diagnose autism.
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End quote,
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they suggest that the evaluation for autism may be warranted in patients with non suicidal self injury.
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So that's the cutting the banging,
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those kinds of things that we talked about and assumed personality disorder who are not benefiting from the treatments that have been used.
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So essentially,
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they're suggesting that if there's a patient that has been diagnosed with a personality disorder but is not benefiting from the treatment.
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and staff feel like,
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gosh,
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I just feel like we're missing something...that might be a good trigger.
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I would say any time borderline personality is on the table,
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autism should specifically be in the differential because of some of these features that can look similar.
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And if you want to know more about differentials,
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go ahead and listen to the first episode in our series. With regard to the young adult that they were describing in the article.
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Um,
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they could see that there were characteristics of several different personality disorder conditions.
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Um,
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but nothing that really hit the spot with any one personality disorder.
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Uh,
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so they looked at schizoid,
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avoidant. dependent, and borderline,
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but there were not sufficient symptoms to meet criteria for any of those.
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And it was noted that,
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quote,
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his difficulties with regard to social engagement were pervasive rather than transient.
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So what they're trying to say is that really they did an in depth assessment for autism and they saw that really he was not able to navigate neurologically the theory of mind issues and the nonverbals, and
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social reciprocity and conversation.
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So they concluded that his social difficulties really were not the result of his intense personality,
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but more the result of a neurologic wiring that it was different and he was not able to navigate social interactions in that context.
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They also state he did not display a pattern of attachment and rejection in interpersonal relationships, and his non suicidal self injury.
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(And for him this was cutting) rarely occurred as a response to an interpersonal conflict.
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So they're also just trying to point out that although he had dysregulation, and he had self harm in that context,
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it didn't have...
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it wasn't triggered by the same kinds of things that a borderline personality might be triggered by.
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Now,
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in my own clinic,
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what I see is that in addition to the borderline personality as a common misdiagnosis,
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I also frequently see narcissism or narcissistic personality disorder uh as a misdiagnosis as well.
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So where does this misdiagnosis stem from?
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Well,
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if you listened to the episode two sessions ago,
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it was called why pattern is important.
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And in our episode today we are making some generalizations about how the autistic neurology,
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when it has a certain pattern,
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it can lend itself to misdiagnosis of certain conditions.
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So what we've done so far is we've talked about how some people on the spectrum have a pattern of neurology that fits within that autism schema and that also could look in some aspects like a borderline personality.
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Now here we're looking at a different pattern and how some aspects of the autism neurology may be heightened in an individual in a way that looks like narcissism.
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So one of the reasons for that can be that if you have an individual on the spectrum who uh is very passionate about topics and they have a great value for fact and rightness and correctness.
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Um,
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and they love um certain pieces of information so that their special interest,
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maybe politics or religion or the environment and ... boy,
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they deep dive into this.
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They love talking about this particular topic or handful of topics and being correct about the facts is also very important to them.
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And so they have this deep commitment to being right now.
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What they are less attuned to neurologically is understanding the internal of the other person.
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How does this conversation affect the personhood...
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The person,
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the internal person of this individual I'm speaking with.
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So they have less of a sense of do they feel criticized?
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How does that impact our relationship because to them we're talking because this topic is important and their whole reason sometimes for talking with you about it is to uh enlighten you or instruct you or help you understand what the right facts are.
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And some of the autistic individuals with this pattern may say,
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well I will shift my beliefs if someone proves that I'm wrong but I'm not wrong.
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Um,
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and so that quality of having difficulty with thinking in gray areas.
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So someone who may have that black and white thinking this is right and this is wrong.
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Someone who has difficulty shifting and giving um like they are committed to a thought or an idea or an opinion and it really does.
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Uh they're not wishy washy,
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you know,
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their strength is that they have this very strong commitment and so when they have that and they're gonna stick to it neurologically,
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and they don't have as much sense of what you need during a conversation as the other person.
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Uh then you can get the sense of narcissism and somebody may say they want to lecture me or talk to me,
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but they don't want my opinion or they don't want me to participate.
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Um and that could be a feeling that lends itself to this descriptor,
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another piece of this really...
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... if you do have that black and white thinking that this is right and this is wrong and you do want to commit to be right.
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Um one of the things can,
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that can happen with that neurology is that there's a strong um commitment to being correct and if they are wrong or they fail something or they lose a competition that can be extremely difficult um with their emotional regulation because they want to be in the good category.
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And if the only thing left,
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once they make a mistake is the bad category,
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that's just so difficult for them to land there because their brain really doesn't show them any in between or any complexity that yeah,
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I'm this mix of good things and difficult things and I have achieved,
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um,
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correct things here,
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but I really missed the boat here.
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Um,
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so you can have this real resistance to losing or being wrong or falling short.
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There's another feature in the list of narcissistic personality,
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um,
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criteria and that is lacks empathy,
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is unwilling to recognize or identify with the feelings and needs of others.
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Now,
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for the autistic,
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that is really not the case.
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It's not that they're unwilling.
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And some people have a deep empathy for,
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um,
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you know,
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wanting every person to be good and to be doing well.
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Um,
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but sometimes in their mind you will be doing really well if you have the correct facts,
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so they may not be in tune with the internal emotions and relational needs of the other person.
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Um,
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but it's not that they're unwilling to recognize the feelings or needs of others.
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And as I mentioned,
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there are many other personality disorders that end up being misdiagnoses for autism.
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But hopefully this gives you a flavor of how someone might see the interaction style and behavioral pattern of someone presenting for,
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let's say,
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counseling or some type of assistance and they may look at that pattern of neurology that fits within the autism spectrum and make conclusions about personality and therefore assign a personality diagnosis when if they really knew what the autism flags were and could add that to the differential and specifically assess for autism.
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When considering these other personality structures,
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then we would get a much more beneficial diagnostic process.
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We don't want someone with another mental health condition to be mistakenly diagnosed as autistic and vice versa.
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So we want the diagnoses that are used to really empower you and people around you to improve your well being and to really get you to those goals that you want.
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Thank you for joining me today as we talked about personality disorders as misdiagnoses for autism.
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We reviewed borderline,
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we reviewed narcissism and we reviewed some of the research and publications that are emerging both on a statistical level and also with regard to case studies about why it's really impactful to the individual.
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To get these diagnoses correct.
I hope you can join me for the next episode.