Borderline Personality Disorder (BPD) And Autism: Are They Related?

Hannah suffered sexual abuse at the hands of both her father and her older brother from early childhood. She escaped her nightmare family the only way she knew how when she was 18, by marrying a man who later turned out to be a wife-beater with an alcohol problem. By the time she was 29, she was trying her best to raise four children in abject poverty with the threat of another of her husband's angry outbursts always hanging over her. 

Hannah finally left the man who released her from one horror show by dragging her right into another at 35, after he nearly killed her and she took a leap into the unknown — though she still speaks of her ex-husband with love and fondness. He may have hurt her, but he protected her from everyone else who otherwise would have. 

Ending up in "the system" — a stream of homeless shelters, social workers, and welfare hoops — meant Hannah had several psychological evaluations. Being around doctors and "shrinks" triggered her startle response, however, and Hannah's reactions were at times so severe that she ended up being an inpatient in a mental health facility for a while.

Somewhere along the line, a diagnosis of Borderline Personality Disorder made its way to Hannah's, now large, medical records. Other mental health professionals suggested, at different times, that she was instead bipolar or had PTSD, and to make matters even more complicated, Hannah had also developed a substance use disorder.

When I met Hannah, she was in her forties. She was clean, had enrolled in college, and had found God. She was a smart, out-of-the-box, thinker who was fiercely protective of those she cared about and who had made it through more than her fair share hardships, still standing. Someone whose barely existent trust in the world was the inevitable consequence of the trauma it had inflicted on her, and who sometimes had to escape it all by holing up at home and keeping her distance from everyone, but who hadn't given up. 

What is borderline personality disorder?

Look at the fifth (and current) edition of the DSM, the diagnostic and statistical manual of mental disorders, and you'll see that Borderline Personality Disorder is a Cluster B personality disorder characterized by a chronic pattern of instability and impulsivity that will have made an appearance by early adulthood. Turbulence follows someone with the disorder into all realms of life — friendships, romantic relationships, other relationships, moods, behaviors, and sense of identity.

Someone with Borderline Personality Disorder will have at least five of these attributes (courtesy of the DSM-5):

• "Frantic" attempts to prevent being abandoned by other people.
• Relationships marked by periods during which they practically worship the person as well as periods during which they totally reject them ("push-pull").
• A fragile and uncertain sense of identity. 
• Impulsive and risky ("self-sabotaging") behaviors — unsafe sex, out-of-control spending, or binge eating, for instance.
• Frequent suicidal behavior, feelings, threats, or attempts, and/or self-harm.
• Markedly unstable moods that can include extreme irritation, depression, or anxiety. 
• Chronic feelings of emptiness. 
• Intense anger that is hard to keep under control.
• Paranoid feelings or dissociation. 

While research has identified Borderline Personality Disorder as separate from Complex Post-Traumatic Stress Disorder, a variety of PTSD that can result after prolonged and multiple traumas, usually in childhood, many symptoms overlap. The lion's share of people diagnosed with Borderline Personality Disorder are women, who are known to fall victim to childhood sexual abuse more often than men.

Borderline Personality Disorder is also heavily stigmatized, not just by laypeople, but also by mental health professionals. One study found that the stigma clinicians feel towards people diagnosed with BPD "goes beyond [that] associated with other mental illnesses". This, in turn, affects the empathy doctors, psychologists, and psychiatrists feel towards such patients, and with that, their quality of care. Borderline Personality Disorder is not a comfortable diagnosis to end up with, particularly if you don't actually have it.

Why might autistic people be misdiagnosed with Borderline Personality Disorder?

Autism is a neurological condition characterized by differences in two main domains that the DSM-5 describes as "deficits in social interaction and communication" and "restrictive, repetitive patterns of behavior, interests, or activities". While the way in which autism manifests will greatly differ from one autistic person to another, symptoms can include:

• Finding it hard to relate to neurotypical people (those without autism) and their social rules — this may mean that an autistic person is unclear how to initiate a conversation or how to reply in a way considered socially-appropriate, how to build and maintain friendships, and how to talk about their feelings. While some autistic people will indeed, as the stereotype goes, lack empathy, others have it in heaps but express it in ways others may not understand.
• Unusual non-verbal communication, like a monotone voice, "wooden" gait, lack of expected gesturing, and inability to maintain eye contact. 
• Being extremely passionate about certain subjects and having a strong preference for sameness and routine, while quickly becoming distressed by change. 
• Being highly sensitive to certain stimuli others may not even notice (bright lights, crowds of people, noises) while less sensitive than expected to other stimuli. 
• In some cases, delayed verbal language skills or being non-verbal. 

Many autistic people will, from an early age, face an inherent mismatch between them and much of the rest of the world — just like they don't "get" the neurotypical majority, the people in their lives don't understand them. Autistic people stand out as different, and vulnerable, particularly if they are also non-verbal. They are more vulnerable to social isolation as well as abuse of all kinds, and this inevitably leads to an increased risk of mental health struggles. 

It is important, here, to note that autism is more likely to remain undiagnosed in females, who incidentally make up the majority of people with the label of Borderline Personality Disorder. A missed autism diagnosis means that the normal autistic behaviors a clinician ends up seeing may be entirely misinterpreted. 

Research has indeed suggested that some people who are actually autistic wrongly get a Borderline diagnosis. Some of those people should really have a dual diagnosis of autism and PTSD. A correct diagnosis would not only lead to a radically different treatment approach, but also — as the fact that even mental health professionals have been shown to heavily stigmatize Borderline Personality Disorder shows — a higher chance of being treated like a human being.