#AutismNotPD: Borderline Personality Disorder Vs. Autism Spectrum Disorder

[Content Warning: Contains mention of suicide, self-harm, iatrogenic harm, child abuse]

(19 minute read: The reference section adds 8 minutes to the read time)

N.b. Throughout this blog post I sometimes use the term “misdiagnosis” to describe autistic people being wrongly diagnosed with BPD. I have used this term to simplify my language. For clarity - I do not actually believe anyone can be “misdiagnosed” with BPD, because such a statement gives validity to the BPD construct. I stand in opposition to the entire concept of “personality disorder” and do not believe anyone can legitimately be “diagnosed” as having a disordered personality. PD labels, (particularly BPD/EUPD) are unscientific, moralistic, pejorative value judgements which serve to silence, stigmatise, dismiss, and degrade women; LGBT+ people; gender non-conforming people; victims of sexual abuse, violence, and other forms of trauma; neurodivergent people; and people mental health services perceive as “difficult”, “complex”, or expensive. While I have previously written my views on BPD, misogyny, and trauma here, this blog post specifically discusses the apparent similarities between autism and BPD, with particular focus on “misdiagnosis” of autistic women and AFAB people. (I have tried to include trans and non-binary people as much as possible, but given that much of what is discussed is under researched, in many areas of the blog I can only refer to cis men and women, as there is no research looking at trans/non-binary peoples experiences.)

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I write this holding my friends, Zoe "AspieZ" Zaremba and Fern "Elyssa" Foster in mind. Two young autistic women, wrongly labelled with personality disorders, and treated so appallingly by mental health and social services they eventually ended their lives. I miss them. I hope one day they both receive justice.

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Autism is under diagnosed in women and AFAB people; for many years it was thought to be the exclusive territory of cis boys and men, and this misconception has continued to roll over through health, education, and social care services even to this day. It’s recognised that autistic women and girls can sometimes “present” differently in emotion/behaviour/social interaction to autistic men and boys [1]. However, while women and girls may be socialised to mask more heavily and force ourselves to appear more neurotypical, this is not the only reason for lower diagnostic rates. Bias within the diagnostic framework itself, and in the perception of assessors, actively excludes women and girls. Studies show that teachers are more likely to underreport autistic traits in their female students [2]. Autistic girls need to display far greater traits of ASD than boys to be considered for assessment, including higher rates of learning disabilities and behavioural problems. This bias is also present within mental health services. Traditionally, when people think “autism”, they think young white cis boys playing with trains, reciting all the number plates of cars parked in their street. They do not think adult women or AFAB people who struggle with relationships, have a history of trauma, and who self-harm or attempt suicide. Services automatically file all of the above under “personality disorder” without a second thought.

NHS autism diagnostic services are scarce, and few professionals feel they are trained to recognise ASD, which seems to be considered some kind of ridiculously complex process. Autism services have in-depth assessments, high referral rates, and low staff numbers, which creates long waiting lists where many people languish for years waiting for a diagnosis [3]. BPD, however, is often diagnosed in minutes, sometimes by staff entirely unqualified to give such a diagnosis; by staff who haven’t met the person they are diagnosing, or only met them briefly; during crisis; and without anything even approaching a structured diagnostic assessment. It seems preferable for services to label someone with BPD rather than assess and provide support for ASD. There are no national mainstream services for autistic people who have mental health problems, or for so called “high functioning” autistic adults who require support in the community. Very little is understood about ASD-specific needs in terms of self-harm, suicidality, and emotional crises. If our difficulties are not re-labelled or hidden beneath other diagnoses, we are either locked away in inpatient units for years [4]; or ignored and left to deal with our struggles ourselves [5]. Much like people struggling with complex trauma, personality disorder creates a (grim) framework for staff to “understand” and “manage” us, under the shroud of PD services. Our differences, difficulties, and diversities become bad behaviour. Autistic culture is erased. We are forced to conform. It becomes clinically “legitimate” to blame, exclude, and dismiss us.

A number of studies have looked at autism and autistic traits in people labelled with BPD and found huge crossovers in symptomatology and general presentation [6-8]. Studies which measured autistic traits in people labelled with BPD, found a significant percentage of the study participants scored above the Autism-Spectrum Quotient cut off range for autism [9,10], or were diagnosed autistic, following a full assessment [11]. However, while blogs and news articles discuss “misdiagnosis” [12-14], academic studies tend not to consider BPD from a critical perspective, often failing to consider that autistic people are being misdiagnosed with BPD due to discrimination against particular traits. The usual conclusion they draw is “similarities between BPD and ASD”; “high rates of ASD traits in BPD patient populations”; or “many people with BPD are also autistic” [15-17]. This bizarre, or possibly deliberate, ignorance appears to be creeping into mainstream mental health services and research, where we are now seeing classic autistic traits and experiences being added to the diagnostic criteria for BPD. So desperate to avoid the possibility that many people labelled with BPD are in fact autistic, the ever-expansive boundaries of BPD are merely repeatedly widened to capture neurodivergent experiences.

Figure 1 - ICD-11 PD borderline pattern, extra criteria [18]

BPD diagnostic criteria:

Personally, I do not believe anyone “has” BPD, rather, BPD serves as a wastebasket into which mental health services can dump anyone and everyone individual staff members hold prejudice towards. The diagnostic criteria are so wide and non-specific, they cover a multitude of mental health and neurodevelopmental conditions, including PTSD, C-PTSD, OCD, eating disorders, depression, anxiety, schizophrenia, dissociative disorders, ASD, and ADHD. BPD is often not diagnosed with a structured diagnostic assessment (of which there are many), rather, the reality in practice is a little more nebulous. People are frequently diagnosed based on discrimination against stereotypical “symptoms”, such as self-harm; a woman or AFAB person experiencing emotional distress; or someone describing a history of childhood abuse. Such a cursory assessment fails to appreciate anything other than the assessor’s prejudice. More disturbingly is the practice of diagnosing BPD based on the “countertransference feeling” – i.e. the emotional response of the clinician to the patient. If the clinician doesn’t like the patient; feels uncomfortable; gets annoyed or angry; feels their ego has not been appropriately massaged; feels overwhelmed; or notes that it is an “unusual” interaction, they seem likely to leap to PD when that patient is a woman or AFAB person. This is where it becomes dangerous for autistic people, as we often communicate and interact differently to neurotypical people. Questions; misunderstandings; taking things literally; expecting rules to be followed; trying to understand the reasons things are done; needing routine; struggling when things do not happen as planned etc. These things are often interpreted by services as patients being “difficult”, “argumentative”, “demanding”, or “playing games” – the apparent hallmarks of PD.

I thought it would be interesting to go through the BPD diagnostic criteria and consider how each of them could apply, or be made to apply, to autism. The DSM-5 requires 5 of 9 criteria to be met, while the ICD-10/11 is a little vaguer, but still based on these same “symptoms”:

1. Fear of abandonment: A common misperception of autistic people is that we do not want friends or romantic/sexual partners and are generally uninterested in socialising. While this is true for some, it is certainly not true for all. The majority of autistic people desire interaction and relationships with others [19,20], but are more likely to experience social victimisation than neurotypical people [21]. Many autistic people move through life gaining and losing friends or weaving in and out of social groups. Struggling to retain friends, and experiencing multiple relationship breakdowns, seems a logical reason for a fear of abandonment. Rejection sensitive dysphoria (RSD) is common in autistic people. RSD can be experienced as extreme sensitivity to perceived social rejection or criticism. This might include anxiety and rumination over relationships, people-pleasing, and fear of abandonment. Many of us also need consistency and routine in our day-to-day activities and interactions. The loss of people in our lives (e.g. a new teacher or doctor) can be really emotionally challenging. Anxiously anticipating possible changes could appear to others as a fear of abandonment. For example - I don’t struggle with fear of abandonment, however, mental health services interpreted my difficulty with the ending of a 3-year therapeutic relationship as abandonment issues, when in reality, my upset stemmed from how difficult it was cope with the change in personnel.

2. Intense and unstable relationships: Interpersonal difficulties are a diagnostic criterion of autism. Autistic people can find relationships exhausting, confusing, and difficult to navigate. We may struggle to understand and remember social rules or, conversely, take them so seriously and literally that it compromises our ability to “fit in”. Relational difficulties are not one way, however, as studies have found that neurotypical people are reluctant to pursue interactions with autistic people and view us less favourably in terms of likeability and attractiveness [22]. We are also more frequently the victims of bullying, ostracism, and relational aggression than our neurotypical peers [23-25]. “Intense” relationships are also common in autistic people, particularly women and girls [26]. We may struggle to maintain multiple friendships at once, finding it preferable to intensely focus on one relationship at a time. I know for myself and my partner, we both tend to view new friendships like a project and want to learn as much as possible about the person in question. If that friendship later ends, it can give the impression of an intense social rollercoaster.

3. Identity disturbance: Identity disturbance in ASD can be broken down into two categories. Real identity disturbance and incorrectly perceived identity disturbance.

Real: Many autistic people “mask” their autism to different degrees. Masking can be described as the conscious or unconscious suppression of aspects of a person’s identity, behaviour, and emotions, with the intention of fitting in or conforming to specific social or occupational situations. Masking can involve mirroring facial expressions and body language; mimicking the behaviour and interests of others; expressing or suppressing specific emotions; suppressing sensory related pain or discomfort; suppressing excitement or interest in a particular subject; and suppressing self-stimulatory behaviours. Masking is used for a number of reasons, including to “pass” as non-autistic, and to avoid stigma and discrimination [27]. Studies have found that masking is detrimental to the health of autistic people, and along with increasing burnout and suicidal feelings, it can also cause a loss of personal identity. Autistic people have described losing track of their sense of self, struggling to realise their own authentic identity, and losing a sense of grounding and security in who they are [28].

Incorrectly perceived: A greater percentage of autistic people identify as LGBT+ than neurotypical people [29]. Disturbingly, LGBT+ identities are commonly considered to be an indication of identity disturbance by mental health clinicians [30-32], or even a subgroup of BPD [33]. LGBT+ people are much more likely to be diagnosed with BPD than heterosexual and cisgendered people. Research on this phenomenon suggests that irrespective of the persons clinical presentation, clinicians may be predisposed to provide a BPD diagnosis to LGBT+ patients [34]. A further shallow perception of identity disturbance by mental health professionals comes in the form of prejudice towards eccentric, changeable, or colourful personal appearances, such as bright clothes and hair dyes. Within autistic communities, a well-known stereotype for autistic women is our use of bright hair dyes. This is also the same for women labelled with BPD. Lots of mental health patients, survivors, and neurodivergent people discuss in online spaces the tendency of mental health clinicians to diagnose mania, impulsivity, and identity disturbance based on colourful dyed hair and/or eccentric or bright clothing. This practice does not appear to have any scientific basis, and yet it persists.

4. Impulsivity: ADHD is the most common co-occurring condition in autistic children, with rates from 40-70% [35]. ADHD is characterised not only by inattention and/or hyperactivity, but also high levels of impulsive behaviour. With or without ADHD, however, research has found that autistic people display greater levels of impulsivity than neurotypical people [36].

5. Suicide/self-harm: Suicide attempts, deaths by suicide, and experiences of suicidal ideation are extremely common in the autistic community. Lifetime prevalence of suicidal ideation ranges between 20-66% in autistic adults, while suicide attempts are between 2-36% [37]. A recent study which examined 372 coroners’ inquests in two regions of England, found evidence of elevated autistic traits (indicating possible autism) in 41.4% of those who died by suicide [38]. While autistic people experience high levels of mental health issues, suicidality in autistic people may or may not be accompanied by mental illness as autism itself is found to be an independent suicide risk factor [39,40]. Unlike neurotypical populations, which see higher rates of suicide in men, more autistic women than men die by suicide [41]. Autistic women presenting to mental health services, struggling with suicidal ideation, or following a suicide attempt, are at risk of being labelled with BPD, as we are less likely to fit the “typical” appearance of a depressed suicidal person, and may subsequently be misidentified as lower risk due to our gender.

Self-harm is also prevalent within autistic populations [42], but under researched and not understood well. Like suicide, self-harm is also more common in autistic women than men. One study found that 75% of autistic women reported a history of self-harm, compared to 33% of autistic men [43]. While most reasons for self-harming are similar between autistic and neurotypical people (emotional regulation, control, self-punishment, communication, sensation-seeking etc.), a significantly higher proportion of autistic people report using self-harm to stop themselves attempting suicide [44].

6. Chronic emptiness: Chronic emptiness is a difficult concept to define. A systematic review of studies which considered chronic emptiness in people labelled with BPD concluded that emptiness could be described as a “feeling of disconnection” from others and oneself [45]. Emptiness in this sense was separate to loneliness, boredom, and hopelessness. Feeling disconnected, different, or separate to others is common in autistic people, as is exclusion and isolation from wider society [46]. In general, research finds that autistic people experience a lower quality of life than neurotypical people in terms of goal attainment, physical and psychological health, social relationships, and subjective wellbeing [47]. Despite the majority of autistic people reporting wanting to find work, only 22% of autistic people are currently employed (in comparison to 80% of non-disabled people) [48]. The Roots of Loneliness project looked at loneliness in Autistic people, describing how some autistic people feel separated from the world, as if they are looking in at life from the outside [49]. Being neurodivergent in a neurotypical world can be overwhelming and difficult. Not knowing that you are neurodivergent can be deeply distressing, as you know you feel different, but you can’t explain why. As already discussed, masking can also cause identity disturbances, making it difficult for autistic people to maintain a strong sense of who we are. Struggling with personal identity and lacking a feeling of grounding and security could cause someone to feel disconnected from themselves.

7. Anger: Anger in autism can be broken down into two categories. Real anger and incorrectly perceived anger.

Real: Some autistic people may feel anger more keenly than neurotypical people, as we commonly have strong feelings and beliefs, particularly in terms of right and wrong. Some autistic people experience extreme empathy, which can lead to intense anger at injustice. We may also be more likely to react with anger to discrimination directed towards us. For example, research has found that young autistic boys are more likely to feel anger in response to being bullied, rather than fear or sadness [50].

Incorrectly perceived: Autistic people are commonly told we are angry when we aren’t. While some of us may struggle to recognise and interpret others’ emotions, the same is also true in reverse – neurotypical people often struggle to recognise and interpret our emotions. Anxiety, emotional or sensory overload, meltdowns, frustration, inability to communicate emotions or needs etc. may be interpreted as anger. I can’t tell you the number of times I have been asked why I am angry, or told I look really annoyed, when I have actually been deeply anxious or so overwhelmed, I’m about to cry. Self-harm or self-injurious behaviours, such as head banging, hitting, or biting oneself, may also be interpreted as acts of anger, as they can appear “aggressive” to people who do not understand their purpose.

8. Mood swings: Autistic people experience large emotions and can have strong reactions to things, which can include sudden changes in emotion and emotional dysregulation [51]. We can also struggle to express emotion, supressing it until it reaches explosion level, which may appear to onlookers as a sudden and dramatic change in emotion, when in reality, it has merely moved from below to above the surface. “Meltdowns” (intense responses to overwhelming situations [52]) are also common in autistic people and can be interpreted as mood swings. Many autistic people experience meltdowns, which might include crying, screaming, self-harm, lashing out at other people, withdrawing into oneself, and the inability to communicate what is happening – this can sometimes appear to happen suddenly and without warning. As previously mentioned, a very high number of autistic people also have ADHD. Sudden changes in mood are common in people with ADHD. Similar to the affective instability in the BPD diagnostic criteria, the shift in emotions in ADHD often lasts from hours to days [53]. Finally, misophonia can be read as a “mood swing”, as people can suddenly feel a rush of intense emotion in response to particular sounds. Anecdotally, it seems that misophonia is common in autistic people. There are certain sounds (e.g. the cats licking themselves) that I find so utterly horrific, if I cannot escape or stop the sound, I can actually feel suicidal or start banging my head on things to cope.

9. Paranoia and/or dissociation – Paranoia and/or dissociation in autism can be broken down into two categories. Real and incorrectly perceived paranoia and/or dissociation.

Real: Given the high rates of trauma experienced by autistic people [54,55] it seems logical to expect that trauma related symptoms, such as dissociation and paranoia, would be common in autistic people. Masking can include dissociating away from emotions and surroundings [56] – we are socialised to push away our thoughts and natural responses, build walls between ourselves and our feelings, to resist impulses, and separate ourselves from sensory difficulties. Dissociation can therefore become an automatic response to stressful situations [57]. Autistic burnout (explained further below) also appears to be associated with dissociative and fugue states [58].

Perceived: It’s very common for autistic people’s experiences of the world, including our experiences of prejudice and discrimination, to be dismissed. We may have our justified fears, worries and anxiety reframed as paranoia by people who do not recognise the difficulties we experience. I was once told by an NHS psychologist that I wasn’t autistic and my anxiety about facing “imaginary” discrimination was the reason I found social interaction difficult, not the complex and overwhelming nature of the interaction itself, or the actual discrimination I had previously experienced. Despite being officially diagnosed autistic by her colleagues, my autism was swept away and reframed as anxiety and paranoia. Autistic shutdowns (similar to meltdowns) can also be incorrectly interpreted as dissociation, as they present as the person closing down, becoming unresponsive, immobile, or sleepy, in response to stressful or overwhelming situations [59].

Co-occurring conditions and similar experiences: The following list contains other symptoms, similar experiences, and co-occurring conditions which are not listed in the BPD diagnostic criteria, but are commonly associated with BPD:

1. Eating disorders: Eating disorders are very common in both autistic people and people labelled with BPD. Studies have found between 33-65% of people diagnosed with BPD have experienced an eating disorder at some point in their life (including anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified) [60-62]. Research also shows evidence of a significant overrepresentation of ASD in people with eating disorders [63-65]. Some studies suggest routinely screening eating disorder patients for autism, given how commonly they co-occur [66].

2. Alexithymia: Alexithymia is characterised by an inability or difficulty identifying and describing your own emotions. Alexithymia is highly prevalent in autistic people [67] and people labelled with BPD [68]. Alexithymia in autism and BPD are both associated with higher levels of self-harm [69,70].

3. Autistic burnout: Autistic burnout is different to the neurotypical concept of burnout and appears to be related to masking and coping with the demands of a hostile neurotypical society [71]. Autistic burnout can involve a loss of executive function, self-care, social skills, memory, speech, a reduced capacity to cope with sensory overload, and an increase in autistic traits. Autistic burnout can present like atypical depression, or PD, and seems to last for a long time – some autistic people on social media indicate that they have never fully recovered after experiencing burnout. Autistic burnout may not respond to antidepressants or psychological therapies in the same way as depression, including potentially worsening with treatment [72], leading staff to believe it is a sign of PD.

4. PTSD and C-PTSD: A history of trauma is extremely common in autistic people and people labelled with BPD [73,74].

5. Sleep disturbances: Difficulties with sleep are very common in autistic people and people labelled with BPD [75,76].

6. Executive dysfunction: Executive function can be described as the cognitive processes which allow people to regulate thoughts and behaviours. This includes planning, concentration, problem solving, working memory, reasoning skills, self-control, flexible thinking, and the ability to initiate actions. Executive function difficulties are common in autistic people [77] and people labelled with BPD [78]. This can include struggling to adjust or monitor behaviour in changing environments; finding it difficult to concentrate and stay on task; forgetting new information; poor time management; and struggling to start new tasks; etc. Executive dysfunction is commonly mistaken for irresponsibility, laziness, disorganisation, and incompetence [79].

While BPD already has a hefty number of potential diagnostic criterion for mental health clinicians to play with, the stigma surrounding BPD (much of it created and perpetuated by mental health clinicians and researchers) adds a number of “unofficial” criteria. This includes manipulative behaviour; attention-seeking; lying; complaints about staff or services; black and white thinking; pitting staff against one another; unrealistic demands or expectations of services; and an abrasive style of communication. Anyone approaching mental health services who fits any part of the BPD clinical stereotype (eg. young woman or LGBT+ person; history of trauma; self-harm or suicide attempt; atypical or complex mental health presentation etc.) is at risk of having all their thoughts, words and behaviour run through a special prejudiced BPD lens and interpreted as the above. Subsequently, in some kind of strange circular logic, once someone is perceived as being manipulative or attention-seeking due to BPD stigma, this then acts as confirmation that they have BPD. It becomes an inescapable cycle. In terms of BPD and ASD, it’s interesting to consider how so many autistic traits can be interpreted as these behaviours.

1. Literalism: Autistic people can communicate and interpret communication in a literal manner. Sometimes this can cause confusion and misunderstandings. Mental health staff can interpret literalism as the person being deliberately difficult, obtuse, or “playing games” with them.

2. Meltdowns and shutdowns: While both of these have already been discussed in terms of mood swings and dissociation, meltdowns and shutdowns can also be (wrongly) perceived by people as “temper tantrums” or attention-seeking.

3. Black and white thinking: An incredibly common charge put to autistic people (and people labelled with BPD) is that we think in black and white, or “all or nothing”, terms. While this may be true for some (and is heavily linked to trauma [80]), something I have observed is that being told you have “black and white” thinking can also be a response from mental health staff when someone describes negative experiences, such as bullying, discrimination, or mental health service-specific failures. I was told by an NHS psychotherapist that I was too “black and white” when I explained that I no longer wanted to live with my roommate after he blamed me for my own sexual abuse. I was later told by an NHS psychiatrist that I was too “black and white” in my view of services when I said that waiting for help wasn’t actually help. Apparently, in both cases, I failed to appreciate the nuance and complexity of the situation, and that a “reasonable” person would put up with victim blaming and accepted that mental health waiting lists are actually therapeutic.

4. Honesty: Some autistic people find it difficult to lie; telling the truth even if it negatively affects us [81]. This may be interpreted as manipulative behaviour by mental health services. For example, not long before she ended her life, my friend Zoe (@AutismMH) talked about how the crisis team told her she was not suicidal, rather, she was manipulative and attention-seeking. Their “proof” of this was that on occasions where she had been taking steps to end her life, and was stopped and questioned by police, she always told them that she was suicidal and intended to end her life. This then resulted in her being detained under section 136. The crisis team staff felt that if she was “genuinely” suicidal, she would have lied to the police, so that she wouldn’t be detained, and would have been able to go ahead and end her life. She responded that she did not ever lie, which they did not believe.

Along with manipulation, honesty can also be interpreted as rudeness or an abrupt style of communication by neurotypical people [82].

5. Unemotional description of difficult topics: Autistic people are often able to talk about difficult and emotional topics without an obvious external display of emotion [83]. Mental health professionals commonly believe that people labelled with BPD are lying about being suicidal, because they want to be admitted to hospital, or are seeking a specific response from services. “Dispassionate” discussions about suicide, self-harm, trauma history, and mood may be misinterpreted by mental health professionals as the person lying, due to the expected emotional reaction to such topics being absent.

6. Rigid rule following: Autistic people often stick to the rules: it can be difficult to waiver from them, and distressing to see others waiver from them [84]. NHS mental health staff frequently deviate from expected practice; ignore NICE and regulatory body guidelines; breach the NHS constitution; display ignorance of individual Trust or local authority policy; and, in some cases, flout statutory duties and human rights, mental health, capacity, and equality laws. This can be very difficult for autistic people to cope with, but complaints or notification that this is occurring may be viewed particularly negatively by staff, due to the common belief in services that people labelled with BPD have unrealistic expectations of mental health services and make frequent, malicious, unfounded complaints. This belief is so well established that “making a complaint” is now considered a symptom of BPD.

Figure 2. “How do I recognise when someone has personality disorder?”: Complaints about services interpreted as difficulties with engagement [85]

7. Situational mutism: Research has found a significant overlap between autism and situational mutism [86]. People with situational mutism can speak fluently in many situations but are unable to speak in others. Often this occurs in anxiety-provoking, emotionally charged, or frightening situations. Situational mutism is not well understood and can be misinterpreted as stubbornness, or manipulative/oppositional behaviour [87].

8. Tone and volume of voice: Some autistic people struggle to regulate the volume and tone of their voice and may not notice that they are suddenly talking very loudly, or people are interpreting their tone as negative [88]. This could easily be perceived by staff as aggressive or confrontational.

The combination of an unwillingness to see autism in anyone other than cis boys/men, and widespread discrimination in mental health services against women, LGBT+ people, people who self-harm, and people who have experienced abuse, leads to a situation in which autistic women and AFAB people are told that rather than being neurodivergent, we have something wrong with our personalities. I believe this to be an important discussion to be had by the autistic community. Autistic people are being misdiagnosed with one of the most stigmatised psychiatric diagnoses in existence. Instead of discovering our neurodivergence, finding a community, and celebrating our existence, we are instead being told that our personalities are disordered and dealing with the fallout of the immense shame and self-loathing that can cause. Our shared culture, our feelings, actions, our ways of existing, are being pathologised. We are being medicalised, stigmatised, dismissed, and forced to hide ourselves. Some of the most vulnerable members of our community are missing. Some of us do not know they belong in the autistic community. Some of us have died under the clinical management of a disorder we do not have. This is not ok. We should be talking about this. Whether you are likely to be given this label or not, the pathologising and stigmatisation of autistic traits hurts all autistic people.

Finally, to professionals: Please learn more about what autism looks like in people other than white cis boys. Routinely add autism to your differentials. Assess for autism in people you are thinking of diagnosing with PD. Reflect on why you are considering PD. Is it based in prejudice? Are you judging someone on one or two stereotypical traits? Are you missing the bigger picture? Would you be considering PD if they were a cis, heterosexual man? Could they in fact be autistic? Consider whether an autistic person needs to be diagnosed with PD if they already have a diagnosis of autism. For people who already have both diagnoses, think about what actions you could take to accommodate autism-specific needs, and consider reassessing the PD diagnosis – and getting rid of it, if that is what the person wants.

#AutismNotPD

#JusticeForZoe

#JusticeForFernF

Wren

References

1. Hull L, Petrides K, Mandy W. The Female Autism Phenotype and Camouflaging: a Narrative Review. Review Journal of Autism and Developmental Disorders. 2020;7(4):306-317.

2. Bargiela S, Steward R, Mandy W. The Experiences of Late-diagnosed Women with Autism Spectrum Conditions: An Investigation of the Female Autism Phenotype. Journal of Autism and Developmental Disorders. 2016;46(10):3281-3294.

3. Weale S. Children waiting up to three years for autism diagnosis, poll reveals. The Guardian [Internet]. 2020 [cited 23 February 2022];. Available from: https://www.theguardian.com/society/2020/jan/14/children-waiting-up-to-three-years-for-autism-diagnosis-poll-reveals

4. National Autistic Society. Number of autistic people in mental health hospitals: latest data [Internet]. Autism.org.uk. 2022 [cited 23 February 2022]. Available from: https://www.autism.org.uk/what-we-do/news/autistic-people-in-mental-health-hospitals

5. Camm-Crosbie L, Bradley L, Shaw R, Baron-Cohen S, Cassidy S. ‘People like me don’t get support’: Autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism. 2018;23(6):1431-1441.

6. Rydén G, Rydén E, Hetta J. Borderline personality disorder and autism spectrum disorder in females: A cross-sectional study. Clinical Neuropsychiatry: Journal of Treatment Evaluation. 2008;5(1), 22–30.

7. Dell'Osso L, Cremone I, Carpita B, Fagiolini A, Massimetti G, Bossini L et al. Correlates of autistic traits among patients with borderline personality disorder. Comprehensive Psychiatry. 2018;83:7-11.

8. Trubanova A, Donlon K, Kreiser N, Ollendick T, White S. Underidentification of Autism Spectrum Disorder in Females: A Case Series Illustrating the Unique Presentation of this Disorder in Young Women. Scandinavian Journal of Child and Adolescent Psychiatry and Psychology. 2014;2(2):66-76.

9. Dudas R, Lovejoy C, Cassidy S, Allison C, Smith P, Baron-Cohen S. The overlap between autistic spectrum conditions and borderline personality disorder. PLOS ONE. 2017;12(9):e0184447.

10. Nanchen K, Brodführer A, Heinrichs M, Philipsen A, Tebartz van Elst L, Matthies S. Autistische Züge bei Patientinnen mit Borderline-Persönlichkeitsstörung unter besonderer Berücksichtigung der Empathie. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie. 2016;64(4):247-255.

11. Rydén G, Rydén E, Hetta J. Borderline personality disorder and autism spectrum disorder in females: A cross-sectional study. Clinical Neuropsychiatry: Journal of Treatment Evaluation. 2008;5(1), 22–30.

12. Hunt R. Why are those with autism getting misdiagnosed as having a personality disorder?. Morning Star [Internet]. 2021 [cited 21 February 2022];. Available from: https://morningstaronline.co.uk/article/why-are-those-autism-getting-misdiagnosed-having-personality-disorder

13. Adult Misdiagnosis – The Default Path to an Autistic Identity [Internet]. Autistic Science Person. 2019 [cited 25 February 2022]. Available from: https://autisticscienceperson.com/2019/06/15/adult-misdiagnosis-the-default-path-to-an-autistic-identity/

14. Regan T. Autism Misdiagnosis: Borderline Personality Disorder [Internet]. Adult and Geriatric Autism. 2020 [cited 21 February 2022]. Available from: https://www.adultandgeriatricautism.com/post/autism-misdiagnosis-borderline-personality-disorder

15. Rydén G, Rydén E, Hetta J. Borderline personality disorder and autism spectrum disorder in females: A cross-sectional study. Clinical Neuropsychiatry: Journal of Treatment Evaluation. 2008;5(1), 22–30.

16. Dell'Osso L, Cremone I, Carpita B, Fagiolini A, Massimetti G, Bossini L et al. Correlates of autistic traits among patients with borderline personality disorder. Comprehensive Psychiatry. 2018;83:7-11.

17. Nanchen K, Brodführer A, Heinrichs M, Philipsen A, Tebartz van Elst L, Matthies S. Autistische Züge bei Patientinnen mit Borderline-Persönlichkeitsstörung unter besonderer Berücksichtigung der Empathie. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie. 2016;64(4):247-255.

18. Bach B, First M. Application of the ICD-11 classification of personality disorders. BMC Psychiatry. 2018;18(1).

19. Strunz S, Schermuck C, Ballerstein S, Ahlers C, Dziobek I, Roepke S. Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. Journal of Clinical Psychology. 2016;73(1):113-125.

20. Crompton C, Hallett S, Ropar D, Flynn E, Fletcher-Watson S. ‘I never realised everybody felt as happy as I do when I am around autistic people’: A thematic analysis of autistic adults’ relationships with autistic and neurotypical friends and family. Autism. 2020;24(6):1438-1448.

21. Haruvi-Lamdan N, Horesh D, Zohar S, Kraus M, Golan O. Autism Spectrum Disorder and Post-Traumatic Stress Disorder: An unexplored co-occurrence of conditions. Autism. 2020;24(4):884-898.

22. Sasson N, Faso D, Nugent J, Lovell S, Kennedy D, Grossman R. Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Scientific Reports. 2017;7(1).

23. Sedgewick F, Hill V, Pellicano E. ‘It’s different for girls’: Gender differences in the friendships and conflict of autistic and neurotypical adolescents. Autism. 2018;23(5):1119-1132.

24. Kloosterman P, Kelley E, Craig W, Parker J, Javier C. Types and experiences of bullying in adolescents with an autism spectrum disorder. Research in Autism Spectrum Disorders. 2013;7(7):824-832.

25. Heinrichs R, Myles B. Perfect Targets: Asperger Syndrome and Bullying: Practical Solutions for Surviving the Social World. Shawnee Mission, Kan.: Autism Asperger Pub.; 2003.

26. Sedgewick F, Hill V, Pellicano E. ‘It’s different for girls’: Gender differences in the friendships and conflict of autistic and neurotypical adolescents. Autism. 2018;23(5):1119-1132.

27. Miller D, Rees J, Pearson A. “Masking Is Life”: Experiences of Masking in Autistic and Nonautistic Adults. Autism in Adulthood. 2021;3(4):330-338.

28. Hull L, Petrides K, Allison C, Smith P, Baron-Cohen S, Lai M, et al. “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal of Autism and Developmental Disorders. 2017;47(8):2519-2534.

29. Weir E, Allison C, Baron‐Cohen S. The sexual health, orientation, and activity of autistic adolescents and adults. Autism Research. 2021;14(11):2342-2354.

30. Wadley J. Diagnosis bias of borderline personality disorder high among LGB community [Internet]. University of Michigan. Michigan News. 2021 [cited 21 February 2022]. Available from: https://news.umich.edu/diagnosis-bias-of-borderline-personality-disorder-high-among-lgb-community/

31. McCann E, Sharek D. Challenges to and opportunities for improving mental health services for lesbian, gay, bisexual, and transgender people in Ireland: A narrative account. International Journal of Mental Health Nursing. 2014;23(6):525-533.

32. Reich D, Zanarini M. Sexual Orientation and Relationship Choice in Borderline Personality Disorder Over Ten Years of Prospective Follow-Up. Journal of Personality Disorders. 2008;22(6):564-572.

33. Murray J. Borderline Manifestations in the Rorschachs of Male Transsexuals. Journal of Personality Assessment. 1985;49(5):454-466.

34. Rodriguez-Seijas C, Morgan T, Zimmerman M. Is There a Bias in the Diagnosis of Borderline Personality Disorder Among Lesbian, Gay, and Bisexual Patients?. Assessment. 2020;28(3):724-738.

35. Antshel K, Zhang-James Y, Wagner K, Ledesma A, Faraone S. An update on the comorbidity of ADHD and ASD: a focus on clinical management. Expert Review of Neurotherapeutics. 2016;16(3):279-293.

36. McClain M, Hasty Mills A, Murphy L. Inattention and hyperactivity/impulsivity among children with attention-deficit/hyperactivity-disorder, autism spectrum disorder, and intellectual disability. Research in Developmental Disabilities. 2017;70:175-184.

37. Cassidy S, Au-Yeung S, Robertson A, Cogger-Ward H, Richards G, Allison C et al. Autism and autistic traits in those who died by suicide in England. The British Journal of Psychiatry. 2022;1-9.

38. Cassidy S, Au-Yeung S, Robertson A, Cogger-Ward H, Richards G, Allison C et al. Autism and autistic traits in those who died by suicide in England. The British Journal of Psychiatry. 2022;1-9.

39. Cassidy S, Rodgers J. Understanding and prevention of suicide in autism. The Lancet Psychiatry. 2017;4(6):e11.

40. Chen M, Pan T, Lan W, Hsu J, Huang K, Su T et al. Risk of Suicide Attempts Among Adolescents and Young Adults With Autism Spectrum Disorder. The Journal of Clinical Psychiatry. 2017;78(9):e1174-e1179.

41. Hirvikoski T, Mittendorfer-Rutz E, Boman M, Larsson H, Lichtenstein P, Bölte S. Premature mortality in autism spectrum disorder. British Journal of Psychiatry. 2016;208(3):232-238.

42. Moseley R, Gregory N, Smith P, Allison C, Baron-Cohen S. A ‘choice’, an ‘addiction’, a way ‘out of the lost’: exploring self-injury in autistic people without intellectual disability. Molecular Autism. 2019;10(1).

43. Maddox B, Trubanova A, White S. Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism. 2016;21(4):412-422.

44. Maddox B, Trubanova A, White S. Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism. 2016;21(4):412-422.

45. Miller C, Townsend M, Day N, Grenyer B. Measuring the shadows: A systematic review of chronic emptiness in borderline personality disorder. PLOS ONE. 2020;15(7):e0233970.

46. Camm-Crosbie L, Bradley L, Shaw R, Baron-Cohen S, Cassidy S. ‘People like me don’t get support’: Autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism. 2018;23(6):1431-1441.

47. van Heijst B, Geurts H. Quality of life in autism across the lifespan: A meta-analysis. Autism. 2014;19(2):158-167.

48. National Autistic Society. New shocking data highlights the autism employment gap [Internet]. 2022 [cited 23 February 2022]. Available from: https://www.autism.org.uk/what-we-do/news/new-data-on-the-autism-employment-gap

49. Deaton E. Autism Loneliness: Why Those On The Spectrum Often Feel Alone [Internet]. The Roots of Loneliness Project. 2022 [cited 23 February 2022]. Available from: https://www.rootsofloneliness.com/autism-loneliness

50. Novin S, Broekhof E, Rieffe C. Bidirectional relationships between bullying, victimization and emotion experience in boys with and without autism. Autism. 2018;23(3):796-800.

51. Trubanova A, Donlon K, Kreiser N, Ollendick T, White S. Underidentification of Autism Spectrum Disorder in Females: A Case Series Illustrating the Unique Presentation of this Disorder in Young Women. Scandinavian Journal of Child and Adolescent Psychiatry and Psychology. 2014;2(2):66-76.

52. National Autistic Society. Meltdowns - a guide for all audiences [Internet]. 2020 [cited 23 February 2022]. Available from: https://www.autism.org.uk/advice-and-guidance/topics/behaviour/meltdowns/all-audiences

53. Landaas E, Halmøy A, Oedegaard K, Fasmer O, Haavik J. The impact of cyclothymic temperament in adult ADHD. Journal of Affective Disorders. 2012;142(1-3):241-247.

54. Peterson J, Earl R, Fox E, Ma R, Haidar G, Pepper M et al. Trauma and Autism Spectrum Disorder: Review, Proposed Treatment Adaptations and Future Directions. Journal of Child & Adolescent Trauma. 2019;12(4):529-547.

55. Haruvi-Lamdan N, Horesh D, Golan O. PTSD and autism spectrum disorder: Co-morbidity, gaps in research, and potential shared mechanisms. Psychological Trauma: Theory, Research, Practice, and Policy. 2018;10(3):290-299.

56. Pearson A, Rose K. A Conceptual Analysis of Autistic Masking: Understanding the Narrative of Stigma and the Illusion of Choice. Autism in Adulthood. 2021;3(1):52-60.

57. Autistic Masking, Late Diagnosis, and Dissociation: The Toll It Takes on Autistic Mental Health [Internet]. Autistic Science Person. 2018 [cited 24 February 2022]. Available from: https://autisticscienceperson.com/2018/05/20/autistic-masking-late-diagnosis-and-dissociation-the-toll-it-takes-on-autistic-mental-health/

58. Higgins J, Arnold S, Weise J, Pellicano E, Trollor J. Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout. Autism. 2021;25(8):2356-2369.

59. Loos Miller I, Loos H. Shutdowns and Stress in Autism [Internet]. Autism Awareness. 2015 [cited 24 February 2022]. Available from: https://autismawarenesscentre.com/shutdowns-stress-autism/

60. Kelly C, Davies M. A Review of Anorexia Nervosa, Its Relationship to Autism and Borderline Personality Disorder, and Implications for Patient Related Outcomes. Journal of Psychiatry and Psychiatric Disorders. 2019;03(04):207-215.

61. Khosravi M. Eating disorders among patients with borderline personality disorder: understanding the prevalence and psychopathology. Journal of Eating Disorders. 2020;8(1).

62. Chen E, Brown M, Harned M, Linehan M. A comparison of borderline personality disorder with and without eating disorders. Psychiatry Research. 2009;170(1):86-90.

63. Mandy W, Tchanturia K. Do women with eating disorders who have social and flexibility difficulties really have autism? A case series. Molecular Autism. 2015;6(1).

64. Huke V, Turk J, Saeidi S, Kent A, Morgan J. Autism Spectrum Disorders in Eating Disorder Populations: A Systematic Review. European Eating Disorders Review. 2013;21(5):345-351.

65. Brown C, Stokes M. Intersection of Eating Disorders and the Female Profile of Autism. Psychiatric Clinics of North America. 2020;43(4):735-743.

66. Barnett A, Edwards K, Harper R, Evans E, Alexander D, Choudhary M et al. The Association Between Autistic Traits and Disordered Eating is Moderated by Sex/Gender and Independent of Anxiety and Depression. Journal of Autism and Developmental Disorders. 2020;51(6):1866-1879.

67. Poquérusse J, Pastore L, Dellantonio S, Esposito G. Alexithymia and Autism Spectrum Disorder: A Complex Relationship. Frontiers in Psychology. 2018;9:1196.

68. Sleuwaegen E, Houben M, Claes L, Berens A, Sabbe B. The relationship between non-suicidal self-injury and alexithymia in borderline personality disorder: “Actions instead of words”. Comprehensive Psychiatry. 2017;77:80-88.

69. Moseley R, Gregory N, Smith P, Allison C, Baron-Cohen S. A ‘choice’, an ‘addiction’, a way ‘out of the lost’: exploring self-injury in autistic people without intellectual disability. Molecular Autism. 2019;10(1).

70. Norman H, Oskis A, Marzano L, Coulson M. The relationship between self‐harm and alexithymia: A systematic review and meta‐analysis. Scandinavian Journal of Psychology. 2020;61(6):855-876.

71. Higgins J, Arnold S, Weise J, Pellicano E, Trollor J. Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout. Autism. 2021;25(8):2356-2369.

72. Higgins J, Arnold S, Weise J, Pellicano E, Trollor J. Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout. Autism. 2021;25(8):2356-2369.

73. Lobregt-van Buuren E, Hoekert M, Sizoo B. Chapter 3: Autism, Adverse Events, and Trauma. In: Grabrucker A, ed. by. Autism Spectrum Disorders. Brisbane (AU): Exon Publications; 2020.

74. Porter C, Palmier‐Claus J, Branitsky A, Mansell W, Warwick H, Varese F. Childhood adversity and borderline personality disorder: a meta‐analysis. Acta Psychiatrica Scandinavica. 2019;141(1):6-20.

75. Hafizi S. Sleep and borderline personality disorder: A review. Asian Journal of Psychiatry. 2013;6(6):452-459.

76. Devnani P, Hegde A. Autism and sleep disorders. Journal of Pediatric Neurosciences. 2015;10(4):304.

77. Demetriou E, Lampit A, Quintana D, Naismith S, Song Y, Pye J et al. Autism spectrum disorders: a meta-analysis of executive function. Molecular Psychiatry. 2017;23(5):1198-1204.

78. Ghanem M, El-Serafi D, Sabry W, ElRasheed A, Abdel Razek G, Soliman A et al. Executive dysfunctions in borderline personality disorder. Middle East Current Psychiatry. 2016;23(2):85-92.

79. Kim C. Executive Function Primer (PART 1) [Internet]. Musings of an Aspie. 2014 [cited 25 February 2022]. Available from: https://musingsofanaspie.com/2014/01/07/executive-function-primer-part-1/

80. Powell T. Finding Gray in Black-and-White Thinking in Complex PTSD [Internet]. HealthyPlace. 2017 [cited 25 February 2022]. Available from: https://www.healthyplace.com/blogs/traumaptsdblog/2019/1/finding-gray-in-black-and-white-thinking-in-complex-ptsd

81. Bagnall R, Russell A, Brosnan M, Maras K. Deceptive behaviour in autism: A scoping review. Autism. 2021;26(2):293-307.

82. Chevallier C, Molesworth C, Happé F. Diminished Social Motivation Negatively Impacts Reputation Management: Autism Spectrum Disorders as a Case in Point. PLoS ONE. 2012;7(1):e31107.

83. The Psychiatric Management of Autism in Adults. College Report. Royal College of Psychiatrists; 2020.

84. Bolling D, Pitskel N, Deen B, Crowley M, McPartland J, Kaiser M et al. Enhanced neural responses to rule violation in children with autism: A comparison to social exclusion. Developmental Cognitive Neuroscience. 2011;1(3):280-294

85. Bolton W, Lovell K, Morgan L, Wood H. Meeting the Challenge, Making a Difference: Working effectively to support people with personality disorder in the community. Department of Health; 2014.

86. Steffenburg H, Steffenburg S, Gillberg C, Billstedt E. Children with autism spectrum disorders and selective mutism. Neuropsychiatric Disease and Treatment. 2018;Volume 14:1163-1169.

87. Myths About Selective Mutism [Internet]. Child Mind Institute. 2022 [cited 25 February 2022]. Available from: https://childmind.org/article/myths-about-selective-mutism/

88. Edgerton L, Wine B. Speak Up: Increasing Conversational Volume in a Child with Autism Spectrum Disorder. Behavior Analysis in Practice. 2017;10(4):407-410.