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. 2024 Dec 2;6(4):401-427.
doi: 10.1089/aut.2023.0034. eCollection 2024 Dec.

Borderline Personality as a Factor in Late, Missed, and Mis-Diagnosis in Autistic Girls and Women: A Conceptual Analysis

Goldie A McQuaid  1 , John F Strang  2   3   4   5 , Allison Jack  1
Affiliations

Borderline Personality as a Factor in Late, Missed, and Mis-Diagnosis in Autistic Girls and Women: A Conceptual Analysis

Goldie A McQuaid et al. Autism Adulthood. .

Abstract

Autism without intellectual disability is diagnosed later and with greater difficulty in girls/women relative to boys/men. For autistic girls and women, the journey to an autism diagnosis may include one or more misdiagnoses. Misdiagnosis with borderline personality disorder (BPD) or borderline traits may be particularly common, and characteristics often observed in autistic girls and women may contribute specifically to a risk of misdiagnosis with BPD. This review draws from a burgeoning literature on autism in girls and women to provide a detailed discussion of differential diagnosis of BPD and autism in cisgender girls/women, with a focus on phenotypic traits and/or their presentation that may be more common in autistic girls/women and that may be particularly prone to miscategorization as BPD. Distinctions between autism and BPD are identified, emphasizing the need for scrutiny of an individual's clinical presentation to tease apart differences between the autism and BPD phenotypes. We highlight instances in which similar phenotypic expressions may be driven by differing underlying factors. Implications for the distinction of autism and BPD/borderline traits in informing appropriate therapeutic intervention are discussed.

Keywords: autism; borderline personality; diagnosis; gender; misdiagnosis; sex.

Plain language summary

Community brief Why is this topic important? Autistic girls/women may be more likely to get an autism diagnosis late (or not at all). They may also be more likely to get misdiagnoses of mental health conditions. These misdiagnoses might interfere with getting an appropriate autism diagnosis. Later age at autism diagnosis is associated with more mental health problems. This makes understanding factors related to delayed or missed diagnosis in autistic girls/women important to autistic well-being. What is the purpose of this article? Autistic girls/women may be at risk for misdiagnosis with borderline personality disorder (BPD). In this article, we discuss why this may be. Autistic girls/women may meet the diagnostic criteria for autism in different ways relative to autistic boys/men. This different presentation of autism may not be recognized by the professionals these girls/women go to for a diagnosis. These girls/women may also mask or camouflage autistic traits. This means that they might not be referred to medical professionals until they are older. If an autistic girl/woman first sees a diagnostic professional in adolescence or adulthood, that professional might only consider their current presentation. Early developmental differences related to autism might be overlooked. These girls and women may not be screened for autism and instead receive a diagnosis of a mental health condition, such as BPD. This article reviews each of the diagnostic criteria for BPD. We show how differences in the ways some autistic girls/women present with autism, combined with a lack of awareness by mental health professionals regarding what autism can look like in girls/women (vs. boys/men), may contribute to a diagnosis of BPD or borderline personality traits. What do the authors suggest? We suggest that clinicians look carefully at the presentation of girls/women who are referred to them and in whom BPD is suspected. We lay out potential ways to distinguish autism as presented in girls/women from BPD. Mental health professionals should collect a comprehensive history of neurodevelopment. We point to the importance of understanding the different ways that girls and women may present with autism. We talk about the role that camouflaging may play in changing how girls and women may present with autism. We discuss how this may change over the course of development. We also discuss how this may change when a person is in the presence of a mental health professional. How will this study help autistic adults now and in the future? This study aims to raise awareness of factors that may make it more likely for an autistic girl/woman to get a diagnosis of BPD. Just as there may be a sex/gender-related bias against the diagnosis of autism in girls/women, there may be a sex/gender-related bias toward diagnosing BPD in girls/women. Drawing awareness to these biases and showing how the diagnostic criteria of BPD can be incorrectly applied to certain presentations of autism will help reduce misdiagnosis of autistic people and thus improve well-being for autistic adults.

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References

    1. Baio J, Wiggins L, Christensen DL, et al. . Prevalence of autism spectrum disorder among children aged 8 years—Autism and developmental disabilities monitoring network, 11 sites, United States, 2014. MMWR Surveill Summ. 2018;67(6):1–23. 10.15585/mmwr.ss6706a1. - DOI - PMC - PubMed
    1. Fombonne E. The changing epidemiology of autism. J Appl Res Intellect Disabil. 2005;18(4):281–294. 10.1111/j.1468-3148.2005.00266.x. - DOI
    1. Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(6):466–474. 10.1016/j.jaac.2017.03.013. - DOI - PubMed
    1. Giarelli E, Wiggins LD, Rice CE, et al. . Sex differences in the evaluation and diagnosis of autism spectrum disorders among children. Disabil Health J. 2010;3(2):107–116. 10.1016/j.dhjo.2009.07.001. - DOI - PMC - PubMed
    1. Begeer S, Mandell DS, Wijnker-Holmes B, et al. . Sex differences in the timing of identification among children and adults with autism spectrum disorders. J Autism Dev Disord. 2013;43(5):1151–1156. 10.1007/s10803-012-1656-z. - DOI - PubMed