Why Autistic women tend to be misdiagnosed with personality disorders
Borderline Personality Disorder (BPD) is described as “a mental health disorder that impacts the way you think and feel about yourself and others, causing problems functioning in everyday life. It includes self-image issues, difficulty managing emotions and behavior, and a pattern of unstable relationships.”
Because this was 12 years ago, I’d hoped this would be less likely in 2022. I’d sort of assumed clinicians would have taken steps to better understand Autism and BPD, as well as how to differentiate them.
Yet even now, I continue to hear and read stories about people — especially women and other marginalized genders — being misdiagnosed with BPD because they experience intense emotional dysregulation, self-harming behaviours, and have significant relationships.
The assumption being Autistics lack meaningful connections with others and are too naïve and innocent of engaging in risky behaviour or intentionally self-harm.
The reality is quite the opposite.
Autistics are much more likely to self-harm and experience emotional dysregulation when compared to the general population. We can and do have romantic and other significant relationships. They just might look different from neurotypical (NT) relationships. That doesn’t make them any less important or meaningful.
Trauma, depression, and suicidality
Both Autistics and people with BPD have a much higher incidence of anxiety, depression, and suicidality compared to the general population. This includes studies of Autistic children, who are also at greater risk for depression and suicidal ideation than their peers.
Autistics and those with BPD both very frequently have trauma histories, often complex. Whereas it is understood that Autism makes us more vulnerable to experiencing abuse and trauma, it is believed that childhood trauma puts people at risk of developing borderline personality disorder.
Autistics and people with BPD both experience social difficulties. BPD can lead to extreme hot-and-cold relationships, wherein a person is infatuated with someone for a period of time, then suddenly has intense feelings of dislike or hatred toward them.
Autistics are more likely to shut down due to feeling overwhelmed. We may distance ourselves socially when experiencing burnout or when needing alone time to recharge.
Additionally, we often struggle with miscommunication or misunderstandings due to our differences in communication styles and processing as compared to allistic (non-Autistic) people.
People with BPD may also struggle with misreading social situations and frequently experience fear of abandonment or rejection. A lot of Autistics experience something called Rejection Sensitive Dysphoria (RSD), so we can similarly be prone to fear of rejection.
People with BPD often have an unstable sense of identity, described as rapid changes in self-identity and self-image, which include shifting goals and values.
This, alongside intense love-hate relationships, are often ways clinicians differentiate between BPD and Autism.
While Autistics do tend to possess a strong sense of our own values and are less influenced by peers, many of us also lack a secure sense of identity, especially those of us who have been masking for most of our lives.
What most clinicians don’t recognize is a lot of Autistics have been subject to a lifetime of criticism, rejection, and attempts to mould us into something resembling “normal” (read: neurotypical).
As a result, we are socially conditioned to mask our Autistic traits in attempts to avoid negative repercussions. Masking is seen as a form of stigma management, a way to hide one’s differences and try to fit in.
When we’re trying to suppress our uniqueness and blend in as much as possible, this causes us to hide some of the most essential aspects of ourselves. It’s no wonder, then, that those of us who have masked for a long time struggle with an unstable or insecure sense of identity.
It’s the sexism and gender bias for me
I don’t care what identity, label, or diagnosis a person has. People should embrace whatever feels right, fits with their experiences, and gets them the right supports.
My issue is that many clinicians look at a distraught or emotional female-presenting patient with a trauma history and unstable identity and are very quick to jump to a BPD diagnosis.
Don’t believe me?
Many women have fought for years, deep-diving into extensive research and paying thousands of dollars for private assessments.
They break the bank only to be told they have anxiety or BPD and couldn’t possibly be Autistic. This usually comes from an ill-informed clinician who then proceeds to spout stereotypes, completely neglecting the fact that women are more likely to mask their Autism and that women present differently from males.
Meanwhile, if an Autistic woman ends up in the hospital due to self-harm or a suicide attempt, they are much more likely to walk out with a BPD label than a referral for an Autism assessment.
The problem with an incorrect diagnosis is that it leads to the wrong types of support, which can exacerbate a person’s distress and suffering rather than helping them.
Recent research has shown that compared to males, Autistic females showed a significantly greater delay in referral to mental health services, and are more likely to be misdiagnosed at first evaluation.
If an Autistic woman ends up in hospital due to self-harm or a suicide attempt, they are much more likely to walk out with a BPD label than a referral for an Autism assessment.
Characteristics that influenced delays and misdiagnoses were attention to detail, empathy, and verbal communication. These last two stem from stereotypes that incorrectly portray Autistics as lacking empathy and language skills (Autistics can be non-speaking or hyper-verbal, and everywhere in between).
Delays in identification often cause people to blame themselves for their struggles, miss out on receiving proper support, and miss out on finding their community of neurokin.
When we’ve felt like outsiders our entire lives, discovering one’s community of neurokin can be positively life-changing — even life-saving — and everyone deserves that opportunity.
© Jillian Enright, Neurodiversity MB
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