From my own experience of being diagnosed with both Autism and Emotionally Unstable Personality Disorder, and from many conversations with others in similar positions, I often question the validity and reliability of diagnoses when it comes to Autism and Borderline Personality Disorder (BPD) or Emotionally Unstable Personality Disorder (EUPD) together.
Many autistic people who don’t have a diagnosis of autism are at first misdiagnosed with BPD or EUPD (yes, these are the same thing) before discovering that they are in fact autistic. Additionally, many autistic people who already have their autism diagnosis are then also diagnosed with BPD or EUPD, without the impact of their autism on their BPD-like symptoms being understood.
The overlap between Autism and BPD/EUPD raises a lot of confusion.
During this conversation is necessary that we validate and listen to all autistic people – those who are angry and upset that they have been labelled with a disordered personality instead of having their autism understood, and those who relate to and find the diagnosis of EUPD/BPD helpful.
Let me tell you a little about my experience.
I was diagnosed with traits of Emotionally Unstable Personality Disorder when I was 16 and sectioned in an adolescent psychiatric unit. Six months after I was discharged, I was assessed for autism and found to be autistic. The autism professionals there, who specialised in autistic girls since they are often misunderstood and misdiagnosed, said I didn’t have EUPD as my autism was the reason for my behaviour and emotions which presented this way. The diagnosis was removed. However it was soon after put back on by my mental health team.
I think there is a huge lack of understanding of both Autism and EUPD/BPD.
Autism isn’t widely understood, especially in girls. Many autistic traits present similarly to the symptoms of EUPD/BPD. Many also criticise the diagnosis of EUPD/BPD due to their assessment criteria being unspecific and very varied, with many arguing it should be split into different disorders (Tyrer, 1999).
Autism is classified as a developmental condition. It is not an illness. Someone is born autistic. This is different to BPD/EUPD which is classified as an illness. To be diagnosed with autism, the person has to have experienced autistic traits in childhood (because they do not suddenly develop it). The problem is, many autistic people go undiagnosed. They may not present stereotypically (especially girls), so it is not seen to be autism. This can lead to a BPD/EUPD misdiagnosis.
In order to be diagnosed with EUPD/BPD, you only need to meet 5 out of the 9 criteria.
The criteria includes:
- Chronic feelings of emptiness.
- Intense, unstable emotions.
- Efforts to avoid abandonment.
- Unstable self-image or sense of self.
- Impulsive behaviour.
- Intense anger.
- Difficulty making and keeping relationships.
- Recurrent suicidal behaviour and self-harm.
- Experiencing paranoia and dissociation.
I don’t think it is that difficult to meet five out of the nine criteria if you are depressed. Even more so if you are autistic and depressed. Autistic people may struggle with self-image. They may find it hard to regulate emotions, particularly anger due to an extremely strong sense of injustice. Autistic people, especially those who also have ADHD (which is 30-80%), may struggle with impulsivity. Making friends and keeping friends can be hard due to some finding socialising difficult. Efforts to avoid abandonment may conflict with the fact autistic people often struggle immensely with change. If you mix that with them being depressed, it is no wonder they easily meet this criteria to be diagnosed with EUPD/BPD.
Autistic people can be seen as having BPD symptoms, but these may be a response due to being autistic.
For example, ‘extreme emotional mood swings’ may be caused by a sudden change in routine which many find difficult to deal with, or a meltdown because they aren’t able to engage with their special interest which helps them get through the day. Their presentation of behaviour matches the symptoms of a personality disorder, but it is occurring because they are autistic. Does this mean they have BPD/EUPD too? I don’t think it does.
Many autistic traits and BPD/EUPD experiences overlap.
For example, sensitivity, distress, anxiety, self-destructive behaviour, black and white thinking and feeling misunderstood. I often read stories of people with BPD and think ‘wow this could so apply to an autistic person’. Many autistic people relate to those with BPD when they speak about their experiences, and the same thing occurs vice versa.
Many autistic people who begin to present with mental health issues, usually if they are suicidal and admitted to hospital, are then diagnosed with BPD/EUPD. Some may have BPD too. But I don’t believe they all do. Their distressed presentation, often a result of autistic traits enhanced due to the hospital environment and a lack of familiarity/routine/control, combined with depression and misunderstood autistic traits, appears like BPD to professionals.
My conclusion is that this is all very complicated.
I don’t identify as having EUPD/BPD even though I am diagnosed with it, and I relate to those who discuss their experiences of it. But I think I relate to their experiences because a lot of the time they are similar to autistic traits and experiences too.
The confusion of those misdiagnosed with either condition does raise uncertainty about the validity of diagnoses. Both ASD and BPD/EUPD are often misunderstood and complex conditions. More research into this is definitely needed.