Identifying autism in women diagnosed with borderline personality disorder: Clinician and lived experience perspectives.

BackgroundGrowing numbers of people with a borderline personality disorder (BPD) diagnosis are realising they may have undiagnosed autism. Previous qualitative research has not focused on identifying barriers and facilitators to this diagnostic journey, did not explore the perspectives of clinicians, and did not include the experiences of people who are unsure whether they are autistic or not. We aimed to understand lived experience and clinician perspectives on facilitators and barriers to recognising undiagnosed autism, in women and people assigned female at birth (PAFAB) with a diagnosis of personality disorder. MethodsWe carried out in-depth qualitative interviews with 15 mental health clinicians, and 15 women/PAFAB who had a current or prior diagnosis of BPD and identified as definitely or possibly autistic, from across the United Kingdom. We analysed the interview data using reflexive thematic analysis. ResultsBoth clinician and lived experience participants identified many barriers to recognising autism in women and PAFAB with a BPD diagnosis: BPD diagnoses being made with minimal assessment during mental health crises, systemic incentivisation to diagnose BPD in order to access psychological therapies, siloed service pathways, clinician reluctance to question pre-existing BPD diagnoses, pathologizing of patients for questioning their BPD diagnosis, and lack of clinician knowledge about different presentations of autism or about ways that autism presents similarly and differently to BPD. Participants identified numerous ways in which autistic characteristics could be misattributed as symptomatic of BPD, further contributing to missed or misdiagnosis. ConclusionOur findings suggest that improving clinician awareness of different presentations of autism, and of differential diagnosis from BPD is likely to reduce misdiagnosis, alongside avoiding rapid diagnostic decisions during mental health crises. Our study further highlights the value of being open to questioning pre-existing diagnoses, joint working across autism and personality disorder services, and improving transdiagnostic access to psychological interventions. Community BriefO_ST_ABSWhy is this an important issue?C_ST_ABSAutism in adults may be missed, or mis-diagnosed as a mental health condition. Borderline personality disorder (BPD) is the most common perceived misdiagnosis held by autistic people. Unrecognised autism may lead to worsened mental health in BPD-diagnosed people. What was the purpose of this study?We aimed to understand lived experience and clinician perspectives on what gets in the way of recognising undiagnosed autism, in people with a diagnosis of BPD. What did the researchers do?We interviewed 15 mental health clinicians, and 15 women/people assigned female at birth (AFAB), who had a current or prior diagnosis of BPD and identified as definitely or possibly autistic. We asked lived experience participants about their experiences of realising that they may be autistic. We asked clinicians to share their experiences of differentiating autism and personality disorder in clinical practice. We asked all participants to discuss their experiences of what makes it challenging to recognise autism in BPD-diagnosed people, and what helps. What were the results and conclusions of the study?Both clinician and lived experience participants identified many barriers to recognising autism in women and AFAB people with a BPD diagnosis. They said BPD diagnoses are made with minimal assessment during mental health crises. They said clinicians feel that they have to diagnose BPD in order to help people access psychological therapies. They said service pathways separate out autism and BPD rather than considering them together. They said clinicians are reluctant to question pre- existing BPD diagnoses, and that patients questioning of their BPD diagnosis is sometimes seen as symptomatic of mental health difficulties. They said clinicians lack knowledge about how autism can look different in women and AFAB people, and about ways that autism can look similar and different to BPD. Participants identified numerous ways in which autistic characteristics could be misattributed as symptomatic of BPD, further contributing to missed or misdiagnosis. We concluded that improving mental health clinicians understanding of autism, and how it is different from BPD, may help to improve recognition of autism in BPD-diagnosed people. We also concluded its important for clinicians to be open to questioning pre-existing diagnoses, to establish joint working across autism and personality disorder services, and to improve transdiagnostic access to psychological interventions. What is new or controversial about these findings?Its the first time clinician and lived experience perspectives on this issue have been brought together. Its controversial because it suggests that mental health services are sometimes not good at recognising autism in BPD- diagnosed people, and that people are potentially being harmed by this. What are potential weaknesses in the study?We would have liked to understand more about the experiences of ethnically diverse people. Our study may have attracted people who disagree with the idea of BPD and who believe autism is underdiagnosed. How will these findings help autistic adults now or in the future?We hope it will help BPD-diagnosed people with undiagnosed autism to be better recognised and understood by mental health services.