The same coin: understanding ASD and BPD

Difficulties with personal relationships, emotional and behavioral dysregulation. Two pillars of two disorders, with a particular, peculiar manifestation in girls and women, cisgendered or trans. Two diagnoses. Two sides of the same coin.

I was diagnosed with Borderline Personality Disorder (BPD) in my 20s, after a difficult childhood and adolescence, lived at the intersection of not-entirely-Westernized cultural values, familial trauma, and financial hardship.

Bluntly, I was a strange, smart child and an angry, stubborn teenager out of place everywhere, always.

BPD answered as many questions as it, simultaneously, raised. Its cornerstone treatment, Dialectical Behavioral Therapy (DBT) gave me some skills to make myself, well, more palatable to the world, to mitigate my nature in the “ways that count.”

My strangeness, smartness, anger, and stubbornness still leak out, in ways that don’t “count,” as much — and this led to my discovery that I may be on the Autism spectrum.

Instead? In addition?

It feels like having come this far, that these are reasonable questions. BPD and Autism Spectrum Disorder (ASD) are like the opposite sides of a coin.

But opposite sides are just that: two sides of the same coin. They lean on one another, existing together, on the same plane.

They face away. But their backs always touch.

Researchers have shown, time (Dudas et al., 2017) after time (Smith, 2013) after time (Chabrol & Raynal, 2018) after time (Dell’osso et al., 2018) — you get the picture — that the symptom overlap between BPD and ASD is significant, with the ASD-only symptoms, not commonly seen in BPD, are those most noted in boys and men with ASD.

We know females, particularly those with “high functioning” (a terrible, condescending, and ableist term, my apologies) ASD tend to manifest their ASD traits differently than males.

And these traits strongly correspond to symptoms of BPD.

In fact, whether these traits/symptoms are viewed as traits of ASD or symptoms of BPD may come down to the judgement of an individual clinician.

An educated, qualified clinician, who is also, you know, a human, with biases, opinions, preferences, and tastes.

Is it a “difficulty” or an “impairment” when a female struggles to read the emotional states of other people; does a case of self-harm stem from emotional dysregulation or as a response to sensory overload; (Dudas et al., 2017)?

When presentation is so close, it could help diagnosis if there was an objective marker for ASD or BPD, but there’s not a clear aetiology for either, a set of genetic or environmental factors (Dudas et al., 2017) to define one against another.

But there isn’t.

The examples above refer to traits and behaviors once considered specific to either ASD (poverty of empathy) or BPD (suicidality and self harm). However, electromyographic records disprove lack of empathy in people — of any gender — with ASD, demonstrating that people with ASD have strong responses to emotional expressions (Smith, 2013), but may have impediments to showing reciprocity or identifying socially-acceptable feedback. And people with ASD, especially ones with few adaptive coping skills and low environmental supports, may show levels of suicidal ideation and self-harm comparable to, or exceeding, those seen in populations with BPD. (Chabrol & Raynal, 2018)

That an individual survived childhood trauma has been a cornerstone in BPD diagnosis — but some level of trauma is also common in the experiences of people with ASD (Chabrol & Raynal, 2018) — and there are clusters of women exhibiting the overlapped symptoms/traits without reporting significant past traumas (Dudas et al., 2017).

There’s no longer any doubt that there’s a correlation between ASD and BPD. What that is, exactly, is still unknown. There’s speculation that some types of BPD are actually a — currently — subthreshold, subclinical type of autism (Dell’osso et al., 2018), or even that a subset of BPD may be a part of some manifestations of “higher functioning” (again, ick) autism (Smith, 2013).

The more we learn about both conditions, the harder it becomes to tell them apart. The coin is a trick one, from a magic shop. No matter how many times you flip, it always comes up heads.

So, if the question isn’t what the difference is between ASD and BPD, then maybe the question is: does it matter?

Honestly, for someone like me, probably not, Like I said, I wound up with tools that help me cope with my world, for the most part, mainly — at first, at least — from having a BPD diagnosis, and then, later, from reading and researching ASD in adult women. Someone like me would benefit from ASD-specific services, but the truth is that those services, for adults, are far and few between.

But, I’m one case out of many — a cursory search turns up way more personal stories than expected. I did not contend with some of the more physical impulses toward self-harm, nor did I exhibit dangerous impulsivity. But these are, indeed, common, dangerous, and destructive.

More research could lead to better interventions. It took a few tries before I teased out of DBT the skills useful for me, and, only then, because I had an extremely supportive partner.

And because ASD is (usually) diagnosed in childhood, while BPD is diagnosed in early adulthood, these interventions could be implemented earlier.

Any one girl saved from an angry, stubborn adolescence of feeling like an alien is worth all the coins in the world.

Chabrol, H., & Raynal, P. (2018). The co-occurrence of autistic traits and borderline personality disorder traits is associated to increased suicidal ideation in nonclinical young adults. Comprehensive Psychiatry, 82, 141–143. doi:10.1016/j.comppsych.2018.02.006

Dell’osso, L., Cremone, I. M., Carpita, B., Fagiolini, A., Massimetti, G., Bossini, L., . . . Gesi, C. (2018). Correlates of autistic traits among patients with borderline personality disorder. Comprehensive Psychiatry, 83, 7–11. doi:10.1016/j.comppsych.2018.01.002

Dudas, R. B., Lovejoy, C., Cassidy, S., Allison, C., Smith, P., & Baron-Cohen, S. (2017). The overlap between autistic spectrum conditions and borderline personality disorder. Plos One, 12(9). doi:10.1371/journal.pone.0184447

Smith, A. (2013). Autism, Borderline Personality Disorder, and Empathy. Emotion Review, 5(2), 223–224. doi:10.1177/1754073912469685