Identifying Autism in Women Diagnosed with Borderline Personality Disorder: Clinician and Lived Experience Perspectives

Background: Growing numbers of people with a borderline personality disorder (BPD) diagnosis are querying whether they have undiagnosed autism. Previous qualitative research has not focused on identifying barriers and facilitators to this diagnostic journey, has not explored the perspectives of clinicians, and has not included 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 recognizing undiagnosed autism in women and people assigned female at birth (AFAB) with a diagnosis of personality disorder. Methods: We carried out in-depth qualitative interviews with 15 mental health clinicians and 15 women/AFAB people who had a current or prior diagnosis of BPD and identified as definitely or possibly autistic, from across the United Kingdom. We analyzed the interview data using reflexive thematic analysis. Results: Both clinician and lived experience participants identified many barriers to recognizing autism in women and AFAB people with a BPD diagnosis: BPD diagnoses being made with minimal assessment during mental health crises, systemic incentivization to diagnose BPD in order to access psychological therapies, siloed service pathways, clinician reluctance to question preexisting 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. Conclusion: Our 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 highlights the value of being open to questioning preexisting diagnoses, joint working across autism and personality disorder services, and improving transdiagnostic access to psychological interventions.