Qualitative review highlights barriers to recognizing autism in women with borderline personality disorder diagnoses

Background. Growing 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. Methods. We 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. Results. Both 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. 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 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.