Co-Occurring Autism Spectrum and Borderline Personality Disorder: An Emerging Clinical Challenge Seeking Informed Interventions

Abstract

INITIAL CASE PRESENTATION Brittany, a 21-year-old woman with borderline personality disorder (BPD), was referred to our specialist personality disorder service, with a presentation distinguished by high-lethality suicidal behaviors including ingestion of toxic substances and dangerous objects. She frequently ran to train stations and bridges. Brittany also engaged in daily cutting. Due to her high level of risk, she was increasingly restricted within her family home. She was not allowed into the backyard for fear that she would elope and engage in high lethality behavior. Brittany is an only child, conceived via in vitro fertilization. Diagnosed with Asperger’s Syndrome at age six, Brittany displayed early restricted interests, desire for routine, and sensory difficulties, accompanied by a high level of social interest. Multi-disciplinary assessments showed pragmatic language impairment and social difficulties that included inflexibility and egocentricity in her play. Brittany demonstrated difficulty with sharing, losing in games, and when not able to take first turn. High levels of emotional distress were reported when she did not get what she wanted. Brittany worked with a speech pathologist during this childhood period. She was subsequently diagnosed with obsessive compulsive disorder (OCD) and generalized anxiety. Restricted eating and self-injurious behaviors began in her early teen years. Brittany reported experiencing traumatic bullying from her peers during this period of her life. She reported that she began to cut herself after reading online about people using cutting to regulate emotions. Her first admission to a psychiatric unit occurred at age 15. Following poor oral intake while in the unit, she was transferred to the pediatric ward for nutrition replacement during an extended admission of six weeks. She was then referred for case management. Brittany continued to struggle with severe eating disorder symptoms until age 17, when she transferred to a small Christian school to escape bullying and receive additional support. For the next two years, she experienced relative stability with reduced admissions despite ongoing suicidal thoughts. After graduating from school, her suicide attempts rapidly escalated, both in frequency and lethality. Despite extensive intervention from public services, this pattern of risk continued to escalate leading up to referral to our service in late 2019. Assessments of Cognitive Domains A neuropsychological assessment indicated relative strengths in processing verbal information, vocabulary, and short-term memory. Brittany displayed below age abilities in verbal abstract reasoning and speed of information processing; the assessing neuropsychologist reported that “she is overwhelmed by lengthy, detailed verbal information presented only once.” The report also noted “the most striking feature … was her executive difficulties. She demonstrated significant difficulty with planning and organization of information as well as problem solving and flexible thinking.” Additional screening measures were administered to investigate the need for further neuropsychological assessment due to Brittany’s apparent difficulty with concepts in psychotherapy. Montreal Cognitive Assessment (MOCA) The MOCA is a rapid and generalized screening test of multiple cognitive domains. Outcome: – Brittany scored below normative averages at 20 out of a possible 30. A score of 26 or higher on the MOCA is considered within normal range. – Consistent with previous neuropsychological testing, her most significant deficits were found in visuo-spatial and executive functioning. The Awareness of Social Inference Test (TASIT) - Short The TASIT-S comprises short video clips of actors displaying particular emotions and having brief social interactions. The test assesses naming of emotions and understanding of subtext during social interactions that may involve lying or sarcasm. Outcome – Emotion Evaluation – positive emotions 0/5, negative emotions 1/5 – Social Inference – minimal: Sincere 16/16, Sarcasm 6/16 – Social Inference – enriched: Lie 10/16, Sarcasm 7/20 These findings suggested performance below the 2nd percentile in emotion recognition and understanding complexity within social interactions. Brittany’s performance on evaluating emotions was in the extreme low range. Importantly, she displayed normal range performance in understanding sincere social interactions. This raised the concern that this relatively intact function of understanding straightforward social interactions may hide significant underlying deficits in her understanding of more nuanced social interactions. Autism Quotient (AQ), Empathy Quotient (EQ) The AQ is a self-report focusing on the common features of autism. The questions in the EQ assess a person’s own impression of their capacity for empathy. Outcome: AQ—26/50 (cut-off for a diagnosis of autism is a score > 32) EQ—37/80 (cut-off for a clinically significant deficit in empathy is a score < 30) For both measures, Brittany’s responses put her below the thresholds which would suggest autism spectrum disorder (ASD). The AQ and EQ are self-report measures, therefore these results suggested that Brittany lacks insight into the difficulty she has in social understanding as identified in the TASIT. McLean Screening Instrument for BPD (MSI-BPD) The MSI-BPD is a 10-item yes or no questionnaire based on the DSM 5 criteria for BPD. – Brittany self-reported in the affirmative for 10 out of a possible 10 questions. A score of 8 or more is indicative of a diagnosis of BPD. Clinical assessment confirmed that Brittany met criteria for BPD according to DSM 5. Differential Diagnoses Brittany’s diagnosis of ASD was established; she had also previously been diagnosed and treated for generalized anxiety and major depressive disorders. A DSM-5 diagnosis of BPD was confirmed, better explaining features of her presentation including high risk of self-injury, suicidal behaviors, impulsivity, severe emotion dysregulation, intense anger, unstable relationships, and persistently unstable self-image. However, there was concern that differentiating the relative contribution of ASD or BPD to the clinical presentation was difficult and that an emphasis on a BPD formulation may overlook the importance of her neurodevelopmental history in her recovery plan. Clinical Course Following Initial Presentation: Treatment Attempts Brittany commenced a comprehensive dialectical behavioral therapy (DBT) program. Brittany engaged actively, completed all homework, and attempted to use DBT skills, but she reported that skills did not help her in crisis. She struggled with the abstract concepts in DBT and had even greater difficulty implementing the skills when distressed. In the early stages, the overall treatment approach was based on principles for supporting a person with BPD. These principles include a treatment plan that encourages the autonomy and independent decision-making capacity of the person receiving support. Brittany’s relatively strong language function may give the impression that her cognitive function is higher than it truly is when objectively measured. An inaccurate understanding of Brittany’s neurocognitive abilities may lead expectations of her behavior and decision-making that are unrealistic and potentially counter-therapeutic. Treatment plans were subsequently reconsidered to emphasize the primacy of her neurodiversity, with BPD as a secondary consideration. Over time, the focus shifted from psychotherapy as the primary intervention toward an emphasis on providing disability services in response. Brittany continued to receive psychotherapy sessions in order to maximize her reflective capacity, but also required around-the-clock support to help her absorb and apply behavioral and psychological interventions. At the time of writing, she was in the process of transitioning from her parents’ home to disability accommodation with 24-hour support. A guardian was appointed by the Office of the Public Advocate, as it was increasingly apparent that her executive impairment affected her decision-making capacity. Support services included medical, mental health, disability, housing, neuropsychology, and behavioral specialists to comprehensively address Brittany’s multiple areas of need. PARENTS’ PERSPECTIVE As Brittany’s parents, we have always said “If only our daughter had come with an instruction manual” life for all of us might have been much easier. Brittany was a much-wanted baby and we had never been happier in those first five years of her life. At 5 years old, she went to school, and, within a term, she was referred to an occupational therapist for dyspraxia. Soon after, she was diagnosed with Asperger’s syndrome. So began the journey of appointments, social skills classes, reading about ASD, and extra support at school. Brittany found school challenging in many ways. Her teachers were fantastic, knowledgeable and nurturing for the first three years, but Brittany had difficulties with her motor skills, schoolwork, and the complicated world of socializing. As my friend described, “Your daughter never seems comfortable in her own skin.” Brittany was eight years old when we explained that she had Asperger's. We are not sure she understood, but we know she hated being different from the other children. She still considers it a curse. She is quite rigid in her thinking and behavior and is not willing to learn things or do things unless she wants to. Her anxiety levels grew as her resilience to teasing and being excluded was very low. She struggled with her academic work. At the end of year 5 we decided to have her repeat year 5 at a new school where she would get specialist support and smaller classes. 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Clinical The results of Brittany’s neuropsychological assessment suggest that she additional time to process information and may from to Her processing speed may to an to up with DBT at a to her As processing speed is a for the of and information, therapy focus on at a time using with and extra time for skills Brittany is as having to and therefore might have difficulty concepts from abstract verbal information understanding DBT skills as out of DBT skills with language and may As Brittany’s other verbal abilities are as intact verbal and DBT may an may include using DBT behavior to help Brittany sensory and of may include DBT skills that are to Brittany’s sensory For sensory to the may more than those suggested in which for people with ASD may to the or may an restricted or strong of Brittany’s into therapy may the or of therapy using restricted to a with of these that an DBT intervention for ASD disability The importance of the clinically ASD and BPD As of both specialists this problem increasingly as more and more people have and in primary and secondary to more to specialists in both at are to are in both in of and and which is to assessment and For relatively are diagnosed and treated with BPD and those are diagnosed are to receive psychiatric and psychological to are more frequently diagnosed with autism than ASD with social and difficulties, and this may lead to many of diagnosed or an is and the school up that are of ASD or that might the of a diagnosis of but the person has the school diagnosis is the person has not been diagnosed until old both the affected and would to of their as an for the person’s difficulties. 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