Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art

Available Treatments for Autism Spectrum Disorder: From Old Strategies to New Options

Autism spectrum disorder (ASD) is a condition that is gaining increasing interest in research and clinical fields. Due to the improvement of screening programs and diagnostic procedures, an increasing number of cases are reaching clinical attention. Despite this, the available pharmacological options for treating ASD-related symptoms are still very limited, and while a wide number of studies are focused on children or adolescents, there is a need to increase research about the treatment of ASD in adult subjects. Given this framework, this work aims to review the available literature about pharmacological treatments for ASD, from older strategies to possible new therapeutic targets for this condition, which are often poorly responsive to available resources. The literature, besides confirming the efficacy of the approved drugs for ASD, shows a lack of adequate research for several psychopharmacological treatments despite possible promising results that need to be further investigated.

Autistic traits are associated with the presence of post-traumatic stress symptoms and suicidality among subjects with autism spectrum conditions and Anorexia nervosa

INTRODUCTION

Recently, growing attention has been paid to the presence of undetected Autism Spectrum Disorder (ASD) and subthreshold autistic traits (ATs) among females, and on their gender specific manifestation. In particular, the recent literature focused on the overlap between autism spectrum and eating disorders, which share with ASD not only features such as of cognitive inflexibility but also a link with trauma- and stress-related disorders. In this framework, we aimed to assess the interaction between ATs, stress- or trauma-related symptoms, and the risk of suicidality in subjects with different mental conditions.

METHODS

184 subjects were divided in three diagnostic groups: Broad autism phenotype (BAP), Anorexia Nervosa (AN) and Healthy Controls (HCs) and assessed with the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire, the Trauma and Loss Spectrum - Self Report (TALS - SR) questionnaire and the Mood Spectrum - Self Report (MOODS - SR) questionnaire.

RESULTS

AN subjects reported notable ATs reinforcing the hypothesis that AN might represent an atypical ASD manifestation more common in women. Furthermore, both AN and BAP subjects showed a considerable presence of trauma/stress associated symptoms. The dimension of trauma/stress related symptoms also appeared to be associated with ATs, and to significantly mediate the relationship between ATs and suicidality risk. Lastly, AN were found to have a stronger correlation with the presence of post-traumatic stress symptoms.

CONCLUSIONS

the results support the presence of a link between ATs and AN. Moreover, AN seems to be more strongly associated with post-traumatic stress symptoms than BAP. ATs and trauma/stress related symptoms may interact in shaping suicidality risk in these patients.

Personality Disorders and Clinical Disorders: The Challenge of Comorbid Autism Spectrum Disorder (ASD), Eating Disorders (EDs), Posttraumatic Stress Disorder (PTSD), or Somatic Symptom Disorder (SSD)

PURPOSE OF THE REVIEW

The purpose of this review is to report on prevalence of co-occurrence, possible etiologic mechanisms, and course and treatment implications of each of these challenging clinical disorders (Autism Spectrum Disorder, Eating Disorders, Posttraumatic Stress Disorder) comorbid with Personality Disorders.

RECENT FINDINGS

These comorbidities often increase the symptom severity, worsen the course and outcome, and increase the risk of self-harm and suicidal behavior. For EDs and PTSD, existing therapies may prove somewhat helpful but novel approaches are needed and under investigation in the context of comorbid PDs and ASD, EDs and PTSD to address common underlying diatheses. Treatments for these comorbid disorders need to incorporate interventions addressing suicide risk, emotion dysregulation, be trauma-informed and attend to patient engagement. Future research should prioritize studying the course and outcome of ASD comorbid with PDs, novel therapies for EDs comorbid with PDs; refining the concept of Complex PTSD and commencing study of SSD comorbid with PDs.

Altered Rhythmicity, Depressive Ruminative Thinking and Suicidal Ideation as Possible Correlates of an Unrecognized Autism Spectrum in Patients with Borderline Personality Disorder

BACKGROUND/OBJECTIVES

Recent research has explored the presence of subthreshold autistic traits (ATs) in individuals with borderline personality disorder (BPD), suggesting that these traits may contribute to the severity of BPD symptoms and increase the risk of other mental health issues, including suicidal behaviors. This study aims to investigate the relationship between ATs and affective symptoms, such as mood instability and suicidality, in people diagnosed with BPD.

METHODS

A total of 48 subjects with BPD were assessed with self-report questionnaires including the Adult Autism Subthreshold Spectrum (AdAS Spectrum), the mood spectrum self-report version (MOODS-SR) and the ruminative response scale (RRS).

RESULTS

Subjects with significant ATs scored higher than BPD subjects in all domains and in the total score of AdAS Spectrum, RRS, and MOODS-SR, as well as in the items investigating suicidality. RRS total score, its depression domain, and the MOODS-SR rhythmicity domain, as well as suicidality, were predictors of the presence of ATs.

CONCLUSIONS

Our data confirm the relationship between the presence of clinically significant ATs and affective symptoms, ruminative thinking, and suicidality in patients with BPD.

A computational signature of self-other mergence in Borderline Personality Disorder

A tendency to merge mental representations of self and other is thought to underpin the intense and unstable relationships that feature in Borderline Personality Disorder (BPD). However, clinical theories of BPD do not specify, in computational terms, how the perspectives of self and other might become confused. To address this question, we used a probabilistic false belief task (p-FBT) to examine how individuals with BPD (N = 38) and matched controls from the general population (N = 74) selectively assigned beliefs to self or other. The p-FBT requires participants to track a gradually changing quantity, whilst also predicting another person's belief about that quantity. We found that BPD participants showed less selectivity in belief assignment compared with controls (Cohen's d = 0.64). Behaviourally, participants with BPD tended to predict that others' beliefs resembled their own. Modelling analysis revealed that BPD participants were prone to generalise their own learning signals to others. Furthermore, this generalising tendency correlated with BPD symptomatology across participants, even when controlling for demographic factors and affective psychopathology. Our results support a computational account of self-other mergence, based on a generalisation of learning across agents. Self-other generalisation in learning purports to explain key clinical features of BPD, and suggests a potential transdiagnostic marker of mentalising capability.

Autistic traits as predictors of post-traumatic stress symptoms among patients with borderline personality disorder

Background

Autistic traits (AT) seem to be particularly frequent among patients with borderline personality disorder (BPD). Moreover, the autism spectrum is considered a vulnerability factor for the development of post-traumatic stress disorder (PTSD) symptoms, increasing the vulnerability of BPD subjects toward the development of a stress-related disorder.

Aim

The study aimed to investigate the association between AT and trauma-related symptoms in a clinical sample of patients with BPD.

Methods

A total of 48 patients with a clinical diagnosis of BPD and 52 healthy control (HC) subjects were recruited and assessed with the Adult Autism Subthreshold Spectrum Self-Report (AdAS Spectrum) questionnaire and the Trauma and Loss Spectrum-Self-Report questionnaire (TALS-SR). The BPD group was divided into two subgroups: BPD with a symptomatological diagnosis of PTSD (pBPD = 25) and BPD not diagnosed with PTSD (No-pBPD = 23).

Results

The clinical sample scored significantly higher in almost all AdAS domains. Moreover, pBPD groups reported higher AdAS and TALS-SR scores in the total and in various domains than the No-pBPD group, which scored higher in several domains than HC. AdAS Restricted interests and rumination domain scores were positive predictors of BPD presence independently from PTSD, while Inflexibility and adherence to routine domain was a negative predictor. Finally, AdAS Hyper/hyporeactivity to sensory stimuli domain was a positive predictor only for inclusion in the pBPD group.

Conclusion

Our study confirmed the existence of a statistically significant relationship between the autism spectrum and BPD, while BPD subjects diagnosed with PTSD seem to show a higher autism spectrum burden.

Borderline personality trait is associated with neural differentiation of self-other processing: A functional near-infrared spectroscopy study

BACKGROUND

Individuals with borderline personality traits are known to have disturbed representations of self and others. Specifically, an unstable self-identity and difficulties distinguishing between self and others can impair their mentalizing abilities in interpersonal situations. However, it is unclear whether these traits are linked to differences in neural representation of self and others.

METHODS

In this study involving 156 young adults, changes in neural function during self-other processing were measured using a Functional Near-Infrared Spectroscopy (fNIRS) task and a self-report survey. During the fNIRS task, participants were asked about their own traits, others' traits, how they believed others perceived them, and the basic meaning of words. The study aimed to determine whether the degree of neural differentiation between the task conditions was related to borderline personality traits.

RESULT

The study found that traits indicative of identity instability could be predicted by similarities in task-dependent connectivity. Specifically, the neural patterns when individuals estimated how others perceived them were more similar to the patterns when they judged their own traits.

CONCLUSIONS

These findings suggest that borderline personality traits related to identity issues may reflect difficulties in distinguishing between neural patterns when processing self and other information.

Assessing Autistic Traits, Hikikomori Tendencies, Pathological Videogaming, and Eating Disorders in University Students: Are Pathological Videogaming and Eating Disorders Gender-Specific Manifestations of the Autism Spectrum?

In the previous literature, specific attention has been paid to investigate autism spectrum symptoms and traits in university students. In this framework, we aimed to evaluate the presence and correlates of autistic traits, hikikomori tendencies, altered eating behaviors, and pathological videogaming in a sample of Italian university students enrolled in bachelor's degree courses. A total of 1192 students were recruited via an online survey and assessed with the Hikikomori Questionnaire-25, the Adult Autism Subthreshold Spectrum Questionnaire, the Eating Attitude test-26, and the Assessment of Internet and Computer Game Addiction. Our results highlighted significant differences in the prevalence of autistic traits, social withdrawal tendencies, altered eating habits, and pathological videogame use in university students based on gender, age, parents' level of instruction, and field of study. A significant effect of the presence of autistic traits and gender on the scores obtained with the other questionnaires was reported. Our results not only support the role of autistic traits as a vulnerability factor for the development of a set of psychopathological conditions but also suggest that gender could modulate this vulnerability, supporting the hypothesis of gender-specific phenotypes in the autism spectrum.

May Female Autism Spectrum Be Masked by Eating Disorders, Borderline Personality Disorder, or Complex PTSD Symptoms? A Case Series

Introduction: The prevalence of Autism Spectrum Disorder (ASD) is four times higher in males than females; however, females are significantly more likely to go undiagnosed due to the existence of a "female autistic phenotype", a manifestation unique to females that conflicts with conventional, masculine conceptualizations of ASD. Furthermore, subthreshold autistic traits, which exert a significantly negative impact on quality of life and represent a vulnerability factor for the development of other psychopathological conditions, may remain even more under-recognized. Subsequently, many women with ASD may never receive a diagnosis or any resulting care, with serious consequences for their health. Aims: We aimed to describe two brief cases in order to confirm the diagnostic difficulties that ASD female undergo during their clinical evaluation and the possible alternative phenotype that they can manifest. Methods: We reported the cases of two young women on the autism spectrum that came to clinical attention only after the development of severe symptomatology attributed to other mental disorders, overlooking the presence of underlying autism spectrum features and a brief résumé of the literature on this topic. Results: These cases confirm the need for a timely and proper identification of females on the autism spectrum in order to prevent complications and improve the outcome. Conclusions: Research on gender differences could lead to a reexamination of the sex ratio in the prevalence of ASD and provide a better understanding of several psychiatric conditions that are frequently diagnosed in women, supporting the neurodevelopmental approach to psychopathology.

The Illness Trajectory in Marilyn Monroe's Psychological Autopsy: From Autism Spectrum Disorder to Borderline Personality Disorder and Bipolar Disorder with Catatonia

OBJECTIVE

A mounting body of literature is showing that, in the clinical and general population, autism spectrum disorder (ASD) or autistic traits (ATs) would appear to be spread along a continuum, reaching the highest levels among individuals affected by other mental disorders, such as borderline personality disorder (BPD) and bipolar disorder (BD). Furthermore, individuals with ASD or ATs appear to be more vulnerable to psychological traumas, with greater likelihood of developing post-traumatic stress disorder (PTSD) and BD. Marilyn Monroe was a famous actress, singer and model, as well as one of the most admired stars of American cinema and a timeless icon. The present report debates the possibility to explore Marilyn Monroe's case under a neurodevelopmental perspective according to which a ASD favored, on one hand, her worldwide success and, on the other, her mental illness trajectory.

METHOD

The analysis is based on the review of her four biographies written by psychiatrists and clinical psychologists, her complete filmography, interviews, filmed material and personal scripts.

RESULTS

The present work reconstructed a hypothetical illness trajectory originating from a ASD and culminating in a BD with unspecified catatonia, followed by premature death whose cause has never been clarified. The description of this illness trajectory also confirms the strong impact of psychological traumas on the substrate of ASD vulnerability and its correlation with the development of BPD and BD.

CONCLUSIONS

This paper suggests Marilyn Monroe as a possible prototypical case of BPD under a neurodevelopmental perspective that accounts the ASD, as reported in DSM-5-TR (2022), in verbal adult without intellectual impairment, high-functioning autism (HFA), as vulnerability background predisposing to the progression to BPD and BD with unspecified catatonia, triggered by multiple traumas.