Personality disorders vs ASD

[Anonymity1]

From what I have gathered, there are overlaps between autism / aspergers, and personality disorders, particularly in terms of empathy and social skills deficits.

A personality disorder might be diagnosed if a clinician believes one to have a personality which does not fit into society's norm. Both nature and nurture might be responsible for these differences. There are treatments available (CBT, DBT etc) which may help the person learn to get along better with others.

ASD might be diagnosed if one has certain additional traits, or if problems emerged at an earlier age. Nature (not nurture) are thought to be responsible. Management, as opposed to treatment, is the suggested way forward, and education of others.

Please correct me if my understanding is wrong.

Now my question(s) ...

Is there a reason that CBT etc is not offered for ASD? Does it not help?
What about if there were a question mark over the cause of a person's difficulties / differences?
Would a personality disorder be the preferable diagnosis, as it might lead to psychological intervention that might help?
Is there a minimum age that clinicians would consider personality rather than ASD, and would they demand a history of neglect / trauma?

I think personality disorder can be achieved by 4 years of age

Perceived trauma from birth to 3 years

Modified forms of CBT can be used to treat the secondary results of ASD such as anxiety from living in a NT world, or low self worth from bullying etc, it can't be used to treat or make ASD 'go away' because the behaviors around ASD are as a result of it, not behind the condition.

People with personality disorders such as BPD /UPD can be treated using DBT, an adapted form of CBT, because there are maladaptive behaviors behind it driving it, and these can be treated.
Not everyone with a PD has a history of neglect or trauma.

It is possible to have both conditions.

People don't get diagnosed because they have personality's that don't fit society's norms, they get diagnosed because they are visibly struggling with life and they or others are seeking to understand why.

Explaining why you're asking might get you better answers.

Autism is a neurological disorder; a physical, structural issue with the brain itself which results in difficulty processing incoming sensory information: it is not a psychological problem, which is why CBT is not offered for it.

ASD is a lifelong neurological disorder. It can't be cured by CBT or anything else. Many people with autism also suffer with anxiety, low self esteem and depression as a result of being autistic in a neurotypical world. Those impacts of autism can be helped by CBT (although the rigid thinking that is typical of many autistic people may make it difficult for them to engage effectively with talking therapies).

BTW far from an empathy deficit a lot of people with autism experience affective empathy so overwhelmingly it causes them to shut down. Very often it isn't an empathy deficit, it's a social communication deficit being misread.

I am Autistic. I have never been diagnosed with a PD.
Before retirement I worked as part of n autism diagnostic team. We do not diagnose personality disorders.

Elleherd That was so eloquently put. Thank you! I had never heard it explained like that before.

The problem is that trauma can cause behaviours that may look similar to the difficult aspects of ASD - rigid thinking, severe anxiety, meltdowns, low capacity to tolerate stress, inability to cope with change, self harming behaviours as a coping mechanism. Masking also features heavily for both trauma survivors and neurodivergent people, who both often feel they have to “act normal” in front of others, which can often be exhausting, like trying to suppress a tidal wave of feelings that has to come out somehow and at some point. Relationships can be difficult because others don’t always understand the person’s way of relating. Relational trauma can embed ways of relating to others that can be counter productive.

Where it gets even stickier is that most ND people will experience relational trauma by virtue of growing up ND in a neurotypical world. So inevitably, many adults with ASD and conditions such as ADHD also exhibit symptoms of post traumatic stress.

PD is not usually diagnosed under the age of 18 and many clinicians prefer not to diagnose it under the age of 21 or even 25. Those of us who are critical of the whole concept of PD, particularly BPD/EUPD, are also growing in number. But that’s another story!

CBT alone rarely helps either PD or ASD in my view. Relational and trauma informed approaches aren’t as well researched, because CBT is a) cheap and b) easier to measure and c) has received the most backing and publicity via IAPT and its hordes of manual-wielding automatons. The US is far more innovative than we are in this whole area and the NHS is literally in the dark ages still. The social and empathy deficits are less in the patients than in how the system treats them.

I am enquiring from the perspective of a parent of a difficult son, who has struggled socially for years and alienates people through his behaviour (impulsive / rude / silly / inappropriate). He is not introverted, he enjoys social experiences, and wants to be involved, but usually fails.
I never considered him to be without empathy, as he has rescued animals, and feels for story characters / people in the news etc. But I recently read a description of empathy as "seeing from another's point of view in a social context", which he cannot seem to do.
School have referred for neuro assessment, and a psychologist he spoke to suggested ASD, I wondered why not PD.
He is a rigid thinker (I think!) which perhaps is why no rewards, punishments, or conversations have ever seemed to help.
I thought perhaps someone specifically trained in how to "talk to brains" might be able to help get through somehow? He is open to the idea, as he wants to be able to make friends.
But perhaps this is only a possibility if he is deemed to not have ASD.

Pineapplemojito

That's such a helpful post.

Op we went to a homeopath who listened so carefully to everything. She's not solved everything but many things are significantly improved.

@Elleherd

BTW far from an empathy deficit a lot of people with autism experience affective empathy so overwhelmingly it causes them to shut down. Very often it isn't an empathy deficit, it's a social communication deficit being misread.

With DS (ASD), his needs will override empathy. If his brother falls over and hurts himself he can feel empathy. If he's whacked his brother because he percieves that his brother did something to wrong him, his emotions come first. He struggles to manage both at the same time.

He can feel empathy to seemingly random things. He loved Hot Fuzz, until he dissolved into floods of tears when Nick Angel smashed his lily over the trolley boys head. Oh the howls and sobs "he loved that lily!" ("It's OK, he can pot it back up with some fresh compost, it will recover") He felt it like it happened to one of his special possessions. He knew that feeling of hurt.

He's fine with bang, bang, shoot 'em up action. Mild peril is too emotionally overwhelming.

There is lots of empathy and emotion, it just gets felt and expressed differently. He's one person with ASD and not representing all, but it's one way it can present. It's another reason why melting down can happen after a day of masking and releasing all that pent up emotion.

I never considered him to be without empathy, as he has rescued animals, and feels for story characters / people in the news etc. But I recently read a description of empathy as "seeing from another's point of view in a social context", which he cannot seem to do.

This is such a common misunderstanding of empathy and autism. You need to read of the difference between cognitive and affective empathy. I have Asperger’s syndrome - I am extremely and I believe hyper empathetic amd I really struggle seeing anyone suffer. I know losing a loved one is terrible - of course I understand. I may not want to hug you and tell you it will be ok, but I will really, really want to help practically. That’s affective empathy.

Cognitive empathy is the “putting yourself in someone’s shoes”. I don’t have that. So I’m not very good at explaining it but I think for example if someone is worried about having a general anaesthetic then I don’t really se why as statistically there is little risk. (And personally I absolutely love them as it’s the only time my rain actually gives me a moment’s peace”). But I just don’t get why you would be worried, but I’ve learned that it’s not appropriate to say “don’t be so silly you’re very unlikely to die”.

But seeing people suffering amd in pain. I can’t cope. Because it provokes a huge emotional response in me that won’t leave me for days, weeks or even ever.

I really wish more people understood that we are not cold robotic monsters.

@Anonymity1

If your son is still in school he is too young for PD to be under consideration.

Thank you all so much for your replies - sorry I don't know how to put names in.

I assume then, as my son is of secondary school age and has been brought up loved, that his issues would probably be ASD related.

I have met people on the spectrum who come across as nice but a little odd. My son however is seen by many as annoying, weird, selfish, provocative, and worse. He is aware that he needs to change if he wants to make friends (and stop getting into trouble).

So how do you help someone - who wants to be more likeable - if CBT won't be offered, or won't work?

You need someone to practise relationship building and social settings.

There are various Autism groups around the country who can help with learning to develop and maintain social friendship Les.
In the meantime take a look at social stories.

My DD went to a social skills group at school but that was in primary. She has a lovely bunch of friends now.

That all sounds very like ASD to me (as a parent of one with ASD). My understanding is that CBT isn't affective because people with ASD can't just change their behaviour, it's their nature.

I would do a lot of talking about 'how does a good friend behave'. As situations come up talk about what he could do differently next time. I would expect that he finds hanging out and chit chat difficult and get him into groups where he can make friends while doing a structured activity that he is interested in.

Obviously you can't change him, he needs to want to change. And you can't "fix" autism at all - if he is then, like the rest of us, he will always seem strange to others. He might find more of a tribe at university.

Meanwhile though there are loads of self-help guides out there. If he just wants to put on the performance better, I personally found the "how to win friends and influence people" and "how to talk so kids will listen" books to be really helpful about making yourself appear more open and understanding communication.

I would take all pressure off. You say he wants to make friends, does he actually or his he trying to live up to the expectation of 'normal' ?

Your posts he really sound like you are looking for a cure here. Like you want him to have a personality disorder rather than autism so it can be 'fixed'

I'm autistic and in my 40s. It took me many years to realise that even though I have had friends and wanted them, I wasn't very good at the friendships or relationships. My judgement of people is awful. I got it wrong so many times. I have come to terms with the fact that making new connections is something I am terrible at.

Please let your son know that he does not have to make friends if he isn't comfortable doing so. It could be that he does want to, but equally he may just be trying to say and do the right things. Maybe he needs more time. Maybe he doesn't. But please, let him know the choice is all his.

Anonymity1 You put names in by typing them in, and to make them bold you put an asterisk at the beginning and end of the word/name but without the spaces.

My Ds has ASD. One of his bullies was very much ‘annoying, weird, selfish, provocative, and worse.’ Everything I later learned suggested he had learnt to be that way to protect himself from similar rejection my Ds faced at primary school, by being the loud, outgoing, up for it, class clown. (Ds tried it briefly as an opposite of himself strategy.) The one who’d do the impulsive rude thing for attention, ‘liven things up a bit,’ often encouraged by the class. It gave him a little status with some kids and was primarily seen as ‘naughty’ by adults. He was also overweight which added to the social stigma hit in secondary. (There was a lad at Ds primary in exactly the same position including weight. In secondary his behaviors changed as he realized they no longer worked and was able to adapt.)

Yr 7 'loud lad' was doing the same things but now mainly only encouraged by the disruptive kids who actively didn’t want to learn.
He saw Ds was ostracized as ‘weird’, first tried to force him to pair up, responded to disinterest stupidly, then sought to make Ds an even bigger target. Trying to regain earlier popularity, he upped his game over appalling things said to female teachers, did more and more stupid things, and targeted Ds heavily.

Ds got into trouble for accusing him of ‘working really hard to have surface popularity so as not to be the one torn apart and now it’s compulsive and you're finished if I go.’

Ds could see what everyone else saw as disruptive, rude, stupid etc was the only shield saving him and tried to use the threat of his withdrawal as the whipping boy to control his actions.
Lad was eventually diagnosed with ASD and OCD.
Because of how ASD presents stereotypically, including tending towards rule adherence, a child who’s absorbed adhering to 'I am the disruptive clown rules' easily gets missed and mislabeled for years.

I am not suggesting this is your son, more trying to show how that profile can evolve hiding what's behind it.

Maybe things are better now, but IME diagnosis (Ds has a few) doesn’t get quality targeted help, what it does is offers a framework to understand and try and work with.

As Gilead has said, social stories can be useful, but a lot depends on the person and if things are correctly adapted to meet their needs and wants. If I’d tried to do social stories ‘direct’ with my Ds, he’d have point blank refused. By the time I knew he had ASD he had no wish to ‘learn how to be accepted,’ he was done.
I slid ideas in under the guise of animation, puppetry and shadow puppetry, theater, working with animals and talking things through.

If and when your son is diagnosed OP, a counsellor experienced in working with ASD may be able to help with the social and relational side of things. Depending on how old he is, he may benefit from something like AutPlay. That’s normally done as a family based therapy and is designed to help emotional regulation, self and other awareness, carer-child communication, attachment and bonding. It may help both of you to participate in something like this to build mutual understanding and help him develop communication skills.