The co-occurrence of autistic traits and borderline personality disorder traits is associated to increased suicidal ideation in nonclinical young adults

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

Autistic and Catatonic Spectrum Symptoms in Patients with Borderline Personality Disorder

BACKGROUND

Recent literature has shown that a considerable percentage of patients with severe mental disorders can develop, over time, full-blown or subthreshold catatonia. Some studies corroborate the model of an illness trajectory in which different mental disorders would be arranged along a continuum of severity until the development of catatonia. In such an illness pathway, autistic traits (AT) and borderline personality disorder (BPD) may represent important steps. In order to further explore the association between AT, BPD, and catatonia, the aim of this study was to compare catatonic spectrum symptoms and AT among patients with major depressive disorder (MDD), BPD, and healthy controls (CTL), also evaluating possible predictive dimensions of the different diagnoses.

METHODS

A total of 90 adults affected by BPD, 90 adults with a diagnosis of MDD, and 90 CTL, homogeneous in terms of gender and age, were recruited from six Italian university departments of psychiatry and assessed with the SCID-5-RV, the Catatonia Spectrum (CS), and the Adult Autism Subthreshold Autism Spectrum (AdAS Spectrum).

RESULTS

The total CS score was significantly higher in the BPD and MDD groups than in the CTL group, while the majority of CS domain scores were significantly higher in the BPD group than in the MDD group, which scored significantly higher than the CTL group. The total AdAS Spectrum score and the AdAS Spectrum domain scores were significantly higher in the BPD group than in the MDD group, which in turn scored significantly higher than the CTL group. The CS domains "psychomotor activity" and "impulsivity", and AdAS Spectrum domains "verbal communication", "empathy", and "hyper-/hyporeactivity to sensory input" were associated with the risk of presenting a diagnosis of BPD.

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

Despite the relationship between Autism spectrum disorder (ASD) and personality disorders (PD) still being scarcely understood, recent investigations increased awareness about significant overlaps between some PD and autism spectrum conditions. In this framework, several studies suggested the presence of similarities between BPD and ASD symptoms and traits, based on the recent literature that increasingly reported increased comorbidity rates and significant symptomatologic overlaps between the two conditions. The aim of this review is to describe the available studies about the prevalence of the association between different forms of autism spectrum (full-fledged clinical conditions as well as subthreshold autistic traits) and BPD. Despite some controversial results and lack of homogeneity in the methods used for the diagnostic assessment, the reviewed literature highlighted how subjects with BPD reported higher scores on tests evaluating the presence of AT compared to a non-clinical population and hypothesized the presence of unrecognized ASD in some BPD patients or vice versa, while also describing a shared vulnerability towards traumatic events, and a greater risk of suicidality in BPD subjects with high autistic traits. However, the specific measure and nature of this association remain to be explored in more depth.

A systematic review of predictors of suicidal thoughts and behaviors among autistic adults: Making the case for the role of social connection as a protective factor

Autistic adults are a high-risk population for suicidal thoughts and behaviors (STBs). Accordingly, this systematic review aims to review the prevalence of STBs among autistic adults, review the risk and protective factors for STBs in autistic adults, and formulate a disorder-specific conceptualization of risk in this population. We systematically searched PsycINFO and Google Scholar for all studies published prior to March 28th, 2022. We included empirical articles focused on autistic adults, ages 18 years and older, reporting on suicide-related outcomes. In total, 45 peer-reviewed empirical articles were included in the current systematic review. The most frequently studied factors in relation to suicide risk among autistic adults were interpersonal constructs (42.4% of total studies looking at risk/protective factors) and depressive symptoms (36.4% of total studies looking at risk/protective factors). We conclude by summarize two key content areas: exploring social and interpersonal constructs and better understanding the role of depressive symptoms in autism. As researchers continue to explore STBs among autistic adults, it will be necessary to addressing the overreliance on autistic symptoms instead of autism diagnoses, measurement issues of STBs, and a need for treatment adaptations.

Media coverage of Belgium's first criminal case concerning euthanasia for psychiatric patients: A content analysis of Flemish newspapers and magazines

BACKGROUND

Belgium is one of the few countries worldwide where euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder is legally possible. In April 2010 euthanasia was carried out on a 38-year-old Belgian woman with borderline personality disorder and/or autism. After a complaint by the family, three physicians were referred to the Court of Assizes on the charge of "murder by poisoning".

METHODS

A content analysis of print and online news coverage of the euthanasia case in a selected sample of Flemish newspapers and magazines, published between December 1, 2019 and March 1, 2020, was conducted to analyze the prominence and framing of the euthanasia case, as well as the portrayal of key figures in this case. A quantitative analysis, as well as an in-depth qualitative analysis (with the aid of NVivo 1.0 software) was performed.

RESULTS

One thousand two hundred fifteen news articles were identified through database searching. Of these, 789 articles were included after screening for relevance and eligibility. Mean prominence scores were moderate and did not statistically significantly differ between newspapers with a different historical ideological background or form (elite versus popular). The most frequent headline topics featured legal aspects (relating to the Belgian Euthanasia Law or the course of the trial). Headlines and content of most articles (90 and 89%, respectively) did not contain an essential standpoint on the euthanasia case itself or, if they did, were neutral. Historical ideological background, nor form of newspaper (elite versus popular) significantly influenced headline tone or article direction toward the euthanasia case. Despite this, our qualitative analysis showed some subtle differences in selection, statement or tonality of reports between certain newspapers with a different historical ideological background.

CONCLUSION

Although major Flemish newspapers and magazines generally were neutral in their coverage of the judicial case, major points of contention discussed were: the need for an evaluation and possible amendments to the existing Euthanasia Law, including a revision of the Belgian Control Commission and the system of penalties for physicians, and the absence of any consensus or guidance on how to define psychological suffering.

Overlap of autism spectrum disorder and borderline personality disorder: A systematic review and meta-analysis

Autism spectrum disorder (ASD) and borderline personality Disorder (BPD) share features, including social and emotion regulation difficulties. The evidence for the overlap in prevalence and clinical characteristics was systematically reviewed. Ovid Medline, PsycInfo, and PubMed were searched until November 30, 2020 using keywords relating to BPD and ASD. Studies that reported on the overlap of ASD and BPD diagnoses or traits and used a case, cohort, or case-controlled design were included. Of 1633 screened studies, 19 were included, of which 12 reported data suitable for meta-analysis. Most samples were of small, clinically ascertained groups, with 11 having high risk of bias. The pooled prevalence of BPD in ASD was 4% [95% CI 0%-9%] and of ASD in BPD, 3% [95% CI 1%-8%]. There were inconsistent findings across clinical areas. The prevalence of a dual diagnosis of BPD in ASD cohorts and of ASD in BPD cohorts was within population prevalence estimates of each disorder. Based on this data we were not able to assess whether there is misdiagnosis of one in favor of the other. Neurocognitive differences may underlie similar behavioral symptoms, but further research using larger, well-validated samples is needed. LAY SUMMARY: Autism spectrum disorder (ASD) and borderline personality disorder (BPD) have overlaps in their symptoms. The overlap in how frequently they co-occur and their presentation was systematically reviewed. We searched the key databases and including all studies that reported on the overlap of ASD and BPD diagnoses or traits and used a case, cohort or case-controlled design. Of 1633 studies, 19 were included, of which 12 reported data suitable for pooling. Most samples were of small, clinical groups, with 11 having high risk of bias. The pooled prevalence of BPD in ASD was 4% [95% CI 0%-9%] and of ASD in BPD, 3% [95% CI 1%-8%]. There were inconsistent findings across studies comparing ASD and BPD related symptoms and problems. The prevalence of a dual diagnosis of BPD in ASD cohorts and of ASD in BPD cohorts was similar to the population prevalence of each disorder. Further research using larger, well-validated samples is needed.

Investigating the Relationship between Autistic Traits, Ruminative Thinking, and Suicidality in a Clinical Sample of Subjects with Bipolar Disorder and Borderline Personality Disorder

(1) Background: Previous literature reported in both subjects with Borderline personality disorder (BPD) and Bipolar disorder (BD) higher levels of autistic traits, linked to a greater suicidality risk. The aim of this study was to evaluate and compare the presence of autistic traits in a sample of individuals with BD or BPD, with a specific focus on suicidality. (2) Methods: We recruited two clinical samples of subjects (BPD and BD) and a control group without a diagnosis according to DSM-5 (CTL). Subjects were assessed with the AdAS Spectrum, the RRS and, for evaluating suicidality, the MOODS-SR. (3) Results: The CTL group showed significantly lower scores of both BD and BPD on AdAS Spectrum, RRS, and suicidality scores. BPD subjects showed significantly lower scores than BD ones in most of AdAS Spectrum domain scores. Correlation and regression analyses highlighted specific patterns of association among AdAS Spectrum domains, RRS, and suicidality in each clinical group. (4) Conclusions: Both BPD and BD individuals show greater levels of autistic traits, which seem to be distributed in a continuum featuring the highest levels among BD subjects. In both disorders, higher autistic traits were linked to suicidal tendencies, although with different patterns of association between BD and BPD subjects.

Is There a Major Role for Undetected Autism Spectrum Disorder with Childhood Trauma in a Patient with a Diagnosis of Bipolar Disorder, Self-Injuring, and Multiple Comorbidities?

This case report highlights the relevance of the consequences of trauma in a female patient with an undetected autism spectrum disorder (ASD) affected by bipolar disorder (BD) with multiple comorbidities. A 35-year-old woman with BD type II, binge eating disorder and panic disorder was admitted in the Inpatient Unit of the Psychiatric Clinic of the University of Pisa because of a recrudescence of depressive symptomatology, associated with increase of anxiety, noticeable ruminations, significant alteration in neurovegetative pattern, and serious suicide ideation. During the hospitalization, a diagnosis of ASD emerged besides a history of childhood trauma and affective dysregulation, marked impulsivity, feeling of emptiness, and self-harm behavior. The patient was assessed by the Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale (RAADS-R), the Adult Autism Subthreshold Spectrum (AdAS Spectrum), Trauma and Loss Spectrum (TALS-SR), and Ruminative Response Scale (RRS). Total scores of 38/50 in the AQ, 146/240 in the RAADS-R, 99/160 in the AdAS Spectrum emerged, compatible with ASD, 47/116 in the TALS-SR, and 64/88 in the RRS. We discuss the implications of the trauma she underwent during her childhood, in the sense that caused a complex posttraumatic disorder, a lifelong disease favored and boosted by the rumination tendency of high functioning ASD.