[Posted on 6 May, 2019 by Christopher Gillberg]
Almost everybody with an autism or ADHD diagnosis delivered before age seven years will eventually meet criteria for a diagnosis of (any) personality disorder by age 18 years. Conversely, most people (perhaps all) with a diagnosis of personality disorder diagnosed at or after age 18, will have had problems that belong in the ESSENCE group of early onset symptoms, long before the “debut” of their chronic personality disorder. Is this because of “comorbidity” (i.e. that another disorder develops or appears in the context of autism or ADHD), a matter of semantics, or the lack of training/understanding on the part of psychiatrists? Well, I for one would put my money on the two latter explanations.
Some time ago, a patient – A, age 25 years now – came into a colleague’s office complaining that she had not made a correct diagnosis when A was younger. A had seen an adult psychiatrist who had told him he suffered from a personality disorder (“perhaps schizoid” is what A had said the psychiatrist had told him). According to A’s medical records he had been diagnosed by my colleague 16 years ago as suffering from Asperger syndrome and ADHD. He had been treated with a stimulant for two years and his academic performance had been excellent for those two years. From the age of 12 years he was taken off the medication (because he himself refused to stay on it). He deteriorated academically over the next several years. He and his family moved to another city, and the contact with my colleague was broken off. He had no further contact with mental health services for 10 years.
At the age of 24 years he had slit his wrists (relatively superficial wounds) on several occasions, and on one of these, his parents had been present, and they had taken him to psychiatry A&E. He had been told he was severely depressed, put on an SSRI and given three follow-up appointment times with a psychiatrist. On the last of these, A had been told that he suffered from personality disorder, and that he would be offered further follow-up by a psychologist for psychotherapy because of this. In addition, he had been told that he was overdependent on his parents (as evidenced by the fact that they were the ones who had brought him to A&E), and that he should try and reduce contact with them. He had then broken all contacts with them.
A now wanted to know how my colleague could have been so mistaken in her assessment of him when he was a young boy.
Was my colleague mistaken? Well, I think not, and, eventually, A did not think so either, and he started meeting up with his parents again. He had been very depressed and he had benefitted greatly from getting good pharmacological treatment for his depression. But the diagnosis of personality disorder had not been good for him. He still fitted the clinical picture of Asperger syndrome (and actually met criteria for autism/autism spectrum disorder), and he still had a number of features typical of ADHD. He also met criteria for schizoid personality disorder. However, this diagnosis – on top of the other two (autism/Asperger syndrome and ADHD) – was of no use to him. It was still his childhood Asperger syndrome “masquerading” as personality disorder.
There are many similar cases in adult psychiatry. I believe that the vast majority of cases labelled personality disorder have an ESSENCE-type problem and that the “personality disorder” is not something that suddenly arises in adult age. There have been ESSENCE-symptoms from before five years of age in almost all cases, and these may or may not have been diagnosed as autism, ADHD, Tourette syndrome, DCD or language disorder/learning disorder.
There is not yet sufficient scientific evidence to conclude that all individuals with a diagnosis of personality disorder “really” have ESSENCE, but there is sufficient clinical experience and scientific evidence to make the point that nobody should accept a personality disorder diagnosis without the issue of underlying ESSENCE at least having been discussed. For people with autism, the diagnosis of personality disorder may put them on the path to poor outcomes.