Differential Diagnosis of ICD-11 Personality Disorder and Autism Spectrum Disorder in Adolescents
Open accessAbstract
The International Classification of Diseases 11th Revision (ICD-11) introduces fundamentally new diagnostic descriptions for personality disorder and autism spectrum disorder. Instead of the traditional categorical taxonomies, both personality disorder and autism spectrum disorder are described as being on a continuum. Accumulating research has pointed out that, in some cases, adolescents with autism spectrum disorder are at risk of being confused with having a personality disorder, which particularly applies to female adolescents. Case reports describe how adult autistic women struggled with social and identity roles as children and adolescents, using compensatory strategies such as social imitation and other types of camouflaging. Furthermore, some adolescents with autism display emotion dysregulation and self-injury. The ICD-11 recognizes that features of autism spectrum disorder may resemble features of personality disorder, but the two diagnoses have not yet been formally compared to one another. The present article therefore sought to outline and discuss the overlap and boundaries between the ICD-11 definitions of personality disorder and autism spectrum disorder and propose guiding principles that may assist practitioners in differential diagnosis with female adolescents. We specifically highlight how aspects of the self and interpersonal functioning along with emotional, cognitive, and behavioral manifestations may overlap across the two diagnoses. Restricted, repetitive, and inflexible patterns of behavior, interests, and activities are core features of autism spectrum disorder, which may be masked or less pronounced in female adolescents. Collecting a developmental history of the early presence or absence of autistic features is vital for a conclusive diagnosis, including features that are typically camouflaged in females. A number of future directions for research and clinical practice are proposed.
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Brezis, R. S. (2015) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2015.00076 · Cited by 34 · cited 1× · see citing works
“For instance, mentalizing and autobiographical memories are central to the development of narrative identity [44], and autistic adolescents experience problems with mentalizing and recalling autobiographical memories [48].”
BackgroundA pilot study of dialectical behaviour therapy skills training for autistic adults
Ritschel, L., Guy, L., & Maddox, B. (2021) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465821000370 · Cited by 33 · see citing works
Ben‐Itzchak, E., Koller, J., & Zachor, D. A. (2020) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-020-00673-0 · Cited by 32 · see citing works
Gillett, G., Leeves, L., Patel, A., Prisecaru, A., Spain, D., & Happe, F. G. E. (2022) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674221114603 · Cited by 32 · cited 1× · see citing works
“Individuals with such PD features are inflexible and lack spontaneity, stubbornly insisting on following set schedules and adhering to plans, which is quite similar to ASD [3,4].”
Case Report: Mechanisms in Misdiagnosis of Autism as Borderline Personality Disorder
Iversen, S., & Kildahl, A. N. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.735205 · Cited by 32 · see citing works
Vuijk, R., & Arntz, A. R. (2017) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2017.01.001 · Cited by 31 · see citing works
Hamdani, Y., Kassee, C., Walker, M., Lunsky, Y., Gladstone, B., Sawyer, A. R., Ameis, S., Desarkar, P., Szatmari, P., & Lai, M.-C. (2023) · Women's Health · doi:10.1177/17455057231163761 · Cited by 29 · cited 1× · see citing works
“Thus, it seems important for clinicians not to get tunnel vision on symptoms of PD that may conceal underlying ASD in order to avoid yet another “lost generation” while also considering the risk of expanding the autism spectrum, resulting in potential overdiagnosis [31,32].”
BackgroundHutsebaut, J., Weekers, L. C., Tuin, N., Apeldoorn, J. S. P., & Bulten, E. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.617702 · Cited by 28 · cited 1× · see citing works
“1 [88], may be used to yield most of the information needed for diagnosing PD according to ICD-11.”
BackgroundGadelkarim, W., Shahper, S., Reid, J. E., Wikramanayake, M., Kaur, S., Kolli, S., Osman, S., & Fineberg, N. A. (2019) · International Journal of Psychiatry in Clinical Practice · doi:10.1080/13651501.2019.1638939 · Cited by 28 · cited 1× · see citing works
“Individuals with such PD features are inflexible and lack spontaneity, stubbornly insisting on following set schedules and adhering to plans, which is quite similar to ASD [3,4].”
Cheney, L. B., Dudas, R. B., Traynor, J. M., Beatson, J. A., Rao, S., & Choi-Kain, L. W. (2023) · Harvard Review of Psychiatry · doi:10.1097/hrp.0000000000000361 · Cited by 28 · cited 1× · see citing works
“The question about the co-occurrence of PD and ASD also seems to be an emerging clinical challenge complicated by the introduction of a multi-axial system in DSM-III, in which the two diagnoses were allowed to co-occur [2,8,18].”
BackgroundZimmermann, R., Steppan, M., Zimmermann, J., Oeltjen, L., Birkhölzer, M., Schmeck, K., & Goth, K. (2022) · PLoS ONE · doi:10.1371/journal.pone.0269327 · Cited by 26 · see citing works
Emotional regulation deficits in autism spectrum disorder: The role of alexithymia and interoception
Hassen, N. B., Molins, F., Petisco, D. G., & Serrano, M. Á. (2022) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2022.104378 · Cited by 26 · see citing works
Mentalization-Based Treatment in Groups for Adults With Autism Spectrum Disorder
Krämer, K., Vetter, A., Schultz-Venrath, U., Vogeley, K., & Reul, S. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.708557 · Cited by 25 · see citing works
Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family
Guerrera, S., Pontillo, M., Tata, M. C., Vincenzo, C. D., Bellantoni, D., Napoli, E., Valeri, G., & Vicari, S. (2022) · Brain Sciences · doi:10.3390/brainsci12121597 · Cited by 25 · see citing works
A case study of suicidality presenting as a restricted interest in autism Spectrum disorder
Weiner, L., Flin, A., Causin, J.-B., Weibel, S., & Bertschy, G. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2122-7 · Cited by 19 · cited 1× · see citing works
“Notably, a case study has illustrated how suicidality may also present as a restricted interest in ASD, which would not apply to PD [74].”
BackgroundAutism and self‐harm: A population‐based and discordant sibling study of young individuals
Stark, I., Rai, D., Lundberg, M., Culpin, I., Nordström, S. I., Ohlis, A., & Magnusson, C. (2022) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.13479 · Cited by 19 · cited 1× · see citing works
“The significance of self-harm is consistent with a large-scale Swedish study (N = 410,732) that found ASD to have a fivefold increased relative risk of self-harm [72].”
ResultICD-11 Personality Disorder: The Indispensable Turn to Narrative Identity
Lind, M. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.642696 · Cited by 18 · cited 2× · see citing works
“For instance, mentalizing and autobiographical memories are central to the development of narrative identity [44], and autistic adolescents experience problems with mentalizing and recalling autobiographical memories [48].”
BackgroundEngendering misunderstanding: autism and borderline personality disorder
Watts, J. (2023) · International journal of psychiatry in clinical practice · doi:10.1080/13651501.2023.2187843 · Cited by 17 · see citing works
Epidemiology of personality disorders in individuals with gender dysphoria
Furlong, Y., & Janča, A. (2021) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000757 · Cited by 13 · cited 1× · see citing works
“In relation to gender-related identity, the ICD-11 also recognizes research showing that ASD is overrepresented among children and adolescents with gender incongruence [40], which also applies to individuals with PD [41].”
BackgroundOshima, F., Murata, T., Ohtani, T., Seto, M., & Shimizu, E. (2021) · BMC Research Notes · doi:10.1186/s13104-021-05556-1 · Cited by 13 · see citing works
Rasmussen, P. D. (2022) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2022.2112973 · Cited by 12 · see citing works
Sweetmore, V. (2021) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12762 · Cited by 10 · see citing works
Hedges, S. (2021) · Practical canine behaviour: for veterinary nurses and technicians · doi:10.1079/9781789246810.0008 · Cited by 9
Related Personality Disorders Located within an Elaborated Externalizing Psychopathology Spectrum
Sellbom, M., Bach, B., & Huxley, E. (2017) · doi:10.1002/9781119092254.ch7 · Cited by 8 · cited 1× · see citing works
“This pattern is consistent with research showing that disruptive behavior disorders, impulse control disorders, and attention-deficit hyperactivity disorders are common in ASD [50] as well as in PD [69,70].”
ResultSelf-citationAutism, Borderline Personality Disorder, and Empathy
Smith, A., & Hobson, R. P. (2013) · Emotion Review · doi:10.1177/1754073912469685 · Cited by 7 · see citing works
Alexander, L., & Farrelly, N. (2019) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2019.3 · Cited by 6 · see citing works
[A mentalization-based perspective on childhood autism treatment].
Thevenet, M., Dondé, C., Machabert, R., Ancona, L., Jost, C., & Georgieff, N. (2017) · L'Encephale · doi:10.1016/j.encep.2017.10.008 · Cited by 4 · see citing works
Fossati, A. (2011) · Personality and Mental Health · doi:10.1002/pmh.164 · Cited by 4 · see citing works
Autism diagnosis in adulthood tied to increased burden of psychiatric conditions
Choi, C. Q. (2022) · Spectrum · doi:10.53053/gcoy5940 · Cited by 2 · see citing works
Flagged first, then by citations
5 of the 107 references couldn’t be matched to a known paper.
Research works printed but not linked: 2
- [11]Amaral D.G. Examining the Causes of Autism Cerebrum 2017 2017 cer-01-17 PMC5501015 28698772
- [92]Bach B. Brown T.A. Sellbom M. Personality Disorder Severity ICD-11 (PDS-ICD-11) Clinician-Rating Form 1.1 2023 Available online: https://www.psykiatrienregsj.dk/om-psykiatrien/psychiatric-research-unit/centers/center-for-personality-disorder-research/pds-icd-11-scales (accessed on 1 January 2023) 37941508
Cited by
Sorted by citations
Mental health challenges faced by autistic people
Lai, M. (2023) · Nature Human Behaviour · doi:10.1038/s41562-023-01718-2 · Cited by 80 · see citing works
“…behaviour labelled as oppositional or ‘disruptive’, autistic language features labelled as psychotic, and/or emotion dysregulation labelled as manic), and offers critical reflections on whether certain diagnoses are applicable or helpful (for example, personality disorders) 267,268 .”
BackgroundMorejón, C. E. Q., Calderón, A. S. R., Dávila, L. E. L., & Caraballo, G. D. L. C. M. (2025) · Arandu-UTIC · doi:10.69639/arandu.v12i2.1055 · Cited by 69
Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach.
Graf‐Kurtulus, S., & Gelo, O. C. G. (2025) · Counselling and Psychotherapy Research · doi:10.1002/capr.12874 · Cited by 34 · see citing works
Sarr, R., Spain, D., Quinton, A. M. G., Happé, F., Brewin, C., Radcliffe, J., Jowett, S., Miles, S., González, R. A., Albert, I., et al. (2024) · British Journal of Psychology · doi:10.1111/bjop.12731 · Cited by 28 · see citing works
“However, literature has suggested that features can manifest in childhood, although they are not typically diagnosed until adulthood (Bach & Vestergaard, 2023).”
BackgroundBach, B., Simonsen, E., Kongerslev, M., Bo, S., Hastrup, L., Simonsen, S., & Sellbom, M. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115484 · Cited by 26 · see citing works
“Third, in some cases a PDS-ICD-11 score may potentially be attributed to other pervasive and persistent conditions characterized by self-and interpersonal issues such as Autism Spectrum Disorder (Bach and Vestergaard, 2023) and Complex PTSD (Felding et al., 2021), which usually overrule a PD diagnosis.”
BackgroundSelf-citationKritika, K., Williams, R. M., & Ringland, K. E. (2025) · Proceedings of the 2025 CHI Conference on Human Factors in Computing Systems · doi:10.1145/3706598.3714094 · Cited by 13 · see citing works
“Similarly, at the doctor’s offices, people may mask to receive unbiased healthcare, since patients from marginalized identities are frequently diagnosed late [25, 83, 146], often misdiag-nosed [7, 32], and neglected within medical systems [90].”
Ćirović, M., Jeličić, L., Maksimović, S., Fatić, S., Marisavljević, M., Matić, T. B., & Subotić, M. (2023) · Diagnostics · doi:10.3390/diagnostics13182878 · Cited by 10 · see citing works
“More specifically, ASD identification is determined by two factors that must be evident in the area of various possible manifestations that may differ depending on gender and chronological age: (a) continuing difficulties in establishing and retaining social communication and reciprocal social relationships that excee…”
BackgroundPowell, T., Parker, J., Kitson, H., & Rogalewski, M. (2024) · Autism in Adulthood · doi:10.1089/aut.2023.0031 · Cited by 10 · see citing works
Schema therapy in adults with autism spectrum disorder: A scoping review
Vuijk, R., Turner, W. A., Zimmerman, D., Walker, H., & Dandachi‐FitzGerald, B. (2024) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2949 · Cited by 17 · see citing works
Allman, M. E., Kerr, S., Roldan, C. I., Harris, G. M., & Harris, G. E. (2024) · Advances in Autism · doi:10.1108/aia-02-2024-0013 · Cited by 4 · see citing works
Convergence between the dimensional PD models of ICD-11 and DSM-5: a meta-analytic approach
Hualparuca-Olivera, L., Caycho-Rodríguez, T., Torales, J., & Ramos-Campos, D. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1325583 · Cited by 4 · see citing works
“In the ICD-11, the first diagnostic step is the severity of intra-and interpersonal functioning, similar to that of the other model; however, guidelines for manifestations (cognitive, emotional and behavioral) and deterioration (personal and social) are added (6).”
MethodTenev, A., Markovska-Simoska, S., Müller, A., & Mishkovski, I. (2025) · Brain Sciences · doi:10.3390/brainsci15090951 · Cited by 2 · see citing works
Dimitrov, P., Petrova, A., Bell, V., & Fernandes, T. (2026) · Nutrients · doi:10.3390/nu18020248 · Cited by 1
Compensación social e identidad en los adolescentes con trastorno del espectro autista
Ageitos, A. M. G., Alba, J. V., Pérez, V. Á., Hijano, C. M. G., & Millares, M. V. (2024) · Revista de Psiquiatría Infanto-Juvenil · doi:10.31766/revpsij.v41n4a5 · Cited by 1 · see citing works
Exploring Effectiveness of an Emerging Taxonomy of Diagnostic Method for Autism Spectrum Disorder
Spoorthi, M., & Rai, B. K. (2026) · SN Computer Science · doi:10.1007/s42979-026-05379-6
Distefano, G., Berloffa, S., Sesso, G., Valente, E., Narzisi, A., Sorella, G., DˈAmbrosio, C., Masi, G., & Milone, A. (2026) · Autism · doi:10.1177/13623613261476742
“…the egosyn-tonic characteristics and common traits such as rigidity, per-fectionism, and low social functioning, complicates the differential diagnosis, highlighting the need for a specific assessment to distinguish between these two conditions (Bach & Vestergaard, 2023; Lai & Baron-Cohen, 2015).”
Differentiation between Autism Spectrum Disorder and Personality Disorders: a systematic review.
Laguna, G. G. D. C., Andrade, B. F., Paulo, V. S., Aguiar, M. G. L., Rodrigues, I. B., da Cruz, J. D., & de Azevedo, K. R. M. (2026) · Psychology, Health & Medicine · doi:10.1080/13548506.2026.2691413
Diagnoza różnicowa zaburzeń ze spektrum autyzmu i zaburzeń osobowości
Danielewicz, D. (2025) · Man – Disability – Society · doi:10.71358/cns.2785
Wichstrøm, L., Grønli, H., Walstad, J. S., Raballo, A., Kvarstein, E. H., & Steinsbekk, S. (2025) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-025-02936-x · Cited by 1 · see citing works
Lee, C., Man, L. L. Y., Morra, A., Pace-Tonna, C., Castelino, C., Courchesne, V., Frayne, M., Luk, V., Baharikhoob, P., Jachyra, P., et al. (2025) · Autism Research · doi:10.1002/aur.70148
“Autism and BPD may coexist and/or be diagnosed in the same individual (Bach and Vestergaard 2023; Bemmouna et al. 2023; Dell'Osso et al. 2023; Lai and Baron-Cohen 2015; May et al. 2021).”
Barr, E., & White, A. (2025) · Advances in Autism · doi:10.1108/aia-08-2025-0085
Alexithymic and autistic traits differentially predict personality disorder dimensions
Albantakis, L., Weindel, L., Brandi, M., Zillekens, I. C., Henco, L., Thaler, H., Schliephake, L., & Schilbach, L. (2025) · Autism · doi:10.1177/13623613251338650
“Previous attempts to better understand the co-occurrence of traditional PD categories and autism (without co-occurring intellectual impairment) have identified a mixed pattern of overlapping symptoms in PD and autism, which warrants further research (Bach & Vestergaard, 2023; Rinaldi et al., 2021).”
Abakumow, M., Przybylski, M., Słoma, M., Markowska, O., Sowa, K., Jaśkiewicz, P., & Kowalczuk, K. (2024) · Journal of Personalized Medicine · doi:10.3390/jpm14091010
“The ICD-10 classification was introduced in 1992 (WHO— World Health Organization , 1992); its newer version from 2022 is known as the WHO classification ICD-11 and it reflects the current understanding of the disorder [6].”
Method
- Authors
- Bach, B., & Vestergaard, M.
- Affiliations
- University of Southern Denmark (DK)
- Region Zealand (DK)
- Corresponding author
- Bach, Bo
- Venue
- Children
- Publisher
- MDPI AG
- Published
- 2023-06-01
- Volume
- 10
- Issue
- 6
- Pages
- 992
- ISSN
- 2227-9067 (ISSN-L)
- PMC
- PMC10297099
- OpenAlex
- W4379053802
- Cited by
- 27
- References
- 107
- Citations by year
- 2026: 3 · 2025: 11 · 2024: 9 · 2023: 4
- FWCI
- 7.87
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Children (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (publishedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, cc-by)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
- Keywords
- ICD-11, personality disorders, autism spectrum disorder, differential diagnosis, adolescent girls, camouflaging, restricted and repetitive behaviors, emotional dysregulation, self-harm, diagnostic overlap, developmental history
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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