Autism is a neurodivergence that manifests as difficulty interpreting neurotypical social cues and rules, strong adherence to routines and rituals, and sensory sensitivity, and it occurs as a result of neurodevelopmental differences.
An autistic person might cope with difficulties associated with their neurodivergence, but they do not “grow out” of being autistic.
This article covers why autism may be misdiagnosed and what those misdiagnoses might be. If you have concerns about a diagnosis you have been given, talk to your provider. They can answer your questions about your diagnosis, and they can give referral information for a second opinion if you need one. This article is not intended to diagnose or treat any condition.
Why Autism Can Be Misdiagnosed
Psychological assessment for autism includes behavioral observations provided by parents and teachers, as well as testing and behavioral observations completed by the evaluator.
Bias, misunderstanding of neurodivergence, and masking can cause evaluators to misdiagnose autistic individuals. In addition, much of the existing research on diagnosing autism focuses on presentation seen in white boys, and so other races1 and genders2 sometimes get missed.
Autistic adults who were not diagnosed in childhood can struggle to find a provider who can assess them since many tests for autism are designed for children. In addition, many autistic individuals have an additional mental health diagnosis. As such, they are sometimes misdiagnosed.
Anxiety Disorders
Many autistic individuals also meet the criteria for an anxiety disorder.3 However, prior to being identified as autistic, many are told that they have anxiety rather than autism.
A strong need for routine, difficulty with abrupt or unanticipated transition, and sensory meltdowns can look like an anxiety disorder. In addition, if an autistic person has experienced backlash due to difficulty interpreting social cues, they might become highly anxious in social settings.
If someone has been diagnosed with social anxiety disorder and notices that their anxiety stems from unpredictable conversations or difficulty picking up body language and voice tone, the anxiety might be secondary to autism.
Similarly, if someone is diagnosed with generalized anxiety disorder and finds that their “anxious” behaviors do not accompany nervous behaviors, it is possible that they have been misdiagnosed.
Attention-Deficit/Hyperactivity Disorder
Approximately half of autistic individuals also have ADHD,4 so it is very common for someone to meet the criteria for both diagnoses. If someone has been diagnosed with ADHD but feels like the diagnosis does not fully describe all of their symptoms, they might benefit from an additional assessment that can test for autism.
There is overlap between the diagnostic criteria for these two disorders, with both autistic people and those with ADHD displaying issues with attention, communication, and routines.4 The differences in presentation are detailed below:
- Have difficulty focusing on non-preferred activities but hyper-focus on activities of interest.
- Might struggle to pick up on social cues (unless these interactions are a special interest). May struggle with word finding and verbal communication.
- May craft specific routines that might be difficult for others to follow, and they might experience anxiety or distress if the routine changes.
- Individuals may hyper-focus, but prefer tasks that do not require sustained focus.
- May have difficulty with “filtering” what thoughts they want to share. They might interrupt frequently or impulsively enter conversations.
- Thrive with a consistent routine but may struggle to follow a routine due to disorganization.
Borderline Personality Disorder
Borderline personality disorder (BPD) is a condition marked by mood instability, impulsive behavior, and difficulty with interpersonal relationships.
As with the other diagnoses discussed in this article, it is possible for an autistic person to also have a personality disorder. However, sometimes neurodivergence is misdiagnosed as a personality disorder, and this is especially common for women.5
The following symptoms are sometimes attributed to BPD rather than autism:
- Emotion regulation: People with BPD exhibit significant mood swings and difficulty regulating their emotions appropriately. Sometimes, sensory meltdowns due to autism are labeled as dysregulation.
- Impulsivity: Both autistic people and those with BPD might engage in impulsive behavior, including spending large amounts of money or engaging in substance use.
- Relationship Conflict: Because autistic people’s social and communication skills are different from neurotypical people, they may experience conflict in relationships, especially if they do not know they are autistic.
Obsessive Compulsive Disorder
Obsessive-compulsive disorder (OCD) manifests as intrusive thoughts or images that are distressing and that are difficult to get rid of or ignore, as well as compulsive behaviors that are done repeatedly to reduce anxiety caused by the thoughts. Individuals with OCD can experience obsessions, compulsions, or both.
Some autistic individuals also have OCD. However, sometimes stimming behavior is mislabeled as compulsions, as repetitive language or movement can look like compulsive behavior.
In addition, rituals and routines can look compulsive. If the routines do not develop in an effort to reduce anxiety, they are not compulsions.
Post-Traumatic Stress Disorder
Existing as some who is neurodivergent in a world created for neurotypical people is incredibly stressful, especially for those who are undiagnosed.
Masking, or trying to behave in a neurotypical way when this does not come naturally, causes a lot of stress.6 In addition, autistic individuals are at higher risk for bullying, abuse, and exploitation than neurotypicals.
Because of this, a high percentage of autistic people have a history of trauma.7 There is an overlap between autistic presentation and trauma symptoms, which may be due in part to the high number of autistic people who also have a trauma history.
This can lead to autistic people being diagnosed with post-traumatic stress disorder and their behaviors might be attributed to trauma rather than to neurodivergent traits.
Psychotic Disorders
In the 1940s, autism was considered a type of schizophrenia that began in childhood and manifested as difficulty staying in touch with reality.8
As with the other diagnoses described in this article, autism and psychotic disorders have symptom overlap, including difficulty communicating effectively and social detachment or withdrawal.
In addition, psychosis is often identified using personality tests that ask specific questions about perception and reality.
Autistic people sometimes read questions on these tests in a more literal manner than intended by the test creators, which can elevate scales measuring for psychosis.
For example, a question asking whether you hear things that others do not hear is intended to screen for hallucinations, but an autistic reader might endorse this because they heard someone speaking when other people were not listening.