hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults

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Eur Arch Psychiatry Clin Neurosci (2006) 256 [Suppl 1]:I/42–I/46

DOI 10.1007/s00406-006-1006-2

Alexandra Philipsen

Differential diagnosis and comorbidity of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults Received:  / Accepted:  / Published online: 

■ Abstract Attention-deficit/hyperactivity disorder (ADHD) in adults and borderline personality Disorder (BPD) share some similar clinical features (e. g. impulsivity, emotional dysregulation, cognitive impairment). ADHD in childhood has been reported to be highly associated with the diagnosis of BPD in adulthood and adult ADHD often co-occurs with BPD. Treatment studies revealed an efficacy of dialectical behavioral therapy (DBT) and DBT-based psychotherapy, respectively, in BPD and adult ADHD as well as neuroimaging and psychopharmacological studies showed some evidence for a potential common neurobiological dysfunction suggesting the hypothesis that ADHD and BPD may not be two distinct disorders, but represent at least in a subgroup of patients two dimensions of one disorder. ■ Key words attention-deficit hyperactivity disorder · borderline personality disorder · comorbidity · emotional dysregulation · impulsivity

ADHD in adults, which beyond childhood history of ADHD and persisting inattention and hyperactivity include affective lability (extreme mood swings), hot temper, inability to complete tasks and disorganization, stress intolerance and impulsivity.According to DSM-IV ADHD should only be diagnosed if the disorder is not better accounted for by another mental disorder, e. g. personality disorder. However, personality disorders (especially Cluster B) often co-occur with adult ADHD [4, 12, 45] and, particulary, ADHD and borderline personality disorder (BPD) are known as frequent comorbid disorders [4, 12, 45]. In addition,ADHD in childhood has been reported to be highly associated with the diagnosis of BPD in adulthood [14] indicating that ADHD in childhood may be a serious risk factor for BPD. In clinical practice, we have seen many patients fulfilling both diagnostic criteria for adult ADHD and BPD.

Clinical features Introduction

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In childhood and adolescence, attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder characterized by a persistent pattern of impaired inattention, impulsive behavior and hyperactivity, which often persists into adulthood [12]. The DSM-IV and ICD-10 criteria for ADHD were developed for children (American Psychiatric Association 1994, World Health Organization 1992). At present there are no specific DSM-IV or ICD-10 criteria for adults with ADHD, while Wender developed the Utah criteria [43] to assess A. Philipsen, M.D. Department of Psychiatry and Psychotherapy University of Freiburg Medical School Hauptstr. 5 79104 Freiburg, Germany Tel.: +49-761/270-6931 Fax: +49-761/270-6526 E-Mail: [email protected]

From a phenomenological point of view there are some similarities between ADHD and BPD, first of all deficits in affect regulation and impulse control [9, 17] (see Table 1). However, substance abuse, low self esteem and disturbed interpersonal relationships are also common in both disorders. In ADHD the attention deficit is most pronounced in situations which lack external stimulation. In contrast, BPD patients experience dissociative features when they Table 1 Similar clinical features of adults with ADHD and BPD       

Attention deficits Deficits in affect regulation Deficits in impulse control Substance abuse Disturbed interpersonal relationship Low self esteem States of aversive inner tension

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feel emotionally stressed. With respect to neurophysiology, dissociation could be regarded as a special form of an attention deficit [7]. In BPD, dissociative features are strongly correlated with aversive inner tension [39]. A recently published study revealed that among BPD patients these states of aversive inner tension are mostly provoked by feelings of rejection, failure, and being alone [40], whereas persons with ADHD often report aversive inner tension in situations with decreased external stimulation. Unfortunately, in this study BPD patients were not tested for ADHD, and “being alone”could be also considered as a state of low stimulation. Methods of affect and tension regulation, however, differ seriously in BPD and ADHD. Patients with ADHD, the majority being male, tend to regulate their inner tension and affective lability by extreme sports, novelty seeking, sexual activities as well as aggressive behaviour [17, 39]. In contrast, BPD patients, the majority being female and frequently afflicted by posttraumatic stress disorder (PTSD), often slide in dissociative states and/or end up with self-injurious behaviour to terminate these states of tension. In BPD, higher novelty seeking, particularly in males, has also been reported [2, 13]. These findings, however, are limited by the fact that patients included in these studies were not tested for ADHD in childhood nor in adulthood. As previously mentioned, at present there are no specific DSM-IV or ICD-10 criteria for adults with ADHD. Beside the fact that diagnostic criteria required for the diagnosis of personality disorder are also fulfilled by ADHD (for DSM-IV see Table 2 [10]), the DSM-IV criteria for BPD broadly overlap with ADHD symptoms and the Utah criteria for ADHD (see Table s3 and 4 [25]). The “emotionally unstable personality” of ICD-10 (F60.3), which is divided into an impulsive (F60.30) and a borderline subtype (F 60.31), also shares common criteria with typical ADHD symptoms. The “emotionally unstable personality” is described as a personality “in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability . . . and outbursts of intense anger may often lead to violence or behavioural explosions . . .” In both subtypes the general theme of impulsiveness and lack of self-control is warranted, which are Table 2 DSM-IV criteria for personality disorders also fulfilled by ADHD Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can be traced back to adolescence or at least early adulthood. The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person’s life. Symptoms are seen in at least two of the following areas:  Thoughts (ways of looking at the world, thinking about self or others, and interacting)  Emotions (appropriateness, intensity, and range of emotional functioning)  Interpersonal functioning (relationships and interpersonal skills)  Impulse control

Table 3 DSM-IV criteria for BPD overlapping with ADHD symptoms in adults and the Utah Criteria for adults with ADHD DSM-IV criteria for BPD: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. frantic efforts to avoid real or imagined abandonment 2. a pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation 3. identity disturbance: markedly and persistently unstable self-image or sense of self 4. impulsivity in at least two areas that are potentially self-damaging (e. g., spending, sex, substance abuse, reckless driving, binge eating) 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability due to a marked reactivity of mood (e. g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e. g., frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociative symptoms

Table 4 Utah criteria for ADHD in adults overlapping with BPD symptoms (Wender 1995) I. Childhood history consistent with ADHD is required, dating back to at least age seven. II. Adult symptoms: 1. Hyperactivity and poor concentration should be present in adulthood 2. In addition two of the following symptoms are required.:  Affective lability  Hot temper  Inability to complete tasks and disorganization  Stress intolerance  Impulsivity

also core symptoms of ADHD. The borderline subtype is additonally characterized by unclear or disturbed selfimage, aims, and internal preferences (including sexual) and chronic feelings of emptiness as well as by a liability to become involved in intense and unstable relationships which cause repeated emotional crises (potentially associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm). Disturbed “self-image, unclear aims and internal preferences” can also be found in ADHD, evoked by negative experiences and affected interpersonal relationships, e. g. at school, work and home resulting in criticism and rejection. However, chronic suicidality and parasuicidal behavior mostly is not part of ADHD and despite chaotic relationships in both disorders most clinicians agree, that the interpersonal functioning of patients with BPD and ADHD differs significantly, with fewer difficulties in establishing a therapeutic relationship in ADHD. Up to now, however, there are no studies investigating these differences of interpersonal functioning in BPD and adult ADHD systematically.

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I/44 Fig. 1 Treatment modules based on dialectical behavioral therapy adapted for ADHD symptomatology

Poor Poorconcentration, concentration, distractability distractability

Stress Stress intolerance, intolerance, disorganization disorganization

“Mindfulness” “Mindfulness”

“Distress tolerance” “Distress tolerance”

Hot temper, Hot temper, affective affective lability lability

Disturbed andchaotic chaotic Disturbed and interpersonal relationships interpersonal relationships

“Emotion modulation” “Emotion modulation”

“Interpersonal effectiveness” “Interpersonal effectiveness”

Psychotherapy

Neurochemical mechanisms

Taking into account these overlapping clinical features and diagnostic criteria of adult ADHD and BPD, a structured skills training program for patients with adult ADHD was tailored. The program is based on the principles of dialectical-behavioral treatment (DBT) for BPD developed by M. Linehan [23, 27] and was modified to suit the special needs of adult patients with ADHD (see Fig. 1) [17, 19]. It was developed for a group setting with 13 sessions on a weekly basis and includes the following elements: mindfulness, chaos and control, behavior analysis, emotion regulation, depression, medication in ADHD, impulse control, stress management, substance abuse, ADHD in relationship and self respect. In an open study design this treatment resulted in positive outcomes and patients significantly improved on all psychometric scales [17]. The significant results of a current multicenter study are also encouraging and reveal clinical benefits (Philipsen et al., submitted). Meanwhile other cognitive behavioral approaches in adult ADHD have also been reported. Stevenson et al. [38] presented a cognitive remediation group program in eight weekly sessions with significant clinical benefits. Recently, Safren et al. [31] reported significantly better outcome measures in ADHD patients who received cognitive-behavioral psychotherapy (CBT) and psychopharmacological treatment compared to psychopharmacology alone. Accordingly, psychotherapeutic treatment (CBT- or DBT-based therapy) appears to be a useful component of treatment for adults with ADHD. Larger randomized studies are warranted to investigate the effects of psychotherapy in adult ADHD compared to psychopharmacological treatment and the combination of both.

In ADHD a dopaminergic dysfunction is known as the crucial neurochemical mechanism of the attention deficit [5]. However, there is also some evidence for a dopaminergic dysfunction in BPD [15]. In the late 1980s, Schulz et al. [34] used amphetamines as a psychopharmacological probe to investigate the earlier hypothesis that BPD patients are prone to psychosis following ingestion of a dopamine agonist. In this early study, patients with the diagnosis of both schizotypal and BPD worsened transiently. Patients with only the borderline diagnosis improved. Thus, one could speculate that these BPD patients who improved had comorbid ADHD or were undiagnosed adult ADHD patients. ADHD and BPD are both characterized by impulsive behavior. The serotonergic [24] and noradrenergic [8] systems are involved in impulsivity and aggression. Treatment with serotonin reuptake inhibitors (SSRI) reduces impulsivity in BPD [24, 30, 47] and recently, findings of a potential serotonergic dysfunction in ADHD were reported [29]. Moreover, there is also evidence for a noradrenergic dysfunction in ADHD and BPD. Treatment with clonidine, an α2-adrenergic receptor agonist, is effective in reducing hyperactivity and impulsivity in children and adolescents with ADHD [1, 20, 44] as well as in decreasing acute aversive inner tension and urge to commit self-injurious behavior in BPD patients [28].

Neuroimaging In ADHD, the most replicated alterations include significantly smaller volumes in the dorsolateral prefrontal cortex, caudate, pallidum, corpus callosum, and cerebellum (for review see [35]). Findings of functional neuroimaging studies also suggest that fronto-striatal abnormalities contribute to ADHD pathology [6]. However, several neuroimaging studies in adults with ADHD and BPD also revealed similar findings. A dys-

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function in the prefrontal cortex as a core region for attentional mechanisms was reported in ADHD and BPD [11, 16, 22, 32, 33, 36, 37, 42], as well as in the orbitofrontal cortex as a core region for impulsivity and emotional instability [18, 32, 37, 42]. Furthermore, functional neuroimaging studies in children with ADHD found reduced orbitofrontal activity, which was normalized after methylphenidate treatment [26]. These findings were supported by neuropsychological results in children with ADHD [21]. In BPD, there are also some hints deriving from functional neuroimaging studies [32, 37] and clinical neuropsychology [3] for an orbitofrontal hypometabolism or an altered orbitofrontal activation [42].Volumetric magnet resonance studies, e. g., showed patterns of volume loss left orbitofrontal in BPD [41]. With regard to frequent traumatization in BPD, the diagnosis of comorbid PTSD is often considered in BPD. In contrast, the diagnosis of ADHD is not taken into account despite a potentially large impact on neuroimaging findings in BPD.

Conclusion Considering the common clinical features in adult ADHD and BPD, and the findings of ADHD as a serious risk factor for adult BPD as well as the overlapping findings of neuroimaging studies, one could hypothesize that ADHD and BPD are not two distinct disorders, but represent two dimensions of the same disorder. However, it is not just a difference of severity of symptoms between ADHD and BPD. BPD patients are characterized by additional symptoms of suicidal behavior and self-injurious behavior. Moreover, the interpersonal functioning and social interaction differ quite severely. In BPD, several studies reported associations between BPD and sexual abuse or attachment disturbances in childhood as serious risk factors for adult BPD [46]. Thus, the development of borderline typical symptomatology in ADHD might depend on additional developmental antecedents. The majority of BPD patients are females. As a consequence of negative experiences in childhood (e. g. sexual abuse, violence, chronic invalidation of emotions), which could lead to low self-esteem and disturbed “body experience” stimulation and/or tension regulation e. g. by sports or sexual behavior, could be limited and effective interpersonal interaction could be disturbed. Consequently, further research should investigate developmental antecedents as predictors for borderline typical symptomatology in ADHD and the diagnosis of ADHD should be taken into account in further psychotherapeutic and neurobiological research in BPD as a severe covariate.Finally,the development of further diagnostic criteria considering overlapping symptoms and findings as well as further psychopharmacological and psychotherapeutic treatment studies in ADHD and BPD are warranted.

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