Borderline Personality Disorder & Its Connection to ADHD (with Roberto Olivardia, Ph.D.)

Borderline Personality Disorder and its Connection to ADHD

In this webinar, Dr. Roberto Olivardia discusses the connection between borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD). He explains how they share overlapping symptoms, which can lead to misdiagnosis and ineffective treatment plans.

Introduction

• Dr. Olivardia is a clinical psychologist and clinical instructor of psychology at Harvard Medical School.

• BPD and ADHD share overlapping symptoms, including emotional dysregulation.

• Up to 40% of people with BPD may also have ADHD.

Symptoms of BPD

• Emotional dysregulation is a key symptom of BPD.

• Other symptoms include impulsivity, unstable relationships, fear of abandonment, identity disturbance, chronic feelings of emptiness, anger management issues, dissociation or paranoia under stress.

Distinguishing BPD from ADHD

• It's important to distinguish between the two disorders because they require different treatments.

• People with ADHD struggle with executive functioning issues such as organization and time management while those with BPD struggle more with interpersonal relationships.

• People with BPD are more likely to engage in self-harm behaviors than those with ADHD.

Comorbidity Statistics

• Studies show that up to 40% of people with BPD may also have ADHD.

• The comorbidity rate is higher in women than men.

Risk Factors for Comorbidity

• Childhood trauma is a risk factor for both disorders.

• Genetics may also play a role in the development of both disorders.

Treatment Recommendations

• Treatment for comorbid BPD and ADHD should address both disorders separately but concurrently.

• Medication can be helpful for both disorders, but therapy is essential for BPD.

• Dialectical behavior therapy (DBT) is a recommended treatment for comorbid BPD and ADHD.

Conclusion

• ADHD rarely travels alone, and it's important to recognize the comorbidity of other disorders such as BPD.

• Misdiagnosis can lead to ineffective treatment plans, so it's crucial to distinguish between the two disorders.

• Treatment should address both disorders separately but concurrently.

Comorbid ADHD and Borderline Personality Disorder

In this section, the speaker discusses the challenges of diagnosing and treating comorbid ADHD and borderline personality disorder (BPD). They explain the symptoms of BPD and how they can be misdiagnosed as ADHD-related behaviors.

Symptoms of Borderline Personality Disorder

• BPD is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects.

• People with BPD may exhibit frantic efforts to avoid real or imagined abandonment, leading to desperate behaviors to hold onto relationships while struggling to connect in those relationships.

• The name "borderline" refers to being at the border between psychosis and reality. People with BPD may experience thinking that isn't always reality-based, making it difficult for them to maintain healthy relationships.

• Other symptoms include identity disturbance, impulsivity in potentially harmful areas (e.g., spending, sex), recurrent suicidal behavior or threats, affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria), chronic feelings of emptiness, inappropriate anger or difficulty controlling anger.

Misdiagnosis Between ADHD and BPD

• Clinicians often don't receive adequate training in both ADHD and personality disorders when treating comorbid conditions. This can lead to misdiagnosis between ADHD-related behaviors and symptoms of BPD.

• While people with both ADHD and BPD may exhibit efforts to avoid being alone or abandoned, those with ADHD may do so because they struggle with boredom rather than fear of rejection. Relationships provide stimulation for people with ADHD who have difficulty entertaining themselves.

• When patients exhibit behaviors related to both conditions, clinicians must determine whether the behavior is more ADHD-activated or BPD-activated.

Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD)

In this section, the speaker discusses how people with BPD and ADHD experience idealization and devaluation in their relationships differently.

Idealization and Devaluation in Relationships

• People with BPD have a pattern of unstable and intense interpersonal relationships marked by extremes of idealizing or devaluing relationships.

• Initially, people with BPD could idealize their partner until they perceive them as awful, leading to a dichotomous view of other people.

• People with BPD struggle to find where they fit in terms of relating and connecting to others because nobody is all good or bad.

• People with ADHD might idealize a dating relationship initially due to the honeymoon phase but may devalue it if the person is not engaging enough.

Sense of Self

• People with BPD don't feel like themselves when alone; their sense of self is in conjunction with other people.

• There's a dysregulation of relating and connecting to people for those with BPD because nobody is all good or bad. Trusting oneself and others can be difficult.

• For someone with BPD, affiliating themselves with someone who they idealize means that person becomes an extension of them. If they recognize flaws or imperfections, that person becomes an extension of something bad.

Identity Disturbance

• People with BPD have an unstable self-image or sense of self, which can sound bizarre to those without personality disorders.

• People with ADHD might have a very strong sense of self and realize that an individual might not be engaging enough, leading to devaluation.

ADHD and BPD: Understanding the Differences and Overlaps

In this section, the speaker discusses the development of treatment for ADHD and how it can be misdiagnosed as identity issues. They also explore how people with ADHD can have a solid sense of self, but sometimes struggle to form their identity due to executive functioning delays. The speaker then compares this to people with Borderline Personality Disorder (BPD), who may have an unstable sense of self.

Developing Identity with ADHD

• People with ADHD can have a solid sense of self defined through an ADHD lens.

• Executive functioning delays may make it harder for individuals with ADHD to form their identity, but they are still searching for their niche.

• Finding the right support is crucial for individuals with ADHD to fully realize their identity.

Understanding BPD

• People with BPD may not have a stable sense of self and may be malleable based on where they think they will get the most love or validation.

• Impulsivity in at least two areas is common in both BPD and ADHD, such as spending, sex, substance abuse, reckless driving, and binge eating issues.

• Recurrent suicidal behaviors are more common in people with BPD than those without it; however, people with ADHD also carry a higher suicide risk when compared to those without it.

Mechanisms Behind Suicidal Behaviors

• For people with BPD, suicidal behaviors often stem from wanting to die or feeling like they don't fit into the world around them.

• For people with ADHD, suicidal behaviors may be a method of grounding oneself and regulating emotions.

Suicidal Ideation and Self-Harm in ADHD and BPD

In this section, the speaker discusses suicidal ideation and self-harm behaviors in individuals with ADHD and Borderline Personality Disorder (BPD). They explain that while both groups may engage in self-harm, the reasons behind it differ.

Suicidal Ideation and Self-Harm in ADHD

• Individuals with ADHD may experience suicidal ideation due to feeling overwhelmed by executive demands or feeling lost in their adult life.

• Self-harm behaviors in individuals with ADHD are often for sensation-seeking or to relieve tension. The pain caused by self-harm can release dopamine, which is stimulating for the ADHD brain.

• Emotional dysregulation is common in individuals with ADHD, but it is more context-specific than episodic like it is in BPD. External triggers can cause emotional dysregulation.

Suicidal Ideation and Self-Harm in BPD

• Individuals with BPD may engage in self-harm as a form of self-punishment or to relieve numbness associated with trauma.

• Cutting oneself can produce pain and blood, which provides validation that one exists. This behavior is not typically seen in individuals with pure ADHD.

• Anger issues are common among individuals with BPD, marked by significant levels of anger or rage. This anger can be triggered by situations where they feel slighted or perceive being slighted.

Overlap between ADHD and BPD

• Both groups may experience chronic feelings of emptiness, but it is modulated by the level of stimulation for those with ADHD.

• Inappropriate and intense anger is also common in individuals with ADHD, but it is usually in response to something external.

Understanding the Differences Between ADHD and BPD

In this section, the speaker discusses the differences between ADHD and BPD in terms of emotional regulation, activation of the amygdala, and other brain functions.

Emotional Regulation

• Studies show that ADHD brains activate similarly to non-ADHD brains in response to emotions.

• The difference lies in emotional regulation, specifically in the interior cingulate cortex's connection to the amygdala. People with ADHD have a delay in this connection, which can cause emotional outbursts.

• Bipolar disorder is associated with hyperactivation of the amygdala, while BPD is more stress-related and can lead to paranoia or dissociation.

Brain Functions

• Dopaminergic deficits are implicated in ADHD brains, while dopaminergic dysfunction is present in BPD brains.

• Oxytocin dysregulation is also present in BPD brains, leading to poor social bonds.

• Both disorders share impulsivity and attentional deficits.

Intersection of ADHD and BPD

• Studies are starting to look at how these two disorders intersect.

• 1.4% of adults currently have been diagnosed with BPD.

Comorbidity of ADHD and BPD

This section discusses the comorbidity of ADHD and BPD, including the significant association between the two disorders.

Association between ADHD and BPD

• Studies show that a significant number of people with BPD also have ADHD.

• There is a significant association of ADHD to later develop BPD, particularly in women.

• Children with ADHD are at greater risk of later developing BPD than what would be expected by chance.

Comorbid Disorders

• The presence of ADHD can have a compounding and exacerbating effect on whatever present BPD symptoms there are.

• People with BPD were found to be at higher risk for mood disorders than people with ADHD and BPD.

• The combined group had a higher likelihood of lifetime aggression, oppositional and disruptive disorders, anti-social personality disorder, obsessive-compulsive personality disorder, and odd diagnosis.

Treatment Implications

• Most people with ADHD do not have borderline personality disorder but there is a higher risk factor.

ADHD and BPD: Understanding the Link

In this section, the speaker discusses the link between ADHD and BPD, including comorbidity rates and shared traits.

Comorbidity Rates

• About 20% of people with ADHD also have a bipolar spectrum disorder.

• People with ADHD are at increased risk for trauma histories, which is also a contributing factor to what we see in individuals with BPD.

• Having a trauma history can make it very difficult to form identity through the timeline that we're supposed to.

Shared Traits

• Dysregulated metabolism of energy particularly in the frontal lobe serotonergic or serotonin and other neurotransmitters that also tend to be impaired sometimes in ADHD brains as well as BPD brains.

• Impulsivity and emotional dysregulation are traits associated with both ADHD and BPD.

• Poor peer relationships, difficulty tolerating negative affect, being bullied, low self-esteem are some of the symptoms associated with both conditions.

• Genetic influences play a role in both conditions. Emotional and environmental impact of emotionally disregulated parents can also contribute.

Negative Feedback Loop

• For those people who have poor reading of social cues who have ADHD there could be this negative feedback loop of really negative social experiences that can make it hard for people with ADHD to kind of practice being in longer-term relationships.

• With BPD parents they can neglect a child who then doesn't develop that normal identity as well as other defenses because you know with emotional dysregulation you're not kind of tolerating some of the nuances of things you don't have the safety too so you have to split like is this person good are they bad.

Treatment

• Both conditions need to be treated because ADHD is always present.

BPD Treatment and ADHD

In this section, the speaker discusses how treating ADHD can benefit BPD treatment. They also discuss different types of therapy and medication that can be used to treat BPD.

Treating ADHD in Conjunction with BPD

• Treating ADHD alongside BPD treatment can lead to better outcomes.

• DBT is an effective treatment for both BPD and ADHD, but it requires a certain level of executive function.

• Other therapies that may be helpful include CBT, psychotherapy, couples therapy, and executive functioning coaching.

• The therapeutic relationship is important in treating BPD.

Medications and Crisis Planning

• There are no specific medications approved for BPD, but SSRIs, mood stabilizers, and antipsychotics may be used to control mood regulation or self-harm behavior.

• Developing a crisis plan is important for managing symptoms.

DBT as a Treatment Option

• DBT has been shown to increase functioning in both ADHD and BPD patients.

• DBT can help individuals learn assertiveness skills and reduce self-judgment around their symptoms.

Understanding Symptoms

• It's important to understand the biological and environmental factors that contribute to symptoms of both ADHD and BPD.

• Books such as "BPD Survival Guide" by Alexander Chapman & Kim Gratz or "I Hate You, Don't Leave Me" by Jerold Kreisman & Hal Straus can be helpful in understanding symptoms.

BPD and Adolescence

• Symptoms of BPD can be seen in adolescence, but it's important to rule out other conditions such as ADHD before making a diagnosis.

Understanding Borderline Personality Disorder in Adolescents

In this section, Dr. Olivarida discusses the diagnosis of borderline personality disorder (BPD) in adolescents and cautions against misdiagnosis.

Diagnosis of BPD in Adolescents

• Personality disorders were originally diagnosed only after 18 years old due to emotional dysregulation during puberty.

• However, BPD traits can be seen in younger people, cautioning against an actual diagnosis as it can follow individuals for a long time.

• BPD traits can manifest as precursors to what is seen with BPD later on.

Differentiating between Hormones and Mental Health Issues

• Rejection sensitivity dysphoria is not a clinical diagnosis but is used in the ADHD community to describe individuals who feel pain around being rejected.

• With ADHD, rejection sensitivity may cause a sense of longing for affiliation and validation while still maintaining a sense of self.

• With BPD, rejection sensitivity can lead to a loss of identity as individuals become chameleons trying to fit into what others want them to be.

Red Flags for Parents

• The book "Borderline Personality Disorder in Adolescents" provides helpful information for parents grappling with differentiating between hormones and mental health issues.

• Parents should look out for red flags such as projection defense mechanisms that are more commonly associated with BPD than ADHD.

Understanding BPD and ADHD

In this section, the speaker discusses how individuals with borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD) experience emotions differently. They also highlight the differences in how individuals with BPD and ADHD hold grudges.

Emotional Dysregulation in BPD vs ADHD

• Individuals with BPD have a hard time tolerating emotions and may distort situations to match their emotions.

• People with BPD can interpret things differently due to emotional dysregulation, leading to distorted perceptions of reality.

• People with ADHD can be highly empathic, which is an adaptive element that needs regulation.

Holding Grudges in BPD vs ADHD

• Individuals with BPD tend to hold grudges more than those with ADHD.

• Men are typically diagnosed with narcissistic personality disorder or anti-social while women are diagnosed with BPD. However, men can also have borderline personality disorder.

Trauma and Diagnosis

In this section, the speaker talks about trauma's role in diagnosing individuals who may have either ADHD or BPD. They also discuss how diagnoses should not stigmatize people but rather guide them towards appropriate treatment.

Diagnosing Trauma vs ADHD/Emotional Dysregulation

• Clinicians should assess whether issues stem from trauma or emotional dysregulation when diagnosing someone.

• Stimulant medication does not help if someone has attention issues due to intrusive thoughts about trauma.

• BPD is a highly stigmatized diagnosis, but it is essential to look at the diagnosis as an understanding and guide for treatment.

Gendered Stigmatization of BPD

• Women are often stigmatized with the label of "difficult borderline patient," while men are diagnosed with narcissistic personality disorder or anti-social. However, men can also have borderline personality disorder.

Trauma and Borderline Personality Disorder

Dr. Roberto Olivardia discusses the relationship between trauma and borderline personality disorder (BPD). He explains that while most people with BPD have a history of trauma, not all individuals who experience trauma develop BPD. The implications of traumatic experiences on identity development can put someone at higher risk for BPD.

Trauma and Identity Development

• Both drugs/alcohol abuse and BPD are valid issues that need treatment, as they may stem from self-medicating other underlying issues.

• The nuances of how much trauma intersects with identity development can distinguish the implications of traumatic experiences on an individual's life.

• Traumatic events involving family members or those close to an individual can have a greater implication on identity development, putting them at higher risk for developing BPD.

• It is important to understand the meaning that someone makes from their traumatic experience because not everyone who experiences trauma develops BPD.

Understanding Trauma

• Trauma is always important to assess and understand fully, including its ripple effects on an individual's life.

• The nuances of PTSD in veterans include sensory triggers or feeling helpless in saving somebody.

• Processing the trauma is necessary to understand its implications fully.

Conclusion

• Everyone has their unique story around traumatic experiences, which should be assessed comprehensively.

• Attendees learned a great deal about this nuanced topic during the discussion.

• Future webinars will cover topics such as ADHD.