Attention deficit hyperactivity disorder (ADHD) occurs in approximately 25% of people with borderline disorder; at least 5 times more often than it does in the general population. The symptoms of ADHD include decreased attention and concentration, easy distractibility, difficulty in the completion of tasks, and poor management of time and the space area that you use. These symptoms of ADHD result in significantly impaired school, work and social performance, and are described in detail below.
ADHD is estimated to occur in about 5% of school age children. It is more common in boys than in girls. There are subtypes associated with hyperactivity and normal activity levels. The hyperactive subtype is more common in boys, and is associated with impulsivity, while the inattentive subtype (the subtype with normal levels of activity and impulsivity) is somewhat more evenly distributed among boys and girls. The symptoms of ADHD are now known to persist into adulthood in many people, and to require continued treatment. There is often a strong family history of ADHD.
Identifying the symptoms of ADHD in patients with Borderline Disorder is critical for their treatment plan.
Symptoms of ADHD*
- fails to give close attention to details or makes careless mistakes in school work, work, or other activities
- has difficulty sustaining attention in tasks or play activities
- does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
- has difficulty organizing tasks and activities
- avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
- loses things necessary for tasks or activities (e.g., toys, school assignment, pencils, books, or tools)
- is easily distracted by extraneous stimuli
- is often forgetful in daily activities
- fidgets with hands or feet or squirms in seat
- leaves seat in classroom or in other situations in which remaining seated is expected
- runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
- has difficulty playing or engaging in leisure activities quietly
- is often “on the go” or often acts as if “driven by a motor”
- talks excessively
- blurts out answers before questions have been completed
- has difficulty awaiting turn
- interrupts or intrudes on others (e.g., butts into conversations or games)
Treatment of ADHD in Patients with Borderline Disorder
It is not uncommon for children, teenagers and adults with borderline disorder who have some symptoms of ADHD to be misdiagnosed with only ADHD, and then receive customary treatment with stimulants such as methylphenidate or an amphetamine derivative.
If borderline disorder and ADHD co-occur, patients often do worse when treated for ADHD if they first receive a medication for the symptoms of ADHD. Under these circumstances, they may then demonstrate an increase in emotionality, aggressive impulsivity and even paranoid thinking. Fortunately, clinical experience and anecdotal reports in the scientific literature suggest that this problem can be effectively managed in one of two ways.
When the symptoms of ADHD are mild, behavioral treatments alone may be effective, thereby avoiding the risk of increasing the symptoms of borderline disorder with a stimulant.
However, if medications are required to bring the symptoms of ADHD under optimal control, it appears to be helpful to initiate treatment with a low dose of an antipsychotic agent for the symptoms of borderline disorder [Medications]. Doing so permits the use of a stimulant to produce a beneficial effect on the symptoms of ADHD with a minimal risk of worsening the core symptoms of borderline disorder.
*Adapted from DSM-5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American Psychiatric Association, 2000.