It’s not Borderline, it’s ADHD!

Diagnosing Emotional Dysregulation in adults (women in particular) is a very difficult task, and therefore too many are misdiagnosed with Borderline when it’s actually ADHD. Let’s get this cleared up, once and for all.


An illness (BPD) can be cured, a disorder (ADHD) cannot …

ADDspeaker, 2019

Summary

Borderline Personality Disorder (BPD) is an acquired mental illness, whereas ADHD is an neurobiological mental disorder.

Although they share many traits, behaviours and symptoms which presents to be the same, the root cause for each of them are very different indeed.

BPD is caused by traumatic life events (and in some part by a genetic disposition due to family genetics), whereas ADHD is caused by either genetics (70%) or neurobiological environmental factors (30%) such as infections during pregnancy.

Behaviour in BPD is caused by psychological factors stemming from trauma, whereas ADHD stems from neurobiological factors due to delayed neurodevelopmental growth, creating a 30% lag in maturity in brain growth, which then again results in an immature, disinhibited behaviour in people with ADHD.

Treatment for people with BPD is psychosocial therapy, whereas treatment for ADHD has to be a combination of medication (neurobiological factors) and psychosocial therapy (psychosocial factors). BPD is an illness and is therefore curable, whereas ADHD is a disorder, and is therefore not curable.

Both result in significant social impairments, severe risk of interpersonal conflict and emotional instability. ADHD causes a wide array of somatic co-morbid disorders and illnesses as well as significant high risk of other mental disorders being present (anxiety, depression, ODD, addiction etc.). BPD causes a significant higher risk of social retaliation (violence, arguing, shunning) than that seen in ADHD.

This is partly due to the ‘splitting‘ component of BPD, where the person tries to pit two parties (who are normally in good standing) against each other to create conflict between them, in order for the person to ‘move in and take their place’.

ADHD does not create this behaviour and the social conflict is more in relation to lack of inhibitory control over verbal and non-verbal behaviour (e.g.: blurts out their unsolicited opinion to others or fails to recognise other’ intimacy-sphere‘ thereby getting too close to them).

Both BPD and ADHD creates what is termed as ‘Emotional Dysregulation‘, (ED) which means that the person is unable to emotional self-control and emotional self-regulate their emotions, causing behaviour which is experienced by others, as ‘over the top’. ED is caused by psychological factors in BPD, but caused by neurobiological/neurochemical factors in ADHD.

As a Rule of Thumb, one could say that BPD has rapidly changing moods, whereas ADHD causes rapidly changing emotions. BPD causes massive impairment on the internal identity level, whereas ADHD creates massive impairment on the external social-reciprocal level, not being able to read others cues and intentions, while failing to inhibit their impulsive need for immediate gratification of needs.

A person with BPD will, most often, plan out how to get they’re needs met, but will be able to postpone gratification until later, if a bigger reward could be obtained.

Introduction

It may look like it’s the same, but it’s not!

This article aims at giving you, the reader, a more in-depth understanding of the distinct differences between Borderline Personality Disorder (BPD) and Attention-Deficit Hyperactivity Disorder (ADHD.

Since these to disorders, one biological (ADHD) and the other psychological (BPD) share so many symptoms, they are often misdiagnosed in clinical practice today. Especially women have an overwhelming risk of misdiagnosis with BPD when the root cause is actually ADHD.

This results in non-effective treatment of both disorders, as ADHD requires medicinal treatment and psychotherapy in combination, BPD cannot be outright medicated and requires years of psychotherapy to realign the core essence of the person’s thinking and behaviour.

In order to help clinicians and patients better understand the differences between BPD and ADHD, as well as describing what BPD with co-morbid ADHD results in, regarding symptomatology.


Core features of BPD

The features of BPD are generally considered to consist of three core features: emotional instability, impulsivity, and interpersonal turmoil.

Researchers think that BPD is caused by a combination of factors, including: Stressful or traumatic life events, and genetic factors exposing you to susceptibility of BPD.

Borderline personality disorder is a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with borderline personality disorder may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.

People with borderline personality disorder may experience mood swings and display uncertainty about how they see themselves and their role in the world. As a result, their interests and values can change quickly.

People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their opinions of other people can also change quickly. An individual who is seen as a friend one day may be considered an enemy or traitor the next. These shifting feelings can lead to intense and unstable relationships.

Anatomical causes: None. BPD is a psychological mental illness, not a (neuro)biological mental disorder. Some evidence suggests that BPD could have a genetic cause, because you’re more likely to be given this diagnosis if someone in your close family has also received it. But it’s very hard to know if difficulties associated with BPD are inherited from your parents or caused by other factors, such as the environment you grow up in or the ways of thinking, coping and behaving that you learn from the people around you.

Psychological causes: Stressful, or traumatic life events, or traumatic experiences growing up, such as:

  • often feeling afraid, upset, unsupported or invalidated
  • family difficulties or instability, such as living with a parent who has an addiction
  • sexual, physical or emotional abuse or neglect
  • losing a parent

If you had difficult childhood experiences like these they may have caused you to develop particular coping strategies, or beliefs about yourself and other people, which might become less helpful in time and cause you distress. You might also be struggling with feelings of anger, fear or sadness.

You might also experience BPD without having any history of traumatic or stressful life events, or you might have had other types of difficult experiences.

There’s no clear reason why some people experience difficulties associated with BPD. More women are given this diagnosis than men, but it can affect people of all genders and backgrounds.

It’s possible that a combination of factors could be involved. Genetics might make you more vulnerable to developing BPD, but often it’s due to stressful or traumatic life experiences that these vulnerabilities are triggered and become a problem.

Behavioural symptoms: You might be given a diagnosis of BPD if you experience at least five of the following things, and they’ve lasted for a long time or have a big impact on your daily life:

  • You feel very worried about people abandoning you, and would do anything to stop that happening.
  • You have very intense emotions that last from a few hours to a few days and can change quickly (for example, from feeling very happy and confident to suddenly feeling low and sad).
  • You don’t have a strong sense of who you are, and it can change significantly depending on who you’re with.
  • You find it very hard to make and keep stable relationships.
  • You feel empty a lot of the time.
  • You act impulsively and do things that could harm you (such as binge eating, using drugs or driving dangerously).
  • You often self-harm or have suicidal feelings.
  • You have very intense feelings of anger, which are really difficult to control.
  • When very stressed, you may also experience paranoia or dissociation.

Core features of ADHD

The core symptoms of attention-deficit/hyperactivity disorder (ADHD) include inattention, hyperactivity, and impulsivity.

ADHD is an inherited (70%) or acquired (30%), neurobiological mental disorder. Inherited ADHD is caused by genetics, acquired ADHD is cause by neurobiological contamination during pregnancy (in vitro), like inflammation or infections.

The root cause of these symptoms are neurobiological, stemming from a neurodevelopmental delay in maturation of the brain, more precisely in the Inhibition Control and Motor Control systems.

Anatomical causes: Research has consistently shown that a brain with ADHD will physically grow slower than one without ADHD, at a 30-40% time delay, which causes the Motor Control to develop prematurely in relation to the Inhibition Control. This discrepancy is what causes the core symptoms of ADHD as they are all interrelated to Inhibition Control not being able to manage the Motor Control, at an age-expected functional level.

Psychological causes: Research has consistently shown, that parenting or psychosocial context do not cause ADHD. Psychosocial context may contribute to the impairment experienced, due to ADHD, but it is not related in any way to the development of ADHD, nor does diet, exercise or TV/Computer/iPad cause ADHD.

Late or Adult-onset ADHD: You cannot acquire ADHD later in life, since this is a developmental disorder, not a disease or illness. Some adults show symptoms of ADHD-like behavior, but the causality is not ADHD, as is the example with Traumatic Brain Injury (TBI) or as in this case, Borderline Personality Disorder.

Expected Life Outcome: Challenges with ADHD come into play when the diagnosis is delayed or treatment is not promptly initiated or continued. Without proper diagnosis or treatment, patients may experience higher rates of substance abuse, depression, anxiety, obesity, autoimmune diseases (Thyroid, Diabetes Type-II, Asthma & Allergies, as well as many other somatic diseases such as Crohn’s and Irritable Bowel Syndrome). Latest research show that people with untreated ADHD in childhood have an 43% increased risk of accidents, and that ADHD will generally increase your risk of a sudden death (Mortality) by 50%, compared to the background population. Estimated Life Expectancy is reduced by 12.7 years and life quality in general is significantly reduces, compared to the background population.

Behavioural symptoms: The symptoms in children and teenagers are sometimes also applied to adults with possible ADHD. But some specialists say the way in which inattentiveness, hyperactivity and impulsiveness affect adults can be very different from the way they affect children. 

For example, hyperactivity tends to decrease in adults (maturation of the brain leads to Inhibition Control better managing Motor Control), while inattentiveness tends to get worse as the pressures of adult life increase (lack of dopamine, norepinephrine, epinephrine decrease neuronal communication due to reduced synaptic transmission potential, resulting in impairment of Executive Functioning). Adult symptoms of ADHD also tend to be far more subtle than childhood symptoms.

Some specialists have suggested the following as a list of symptoms associated with ADHD in adults:

  • carelessness and lack of attention to detail 
  • continually starting new tasks before finishing old ones 
  • poor organisational skills 
  • inability to focus or prioritise 
  • continually losing or misplacing things 
  • forgetfulness 
  • restlessness and edginess 
  • difficulty keeping quiet, and speaking out of turn 
  • blurting out responses and often interrupting others 
  • mood swings, irritability and a quick temper 
  • inability to deal with stress 
  • extreme impatience 
  • taking risks in activities, often with little or no regard for personal safety or the safety of others – for example, driving dangerously

BPD vs. ADHD

As explained in details above, the core difference between BPD and ADHD is that BPD is a mental illness, whereas ADHD is a mental disorder.

What that means is that BPD is an illness which can be treated and you can be cured of having BPD, while ADHD is a disorder that you are born with and for which there is no cure.

The core root of symptoms of BPD are caused in psychological events that have created a trauma which then causes an insecure and emotional instability within one self, interpersonal conflicts with others both caused the third symptom, impulsiveness.

In ADHD the core root is (lack of) Emotional Self-regulation and Emotional Self-control due to a neurobiological inability to regulate several important systems relating to verbal and non-verbal behaviour, which causes a person with ADHD to come across as hyperactive, impulsive and inattentive, but where the real cause is to be found in the inability to ‘ignore task-irrelevant stimuli’, ‘restrain from acting on task-irrelevant stimuli’ and ‘regulating feelings caused by sensory stimuli‘.

This inability to ‘filter’ out the task-relevant stimuli from the task-irrelevant stimuli, is what causes the emotional overstimulation (anger, frustration, agression, sadness etc.), which then, from the outside, might seem to be rapidly fluctuating in intensity, understood as emotional lability. But this is no so in ADHD.

The overstimulation caused by stimuli puts stress on the systems handling these feelings, Amygdala, Thalamus etc., and since the Executive Functioning is impaired due to delayed neurodevelopmental growth, the system that is tasked with handling these feelings, simply isn’t available, causing the complete emotional system to become dysfunctional.

Even though BPD and ADHD both causes what is called Emotional Dysregulation, these stems from markedly different root causes, ADHD is neurobiological, BPD is psychological.

ADDspeaker, 2019

Differentiating BPD from ADHD

So how do we distinguish BPD from ADHD? I’ve researched this and have come across an article that have studied this. Unfortunately it is in German only, but I’ve tried to translate the key messages from this study, so that we can use the very relevant key findings found within.

Witt, O., Brücher, K., Biegel, G., Petermann, F., & Schmidt, S. (2014). ADHS im Erwachsenenalter versus Borderline- Persönlichkeitsstörung: Kriterien zur Differenzialdiagnostik. Fortschritte Der Neurologie Psychiatrie82(6), 337–345. https://doi.org/10.1055/s-0034-1366242

Excerpt from Witt, O. et al., 2014:

[…]Multivariate analyses of variance revealed that BPD patients differed significantly with respect to self-mutilating behaviour, suicidality, dissociation, paranoia and dichotomy from all other groups. The same effect was found for affect regulation.[…]

[…]Furthermore BPD patients differed significantly from ADHD patients by a more severe impulsiveness (IES-27), but not through disturbed impulse control and disinhibition overall.[…]

[…]Regarding mean differences between ADHD and BPD patients for attentional control, ADHD patients revealed higher scores which just missed significance.[…]

[…]For hyperactivity no significant group differences were found which is assumed to be influenced by symptom overlap like restlessness and aversive tension.[…]

Conclusion

To conclude this lengthy article, I present the table from the study, where the symptom severity is being analysed and compared, in order for us to spot the key differences.

What this table shows us, is that the difference in symptom origin, as explained above, can directly be read of the study results, as degrees of severity of the symptom, in BPD or ADHD alone, in BPD with co-morbid ADHD and with Depression and Control Group as reference points.

The table shows 5 distinct measurement point; ADHD, BPD, BPD/ADHD, DEP and CG. In a multivariate analyses, statistical ‘magic’ have been performed, so that ignorants like myself are able to compare the 5 different measurement points to understand what differentiate these from one another.

As we can see, BPD has the most severity of all the measurements. BPD/ADHD (BPD with co-morbid ADHD) is second, then ADHD alone, with DEP (depression) fourth. The Control Group is shown as CG.

What this table shows, visually, is that BPD have a high risk of causing self-injury, suicidal behaviour, dissociative behaviour, paranoia and dichotomy, which is also prevalent in ADHD, but as seen in the table, ADHD has these to a significantly lesser degree of severity.

If we look at BPD with co-morbid ADHD (BPD/ADHD) we can see that ADHD actually mediates some of the severity of self-injury, suicidality, paranoia and dichotomy, which is quite interesting in it self.


Relevant Diagnostic Criteria

In order to better understand how and why BPD and ADHD differentiate significantly from one another, it is important to define the diagnostic criteria.

Self-mutilating behaviour:
Self-harm, also known as self-injury, is defined as the intentional, direct injuring of body tissue, done without suicidal intentions. Other terms such as cutting and self-mutilation have been used for any self-harming behavior regardless of suicidal intent.

Suicidality:
The term suicidality covers suicidal ideation (serious thoughts about taking one’s own life), suicide plans and suicide attempts. People who experience suicidal ideation and make suicide plans are at increased risk of suicide attempts, and people who experience all forms of suicidal thoughts and behaviours are at greater risk of completing suicide.

Dissociation:
Dissociation is any of a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a loss of reality as in psychosis

Paranoia:
Paranoia is the irrational and persistent feeling that people are ‘out to get you’. The three main types of paranoia include paranoid personality disorder, delusional (formerly paranoid) disorder and paranoid schizophrenia.

Dichotomy:
Dichotomy refers to the division of one whole idea, thought, or concept into two separate and unrelated ideas. Also known as black-or-white thinking.

Affect regulation:
Affect regulation, or emotion regulation, is the ability of an individual to modulate their emotional state in order to adaptively meet the demands of their environment. Individuals with a broad range of affect regulation strategies will be able to flexibly adapt to a range of stressful situations. Also known as Emotional Self-regulation.

Impulsiveness:
In psychology, impulsivity (or impulsiveness) is a tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences.

Impulse control:
An impulse is a wish or urge, particularly a sudden one. It can be considered as a normal and fundamental part of human thought processes, but also one that can become problematic, as in a condition like obsessive-compulsive disorder, borderline personality disorder, and attention deficit hyperactivity disorder. Also know as Inhibition Control.

Disinhibition:
Disinhibition is characteristic of mania, and is usually first noticed by family or friends. This may have ruinous consequences in terms of personal relationships, occupation and finances. When present, it is often evident during the psychiatric interview and the individual may be over-familiar, outspoken or abusive. Overactivity may be mild or severe. In its more severe form, food and fluid intake may be reduced with serious biochemical disturbance, and physical exhaustion may ensue. More typical is inner restlessness and increased motor activity manifested by an inability to remain seated during an interview, pacing around the room or excessive use of gestures. Occasionally increased activity may be productive, but often the individual is unable to complete tasks, and engages in disorganized and purposeless activity, which may occur in response to environmental stimuli. Also known as (lack of) Self-control.

Attentional control:
Attentional control refers to an individual’s capacity to choose what they pay attention to and what they ignore. It is also known as endogenous attention or executive attention. In lay terms, attentional control can be described as an individual’s ability to concentrate. Also known as Distractibility.

Hyperactivity:
Hyperactive behavior usually refers to constant activity, being easily distracted, impulsiveness, inability to concentrate, aggressiveness, and similar behaviours. Typical behaviors may include: Fidgeting or constant moving. Wandering.

Restlessness:
Restlessness is a form of neurosis. Neurosis is excessive and irrational anxiety or obsession. It’s a sign of mental imbalance. That is, the root problem is in the mind itself. Neurosis produces unnecessary stress that often leads to depression and feelings of helplessness.

Aversion tension:
Aversion is a strong feeling of dislike, opposition, repugnance, or antipathy (usually followed by to): a strong aversion to snakes and spiders. a cause or object of dislike; person or thing that causes antipathy; the act of averting; a turning away or preventing. Also related to Demand Avoidance.


References

Stepp, S. D., Lazarus, S. A., & Byrd, A. L. (2016). A Systematic Review of Risk Factors Prospectively Associated with Borderline Personality Disorder: Taking Stock and Moving Forward. Personality Disorders: Theory, Research, and Treatment7(4), 316–323. https://doi.org/10.1037/per0000186

Kooij, J. J. S., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balázs, J., … Asherson, P. (2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry56, 14–34. https://doi.org/10.1016/j.eurpsy.2018.11.001

Petrovic, P., & Castellanos, F. X. (2016). Top-Down Dysregulation—From ADHD to Emotional Instability. Frontiers in Behavioral Neuroscience10. https://doi.org/10.3389/fnbeh.2016.00070

Bilbow, A., Larsson, H., Lesch, K.-P., Michelini, G., Ribases, M., Banaschewski, T., … Buitelaar, J. K. (2018). Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. European Neuropsychopharmacology28(10), 1059–1088. https://doi.org/10.1016/j.euroneuro.2018.08.001

Witt, O., Brücher, K., Biegel, G., Petermann, F., & Schmidt, S. (2014). ADHS im Erwachsenenalter versus Borderline- Persönlichkeitsstörung: Kriterien zur Differenzialdiagnostik. Fortschritte Der Neurologie Psychiatrie82(6), 337–345. https://doi.org/10.1055/s-0034-1366242

Carpenter, R. W., & Trull, T. J. (2013). Components of emotion dysregulation in borderline personality disorder: A review. Current Psychiatry Reports15(1). https://doi.org/10.1007/s11920-012-0335-2

Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHDItalian Journal of Pediatrics(Vol. 36). https://doi.org/10.1186/1824-7288-36-79

Matthies, S. D., & Philipsen, A. (2014). Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)–review of recent findingsBorderline Personality Disorder and Emotion Dysregulation(Vol. 1). https://doi.org/10.1186/2051-6673-1-3

Moukhtarian, T. R., Mintah, R. S., Moran, P., & Asherson, P. (2018). Emotion dysregulation in attention-deficit/hyperactivity disorder and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation5(1). https://doi.org/10.1186/s40479-018-0086-8

Copeland, W. E., Fairbank, J. A., Chan, R. F., Hinesley, J., van den Oord, E. J. C. G., Aberg, K. A., … Shanahan, L. (2018). Association of Childhood Trauma Exposure With Adult Psychiatric Disorders and Functional Outcomes. JAMA Network Open1(7), e184493. https://doi.org/10.1001/jamanetworkopen.2018.4493

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