ADHD and Borderline Personality Disorder: Connections, Causes, and Treatments
Anywhere from 16% to 40% of individuals with borderline personality disorder also have ADHD, a condition with similar symptoms, traits, and elevated risk factors. What explains this relationship? And what’s critical to understand about the role ADHD can play in BPD’s development and treatment? Here, we explain the link and treatment considerations for comorbid ADHD and BPD.
Of all the conditions that exist alongside ADHD, personality disorders — especially borderline personality disorder (BPD) — are perhaps the least explored or understood.
Marked by patterns of unstable interpersonal relationships, distorted identity/self-image, emotional dysregulation, and impulsivity, BPD overlaps significantly with attention deficit hyperactivity disorder (ADHD). The conditions share symptoms and features, and they can be conflated, leading to misdiagnosis. Then there is the complicating fact that ADHD is a risk factor for BPD — and the reality that the conditions often co-occur.
In individuals with both ADHD and BPD, it’s often the case that one of these conditions goes undetected, or that their reciprocal impact on course and treatment goes unrecognized. Understanding the interplay is integral to improving treatment outcomes.
What Explains the ADHD-BPD Link?
ADHD and BPD intersect across several points, from shared symptomatology to underlying genetic and environmental risk factors. Anywhere from 16% to 40% of individuals with BPD also have ADHD, according to some studies.1 2 3
(Interestingly, one study found that individuals with ADHD scored significantly higher across BPD symptom measures than did those without ADHD.4 Findings like these have spurred a number of theories on the ADHD-BPD link.)
Biological and Neurological Factors
Several key areas, systems, and processes of the brain that are impaired in ADHD are also affected in BPD, suggesting shared neurological underpinnings.5 Individuals with ADHD and BPD, for example, exhibit dysfunction in prefrontal regions of the brain that are implicated in impulsivity. 6
ADHD Traits, Symptoms, and Challenges
ADHD itself is a risk factor for BPD.7 8 9 Several aspects of the ADHD experience — such as poor peer relationships, impulsivity, low self-esteem, negative feedback, and emotional dysregulation — may help to explain why the condition increases risk for BPD.
Struggling to read social cues, for example, can lead to negative social interactions and dysfunctional interpersonal relationships, which may increase the risk for BPD. It’s also not hard to imagine how a lifetime of executive dysfunction can harm self-esteem and distort an individual’s sense of self — a key symptom of BPD.
Children with ADHD may also develop protective, defensive behaviors that place them at risk for BPD. “Misbehavior” tied to ADHD, for instance, often attracts negative, corrective feedback that may propel these children to view themselves entirely as “bad” and others (like siblings and classmates) as “good.” This black-and-white thinking — sometimes called splitting — is a common behavior associated with BPD.
BPD and ADHD both have strong genetic components.11 12 They run in families, and their most challenging symptoms — like severe emotional dysregulation and executive dysfunction — may sour parent-child relationships and inadvertently create a negative home environment that increases a child’s risk for BPD. A child who feels emotionally invalidated and neglected at home, for example, could seek validation through other relationships and experience intense fears around abandonment.
The ADHD-BPD Interplay
ADHD has a compounding and exacerbating effect on BPD, and vice versa. Compared to individuals with BPD or ADHD alone, individuals with both ADHD and BPD are more likely to experience substance use disorder (cannabis dependence in particular), oppositional defiant disorder (ODD), and other cluster B personality disorders, among other comorbid conditions. They also show higher levels of aggression, anger, impulsivity, and psychosocial difficulties. 3 13 14 15
ADHD and Borderline Personality Disorder: Treatment for Co-occurring Conditions
A comprehensive screening and treatment plan that factors the ADHD-BPD overlap may greatly improve outcomes for individuals with both conditions. Incomplete diagnoses and inadequate treatment contribute unnecessarily to a poorer prognosis for these patients.
Treating ADHD in conjunction with BPD is especially important because it decreases the symptoms of BPD and makes individuals more likely to engage with and benefit from traditional BPD treatments. The bottom line: Untreated ADHD undermines the treatment of BPD.
The following interventions are helpful for individuals with ADHD and BPD:
- Dialectical behavior therapy (DBT) is considered the gold standard treatment for BPD. DBT generally comprises four modules — mindfulness skills, distress tolerance skills, emotional regulation skills, and interpersonal skills — all of which aim to reduce the severity of BPD symptoms and behaviors that interfere with quality of life. Though DBT was originally developed to help individuals with BPD, it has been adapted for multiple conditions, including ADHD.
- Transference-focused psychotherapy (TFP) was developed to help individuals improve their relationships and problematic behaviors outside of therapy by examining the feelings that come up during therapy. Under this approach, the individual’s feelings in therapy and toward the therapist, invariably influenced by symptoms of BPD, become a highly important tool of treatment.
- Cognitive behavioral therapy (CBT) is used quite often to help patients with ADHD manage symptoms and improve functioning. CBT is a goal-oriented form of psychotherapy that aims to change a patient’s negative patterns of thinking to improve the way they feel about themselves. CBT and stimulant medication are used concurrently as complementary treatments.
- Couples therapy for BPD can help partners understand how symptoms show up and how to improve their relationship.
- Stimulants are first-line treatments for ADHD, though non-stimulant medications are also used for a variety of reasons.
- The FDA has approved no medications for the treatment of BPD, though many individuals with BPD use SSRIs, mood stabilizers, or anti-psychotics to improve mood regulation or self-harm behavior.
- For individuals with ADHD, executive function coaching could help develop self-management skills and improve daily functioning.
- Given BPD’s association with high rates of self-harm and suicidal behavior, a crisis plan involving medical providers and family members is essential.
- The National Education Alliance for Borderline Personality Disorder
- Borderline Personality Disorder: A Guide for the Newly Diagnosed & The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD by Alexander L. Chapman, Ph.D., RPsych, and Kim L. Gratz, Ph.D.
- I Hate You — Don’t Leave Me: Understanding the Borderline Personality & Sometimes I Act Crazy: Living with Borderline Personality Disorder by Jerold J. Kreisman, M.D., and Hal Straus
- Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. Mason, M.S., and Randi Kreger
- Borderline Personality Disorder in Adolescents by Blaise Aguirre, M.D.
- For Clinicians: Cognitive-Behavioral Treatment of Borderline Personality Disorder & Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan, Ph.D.
ADHD and Borderline Personality Disorder: Next Steps
- Take This Self-Test: Borderline Personality Disorder
- Read: What is a Personality Disorder?
- Read: A Clinician’s Guide to Differentiating ADHD and Borderline Personality Disorder
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Borderline Personality Disorder & Its Connection to ADHD” [Video Replay & Podcast #446] with Roberto Olivardia, Ph.D., which was broadcast on March 15, 2023.
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