Jessie had been impulsive and prone to tantrums since she was in kindergarten. As a teen, she was obsessed with social status and desperate to be liked by the popular girls. When she was included, she took great pleasure in lording her status over everyone. But when she was left out, she took it personally. Sometimes, she tried to buy friends with gifts; other times, she sought to get back at them.
At home, Jessie ran the house. In response to her angry demands, her mother indulged her, but, regardless of the concessions, Jessie kept up the threats. Eventually, the family’s home life revolved around anticipating her needs, and her parents were constantly exhausted from walking on eggshells. Jessie described herself as “super-sensitive and super-anxious,” and entered college an intense young woman who clung to anyone willing to be accessible, validating, and compliant. She felt miserable and alone.
Until recently, Jessie might have been labeled a normal teen. Society still doubts the credibility of women who appear too emotional, too demanding, or too needy. Today, Jessie’s impulsivity and low frustration tolerance might lead a clinician to consider a diagnosis of ADHD — or Borderline Personality Disorder (BPD). ADHD and BPD share many symptoms, which demand a challenging differential diagnosis. Because ADHD was rarely diagnosed in inattentive women until relatively recently, many lived with a misdiagnosis of BPD.
ADHD does often co-occur with BPD, but the combination brings severe impairments that can be debilitating without treatment and support. Here’s what women struggling with both conditions need to know.
BPD: Tough to Understand, Tougher to Treat
“Borderline” is a common personality style, affecting about six percent of the population. It usually develops in adolescence, alone or in combination with other disorders. The “Borderline style” reaches the level of a disorder when patterns of thinking, feeling, and behaving become so rigid that functioning is impaired. It develops as a result of genetic and temperamental vulnerabilities combined with childhood stressors. Considered to be a difficult disorder for family and friends to understand, it is also a difficult disorder for clinicians to treat. And it is the personality disorder most likely to co-occur with ADHD in women.
Women with BPD experience chronic instability — in their emotions, behaviors, relationships, and sense of self. They are impulsive in response to rapid mood changes. Their sense of self fluctuates based on their ability to cope with feelings of abandonment. However, their rejection sensitivity contributes to the need to make dramatic shifts in relationships, often sabotaging and then reestablishing connection. Many misinterpret the behaviors of Borderline women to be intentionally manipulative, and they are often stigmatized. Their demands escalate in response to their intolerable fear. Unfortunately, that emotional urgency evokes feelings of guilt or resentment in others. In fact, these women are in intense emotional pain, and feel unable to elicit what they need from others to feel safe.
For women with BPD, rifts with friends or breakups are often triggers for self-harm, suicidal thoughts, and suicide attempts. Self-destructive behaviors, like cutting or burning, can defuse their skyrocketing panic, and become strategies for emotional control. BPD women who are impulsive, emotionally unstable, with histories of trauma have the highest risk of acting on their suicidal ideation, especially if they had been diagnosed with ADHD as children.
Does BPD Camouflage ADHD Symptoms?
There is a lot of overlap between the symptoms of the two disorders. The experience of women with ADHD, BPD, or both is characterized by difficulties in self-regulation; feelings, behavior, relationships, and sense of self are chronically unstable. They are challenged by impulsivity and emotional volatility, especially in managing anger. In both disorders, impulsivity can lead to gambling, financial troubles, eating disorders, substance abuse, and unsafe sex.
Both groups are hypersensitive to sensory changes. With either or both disorders, the battle to self-regulate leads women to feel ashamed, unsupported, and alone, struggling with anxiety, depression, rage, panic, and despair. In some cases, the more dramatic BPD symptoms can camouflage the more classic ADHD symptoms.
There are clear differences between the two diagnoses as well. The core symptoms of ADHD, such as persistent inattention, distractibility, and hyperactivity, are not among the criteria for BPD. Stress-related dissociative symptoms and paranoid thoughts that may occur in BPD are not ADHD symptoms. While women with either disorder may experience despair, women with ADHD are more likely to be responding to the shame and demoralization they feel about the choices they’ve made. Women with BPD are more likely to feel hopeless and frantic in response to perceived losses in relationships.
For untreated women with either or both diagnoses, there is the risk for self-harm and suicidality. However, the risk for these self-destructive behaviors is much higher for women with BPD. The risk of suicide is real, and must be taken seriously.
Does Childhood ADHD Increase the Severity of BPD Symptoms?
ADHD and BPD have a genetic component, although the hereditary aspect of ADHD is stronger. When parents have ADHD, home life is more likely to be inconsistent, unstructured, and emotionally volatile. Intense emotional responses may have been labeled as unacceptable over-reactions because the parents found them hard to tolerate. It seems that a history of childhood ADHD may increase the risk for developing BPD, and will increase the severity of BPD symptoms. In those with histories of early trauma, co-occurrence of the two disorders results in greater impulsivity and emotional dysregulation.
Does Trauma Contribute to BPD?
It is not surprising that childhood neglect and abuse increases the risk for developing a range of disorders as adults. In fact, studies have found that women with ADHD and BPD often have traumatic early histories. It is likely that early childhood trauma can exacerbate ADHD symptoms and contribute to the development of BPD. ADHD histories are more strongly associated with neglect and physical and emotional abuse, while BPD histories are more likely to involve emotional and sexual abuse. At least a quarter of those women with BPD will suffer from Post-Traumatic Stress Disorder (PTSD). There is also a high degree of overlap between PTSD and ADHD behaviors, including inattention, impulsivity, emotional dysregulation, and restlessness. Women with ADHD and BPD have been shown to have the highest levels of neglect in their histories.
The presentations of ADHD and PTSD can be remarkably similar. The state of hyper-arousal that typifies trauma survivors closely mimics the appearance of hyperactivity. Similarly, the dissociative state that can typify other trauma survivors closely mimics inattention. Stress-related dissociation is often a response to trauma in Borderline women, but it is usually not seen in ADHD. Since many women with ADHD are predominantly inattentive, differentiating between inattentive symptoms of ADHD and dissociative symptoms of trauma is challenging. Some women diagnosed with ADHD may have BPD, and may be manifesting the symptoms of early chronic trauma.
Does Early Intervention Improve Outcomes?
A recent reconsideration of criteria allows for the diagnosis of BPD in adolescents. This welcome change enables earlier intervention, which improves long-term outcomes. Dialectical behavior therapy (DBT) has been the gold standard for teaching the skills needed for managing emotional dysregulation. It is a structured program that acknowledges the needs for acceptance and change, and offers skills to handle both. Learning these adaptive skills as early as possible is better than having to unlearn unhealthy behaviors later.
Stimulants are helpful for managing the symptoms of emotional dysregulation connected to ADHD. However, these medications may over-stimulate traumatized brains, already on high alert, and exacerbate symptoms. Unfortunately, no medications have been consistently helpful in treating BPD symptoms. Medication options may be further limited by the likelihood of substance dependence or abuse. In addition, the goals of psychotherapy differ significantly. The focus for those with ADHD is inhibiting impulsive responses, while those with BPD and a trauma history work toward safely revealing their secrets.
The importance of correct diagnoses is underscored by these treatment differences, and highlights the necessity for trauma-informed evaluations, which are not yet part of ADHD evaluations. Without treating both disorders, the likelihood of therapeutic success is minimized.
Take-Home Messages for Women
As emotional dysregulation becomes more widely accepted as a core symptom of adult ADHD, its overlap with BPD becomes of greater importance. For women with ADHD, emotional hyper-reactivity is a prime symptom that undermines their sense of control. As an ADHD comorbidity, BPD heightens the chaotic experience of understanding the self and managing relationships. Managing the symptoms of ADHD and BPD gets more difficult as time goes on.
These are ample reasons to consider women with ADHD, BPD, and a history of trauma to be at the greatest risk for negative outcomes. It is critical that they be correctly identified, supported, and treated by clinicians who are experienced with both complex conditions.
Ellen Littman, Ph.D., is a member of ADDitude’s ADHD Medical Review Panel.
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Updated on February 7, 2021