Differential diagnosis, comorbidity, and treatment of attention-deficit/hyperactivity disorder in relation to bipolar disorder or borderline personality disorder in adults

Abstract

Background:

Attention-deficit/hyperactivity disorder (ADHD) in adults can resemble, and often co-occurs with, bipolar disorder (BD) and borderline personality disorder (BPD). This can lead to mistaken diagnoses and ineffective treatment, resulting in potentially serious adverse consequences. All three conditions can substantially impair well-being and functioning, while BD and BPD are associated with suicidality.

Objectives:

To update clinicians on the overlap and differences in the symptomatology of ADHD versus BD and BPD in adults; differential diagnosis of ADHD from BD and BPD in adults; and diagnosis and treatment of adults with comorbid ADHD-BD or ADHD-BPD.

Methods:

We searched four databases, referred to the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition, used other relevant literature, and referred to our own clinical experience.

Results:

ADHD coexists in ∼20% of adults with BD or BPD. BD is episodic, with periods of normal mood although not necessarily function. In patients with comorbid ADHD-BD, ADHD symptoms are apparent between BD episodes. BPD and ADHD are associated with chronic trait-like symptoms and impairments. Overlapping symptoms of BPD and ADHD include impulsivity and emotional dysregulation. Symptoms of BPD but not ADHD include frantically avoiding real/imagined abandonment, suicidal behavior, self-harm, chronic feelings of emptiness, and stress-related paranoia/severe dissociation. Consensus expert opinion recommends that BD episodes should be treated first in patients with comorbid ADHD, and these patients may need treatment in stages (e.g. mood stabilizer[s], then a stimulant/atomoxetine). Data is scarce and mixed about whether stimulants or atomoxetine exacerbate mania in comorbid ADHD-BD. BPD is primarily treated with psychotherapy. Principles of dialectical behavioral treatment for BPD may successfully treat ADHD in adults, as an adjunct to medication. No fully evidence-based pharmacotherapy exists for core BPD symptoms, although some medications may be effective for individual symptom domains, e.g. impulsivity (shared by ADHD and BPD). In our experience, treatment of ADHD should be considered when treating comorbid personality disorders.

Conclusions:

It is important to accurately diagnose ADHD, BD, and BPD to ensure correct targeting of treatments and improvements in patient outcomes. However, there is a shortage of data about treatment of adults with ADHD and comorbid BD or BPD.

Keywords::

• ADHD
• Adults
• Bipolar disorder
• Borderline personality disorder
• Comorbidity
• Differential diagnosis
• Treatment

Transparency

Declaration of funding

This review was funded by Eli Lilly & Co.

Declaration of financial/other relationships

P.A. has disclosed that he has acted as a consultant on behalf of King’s College London for Lilly, Shire, Janssen-Cilag, and Novartis. He has also received educational or research grants from Shire, Janssen-Cilag, Lilly, Vifor Pharma, and QBTech, and participated in educational meetings or talks, sponsored by the same companies. W.D. and V.P. have disclosed that they are full time employees and stockholders of Eli Lilly & Co. D.E.-H. has disclosed that she has acted as a consultant of Psychiatric University Hospital, Zürich, for Lilly, Novartis, and Janssen-Cilag, and participated in educational meetings or talks sponsored by the same companies, as well as by Shire. D.E.-H. has not received any educational or research grants from any company. P.M. has disclosed that he has received a grant from Guy’s and St Thomas’ Charity. A.H.Y. has disclosed that he has participated in paid lectures and advisory boards for all major pharmaceutical companies involved in affective disorders including Eli Lilly and has also received grant support from Eli Lilly and acted as an expert witness in legal proceedings.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Michael Riley and Thomas Wagner from Trilogy Writing and Consulting GmbH, Frankfurt, Germany, provided medical writing support on behalf of Eli Lilly & Co.