BPD and ADHD comorbidity

[thelastpsych]

There is a subset of BPD patients that I see that checks all the boxes for ADHD criteria. Now, I know these are treacherous waters, so I always try to check and double-check these cases: can the impulsivity be associated with emotional triggers and chronic feelings of emptiness, or it has a strong motor and learning component as well? Did these symptoms began before 12y.o? Do other family members give similar informations as well? Do the patients report significant sympotms from standarized tools, in multiple sessions, and can give real-life examples from where these symptoms impact them?

And even though I'm very diligent in these evaluations, some patients DO fill the criteria for ADHD and BPD - they seem to coexist, and usually amplify the other condition (dificulty in paying attention in a job setting makes them even more rejection-sensitive to colleagues; the emotional instability makes it even harder for them to concentrate). There seems to be a literature that indicates a significant overlap between the two: Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder - PubMed

My question is: how do you usually manage these patients? Ofc, I always offer psychotherapy as a primary resource, but am much more conflicted on giving dopamine-agonists, specially if the patient has a history of drug abuse as some BPD have. Am I being overtly cautious? Can you guys please share some insights?

Thanks in advance!

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[Celexa]

I treat them. I have the same rules about controlled substances I have for every patient. Clean UDS. No early refills. No angry calls if they end up not having the med a day or two due to refill challenges (part of my spiel is that these meds can be very helpful, but they are not immediately life saving, and missing them for a short period of time is NOT an emergency). Etc. Patients with a hx of substance use require very careful evaluation, but is not an absolute contraindication if sober and stable from that perspective.

What are you afraid of in treating these patients with an indicated medication for the condition you believe they have? The problem with overuse of stimulants is when the diagnosis is poorly done and/or stimulants are part of thoughtless polypharmacy, particularly if combined with benzos etc and so part of an endless chain of push and pull side effects. Those situations are completely different from patients you have taken the time and care to diagnose yourself and treated rationally.

The benefits of stimulants in true ADHD are significant. I have even had patients who, once the ADHD was treated, didn't even seem to meet criteria for borderline anymore. Try to weight the risks of NOT treating the disease in your mind as heavily as the theoretical risks of treating and see if you can still justify your hesitance.

If the stimulant trial goes poorly, you can just... Not continue to prescribe. It's not an irreversible decision.

I tell my patients: I am prescribing you this medication because right now I believe the potential benefits outweigh the potential risks/harms. If at any point I am worried for your health and see the harms outweighing benefits I will not prescribe this medication any longer. Just like for every other med.

I also NEVER go to adderall first, as risk of abuse seems clearly higher in my experience. Methylphenidate preparations first, then Vyvanse if the methylphenidate didn't work. Always long acting initially and then adding an afternoon booster if indicated. And I have found guanfacine a very useful medication, and even had success in dual treating someone with both adhd and ptsd nightmares. They thought I was a wizard when the nightmares went away. Given the link between trauma and borderline it's useful to think about. But I don't make patients fail non stimulant options if I truly think they have ADHD.

 

[thelastpsych]

I treat them. I have the same rules about controlled substances I have for every patient. Clean UDS. No early refills. No angry calls if they end up not having the med a day or two due to refill challenges (part of my spiel is that these meds can be very helpful, but they are not immediately life saving, and missing them for a short period of time is NOT an emergency). Etc. Patients with a hx of substance use require very careful evaluation, but is not an absolute contraindication if sober and stable from that perspective.

What are you afraid of in treating these patients with an indicated medication for the condition you believe they have? The problem with overuse of stimulants is when the diagnosis is poorly done and/or stimulants are part of thoughtless polypharmacy, particularly if combined with benzos etc and so part of an endless chain of push and pull side effects. Those situations are completely different from patients you have taken the time and care to diagnose yourself and treated rationally.

The benefits of stimulants in true ADHD are significant. I have even had patients who, once the ADHD was treated, didn't even seem to meet criteria for borderline anymore. Try to weight the risks of NOT treating the disease in your mind as heavily as the theoretical risks of treating and see if you can still justify your hesitance.

If the stimulant trial goes poorly, you can just... Not continue to prescribe. It's not an irreversible decision.

I tell my patients: I am prescribing you this medication because right now I believe the potential benefits outweigh the potential risks/harms. If at any point I am worried for your health and see the harms outweighing benefits I will not prescribe this medication any longer. Just like for every other med.

I also NEVER go to adderall first, as risk of abuse seems clearly higher in my experience. Methylphenidate preparations first, then Vyvanse if the methylphenidate didn't work. Always long acting initially and then adding an afternoon booster if indicated. And I have found guanfacine a very useful medication, and even had success in dual treating someone with both adhd and ptsd nightmares. They thought I was a wizard when the nightmares went away. Given the link between trauma and borderline it's useful to think about. But I don't make patients fail non stimulant options if I truly think they have ADHD.

Thank you Celexa, my worries seem to be from the history of substance abuse but also the impulsivity associated with these patients, so I'm always hesitant to use psychostimulants. Also, I've seen some BPD patients using dopamine/noradrenaline agonists, such as bupropion, stimulants, etc, and getting substantially more unstable and impulsive, or extremely anxious even in low doses of these drugs. Of course, most of these patients I was not the one who prescribed originally the drug, and I disagreed with the previous doctor on the diagnosis of ADD, so it may just be my previous bad experience in this population. I have used ADHD medications in a handful of comorbid BPD and ADHD patients, with initially good results, but I'm always hesitant.

 

[Celexa]

Thank you Celexa, my worries seem to be from the history of substance abuse but also the impulsivity associated with these patients, so I'm always hesitant to use psychostimulants. Also, I've seen some BPD patients using dopamine/noradrenaline agonists, such as bupropion, stimulants, etc, and getting substantially more unstable and impulsive, or extremely anxious even in low doses of these drugs. Of course, most of these patients I was not the one who prescribed originally the drug, and I disagreed with the previous doctor on the diagnosis of ADD, so it may just be my previous bad experience in this population. I have used ADHD medications in a handful of comorbid BPD and ADHD patients, with initially good results, but I'm always hesitant.

Always important to not misapply lessons accross different patient populations... Someone becoming more impulsive on stimulants is a strong sign to reconsider that ADHD diagnosis to be sure. In the cases you describe here, I would actually wonder if there was missed bipolar either in addition to or instead of the borderline. And/or substance use disorders, of course. There's a reason diagnosis is often the hardest part of what we do!

One other thing about my approach to these patients is I take my time to be comfortable with the diagnosis before starting the stimulant. It's not gonna happen in the first visit. If the patients are genuinely invested in their own mental health, they respond very well and appreciate the thoughtfulness. It sounds like this are patients you have taken the time to diagnose thoughtfully, so by all means thoughtfully treat them with stimulants if it seems appropriate.

 

[Ceke2002]

There is a subset of BPD patients that I see that checks all the boxes for ADHD criteria. Now, I know these are treacherous waters, so I always try to check and double-check these cases: can the impulsivity be associated with emotional triggers and chronic feelings of emptiness, or it has a strong motor and learning component as well? Did these symptoms began before 12y.o? Do other family members give similar informations as well? Do the patients report significant sympotms from standarized tools, in multiple sessions, and can give real-life examples from where these symptoms impact them?

And even though I'm very diligent in these evaluations, some patients DO fill the criteria for ADHD and BPD - they seem to coexist, and usually amplify the other condition (dificulty in paying attention in a job setting makes them even more rejection-sensitive to colleagues; the emotional instability makes it even harder for them to concentrate). There seems to be a literature that indicates a significant overlap between the two: Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder - PubMed

My question is: how do you usually manage these patients? Ofc, I always offer psychotherapy as a primary resource, but am much more conflicted on giving dopamine-agonists, specially if the patient has a history of drug abuse as some BPD have. Am I being overtly cautious? Can you guys please share some insights?

Thanks in advance!

I was diagnosed with both. There is definitely some crossover with symptoms, as you've said, but speaking personally in the brief period I was taking ADHD medicine it did absolutely nothing for my BPD symptoms (that required therapy, and lots of). Happy to go into more detail for you if it will help.

 

[Merovinge]

While I wouldn't necessarily have a problem with psychostimulants in the population of known BPD, I am always a bit suspicious if someone who has had longstanding impairment and thus likely lot of contact with the mental health field has not been diagnosed or at least had conversations around ADHD in the past. Everyone (and their mother's) talks about ADHD these days. I would certainly want to talk to a previous psychiatrist, or therapist, to get some more collateral around what they saw versus what you are seeing.

Once you have decided on a novel ADHD dx, I would strongly consider the norepi meds (Strattera, Qelbree) and/or Intuniv. I do think psychostims done with good practice (regular utox, checking controlled sub registry) are reasonable but when you know the person is statistically more likely to misuse prescription medications the non-stimulants certainly elevate further in the risk/benefit ratio. For active SUD, I would limit to only non-stim medications.

 

[comp1]

BPD is of course not an absolute contraindication. However, you are very right to be more vigilant because the symptoms are going to so tightly overlap. I would want to make sure the person was in or had completed formal BPD treatment of some sort or at least planned to be prior to starting a stimulant. Also second non-stimulant options.

 

[Ceke2002]

While I wouldn't necessarily have a problem with psychostimulants in the population of known BPD, I am always a bit suspicious if someone who has had longstanding impairment and thus likely lot of contact with the mental health field has not been diagnosed or at least had conversations around ADHD in the past. Everyone (and their mother's) talks about ADHD these days. I would certainly want to talk to a previous psychiatrist, or therapist, to get some more collateral around what they saw versus what you are seeing.

Once you have decided on a novel ADHD dx, I would strongly consider the norepi meds (Strattera, Qelbree) and/or Intuniv. I do think psychostims done with good practice (regular utox, checking controlled sub registry) are reasonable but when you know the person is statistically more likely to misuse prescription medications the non-stimulants certainly elevate further in the risk/benefit ratio. For active SUD, I would limit to only non-stim medications.

Just out of sheer curiosity, what do you do when the person was diagnosed eons ago, the clinic where the diagnosis was made no longer exists, and all of the diagnosing physicians have likely passed on? What level of secondary (? is that the correct term) collateral would you then be satisfied with to make a diagnosis of ADHD under the aforementioned conditions of comorbid (dual diagnosis?) BPD?

*Not looking for medical advice, I've already been diagnosed with ADHD in childhood, re-diagnosed as an adult, and then had the adult diagnosis confirmed a second time, so I don't need to know how to get a diagnosis for myself. I'm just genuinely curious, because the above situation was exactly what I found myself in and it took ages to find a Psychiatrist who would accept other forms of collateral such as partners, friends, and/or family members. Plus it might help other physicians in a similar situation.

 

[comp1]

I don't think you have to get the Ouija board out to talk to dead providers. Collateral from living family members who knew you as a kid could be almost as helpful.

 

[annoyedpsychiatrist]

i have a good number of young people with BPD on stimulants because they have comorbid ADHD. More than possible to have both. Same principle with BPD and depression. Dont ignore the depression and say its just their BPD. I have a patient with BPD and hx of drug use. But honestly, she was extremely honest about everything and has been clean for >2 years as evidenced by multiple UDS at different intervals. She has clear diagnosis of ADHD, multiple notes showing this from her childhood hx. I give her concerta but I also do intermittent UDS and there is a general understanding that active substance use disorder=no stimulants.

 

[comp1]

I've rarely found that people ignore any other comorbid condition. Providers tend to ignore or minimize the role of the BPD in symptoms since there's nothing like a stimulant or SSRI to manage that.

 

[annoyedpsychiatrist]

I've rarely found that people ignore any other comorbid condition. Providers tend to ignore or minimize the role of the BPD in symptoms since there's nothing like a stimulant or SSRI to manage that.

i think it goes both ways- there is also a very negative stigma attached to BPD, imo.

 

[comp1]

BPD targets nearly every person's countertransference at a very core and kind of universal place. On a societal level, it would be very odd for it to not to have a stigma. As clinicians, we have to power through that, hopefully in our own therapy, and definitely not ignore or minimize it. It is treatable. The stigma is a reason it gets ignored, easier than facing it head on in the short term.

 

[Ceke2002]

I don't think you have to get the Ouija board out to talk to dead providers. Collateral from living family members who knew you as a kid could be almost as helpful.

That's what I thought. I did get the feeling that providers who insisted on medical records above anything else didn't actually want to be diagnosing or treating an ADHD patient, which did make me wonder why they bothered to accept the referral in the first place.

i have a good number of young people with BPD on stimulants because they have comorbid ADHD. More than possible to have both. Same principle with BPD and depression. Dont ignore the depression and say its just their BPD. I have a patient with BPD and hx of drug use. But honestly, she was extremely honest about everything and has been clean for >2 years as evidenced by multiple UDS at different intervals. She has clear diagnosis of ADHD, multiple notes showing this from her childhood hx. I give her concerta but I also do intermittent UDS and there is a general understanding that active substance use disorder=no stimulants.

This is an excellent point, and important to note from a patient's point of view as well. Aside from just not liking the side effects of ADHD medication, the other reason I stopped taking meds is just being peeved at the attitude of, "well I gave you a pill, what more do you want', when raising other diagnosis such as depression and GAD. In my case it was like the ADHD medication was expected to treat everything, and the only thing it did treat (surprise, surprise) was the ADHD itself.

 

[mistafab]

There is a historical, research debate.

Borderline is shown to have, on average, 5 comorbid conditions.

The debate is do they have 1 condition or 6 conditions.

My stance is that they have 1.

 

[solitarius]

Another perspective is their impulsivity is worsened if you don't treat their ADHD, which can't help their baseline BPD functioning.

 

[thelastpsych]

There is a historical, research debate.

Borderline is shown to have, on average, 5 comorbid conditions.

The debate is do they have 1 condition or 6 conditions.

My stance is that they have 1.

I get what you are saying, especially related to BPD and comorbid eating disorders, SUD and GAD - they sometimes appear like different facets of the same problem (impulse control, prefrontal and limbic conectivity, self-image issues and other psychodinamic processes). But ADHD, although sharing some characteristics in phenomenology and neurocircuitry, seem like a different beast altogheter, with a VERY distinct clinical presentation and treatment. So I was curious if you could expand on your explanation, because it definately fits in some cases, but appears to me to not fit that much on others.

 

[Ceke2002]

There is a historical, research debate.

Borderline is shown to have, on average, 5 comorbid conditions.

The debate is do they have 1 condition or 6 conditions.

My stance is that they have 1.

So if someone was legitimately diagnosed with ADHD in early childhood, then showed symptoms of BPD in their later teen years, is it your stance that 1) The ADHD was a misdiagnosis and the person has only ever had BPD, or 2) That the ADHD itself has somehow morphed into BPD, thereby becoming a different diagnosis all together, or C) The person grew out of their ADHD diagnosis and then developed BPD, or D) Something else entirely?

I am also interested in an expanded explanation, and just from my own experience do agree with what thelastpsych said above.

 

[Osminog]

The concept of "comorbidity" is nebulous in psychiatry. For two conditions to be "comorbid" in the medical sense, they need to be clinically distinct entities. In psychiatry, we usually cannot confidently label entities as clinically distinct from one another. This is because we have a poor understanding of the etiologies of primary psychiatric disorders and because the disorders are poorly demarcated. The DSM-5-TR explains, "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder." For practical purposes, discussions about whether symptoms stem from a single psychopathology or from multiple "comorbid" ones are usually complete wastes of time.

 

[PsyDr]

The concept of "comorbidity" is nebulous in psychiatry. For two conditions to be "comorbid" in the medical sense, they need to be clinically distinct entities. In psychiatry, we usually cannot confidently label entities as clinically distinct from one another. This is because we have a poor understanding of the etiologies of primary psychiatric disorders and because the disorders are poorly demarcated. The DSM-5-TR explains, "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder." For practical purposes, discussions about whether symptoms stem from a single psychopathology or from multiple "comorbid" ones are usually complete wastes of time.

uhhhhmmm...

"E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal)."

 

[clausewitz2]

uhhhhmmm...

"E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal)."

I think that's slightly different. It's more of a statement of an implicit hierarchy of diagnosis. "don't give someone this diagnosis if they're a better fit for the following diagnoses, because they trump it."

 

[Stagg737]

uhhhhmmm...

"E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal)."

Yes, we like to say that symptoms are consistent to the criteria listed in the DSM with ways to easily distinguish causal pathology, but in our field, especially the outpatient setting, this is highly subjective. A good interview is important to differentiate if a period of depression in someone with BPD as a discrete etiology vs an exacerbation of borderline symptoms. However, unless one is able to directly witness it then our diagnosis is dependent on secondhand accounts which may be inaccurate or straight up wrong. I constantly see patients where my assessment and diagnoses are very different from what another psychiatrist or psychologist has said. I'm sure there are times I'm wrong, many times I'm not and the previous assessment was trash. It is common in our field.

This is not like other areas of medicine where we can get labs/imaging, do a biopsy and determine what is going on which have well-known, observable, and discrete pathophysiology. Yes, there are plenty of gray areas in other fields of medicine with some conditions being diagnoses of exclusion, but I don't know any other fields in which basically every diagnosis is determined by a interview and basic clinical observations without more objective diagnostic criteria and testing available.

 

[thelastpsych]

The concept of "comorbidity" is nebulous in psychiatry. For two conditions to be "comorbid" in the medical sense, they need to be clinically distinct entities. In psychiatry, we usually cannot confidently label entities as clinically distinct from one another. This is because we have a poor understanding of the etiologies of primary psychiatric disorders and because the disorders are poorly demarcated. The DSM-5-TR explains, "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder." For practical purposes, discussions about whether symptoms stem from a single psychopathology or from multiple "comorbid" ones are usually complete wastes of time.

That is very true, although there are some 'clusters' of conditions, hence the continuum of bipolar and schizophrenia in broad studies. There seems to be also a strong component of personality disorders in patients with substance use disorders. But, although we have a very poor understanding of the underlying etiology, and conditions usually 'pile up' on top of one another (magnified by our mostly subjective analysis and no objective findings), from a very pragmatic point of view, which comes down to treatment and management, it seems very useful to treat them as discrete entities, knowing full well that they are not.

Examples where this is true: Unipolar versus Bipolar depressive disorders (do I use mood stabilizers or antidepressants? Or both?); Manic episode with psychotic symptoms versus schizophrenia (do I add a mood stabilizer?); is there comorbid ADHD (do I use a psychostimulant or dopaminergic/noradrenergic agent?); is there an underlying personality disorders, such as borderline (do I give a bigger focus on psychotherapy? How do I manage crisis and such?); is there a SUD associated? All these questions, far from answering if they are truly discrete entities, point to the practical aspects of management and case formulation - ofc, we shoulnd't be so fixated on the DSM that ALL we can see is this, but definately is important for us to structure our thought.

So, in a sense it is not epistemiologically all that important to know if the BPD patient has a different condition artificially called ADHD (based on observation and subjective analysis), but it sure as heck helps in the management of these patients - patients with ADHD tend to respond well to stimulants, with one of the lowest NNTs in medicine, and patients without the artifical/comorbid/whatever condition we label ADHD tend to NOT respond well.

 

[smalltownpsych]

One way to improve diagnostic reliability, studies have shown that using base rates improves accuracy. I believe that there are cases where BPD and ADHD cooccur and should be treated individually. I just suspect that it is not very common and that the rate of stimulants being prescribed for all patients is far higher. Almost all of my patients with BPD say at one time or another that they think they have ADHD usually because they have PTSD which I think cooccurs with the majority of BPD patients. I recall that it was estimated to be about 80% of BPD patients reporting having experienced trauma. I have been treating patients with BPD for quite a while and I can’t think of any where I felt stimulants made a lot of clinical sense. Not saying it never does just that I think it is rarer than what we see which is that almost all of my patients with BPD have had stimulants thrown at them (along with a lot of other poorly thought out polypharmacy) at some time during he course of treatment so I tend to be skeptical.

 

[Celexa]

It's being implied in some of the conversation here but I just wanted to highlight again the question of time in sorting through diagnosis and comorbidity. I see way too much where people treat the initial visit as the diagnostic visit and then everything after as treatment, which causes all sorts of issues. All the more so if follow ups are <15 mins of actually talking with the pt.

I've seen patients that came in with six labels and had a single diagnosis at the bottom of it, and I've had patients that came in with a single labeled pinned to them who had multiple untreated comorbidities. For better or worse we mainly medicate via symptom, which means we don't need to be 100% certain of our diagnoses to prescribe thoughtfully. We just have to have done our due diligence in assessment and have good reason to think the medication is more likely to be helpful than harmful. Diagnostic uncertainty should inform your treatment choices but unlike in, say, oncology, it isn't a barrier to treatment. But it does require tolerance of ambiguity, which is not a quality the modern medical system is good at handling.

 

[Ceke2002]

One way to improve diagnostic reliability, studies have shown that using base rates improves accuracy. I believe that there are cases where BPD and ADHD cooccur and should be treated individually. I just suspect that it is not very common and that the rate of stimulants being prescribed for all patients is far higher. Almost all of my patients with BPD say at one time or another that they think they have ADHD usually because they have PTSD which I think cooccurs with the majority of BPD patients. I recall that it was estimated to be about 80% of BPD patients reporting having experienced trauma. I have been treating patients with BPD for quite a while and I can’t think of any where I felt stimulants made a lot of clinical sense. Not saying it never does just that I think it is rarer than what we see which is that almost all of my patients with BPD have had stimulants thrown at them (along with a lot of other poorly thought out polypharmacy) at some time during he course of treatment so I tend to be skeptical.

I remember coming across the idea of base rates when I was hoping to return to psychology studies. It made a lot of sense to me at a time, that is if I was understanding it correctly. So would it be correct to say that base rates for diagnoses like ADHD and BPD would be something like - "90 percent of kids show some signs of hyperactivity and impulse control, but 90 percent of kids are not going to found up a tree impulsively trying to climb into a zoo enclosure." or "90 percent of people feel upset after the end of a relationship, but 90 percent of people do not down half a bottle of vodka and slice their arms up when a relationship ends after a week."?

 

[Celexa]

I remember coming across the idea of base rates when I was hoping to return to psychology studies. It made a lot of sense to me at a time, that is if I was understanding it correctly. So would it be correct to say that base rates for diagnoses like ADHD and BPD would be something like - "90 percent of kids show some signs of hyperactivity and impulse control, but 90 percent of kids are not going to found up a tree impulsively trying to climb into a zoo enclosure." or "90 percent of people feel upset after the end of a relationship, but 90 percent of people do not down half a bottle of vodka and slice their arms up when a relationship ends after a week."?

It's more like, if 10% of the population has disease x, and 20% has disease y, then the chances that someone with disease x having disease y will be between 2% (if there is no relationship between the two whatsoever) and 100% (if every single person with disease x has disease y), but if it's 100% then disease x probably needs to be rethought as a diagnostic entity. And based on what is know about the genuine rate of comorbidity between the two, it can help you in feeling out the diagnosis for a given pt.

To put out a clearer real world example, there's an unfortunate diagnostic epidemic in my neck of the woods of patients being diagnosed with all three of: intellectual disability, borderline, and schizoaffective disorder . True schizoaffective disorder is fairly rare and the 'borderline' traits these patients allegedly have are impulsivity and poor distress tolerance with change. Most of them have ID but not the other two diagnoses and the baseline rates of schizoaffective and borderline and their co-occurence illustrate why there's little reason to believe the diagnoses are accurate.

Going back to the BPD and ADHD discussion, if you diagnose SOME of your borderline pts with ADHD, that's fair enough, if you diagnosis ALL of them with ADHD, you've prob got a problem in your diagnostic algorithms. You could word it the other way too but I think in adults borderline is often easier to diagnosis compared to ADHD.

 

[Ceke2002]

It's more like, if 10% of the population has disease x, and 20% has disease y, then the chances that someone with disease x having disease y will be between 2% (if there is no relationship between the two whatsoever) and 100% (if every single person with disease x has disease y), but if it's 100% then disease x probably needs to be rethought as a diagnostic entity. And based on what is know about the genuine rate of comorbidity between the two, it can help you in feeling out the diagnosis for a given pt.

To put out a clearer real world example, there's an unfortunate diagnostic epidemic in my neck of the woods of patients being diagnosed with all three of: intellectual disability, borderline, and schizoaffective disorder . True schizoaffective disorder is fairly rare and the 'borderline' traits these patients allegedly have are impulsivity and poor distress tolerance with change. Most of them have ID but not the other two diagnoses and the baseline rates of schizoaffective and borderline and their co-occurence illustrate why there's little reason to believe the diagnoses are accurate.

Going back to the BPD and ADHD discussion, if you diagnose SOME of your borderline pts with ADHD, that's fair enough, if you diagnosis ALL of them with ADHD, you've prob got a problem in your diagnostic algorithms. You could word it the other way too but I think in adults borderline is often easier to diagnosis compared to ADHD.

Thank you, that makes more sense now.

 

[thelastpsych]

It's more like, if 10% of the population has disease x, and 20% has disease y, then the chances that someone with disease x having disease y will be between 2% (if there is no relationship between the two whatsoever) and 100% (if every single person with disease x has disease y), but if it's 100% then disease x probably needs to be rethought as a diagnostic entity. And based on what is know about the genuine rate of comorbidity between the two, it can help you in feeling out the diagnosis for a given pt.

To put out a clearer real world example, there's an unfortunate diagnostic epidemic in my neck of the woods of patients being diagnosed with all three of: intellectual disability, borderline, and schizoaffective disorder . True schizoaffective disorder is fairly rare and the 'borderline' traits these patients allegedly have are impulsivity and poor distress tolerance with change. Most of them have ID but not the other two diagnoses and the baseline rates of schizoaffective and borderline and their co-occurence illustrate why there's little reason to believe the diagnoses are accurate.

Going back to the BPD and ADHD discussion, if you diagnose SOME of your borderline pts with ADHD, that's fair enough, if you diagnosis ALL of them with ADHD, you've prob got a problem in your diagnostic algorithms. You could word it the other way too but I think in adults borderline is often easier to diagnosis compared to ADHD.

That is precisely what I was pointing at: I do understand that our diagnosis are inherently imprecise and should not be considered as absolute truths. But these categories are not also merely artificial fabrications, there is an element of observation and treatment pragmatism.

So while ID, Schizoaffective disorder AND borderline CAN co-occur, they are most likely the behavioral manifestations of only ID. Some disorders seem to cluster around other disorders (Eating disorders and BPD for instance, or Panic Disorder and other anxiety disorders), but some DO NOT, and seem like entirely different 'entities' (e.g schizoaffective, ID and borderline; or Cluster A personality traits and Eating disorders). We should be careful to not throw the baby out with the babywater and say that disorders can't be realiably distinct from one another, nor that they are fixed and rigid categorical structures of diagnosis. The idea of axis, and transdiagnostic characteristics seem to be an adequate middle point.

 

[Stagg737]

I think this thread is overthinking things a bit. Frankly, the entire concept of personality disorders is somewhat nebulous with frequent changes between DSM editions and poor construct validity to the point that the general consensus of PD specialists today is that the categorical model should be replaced by the dimensional model. With the current model, 2 patients could both meet criteria for BPD and have almost no overlap in criteria. Bottom line is that BPD as currently diagnosed is a wide spectrum, likely to the point of being inappropriately wide, which can go from clear, severe pathology to what should be considered just traits. Imo, we should be teaching and using criteria A from the AMPD/dimensional model as that tells us if there is even functional deficits at all.

Given that, I focus a lot more clinically on determining if there is a true ADHD diagnosis regardless of a BPD co-morbidity and I'm more concerned about anxiety, depression, or PTSD masquerading as supposed ADHD. Do they meet full criteria for ADHD, specifically the chronicity going back to childhood with ongoing functional difficulties? If yes, then treat it. If not, then don't. If there's concerns of BPD or ongoing SUD making you second guess stimulants, non-stimulant options are fine. When I get a new consult for ADHD one of my first questions is always "Why now?". Just that answer alone is often very telling of what direction things will go in.