Addition of methylphenidate to intensive dialectical behaviour therapy for patients suffering from comorbid borderline personality disorder and ADHD: a naturalistic study

Prevalence and Correlates of Self-Reported ADHD Symptoms in Bariatric Patients: Focus on Mood and Anxiety Comorbidity, Disordered Eating, and Temperamental Traits

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity. A positive association between ADHD and obesity has been observed, especially in adult samples. In this study, prevalence and correlates of self-reported symptoms indicative of a positive screening for ADHD were examined in patients seeking bariatric treatment.

MATERIAL AND METHODS

The study sample was composed of 260 adult patients with obesity referred for bariatric surgery to the Obesity Center of the Endocrinology Unit in Pisa University Hospital between January 2006 and November 2016 (BMI ≥ 30 kg/m2; mean ± standard deviation = 46.27 ± 7.45 kg/m2). ADHD symptoms were identified using ADHD Symptom Check-List-90-R Screening Scale. Night-eating, binge-eating/purging behaviors, and temperamental and character traits were assessed in a subsample of 95 patients.

RESULTS

Thirty participants had a positive screening for ADHD (11.5%, 95% CI = 7.9-16.1%). Patients with a positive screening showed significantly higher rates of anxiety disorders (40% vs. 16.5%, χ2 = 7.97, p = 0.005) panic disorder (40% vs. 14.3%, χ2 = 10.48, p = 0.001), and a higher severity of psychopathological symptoms and sleep disturbances than those without. In subsample analyses, ADHD symptoms severity was associated with more bulimic behaviors (r = 0.31-0.46), greater harm avoidance (r = 0.45-0.66), less self-directedness (r =  - 0.44-0.63), and cooperativeness (r =  - 0.26-0.42).

CONCLUSION

ADHD symptoms may be common in patients with obesity seeking bariatric treatment and are positively associated with disordered eating, internalizing features, and maladaptive character traits.

LEVEL OF EVIDENCE

V, cross sectional descriptive study.

Effectiveness of an online dialectical behavior therapy skills training in adults with attention-deficit/hyperactivity disorder: A randomized controlled trial

OBJECTIVE

The current study aims to examine the efficacy of an add-on dialectical behavior therapy skills training (DBT-ST) on adult attention-deficit/hyperactivity disorder (ADHD). The DBT-ST was applied online under the pandemic conditions that occurred after the study had started.

METHODS

The current randomized controlled trial consists of an intervention group to whom the DBT-ST was applied in online setting and a waitlist control group who received treatment as usual (TAU). Data were collected pre-, post-, and mid-treatment. ADHD symptoms (with the sub-dimensions of inattention and hyperactivity), impulsivity, mindfulness, difficulty with emotion regulation, interpersonal effectiveness, distress tolerance, life satisfaction, functionality in daily life, and general psychological symptom levels were measured with self-report scales. The data were analyzed using mixed-design ANOVA.

RESULTS

The global ADHD, inattention, and hyperactivity symptoms of the DBT-ST group significantly decreased more than those in the TAU control group. The DBT-ST group also showed a significant decrease regarding difficulty with emotion regulation and increases in life satisfaction and functionality, though the group × time effect was not significant.

CONCLUSION

DBT-ST was found effective against the participants' ADHD symptoms. The treatment was additionally found to improve their emotion regulation and quality of life. Further investigation is needed to investigate DBT-ST in an online setting.

Suicidality and nonsuicidal self-injury in females diagnosed with attention-deficit hyperactivity disorder - a narrative review

PURPOSE OF REVIEW

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder and is associated with an increased risk of suicidal behavior, especially in females. The differences in the presentation of ADHD in females, factors contributing to suicidality and the effects of therapeutic interventions are presented in this review to highlight the relationship between ADHD and suicidality and self-harm behavior.

RECENT FINDINGS

Impulsivity, an inherent symptom of ADHD, commonly acts as a risk factor of suicidality and is associated with both suicidal behavior and nonsuicidal self-injury. The combined subtype of ADHD, which typically is characterized by significant impulsivity, is linked with the highest vulnerability to suicide attempts. Female gender, lower educational attainment, comorbid substance abuse, a history of depression, and experience of childhood maltreatment were singled out as distinct factors that were independently linked to lifetime suicide attempts.

SUMMARY

The association of the ADHD and suicidality is gaining an increasing interest in recent years. Active suicide prevention is required in this population and it is crucial for clinicians and researchers to have access to the most current information in this field.

Management Strategies for Borderline Personality Disorder and Bipolar Disorder Comorbidities in Adults with ADHD: A Narrative Review

This narrative review examines two of the common comorbidities of attention-deficit/hyperactivity disorder, bipolar disorder (BD), and borderline personality disorder (BPD), which each share several common features with ADHD that can make assessment and diagnosis challenging. The review highlights some of the key symptomatic differences between adult ADHD and these disorders, allowing for more careful consideration before establishing a formal diagnosis. When the disorders are found to be comorbid, further complications may arise; thus, the review will also help to provide evidence-based treatment recommendations as well as suggestions on how to minimize adverse events. Incorporating evidence from systematic reviews, journal articles, randomized controlled trials, and case reports, this review highlights that the diagnosis of ADHD and some of its common comorbidities is challenging and requires full, in-depth assessment and management. The management strategies of these comorbidities will also be addressed, with emphasis on achieving mood stabilization for BD prior to initiating appropriate ADHD pharmacotherapy. Medications, specifically mood stabilizers, antipsychotics, and antidepressants, are fundamental in treating symptoms seen in BD and some cases of BPD, alongside psychotherapy and lifestyle modifications when appropriate. The review highlights the effectiveness of specific medications, including psychostimulants, atomoxetine, and bupropion, as add-on therapies to mood-stabilizing treatments for addressing ADHD symptoms in patients with these comorbidities. Despite limited research, the review will address various pharmacological and psychotherapeutic approaches for managing comorbid ADHD and BPD, emphasizing the need for further investigations to better understand the unique needs of this patient population.

Borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD) revisited - a review-update on common grounds and subtle distinctions

BACKGROUND

Overlap in symptom domains particularly in the field of impulsivity and emotional dysregulation in attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have stimulated further research activities since our last review from 2014.

MAIN BODY

Disentangling features of impulsivity in ADHD and BPD revealed that impulsivity is a feature of both disorders with patients suffering from both ADHD and BPD having highest impulsivity ratings. BPD individuals have more problems using context cues for inhibiting responses and their impulsivity is stress-dependent, whereas ADHD patients have more motor impulsivity and therefore difficulties interrupting ongoing responses. For emotion regulation difficulties the ranking order ranges from ADHD to BPD to the comorbid condition, again with the patients suffering from both, ADHD and BPD, having the most pronounced emotion regulation problems. Environmental influences namely adverse childhood events were shown to be linked to both ADHD and BPD. Traumatic experiences seem independently linked to impulsivity features. Thus, some authors point to the risk of misdiagnosis during childhood and the necessity to screen for traumatic experiences in both patient groups. Genetic research confirmed genetic overlap of BPD with bipolar disorder (BD) and schizophrenic disorders, as well as genetic overlap of BD and ADHD. A population-based study confirmed the high co-occurrence and familial co-aggregation of ADHD and BPD. Interesting questions in the field of gene-environment-interactions are currently dealt with by genetic and epigenetic research. Few studies have investigated treatment strategies for the comorbid condition, though the issue is highly important for the management of patients suffering from both disorders and presenting with the highest symptom scores.

CONCLUSION

Research on the different impulsivity features might point to a necessity of disorder-specific treatment strategies in the field of impulse control. Future research is needed to base treatment decisions for the comorbid condition on an evidence basis.

Childhood maltreatment, anxiety disorders and outcome in borderline personality disorder

INTRODUCTION

Anxiety disorders are a frequent in borderline personality disorder (BPD) and are associated with more severe symptomatology and poorer functional outcomes. Their presence in BPD is also believed to be the consequence of early life adversities. The aim of our study was to examine the relationship between comorbid anxiety disorders, childhood maltreatment and severity of BPD.

METHODS

388 BPD outpatients were assessed for lifetime anxiety disorders and history of childhood maltreatment. Severity of BPD was measured by the number of DSM-IV BPD criteria, history of suicide attempts, hospitalizations, psychotic symptoms, comorbid substance use disorder, other comorbid disorders, level of depression, hopelessness, impulsivity and trait anger. We used logistic regressions to test the association between childhood maltreatment and anxiety disorders and the effect of those factors on severity indicators RESULTS: More than half of the participants suffered from two or more anxiety disorders. The most common comorbidity was social phobia. Childhood maltreatment was associated with an increased number of anxiety disorders. Both anxiety disorders and childhood maltreatment had, independently from one another, an effect on severity indicators. Anxiety disorders were significantly associated with the number of DSM-IV BPD criteria, suicide attempts and psychotic symptoms. Anxiety disorders had an impact on the level of depression and hopelessness, whereas childhood maltreatment impacted impulsivity and anger trait.

CONCLUSION

Our results show the importance of comorbid anxiety disorders in BPD, as well as their impact on severity. Anxiety disorders and childhood maltreatment should be considered by healthcare professionals to ensure optimal care. Furthermore, interventions targeting those issues need to be developed.

Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.

Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD)

Introduction: ADHD is characterized by a developmentally inappropriate level of inattentiveness, impulsivity and/or hyperactivity. In adults, the disorder is frequently accompanied by Emotional Dysregulation (ED), associated to a variety of related psychiatric comorbidities, complicating its recognition and treatment management. Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in adults with ADHD and ED, other neurodevelopmental disorders, Bipolar Disorder (BD) and Anxiety Disorders (ADs). When controlled data are unavailable, the authors have included open-label and observational studies. Expert opinion: ED in adult patients with ADHD is a very common and impairing problem that can be treated with stimulants or atomoxetine. ADHD studies in adults with other neurodevelopment disorders are scarce; stimulants seem to be the most effective and safe drugs in treating ADHD symptoms, without worsening the core features of other neurodevelopmental disorders. In patients with ADHD and comorbid BD, the treatment of BD alone may result in residual symptoms of ADHD. Patients should be treated hierarchically: BD should be treated first, while ADHD should be treated combining ADHD medications and mood stabilizers after mood stabilization. The available evidence for treating patients with ADHD and comorbid ADs in adults supports the idea of an anti-anxiety/ADHD-specific treatment association.

EEG-vigilance regulation in Borderline Personality Disorder

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by emotional instability, impulsivity, disturbed cognition, sleeplessness and states of high inner tension. Altered arousal regulation which is regarded as a higher domain of functioning according to the research domain criteria of the NIMH and which has previously been reported in several psychiatric disorders, such as mania or major depression could be involved in these features of BPD.

METHODS

40 unmedicated patients with BPD and 42 matched healthy volunteers participated in a twenty minute resting-state EEG measurement with closed eyes. EEG-vigilance regulation was assessed with VIGALL2.0 (Vigilance Algorithm Leipzig), which allows a classification of consecutive 1-s segments in different vigilance stages ranging from high alertness/relaxed wakefulness (stages 0, A1, A2, A3) to drowsiness (B1, B2/3) and sleep onset (C).

RESULTS

Across 20 min, both groups showed a similar decline from higher to lower vigilance stages, but patients with BPD remained in higher stages of vigilance compared to healthy volunteers across the whole measurement (p = .013). Contrary to this, pre-experimental ratings indicated enhanced subjective sleepiness but no differences in self-reported sleep quantity in the previous night in patients with BPD compared to healthy volunteers.

CONCLUSIONS

The results of an elevated arousal regulation (in combination with increased subjective sleepiness) might reflect several symptoms, such as aversive inner tension and impoverished sense of self in patients with BPD. As arousal is linked to the noradrenergic system, further investigations in this field seem to be promising.

Attention Deficit Hyperactivity Disorder And Borderline Personality Disorder In Adults: A Review Of Their Links And Risks

Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are particularly common disorders, that are highly comorbid in adult populations. The symptomatic overlap between adult ADHD and BPD includes impulsivity, emotional dysregulation and interpersonal impairment, which makes the differential diagnosis difficult. Our review aims at focusing on recent data on the comorbid ADHD+BPD form, as well as the risk factors involved in the emergence of the two disorders. While adult ADHD and BPD share some genetic and temperamental risk factors, adult ADHD is characterized by more severe trait-impulsivity compared to non-comorbid BPD; BPD patients display more severe trait-emotion regulation symptoms compared to non-comorbid ADHD. Patients with the comorbid ADHD+BPD form have severe symptoms in both dimensions. Early-life exposure to adverse events is a shared risk factor for the development of ADHD and BPD, but type and timing of adversity seem to play a differential role in the development of BPD and ADHD symptoms. Age of onset used to be a discriminative diagnostic criterion between ADHD, an early-onset neurodevelopmental disorder, and BPD, a late-onset psychological disorder. However, this distinction has been recently called into question, increasing the need for more research aiming at delineating the disorders from a developmental and clinical standpoint. Clinicians should carefully consider the comorbidity, and consider ADHD and BPD dimensionally, in order to provide more effective patient management. This might improve early preventive interventions, and treatment for comorbid conditions in adulthood.

The effect of methylphenidate on decision making in patients with borderline personality disorder and attention-deficit/hyperactivity disorder

Impaired decision making in patients with borderline personality disorder (BPD) has been reported in several studies. Although methylphenidate (MPH) is known to ameliorate impaired decision making in patients with attention-deficit/hyperactivity disorder (ADHD), it has not yet been examined in patients with BPD. We therefore assessed the efficacy of a single dose of MPH on cognitive functions and decision making in patients with BPD. Twenty-two patients diagnosed with BPD participated in the study. The study was a randomized, double-blind placebo-controlled, random block order cross-over trial. Patients participated in two sessions and performed the Test of Variables of Attention, a digit-span test, and the computerized Iowa Gambling Task, after they had been administered either the MPH or a placebo. ADHD symptoms were assessed using the Adult ADHD Self-Report Scale-18. Lower scores on the inattention symptoms scale were associated with a greater improvement in decision making following the administration of MPH when compared with improvements in patients with higher ADHD scores [F(1,17)=5.63, P=0.030]. We conclude that MPH may improve decision making in patients with BPD, although this effect is mediated by the level of ADHD symptoms. Further studies are needed to assess whether a prolonged beneficial effect of MPH on decision making in patients with BPD might also be present in 'real life'.

Emotion dysregulation in attention-deficit/hyperactivity disorder and borderline personality disorder

There is ongoing debate on the overlap between Attention-Deficit/Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD), particularly regarding emotion dysregulation (ED). In this paper, we present a narrative review of the available evidence on the association of these two disorders from several standpoints. First, we discuss the unique and shared diagnostic criteria for ADHD and BPD, focusing particularly on ED. We consider the methodology of ecological momentary assessment and discuss why this approach could be an alternative and more accurate way to qualitatively distinguish between ADHD and BPD. We summarise key findings on the genetic and environmental risk factors for ADHD and BPD and the extent to which there are shared or unique aetiological and neurobiological risk factors. Finally, we discuss the clinical relevance of considering both disorders in the assessment of patients presenting with trait-like behavioural syndromes, distinguishing the two conditions and implications for treatment.

Top-Down Dysregulation-From ADHD to Emotional Instability

Deficient cognitive top-down executive control has long been hypothesized to underlie inattention and impulsivity in attention-deficit/hyperactivity disorder (ADHD). However, top-down cognitive dysfunction explains a modest proportion of the ADHD phenotype whereas the salience of emotional dysregulation is being noted increasingly. Together, these two types of dysfunction have the potential to account for more of the phenotypic variance in patients diagnosed with ADHD. We develop this idea and suggest that top-down dysregulation constitutes a gradient extending from mostly non-emotional top-down control processes (i.e., “cool” executive functions) to mainly emotional regulatory processes (including “hot” executive functions). While ADHD has been classically linked primarily to the former, conditions involving emotional instability such as borderline and antisocial personality disorder are closer to the other. In this model, emotional subtypes of ADHD are located at intermediate levels of this gradient. Neuroanatomically, gradations in “cool” processing appear to be related to prefrontal dysfunction involving dorsolateral prefrontal cortex (dlPFC) and caudal anterior cingulate cortex (cACC), while “hot” processing entails orbitofrontal cortex and rostral anterior cingulate cortex (rACC). A similar distinction between systems related to non-emotional and emotional processing appears to hold for the basal ganglia (BG) and the neuromodulatory effects of the dopamine system. Overall we suggest that these two systems could be divided according to whether they process non-emotional information related to the exteroceptive environment (associated with “cool” regulatory circuits) or emotional information related to the interoceptive environment (associated with “hot” regulatory circuits). We propose that this framework can integrate ADHD, emotional traits in ADHD, borderline and antisocial personality disorder into a related cluster of mental conditions.