Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)-review of recent findings

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.

Psychopathological Dissection of Bipolar Disorder and ADHD: Focussing on Racing Thoughts and Verbal Fluency

In the present study, we propose a review and a synthesis of the work of our group about the phenomenology and the cognitive mechanisms of racing thoughts in bipolar disorder (BD) and ADHD. Contrary to the mainstream idea according to which racing thoughts are pathognomonic of BD, our work suggests that racing thoughts are enhanced in ADHD compared to hypomanic episodes of BD, whereas in euthymic episodes of BD self-reported racing thoughts are similar to the rates reported by healthy controls. Using verbal fluency tasks, we found many similarities between bipolar and ADHD subjects with one clear difference: lexical search strategy in hypomania is based on phonemic similarities rather than semantic-relatedness. However, this distinction observed in this cognitive task is certainly difficult to grasp during a clinical interview aiming to differentiate mild hypomania from combined ADHD presentation. The main landmark to distinguish them remains the episodic nature of bipolar disorders as opposed to the lifelong presentation of ADHD symptoms, a dichotomous view that is not so clear-cut in clinical practice.

Group-based emotion regulation skills training for adults with ADHD: A feasibility study in an outpatient psychiatric setting

The aim of this open non-controlled clinical trial was to investigate the feasibility and preliminary treatment effects of a new group-based skills training program for adult ADHD: Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD (GEARS). Out of the 226 allocated patients, 213 initiated the treatment and 170 (80%) were considered treatment completers (i.e., attending at least 9 out of 14 sessions). A total of 158 of the completers also completed pre- and post-treatment assessments, and 126 provided assessments at the 3-month follow-up. Treatment credibility received high ratings, as did treatment satisfaction. Preliminary treatment effects showed significant improvements in emotion regulation with large effect sizes. Significant effects were also found for all secondary outcome variables: ADHD symptom levels, depression, anxiety, and quality of life. All significant effects remained at the 3-month follow-up. In conclusion, GEARS should be considered a feasible treatment in an outpatient psychiatric setting. The results also indicate that GEARS could be an effective treatment for adults with ADHD who are also experiencing problems with emotion regulation. However, a randomized controlled trial is needed to further evaluate the effectiveness of this new treatment.

Low-grade inflammation as mediator between diet and behavioral disinhibition: A UK Biobank study

BACKGROUND

Dietary patterns have been associated with variations in behavior. However, evidence has been limited and mixed, and the underlying mechanism remains unclear.

OBJECTIVE

Extend a previous study reporting significant associations between food patterns and behavioral disinhibition and explore whether low-grade inflammation is linked to behaviors and mediates the association between diet and behavioral disinhibition.

DESIGN

Among participants of the UK Biobank (UKB) we extracted a single behavioral disinhibition principal component using the UKB touchscreen questionnaire, Mental Health Questionnaire (MHQ), and registered diagnoses. We identified four dietary patterns (prudent diet, elimination of wheat/dairy/eggs, meat-based diet, full-cream dairy consumption) by using the Food Frequency Questionnaire (FFQ). Immune biomarkers and an aggregated inflammation score (INFLA-score) were used to characterize low-grade inflammation. Associations between dietary patterns and immune biomarkers, between immune biomarkers and disinhibition were assessed, with adjustment for demographics, lifestyle factors, and somatic health conditions. Next, mediation analyses were run to examine whether the association between dietary patterns and disinhibition was partially explained by inflammatory levels. We also conducted subgroup analyses to explore whether associations and the mediation effect differed by sex, age, ethnicity/race, body-mass-index (BMI), and socioeconomic status (SES).

RESULTS

The prudent diet was negatively, and the meat-based diet was positively associated with several pro-inflammatory biomarkers. Most immune biomarkers were positively associated with disinhibition (numbers of lymphocytes (β_standardized = 0.082, p < 0.001), monocytes (β_standardized = 0.043, p < 0.001), neutrophils (β_standardized = 0.071, p < 0.001), platelets (β_standardized = 0.022, p < 0.001), leukocytes (β_standardized = 0.093, p < 0.001), C-reactive protein (β_standardized = 0.051, p < 0.001), and for INFLA-score (β_standardized = 0.074, p < 0.001). In the mediation model, the INFLA-score mediated the association between prudent diet and meat-based diet and disinhibition score, with a significant indirect effect of low-grade inflammation for the prudent diet-disinhibition association (β_standardized = -0.007, p < 0.001) and for meat-disinhibition association (β_standardized = 0.001, p < 0.001)). Although all effects were small, covariates and interaction term adjustments did not attenuate the effects, and neither did most subgroup-only analyses.

CONCLUSIONS

The prudent diet was associated with a lower disinhibition score and this effect was partially mediated by the lower inflammation. Reversely, the meat-based diet was linked to more inflammation, which was associated with more disinhibition. Our findings suggest mediating effects of immune function in the relationship between diet and behavioral disinhibition. However further alternative designs such as interventional trials are needed to establish causal effects.

Effect of comorbid ADHD on mortality in women with borderline personality disorder

BACKGROUND

Many similarities exist between borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD), more so in women than in men. People with comorbid ADHD and BPD represent a subgroup of BPD patients with distinct symptom expression and, consequently, a different prognosis. We used Swedish national high quality registers to assess whether such comorbidity is related to increased mortality risk. The study focused on women with BPD because they are more likely than men to be clinically diagnosed with BPD and present a higher mortality risk, especially for unnatural causes of death, including suicide.

FINDINGS

In a cohort of 15 847 women diagnosed with BPD a subsequent clinical diagnosis of ADHD did not influence the overall risk of mortality, including suicide.

CONCLUSIONS

Women with comorbid ADHD and BPD have a similar mortality risk as those only diagnosed with BPD.

ADHD Symptoms, Peer Problems, and Emotion Dysregulation as Longitudinal and Concurrent Predictors of Adolescent Borderline Personality Features

OBJECTIVE

ADHD and borderline personality (BP) disorder are highly comorbid and characterized by emotion dysregulation and peer problems. However, limited research has examined social and emotional predictors of BP features in samples that include youth with ADHD.

METHOD

Using a sample of 124 youth with and without ADHD (52% female), ADHD symptoms, peer problems, and emotion dysregulation were assessed in childhood (8-13 years) and in adolescence, along with BP features (13-18 years).

RESULTS

In addition to the significant effect of ADHD symptoms, teacher-rated child peer victimization and adolescent-reported peer victimization, poorer close friendships, and emotion dysregulation domains significantly predicted adolescent BP features. Greater parent-rated child and adolescent emotion dysregulation domains also significantly predicted adolescent BP features, with ADHD symptoms no longer significant.

CONCLUSION

Even for youth with ADHD, peer and emotional vulnerabilities in childhood and adolescence may serve as important markers of risk for adolescent BP features.

Exploring ADHD Users’ Behavior on Twitter: A Comparative Analysis of Tweet Content and User Interactions (Preprint)

BACKGROUND

With the widespread use of social media, people share their real-time thoughts and feelings via interactions on these platforms, including those revolving around mental health problems. This can provide a new opportunity for researchers to collect health-related data to study and analyze mental disorders. However, as one of the most common mental disorders, there are few studies regarding the manifestations of attention-deficit/hyperactivity disorder (ADHD) on social media.

OBJECTIVE

This study aims to examine and identify the different behavioral patterns and interactions of users with ADHD on Twitter through the text content and metadata of their posted tweets.

METHODS

First, we built 2 data sets: an ADHD user data set containing 3135 users who explicitly reported having ADHD on Twitter and a control data set made up of 3223 randomly selected Twitter users without ADHD. All historical tweets of users in both data sets were collected. We applied mixed methods in this study. We performed Top2Vec topic modeling to extract topics frequently mentioned by users with ADHD and those without ADHD and used thematic analysis to further compare the differences in contents that were discussed by the 2 groups under these topics. We used a distillBERT sentiment analysis model to calculate the sentiment scores for the emotion categories and compared the sentiment intensity and frequency. Finally, we extracted users' posting time, tweet categories, and the number of followers and followings from the metadata of tweets and compared the statistical distribution of these features between ADHD and non-ADHD groups.

RESULTS

In contrast to the control group of the non-ADHD data set, users with ADHD tweeted about the inability to concentrate and manage time, sleep disturbance, and drug abuse. Users with ADHD felt confusion and annoyance more frequently, while they felt less excitement, caring, and curiosity (all P<.001). Users with ADHD were more sensitive to emotions and felt more intense feelings of nervousness, sadness, confusion, anger, and amusement (all P<.001). As for the posting characteristics, compared with controls, users with ADHD were more active in posting tweets (P=.04), especially at night between midnight and 6 AM (P<.001); posting more tweets with original content (P<.001); and following fewer people on Twitter (P<.001).

CONCLUSIONS

This study revealed how users with ADHD behave and interact differently on Twitter compared with those without ADHD. On the basis of these differences, researchers, psychiatrists, and clinicians can use Twitter as a potentially powerful platform to monitor and study people with ADHD, provide additional health care support to them, improve the diagnostic criteria of ADHD, and design complementary tools for automatic ADHD detection.

Unimpaired social cognition in adult patients with ADHD: brain volumetric and behavioral results

The present study aimed to investigate whether adult patients with attention deficit hyperactivity disorder (ADHD) show deficits in social cognition and to identify the structural neural correlates of social cognitive skills in ADHD. Twenty-six adult patients with ADHD and 26 matched healthy control participants performed the Movie for the Assessment of Social Cognition and underwent a structural magnetic resonance imaging scan. We compared theory of mind (ToM) performance between ADHD patients and healthy controls. Using voxel-based morphometry, we further compared gray matter volumes in regions that are critical for social cognition between the two groups and examined whether ToM performance was correlated with brain morphometry measures. We did not observe any between-group differences in ToM abilities or regional gray matter volumes. Across both groups, performance on affective aspects of ToM correlated positively with gray matter volumes in the medial part of the superior frontal gyri, which is typically involved in social cognition. This study is the first to relate brain structure to social cognitive abilities in adult patients with ADHD. Although our sample was small and heterogeneous, with half of the patients showing mild-to-moderate psychiatric comorbidities, our results may encourage longitudinal studies that relate social cognitive development in childhood and adolescence to brain maturation of ADHD patients.

Link between History of Childhood Maltreatment and Emotion Dysregulation in Adults Suffering from Attention Deficit/Hyperactivity Disorder or Borderline Personality Disorder

Childhood maltreatment (CM) may have a long-term effect on emotion regulation. This study aimed to explore the relationship between CM and emotion dysregulation (ED) in a heterogeneous population. Four hundred seventy French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 ADHD + BPD, N = 61 clinical controls) completed the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), the Childhood Trauma Questionnaire (CTQ), and the Relationship Scales Questionnaire (RSQ). Reports of childhood maltreatment experiences were significantly associated with increased levels of emotion reactivity in all our groups and in the whole population, with a greater use of non-adaptive cognitive emotion regulation strategies and insecure attachment patterns. Emotional abuse showed the strongest effect. Further analysis indicated that an anxious attachment style significantly mediated the relationship between CM and the use of non-adaptive cognitive emotion regulation strategies and emotion reactivity. The results of our study suggest an impact of CM on ED and a potentially marked effect of emotional abuse. They also indicate a potentially mediating role of insecure attachment in the relationship between a history of childhood abuse and emotion reactivity and a higher use of non-adaptive cognitive emotion regulation strategies in adulthood.

Divergent mentalization types in adolescent borderline personality disorder and attention deficit/hyperactivity disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have several similarities and it is difficult to distinguish these disorders in adolescents. We aimed to identify the unique correlates of mentalization abilities that may distinguish these two disorders, and to investigate the mentalization abilities of adolescents with ADHD, BPD and ADHD + BPD in an inpatient sample to determine the effect of co-morbidity on mentalization abilities.

METHODS

We have explored the relationship between Child Eye Test (CET) scores, Movie for the Assessment of Social Cognition (MASC) subscales, and ADHD and BPD symptoms in adolescent inpatients. In addition, we compared ADHD, BPD and ADHD + BPD groups in terms of their mentalization abilities.

RESULTS

Correct MASC scores were negatively associated with both ADHD and BPD symptoms in girls, and negatively associated with ADHD symptoms in boys. In addition, hypermentalization scores were associated with BPD symptoms in girls, and hypomentalization and no mentalization scores were associated with ADHD symptoms in girls. CET scores were negatively associated with ADHD symptoms in girls, but no relations with BPD were found. Group comparisons revealed no significant difference among groups.

LIMITATIONS

We included only inpatient sample without considering their medication condition, we did not compare the mentalization scores of the patient groups with healthy controls and we used self-report measures for several assessments.

CONCLUSION

Mentalization patterns in ADHD and BPD are distinct. ADHD may be related to hypomentalization, instead, BPD may be related to hypermentalization.

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.

Standard set of patient-reported outcomes for personality disorder

PURPOSE

The purpose of the article is to present standard set of outcomes for people with personality disorder (PD), in order to facilitate patient outcome measurement worldwide.

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) gathered a multidisciplinary international working group, consisting of 16 experts, including clinicians, nurses, psychologists, methodologists and patient representatives, to develop a standard set of outcome measures for people with PD. The Delphi method was used to reach consensus on the scope of the set, outcome domains, outcome measures, case-mix variables and time points for measuring outcomes in service users. For each phase, a project team prepared materials based on systematic literature reviews and consultations with experts.

RESULTS

The working group decided to include PD, as defined by International Classification of Diseases 11th revision (ICD-11). Eleven core outcomes and three optional outcomes across four health domains (mental health, behaviour, functioning and recovery) were defined as those relevant for people with PD. Validated measures for the selected outcomes were selected, some covering more than one outcome. Case-mix variables were aligned to other ICHOM mental health standard sets and consisted of demographic factors and those related to the treatment that people received. The group recommended that most outcomes are measured at baseline and annually.

CONCLUSION

The international minimum standard set of outcomes has the potential to improve clinical decision making through systematic measurement and comparability. This will be key in improving the standard of health care for people with PD across the world.

Adult ADHD and emerging models of maladaptive personality: a meta-analytic review

BACKGROUND

ADHD is a highly consequential disorder that is estimated to affect 2.5% of the adult population. Emerging models of psychopathology posit that disorders like ADHD can be usefully situated within general models of individual differences in personality, such as those recently implemented in the DSM and ICD for the diagnosis of personality disorder. Previous research and systematic reviews have linked adult ADHD to the personality traits Conscientious Inhibition and Negative Emotionality. However, there have been some inconsistencies in the literature and research embedding ADHD-personality connections in the DSM-5 and ICD-11 personality disorder models has been limited. The goal of this paper was to systematically review associations between adult ADHD and personality traits, organized within a maladaptive five factor framework.

METHOD

A comprehensive literature search yielded 13 papers whose effects were meta-analyzed.

RESULTS

Results supported associations between ADHD and low Conscientious Inhibition and high Negative Emotionality. However, interesting patterns of variability were observed, potentially related to issues such as instrumentation and facet variation.

CONCLUSION

Results support the clinical application of personality assessment for suggesting risk for ADHD symptoms, and point to important directions for further research.

ADHD and Bipolar Disorder in Adulthood: Clinical and Treatment Implications

Attention deficit hyperactivity disorder (ADHD) is a condition that usually has its onset in childhood. Although the disorder persists into adulthood in half of cases, adult ADHD is often not recognized due to different psychopathological characteristics, quite often overlapping with other diagnoses such as mood, anxiety and personality disorders. This is especially true for bipolar disorder (BD), which shares several symptoms with adult ADHD. Moreover, besides an overlapping clinical presentation, BD is often co-occurring in adults with ADHD, with comorbidity figures as high as 20%. This review will focus on the comorbidity between ADHD and BD by exploring the magnitude of the phenomenon and evaluating the clinical and functional characteristics associated with ADHD-BD comorbidity in adults. Finally, the review will address the implications of pharmacologically treating the ADHD-BD comorbidity, providing suggestions in how to treat these complex patients and addressing the issue of treatment-induced manic switch with the use of stimulants and other medications for ADHD.

Longitudinal Associations Between Cognitive Deficits in Childhood and Psychopathological Symptoms in Adolescence and Young Adulthood

IMPORTANCE

Cognitive deficits are core features of mental disorders and are important in predicting long-term prognosis. However, it is still unknown whether individual patterns of cognitive deficits predate specific mental disorders.

OBJECTIVE

To investigate the specificity of the associations of attention, working memory, and inhibition in childhood with borderline personality disorder (BPD), psychosis, depression, and hypomania in adolescence and young adulthood.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from the Avon Longitudinal Study of Parents and Children in the United Kingdom. All pregnant women resident in Avon, United Kingdom, with an expected date of delivery from April 1, 1991, and December 31, 1992, were eligible. Data analysis was conducted from April 1 to September 30, 2020. The sample initially comprised 13 988 participants who were alive at 1 year of age. For this study, data were available for 6333 individuals reporting on any psychopathological measure at ages 11 to 12 years, 4903 individuals at ages 17 to 18 years, and 2963 individuals at 22 to 23 years.

EXPOSURES

Sustained attention, selective attention, and attentional control were assessed with the Test of Everyday Attention for Children at age 8 years, and working memory and inhibition were assessed at age 10 years with the Counting Span Task and the stop-signal paradigm, respectively.

MAIN OUTCOMES AND MEASURES

Symptoms of BPD were assessed at ages 11 to 12 years, psychotic experiences and depression were examined at ages 17 to 18 years, and hypomania was examined at ages 22 to 23 years.

RESULTS

Among 5315 individuals included in the statistical analysis, 2551 (48.0%) were male and 2764 (52.0) were female. Higher sustained attention at 8 years was associated with decreased risk of BPD symptoms at ages 11 to 12 years (adjusted odds ratio [aOR], 0.964; 95% CI, 0.933-0.996; P = .03), better performance on inhibition at age 10 years with decreased risk of psychotic experiences at ages 17 to 18 years (aOR, 0.938; 95% CI, 0.890-0.989; P = .02), higher sustained attention at age 8 years with decreased risk of depressive symptoms at ages 17 to 18 years (aOR, 0.969; 95% CI 0.938-0.9997; P = .048), and better performance in working memory at age 10 years with decreased risk of hypomania symptoms at ages 22 to 23 years (aOR, 0.694; 95% CI, 0.529-0.911; P = .008). After controlling for potential psychopathological overlay, all the associations remained, except for working memory and hypomania. Higher sustained attention at age 8 years was associated with decreased risk of BPD symptoms at ages 11 to 12 years (β = -0.05; P < .001) and of depression at ages 17 to 18 years (β = -0.03; P = .04), and better performance in inhibition at age 10 years was associated with decreased risk of psychotic experiences at ages 17 to 18 years (β = -0.03; P = .04).

CONCLUSIONS AND RELEVANCE

These findings suggest that specific cognitive deficits in childhood are distinctively associated with different psychopathological symptoms in young people. Furthermore, these results suggest the potential of early cognitive interventions in childhood as a way of modifying or attenuating risk for subsequent psychopathological symptoms.

Decreased Theory of Mind Abilities and Increased Emotional Dysregulation in Adolescents With ASD and ADHD

OBJECTIVE

The aim of this study is to evaluate the possible relationship theory of mind (ToM) and emotion regulation (ER) skills in adolescents diagnosed with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD).

METHODS

This study comprised 60 individuals with ADHD and 60 individuals with ASD according to DSM-5 and between the ages of 12-16, and 60 adolescents without any psychiatric diagnosis. The Turkish version of the schedule for affective disorders and schizophrenia for school-age children, both present and lifetime versions, was applied to assess psychopathology and comorbidity. The intelligence level of the patients was assessed with the Wechsler Intelligence Scale for Children-Revised. Reading the mind in the eyes test, the Faux Pas Test, and the hinting task were given to patients to evaluate the ToM skills. The difficulties in ER Scale were also used to evaluate the skills of regulating emotions.

RESULTS

Adolescent patients with ADHD and ASD have difficulties in ToM and ER skills. Adolescents diagnosed with ASD had more difficulty in ToM and ER than adolescents with ADHD.

DISCUSSION

This study supports the idea that ADHD and ASD are related to deficits in ToM and ER skills. Therefore, further studies are required to confirm the findings of this study.

Interactive Effects of Parent Emotion Socialization and Child Physiological Reactivity in Predicting Adolescent Borderline Personality Disorder Features

Theories suggest that a transaction between child biological vulnerability and parent emotion socialization underlies the development of borderline personality disorder (BPD) features. Yet, few studies have examined the interaction between these factors prospectively in at-risk samples. Consequently, this study tested whether parental reactions to children's negative emotions moderated the effect of the child's physiological reactivity to stress in predicting adolescent BPD features in a sample of youth with and without clinical elevations in attention deficit/hyperactivity disorder (ADHD). Participants were 61 children (52% female) and parents (90% mothers). When children were 9-13 years old, their physiological reactivity to a social stressor was assessed based on respiratory sinus arrhythmia (RSA) and skin conductance level (SCL) reactivity; parents also reported on their supportive and non-supportive reactions to their child's negative emotions. Children were followed-up four to five years later at ages 14-18 years old and their BPD features were assessed based on parent and adolescent report. Significant interactions between children's SCL reactivity and parental reactions to children's negative emotions were found in predicting adolescent BPD features. Children with low SCL reactivity to social stress and parents high in supportive/low in non-supportive reactions were lowest in adolescent BPD features. However, greater SCL reactivity predicted greater adolescent BPD features specifically when the parent was high in support or low in non-support. Childhood ADHD symptoms also significantly predicted greater adolescent BPD features. Findings suggest that children with different patterns of SCL reactivity may respond differently to parental reactions to their emotions.

Do borderline personality disorder and attention-deficit/hyperactivity disorder co-aggregate in families? A population-based study of 2 million Swedes

Large-scale family studies on the co-occurrence of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are lacking. Thus, we aimed to estimate the co-occurrence and familial co-aggregation of clinically ascertained ADHD and BPD diagnoses using the entire Swedish population. In a register-based cohort design we included individuals born in Sweden 1979-2001, and identified their diagnoses during 1997-2013; in total, 2,113,902 individuals were included in the analyses. We obtained clinical diagnoses of ADHD and BPD from inpatient and outpatient care. Individuals with an ADHD diagnosis had an adjusted (for birth year, sex, and birth order) odds ratio (aOR) of 19.4 (95% confidence interval [95% CI] = 18.6-20.4) of also having a BPD diagnosis, compared to individuals not diagnosed with ADHD. Having a sibling with ADHD also increased the risk for BPD (monozygotic twins, aOR = 11.2, 95% CI = 3.0-42.2; full siblings, aOR = 2.8, 95% CI = 2.6-3.1; maternal half-siblings, aOR = 1.4, 95% CI = 1.2-1.7; paternal half-siblings, aOR = 1.5, 95% CI = 1.3-1.7). Cousins also had an increased risk. The strength of the association between ADHD and BPD was similar in females and males, and full siblings showed similar increased risks regardless of sex. Among both males and females, ADHD and BPD co-occur within individuals and co-aggregate in relatives; the pattern suggests shared genetic factors and no robust evidence for etiologic sex differences was found. Clinicians should be aware of increased risks for BPD in individuals with ADHD and their relatives, and vice versa.

Impulsiveness in borderline personality disorder predicts the long-term outcome of a psychodynamic treatment programme

Despite the preponderance of treatment outcome predictors in patients with borderline personality disorder (BPD), the predictive value of measures of impulsiveness is inconclusive. This naturalistic study consecutively included hospitalized patients with BPD (N = 99) who underwent a standardized and structured 12-week inpatient treatment programme, which integrated cognitive-behavioural and psychodynamic elements. The Brief Symptom Checklist (BSCL) was applied as outcome measure over four time points: pretreatment, posttreatment, first follow-up at 6 to 8 weeks and second follow-up at 1 year after discharge. Impulsiveness was measured using the Barratt Impulsiveness Scale (BIS) at the pretreatment time point. The BSCL significantly decreased between pretreatment and posttreatment, followed by an increase after posttreatment without reaching pretreatment extent. The temporal course of the BSCL significantly varied with pretreatment BIS in that patients with higher impulsiveness revealed a stronger re-increase of symptom severity from posttreatment to end of follow-up than those with lower impulsiveness. The least impulsive patients thereby showed no rebound effect. The robustness of the results was examined by cross-validation. The results indicate that irrespective of the level of impulsiveness, patients with BPD profit from a structured inpatient treatment. However, long-term treatment success was impaired in patients with high level of impulsiveness at pretreatment. Thus, self-ratings of impulsiveness in BPD patients can be utilized for treatment planning. After discontinuation of interventions, relapse prevention should be implemented early in high impulsive patients as symptoms recrudesce in the course after discharge.

Physical exercise in attention deficit hyperactivity disorder - evidence and implications for the treatment of borderline personality disorder

A growing body of literature indicates a potential role for physical exercise in the treatment of attention deficit hyperactivity disorder (ADHD). Suggested effects include the reduction of ADHD core symptoms as well as improvements in executive functions. In the current review, we provide a short overview on the neurophysiological mechanisms assumed to underlie the beneficial effects of exercise. Further, we review the current evidence from experimental studies regarding both acute exercise and long-term interventions in ADHD. While the positive effects observed after acute aerobic exercise are promising, very few well-designed long-term intervention studies have been conducted yet. Moreover, although exercise effects have not yet been studied in borderline personality disorder (BPD), in the end of this paper we derive hypotheses why exercise could also be beneficial for this patient population.

Borderline personality disorder and attention deficit/hyperactivity disorder in adolescence: overlap and differences in a clinical setting

BACKGROUND

With increased consensus regarding the validity and reliability of diagnosing Borderline Personality Disorder (BPD) in adolescents, clinicians express concern over the distinction between BPD and Attention-Deficit/Hyperactivity Disorder (ADHD), and its co-morbidity in clinical settings. The goal of this study was to evaluate differences between BPD, ADHD and BPD + ADHD in terms of co-morbid psychiatric disorders and a range of self-reported behavioral problems in adolescents.

METHODS

Our sample consisted of N = 550 inpatient adolescents with behavioral and emotional disorders that have not responded to prior intervention. We took a person-centered approach (for increase clinical relevance) and compared adolescents with ADHD, BPD and ADHD+BPD in terms of co-occurring psychiatric disorders and behavioral problems. We performed a regression analysis to test whether BPD symptoms make an incremental contribution to the prediction of psychiatric symptoms over ADHD symptoms.

RESULTS

The severity of almost all co-occurring disorders, aggression, self-harm, suicidal thoughts, and substance use, were higher in the ADHD+BPD group. Borderline symptoms made an incremental contribution to the prediction of psychiatric symptoms beyond the contribution of ADHD.

CONCLUSION

Severity and co-morbidity may be helpful factors in distinguishing between ADHD and BPD in clinical practice and the co-morbidity of these two disorders may indicate a worse clinical outcome.

Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals.

METHODS

The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review.

RESULTS

According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching.

CONCLUSION

The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.

Attention Deficit Hyperactivity Disorder Increases Nicotine Addiction Severity in Adults Seeking Treatment for Substance Use Disorders: The Role of Personality Disorders

AIMS

To examine the role of attention deficit/hyperactivity disorder (ADHD) and impulsive personality disorders in nicotine addiction severity among treatment-seeking substance use disorder (SUD) patients.

METHODS

In a cross-sectional study, we examined data from the second International ADHD in Substance Use Disorders Prevalence Study (IASP-2) on 402 adults in SUD treatment from Puerto Rico, Hungary, and Australia using diagnostic interviews for ADHD, antisocial (ASP) and borderline (BPD) personality disorders, and the self-report Fagerström Test of Nicotine Dependence (FTND). We compared SUD patients with and without ADHD on nicotine addiction severity. We tested direct and indirect pathways from ADHD to nicotine addiction and mediation through ASP and BPD.

RESULTS

Overall, 81.4% of SUD patients reported current cigarette smoking. SUD patients with ADHD had higher FTND scores and smoked more cigarettes than those without ADHD, with an earlier onset and more years of smoking. ASP mediated the effect of ADHD on all aspects of nicotine addiction severity, whereas BPD did so only on some aspects of nicotine addiction severity.

CONCLUSIONS

SUD patients with comorbid ADHD show more severe nicotine addiction than those without, which is largely explained by comorbid impulsive personality disorders. In SUD patients, it is important to screen for adult ADHD and other psychiatric disorders, especially those with impulse control deficits such as ASP and BPD.

The role of environmental influences in the complex relationship between borderline personality disorder and attention-deficit/hyperactivity disorder: review of recent findings

BACKGROUND

In recent years, the existence of possible developmental pathways from childhood Attention-Deficit/Hyperactivity Disorder (ADHD) to adult Borderline Personality Disorder (BPD) has been suggested. The existence of common genetic factors has been described but there is little evidence on the role of environmental factors in the possible transition from one disorder to another throughout life. The main goal of this work is to review the literature about the existing evidence on childhood traumas as factors that mediate the risk of developing BPD in children with ADHD.

METHODS

A literature search was conducted using PubMed, Science Direct and PsychInfo databases. Criteria included studies of BPD and ADHD relationships and childhood traumas as environmental influences from epidemiological or clinical samples.

RESULTS

The review only identified 4 studies that matched the search criteria. All studies retrospectively analyzed childhood traumas, and adult patients with BPD, with or without comorbid ADHD, were the most frequently mentioned. The analyzed evidence reinforces the relationship between the number of childhood traumas and higher clinical severity. Three of these analyzed studies describe an increased the risk of children with ADHD who report emotional and sexual traumatic experiences to develop BPD in adulthood.

CONCLUSIONS

The experience of traumatic childhood events, especially those of an emotional type, may have a mediating effect of an increased risk of developing adult BPD in childhood ADHD patients. However, to consider them as risk factors, more studies, and especially longitudinal studies, are necessary to clarify the probable transactional process between the two disorders. Evidence from these studies may be helpful to develop early intervention programs to reduce the functional impairment associated with the two disorders.

A Comparison of Self-Reported Emotional Regulation Skills in Adults With Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder

Objective: Emotion dysregulation has been described as a central feature of both borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD). The current study aims to compare emotion regulation among ADHD, BPD, and healthy controls (HC). Method: Eighty adults with ADHD, 55 with BPD, and 55 HC completed self-report assessments of ADHD and BPD symptoms, psychosocial functioning, and emotion regulation skills. Principal components analysis (PCA) was conducted on the emotion regulation items, followed by multivariate analyses of group differences in emotion regulation. Results: PCA yielded four components: "Being Aware of Emotions," "Making Sense of Emotions," "Modifying and Accepting Emotions," and "Confronting Emotions With Self-Encouragement." The last component best distinguished the two patient groups from the HC. No differences were found between adults with ADHD and BPD. Conclusion: Adults with ADHD and BPD report comparable difficulties in encouraging oneself to attend inner aversive experiences, without engaging in impulsive behavior.

Psychopharmacological treatment of patients with borderline personality disorder: comparing data from routine clinical care with recommended guidelines

Objectives: Borderline personality disorder (BPD) is a life-threatening mental disorder. Guideline recommendations for pharmacological treatment of patients with BPD vary widely. The objective of the present study was to investigate pharmacotherapy of BPD patients in a routine clinical care setting. Methods: Data on the pharmacological treatment of 110 patients (90% female) with BPD (F- 60.3), treated in an inpatient psychiatric-psychosomatic clinic in Austria were assessed. Results: Results show that clinicians frequently prescribe psychotropic medications to patients with BPD, in many cases multiple medications. The most commonly prescribed substance groups were antipsychotics, mood stabilisers and antidepressants. The most commonly prescribed individual drugs were Quetiapine, Lamotrigine and Setraline. There was no significant difference in the different types or overall number of medications prescribed to BPD patients with vs. without comorbid diagnoses. Pharmacotherapy was not related to comorbidity. Conclusions: The present study shows that in routine clinical care settings psychotropic medications are frequently prescribed to patients with BPD, very often resulting in polypharmacy. A positive association between the number of medications and the effectiveness of the inpatient treatment program, as well as the absence of a relationship between number of medications and comorbidity contradicts the often suggested iatrogenic effect of polypharmacy. Key points Guidelines for pharmacotherapy of borderline personality disorders lack consensus Yet, clinicians frequently prescribe psychotropic medications to BPD patients Types/number of medications prescribed to patients with vs. without comorbidities are similar Larger treatment effects are observed for patients with greater numbers of medications Further knowledge is needed about how and why clinicians prescribe medications.

Attention Deficit Hyperactivity Disorder, Impulsivity, Anxiety, and Depression Symptoms Mediating the Relationship Between Childhood Trauma and Symptoms Severity of Obsessive-Compulsive Disorder

Introduction

A growing body of research associates childhood trauma with obsessive-compulsive disorder (OCD). The aim of this study was to investigate the relationships between childhood trauma and OCD, including both its severity and OCD patients' comorbid impulsivity, ADHD, anxiety, and depressive symptoms.

Methods

A convenient sample consisting of 106 patients with OCD was given the Childhood Trauma Questionnaire (CTQ), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Wender Utah Rating Scale (WURS), Hamilton Rating Scale for Depression (HAM-D), Beck Anxiety Inventory (BAI), and Barratt Impulsivity Scale-11 (BIS-11).

Results

The results showed that childhood trauma indirectly predicts the severity of OCD and directly predicts comorbidities in OCD patients, including anxiety, ADHD, WURS, and impulsivity. Patients with childhood trauma had higher WURS, BAI, and BIS-11 scores and fewer years of education. Ongoing adult ADHD was more common in individuals with childhood trauma.

Conclusion

A history of childhood trauma in OCD patients has indirect effects on the severity of OCD and depressive symptoms and is associated with more severe anxiety, higher levels of impulsivity, higher prevalence of ADHD, and lower levels of education. More research is needed to clarify the effects of childhood trauma on OCD severity and comorbidity.

Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD)

BACKGROUND

Emotional dysregulation (ED) is now considered as an important symptom of attention deficit hyperactivity disorder (ADHD). It is believed to have a considerable impact on the severity of the disorder, one's global functioning, and the prognosis. Our research aimed to evaluate and compare ED and cognitive emotional regulation strategies between ADHD and borderline personality disorder (BPD) patients.

METHODS

Four hundred six French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 BPD + ADHD) were assessed with the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), The Basic Empathy Scale (BES-A), the Adult ADHD Self-Report Scale (ARSV-v1.1) and the Beck Depression Inventory II (BDI-II). ADHD, BPD and comorbid patients were compared with each other and with samples of controls extracted from already published data.

RESULTS

ADHD patients, although having higher ED than samples derived from the general population, had less ED, better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients. However, ADHD subjects had similar scores as BPD subjects when looking at difficulties in perceiving self and others. ED generated considerable distress in all groups and was also positively associated with ADHD symptomatology. ADHD patients with comorbid BPD had the highest scores of ED.

CONCLUSIONS

Our results suggest that there may be similarly inefficient cognitive emotional regulation skills leading to ED in both disorders (ADHD and BPD). However, ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than BPD patients.

The relationship between attention deficit hyperactivity disorder, bipolarity and mixed features in major depressive patients: Evidence from the BRIDGE-II-Mix Study

OBJECTIVE

This study primarily focused on the relationship between comorbid attention deficit-hyperactivity disorder (ADHD), mixed features and bipolarity in major depressive patients.

METHODS

The sample comprised 2777 patients with Major Depressive Episode (MDE) enrolled in a multicentre, multinational study originally designed to assess different definitions of mixed depression. Socio-demographic, familial and clinical characteristics were compared in patients with (ADHD + ) and without (ADHD-) comorbid ADHD.

RESULTS

Sixty-one patients (2.2%) met criteria for ADHD. ADHD was associated with a higher number of (hypo)manic symptoms during depression. Mixed depression was more represented in ADHD + patients than in ADHD- using both DSM-5 and experimental criteria. Differences were maintained after removing overlapping symptoms between (hypo)mania and ADHD. ADHD in MDE was also associated with a variety of clinical and course features such as onset before the age of 20, first-degree family history of (hypo)mania, past history of antidepressant-induced (hypo)manic switches, higher number of depressive and affective episodes, atypical depressive features, higher rates of bipolarity specifier, psychiatric comorbidities with eating, anxiety and borderline personality disorders.

LIMITATIONS

The study was primarily designed to address mixed features in ADHD, with slightly reduced sensitivity to the diagnosis of ADHD. Other possible diagnostic biases due to heterogeneity of participating clinicians.

CONCLUSIONS

In a sample of major depressive patients, the comorbid diagnosis of current ADHD is associated with bipolar diathesis, mixed features, multiple psychiatric comorbidity and a more unstable course. Further prospective studies are necessary to confirm the possible mediating role of temperamental mood instability and emotional dysregulation in such a complex clinical presentation.

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.

Effects of transcranial direct current stimulation on the cognitive control of negative stimuli in borderline personality disorder

Borderline personality disorder (BPD) is characterized by impairments in the cognitive control of negative information. These impairments in cognitive control are presumably due to blunted activity of the dorsolateral prefrontal cortex (dlPFC) along with enhanced activations of the limbic system. However, the impact of an excitatory stimulation of the dlPFC still needs to be elucidated. In the present study, we therefore assigned 50 patients with BPD and 50 healthy controls to receive either anodal or sham stimulation of the right dlPFC in a double-blind, randomized, between-subjects design. Participants performed a delayed working memory task with a distracter period during which a grey background screen, or neutral, or negative stimuli were presented. This experimental paradigm was first evaluated in a pilot study with 18 patients with BPD and 19 healthy controls. In both studies, patients with BPD showed an impairment of cognitive control when negative distracters were presented in the delay period of a working memory task. However, excitatory stimulation of the right dlPFC did not ameliorate cognitive control of negative stimuli in BPD, which raises questions about the specific role of the right dlPFC for the understanding of BPD psychopathology. Methodological limitations are discussed.

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.

Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties

BACKGROUND

Childhood maltreatment, such as severe emotional, physical, and sexual abuse and neglect, has been linked to impulse control problems and dysfunctional emotional coping. In borderline personality disorder (BPD), a history of childhood maltreatment may worsen difficulties in emotion regulation, which may in turn give rise to impulsive behaviours. The aim of this self-report study was to investigate associations between childhood maltreatment severity, emotion regulation difficulties, and impulsivity in women with BPD compared to healthy and clinical controls.

METHODS

Sixty-one female patients with BPD, 57 clinical controls (CC, women with Attention Deficit Hyperactivity Disorder and/or Substance Use Disorder, without BPD), and 60 female healthy controls (HC) completed self-report scales on childhood trauma (Childhood Trauma Questionnaire, CTQ), difficulties in emotion regulation (Difficulties in Emotion Regulation Scale, DERS), and impulsivity (UPPS Impulsive Behaviour Scale). A conditional process analysis was performed to investigate whether emotion dysregulation statistically mediated the effect of childhood maltreatment severity on impulsivity depending on group (BPD vs. CC vs. HC).

RESULTS

Childhood maltreatment, particularly emotional maltreatment, was positively associated with impulsivity and emotion regulation difficulties across all groups. Difficulties in emotion regulation statistically mediated the effect of childhood maltreatment on impulsivity in BPD, but not in the other groups.

CONCLUSION

In the context of current conceptualizations of BPD and previous research, findings suggest that problems with emotion regulation may be related to a history of childhood maltreatment, which may in turn enhance impulsivity. Targeting emotion dysregulation in psychotherapy and discussing it in relation to childhood maltreatment can help decreasing impulsive behaviors in individuals with BPD. Given the correlational design of our study which does not allow causal conclusions, future studies have to employ prospective, experimental designs and include larger sample sizes to corroborate associations between childhood maltreatment, emotion dysregulation, and impulsivity.

A negative bias in decoding positive social cues characterizes emotion processing in patients with symptom-remitted Borderline Personality Disorder

BACKGROUND

Impairments in the domain of interpersonal functioning such as the feeling of loneliness and fear of abandonment have been associated with a negative bias during processing of social cues in Borderline Personality Disorder (BPD). Since these symptoms show low rates of remission, high rates of recurrence and are relatively resistant to treatment, in the present study we investigated whether a negative bias during social cognitive processing exists in BPD even after symptomatic remission. We focused on facial emotion recognition since it is one of the basal social-cognitive processes required for successful social interactions and building relationships.

METHODS

Ninety-eight female participants (46 symptom-remitted BPD [r-BPD]), 52 healthy controls [HC]) rated the intensity of anger and happiness in ambiguous (anger/happiness blends) and unambiguous (emotion/neutral blends) emotional facial expressions. Additionally, participants assessed the confidence they experienced in their own judgments.

RESULTS

R-BPD participants assessed ambiguous expressions as less happy and as more angry when the faces displayed predominantly happiness. Confidence in these judgments did not differ between groups, but confidence in judging happiness in predominantly happy faces was lower in BPD patients with a higher level of BPD psychopathology.

CONCLUSIONS

Evaluating social cues that signal the willingness to affiliate is characterized by a negative bias that seems to be a trait-like feature of social cognition in BPD. In contrast, confidence in judging positive social signals seems to be a state-like feature of emotion recognition in BPD that improves with attenuation in the level of acute BPD symptoms.

Personality disorder: a disease in disguise

Personality disorders (PDs) can be described as the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both. They are common and are frequently encountered in virtually all forms of health care. PDs are associated with an inferior quality of life (QoL), poor health, and premature mortality. The aetiology of PDs is complex and is influenced by genetic and environmental factors. The clinical expression varies between different PD types; the most common and core aspect is related to an inability to build and maintain healthy interpersonal relationships. This aspect has a negative impact on the interaction between health-care professionals and patients with a PD. From being discrete and categorical disease entities in previous classification systems, the current concept of PD, reflected in the newly proposed ICD-11, is a dimensional description based on the severity of the disturbed functioning rather than on the type of clinical presentation. Insight about the characteristics of PDs among medical practitioners is limited, which is partly because persons do not seek health care for their PD, but instead for other medical issues which are obscured by their underlying personality problems. What needs to be emphasized is that PDs affect both the clinical presentation of other medical problems, and the outcome of these, in a negative manner and that the integrated effects of having a PD are a shortened life expectancy. Accordingly, PDs need to be recognized in clinical practice to a greater extent than previously.

Relationship between attention-deficit hyperactivity disorder symptoms and problem gambling: A mediation analysis of influential factors among 7,403 individuals from the UK

BACKGROUND AND AIMS

Our goal was to examine the association between attention-deficit hyperactivity disorder (ADHD) symptoms and gambling problems, and to identify potential mediating factors of this association.

METHODS

This study used cross-sectional, community-based data from 7,403 people aged ≥16 years who participated in the Adult Psychiatric Morbidity Survey 2007. ADHD symptoms were assessed using the Adult ADHD Self-Report Scale (ASRS) Screener. Problem gambling was assessed using a questionnaire based on the 10 DSM-IV diagnostic criteria for pathological gambling. Respondents were classified as having no problem, at-risk, or problem gambling. Logistic regression and mediation analyses were conducted to analyze the association between ADHD symptoms (i.e., ASRS score ≥14) and problem gambling and the role of several variables in this association.

RESULTS

The prevalence of at-risk (5.3% vs. 2.4%) and problem gambling (2.4% vs. 0.6%) was higher in individuals with ADHD symptoms than in those without ADHD symptoms. ADHD symptoms were significantly associated with both at-risk (OR = 2.15; 95% CI = 1.22-3.79) and problem gambling (OR = 3.57; 95% CI = 1.53-8.31) when adjusted for age, sex, and ethnicity. Common mental disorders (CMDs; i.e., depression and anxiety disorders) (mediated percentage = 22.4%), borderline personality disorder (BPD) traits (22.1%), stressful life events (13.2%), stress at work or home (12.6%), alcohol dependence (11.8%), and impulsivity (11.2%) were significant mediators in the ADHD-gambling association.

DISCUSSION AND CONCLUSIONS

Overall, ADHD symptoms were positively associated with problem gambling. CMDs, BPD traits, and stressful life events were important mediators in this relationship.

Attention deficit hyperactivity disorder symptoms and disordered eating in the English general population

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) symptoms and eating problems often coexist, but many of the previous studies have not taken into account key variables which may be important in this association. Thus, the goal of this study was to assess the association between ADHD symptoms and disordered eating, while taking into account of a variety of factors.

METHOD

This study used cross-sectional, nationally representative data from 7,403 people aged ≥16 years from England who participated in the 2007 Adult Psychiatric Morbidity Survey (APMS). ADHD symptoms were assessed with the Adult ADHD Self-Report Scale (ASRS) Screener. Questions from the five-item SCOFF screening instrument were used to identify possible ED. Multivariable logistic regression analyses were conducted.

RESULTS

The prevalence of possible eating disorder (ED) was much higher among those with ADHD symptoms (ASRS score ≥14) compared to those without ADHD symptoms (19.2 vs. 5.7%). ADHD symptoms were associated with possible ED (odds ratio [OR] = 3.48; 95% confidence interval [CI] = 2.56-4.72) after adjustment for age, sex, and ethnicity. After further adjustment for alcohol dependence, drug use, intelligence quotient, stressful life events, perceived stress, impulsivity, depression, anxiety disorder, and borderline personality disorder (BPD) traits, the OR was attenuated to 1.32 (95% CI = 0.82-2.13). Anxiety and BPD were the factors that led to the largest degree of attenuation.

DISCUSSION

A high prevalence of disordered eating in individuals with ADHD was observed. Factors such as co-existing anxiety and BPD traits may be particularly important in this association. Future research should focus on the factors involved in the association between ADHD symptoms and disordered eating behavior.

Long-Term Efficacy of Psychosocial Treatments for Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Recent evidence suggests that psychosocial treatments, particularly cognitive-behavioral therapy (CBT), are effective interventions for adult attention deficit hyperactivity disorder (ADHD). The objective of this review was to determine the long-term efficacy of psychosocial interventions in improving clinically relevant variables, including ADHD core symptoms, clinical global impression (CGI), and global functioning. Methods: In total, nine randomized controlled trials and three uncontrolled single-group pretest-posttest studies were included. The data from these studies were combined using the inverse variance method. Heterogeneity and risk of bias were assessed. Subgroup analyses and meta-regressions were performed, to determine the influence of different potential moderator variables (risk of bias, medication status, follow-up length, therapy type and setting, and control group type) on effect size (ES) estimates. Results: Up to 680 of a total of 1,073 participants assessed pre-treatment were retained at follow-up. Treatment groups showed greater improvement than control groups in self-reported total ADHD symptoms, inattention, and hyperactivity/impulsivity, in addition to CGI and global functioning. Blind assessors also reported a large ES in within-subject outcomes. Studies using dialectical behavioral therapy (DBT) in a group setting, with active control matching, and that were rated as having an unclear risk of bias, achieved significantly lower ES estimates for most outcomes. Treatment effectiveness, according to the CGI measure, and global functioning were significantly increased when the percentage of medicated participants was greater. Conclusions: Our results indicate that the post-treatment gains reported in previous reviews are sustained for at least 12 months. Nevertheless, these results must be interpreted with caution, because of a high level of heterogeneity among studies and the risk of bias observed in the majority of outcomes. Thus, these findings indicate that psychological interventions are a highly valuable and stable clinical tool for the treatment of core symptoms and global functioning in adults with ADHD.

Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD)

BACKGROUND

Clinical observations suggest that adults have more diverse deficits than children with Attention Deficit/Hyperactivity Disorder (ADHD). These seem to entail difficulties with emotionality, self-concept and emotion regulation in particular, along with the cardinal symptoms of inattention, impulsivity, and hyperactivity for adult patients. Here, we probed a model that explicitly distinguished positive and negative affect, problems with self-concept and emotion regulation skills as distinct but correlating factors with the symptom domains of inattention, hyperactivity, and impulsivity.

METHODS

Participants were 213 newly diagnosed adults with ADHD (62.9% male, mean age 33.5 years). Symptoms were assessed via self-report on the Conners' Adult ADHD Rating Scales, a modified version of the Positive and Negative Affect Scale and the Emotion Regulation Skill Questionnaire. A confirmatory factor analysis with the R package lavaan, using a robust Maximum Likelihood estimator (MLR) for non-normal data, was conducted to test our new non-hierarchical 7-factor model.

RESULTS

All calculated model-fit statistics revealed good model-fit (χ²/df ratio = 2.03, robust RMSEA = .07). The SRMR in our model reached .089, indicating an acceptable model fit. Factor loadings on the postulated factors had salient loadings ≥ .31 except for one item on the hyperactivity factor. Latent factor associations were especially salient between emotional dysregulation and problems with self-concept, and also partially with impulsivity/emotional lability.

LIMITATIONS

The three models of ADHD and emotion regulation as suggested by Shaw et al. (2014) could not be disentangled in this study, though the overall results support the model with shared neurocognitive deficits. Further, we did not separately analyze ADHD with or without comorbid disorders. As our sample of clinical cases with ADHD is highly comorbid (47.9%), other disorders than ADHD might account for the emotion regulation deficits, though a sensitivity analysis revealed no such differences.

CONCLUSIONS

Our model adequately characterizes the relations between and among clinically and therapeutically relevant symptoms in adult ADHD, thus potentially informing future therapeutic interventions by targeting the successful and flexible use of adaptive emotion regulation skills.

Screening for attention-deficit/hyperactivity disorder in borderline personality disorder

BACKGROUND

A valid screening instrument is needed to detect attention-deficit/hyperactivity disorder (ADHD) in treatment-seeking borderline personality disorder (BPD) patients. We aimed to test the performance of the widely-used Adult ADHD Self-Report Scale v1.1 screener (ASRS-v1.1).

METHODS

317 BPD subjects were systematically assessed for comorbid ADHD and completed the ASRS-v1.1. 79 BPD patients also completed the Wender Utah Rating Scale (WURS-25).

RESULTS

The prevalence of adult ADHD was of 32.4%. The overall positive predictive value of the ASRS-v1.1 was of 38.5%, the negative predictive value 77.0%, the sensitivity 72.8%, and the specificity 43.9%. Combining WURS-25 and ASRS-v1.1 improved sensitivity to 81.8% and specificity to 59.6%.

LIMITATIONS

Cross-sectional study on treatment-seeking patients.

CONCLUSIONS

We found a high prevalence of ADHD using structured interviews. The ASRS-v1.1 was not a sensitive screener for identifying possible ADHD cases in a BPD population, with a high number of false positives. When combined with the WURS-25, it offered improved screening.

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.

Monoamine Oxidase-A Genetic Variants and Childhood Abuse Predict Impulsiveness in Borderline Personality Disorder

Objective

Impulsivity is a core feature of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) that likely arises from combined genetic and environmental influences. The interaction of the low activity variant of the monoamine oxidase-A (MAOA-L) gene and early childhood adversity has been shown to predict aggression in clinical and non-clinical populations. Although impulsivity is a risk factor for aggression in BPD and ASPD, little research has investigated potential gene-environment (G×E) influences impacting its expression in these conditions. Moreover, G×E interactions may differ by diagnosis.

Methods

Full factorial analysis of variance was employed to investigate the influence of monoamine oxidase-A (MAO-A) genotype, childhood abuse, and diagnosis on Barratt Impulsiveness Scale-11 (BIS-11) scores in 61 individuals: 20 subjects with BPD, 18 subjects with ASPD, and 23 healthy controls.

Results

A group×genotype×abuse interaction was present (F(2,49)=4.4, p=0.018), such that the interaction of MAOA-L and childhood abuse predicted greater BIS-11 motor impulsiveness in BPD. Additionally, BPD subjects reported higher BIS-11 attentional impulsiveness versus ASPD participants (t(1,36)=2.3, p=0.025).

Conclusion

These preliminary results suggest that MAOA-L may modulate the impact of childhood abuse on impulsivity in BPD. Results additionally indicate that impulsiveness may be expressed differently in BPD and ASPD.

Mentalization in adults with attention deficit hyperactivity disorder: Comparison with controls and patients with borderline personality disorder

Emotion dysregulation and interpersonal hardships constitute core features of borderline personality disorder (BPD). Research has established the link between these core dysregulations and fluctuations in the capacity to appreciate the mental states that underlie behavior (mentalizing, operationalized as reflective functioning (RF)). As emotion dysregulation and interpersonal hardships also characterize adults with attention deficit hyperactivity disorder (ADHD), this study sought to examine the potential RF impairments affecting this population. 101 adults with ADHD, 108 with BPD and 236 controls were assessed using the RF questionnaire (RFQ), evaluating how individuals employ information about mental states to better understand their own and others' behaviors. The RFQ comprises two dimensions, certainty (RF_c) and uncertainty (RF_u) about mental states. RF scores helped distinguish ADHD from controls, but also from BPD (F = 48.1_(2/441); p < 0.0001 for RF_c and F = 92.5_(2/441); p < 0.0001 for RF_u). The ADHD group showed intermediary RF scores compared to the controls (b = -0.70; p < 0.0001 and b = 0.89; p < 0.0001 for RF_c and RF_u) and BPD group (b = 0.44; p = 0.001 and b = -0.56; p = 0.001 for RF_c and RF_u). Lower RF scores correlated with poor anger control and high levels of impulsivity. Higher severity of ADHD (more attentional and hyperactive/impulsive symptoms) was correlated with RF impairments. In conclusion, RF may constitute an important process underlying attentional, hyperactive/impulsive as well as emotional symptoms in ADHD; it should therefore be considered in the assessment of these patients.

State-Dependent Cross-Brain Information Flow in Borderline Personality Disorder

IMPORTANCE

Although borderline personality disorder (BPD)-one of the most common, burdensome, and costly psychiatric conditions-is characterized by repeated interpersonal conflict and instable relationships, the neurobiological mechanism of social interactive deficits remains poorly understood.

OBJECTIVE

To apply recent advancements in the investigation of 2-person human social interaction to investigate interaction difficulties among people with BPD.

DESIGN, SETTING, AND PARTICIPANTS

Cross-brain information flow in BPD was examined from May 25, 2012, to December 4, 2015, in pairs of participants studied in 2 linked functional magnetic resonance imaging scanners in a university setting. Participants performed a joint attention task. Each pair included a healthy control individual (HC) and either a patient currently fulfilling DSM-IV criteria for BPD (cBPD) (n = 23), a patient in remission for 2 years or more (rBPD) (n = 17), or a second HC (n = 20). Groups were matched for age and educational level.

MAIN OUTCOMES AND MEASURES

A measure of cross-brain neural coupling was computed following previously published work to indicate synchronized flow between right temporoparietal junction networks (previously shown to host neural coupling abilities in health). This measure is derived from an independent component analysis contrasting the time courses of components between pairs of truly interacting participants compared with bootstrapped control pairs.

RESULTS

In the sample including 23 women with cBPD (mean [SD] age, 26.8 [5.7] years), 17 women with rBPD (mean [SD] age, 28.5 [4.3] years), and 80 HCs (mean [SD] age, 24.0 [3.4] years]) investigated as dyads, neural coupling was found to be associated with disorder state (η2 = 0.17; P = .007): while HC-HC pairs showed synchronized neural responses, cBPD-HC pairs exhibited significantly lower neural coupling just above permutation-based data levels (η2 = 0.16; P = .009). No difference was found between neural coupling in rBPD-HC and HC-HC pairs. The neural coupling in patients was significantly associated with childhood adversity (T = 2.3; P = .03).

CONCLUSIONS AND RELEVANCE

This study provides a neural correlate for a core diagnostic and clinical feature of BPD. Results indicate that hyperscanning may deliver state-associated biomarkers for clinical social neuroscience. In addition, at least some neural deficits of BPD may be more reversible than is currently assumed for personality disorders.

Delay discounting and response disinhibition under acute experimental stress in women with borderline personality disorder and adult attention deficit hyperactivity disorder

BACKGROUND

Impulsivity is a core feature of borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD). In BPD, impulsive behavior primarily occurs under acute stress; impulse control deficits under non-stress conditions may be partly related to co-morbid ADHD. We aimed to investigate whether acute experimental stress has an impact on self-reported impulsivity, response inhibition (action withholding, action cancelation) and delay discounting in BPD compared to ADHD.

METHOD

Thirty female BPD patients, 28 female ADHD patients (excluding patients with co-morbid BPD and ADHD), and 30 female healthy controls (HC) completed self-reports and behavioral measures of impulsivity (IMT, assessing action withholding; GoStop, measuring action cancelation, Delay Discounting Task) under baseline conditions and after an experimental stress induction (Mannheim Multicomponent Stress Test).

RESULTS

Both patient groups reported higher impulsivity than HC, ADHD reported higher trait impulsivity than BPD. On the IMT, ADHD showed significant action-withholding deficits under both conditions, while BPD performed significantly worse than HC under stress. In BPD but not ADHD and HC, action-withholding deficits (IMT) were significantly increased under stress compared to baseline, while no group/stress effects were found for action cancelation (GoStop). Delay discounting was significantly more pronounced in BPD than in HC (no stress effect was found).

CONCLUSIONS

In BPD, behavioral deficits in action withholding (but not in action cancelation) appear to be influenced by acute experimental stress. Delay discounting seems to be a general feature of BPD, independent of co-morbid ADHD and acute stress, possibly underlying typical expressions of behavioral impulsivity in the disorder.

An Examination of the Structure and Construct Validity of the Wender Utah Rating Scale

The Wender Utah Rating Scale (Ward, Wender, & Reimherr, 1993 ) has been widely used in adult attention-deficit/hyperactivity disorder (ADHD) research to assess childhood symptoms retrospectively, but little research has examined its factor structure and specificity in predicting ADHD versus other psychopathology. Consequently, this study had 2 goals: (a) to examine the Wender Utah Rating Scale's structure, and (b) to explicate the construct validity of this measure by relating factors from our structural analyses to other ADHD, psychopathology, and personality measures. Structural analyses in an adult community sample (N = 294) yielded a 3-factor structure of aggression (e.g., angry), internalizing distress (e.g., depressed), and academic difficulties (e.g., underachiever). Correlational and regression analyses indicated that these factors failed to display specificity in their associations with ADHD versus other psychopathology. Aggression and internalizing distress associated most strongly with indicators of externalizing (e.g., ill temper, manipulativeness) and internalizing psychopathology (e.g., depression, anxiety), respectively. Academic difficulties associated most strongly with ADHD symptoms, but these relations were relatively weak. Taken together, these findings raise concerns about the Wender Utah Rating Scale's construct validity, although additional longitudinal research is needed to clarify to what extent the Wender Utah Rating Scale validly assesses childhood ADHD symptoms.

Comorbidity of Personality Disorders and Adult Attention Deficit Hyperactivity Disorder (ADHD)--Review of Recent Findings

Children suffering from attention deficit hyperactivity disorder (ADHD) may remit until adulthood. But, more than 60-80% have persisting ADHD symptoms. ADHD as an early manifesting neurodevelopmental disorder is considered a major risk factor for the development of comorbid psychiatric disorders in later life. Particularly, personality disorders are oftentimes observed in adult patients suffering from ADHD. If ADHD and personality disorders share common etiological mechanisms and/or if ADHD as a severely impairing condition influences psychological functioning and learning and leads to unfavorable learning histories is unclear. The development of inflexible and dysfunctional beliefs on the basis of real and perceived impairments or otherness due to the core symptoms of ADHD is intuitively plausible. Such beliefs are a known cause for the development of personality disorders. But, why some personality disorders are more frequently found in ADHD patients as for example antisocial and borderline personality disorder remains subject of debate. Because of the high prevalence of ADHD and the high impact of personality disorders on daily functioning, it is important to take them into account when treating patients with ADHD. Research on the developmental trajectories leading to personality disorders in adult ADHD patients might open the door for targeted interventions to prevent impairing comorbid clinical pictures.

Women with borderline personality disorder do not show altered BOLD responses during response inhibition

Impulsivity is central to borderline personality disorder (BPD). Response inhibition, addressing the ability to suppress or stop actions, is one aspect of behavioral impulse control which is frequently used to assess impulsivity. BPD patients display deficits in response inhibition under stress condition or negative emotions. We assessed whether response inhibition and its neural underpinnings are impaired in BPD when tested in an emotionally neutral setting and when co-morbid attention-deficit/hyperactivity disorder (ADHD) is excluded. To this end, we studied response inhibition in unmedicated BPD patients and healthy controls (HC) in two independent samples using functional magnetic resonance imaging during Simon-, Go/nogo-, and Stopsignal tasks. BPD patients and HC did not differ significantly in their performance in the Go/nogo and the Stopsignal tasks. Response interference in the Simon task was increased in BPD patients in one sample, but this could not be replicated in the second sample. In both samples, no significant differences in brain activation patterns during any of the tasks were present while the neural impulse control network was robustly activated during the inhibition tasks in both groups. Our results provide evidence that under emotionally neutral conditions response inhibition is not impaired in patients with BPD without co-occurring ADHD.