Borderline personality disorder
Onset and course. According to DSM-5 criteria, a diagnosis of borderline personality disorder should not be made before the age of 18 years; however, diagnosis can be made earlier when symptoms are clear and persistent. The peak frequency of symptoms appears to be at 14 years of age.6
Symptom remission (a reduction in the number of symptoms below the diagnostic threshold) is common, especially when diagnosis is made during adolescence.7,8 However, in spite of the high remission rate, the presence of borderline personality disorder in adolescence is far from harmless.
Borderline personality disorder is highly comorbid with depression, anxiety, substance abuse, and eating disorders, with a high risk for suicide. Suicide risk is higher in the event of co-occurrence with a mood disorder or substance abuse and with increasing number of suicide attempts.
The patient’s functioning is significantly impaired, with school withdrawal, frequent job losses, unstable relationships. Functioning in borderline personality disorder is more highly impaired than in other personality disorders.
Clinical picture. Borderline personality disorder is a mental illness with a chronic and pervasive pattern of instability in interpersonal relationships, self-esteem, and mood, with marked impulsivity. Associated features are increased risk for self-harm, suicide, and transient stress-induced psychotic symptoms. There appear to be two clusters of symptoms, one (characterized by anger and feelings of abandonment) tends to be stable while the other (characterized by self-harm and suicide attempts) is less persistent.
Several features of borderline personality disorder overlap with those of ADHD such as a chronic course, emotional instability, impulsivity and risk taking behaviors, and disturbed interpersonal relationships. Patients with borderline personality disorder may experience a special form of inattention as part of dissociative states when they feel emotionally stressed, particularly in response to feelings of rejection, failure, and loneliness. Inattentive symptoms in ADHD are particularly prominent in situations that lack external stimulation (eg, during boring, routine, or familiar tasks).
Patients with borderline personality disorder have a tendency to resort to self-injurious behavior in order to alleviate tension; ADHD patients are more likely to regulate emotional symptoms through extreme sports, novelty seeking, sexual activity, and aggression.
Stimulants are the cornerstone of pharmacotherapy of ADHD and are helpful in reducing the impact of cognitive deficits on academic performance and social interaction, improving classroom behavior, and increasing time on task. Large-population studies have documented reduced criminal behavior in ADHD adults and decreased car accidents in males with ADHD.9
Despite the widespread use of stimulants in pediatric and adult population, the effects of acute exposure during development and chronic exposure in youths and adults are poorly understood. More research is required to assess safety, especially because of the extent of abuse, although several studies suggest relative safety.9,10
Therapeutic approaches are often quite different depending on the primary diagnosis; for instance, mood stabilizing agents and atypical antipsychotics may be beneficial for children with early onset bipolar disorder but are unlikely to enhance attention in children with ADHD and are associated with serious adverse effects.11,12 On the other hand, stimulants have been shown to be ineffective in the treatment of bipolar disorder. They can cause disruption of sleep and circadian rhythms, and negatively affect persons with bipolar disorder.13 Although some findings indicate that stimulants added to mood stabilizers did not result in manic exacerbation.14
In case of comorbidity between ADHD and bipolar disorder, treatment should be directed first to the most severe condition (almost always bipolar disorder). Treatment of ADHD should be considered when ADHD symptoms persist following mood stabilization and have a moderate to severe impact on functioning and quality of life.
Treatment may be needed in stages, for example mood stabilizers for bipolar disorder, followed by stimulants/atomoxetine for ADHD. If a clear diagnosis of ADHD is made, and bipolar disorder is only suspected, then ADHD should be treated first while monitoring potential worsening of bipolar symptoms—stimulants or atomoxetine might exacerbate subthreshold mania. If bipolar symptoms emerge during treatment of ADHD, stop the ADHD treatment until bipolar symptoms have been stabilized and then review the diagnosis of ADHD before considering further treatment.
Dr Marangoni is Attending Psychiatrist, Department of Mental Health, Mater Salutis Hospital, Azienda ULSS 9, Legnago, Italy. Dr Marangoni reports no conflicts of interest concerning the subject matter of this article.
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