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Diagnostic Challenge 2 - Part II

Margaret V. Austin, Ph.D., edited by C. E. Zupanick, Psy.D.

Personality Disorders and ADHD

upset womanPersonality Disorders are a large category of disorders. A personality disorder impacts all aspects of a person's life including social, emotional, cognitive, and behavioral functioning. Each disorder within this category is unique. However, several personality disorders can be easily confused with adult ADHD particularly Borderline Personality Disorder (BPD), Narcissistic Personality Disorder, and Antisocial Personality Disorder. This represents a group of disorders that share some similar-looking symptoms with ADHD. These symptoms include: disorganization, social intrusiveness, impulsivity, and emotional dysregulation. As previously mentioned, individuals with ADHD are disorganized. They are often depressed and/or irritable. Their moods can shift frequently, and they act impulsively.

Despite these similarities, these three personality disorders are different from ADHD in several significant ways. First, a person with ADHD will exhibit momentary impulsivity, without much advance warning. In contrast, someone with a personality disorder, like BPD, will likely express impulsivity in a "driven" or pressured manner. This may be coupled with an irresistible urge to act impulsively. Regarding expressions of anger, those with ADHD exhibit anger in a brief and episodic manner. In contrast, those with personality disorders may have extended periods of brooding anger that often erupt with a retaliatory, impulsive act. A central distinguishing feature between ADHD and personality disorders are the symptoms that are not present in ADHD. These include self-mutilation; passionate but highly-conflicted relationships; unstable sense of self; suicidal preoccupations; intense feelings of abandonment; and, a gross sense of entitlement usually coupled with overt grandiosity. Although there are variations within each disorder, the lack of these troubling symptoms makes ADHD distinct from personality disorders.

Bipolar Disorder and ADHD

Bipolar disorder is characterized by widely unstable moods (labile mood). These moods typically swing from one extreme pole to another; i.e., from depressive mood to a euphoric or manic mood. Keep in mind that for some people, a depressed mood may be experienced as irritability and overall dissatisfaction. Stated differently, there are cultural and gender differences in the way people experience and express depression. Just because someone doesn't look or act "depressed" does not make them ineligible for a depression diagnosis.

Sometimes 'mood swings' rapidly switch back and forth; from a few hours to a few days. Other times moods may last for weeks or months. Moreover, the intensity of each mood state may vary. Sometimes depression may be more severe than mania, making it seem more obvious. Sometimes mania may be more severe than depression, making it seem more obvious.

Many ADHD individuals exhibit a combination of depression, mood swings, and irritability. These similarities between ADHD and bipolar disorder can cause diagnostic confusion between the two. One way to distinguish between them is by examining the length of time between mood swings. In bipolar disorder, moods typically last for weeks or months before shifting over to the other pole. In ADHD, moods last for a much shorter period: usually just a few hours or a few days. The depth of depression tends to be more severe in bipolar disorder than in ADHD, which tends to be less severe and fleeting.

When at the euphoric pole of Bipolar disorder (the manic phase), people demonstrate excessive energy, coupled with impulsive and even dangerous acts. This may look a lot like the hyperactivity-impulsivity symptoms in people with ADHD. Although ADHD adults' intense urge for activity can be easily confused with mania, it lacks the disruptive acting-out quality; i.e., the impulsive reckless behavior and omnipotence found in bipolar disorder. These additional symptoms can accompany bipolar disorder, but not ADHD. Medications commonly used for each disorder are very different. If medication for one disorder is taken by someone with the other disorder, their symptoms will dramatically worsen. This highlights the importance of an accurate diagnosis.

Depression, Anxiety and ADHD

ADHD evaluations should routinely include an assessment for anxiety disorders and mood disorders, particularly depression (a specific type of mood disorder). These disorders may turn out to be the true cause of ADHD-like symptoms; or, they may be separate, co-occurring disorders. The co-occurrence between mood disorders and ADHD is significant. Some studies suggest that the likelihood of a mood disorder in people with ADHD is more than double the likelihood of a mood disorder in the general population (Reinhold, 2015).

The determination as to whether an adult has ADHD alone, or in combination with a mood disorder, is critical in developing an effective treatment plan. Treatment protocols for either disorder or both disorders together, are very different. Depression can be distinguished from ADHD because it is often accompanied by anhedonia; i.e., the inability to experience pleasure. People with depression have depressive symptoms that are unrelenting. In contrast, depressive symptoms fade quickly in people with ADHD once their attention is redirected to something enjoyable. Meanwhile, folks with ADHD have more functional impairment than folks with mild to moderately severe depression. This greater impairment is due to the impulsivity, and organizational deficits that are root causes of ADHD.

Anxiety disorders in various forms often co-occur with ADHD. For example, people with ADHD may feel judged by others and develop a social anxiety disorder (SAD). Adults with ADHD have lived many years with symptoms that limit their ability to be successful. They may feel others are critical or judgmental about their behaviors or lack of success. They may begin to worry about other people's judgments and seek to avoid social interactions. In contrast, those with Social Anxiety often experience extreme worry for weeks or months in advance of an event. They become extremely self-conscious. Subsequently, they may be unable to follow a conversation and may blurt out comments that are irrelevant to the conversation. Likewise, they may have trouble focusing on what others are saying, because of their anxiety. This self-preoccupation and social awkwardness can resemble the ADHD symptoms of impulsivity, and difficulty with concentration. In addition, their challenges forming and maintaining social relationships also resemble ADHD. However, social anxiety disorder can be distinguished from ADHD because people with ADHD continue to engage in social activities. In general, for those with ADHD social activities are enjoyable and rewarding, despite their awkwardness and missteps. In contrast, people with social anxiety disorder find social events so painful and uncomfortable they would typically try to avoid them at all costs. However, as mentioned, a person may have both disorders.