The Difference Between Bipolar Disorder, Borderline Personality Disorder and Adult ADHD

By Scott Shapiro

It can be very challenging for even the most experienced clinician to distinguish the differences between Bipolar Disorder, Type II, Borderline Personality Disorder and Adult ADHD. Symptoms often overlap and these disorders frequently co-occur; however, there can be clues from the history and presentation that often help determine the diagnosis and the appropriate types of treatments. Below, is a case of a patient with a challenging diagnosis followed by tips on differentiating Bipolar Disorder, Type II, Borderline Personality Disorder, and Adult ADHD.

Case:

Anna* is a 46 year-old, married nurse with three children. She presented with persistent low-grade depression, anxiety, and irritability. She was on probation at work for poor performance. She also had a long-standing history of difficulty with friendships.

She complained of life-long depression with intermittent episodes of more severe symptoms. During the more extreme episodes, she overslept, felt more irritable and anxious. She reported chronic racing thoughts and difficulty concentrating.

She had a chaotic childhood. Her father was a successful, workaholic attorney who was also an alcoholic. There were frequent, explosive fights between her parents. Anna was the oldest of 3 children and at the age of 10, her parents divorced. She became ensnarled in their long, drawn-out divorce process. In pre-school and elementary school, she had been quite precocious, according to school reports. She listened well, followed instructions, and had many close friends.

However, as the fighting intensified at home around third and fourth grades her grades dropped and she began to exhibit behavioral problems at school.

The above case represents a challenging diagnosis. Below are tips to help determine the diagnosis and whether there is the possibility of more than one diagnosis.

Mood Swings

Mood swings in Bipolar Disorder, Type II last for one to four days and include the person feeling "hyper", "on top of the world", irritable, invincible, elated, or even depressed despite being in a hypomanic episode.

People with Borderline Personality Disorder also have mood swings but they have feelings of sadness, anger, rage, or depression that is more chronically present and triggered by criticism, disappointment or stress. Also, people with Borderline Personality Disorder rarely feel elation.

People with Adult ADHD also describe mood swings and difficulty with managing moods; however, the duration is usually brief and due to low frustration tolerance. Also, in Adult ADHD there are feelings of shame, irritability, frustration, and sadness secondary to difficulty with school, work and relationships.

Impulsivity

Similarly, the symptoms of impulsivity are present in all the disorders but with different histories. Impulsivity may manifest as sexual promiscuity, excessive shopping binges, poor decision-making, automobile accidents or speeding tickets, and careless mistakes. With Bipolar Disorder, Type II, the impulsivity is present only during the periods of hypomania compared to Borderline Personality Disorder and Adult ADHD, when the impulsivity occurs chronically or due to an emotional trigger.

Concentration

All three disorders present with difficulty concentrating or focusing. This creates challenges with completing tasks, jumping from task to task, and starting projects without completing them. These symptoms occur in Bipolar Disorder, Type II only during the hypomanic phase but can be chronic with the other two disorders.

History

In Borderline Personality Disorder, there is more frequently a history of feeling empty and lonely, chaotic relationships, self-injury, and an extreme fear of abandonment. There is often a history of significant physical or sexual abuse during childhood or severe emotional neglect.

In Bipolar Disorder, Type II, there is frequently a family history of depression or Bipolar Disorder, and the symptoms of depression start at an earlier age. Also, depression is the more frequent complaint than hypomania.

In Adult ADHD, the person has persistent challenges with sustained attention, focus, executive functioning, distractibility, time management, procrastination, and significant difficulty with organization.

These symptoms may appear in the other two disorders; however, in Adult ADHD, the symptoms must have existed since childhood. In addition, ADHD has the highest genetic component of all three disorders and is estimated to have a concordance rate ranging from 60-80%. Thus, eliciting a history of other family members with ADHD increases the likelihood that the person may be dealing with Adult ADHD.

All three disorders can manifest "racing thoughts". In Adult ADHD, these thoughts are intermittently present and are exacerbated when there is greater stress or challenge in the environment.

With Bipolar Disorder, Type II, the symptom of racing thoughts occurs only during the hypomanic phase. The racing thoughts are often described as "crowded thoughts" and thinking of new and creative projects.

In Borderline Personality Disorder, the racing thoughts are usually precipitated by an emotionally laden experience such as a fight with or criticism from a friend or colleague.

Case Continued:

Upon further discussion with Anna, she denied having hypomanic episodes. However, she described feeling empty, lonely and having low self-esteem. Under severe stress, she would become acutely agitated, suicidal, have feelings of worthlessness, and be absent from work.

Over her life, she has gone to the psychiatric emergency room 6 times for suicidal thoughts, but has never made an attempt. She has also had a partial hospitalization. In addition, she has a long history of self-injuring behaviors including anorexia, cutting, and unprotected sex with casual contacts.

Anna has Borderline Personality Disorder as well as dysthymia. My recommendation was to start schema therapy twice a week as well as start on an MAOI and to start treatment in an intensive Dialectical Behavioral Treatment Program (CBT). Even though a MAOI is not FDA approved for Borderline Personality Disorder or dysthymia, there research shows its efficacy.

Two years later, Anna's mood has stabilized and she feels much less anxious. In addition, she has been able to enjoy more pleasure in her personal life and career. She has currently been in a relationship for 14 months, and although the direction of the relationship is unclear, she feels more comfortable tolerating the unknown.

This case presents the diagnostic challenges distinguishing Bipolar Disorder, Type II, Borderline Personality Disorder, and Adult ADHD. Using the above distinguishing features and taking a thorough assessment improves the accuracy of the diagnosis and helps in the determination of an effective treatment plan.

References:

Hirschfeld RM,Cass AR, Hot DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Family Practice. 2005:18: 233-239

McIntyre, Roger. Differential Diagnosis of Bipolar Disorder. Supplement to Current Psychiatry. Bipolar Disorder. 2011: 3-22.

* To Maintain confidentiality

Scott Shapiro, MD is an Assistant Professor at New York Medical College and specializes in Adult ADHD. He has a private private in New York City. For more information contact him at 212-631-8010 or visit his website at http://www.scottshapiromd.com.

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Tips and Tricks for Adult ADHD Conference Attendees

By Laurie Dupar

I wanted to share some experiences about conferences! I love conferences and look forward to the opportunities to travel around the country to enjoy some time with other ADHD coaches and entrepreneurs, increase awareness of ADHD challenges, and finally meet some of my long distance clients face-to-face. It's sort of like the social season of 19th century London, when the movers and shakers gather together in the city for debutante balls, elaborate dinners and spectacular galas. They can be both exhilarating and exhausting.

My next conference will be the three day 6th Annual International ADHD Coaches Organization (ACO) in Atlanta, Georgia. Then I am off to Orlando, Florida for Suzanne Evans's four-day extravaganza "Be the Change Event". At both events I will be presenting on different topics, hosting a booth and trying to connect with as many amazing people as possible.

And as much as I love conferences, they can be incredibly challenging for ADHD adults (and even for those who don't struggle with focus, planning or organization). Over the years, I've become a veteran of these trips and have developed some strategies to offset ADHD symptoms so I enjoy and get the most out of these days. Here are some valuable tips and tricks that I want to share with you:

1. Do your homework. Many conferences post their speaker schedule online or provide some tips on how to travel to and from the airport. Doing research before you arrive makes you more prepared and less likely to miss important things such as when you are speaking or if meals are included.

2. Book your hotel room as soon as you know you are going to attend so you can secure a place at the hotel where the conference is being held. The "conference rate" hotel rooms fill fast. You will save time and money by not having to travel back and forth, (or get distracted by the scenery and miss your speaking time), and you will be able to sneak back to your room to rest if you get a break between sessions. Having quiet time to refuel will go a long way to helping you succeed with ADHD.

3. Bring a highlighter and a small notebook. When you receive the schedule of events, highlight the sessions you want to attend so you can plan your day and be reminded easily. The notebook is your 'ADHD brain cheat sheet'. After you meet someone you want to reconnect with after the conference, jot down the information in your notebook. Or keep track of tidbits of inspiration and knowledge you acquire. Both are ways to offset the information overwhelm and distraction that often accompany conferences.

4. Wear comfortable shoes. No matter your role at the conference, you will be on your feet more than you think. It's hard to smile and be your best self when your feet hurt.

5. Wear layers. The temperature in the rooms throughout a conference varies greatly.

6. Bring a trusted sidekick. If you have a booth, having an assistant there can alleviate the stress of keeping track of sales receipts or other details and allow you more time to network with colleagues and clients.

7. Take your ADHD medication. If your conference is out of town for multiple days, see if your psychiatrist will write you a short prescription you can fill if there is an emergency.

8. Realize that you can't clone yourself. If there are multiple sessions running at the same time you will need to partner with a colleague, divvy up the schedule and share notes on what you learned. Or take advantage of the options to purchase recordings so that you can review them on the plane ride home, but don't buy them if you won't review them!

9. Decide what you want to get out of the conference. Your goal may be to acquire new skills, network with colleagues, build your contact list or interact with clients. If you set your intention before you arrive, you will be in the right mindset and prepared to learn, connect or promote yourself. But be flexible, new opportunities often come from these events and you can move outside your comfort zone to discover great new ideas at conferences.

10. Bring your business cards! In fact put them in your travel bags right now!

11. Be open to learning. You may be an expert in your field, but that doesn't mean you can't pick up something new. And you may be surprised where you learn it. Nuggets of life changing brilliance can happen anywhere - even during a brief conversation on the elevator.

12. Especially at niche specific conferences such as those in the ADHD field, everyone knows everyone. The traditional six degrees of separation is reduced to about two or three. It is a great chance to network and meet those you emulate... but also a damaging place to gossip.

13. Sleep. As much as you can before you go and during the event. It may be tempting to stay up all night at the welcome reception - the energy and thrills of being there can be hard to walk away from. But remember, that's just day one. Conferences are marathons, and you need to recharge and take extra care of yourself so you can get to the end in good spirits.

14. Bring nutritious, easy to pack snacks. Conferences can be exhausting and having healthy snacks on hand such as dried fruit and nuts go a long way to keeping you energized, and your ADHD brain focused. Another trick is to travel with a few of packets of oatmeal and a disposable spoon. Breakfast is typically the hardest meal to catch during conferences. Adding hot water, readily available in most hotel rooms, along with some of those nuts and dried fruit is a great way to start your day.

15. Finally, plan for a day of decompression when you return home. A sudden reentry back into your world could create exhaustion that defeats all the positive energy you experienced at the conference. And it helps to process all of that new information with a clearer perspective.

If you are attending the ACO Conference, "Be the Change Event", stop by and introduce yourself! I'd love to say hello!

And if you have additional tips on conferences, especially ideas on how to cope with ADHD symptoms, share them below...

Laurie Dupar, Senior Certified ADHD Coach and trained Psychiatric Nurse Practitioner, specializes in working with clients who have been diagnosed with ADD/ADHD and entrepreneurs who want to finally understand how their brain works, minimize their challenges and get things done! Through individual/group coaching, live speaking, and her writing, she helps clients and their loved ones use effective strategies to utilize their innate brain traits so they experience success. She is the co-author and editor of 365 Ways to Succeed with ADHD and 365+1 Ways to Succeed with ADHD and author of Unlock the Secrets to Your Entrepreneurial Brain Style. For more information, please visit http://www.coachingforadhd.com.

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Adult ADHD - One Man's Story

Adult ADHD

By Dr. Robert Sprackland

"Robert, stop it!"

Those words haunted me most of my life, whenever people became overwhelmed by my behavior. I just didn't understand what their problem was. Neither did any of the voices in my head.

The voices were constant and all mine, not God or spirits, and they didn't tell me to do anything antisocial. Rather, each (I counted eight) was a stream of regular thoughts, running concurrently, like an eight-track tape playing all tracks simultaneously. I often wandered into a conversational mode described by friends as a "Robin Williams monologue," telling jokes, making puns, jumping from topic to topic, and even changing voices and character.

But my head had always been like that. To me, everyone else moved and thought slowly, took forever to get to the point. I was driving my friends, coworkers and family nuts, and I couldn't to do anything about it. I was also a compulsive eater, injuring my health. Even my decades of meditation practice could not control the internal restlessness.

Then an odd conjunction of events led to help. My sister-in-law, Tina, an Army physician, suffered an injury and needed help driving home from Illinois to New York. I was available, so I spent three weeks with the family, during which time Tina got to observe me at close hand. She soon bluntly told me, "I really, really, really think you have ADHD." When Tina, a lieutenant colonel and formidable diagnostician, uses three "reallys" in a sentence, you had better take her seriously.

But ADHD? Attention Deficit Hyperactivity Disorder? Me? I had thought ADHD, ADD, and all those other new acronyms were children's ailments. I couldn't have ADHD; I was from the generation that found super-fast flashing of movie trailers and TV shows with handheld camerawork difficult, indeed painful, to watch. My attention span could be measured in minutes and hours, not milliseconds and sound bites. I was a trained systematic zoologist, a profession dedicated to compulsive organization of vast amounts of data. No, I couldn't have ADHD.

But as we discussed my symptoms, it became clear that kids do not have a monopoly on brain chemical imbalances. I had all the usual symptomatic suspects. Despite earning my two masters and a doctorate, school had always been excruciatingly painful for me, from staying still in my seat to following laboriously slow lectures. I tested poorly because I either read too much into a question or knew about the rare exceptions. In conversations, I often completed other people's sentences.

Getting to sleep was always an ordeal because my thoughts would not turn off. Though I am very goal oriented, I found it difficult to complete some tasks because I had so many projects going on simultaneously. For example, I had spent a year writing a CD-ROM key to the sharks and rays of the world, but had put off getting it commercially published. On some tasks I focused like a laser, while on others I was dim as a candle. I saw my own physician and a neuropsychologist and, sure enough, got the ADHD diagnosis.

ADHD, first described as "defect of moral control" by an English physician in 1902, is a simple failure of the brain to balance levels of neurotransmitters called dopamine and norepinephrine, which help regulate moods. My diagnosis and subsequent treatment with Adderall radically and swiftly changed my life for the better. This amphetamine--an "upper"--actually quiets the ADHD personality. My hunger cravings are gone, I sleep well, get more things done, do them better, and haven't gotten on anyone's nerves lately--especially my long-suffering wife of thirty years! Overall, I have been clam and happy--not excited or ecstatic--every day since treatment began. Best and strangest of all, I now have only one thought in my head at any time. It is the psychological equivalent, I think, of having sent all the kids off to college, and I get the house to myself.

There has always been stigma attached to mental illness; it's "all in our heads." Mental difficulties are still seen as other than physical or physiological, and even Congress refuses to recognize mental illness for what it is. This stigma is devastating. As a zoologist, I understand how my insides work, so it didn't affect my decision to be treated, but for most people, being "mentally ill" ranks in the bad news category with heart problems or cancer--or worse! People who could benefit deny themselves help that could substantially improve the quality of their lives. We do not mock a person with a faulty heart for taking nitroglycerin; a person with a defective pancreas for taking insulin; or any of us with an overwhelmed or compromised immune system for taking antibiotics.

Even Viagra jokes are rare these days. Why, then, do we see such intolerance when another organ, the brain, is ill? Many influential people had ADHD, including Dustin Hoffman, Will Smith, Jimmy Stewart, Vincent van Gogh, Leonardo da Vinci, Benjamin Franklin, Albert Einstein, Winston Churchill, and, of course, Robin Williams. Brain disorders are real physical manifestations that can often be simply treated. Unless our brains get moved elsewhere, mental illnesses will always "be in our heads." Those of us who can benefit from medication should take it, and the rest of us should support our loved ones who need it. It will make things much happier in our hearts and in our heads.

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ADHD Drug Treatment and Academics

By Tess Messer

Many patients, parents and providers have questions about the academic benefits brought about by the use of childhood ADHD medication. Practical questions such as whether continued stimulant medication use results in permanent cognitive improvement or deterioration have been difficult to answer but medical studies have provided some insight into questions such as these.

Animal studies have suggested that stimulant use during pre-adolescence may predispose individuals to problems with motivation as adults but there are not many human studies looking at the question of ADHD drug treatment and academic improvement. One of the studies that tried to answer this question is the Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study (MTA).

The MTA study occurred at multiple sites and was designed to evaluate the short and long term benefits of ADHD treatment. The study included nearly 600 children, ages 7-9, who were randomly assigned to one of four treatment options. The treatment options included:

• Intensive medication management alone;
• Intensive behavioral treatment alone;
• A combination of both; or
• Routine community care (the control group).

The MTA treatment lasted for 14 months. After the fourteen months, the children were referred back to their community providers. Some of the children continued to receive treatment. Others discontinued their treatment or changed it, based on their individual situation. All the study participants were invited, by the National Institutes of Mental Health, to return to the MTA clinics every one to two years for a check-up of their ADHD symptoms and for an evaluation of their level of functioning.

The initial results of this study indicated that the best treatment for ADHD included a combination of medication and behavioral treatment but after eight years the MTA researchers found that there were no differences in symptoms or functioning among the kids assigned to the four different treatment groups. Children who were no longer taking medication at the eight-year follow-up were generally functioning as well (or as poorly) as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all.

Sixty percent of children who had been medicated during the trial were no longer on medication eight years later. As a whole, the ADHD kids were found to have more academic and social problems compared with their peers who did not have ADHD. They also had more conduct problems including run-ins with police, as well as more depression, and psychiatric hospitalizations.

On the positive side, the kids who had responded well to any treatment and maintained their gains for two more years tended to be doing the best at eight years. The MTA researchers suggested that ADHD treatments might work more effectively if they were adapted to the specific symptoms of individual children taking into account the changing needs of children and teenagers. The researchers also suggested that this type of approach might be more acceptable to patients and families and, over the long run, might provide better continued treatment and outcomes.

Understanding how drug treatment or other treatments affect people with ADHD in the long term is complicated. Individual genetic and environmental factors will affect treatment response and long term benefits and detriments. Understanding the interaction of specific treatments, genetics and the environment will require more study. Though there is little disagreement, in the medical community, about the long term negative effects of not treating ADHD. There is less agreement about how best to treat ADHD symptoms in the long term and about which treatments provide the longest lasting benefits with the fewest risks.

Visit Tess at http://primarilyinattentiveadd.com for a link to Commanding Attention: A Parent and Patient Guide to More ADHD treatment and for more resources and information on the diagnosis and treatment of ADHD.

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