What is the management of a patient with both Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

Managing patients with both Borderline Personality Disorder (BPD) and Attention-Deficit/Hyperactivity Disorder (ADHD) requires an integrated approach combining psychotherapy and medication, with Dialectical Behavior Therapy (DBT) as the first-line psychotherapy for BPD, and non-stimulant medications like bupropion or viloxazine as potential options for ADHD treatment, as evidenced by the most recent study 1.

Key Considerations

• The treatment strategy should begin with stabilizing the BPD symptoms before addressing ADHD, as BPD emotional dysregulation can mask or exacerbate ADHD symptoms.
• DBT is a highly effective therapy for BPD, typically requiring weekly individual sessions and group skills training for 6-12 months, and has been modified to suit the needs of adult patients with ADHD, as shown in the study 1.
• For medication management, non-stimulant options like bupropion or viloxazine may be considered for ADHD treatment, as they have been shown to be effective in adults with ADHD, according to the study 1.
• Close monitoring is essential, as stimulants may worsen impulsivity or emotional lability in some patients with BPD.
• Regular assessment using validated scales for both conditions helps track progress, and patients benefit from having a consistent treatment team with clear communication between providers.

Treatment Options

• DBT: a highly effective therapy for BPD, with four modules: mindfulness skills, distress tolerance, interpersonal effectiveness skills, and emotion regulation skills.
• Bupropion: a non-stimulant medication that has been shown to be effective in adults with ADHD, as a norepinephrine and dopamine reuptake inhibitor.
• Viloxazine: a non-stimulant medication that has been shown to be significantly more efficacious than placebo in treating ADHD in adults, as evidenced by the study 1.

Important Considerations

• The potential teratogenicity of ADHD medications, mainly focused on the use of stimulants, is largely reassuring, according to the study 1.
• Medication adherence is a common problem in ADHD treatment, and regular assessment and open discussion of potential issues can help increase adherence, as noted in the study 1.
• The dosing regimen can also affect medication adherence, with once-daily dosing generally preferred over twice-daily dosing, as suggested by the study 1.

From the Research

Management of Patients with Both BPD and ADHD

• The management of patients with both Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD) is complex and requires a comprehensive approach 2.
• Dialectical Behavior Therapy (DBT) is a structured outpatient treatment that has been shown to be effective in treating BPD, and may also be beneficial for patients with comorbid ADHD 3, 4.
• The addition of methylphenidate to intensive DBT has been shown to improve symptoms in patients with comorbid BPD and ADHD 5.
• It is essential to systematically screen BPD patients for ADHD, as a methylphenidate-based treatment may improve symptoms in patients who are comorbid for BPD and ADHD 5.
• The treatment of ADHD should be considered when treating comorbid personality disorders, and principles of dialectical behavioral treatment for BPD may successfully treat ADHD in adults as an adjunct to medication 2.

Treatment Approaches

• DBT is based on cognitive-behavioral principles and is currently the only empirically supported treatment for BPD 4.
• Traditional DBT is structured into four components, including skills training group, individual psychotherapy, telephone consultation, and therapist consultation team 4.
• The skills taught in DBT include mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, which can help target common symptoms of BPD and ADHD 4.
• Psychopharmacologic interventions may be considered as adjunctive care for patients with BPD and ADHD, although more research is needed to determine the most effective treatment approaches 2, 5.

Comorbidity and Overlap

• BPD and ADHD often co-occur, and the comorbidity of these disorders can lead to complex clinical presentations and treatment challenges 2, 6.
• The overlap in diagnostic criteria and shared psychopathologic symptoms between BPD and ADHD has stimulated research activities in this field 6.
• Longitudinal studies have shown that BPD is frequently diagnosed in adult patients who had been diagnosed with ADHD in childhood, suggesting a possible link between the two disorders 6.