Stimulant use in ADHD with comorbid borderline personality disorder

[annoyedpsychiatrist]

Has anyone found that stimulants worsen mood lability in borderline? I have some BPD patients on stimulants who seem to do well with them but was just curious. I saw a patient today, neuropsych testing (she actually neuropsych testing per pt) suggested ADHD. She had used adderall with a positive response in the past, but she met basically every criteria for BPD but was fairly functional and was mainly just depressed because she recently ended a relationship. I actually was in between bipolar 2 vs BPD but i spent nearly 90 minutes with her and really hammered out the history and it didnt add up for bipolar 2. Plus she had tolerated stimulant medications in the past, so i ended up on a trial of concerta just to see how she responded with the plan to readjust next visit.

So back to the main question, have you guys noticed overall improvements using stimulants in patients with a diagnosis of BPD and comorbid ADHD or do you ever see the mood dysregulation worsen?

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[Alemo]

What’s the stimulant dose and schedule? How’s her sleep? Is she using any illicit drugs? Also, is Concerta doing anything for ADHD symptoms?

 

[annoyedpsychiatrist]

What’s the stimulant dose and schedule? How’s her sleep? Is she using any illicit drugs? Also, is Concerta doing anything for ADHD symptoms?

I just started her on concerta 27mg qam after an intake. No hx of illicit drugs. Upon chart review, there was nothing to indicate she had a SUD. History of positive response to adderall IR low unknown dose, but would crash in between doses. No sleep issues reported.

 

[clausewitz2]

Has anyone found that stimulants worsen mood lability in borderline? I have some BPD patients on stimulants who seem to do well with them but was just curious. I saw a patient today, neuropsych testing (she actually neuropsych testing per pt) suggested ADHD. She had used adderall with a positive response in the past, but she met basically every criteria for BPD but was fairly functional and was mainly just depressed because she recently ended a relationship. I actually was in between bipolar 2 vs BPD but i spent nearly 90 minutes with her and really hammered out the history and it didnt add up for bipolar 2. Plus she had tolerated stimulant medications in the past, so i ended up on a trial of concerta just to see how she responded with the plan to readjust next visit.

So back to the main question, have you guys noticed overall improvements using stimulants in patients with a diagnosis of BPD and comorbid ADHD or do you ever see the mood dysregulation worsen?

If I believe ADHD criteria are actually met then yes I would use stimulants for someone who also met criteria for BPD. It is worth pointing out that the ADHD literature makes it very clear that mood reactivity is absolutely a core part of the classic ADHD phenotype, along with impulsivity. I have worked with a handful of patients who did appear to meet BPD criteria whose symptoms basically disappeared on stimulants, so I conceptualize them as having mostly had ADHD. To be fair they often lacked the core fear of being abandoned.

 

[Candidate2017]

Has anyone found that stimulants worsen mood lability in borderline? I have some BPD patients on stimulants who seem to do well with them but was just curious. I saw a patient today, neuropsych testing (she actually neuropsych testing per pt) suggested ADHD. She had used adderall with a positive response in the past, but she met basically every criteria for BPD but was fairly functional and was mainly just depressed because she recently ended a relationship.

Neuropsych testing for ADHD is a business. It's cash pay, not covered by insurance, rightly so because it is not diagnostic. There are places in my area notorius for giving everyone an ADHD diagnosis. Also, almost everyone has a "positive response" with Adderall. The only people I've seen who have a negative response to Adderall are those with actual ADHD for whom Concerta or Vyvanse works better.

Borderline means increased activity in the neuro-salience system, which stimulants can only worsen. In my opinion, a one year trial of DBT is indicated, rather than a trial of stimulant. It's kind of hard to focus when all criteria of borderline disorder are met. Then again, if this patient is fairly functional as you say, then a borderline diagnosis really isn't met.

 

[annoyedpsychiatrist]

Neuropsych testing for ADHD is a business. It's cash pay, not covered by insurance, rightly so because it is not diagnostic. There are places in my area notorius for giving everyone an ADHD diagnosis. Also, almost everyone has a "positive response" with Adderall. The only people I've seen who have a negative response to Adderall are those with actual ADHD for whom Concerta or Vyvanse works better.

Borderline means increased activity in the neuro-salience system, which stimulants can only worsen. In my opinion, a one year trial of DBT is indicated, rather than a trial of stimulant. It's kind of hard to focus when all criteria of borderline disorder are met. Then again, if this patient is fairly functional as you say, then a borderline diagnosis really isn't met.

I mean, you can have comorbid ADHD and BPD. That is not unheard of. Patient demonstrated symptoms of ADHD and her clinical history did show signs of ADHD, although some things were challenging as there is a cultural impact as she immigrated to this country from a place where things are much different. I had no reason to believe she was lying/exagerrating her symptoms.

Her symptoms influence her relationships with others and often affect her job performance. You can have an impairment in something but still be functional. She has impairment in relationships with others, family relationships, and at times occupational impairment. She did not ask for adderall IR; she stated she didnt like how it made her feel with the crashing periods, but did feel like she had signifiant improvement in concentration, ability to organize tasks, reduced impulsivity, etc. I would think if she was just Adderall seeking she would have asked for adderall.

Also I dunno where you practice, but DBT is not some easy thing that most people have access too. Especially when your insurance isnt great. I have a patient with BPD on a SGA which has helped a lot with stabilizing her mood and vyvanse, which prior to being on vyvanse she nearly flunked out of college, now shes actually holding down a job and making As/Bs.

But I respect all opinions on here

 

[annoyedpsychiatrist]

If I believe ADHD criteria are actually met then yes I would use stimulants for someone who also met criteria for BPD. It is worth pointing out that the ADHD literature makes it very clear that mood reactivity is absolutely a core part of the classic ADHD phenotype, along with impulsivity. I have worked with a handful of patients who did appear to meet BPD criteria whose symptoms basically disappeared on stimulants, so I conceptualize them as having mostly had ADHD. To be fair they often lacked the core fear of being abandoned.

Very fair, I think future follow ups will definitely provide more clarification

 

[clausewitz2]

If you're in a practice setting where you can swing it, if you think there really is BPD, with someone who is capable of being this functional, GPM is probably a reasonable substitute for DBT and has the advantage of being way easier to implement. As written it does call for meeting once per week, however.

 

[mistafab]

It can be difficult at times to distinguish BPD and ADHD at times. Both are hypofrontal, impulsive, and often have elaborate mechanisms to attempt to preserve functioning.

If they truly have both ADHD and BPD, then mood dysregulation would likely improve with stimulants, not worsen. If they have BPD masquerading as ADHD, then stimulants may worsen their stability. You'd essentially just be getting a BPD patient high, which we know even without BPD can lead to mood dysregulation.

Edit: I'm also not sure if any third party testing can really distinguish the deficits in attention from ADHD and personality disorder. I'd say that is the psychiatrist's job.

 

[Liquid8]

Can have comorbid BPD and ADHD, and small amount of stimulants can be justified in terms of augmenting existing antidepressant treatments, and there can also be some benefit in terms of reducing emotional deregulation.

Where one has to be careful is where there are potentially body image issues, as often that ties in with abandonment and self-esteem so the BPD patient who wants to lose weight (but doesn’t tell their doctor) will suddenly report ADHD symptoms which may seem odd or out of place in the context of their overall timeline. Then you may find yourself in a vicious cycle of patients using it as an appetite suppressant, so they don’t have enough energy and can’t concentrate – demanding higher doses of stimulants or inexplicably running out before appointments. Am trying to disentangle one of these at the moment, but it is looking more and more likely I will be sacked due to setting firm limits - no real loss from my perspective.

 

[smalltownpsych]

Rarely would I think stimulants would be a good choice for a patient of mine with BPD. Significant trauma history and it’s resulting state of chronic hyperarousal and intense interpersonal dynamics are the most likely causes of ”attention” problems reported by my patients. They are also desperate to find something to alleviate their distress and research is clear that people with BPD have a greater placebo response initially for medications, although I think it was with ssri’s but I would be concerned about this response with something that is intrinsically reinforcing and I have seen a number of high dose adderall patients with BPD who are demonstrating symptoms of excessive stimulant use, but ”need it to function”. As the treating psychotherapist, I would rather have the psychiatrist reinforce the importance of my treatment than add a medication that is reinforcing. In other words, when I become the reinforcement and emotional regulation tool, then they turn to me for help and I can begin helping them to implement DBT skills into their life.

 

[R. Matey]

Edit: I'm also not sure if any third party testing can really distinguish the deficits in attention from ADHD and personality disorder. I'd say that is the psychiatrist's job.

Ruling out relational instability due to fears of abandonment vs. just plain ole impulsive behavior might be your first clue. On the testing front, the Connors rating scales do a decent job at differentiating this especially when two or more raters are gathered. But it really doesn't matter who if it's a psychologist or psychiatrist who interprets them provided you have the training to do so.