ADHD: the Gift that Keeps on Giving

Jillian Enright

ADHD: the Gift that Keeps on Giving!

Commonly comorbid conditions with ADHD. Also how Personality Disorders are sexist and gender-biased.

If this is a gift, can I return it?

…Except I lost my receipt. (Because ADHD).

When I was diagnosed with ADHD, I had no idea how much of my previously misdiagnosed or misunderstood conditions were related. I had no concept of how many overlapping conditions there are, and how many of my “quirks” were actually related to ADHD.

Well, now I know.

Once you know, what can you do about it?

Firstly, we educate ourselves to better understand ourselves, or our children or partners. Information allows us to advocate for supports or accommodations, and to develop strategies that work best for us and our divergent brains.

What are comorbidities?

Comorbidities are disorders or conditions that are commonly diagnosed together. For example, when you have ADHD, you are more likely than the general population to also have anxiety (Mohammadi et al., 2021).

Comorbid disorders can make it more challenging to receive an accurate diagnosis, to receive effective treatment, and to differentiate symptoms from one condition to the next.

The most common comorbid conditions associated with ADHD are Anxiety Disorders, Obsessive Compulsive Disorder (OCD), Bipolar Disorder (BD), Depression, Substance Use Disorders (SUD), and Borderline Personality Disorder (BPD).

Anxiety Disorders

Anxiety disorders are the most prevalent groups of comorbidities in people with ADHD (Mohammadi et al., 2021).

According to the American Psychiatric Association (APA), the most common anxiety disorders are:

  • Phobias
  • Social Anxiety Disorder
  • Panic Disorder
  • Agoraphobia
  • Generalized Anxiety Disorder
  • Separation Anxiety Disorder

In the fourth edition of the Diagnostic and Statistical Manual (DSM-IV), Obsessive Compulsive Disorder (OCD) was classified as an anxiety disorder. In the fifth and most recent edition, the DSM-V, OCD has been given its own class, Obsessive-Compulsive and Related Disorders (SAMHSA, 2016).

Regardless of classification, OCD is also a common comorbid condition in people with ADHD (Masi et al., 2006; Farrell et al., 2020) and is associated with persistent thoughts and urges which cause marked anxiety or distress (American Psychiatric Association, 2013).

Depression & Bipolar Disorder

Depression and Bipolar disorder (BD) are also highly comorbid with ADHD (Katzman et al., 2017).

It is important to note, however, that recent research concluded with salient advice for clinicians. Schiweck et al. (2021) advised clinicians to be aware of cultural and methodological differences across continents when applying diagnostic criteria, in order to prevent misdiagnosis and provide optimal care for both ADHD and BD.

The risks of misdiagnosis, or missed diagnoses, are significant. A 2010 collaborative project revealed that the adult ADHD phenotype is commonly reported by individuals with major depressive disorder (MDD) or bipolar disorder and is associated with a greater illness burden and complexity (McIntyre et al., 2010).

It is important for clinicians to identify co-morbid conditions so as to most effectively guide their support and treatment for the patient.

Substance Use Disorders

ADHD, especially untreated ADHD, is a very strong risk factor for substance abuse and substance use disorders (Wimberley et al., 2020).

So strong, in fact, that I wrote an entire article about those risks alone, so I won’t cover it again here:

ADHD Puts Us at Greater Risk for Addictions

Personality Disorders

Personality disorders are generally thought to be highly comorbid with ADHD, unfortunately at present there is inadequate robust research to fully explain, support, or refute this suspicion.

Borderline Personality Disorder (BPD) specifically is thought to be the most prevalent personality disorder amongst people with ADHD (Moukhtarian et al., 2018).

One challenge is the significant overlap in the symptoms of ADHD and BPD (Matthies & Philipsen, 2014).

Sexism and BPD

An even greater challenge is the prevalence of sexism and gender bias in the diagnosis of personality disorders, and in diagnosing BPD in particular.

For example, Skodol & Bender (2003) found that the differential gender prevalence of BPD in clinical settings appears to be largely a function of sampling bias.

More recently, Busch and colleagues (2016) found minimal gender differences in Borderline Personality Disorder severity between cis-gendered male and female adults.

This is something that significantly impacted my own experience with seeking support, diagnosis, and treatment. I wrote a separate piece on this as well:

My ADHD was Misdiagnosed as a Personality Disorder

I will add that recent exploration and discussion of BPD through a neuroqueer and feminist framework characterizes BPD as a “complex, historically misogynistic, yet still salient term for emotion dysregulation” (Johnson, 2021).

I find this approach much more nuanced and intersectional, seeking to destigmatize borderline personality disorder and disrupt the racial, neuronormative, and heteronormative baises pervasive in BPD studies.

Transphobia and BPD

Current literature doesn’t even begin to discuss the difficulties and gender bias encountered by non-binary and transgender individuals when trying to access health care.

One study (Anzani et al., 2020) claimed that BPD was the most frequent personality disorder diagnosis amongst individuals seeking gender-affirming treatments. The bias was made clear before the study even began, when researchers started out with the assumption that individuals seeking gender-affirming treatments needed to be assessed specifically for personality disorders.

Secondly, the conclusion that trans people are more likely to have BPD assumes that the BPD symptoms are separate from, or causing, gender dysphoria. This assumes that being transgender in itself is disordered, rather than assuming being trans causes distress because of how our society mistreats trans people.

Perhaps the experience of being transgender in an extremely transphobic society causes distress, some symptoms of which overlap with the symptoms of BPD. For example, chronic feelings of emptiness; recurrent suicidal behaviour, gestures, or threats, or self-harming behaviours; and identity disturbance with markedly or persistently unstable self-image or sense of self (American Psychiatric Association, 2013).

Recent research has shown that higher rates of suicide ideation amongst transgendered individuals was directly related to the higher rates of victimization and discrimination they experienced (Rabasco & Andover, 2021). Regarding a persistently unstable self-image, when one’s outward appearance or presentation doesn’t match one’s inner self, it stands to reason that one might experience challenges with self-identity too.

For great writing on neuroqueering, transgender issues, neurodiversity, and more, I very highly recommend following the Autistic Science Person and Devon Price, as well as other trans, non-binary, queer, and neurodivergent writers.

In particular, I have linked to Devon’s piece about their experiences with gender dysphoria:

Gender Dysphoria Felt Like Being Insane

To be Continued…

Literature to date tells us that the most common comorbid conditions associated with ADHD are Anxiety Disorders, Obsessive Compulsive Disorder (OCD), Bipolar Disorder (BD), Depression, Substance Use Disorders (SUD), and Borderline Personality Disorder (BPD).

Yet there is much to be unpacked as we discover and finally begin to challenge the inherent biases found in our current referral, diagnostic criteria, and diagnostic processes.

© Jillian Enright, CYW, BA Psych.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Anzani, A., De Panfilis, C., Scandurra, C., & Prunas, A. (2020). Personality Disorders and Personality Profiles in a Sample of Transgender Individuals Requesting Gender-Affirming Treatments. International Journal of Environmental Research and Public Health, 17(5), 1521. MDPI AG. http://dx.doi.org/10.3390/ijerph17051521

Busch, A. J., Balsis, S., Morey, L. C., & Oltmanns, T. F. (2016). Gender Differences in Borderline Personality Disorder Features in an Epidemiological Sample of Adults Age 55 – 64: Self Versus Informant Report. Journal of personality disorders, 30(3), 419 – 432. https://doi.org/10.1521/pedi_2015_29_202

Farrell, L. J., Lavell, C., Baras, E., Zimmer-Gembeck, M. J., Waters, A. M. (2020). Clinical expression and treatment response among children with comorbid obsessive compulsive disorder and attention-deficit/hyperactivity disorder. Journal of Affective Disorders, 266, 585 – 594. https://doi.org/10.1016/j.jad.2020.01.144

Jane, J. S., Oltmanns, T. F., South, S. C., & Turkheimer, E. (2007). Gender bias in diagnostic criteria for personality disorders: an item response theory analysis. Journal of abnormal psychology, 116(1), 166 – 175. https://doi.org/10.1037/0021-843X.116.1.166

Johnson, M. L. (2021). Neuroqueer Feminism: Turning with Tenderness toward Borderline Personality Disorder. Signs, 46(3). https://doi.org/10.1086/712081

Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

Masi, G., Millepiedi, S., Mucci, M., Bertini, N., Pfanner, C., Arcangeli, F. (2006). Comorbidity of obsessive-compulsive disorder and attention-deficit/hyperactivity disorder in referred children and adolescents. Comprehensive Psychiatry, 47(1), 42 – 47. https://doi.org/10.1016/j.comppsych.2005.04.008

Matthies, S. D., & Philipsen, A. (2014). Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)-review of recent findings. Borderline personality disorder and emotion dysregulation, 1(3). https://doi.org/10.1186/2051-6673-1-3

McIntyre, R. S., Kennedy, S. H., Soczynska, J. K., Nguyen, H. T., Bilkey, T. S., Woldeyohannes, H. O., Nathanson, J. A., Joshi, S., Cheng, J. S., Benson, K. M., & Muzina, D. J. (2010). Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project. Primary care companion to the Journal of clinical psychiatry, 12(3). https://doi.org/10.4088/PCC.09m00861gry

Mohammadi, M.-R., Zarafshan, H., Khaleghi, A., Ahmadi, N., Hooshyari, Z., Mostafavi, S.-A., Ahmadi, A., Alavi, S.-S., Shakiba, A., & Salmanian, M. (2021). Prevalence of ADHD and Its Comorbidities in a Population-Based Sample. Journal of Attention Disorders, 25(8), 1058 – 1067. https://doi.org/10.1177/1087054719886372

Moukhtarian, T.R., Mintah, R.S., Moran, P. et al. (2018). Emotion dysregulation in attention-deficit/hyperactivity disorder and borderline personality disorder. Borderline personality disorder and emotional dysregulation 5(9). https://doi.org/10.1186/s40479-018-0086-8

Rabasco, A., Andover, M. (2021). Suicidal ideation among transgender and gender diverse adults: A longitudinal study of risk and protective factors. Journal of Affective Disorders, 278, 136 – 143. https://doi.org/10.1016/j.jad.2020.09.052

Schiweck, C., Arteaga-Henriquez, G., Aichholzer, M., Thanarajah, S. E., Vargas-Cáceres, S., Matura, S., Grimm, O., Haavik, J… Reif, A., et al. (2021). Comorbidity of ADHD and adult bipolar disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 124, 100 – 123. https://doi.org/10.1016/j.neubiorev.2021.01.017

Skodol, A.E., Bender, D.S. (2003). Why Are Women Diagnosed Borderline More Than Men?. Psychiatric Quarterly 74, 349 – 360. https://doi.org/10.1023/A:1026087410516

Substance Abuse and Mental Health Services Administration (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Substance Abuse and Mental Health Services Administration (US); Table 3.13, DSM-IV to DSM-5 Obsessive-Compulsive Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13

Wimberley, T., Agerbo, E., Horsdal, H. T., Ottosen, C., Brikell, I., Als, T. D., Demontis, D., Børglum, A. D… Dalsgaard, S., et al. (2020) Genetic liability to ADHD and substance use disorders in individuals with ADHD. Addiction, 115: 1368 – 1377. https://doi.org/10.1111/add.14910

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Neurodivergent. 20+ years social work and psychology experience. I write about mental health, neurodiversity, advocacy, education, and parenting. Founder of Neurodiversity MB. CYW, BA Psychology.

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