Why ADHD Is Often Misdiagnosed As BPD

Speaker 0:00 Many people with ADHD cope really well, function really well. Many people with BPD cope well and function well, but BPD's probably more disabling, and there's a stronger emotional component to it. And that emotional component at times tips into kind of dissociation and where parts of the self don't really talk to each other, and that's where we get these really drastic mood swings, where everything will be fine and then suddenly everything's not fine.

Alex Partridge 0:21 Dr Judith Mohring is a Cambridge-educated psychiatrist.

Speaker 0:24 She's here to spread awareness of ADHD's shared characteristics-

Alex Partridge 0:27 With Borderline Personality Disorder.

Speaker 0:29 For many of us with ADHD, we use a lot of emotional data. I arrived here today not in a great mood. I'm like, "I've got loads of emotional data." But I know it's 'cause I've not been looking after myself very well. It's not real. People who successfully navigate ADHD or BPD are those who learn which emotions need to be listened to. I'll often say to my kids, "Your emotions are important, but they're not in charge." I think the BPD experience is probably more severe. When we add trauma into the mix with neurodiversity, so if you experienced early abandonment, so of course trust is gonna be hard to establish. And so we do know that many people with BPD have a history of trauma, so actually their responses are, in that context, really understandable.

Alex Partridge 1:04 What is the sort of treatment, medication for BPD if someone does get a diagnosis?

Speaker 1:09 This is where it's really interesting actually, because we know-

Alex Partridge 1:13 Quick one before I get distracted. I just wanted to say a very brief thank you to all of my listeners. Thank you for tuning in and thank you for subscribing and following the podcast. It really, really helps. At ADHD Chatter, my mission is to ask the world-leading experts the hard questions to give you access to the most pioneering advice the world has to offer, and with an aim to help you feel seen. Following and subscribing helps me on my mission to book these incredibly insightful guests and to give you these incredibly insightful interviews. Remember, you're not broken, just different, and you have always been enough. Judith, welcome back to the ADHD Chatter studio.

Speaker 1:52 Thank you, Alex. Good to be here.

Alex Partridge 1:54 It's the third time, right?

Speaker 1:56 Yes.

Alex Partridge 1:57 Back by popular demand again.

Speaker 1:59 My mom is gonna be so pleased.

Alex Partridge 2:01 [laughs]

Speaker 2:01 She now has her own Instagram account.

Alex Partridge 2:03 Does she? That's cool.

Speaker 2:03 Yeah, she does.

Alex Partridge 2:04 What's the handle? Oh, you don't need to say. [laughs]

Speaker 2:06 I've got no idea.

Alex Partridge 2:07 [laughs]

Speaker 2:08 I really got no idea.

Alex Partridge 2:09 Do a, have to do a quick shout-out for the mum. [laughs]

Speaker 2:10 [laughs] I know. Hello, Mum. [laughs]

Alex Partridge 2:12 This time we're gonna talk about something a little bit different, which is the, the, the crossover or the link between ADHD and BPD.

Speaker 2:19 Yes.

Alex Partridge 2:20 Borderline Personality Disorder. Um, why was it important for you to come on today and, and talk about this topic?

Speaker 2:28 Um, well, we go back a few years here. So one of the things I'm probably proudest of in my career was, um, about 15 years ago, setting up a service in Holloway Prison for women who had problems with self-harm, and we were creating a therapy service for women with emotionally unstable or borderline personality disorder. And it was just, you know, it was a really good thing to do because those women had no resources, no therapy, no nothing. We got money from the government to do it. It was very... You know, I like setting up services. I'm quite entrepreneurial, as many people with ADHD are, and it was a chance to do something really innovative for very disadvantaged women. And also, um, they would complete their modules and come out and go, "I've got a certificate," and be really proud. And it was just one of the things I'm really proud of doing and has informed now how I think about ADHD, I think.

Alex Partridge 3:17 And if we, if we sort of focus on ADHD for a second, what would you say are the defining traits of ADHD?

Speaker 3:24 So I'm glad you asked that because, um, teaching this to doctors and to clinicians who are trying to diagnose, I now talk about a tree. There's two branches of the tree, and there's the inattentive features of ADHD, so that's difficulty with focus, attention, concentration, motivation, oops, organizing things, sequencing, forgetting, remembering, all of those things, and time management as well. So that's the inattention side of the tree. And then the other side of the tree is the hyperactivity impulsivity. So that's the restlessness, both internal and external. It's the, um, physical energy. It's the talking too much. Um, and then you've got the impulsivity as well, and the impulsivity is the inability to hold back and the blurting things out and the saying what comes on your mind, onto your mind immediately. So these, these different features. You've got the inattention side and the hyperactivity impulsivity side. So those are the kind of core features.

Alex Partridge 4:16 Right. Okay. So interesting.

Alex Partridge 4:17 And if we were to focus on BPD, Borderline Personality Disorder, like how would that look like in, in, in a average adult with it?

Speaker 4:27 Gosh, so, um, there's... I suppose there's no average adult, uh, just as there isn't with ADHD. But, um, we see some areas of overlap and some areas of difference, and I think often people say, "Oh, they're the same thing. BPD, ADHD, it's the same thing." And I don't think that's true. Um, and I wanna be responsible and, and clear. Don't think that's true, but there's definite overlap, and we need to be clear about it. So if we go back to that impulsivity side, impulsivity is one of the first traits of A- of, um, BPD. So impulsivity. Um, the next trait, or the next traits that we think about with BPD are emotional dysregulation. Sound familiar?

Alex Partridge 5:01 Hmm.

Speaker 5:01 Yeah. So you've got your emotional dysregulation, and issues with anger. Obviously, anger's an emotion, so inappropriate anger. So that's an area of commonality, isn't it?

Alex Partridge 5:11 Sounds quite similar to a, an RSD-induced rage maybe.

Speaker 5:15 Definitely could be similar to RSD. And if we broaden the lens out even further and start to bring in autism and AuDHD, and then we start to think about meltdown and being completely emotionally dysregulated, suddenly you go, "Ooh, interesting." So overlap. Definite overlap. Then what we see with BPD is, um, difficulty in managing relationships, and that could be related to issues with social communication or dis- difficulties with m- just managing emotion. So you could see the overlap with neurodiversity there. Um, and then as we go further into the construct, we also see things like chronic emptiness or lack of identity.

Alex Partridge 5:59 Chronic emptiness. What, what do you mean by-

Speaker 6:01 It's a strange... Yeah, I know. It's a strange symptom. Really strange symptom. Um, when I assessed for BPD in the past, I used to just ask peopleAnd people would either say yes or no. It's a very odd one. But what we're getting at is this core sense of, um, a lack of sense of self, a lack of clear sense of self, and, um, in, in more, you know, in people who are suffering more, or quite a disturbed sense of self.

Alex Partridge 6:22 Mm-hmm.

Speaker 6:23 But again, there's overlap, isn't there? 'Cause a lot of people with ADHD will describe this sense of a unstable or a difficulty, difficulty with sense of self. So there's overlap there.

Alex Partridge 6:33 Is... And with these overlaps being so clear, is it possible that some people who have BPD might get an ADHD diagnosis by accident, or someone with ADHD might get a BPD diagnosis by accident?

Speaker 6:46 Definitely that there's... it's possible to get a diagnosis that isn't possibly the best fit, um, and that it might be worth kind of going, "Hmm, maybe there's traits of both." I mean, there are things that definitely distinguish. So people with BPD will have, generally have issues with self-harm, although that can happen as well in, in ADHD, and recurrent issues as- with self-harm. Um, and also this idea of, uh, difficulty with abandonment, and, um, s- begging and pleading to avoid being abandoned, and that's quite a specific BPD symptom in the DSM-5. And then we also have this transient paranoia that is more specific to BPD rather than ADHD. So those are the things that are more distinguishing. But it's very easy to see... Because diagnosis is really complex, right? Really complex. And w- the diagnosticians are only human, and they've only got so much time. And doing a full history for both takes a long time.

Alex Partridge 7:41 So with the, the fear of abandonment being a- an aspect of BPD, what comes first, the chicken or the egg? Do you fear abandonment because you have BPD, or do you have BPD because you had early years of abandonment?

Speaker 7:53 [laughs] I love your questions. I love your confused face as well, 'cause-

Alex Partridge 7:57 [laughs]

Speaker 7:57 ... I was dreading doing this one, 'cause I'm like, "It's a sensitive topic. I don't want to let people down. I don't wanna misrepresent." It's not, you know, this or this, it's like, it's quite complex.

Alex Partridge 8:05 Sure.

Speaker 8:05 So the- the confused face is good, 'cause I'm like, "With you on this." Um, and the answer is we probably don't really know. But we do know, when we add trauma into the mix with neurodiversity, so if you experienced early abandonment, so of course trust is gonna be hard to establish. Of course you're gonna worry about people leaving you. It's rational, right? And so we do know that many people with BPD have a history of trauma, so actually their responses are, in that context, really understandable, almost like a learned response.

Alex Partridge 8:34 Just going off on a tangent ever so slightly, early years experience of abandonment, like, what does that look like? Is that you crying in a pram and your parents ignoring you? I- is it more complicated than that?

Speaker 8:45 So it's not, it's not just like the controlled crying. You know, this kind of, "Oh, don't let the baby cry, there'll be a, there'll be attachment issues." Um, with abandonment, what we're talking about is significant abandonment, so loss of a parent, either through, through death or the parent leaving, or, um, issues with early attachment, so a parent who's very unavailable through reasons relating to addiction, mental illness, difficulty relating. So parents who can't relate to their children, who can't connect and form that attachment. 'Cause, uh, babies when they're young really do need that primary attachment figure who can really form that warm, loving attachment to them.

Alex Partridge 9:19 So is there a genetic component to BPD, uh, in the same way that there, there most likely is with ADHD, um, or is it kind of a consequence of early year exposure?

Speaker 9:33 So as with ADHD, there's a gene environment interaction. The thing with ADHD is that ADHD's been more able to kind of establish a biological basis. There's a lot of biological research in ADHD, so we'd say there's strong genetic links with ADHD, and there's also some environmental in- influence. With BPD we would say, probably say there's environmental influence and some genetic links. So it does, r- the traits do run in families, um, but probably less so than with ADHD.

Alex Partridge 9:58 I feel like BPD has quite a negative connotation. Do you think that's justified?

Speaker 10:06 It, it's has been used as a bit of a kind of diagnostic dumping ground in the past, um, a sense of, "I don't know what to do with this client. I don't know how to help them." And again, if we're gonna take a neuro inclusive lens and a neuro aware lens now, we'd say, "Hang on. Pause." If there's a client that you're not sure what's going on, think neurodiversity, think, can I assess, you know, why is this client struggling with s- such simple things? What's, what's the issue here? Um, so a more neuro inclusive lens, very much something that we want to encourage in sort of mental health services. Um, and there's lots of training going on for that. Um, but yeah, it's, it's been quite stigmatized even in the profession. So I will often say, I've had clients say to me, "Oh, can you diagnose me borderline?" Which you wouldn't expect, but for the client, the borderline diagnosis is not a problem. But for the clinician, it like, it is. So we need to be kind of, uh, aware of our own stigmatizing beliefs in the profession.

Alex Partridge 10:57 Are there any clear-cut traits, characteristics that would separate BPD from someone getting an ADHD diagnosis?

Speaker 11:07 So we, we talked about overlap. There is quite a lot of overlap. Um, but if you were gonna diagnose... So we diagnose BPD on the DSM-5, and there's nine different criteria. Um, we would be looking for enough of those criteria, so five of the nine criteria. The difficulty, if I'm honest, is that if you do an assessment for BPD alongside ADHD, very often you'll find that both are met, and that's okay. Just do a good assessment. That's what I say when I'm teaching. It's okay that if both are met, that's fine. Make both diagnoses, share them with the client, and explain that maybe you could provide a treatment plan that covered both sides, that did some work on the ADHD and some work on the D- on the BPD.

Alex Partridge 11:47 So I speak to a lot of people in the ADHD community, and they, they, they refer to people their, their, their loved ones, people they're in a relationship with, their family members, referring to them as having a very Dr. Jekyll and Mr. Hyde personality. Um, and I feel like my very basic understanding of BPD is that you have drastic mood swings. Like, how far is that stereotype from an accurate representation of what BPD actually is?

Speaker 12:15 So we talk in BPD as, uh, sort of state shifts. So, um-I- if we were to understand that many people with ADHD, you know, cope really well, function really well, many people with BPD cope well and function well as well, but BPD's probably more, I would say, can be more disabling, and there's a stronger emotional component to it. And that emotional component at times tips into kind of dissociation and where parts of the self don't really talk to each other, um, and that's where we get these really d- drastic mood swings where everything can be fine and then suddenly everything's not fine. Um, and again, taking a neuro inclusive lens, there might be other reasons for that, but that Jekyll and Hyde issue is definitely something that we see where things are fine and then suddenly they're not, because there's been this emotional state shift.

Alex Partridge 13:02 What would be, like, some common triggers that might initiate one of those extreme mood swings in someone with BPD?

Speaker 13:10 So it'd probably be something interpersonal. It's quite often... Or, or it'd be something trauma related. So, um, a, a memory of trauma can quite often trigger quite significant state shifts, and we see people dissociating. Dissociating means to really struggle with attention and focus and be, not even be present almost i- i- in the room. Um, and you can have kind of dissociative fugue and stuff where you don't remember things and you go missing and all sorts. Um, but also what we see in, um, BPD with these, these state shifts is you can get them triggered by interpersonal issues, so a relationship going wrong or somebody abandoning you, or the, even the, the threat or the fear of abandonment, that you looked at me funny, I thought this, this is what happened, and you'd see these really big state shifts. And it's very distressing for people with BPD, very distressing.

Alex Partridge 13:56 Mm. I mean, it's sounding very similar to what we speak about a lot on this podcast, which is the sort of perceived rejection or criticism which we know comes with RSD. Like, is it possible to have both, uh, BPD and ADHD, and what might that look like in someone?

Speaker 14:10 Well, I think what we're talking about is this middle ground, that there's a real middle ground, and because we're all talking so much more about mental health, we're talking a lot about ADHD, but we're not talking quite so much about BPD, partly 'cause of the stigma. Um, but also maybe we're not, we didn't realize how emotional ADHD was. So ADHD was, you know, defined in the DSM-5 and before that in various different diagnostic criteria before, and people didn't focus so much on the emotional experience, but it is a massively emotional experience. And RSD has kind of come up through social media as, like, this is what we're all experiencing. And you might internalize it, or it might come through in your behavior, or you might express it through emotion. Um, but many of us experience very powerful emotions either under the surface or expressed externally.

Alex Partridge 14:56 I read a quote recently, and I can't remember who said it, but it was, it was the, having an intense fear of an abandonment will make us perform certain actions and behave in a certain way that almost makes the chances of us being abandoned inevitable. Like, y- you, you act in a certain way, you seek reassurance with your partner always, um, which can almost come across as unattractive if, if not explained and communicated with your partner. Is it possible for someone, like, with ADHD or BPD to almost have enough evidence of this previous behavior of abandonment and recognizing what their behavior leads to, to look into their future and to see that that is just going to repeat and that creating almost quite a, a hopeless feeling?

Speaker 15:47 I think I would agree that you can get into a pattern where you're either very kind of compliant and pleasing as a way of keeping somebody close, um, or needy perhaps as a way of expressing the fact that you need someone. But then when you fear the relationship may be under threat, you might push the person away in a kind of, "I can't bear you leaving, so I'll push you away before I'm left." So almost gaining control by saying, "I'm gonna cut off now. I can't bear you leaving." Um, and there's a phrase, "I love you, don't leave me" that comes from the BPD literature, um, meaning, "I really need you, and yet I can't bear the intimacy and it's too threatening, because I can't bear the fact that you can go away and leave me."

Alex Partridge 16:28 Is that quite an extreme portrayal version of, of BPD? Like, if we were to look at the extreme end of the spectrum, um, what could an extreme version of BPD look like in someone?

Speaker 16:41 So, um, and it's more extreme, and it was actually defined, it's called b- borderline personality because it was defined as being on the borderline of psychosis back in the '50s.

Alex Partridge 16:51 Gosh.

Speaker 16:51 I know. It's like-

Alex Partridge 16:53 Mm

Speaker 16:53 ... it's not, it's not a, it's not a vanill- vanilla diagnosis. It's quite, it was quite an extreme diagnosis. And essentially, um, psychiatrists were going, "Why are these people behaving this way?" Um, predominantly women, I suspect, at the time, but they weren't psychotic, but they were at times paranoid, uh, at times almost psychotic and dissociating and, um... So it's sort of almost as severe as psychosis for some people, um, and that's why it was defined as borderline. So when we see very severe BPD, what we might see is really severe self-harm, real difficulty with managing relationships, real impulsivity, emotional dysregulation, and then you see, often see other patterns that we might see with ADHD, but to a more extreme end. So there used to be something called multi-impulsive personality disorder, which was gambling, recurrent sexual activity you didn't want, eating issues, um, all the kind of things that we might see, drug issues, all this kind of multi-impulsive stuff that you see in ADHD as well.

Alex Partridge 17:49 Mm.

Speaker 17:50 Um, so it, it's all quite confusing.

Alex Partridge 17:53 Paranoia in relationships, I mean, that can cause irreparable damage, right, if not understood.

Alex Partridge 17:58 Um, like, i- is there a link between sort of paranoia, um, fear of abandonment, and BPD?

Speaker 18:06 Yes. It's one of the core features of BPD is that fear of abandonment, and it would be linked with the paranoia. You can imagine that, or not just fear of abandonment, but also an intense, um, sense that other people in some way are negative or harmful or, or, or have ill intent. Um, and that's sort of linked to some of the, the, the-Slightly less intense, but, um, still very distressing experiences people with ADHD can experience around RSD and assuming that people dislike you-

Alex Partridge 18:32 Mm

Speaker 18:33 ... um, that sort of thing.

Alex Partridge 18:34 You mentioned earlier that ADHD never travels alone. What did you mean by that?

Speaker 18:40 Yeah, we s- we've been talking a lot about personality disorders, but, uh, I think it's important to recognize that actually ADHD is really commonly associated with other mental health diagnoses. Now, you can have ADHD and not be distressed and have a great life, but for many people, when they get a diagnosis, actually they, they are at a point where they're very distressed and there's other stuff going on. And about 80% of people with a diagnosis of ADHD will also have another condition, and it could be anything from depression, anxiety, uh, substance use issues, insomnia, um, issues with eating. So we really commonly see binge-eating, or we might see ARFID or avoidant/restrictive food intake disorder. Um, OCD is quite common, as well as the personality issues. So you've got a whole smorgasbord of delightful potential things going on, and it was one of the reasons we get a bit frustrated. If you spent 25 years training to diagnose, and then somebody gets a tick box-

Alex Partridge 19:31 Mm-hmm

Speaker 19:31 ... ADHD assessment, it's a bit disappointing. You think, "Hang on, are you looking for everything else? Are you actually looking properly at this poor person?" Yeah.

Alex Partridge 19:39 With the eating disorders, I mean, how, how can that manifest with someone? Is there a difference between someone with BPD and ADHD in that arena, or is there an overlap?

Speaker 19:47 Well, so the BPD piece is that in the past we used to talk about this multi-impulsive borderline, and you'd often see people who had features of borderline personality and also had binge-eating. But now, when I look at that, I think, "Hang on, it's really common to see binge-eating with ADHD." So common, in fact, that in the US, one of the treatments for ADHD is also licensed for binge-eating. And the binge-eating's really interesting with ADHD 'cause if you're a bit inattentive, um, and you're not paying attention to your hunger, then you won't eat. And if you don't eat, then that represses your emotions, so you manage your emotions quite well during the day 'cause you haven't eaten. And then all of a sudden you get very angry 'cause you're hungry and hangry, um, so you might have emotional dysregulation. And then, um, your focus and concentration isn't good, so you eat, but you don't notice you're eating, so you just eat the whole packet of biscuits or something. So it's really closely associated with the inattention, and it's also closely associated with the executive function issues 'cause it's quite hard to keep the fridge organized-

Alex Partridge 20:44 Mm

Speaker 20:44 ... generally, I think.

Alex Partridge 20:46 I've always got moldy fruit in my fridge.

Speaker 20:49 Yeah.

Alex Partridge 20:49 And I think the reason is because when I'm in a supermarket, the idea of being healthy is quite exciting.

Speaker 20:55 Yeah.

Alex Partridge 20:55 So I'll walk past a packet of blueberries or raspberries and think, "That'll be a nice addition to my porridge. That will be really healthy." But then maybe I'll do it for two, three mornings. But then, because I don't particularly like the taste of blueberries or raspberries, there's no immediate benefit that will motivate me to put them on my porridge.

Speaker 21:13 Yeah.

Alex Partridge 21:14 The health benefits of eating blueberries, you know, in my mind, that's years down the line, and that's invisible for me, so I don't have the motivation to do it. And then I see them two, three weeks later, and they are totally moldy and end up in the bin. And I think the amount of money I've probably spent on impulsively buying superfoods like spinach and, and blueberries and raspberries, and then they end up in the bin. I mean, it's that ADHD tax, I think, that gets so many of us. [laughs]

Speaker 21:38 The ADHD tax. [laughs] It's like spirulina, or is it semolina? I'm not sure which. But there's that sort of, those health foods that you buy-

Alex Partridge 21:43 Yes

Speaker 21:43 ... and you think, "That'll be healthy." And I was, what, reading a blog the other day about ADHD, and somebody said, "Sometimes I just eat beige foods," because almost they've imagined this perfect diet they're gonna, like, feed themselves, and they've got all the cookbooks, and impulsively buying cookbooks.

Alex Partridge 21:57 Mm.

Speaker 21:57 And I do this as well. It's like I'm gonna make this amazing meal, and then when it comes to making the meal, it's so... I find cooking really boring.

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Speaker 23:19 Probably, I would say. And the thing with the impulsivity is it's the feature that unites both, very much unites both conditions. It's a core feature of ADHD. It's a core feature of BPD. And, you know, emotional dysregulation wasn't a core feature of ADHD, but we now see it very much is. Um, and the two things are really, really closely linked.

Alex Partridge 23:37 Mm.

Speaker 23:37 Um, yeah. So I think probably similar, a real overlap there, definitely.

Alex Partridge 23:41 ADHD and impulsivity, is there some new research that backs some of that up?

Speaker 23:46 It's... Oh, this, this is really old research, but it's good research, and it relates to children who are given, I think there were about three or four, maybe there were five, but they had this task where they were told, "You can eat one marshmallow now, or if you don't eat the marshmallow and you wait patiently for five or 10 minutes, then you can have two marshmallows." So how do you resist the marshmallow? And there were kids who kind of sat on their hands, and they used all these techniques, sitting on their hands, looking out the window, whistling, and there were other kids who went, "And ate the marshmallow." Now, obviously, what's the ADHDer gonna do?

Alex Partridge 24:13 Well, yeah, go for the one immediate reward.

Speaker 24:15 Immed-

Alex Partridge 24:16 [laughs]

Speaker 24:16 Eat the marshmallow, exactly. Um, and then when they looked long-term, people's kinda longer term outcomes, the kids who were able to control their impulsivity when they were young did better on lots of outcomes long-term. So the issue with impulsivity is it's, like, core feature of both.And it impacts everything. It impacts our ability to, you know, not tell inappropriate jokes to your mother-in-law. I mean, that's, I, I, I've told a few inappropriate jokes in-

Alex Partridge 24:42 [laughs]

Speaker 24:42 ... in my time. To not, um, drink the bottle of wine, to not spend the money. It impacts everything. Um, and it's kinda such a core feature of both, of both conditions. What would you... Do you, do you see what I mean, how it kind of under- underlies all sorts of things?

Alex Partridge 24:58 Yeah. I mean, impulsivity can get you into loads of trouble, right?

Speaker 25:01 Yes.

Alex Partridge 25:01 Uh, you s- you say something that you shouldn't have said, you blurt something out because you... It makes you feel good in the moment, but then you're overthinking it for the whole night. Um, makes you buy stuff you don't need.

Speaker 25:13 Yes. You were mentioning about the blueberries and how in future, you know, the, the idea of the blueberry being good for your health is great-

Alex Partridge 25:18 Mm

Speaker 25:18 ... for future you, and we, in therapy with ADHD, talk about future you quite a lot. But, you know, saving for a pension, great for future you, but future you isn't here now. Right now, there's someone who wants to buy that watch or takeaway or bottle of wine or new coat. Um, and impulsivity really does, you know, it causes big issues for, for people in lots of ways, in sexual relationships. Oh, leaving jobs, that's the other one, the impulsive job leaving.

Alex Partridge 25:44 Yes. [laughs] Because it, it's, we do stuff in the moment that are, that are fun and rewarding-

Speaker 25:49 Yes

Alex Partridge 25:49 ... 'cause it's new and novelty. We crave novelty, right? So starting a new job is exciting.

Speaker 25:53 Yes. So-

Alex Partridge 25:54 Um, we get a lot from being told that we have been chosen for the job.

Speaker 25:59 Yeah.

Alex Partridge 25:59 Once we settle in and then we're sat at the desk in week two or three or four, then the dopamine's gone.

Speaker 26:03 Yeah.

Alex Partridge 26:04 And, or the tiniest rejection maybe, and that's, that's the trigger, that's enough, we're out the door.

Speaker 26:08 Yeah. And it's, the novelty wears off-

Alex Partridge 26:10 Mm

Speaker 26:10 ... and the excitement of the difficulty, so the difficulty of the new situation. This is stressful. This is new. Oh, novelty's worn off, now I'm leaving. And so impulsively leaving jobs is a massive issue. I once impulsively bought a chest of drawers on the way to work.

Alex Partridge 26:22 [laughs]

Speaker 26:23 Uh, I once impulsively, seemed to impulsively buy furniture. I bought a double bed from IKEA and tried to get it-

Alex Partridge 26:29 Mm

Speaker 26:29 ... home on the bus. Um, that nearly led to a relationship ending, understandably. [laughs]

Alex Partridge 26:35 [laughs]

Speaker 26:36 So it's just, doing crazy things and then you think, "Why did you do that?" But it's the novelty, isn't it?

Alex Partridge 26:42 And, I mean, starting this podcast was impulsive.

Speaker 26:44 Uh-huh.

Alex Partridge 26:44 You know, start... How does one know the difference between an impulsive decision that is gonna stick and can potentially turn into something that is gonna capture your attention for years and years and years and be, and be fun and brilliant, compared to something that is a, is, is a chest of drawers or a packet of blueberries in a supermarket?

Speaker 27:01 It was a nice chest of drawers, actually.

Alex Partridge 27:03 [laughs]

Speaker 27:03 So don't diss my chest of drawers. Um, this is really interesting as well, because you kinda talk... We never talk about borderline strengths, and we will, we should do. But we talk a lot about ADHD strengths, and you mentioned about, you know, starting the podcast, there was quite a lot of intuition. And one of the ADHD strengths, I think, is intuition, this kind of gestalt feeling of being able to see the big picture, of also being able to use emotional information and kinda go, "Hmm, interesting. What does that mean?" And I think impulsivity's also quite closely linked to courage, risk-taking, ability to, to, um, do, do things that other people wouldn't, um, full step in where angels fear to tread, but you kinda do things that you think maybe in hindsight that wasn't so wise, but you do it anyway. I mean, looking back, starting a BPD service in Holloway Prison was massively stressful. Um, but it was worthwhile. Um, and for you, I imagine some of the things you've done in your career have been massively stressful, but worthwhile.

Alex Partridge 27:59 Well, getting over that initial desire to be perfect, um, I think is a hurdle for so many people, and also it's kind of, a lot of people don't give in to that impulsivity and start that business because they're so worried about what other people are gonna think, worried about failure. It's that momentum-building phase that is so difficult, I feel, for so many people. It's starting.

Speaker 28:21 Yeah.

Alex Partridge 28:21 It's buying that domain. It's g- it's getting the first few months out the way so you can kind of accumulate enough positive feedback that, that validates the idea and, and-

Speaker 28:31 Yeah

Alex Partridge 28:31 ... that overpowers that RSD, which I think is, is what stops so many people from even starting. And I wondered what, if there was a difference in how someone with ADHD might a- navigate life, constantly eagle-eyed and worried about criticism, um, and how that impacts their life, compared to someone who might have BPD. How, is there a difference in those two experiences?

Speaker 28:55 I think the BPD experience is probably more severe, is what I would say. But then if we were to compare either of those groups with, um, someone who doesn't have ADHD or BPD, there might be less intuition and courage in someone who's, who's not ADHD or BPD. But there might also be more ability to stick to the path, 'cause I think for many of us with ADHD, we use a lot of emotional data, and the emotional data, it's like I've got loads of emotional data, and then, like, I arrived here today not in a great mood. I'm like, "I've got loads of emotional data, but I know it's 'cause I've not been looking after myself very well." It's not real, and I know-

Alex Partridge 29:28 Mm-hmm

Speaker 29:28 ... that through experience. But it takes years to realize that the emotional data sometimes lies, and that you need to just continue and persevere, and tomorrow will be a better day. Um, and that, I think, you know, people who successfully navigate ADHD or BPD are those who learn which emotions need to be listened to. I'll often say to my kids, "Your emotions are important, but they're not in charge."

Alex Partridge 29:49 Mm.

Speaker 29:49 "So listen to them, validate them, be kind to them, but don't let them rule the roost, if you can." Um...

Alex Partridge 29:56 How does this whole conversation around BPD and ADHD translate into, like, romantic relationships? 'Cause I feel like if you're... [laughs]

Speaker 30:05 Thanks.

Alex Partridge 30:05 You know what's coming.

Speaker 30:06 [laughs]

Alex Partridge 30:07 It's a big one, right? I think, like, if you, if you, if you meet someone and you don't know they are ADHD or BPD, I feel like a lot of people with ADHD specifically, because of you wanna be amazing for someone else, you don't wanna let someone down, you can love bomb someone-

Speaker 30:22 Yeah

Alex Partridge 30:22 ... uh, in the early stages. So I suppose if you're someone who has just met someone and you're experiencing this, this heightened, uh, overexposure, if you like, to, uh, to love, and you're not sure if it's-Someone love bombing you because they have ADHD or BPD, and that's not really a true reflection of who they really are, compared to someone who is genuinely being themselves and is showing you a genuine display of love and affection.

Speaker 30:48 Mm.

Alex Partridge 30:48 Is it possible to sh- tell the difference between someone who is ADHD or BPD and they're love bombing you compared to someone who is genuinely showing you true affection?

Speaker 30:59 Wow. It's a really good question. I, I suppose what I would say is, um, face-to-face interaction is really helpful in relationships, and the, one of the issues we have is so much of our interaction is through text or through technology or online or through apps. So when you meet face to face, it's easier, and also with time, people eventually show their true colors somehow, and we all... Every relationship goes through a honeymoon phase, isn't it? Where you're kind of deeply in love, and they're... And we always put people on a pedestal. "Oh my God, they're amazing. They're like this." And then they come off the pedestal, and that's reality-

Alex Partridge 31:35 Mm

Speaker 31:36 ... unfortunately, is that everybody has flaws, and, um, but yeah, I think it's quite hard to... I think there's a tendency these days, people rush to say, "Oh, they're this, they're that. Oh, they're a narcissist. They're Machiavellian. They're this. They've got the dark triad. They've got this. They've got that." It's like, actually, we're all human beings, and we all have flaws, and relationships are the ultimate kind of dance of trust. They really are the ultimate trying to make things work, sometimes against the odds.

Alex Partridge 32:04 And social media, I feel like, is, just throws a hand grenade in the middle of this, this dance of trust, right?

Speaker 32:10 Yeah.

Alex Partridge 32:10 And in, in particularly maybe ADHD, BPD, where you have this heightened fear of abandonment, um, and perhaps paranoia that you mentioned earlier, and then you throw social media in where there's no clarity really, unless you confront your partner. Like, who's in your DMs? Who are you talking to? Why did you like that photo? Social media can complicate things, right?

Speaker 32:29 Massively. Massively. Yeah. If you think about how life was, I mean, I'm old enough to remember a very, very boring life. My life when I was young was really boring, but in many ways it was much more regulated because nothing happened. You know? And there was nothing to s- there was nothing to obsess over 'cause there were no DMs, no messages, no emails, just letters that would arrive once a fortnight or not. So there was a lack of any data, and actually that's quite soothing sometimes 'cause you're like, "Well, they're there, and I don't know what they're up to, and probably that's a good thing." Whereas-

Alex Partridge 32:59 You only had the postman to worry about. [laughs]

Speaker 33:01 Only had the postman to worry about

Alex Partridge 33:02 ... and you've got an infinite number of people on social media.

Speaker 33:04 Infinite, and, and also-

Alex Partridge 33:05 Yeah

Speaker 33:05 ... it never stops.

Alex Partridge 33:06 Mm.

Speaker 33:06 So it goes on all night, all day. No, and no boundaries.

Alex Partridge 33:10 Mm.

Speaker 33:10 So I'll talk a lot about boundaries in, in ADHD therapy and coaching, and social media has no boundaries at all. It just wants to be in your DMs. It wants to see what you're saying. It wants to work out what really gets you going.

Alex Partridge 33:22 So how dark can it get for someone with ADHD or BPD if they have this paranoia over their partner's supposed infidelity? Like, can they pick up on data points, for example, if their partner puts their phone down on the sofa and the screen faces down, or they go on holiday and their partner posts seven pictures on a carousel and the first picture isn't them as a couple? Like, they're, they're data points, right, that can trigger-

Speaker 33:49 Yeah

Alex Partridge 33:49 ... this, like, "Why? What are they hiding? Who are they trying to get attention from outside of the relationship?" But really they're probably just harmless data points, but we can take those pieces of information and perhaps spiral and create this completely irrational story of infidelity.

Speaker 34:04 Yeah.

Alex Partridge 34:04 Like, how dark can it get, that experience, for someone with ADHD, BPD?

Speaker 34:09 Really dark. I think really, I mean, I think we've all had experiences where you have completely neutral data, and you... Like the email that lands, you're like, "Oh, well, clearly I'm gonna lose my job," or the missed call from your boss, "Oh, I've obviously screwed up massively."

Alex Partridge 34:22 Mm.

Speaker 34:22 Um, or the spiraling that goes on. And I think it depends where your mind naturally goes, that you will fill the, fill in the dots and sort of go to places that perhaps are not that helpful, and in a relationship, that can be really, really disturbing, really, really destabilizing for the relationship. But it's about recognizing that that's a pattern, that that's where, like, as I was saying earlier, you recognize that some days you might be feeling rubbish, and that's perhaps not looking after yourself well enough. So recognizing sometimes your mind goes these places, and you don't need to. You don't have to have those thoughts. You don't have to go those places, and maybe... It's, it's why we talk about mindfulness not a lot. Mindfulness is so hard for people with ADHD, but actually it's evidence-based in the treatment for both DBT, for both BPD and also ADHD, because it allows you to control where your thoughts go.

Alex Partridge 35:08 And if you have these suspicions that, y- you know, a psychiatrist might label them as paranoid, but the person experiencing them doesn't think they're paranoia. Like, you genuinely truly believe that there, that there, there's a red flag in your relationship.

Speaker 35:22 Yes. Yeah, yeah.

Alex Partridge 35:24 And, and if you confront your partner, if you sort of give in to that compulsion, and then your comp- partner re- reassures you and says, "Oh, that's nothing," or whatever, they add context to it, you can then turn that into the theory that they're gaslighting you, and that just creates another spiral.

Speaker 35:40 I haven't thought of it that way, but you're absolutely right. You could, couldn't you? The reassurance, in a way, can be like, "Well, they're obviously lying to me." Um-

Alex Partridge 35:47 How much of, like, a bias towards catastrophization [laughs] do we have, even in the face of reassurance from someone that we do, do trust and love? Like, how much are we almost pressing, doomed to press the self-destruct button all the time?

Speaker 36:01 Ooh, I hope not too much, but yeah, no, I can hear that, the, it's, it's easy to get into that pattern where you are kind of spiraling and where this is a recurring pattern where you kind of get caught up in the... The other thing is that we'll always choose the evidence that fits the thing we can see. So if you think they're having an affair, you'll find the evidence that they're having an affair, and then if they deny it, then you'll go, "Well, in that case, you're gaslighting me," 'cause that conforms with the model. And it's quite risky, particularly if you're thinking about more of the kind of borderline construct with this attachment trauma where you're worried about being abandoned. It's quite risky to create that sense of trust.

Alex Partridge 36:35 Hmm. What about projecting? Like, if, if you have done something yourself, like if you are hiding a DM, uh, or you put your phone or down because you don't want your notifications to show up on the screen, like is, is there a degree that you can almost be paranoid that your partner could act in the same way?

Speaker 36:54 Yeah, there's definitely the, the possibility to pr- of projecting if you've got a particular issue or concern, and rather than dealing with it yourself and being responsible, you kind of, you locate it in the other, you locate it in someone else 'cause it's easier for them to be the villain than it is for you, um, 'cause that requires you to do the processing-

Alex Partridge 37:08 Mm

Speaker 37:08 ... around it, which is,

Speaker 37:09 which is tricky.

Alex Partridge 37:10 What about schizophrenia? Where does that come into this conversation?

Speaker 37:13 So, uh, it, as I say, borderline personality was defined as being on the, on the kind of edge of, um, psychosis or schizophrenia in the 1950s in sort of big inpatient settings in the kind of One Flew Over the Cuckoo Nest kind of setting. Um, and people with BPD can sometimes get paranoid and, or it's called transient psychotic-like experiences, usually under real stress. So you see these real kind of people put under major stress and they start to believe things that aren't real. They may dissociate, they may, um, even hallucinate. Uh, and it's one of the reasons that people with borderline personality disorder can end up on like low-dose antipsychotics 'cause you see these unusual symptoms, and it, I think it's very distressing for people. But that's, that's where the overlap is. It's different from schizophrenia per se.

Alex Partridge 37:57 Mm-hmm. And is there a... I don't like to use the word cure, but what is the sort of treatment, medication for BPD if someone does get a diagnosis?

Speaker 38:06 So this is where it's really interesting actually, because we know there's good drug-based treatments for ADHD, but not such good therapies, and there's good therapeutic approaches for DB- for A- for BPD or borderline, but not such good medicine. So for borderline, it's a bit of a mixed bag. You might end up on a low-dose antipsychotic. You might be on, um, a mood stabilizer like Lamotrigine. You might be on something to manage your mood like an, uh, SSRI antidepressant to reduce anxiety. So it's a bit of a mixed bag, sort of symptom control. And increasingly we're looking at it's possible that some people with A- BPD might do well on stimulants. Some people might do, not everybody, but it's worth considering.

Alex Partridge 38:47 Mm.

Speaker 38:47 And then when we go over to the therapies for ADHD, we know that stimulants for ADHD can be helpful, but then what's the best therapeutic approach? It's likely that actually the best therapeutic approach is closer to what we do for BPD, which is a mixed group approach. So group-based work really works for ADHD, which is one of the reasons we do it in, in the service I run is we do group-based work.

Alex Partridge 39:07 And what about narcissism? Is there a risk that narcissism can be confused for either ADHD or BPD?

Speaker 39:15 Yes, definitely. So one of the reasons we see people say, "Oh, my partner's narcissistic." And then you'll say, "Actually they have ADHD, and I don't think they're narcis- ... They're devastated about the impact that their inattention is having on you." And then the partner will say, "But they don't listen." And then you'll say, "That's 'cause they have ADHD. It's not 'cause they don't care. It's not, not because of that. It's because they can't listen-

Alex Partridge 39:35 Mm

Speaker 39:35 ... and they're finding it hard to pay attention." And also sometimes people with ADHD are so preoccupied with whatever the current interest is, the current preoccupation, um, that it's difficult for us to kind of tune into what our partner is interested in. Um, so you get these conversations that can be quite, um, focused on one's own interests.

Alex Partridge 39:54 That's interesting. So it's not so much the, the ADHD person is, from the partner's perspective, obsessed about themselves. It's they're struggling to pay attention to what the partner's saying perhaps.

Speaker 40:03 It's struggling to do that kind of interpersonal dance of relating to the other and going, "Oh-

Alex Partridge 40:06 Mm

Speaker 40:06 ... so you're interested in that. Right. Okay. Tell me about that. I'm listening. That's interesting," and responding. Instead of going, "I'm sorry, I'm, I'm really focused on this thought that I'm having" or, "I want to tell you this," or whatever.

Alex Partridge 40:16 Mm.

Speaker 40:16 So it can look like narcissism. But narcissism's associated with like very f- inflated self-esteem and a kind of externalizing style where problems and issues relate to others and inability to take responsibility for things going wrong and grandiosity.

Alex Partridge 40:31 Mm.

Speaker 40:31 And that's not like ADHD at all.

Alex Partridge 40:33 The p- the piece I think that can get distra- um, confused with narcissism is if, if you criticize a narcissist, it can be met with considerable rage, a narcissistic rage, and is that, can that look similar to someone with RSD being triggered?

Speaker 40:50 I guess it could, yeah. I mean, there's definitely that sort of the, the thin-skinned narcissist who, who's full of rage when criticized, so it could look similar. And to be honest, you know, it, it, it's all kind of degrees of this and nuance of that. But, um, we do see kind of narcissists when they are criticized becoming quite, quite angry, which might look like, uh, BPD or ADHD. But interestingly, when you see people who've got borderline and narcissistic traits, they actually present to hospital less 'cause they self-harm less 'cause they're less distressed by their symptoms.

Alex Partridge 41:23 Uh, we had a guest on, Dr. Mark Rackley, who said, "You'll never find a narcissist in therapy." Like, they won't admit that they have a problem.

Speaker 41:30 He's right.

Alex Partridge 41:31 And is that the same way that if you don't admit you have a problem, then you won't be self-harming because you don't think you've got anything to medicate?

Speaker 41:37 E- exactly. There's this kind of the externalizing style, so versus the internalizing style. So the externalizing meaning the problem is someone else's, it belongs in someone else. I'm gonna make them feel miserable-

Alex Partridge 41:47 Mm

Speaker 41:47 ... rather than actually this is my problem and I have to deal with it either by ruminating or self-harming or doing something to change my emotional state. So, um, yeah, when you see borderline and narcissistic traits together, they are protective apparently for going into hospital and self-harm.

Alex Partridge 42:01 Mm.

Speaker 42:01 Which is interesting, so.

Alex Partridge 42:03 Truly fascinating, Judith. Um, once again, for a third time-

Speaker 42:07 Yeah. [laughs]

Alex Partridge 42:07 ... uh, thank you so much. Um,

Alex Partridge 42:09 and I think we're gonna find out about your third ADHD item.

Speaker 42:12 Oh, yes.

Alex Partridge 42:12 Yet again, [laughs] uh, which again has been patiently waiting underneath the cloth in front of us, and I'm going to reveal your ADHD item now.

Speaker 42:23 It's not the empty can, is it?

Alex Partridge 42:24 [laughs] Well, one of those is a Kano Water, which we, uh, used to prop up your ADHD item, which is the map.

Speaker 42:29 It's a map. Yes. It's a tourist map of Sorrento. I'm not suggesting that Sorrento is anything to do with ADHD, but it's-

Alex Partridge 42:36 [laughs]

Speaker 42:36 ... it's a map.

Alex Partridge 42:37 Sorrento, the great weather for ADHD management. [laughs]

Speaker 42:40 It's lovely. It's lovely in the autumn. Um-It's a map because, um, as you've probably gathered in the conversation we've just had, very often in ADHD, you're kind of picking your way through research and theories and ideas, and it gets terribly confusing. And so that's kind of what I talk about a lot with my clients in my teachings, is kind of try and find a map, and let's navigate together and create a map that helps you navigate through your experience, 'cause everybody's experience of these things is different, help you navigate through your experience of ADHD.

Alex Partridge 43:10 Mm.

Speaker 43:10 And there's certain things we know that help. So that's why I brought a map, 'cause I like maps. I like the idea of knowing where you're going.

Alex Partridge 43:16 Brilliant. I mean, I d- uh, the, the first thing I bought when I was 18 and I could get a credit card, going back to that impulsivity piece, was a satnav.

Speaker 43:23 Was it?

Alex Partridge 43:23 Satellite navigation, yeah, because my, my ability to f- to, to know where I'm going when driving, uh, was just nothing.

Speaker 43:31 Really?

Alex Partridge 43:31 Yeah. Um, yeah, maps are important. I think it nearly... My bad directions nearly cost me my life once. This is se- Like, I was skiing-

Speaker 43:40 Yeah

Alex Partridge 43:40 ... and I was coming down the mountain, and I couldn't find which way was the right way to get down to the chalet, and this blizzard came in, and so I lost all visibility as well. And luckily, this amazing French woman stopped, saw I was struggling, and, and asked w- i- if, if I needed help, and she guided me back down to the... But it, I, yeah, terrible with directions, and I, the more I speak to people with ADHD, there seems to be this, this struggle with sort of orientation and, and understanding where you are in the world.

Speaker 44:09 Yeah. So there's, I struggle with left and right, which was tricky when I, I was a junior doctor and I had to label limbs for amputation and I didn't know my left from my right.

Alex Partridge 44:17 Right. [laughs]

Speaker 44:18 Never got it wrong-

Alex Partridge 44:19 Gosh

Speaker 44:19 ... in a serious way. There was always-

Alex Partridge 44:21 Mm

Speaker 44:21 ... someone who did the checking, went, "No, that's the, the right leg, not..." I'd be like, "Oh, yeah, sorry."

Alex Partridge 44:24 Good. Well, good to hear that was a-

Speaker 44:26 [laughs]

Alex Partridge 44:26 ... not a disastrous ending.

Speaker 44:27 No disasters occurred, fortunately. There was a, there, we had a cross-check, but-

Alex Partridge 44:31 Mm.

Speaker 44:31 So the map is quite important then, this, uh, idea of getting, kind of finding yourself.

Alex Partridge 44:34 Yeah.

Alex Partridge 44:35 No, very useful. Um, thank you, Judith. I wanna find the Washing Machine of Woes-

Speaker 44:39 Washing Machine of Woes

Alex Partridge 44:40 ... just penultimate, which is the ADHD agony aunt section. Um, and I'm sure the loyal listeners will know why it's called the Washing Machine of Woes, because my ADHD item is, is a washing machine, 'cause for me it represents memory loss. 'Cause I always leave my clothes-

Speaker 44:52 Um-

Alex Partridge 44:52 You've heard this three times now. [laughs]

Speaker 44:54 Yeah, obviously I've not remembered. [laughs]

Alex Partridge 44:55 [laughs]

Speaker 44:56 It's gone in the washing machine, Alex, sorry.

Alex Partridge 44:58 I always leave my clothes in the laundry after the cycle's finished, and then the sme- the smell of damp reminds me, and it goes on again. But I have been using the Tiimo app, um, and I, and i- th- they have really been helping. Um, not perfect, though, but we're getting there. We're getting there.

Speaker 45:13 Good.

Alex Partridge 45:13 Um, this week, Judith, in the Washing Machine of Woes, someone's written in and asked, "I was diagnosed with ADHD 15 years ago, but through the years, my exes have told me it's BPD during arguments. What's the difference, and why is BPD seen as a bad thing?"

Speaker 45:33 Gosh. Well, I hope we've answered some of that.

Alex Partridge 45:35 Yeah.

Speaker 45:35 Um, i- I think, I think it's, for that particular person, what I'd hope is that today might have, might have cast some light on the fact that there's massive overlap. And, um, if your exes are accusing you of having anything, it's probably time to, to move on.

Alex Partridge 45:50 Yes. [laughs]

Speaker 45:51 Um, so that doesn't sound like a particularly supportive, uh, way of communicating. So yeah, there's a lot of overlap, isn't there? Um-

Alex Partridge 45:58 Yeah, clearly.

Speaker 45:59 Mm.

Alex Partridge 45:59 I mean, I came into this conversation with a very limited und- understanding, and I feel like I'm leaving with, with, uh, [laughs] with a more-

Speaker 46:06 With even more limited understanding. [laughs]

Alex Partridge 46:07 [laughs] I'll have to watch it back a couple of times-

Speaker 46:09 Okay. [laughs]

Alex Partridge 46:09 ... because I feel like it's such a new, new territory. Um-

Speaker 46:12 Yeah

Alex Partridge 46:12 ... but, but as new, just as new, just as fascinating as well.

Speaker 46:16 Yeah, in a, in a way, I wish I could be more like, "It's this," or, "It's that," but I think quite often I'll say to people, "It can be both/and."

Alex Partridge 46:23 Mm.

Speaker 46:23 And that's okay.

Alex Partridge 46:24 Sure.

Speaker 46:24 Because there's nothing wrong with how we are. We are how we are, and we have to accept who we are.

Alex Partridge 46:29 Yeah. An amazing finishing note. Judith, thank you so much for joining us.

Speaker 46:33 Thanks very much, Alex. [outro music]