Cambridge educated psychiatrist clarifies differences between ADHD & BPD

0:00Many people with ADHD cope really well, function really well. Many people with BPD cope well and function well. But BPD is 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 can be fine and then suddenly everything's not fine. Dr Judith Mohring is a Cambridge educated psychiatrist. She's here to spread awareness of ADHD's shared characteristics with borderline personality disorder.

0:29For 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. I know it's because 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 abandonments, of course trust is going to be hard to establish.

0:56And so we do know that many people with BPD have a history of trauma. So actually their responses are in that context really understandable. What is the sort of treatment medication for BPD if someone does get a diagnosis? This is where it's really interesting actually because we know... 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.

1:34Following 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.

1:49Judith, welcome back to the ADHD Chatter studio. Thank you, Alex. Good to be here. It's the third time, right? Yes. Back by popular demand again. My mum is going to be so pleased. She now has her own Instagram account. Does she? That's cool. Yes, she does. What's the handle? Oh, you don't need to say. I've got no idea. I really got no idea. A quick shout out for the mum. I know. Hello, mum. This time we're going to talk about something a little bit different, which is the crossover or the link between ADHD and BPD. Yes. borderline personality disorder um why was it important for you to come on today and talk about this topic 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.

2:52We 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 they would complete their modules and come out and go, I've got a certificate and be really proud. It was just one of the things I'm really proud of doing and has informed now how I think about ADHD, I think. and if we if we sort of focus on adhd for a second what would you say are the defining traits of adhd 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 whoops 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 physical energy it's the talking too much 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 right okay so interesting and if we were to focus on BPD borderline personality disorder like how would that look like in in an average adult with it gosh so um there's I suppose there's no average adult but just as there isn't with ADHD but and we see some areas of overlap and some areas of difference and I think often people say oh the same thing BPD ADHD it's the same thing And I don't think that's true.

4:41And I want to be responsible and clear. I 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 BPD. So impulsivity. The next trait or the next traits that we think about with BPD are emotional dysregulation. Sound familiar? Yeah, so you've got your emotional dysregulation and issues with anger. Obviously, anger is an emotion, so inappropriate anger. So that's an area of commonality, isn't it? Sounds quite similar to an RSD-induced rage, maybe. Definitely could be similar to RSD.

5:17And 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, regulated, suddenly you get, oh, interesting. So overlap, definite overlap. Then what we see with BPD is difficulty in managing relationships. And that could be related to issues with social communication or difficulties with just managing emotion. So you could see the overlap with neurodiversity there. And then as we go further into the construct, we also see things like chronic emptiness or lack of identity chronic emptiness what do you mean by 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 people and 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 people who are suffering more are quite a disturbed sense of self but again there's overlap isn't there because 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 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 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 maybe there's traits of both.

6:54I mean, there are things that definitely distinguish. So people with BPD will generally have issues with self-harm, although that can happen as well in ADHD and recurrent issues with self-harm. And also this idea of difficulty with abandonment and 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 the diagnosticians are only human, and they've only got so much time.

7:36And doing a full history for both takes a long time. So with the fear of abandonment being 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 i love your questions i love your confused face as well because i was dreading doing this one because i'm like it's a sensitive topic i don't want to let people down i don't want to misrepresent it's not you know this or this it's like it's quite complex so the confused face is good because 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.

8:15So if you experienced early abandonments, of course, trust is going to be hard to establish. Of course, you're going to 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. 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? Is it more complicated than that? So it's not just like the controlled crying.

8:48You know this kind of, don't let the baby cry, there'll be attachment issues. With abandonment, what we're talking about is significant abandonment, so loss of a parent either through death or the parent leaving or 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. because babies when they're young really do need that primary attachment figure who can really form that warm loving attachment to them so is there a genetic component to bpd uh in the same way that there most likely is with adhd um or is it kind of a consequence of early year exposure so as with adhd there's a gene environment interaction the thing with adhd is that adhd has been more able to kind of establish a biological basis.

9:42There'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 influence. With BPD, we would probably say there's environmental influence and some genetic links. So it does, the traits do run in families, but probably less so than with ADHD. I feel like BPD has quite a negative connotation. Do you think that's justified? It has been used as a bit of a kind of diagnostic dumping ground in the past, 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 going to take a neuro-inclusive lens and a neuro-aware lens now, we'd say, hang on, pause.

10:20If 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 such simple things? What's the issue here? So a more neuro-inclusive lens, very much something we want to encourage in mental health services. and there's lots of training going on for that. But yeah, 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 is.

10:52So we need to be kind of aware of our own stigmatizing beliefs in the profession. Are there any clear-cut traits, characteristics that would separate BPD from someone getting an ADHD diagnosis? So we talked about overlap there is quite a lot of overlap but if you were going to diagnose so we diagnose BPD on the DSM-5 and there's nine different criteria 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 so i speak to a lot of people in the adhd community and they they refer to people 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 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 so we talk in bpd is of sort of state shifts so um 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 is 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 and that's where we get these really drastic mood swings where everything can be fine and then suddenly everything's not fine 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.

13:01What would be like some common triggers that might initiate one of those extreme mood swings in someone with BPD? So it'd probably be something interpersonal it's quite often or it'd be something trauma related so 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 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 even 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 it's very distressing for people with bpd very distressing 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 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 because 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 it's 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 i read a quote recently and i can't remember who said it but it was it was the having an intense fear of abandonment will make us perform certain actions and behave in a certain way that almost makes the chances of us being abandoned inevitable like you you act in a certain way you seek reassurance with your partner always which can almost come across as unattractive 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 hopeless feeling 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 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 and a kind of i can't bear you leaving so i'll push you away before I'm left.

16:11So almost gaining control by saying, I'm going to cut off now. I can't bear you leaving. There's a phrase, I love you, don't leave me, that comes from the BPD literature, 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. Is that quite an extreme portrayal version 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 so um and it's more extreme and it was actually defined it's called borderline personality because it was defined as being on the borderline of psychosis back in the 50s gosh i know it's like it's not it's not it's not a 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 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 and 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 um so it's all quite confusing paranoia and relationships i mean that can cause irreparable damage right if not understood um like is there a link between sort of paranoia um fear of abandonment and bpd 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 not just fear of abandon but also an intense um sense that other people in some way are negative or harmful or or have ill intent and that's sort of linked to some of the slightly less intense but still very distressing experiences people with ADHD can experience around RSD and assuming that people dislike you that sort of thing.

18:34You mentioned earlier that ADHD never travels alone what did you mean by that? Yeah we've been talking a lot about personality disorders but 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 when they're very distressed and there's other stuff going on and about 80 percent of people with a diagnosis of ADHD will also have another condition and it could be anything from depression, anxiety, substance use issues, insomnia, issues with eating so we really commonly see binge eating or we might see ARFID or avoidant restriction food intake disorder um ocd is quite common as well as the personality issue so you've got a whole smorgasbord of delightful potential things going on and one of the reasons we get a bit frustrated if you spent 25 years training to diagnose and then somebody gets a tick box 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 with the eating disorders i mean how can that manifest with someone is there a difference between someone with bpd and adhd in that arena or is there an overlap?

19:47Well, 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 is really interesting with ADHD because if you're a bit inattentive 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 because you haven't eaten and then all of a sudden you get very angry because 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 a 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 because it's quite hard to keep the fridge organized generally I think.

20:46I've always got a mouldy fruit in my fridge. And I think the reason is because when I'm in a supermarket, the idea of being healthy is quite exciting. So I'll walk past a packet of blueberries or raspberries and think that'll be a nice addition to my porridge. That'll 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. The health benefits of eating blueberries, in my mind, that's years down the line and that's invisible for me.

21:18So 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 probably spent on impulsively buying superfoods like spinach 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. 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 and you think that'll be healthy and i was 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 going to like feed themselves they've got all the cookbooks and impulsively buying cookbooks and i do this as well it's like i'm going to make this amazing meal and then when it comes to making the meal it's so i find cooking really boring a quick word from our sponsor with a riddle can you guess the answer only one in 20 people can What has two eyes is smaller than a fingernail, lives inside your phone, and improves every element of your life and helps you remember all those social plans you made because you didn't know how to say no.

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22:58Just a note though, this code is only applicable on the web browser, not the smartphone. Back to the episode yeah the impulsivity that kind of gets so many of us sometimes um like impulsively buying expensive food and then it going off does that come from the same place mentally in someone with adhd than it does with someone with bpd 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 and the two things are really really closely linked yeah so I think probably similar real overlap there definitely ADHD and impulsivity is there some new research that backs some of that up 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 ten minutes then you can have two marshmallows So how do you resist the marshmallow?

24:04And there were kids who kind of sat on their hands, and they used all these techniques, sitting on their hands, looking at the window, whistling, and there were other kids who went, and ate the marshmallow. Now, obviously, what's the ADHD are going to do? Well, yeah, go for the one immediate reward. Eat the marshmallow, exactly. And then when they looked long-term, people's kind of 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.

24:31It impacts our ability to, you know, not tell inappropriate jokes to your mother-in-law. I mean, I've told a few inappropriate jokes in my time. To not drink the bottle of wine, to not spend the money, it impacts everything. And it's kind of such a core feature of both conditions. Do you see what I mean, how it kind of underlies all sorts of things? Yeah, I mean, impulsivity can get you into loads of trouble, right? 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 yes you were mentioning about the blueberries and how in future you know the idea of the blueberry being good for your health is great for future you and we in therapy with ad actually 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 take away or bottle of wine or new coat um and impulsivity really does you know causes big issues for people in lots of ways in sexual relationships oh leaving jobs that's the other one the impulsive job leaving yes because it's we do stuff in the moment that are that are fun and rewarding because it's new and novelty we crave novelty right so starting a new job is exciting yes so we get a lot from being told that we have been chosen for the job once we settle in and then we're sat at the desk in week two or three or four then the dopamine's gone yeah and or the tiniest rejection maybe and that's that's the trigger that's enough we're out the door yep and it's the novelty wears off 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 I once impulsively buy furniture I bought a double bed from Ikea and tried to get it home on the bus that nearly led to a relationship ending understandably so it's just doing crazy things and then you think why did you do that but it's the novelty isn't it and I mean starting this podcast was impulsive how does one know the difference between an impulsive decision that is going to stick and can potentially turn into something that is going to capture your attention for years and years and years and be fun and brilliant compared to something that is a chest of drawers or a packet of blueberries in a supermarket.

27:01It was a nice chest of drawers actually so don't diss my chest of drawers. This is really interesting as well because you kind of 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 kind of go interesting what does that mean and i think impulsivity is 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 fair to tread but you kind of 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 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 going to think and worried about failure it's that momentum building phase that is so difficult i feel for so many people it's starting it's buying that domain it's it's getting the first few months out of the way so you can kind of accumulate enough positive feedback that validates the idea and that overpowers that rsd which i think is what stops so many people from even starting and i wondered what if there was a difference in how someone with adhd might navigate life constantly eagle-eyed and worried about criticism and how that impacts their life compared to someone who might have BPD.

28:52Is there a difference in those two experiences? 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 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 because 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 because I've not been looking after myself very well it's not real and I know 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 so listen to them validate them be kind to them but don't let them rule the roost if you can um how does this whole conversation around bpd and adhd translate into like romantic relationships because i feel like if you're you know what's coming it's a big one right i think like if you if you're 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 want to be amazing for someone else you don't want to let someone down you can love bomb someone yeah 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 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 is it possible to 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?

30:59Wow it's a really good question I suppose what I would say is face-to-face interaction is really helpful in relationships and 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 doesn't it where you kind of deeply in love and there 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 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 trial 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 and social media i feel like is just throws a hand grenade in the middle of this this dance of trust right and yeah 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 the social media can complicate things right 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 there was nothing to there was nothing to obsess over because 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 because you're like well they're there and i don't know what they're up to and probably that's a good thing you only had the postman to worry about you've got an infinite number of people on social media infinite and also it never stops so it goes on all night all day no and no boundaries 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 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 data points right that can trigger 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 perhaps spiral and create this completely irrational story of infidelity yeah how dark can it get that experience for someone with adhd bpd really dark I think we've all had experiences where you have completely neutral data and you like the email that lands.

34:15You're like, oh, well, clearly I'm going to lose my job. Or the missed call from your boss. Oh, I've obviously screwed up massively. Or the spiraling that goes on. And I think it depends where your mind naturally goes that you will 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 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 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 and if you have these suspicions that 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 they're that there's a red flag in your relationship yes yeah and if you confront your partner if you sort of give into that compulsion and then your partner reassures you and says oh that's nothing or whatever that they add context to it you can then turn that into the theory that they're gaslighting you and that just creates another spiral 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 how much of like a bias towards catastrophization 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 oh i hope not too much but yeah now i can hear that 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 because that informs 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 what about projecting like if if you have done something yourself like if you are hiding a dm uh or you put your phone down because you don't want your notifications to show up on the screen like is there a degree that you can almost be paranoid that your partner could act in the same way yeah there's definitely the possibility to 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 because it's easier for them to be the villain than it is for you um because that requires you to do the processing around it which is which is tricky what about schizophrenia where does that come into this conversation so uh 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 flow over the cookie nest kind of setting and people with BPD can sometimes get paranoid and what was 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 even hallucinate and it's one of the reasons that people with borderline personality disorder can end up on like low dose antipsychotics because you see these unusual symptoms and I think it's very distressing for people but that's that's where the overlap is it's different from schizophrenia per se 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 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 BPD or borderline, but not such good medicine.

38:19So for borderline, it's a bit of a mixed bag. You might end up on a low-dose antipsychotic. You might be on a mood stabilizer like the Motrogene. You might be on something to manage your mood like an 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 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 the service I run is we do group-based work.

39:07And what about narcissism? Is there a risk that narcissism can be confused for either ADHD or BPD? 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 narcissistic. 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 because they have ADHD. It's not because because of that it's because they can't listen 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 that's interesting so it's not so much that 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 it's struggling to do that kind of interpersonal dance of relating to the other and go oh 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 so it can look like narcissism but narcissism is associated with like very 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 that's not like adhd at all the piece i think that can get confused with narcissism is 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 i guess it could yeah i mean there's definitely that sort of the thin-skinned narcissist who's full of rage when criticized so it could look similar and to be honest you know 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 because they self-harm less because they're less distressed by their symptoms we had a guest on Dr.

41:24Mark Rackley said, you'll never find a narcissist in therapy, or they won't admit that they have a problem. He's right. 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? Exactly. There's this kind of the externalizing style versus the internalizing style. So the externalizing, meaning the problem is someone else's, it belongs in someone else. I'm going to make them feel miserable 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.

41:55So, yeah, when you see borderline and narcissistic traits together, they are protective, apparently, for going into hospital and self-harm, which is interesting. Truly fascinating, Judith. Once again, for a third time, thank you so much. And I think we're going to find out about your third ADHD item yet again, which again has been patiently waiting underneath the cloth in front of us. and I'm going to reveal your ADHD item now.

42:23It's not the empty can, is it? Well, one of those is a can of water, which we use to prop up your ADHD item, which is the map. It's a map, yes. It's a tourist map of Sorrento. I'm not suggesting that Sorrento has anything to do with ADHD, but it's a map. Sorrento, the great weather for ADHD management. It's lovely. It's lovely in the autumn. It's a map because, 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 because everybody's experience of these things is different help you navigate through your experience of ADHD and there's certain things we know that help so that's why I brought a map Because I like maps.

43:14I like the idea of knowing where you're going. Brilliant. I mean, the first thing I bought when I was 18, I could get a credit card, going back to that impulsivity piece, was a sat-nav. Was it? Satellite navigation. Yeah, because my ability to know where I'm going when driving was just nothing. Really? Yeah. Yeah, maps, so important. I think it nearly... My bad directions nearly cost me my life once. This is a series. I was skiing. Yeah. 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, so I lost all visibility as well.

43:50And luckily, this amazing French woman stopped, saw I was struggling, and asked if I needed help, and she guided me back down to the... But I'm terrible with directions. And the more I speak to people with ADHD, there seems to be this struggle with sort of orientation and understanding where you are in the world. Yeah, so I struggle with left and right, which was tricky when I was a junior doctor and I had to label limbs for amputation and I didn't know my left from my right. Never got it wrong in a serious way. There was always someone who did the checking and went, no, that's the right leg. I'd be like, oh yeah, sorry.

44:24Good to hear that. It was not a disastrous ending. No disasters occurred, fortunately. We had a cross-check. So the map is quite important then, this idea of getting kind of finding yourself. Yeah, no, very useful. Thank you, Judith. I want to find the washing machine of woes, which is the adhd agony 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 because for me it represents memory loss because i always leave my clothes you've heard this three times now it's gone in the washing machine alex sorry i always leave my clothes in the laundry after the cycle's finished and then the smell of damp reminds me and it goes on again but i have been been helping um not perfect though but we're getting there we're getting there 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 gosh well i hope you've answered some of that yeah um I think it's for that particular person, what I'd hope is that today might have cast some light on the fact that there's massive overlap.

45:45And if your exes are accusing you of having anything, it's probably time to move on. Yes. So that doesn't sound like a particularly supportive way of communicating. So, yeah, there's a lot of overlap, isn't there? Yeah, clearly. I mean, I came into this conversation with a very limited understanding, and I feel like I'm leaving with a more limited understanding. I'll have to watch it back a couple of times, because I feel like it's such a new territory. But as new, just as fascinating as well. Yeah, 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.

46:23And that's okay, because there's nothing wrong with how we are. We are how we are, and we have to accept who we are. Yeah, an amazing finishing note. Judith, thank you so much for joining us. Thanks very much, Alex.