there are three diagnoses that can be especially challenging to sort out. That’s combined type ADHD with impulsivity, borderline personality disorder, and bipolar disorder.

Borderline

• there’s often a history of abuse, especially sexual
• patients act out in order to feel better – so if things are going well, they don’t feel the need to take risks
• borderlines typically don’t have the distractibility and procrastination that are famously part of ADHD
• the underlying problem seems to be the inability to make yourself feel good, relying entirely on others, who eventually get tired and let the borderline down, then the relationship goes suddenly and dramatically sour, with rage and hurt and let down being important themes.
• borderlines blame others, have stormy relationships, yet don’t like spending time alone, and often struggle to know who they are.

Bipolar

• the hallmark is the cycle of moods, usually over many days and quite rarely within a day, and when the mood is not manic, the risky behaviour settles down, the larger than life persona shrinks back to normal size, the silliness goes away, and patients become less self absorbed.
• bipolar has been traditionally diagnosed by the manic and hypomanic episodes which are thought to be feeling great – but the excitement can be tempered by agitation and or irritability so it can be a very mixed blessing.

Anxiety

• severe anxiety can make one distracted and it can be hard to accomplish tasks if there is huge fear of failing and perfectionism.
• the hallmark is that when not especially anxious about a task but it’s rather boring, the adhd patient will put it off to the point of late fees, expulsions, firings etc, while the anxious patient has no particular difficulty.
• anxious patients often have a lot fewer adhd symptoms because they are tidy and organized – their anxiety won’t let them screw up.
• it can be challenging to make an accurate diagnosis for or against ADHD in the very anxious.

Obsessive Compulsive Disorder

• You’d think that OCD and ADHD are almost opposites of each other but in fact they commonly co-exist. OCD is about intolerance of uncertainty – ‘but what if’ even when the if is extremely unlikely. Yes, the sore throat of one week could be cancer, but it’s bloody unlikely, but OCD patients can only focus on how I couldn’t ABSOLUTELY guarantee no risk.
• OCD can be associated with rigid thinking and difficulty with changes, something common in kids with ADHD and autism spectrum and can present as being oppositional and defiant.

Depression

• Depression is often associated with a lack of motivation. This is different from procrastination and has little to do with how boring is the task. Depressed patients sit on the sofa, thinking they are too tired to go do X, the ADHD patient has a thousand other things they’d rather be doing than X and so put if off while they work on the fun stuff.
• Depression can cause poor concentration as the brain becomes less and less efficient, and also quite forgetful. Interestingly, in depression the patients complain more than their families – the forgetfulness feels worse than it actually shows, where in ADHD it’s the opposite.

If I suspect that a patient might have a different diagnosis, I have standardized sets of questions I can ask that help me clarify the correct diagnosis. That said, psychiatrists find it very challenging to diagnose bipolar from borderline and patients often receive conflicting diagnoses over time and with new doctors. Sorting it out takes time, often several hours, something family doctors find impractical.

I now routinely screen for bipolar disorder in all new patients.