Attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) can be a crippling neurological impairment. It’s also more treatable today than ever before, thanks to new therapies and medications. As with any medical condition, though, the key to effective ADD/ADHD treatment is getting an accurate diagnosis—which isn’t always easy.
Why ADD/ADHD Can Be Easy to Misdiagnose as a Personality Disorder
ADD/ADHD is one of the most frequently misdiagnosed neurological conditions in children and adults. In my own practice, it’s not unusual for patients to see me for a full battery of brain imaging scans and neuropsychological tests only after they were misdiagnosed with another condition, such as a personality disorder.
This problem of misdiagnosis can raise very real obstacles to getting the right treatment. Whether you’re Mom or Dad trying to address a child’s emotional outbursts and acting out at home and school, or you’re an adult struggling with anxiety, depression, or exaggerated emotions, ADD/ADHD may be the explanation for your troubles.
Or, it may not be. Another explanation for the same symptoms could be borderline personality disorder (BPD) or antisocial personality disorder, both of which commonly involve emotional instability—a frequent feature of ADD/ADHD.
Emotional Instability in ADD/ADHD vs. Personality Disorders
Just how hard is it to know whether ADD/ADHD vs. a personality disorder is the issue when emotional instability is a major presenting symptom? An April 2017 study in the journal Molecular Psychiatry pointed to the complexity of making a differentiation. The study noted that the brain changes and symptoms associated with ADHD are similar (but also different) to the brain changes and symptoms associated with emotional instability disorders such as borderline personality and antisocial personality disorder.
Complicating the diagnostic task further, roughly 80 percent of adults with ADHD reportedly have at least one co-occurring psychiatric disorder sometime during their lifetime, and personality disorders often co-occur with ADD/ADHD. It’s therefore completely within the realm of possibility that a person has both ADD/ADHD and a personality disorder and is not aware of it.
How to Get an Accurate Diagnosis of ADD/ADHD vs. a Personality Disorder
For individuals and families who want and need a diagnosis they can trust, having new knowledge about the extent of overlap between ADD/ADHD and personality disorders and their frequent co-occurrence can be helpful. It also can foster a state of informed paralysis. Take heart. The following advice is intended to reassure you that you can get an accurate diagnosis and will provide some direction about how to do that.
Consider age and childhood history. Be assured that these factors are still reliable in determining whether the diagnosis is ADD/ADHD or a personality disorder. Some people don’t know—and for others, it’s easy to forget—that ADD/ADHD is most often diagnosed before the age of 12 and is largely a childhood condition. Conversely, to be diagnosed with a personality disorder, you must be 18 or older.
When I diagnose ADD/ADHD in adults, more typically it’s because they report that during their childhood, their parents and teachers noticed many of the same symptoms they’re currently experiencing:
- Poor focus and organization
- An inability to sit still
These symptoms are much more likely to be ADD/ADHD if:
- they’re occurring before the age of 12;
- are said to have occurred before the age of 12, by an adult experiencing similar symptoms.
Age and childhood history are therefore worth considering in consultation with an appropriate medical professional.
Keep a detailed record of all psychiatric symptoms and behaviors. An accurate diagnosis of ADD/ADHD will largely depend on the behavioral and psychiatric symptoms that you or your child may be experiencing. Here a comprehensive clinical assessment can be especially helpful at differentiating between ADD/ADHD and a personality disorder.
Say, for example, an adult patient is exhibiting poor impulse control— a symptom that can occur in both ADD/ADHD and personality disorders. After further exploration of the symptoms, I might find the patient is also experiencing extreme fears of abandonment and rejection and engaging in self-destructive behaviors to avoid these fears. I might also discover that his or her mood fluctuations are severe, take place across time frames as short as one hour, and are accompanied by pronounced interpersonal instability. These observations would allow me to rule out ADD/ADHD and diagnose BPD with greater certainty.
Consult a licensed neuropsychologist. A neuropsychologist may be able to acquaint you with the tests used to diagnose ADD/ADHD vs. personality disorders. This information could then help you gauge whether an in-depth neuropsychological evaluation will be worth your time.
A comprehensive neuropsychological evaluation should ideally employ a combination of brain imaging technologies and neuro-psych tests to give you an accurate picture of what’s going on. Look for these in particular:
- Quantitative Electroencephalogram (qEEG) – This diagnostic tool measures and records electrical activity in the brain in the form of brain waves. Theta brain waves are associated with light sleep or a meditative state. Beta brain waves are associated with an awake state of alertness.
Analyzing the theta-beta ratio index on a qEEG helps us diagnose ADD/ADHD with greater accuracy. Typically, a diagnosis of ADD/ADHD will also manifest itself as dysregulation in the bilateral, prefrontal lobe of the brain— although face-to-face evaluations and neuro-psych testing should be done to supplement these findings.
- Event-related potential tasks (ERP) – These help us measure the amplitude of P300 waves when the brain is in an active state. P300 waves register (on a standard EEG) as very small voltages in particular brain structures when the brain is actively engaged with specific tasks. For example, I might ask patients to click their keyboard when they hear a certain noise, then simultaneously remember how many times they’re clicking.
Greater attention to this task will show up as larger P300 waves. On the other hand, reduced P300 amplitude correlates with inattentiveness and poor impulse control and may point to underlying ADD/ADHD. (It’s important to emphasize here again that like the qEEG, ERP results should be considered in combination with findings from in-person testing also.)
- Continuous performance task and number sequences – From my experience, the #1 way to diagnose ADHD is to administer a “continuous performance task.” In this computer-administered test, patients click their keyboard whenever an image flashes at the top of the screen. They’re instructed not to click if the image flashes at the bottom of their computer screen. A person with ADD/ADHD may exhibit increased distractibility, reduced attention, or poor inhibitory control when presented with this task.
Another helpful test: asking someone to verbalize numbers in sequential order or recite them backward. Retaining this information long enough to be able to repeat it is often very difficult for someone with ADD/ADHD, whereas someone with a personality disorder may not struggle when presented with the same task.
Yes, misdiagnoses of ADD/ADHD can be common. (Research into the shared brain changes and symptoms of ADD/ADHD and personality disorders only confirms this fact.) Even so, the above tips can help put you on the path towards a more accurate diagnosis.
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Dr. Antonio Rotondo is a licensed clinical psychologist specializing in neuropsychology at FHE Health. Learn more about how FHE Health is using neurorehabilitative services to treat mental health needs in a residential setting.
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