Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2020) 7:2 https://doi.org/10.1186/s40479-019-0118-z REVIEW Open Access The role of environmental influences in the complex relationship between borderline personality disorder and attention-deficit/ hyperactivity disorder: review of recent findings Natalia Calvo1,2,3,4, Benjamin Lara1,3, Laia Serrat1, Violeta Pérez-Rodríguez1, Òscar Andión1, Josep A. Ramos-Quiroga1,2,3,4 and Marc Ferrer1,2,3,4* Abstract Background: In recent years, the existence of possible developmental pathways from childhood Attention-Deficit/ Hyperactivity Disorder (ADHD) to adult Borderline Personality Disorder (BPD) has been suggested. The existence of common genetic factors has been described but there is little evidence on the role of environmental factors in the possible transition from one disorder to another throughout life. The main goal of this work is to review the literature about the existing evidence on childhood traumas as factors that mediate the risk of developing BPD in children with ADHD. Methods: A literature search was conducted using PubMed, Science Direct and PsychInfo databases. Criteria included studies of BPD and ADHD relationships and childhood traumas as environmental influences from epidemiological or clinical samples. Results: The review only identified 4 studies that matched the search criteria. All studies retrospectively analyzed childhood traumas, and adult patients with BPD, with or without comorbid ADHD, were the most frequently mentioned. The analyzed evidence reinforces the relationship between the number of childhood traumas and higher clinical severity. Three of these analyzed studies describe an increased the risk of children with ADHD who report emotional and sexual traumatic experiences to develop BPD in adulthood. Conclusions: The experience of traumatic childhood events, especially those of an emotional type, may have a mediating effect of an increased risk of developing adult BPD in childhood ADHD patients. However, to consider them as risk factors, more studies, and especially longitudinal studies, are necessary to clarify the probable transactional process between the two disorders. Evidence from these studies may be helpful to develop early intervention programs to reduce the functional impairment associated with the two disorders. Keywords: Borderline personality disorder (BPD), Attention-deficit/hyperactivity disorder (ADHD), Childhood trauma, Abuse and neglect, Environmental influences, Emotion dysregulation, Impulsiveness * Correspondence: maferrer@vhebron.net 1 BPD Program, Psychiatry Department, Hospital Universitary Vall d’Hebron, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain 2 Psychiatry and Legal Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2020) 7:2 Page 2 of 7 Background greater likelihood of detecting other comorbid disorders, Borderline Personality Disorder (BPD) is characterized especially Substance Use Disorder (SUD) [12]. From the by an enduring pattern of instability in interpersonal evidence of the interaction that can be established relationships, self-image and affect, and marked impul- between the two disorders throughout life, possible sivity [1]. DSM-5 also characterizes its development and pathways of childhood ADHD to adult BPD have been course as a pattern of chronic instability, notably in early proposed, and earlier ADHD has been considered as a adulthood, with the greatest impairment found in the possible precursor of a later BPD [13, 14, 16, 17]. young-adult years. BPD is estimated to affect 1.6 to 5.9% To study the transition of childhood ADHD to adult of the adult general population [1]. Furthermore, the BPD, with or without comorbid ADHD, it is necessary cumulative prevalence rates suggest that 1.4% of young to analyze the etiology of each disorder. From twins and people will meet diagnostic criteria for BPD by age 16 twin family studies, ADHD heritability has been esti- years, rising to 3.2% by age 22 [2]. Attention-Deficit/ mated to be between 60 and 80% [18], and around 40% Hyperactivity Disorder (ADHD) is a common neurode- for BPD [19]. Similar genetic findings, especially those velopmental disorder emerging in childhood or early involving the serotonergic and dopaminergic systems adolescence. ADHD is characterized by a pervasive pat- that have been associated with impulsivity and emotional tern of developmentally inappropriate levels of inattention dysregulation have been described in BPD and ADHD and/or hyperactivity-impulsivity that lead to clinically sig- [19]. However, the phenotypic correlation between nificant functional and psychosocial impairment [1]. In ADHD and Borderline Personality (BP) symptoms was the general population, ADHD is estimated to affect about explained not only by genetic factors (49%) but also by 5% of children and adolescents [1] and between 2.5–4% of environmental factors (51%) [19]. It can therefore be the adults [3]. hypothesized that the risk of developing BPD from child- Different studies have highlighted the remarkable hood ADHD may be increased by possible common gen- overlap of symptoms of BPD and ADHD in adulthood, etic etiologic factors, but the mediating effect that as is the case of impulsiveness, which is considered a certain environmental events may have in this transition core component both of ADHD and BPD [4]. Emotional should also be taken into account. The most widely dysregulation (ED) is a set of symptoms that have been studied environmental variables as possible etiological considered a core clinical feature of BPD and have been factors of psychiatric disorders are childhood maltreat- assigned a key role in the main etiopathogenic models of ment, especially in Personality Disorders (PD) [20]. In the the disorder [5]. However, in recent years, the number specific case of BPD, the experience of traumatic events in of studies highlighting the relevant role that ED can also childhood, especially those that can compromise emo- play in ADHD [6, 7] has increased. For differential diag- tional maturation, has been considered as a predisposing nosis, suicidal behavior has been considered more typical factor for the later expression of ED and impulsivity, of BPD than of ADHD [8], whereas primary attentional which are considered relevant clinical components of BPD cognitive deficits are significantly more frequent in [5, 21]. The relevance of childhood traumas in the devel- ADHD than in BPD [8, 9]. However, the diagnostic opment of ADHD is minor and has been associated study in adults often concludes that both disorders can mainly with cases that manifest ED [4, 22]. be diagnosed simultaneously [10], estimating a preva- Thus, to analyze the factors that may have a mediating lence of BPD among adults with ADHD ranging from 19 effect on the increase of the risk of developing BPD in to 37% [11] and of comorbid ADHD of 16–38% in pa- childhood ADHD, it is advisable to study the variables tients with BPD as a primary diagnosis [12–14]. that are more characteristic of the development of BPD However, although previous studies have described than of ADHD. This would justify the main aim of this this significant association between BPD and ADHD, its study, which is to analyze the literature about the exist- nature has not yet been fully clarified. The evidence sug- ing evidence on the environmental factors involved in gests that the high frequency with which the two disor- the developmental trajectory from childhood ADHD to ders coexist should be interpreted not only as a adult BPD, namely traumatic experiences. coincidence of two disorders at a certain period of life [15]. In this sense, the presence of ED in ADHD has Methods been associated with worse functional impairment [12] In this paper, we performed a search for studies dealing and with a greater risk of suicidal behavior among young with the association ADHD-BPD and environmental adults [7]. Similarly, compared to BPD without a comor- traumatic influences. For this purpose, the following bib- bid ADHD, there is evidence of the fact that adult pa- liographic databases were searched: PubMed, Science tients who can be simultaneously diagnosed with both Direct and PsychInfo. The following search terms were disorders exhibit greater clinical severity with higher im- used: Borderline Personality Disorder AND Attention- pulsivity and number of suicide attempts, and there is a Deficit/Hyperactivity Disorder AND childhood traumas Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2020) 7:2 Page 3 of 7 or childhood maltreatment OR environmental vulner- In the specific comparison between ADHD and BPD- ability influences. Given the limited results, we added ADHD groups, the latter had a greater history of key terms by including emotional dysregulation, impul- physical and emotional neglect. The authors found no sivity, environmental, childhood, adolescence, in the differences in the number and type of traumatic ante- association BPD and ADHD, and also in each of the dis- cedents between ADHD patients and ‘no BPD-no orders separately. As this is a review of recently pub- ADHD’ patients. lished articles on the subject, the studies published A study conducted with a non-clinical sample of uni- before 2000, studies that were not published in English, versity students was also analyzed [25]. Dalbudak and unsystematic clinical case reports and treatment studies Evren studied the relationship between the history of were excluded. traumatic childhood events, also assessed with the CTQ We included studies that explicitly mentioned the key [26, 27], and the presence of ADHD symptomatology in terms. The titles and abstracts were screened to elimin- adults and of BP features. A positive correlation was ob- ate non-relevant and duplicate studies. When a title or served between the reference to the history of childhood abstract seemed to describe a study suitable for inclu- emotional and physical abuse and the scores of the sion, the full-text article was obtained and examined to Adult ADHD Self-Report Scales (ASRS-v1.1) [28] and of evaluate its relevance for our work. A total of 11 articles the Borderline Personality Inventory (BPI) [29]. were potentially relevant in relation to the involvement Not all analyzed studies have conducted analyses to esti- of traumatic environmental factors in the transition from mate the effect of childhood traumas on the increased risk ADHD in childhood to BPD in adulthood. However, of developing a BPD in ADHD patients. At the clinical only 4 of them specifically and directly analyzed the pos- level, the study of Philipsen et al. [14] analyzed for the first sible contribution of traumatic childhood experiences in time a possible association between the 5 types of mal- the evolution of one disorder to the other [14, 23–25] treatment included in the CTQ [26, 27], BPD symptoms (see Table 1). and childhood ADHD through a multivariate logistic re- gression analysis in a sample of 118 outpatient adult Results women diagnosed with BPD and BPD-ADHD. The results Differences in childhood trauma history between adult indicated a significant association between a history of patients diagnosed with BPD, ADHD, and comorbid emotional abuse in childhood, childhood ADHD and BPD-ADHD were assessed from the study of Prada greater severity of BPD symptoms. In Ferrer et al.’s study et al., who analyzed the clinical differences between [23], logistic regression analysis was also performed to ex- these disorders in adulthood [24]. This study used the plore a possible increased risk of developing adult BPD, Childhood Trauma Questionnaire (CTQ) [26, 27] for ADHD or BPD-ADHD in patients of the study who re- retrospective assessment of five types of maltreatment in ported childhood traumas. The results showed that infancy –emotional, physical and sexual abuse, and emo- reporting childhood emotional and sexual traumas was as- tional and physical neglect. Compared to the group of sociated with the diagnosis of BPD in adulthood, with or healthy controls, the overall prevalence of childhood without ADHD comorbidity. Also in non-clinical popula- trauma history was higher in the clinical groups, espe- tion [25], an association was described between a history cially in the BPD-ADHD group. The largest difference in of emotional and physical abuse in childhood, the severity prevalence between clinical groups and healthy controls of ADHD measured with the ASRS-v1.1, depressive symp- was found in the concrete trauma of emotional abuse. toms measured with the Beck Depression Inventory (BDI) Within the clinical groups, the only difference was in the [30] and the BPI score [25]. rate of childhood sexual abuse, which was more frequent both in the BPD and the BPD-ADHD groups, compared Discussion to the ADHD group. Although the importance of trauma in the subsequent Ferrer et al.’s study [23] analyzed differences in child- development of BPD has been extensively studied, the hood trauma history between adult BPD, ADHD and co- available evidence so far of the potential mediating role morbid BPD-ADHD patients. Unlike Prada et al. [24], of childhood maltreatment in the evolution from child- no healthy control group was included, but there was a hood ADHD to adult BPD is very scarce. While most of clinical group of patients with BPD criteria, but without the identified studies analyze childhood traumas as a reaching the diagnostic threshold (group referred to as secondary objective, the authors end up highlighting the ‘non-BPD-no ADHD’). The assessment of childhood relevance of the outcome of this specific analysis in the trauma history was also performed retrospectively using interpretation of the relationship between childhood the CTQ [26, 27]. A greater total number of traumatic ADHD and adult BPD. childhood events was described in BPD-ADHD patients, Firstly, all the studies refer to the relationship between the most common being emotional and sexual traumas. the experience of childhood trauma and the severity of Table 1 Studies included in the revision with relevant information about the possible role of childhood traumas in the relationship between childhood Attention-Deficit/ Hyperactivity Disorder (ADHD) and adult Borderline Personality Disorder (BPD) Study Size and election sample Type of study Targeted sample Healthy control Assessment Main findings group instrument Philipsen et al. 2008 [14] BPD outpatients Cross-sectional Clinical study No WURS A significant association is described between childhood ADHD, N = 118 women ADHD-CL childhood emotional abuse, and severity symptoms in women SCID-I with BPD. Childhood ADHD may be considered a risk factor that IPDE predisposes to BPD development in the adulthood. BSL CTQ Prada et al. 2014 [24] Outpatients Cross-sectional Clinical study N = 415 SCID-II Compared with adult ADHD, adult BPD patients showed a higher N = 114 ADHD WURS number of childhood trauma. N = 99 BPD ASRS v.11 CTQ Calvo et al. Borderline Personality Disorder and Emotion Dysregulation N = 67 BPD-ADHD BIS-10 STAXI LHA BDI-II BHS WHOQOL-BREF (2020) 7:2 QFS Ferrer et al. 2017 [23] Outpatients Cross-sectional Clinical study No SCID-II Adult BPD patients with a comorbid ADHD presented the highest N = 82 BPD DIB-R number of childhood trauma experiences. Childhood emotional N = 22 ADHD CTQ-SF and sexual abuse was associated to BPD diagnosis in the adulthood, N = 56 BPD-ADHD CADDID with and without comorbid ADHD. The risk of developing an adult N = 44 No BPD-No ADHD WURS BPD in childhood ADHD could be associated to specific early traumas. Dalbudak and Evren, Volunteer university Cross-sectional Non-clinical study No BPI Depressive symptoms, emotional and physical abuse and severity of 2015 [25] students ASRS ADHD symptoms in adulthood were associated to severity of borderline N = 271 CTQ-28 personality features (BPF). These variables may play a mediator role on BDI the relationship between childhood ADHD and adult BPF. BAI Page 4 of 7 Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2020) 7:2 Page 5 of 7 psychopathology in adulthood. The study of Philipsen in children diagnosed with ADHD may be a mediating et al. [14] already proposed that emotional abuse in factor that increases the risk of subsequent development childhood was associated with greater severity, both of of BPD in adulthood. ED has been indicated as a mediator childhood ADHD and of adult BPD. In this sense, stud- between a history of childhood maltreatment and high im- ies of Prada et al. [24] and Ferrer et al. [23] show the pulsivity in women with BPD but not in ADHD [21]. Pre- highest number of references to traumatic childhood an- viously, the mediating effect of ED had been described in tecedents in adult patients with BPD and comorbid the relationship between childhood ADHD and adult BPD ADHD. These findings are remarkable, as BPD-ADHD in a sample of adult women diagnosed with BPD [34]. In has been considered a severe type of BPD with a higher short, as mentioned, children with more severe ADHD impulsive profile and more comorbid disorders [14, 23, could be at higher risk of experiencing trauma and devel- 24], and severe traumatic childhood antecedents in BPD oping a later BPD [4, 14, 35]. In this developmental path- patients predict a worse response to the treatment [31]. way, emotional trauma seems to favor ED and this, in In addition, the study of Dalbudak and Evren [25] de- turn, mediates subsequent development of BPD. scribes the association between traumatic childhood Despite the above-mentioned considerations, several antecedents and more ADHD symptoms and more BP limitations of the review should be noted. Despite the im- features in non-clinical population. Although no reference portance of these issues, to date, the studies carried out is made to the functional impact associated with these are limited, and we must be cautious when generalizing clinical traits, this finding reinforces the evidence that the results obtained. In addition, the type of studies from traumatic childhood experiences may play a mediating which this evidence comes have relevant methodological role between early ADHD and the severity of later BPD. limitations, especially the fact that most of them are based Secondly, the descriptive analysis of the differences be- on retrospective evaluations and there are no longitudinal tween the groups included in the studies of this review studies. Therefore, the results may be conditioned by shows that most of the adult patients studied reported memory and recall bias and by patients’ subjective evalua- traumatic antecedents in their childhood, even those tions, with a high risk of overvaluing or undervaluing, and that did not reach the diagnostic threshold but suffered thereby reducing the reliability due to the type of designs. from functional impairment as a result of their psycho- However, the fact that the different studies used the same pathology [23, 24]. Although the study of Prada et al. diagnostic instrument, the CTQ, allows us to underline [24] observed differences in the prevalence of childhood the results obtained. Nevertheless, future longitudinal trauma between healthy control versus clinical groups, studies would be necessary to assess the possible impact similarly and more specifically, differences were found of trauma from childhood to adulthood from a develop- between the clinical groups, with a greater number of mental perspective for a better understanding of ADHD- emotional and/or sexual abuses in BPD patients, with BPD across the lifespan. Therefore, in the coming years, it and without comorbid ADHD, in comparison with is essential for studies to be carried out to define the bio- ADHD patients [23, 24]. These results indicate that, logical and environmental risk factors to intervene early in although severe forms of childhood maltreatment are childhood and adolescence, to improve their prognosis present in multiple psychiatric disorders [32], there may and to prevent the crystallization of these disorders. be differences in prevalence even between disorders with very similar phenotypes such as BPD and ADHD. These Conclusion results invite the question of whether the type of child- Although trauma has been extensively studied in relation hood trauma that has been associated with the develop- to the development of BPD, in recent years, research has ment of BPD [5, 21, 33] may also increase the risk of raised the question of its role in the ADHD-BPD associ- this disorder in patients with childhood ADHD. ation. This work reviews the studies published to date In relation to the analysis of the traumatic childhood and notes that, although they are scarce, some conclu- event as a risk factor for a subsequent development of sions can be drawn from the available evidence. They all BPD in ADHD patients, a history of childhood sexual and agree that whether or not adult BPD develops from emotional abuse has been associated with adult BPD or childhood ADHD could be conditioned by the differ- BPD-ADHD diagnosis [23], especially in cases with severe ences in the environmental factors. Specifically, it can be childhood ADHD [14]. In contrast, childhood physical hypothesized that exposure to childhood traumas, espe- trauma has been linked to an increased risk of ADHD per- cially emotional trauma, which compromise the individ- sistence in adulthood [23]. Also in non-clinical population, ual’s emotional maturation, could be one of the variables traumatic childhood emotional abuse has been proposed that increase the possibility of a child with ADHD devel- as a risk factor for developing ADHD and BP features in oping BPD in adult life. The possibility of identifying the adulthood [25]. Therefore, even with the limited evidence role of these variables can be highly beneficial for early available, it seems that the experience of emotional abuse diagnosis and intervention in these patients. Calvo et al. Borderline Personality Disorder and Emotion Dysregulation (2020) 7:2 Page 6 of 7 Abbreviations 11. Miller C, Flory J, Scott R, Harty S, Newcorn J, Halperin J. Childhood ADHD ADHD: Attention-Deficit/Hyperactivity Disorder; BPD: Borderline Personality and the emergence of personality disorders in adolescence: a prospective Disorder; DSM: Diagnostic and Statistical Manual of Mental Disorders; follow-up study. 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