1.INTRODUCTION : Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are both common mental health conditions that can have a serious impact on a person’s life[1].

Attention deficit hyperactivity disorder(ADHD)

ADHD is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development[2]. Symptoms of ADHD include:

·         Problems with focus

·         Hyperactivity

·         Impulsivity, such as acting without consideration of consequences, blurting out answers before a question is completed, interrupting others, and difficulty waiting for one’s turn.

Prevalence of ADHD

According to a 2014 field trial, the prevalence of DSM-5 ADHD in adults is 3.55%[3]. However, a 2017 study found that the prevalence of DSM-5 ADHD criteria is 2.1%, while the prevalence of ADHD without the age-of-onset criterion is 5.8%[4]. A 2023 estimate puts the prevalence of symptomatic adult ADHD at 6.76%, which is about 366 million adults worldwide[5].

Dsm-5 Criteria ADHD

A persistent pattern of inattention and/or hyperactivity-impulsivity [6]that interferes with functioning or development, as characterized by (1) and/or (2).

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

·         Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

·         Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

·         Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

·         Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

·         Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

·         Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

·         Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

·         Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

·         Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

·         Often fidgets with or taps hands or feet or squirms in seat.

·         Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

·         Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless).

·         Often unable to play or take part in leisure activities quietly.

·         Is often “on the go” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

·         Often talks excessively.

·         Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

·         Often has trouble waiting his/her turn (e.g., while waiting in line).

·         Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

Borderline personality disorder (BPD)

BPD is a personality disorder characterized by a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity[7]. Symptoms of BPD include: Impulsiveness, Difficulty regulating emotions, Challenges with interpersonal interactions and relationships, and Deep fear of being alone. Symptoms include:[8]

·         Fear of abandonment

·         Unstable relationships

·         Unclear or shifting self-image

·         Impulsive, self-destructive behaviors

·         Self-harm

·         Extreme emotional swings

·         Chronic feelings of emptiness

·         Explosive anger

ADHD and BPD are separate diagnoses, but they share some overlapping symptoms, and an individual may have both conditions[9]. Some studies estimate that 18 to 34% of adults being treated for ADHD also have BPD. This is called comorbidity[10].

Prevalence of BPD

According to NCBI, the prevalence of borderline personality disorder (BPD) in the global population is 0.7–5.9%[11]. In psychiatric services, BPD is diagnosed in 12% of outpatients and 22% of inpatients[12]. In the US, about 5.9% of adults, or about 14 million Americans, experience BPD at some point in their lives. However, NAMI estimates that only 1.4% of the adult US population experiences BPD, and nearly 75% of people diagnosed with BPD are women[13].

DSM-5 Diagnostic Criteria for BPD

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for borderline personality disorder, considered a personality disorder, are defined as a pervasive pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:[14]

1.       fear of abandonment /Intolerance

2.       unstable or changing relationships

3.       unstable self-image, including struggles with sense of self and identity

4.       stress-related paranoia

5.       anger regulation problems, including frequent loss of temper or physical fights

6.       consistent and constant feelings of sadness or worthlessness

7.       self-injury, suicidal ideation, or suicidal behaviour

8.       frequent mood swings

9.       impulsive behaviours such as unsafe sex, reckless driving, binge eating, substance abuse, or excessive spending

ADHD and borderline personality disorder: Is there a link?

While ADHD (Attention Deficit Hyperactivity Disorder) and borderline personality disorder (BPD) are distinct mental health conditions, there can be some overlap in symptoms, which might lead to misdiagnosis or co-occurrence[16]. Both ADHD and BPD can involve impulsivity, mood swings, and difficulty regulating emotions. However, the underlying causes and specific symptoms of each disorder are different[16]. ADHD is primarily characterized by difficulties with attention, hyperactivity, and impulsivity, often starting in childhood and persisting into adulthood. On the other hand, BPD is characterized by unstable relationships, self-image, and emotions, as well as impulsive behaviors, often emerging in adolescence or early adulthood[13]. Research suggests that individuals with ADHD may be at a higher risk of developing other mental health conditions, including BPD. However, the exact nature of this relationship is complex and not fully understood[16]. Some studies have found a higher prevalence of BPD traits or diagnosis in individuals with ADHD, but more research is needed to understand the underlying mechanisms and potential causal relationships between the two disorders[16]

2.Significance of the Study:

 Understanding the prevalence rates of Adult ADHD and BPD among university students, particularly at SOA University, is crucial for identifying mental health needs and designing appropriate interventions. Additionally, exploring the relationship between these disorders and substance use patterns can inform targeted prevention and treatment strategies. This study can contribute to the development of comprehensive mental health services and substance use interventions tailored to the specific needs of University students, ultimately promoting their overall well-being and academic success.

4.A brief review of the literature

Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are two common psychiatric disorders that affect young adults. Both disorders have been associated with substance use and abuse, particularly among university students. BPD is a complex mental health disorder that can cause intense and unstable emotions, impulsive behaviour, a distorted sense of self, and difficulties in relationships. ADHD with BPD may use substances to cope with intense emotions or numb their pain. Substance use can also be a way to self-medicate symptoms such as anxiety, depression, and impulsivity.[21]

The study by Ganesan et al. (2021) investigates the correlation between ADHD symptoms and substance use among undergraduate engineering college students using a cross-sectional survey. The study included 711 undergraduate engineering students and utilized the ASSIST version 3.0 to screen substance use and various scales to assess ADHD symptoms. The results show that students with substance use had higher ADHD symptoms, and the study found a pattern of substance use among the sample. The study concludes that early identification and intervention for ADHD symptoms are necessary to reduce the risk of developing substance use disorders. The study’s findings suggest the need for more research into the relationship between ADHD and substance use disorders and intervention strategies[22].  

 Pizzarello.S, et. al (2011) aimed to investigate whether the substance use patterns of one’s close friends and romantic partners were a significant contributor to the co-occurrence of borderline personality disorder (BPD) features and drug use problems, even after controlling for impulsivity and negative emotionality. The participants of the study were 2,202 undergraduate students who attended a large south-eastern university between 2003 and 2006. The study employed measures that assessed the presence of BPD symptoms, drug use problems, general personality traits, and the proportion of friends and partners who had used illicit drugs within the past year. The study found that the illicit drug use patterns of one’s friends and romantic partners were indeed significant contributors to the co-occurrence of BPD features and drug use problems, even when controlling for levels of impulsivity and negative emotionality. These findings suggest that treatment for students with BPD and drug use problems may benefit from focusing on modifying their social group. Overall, this study highlights the importance of considering social factors in understanding the co-occurrence of BPD and drug use problems and underscores the need for integrated treatment approaches that address both individual and social factors.[23]

RESEARCH GAP

Limited Research on ADHD and BPD Prevalence in University Students: There is a scarcity of studies specifically focusing on the prevalence of ADHD and BPD among university students in general, and particularly at SOA University. Most existing research tends to focus on clinical or community samples rather than students in higher education settings.

Correlation with Substance Use Patterns: While there is some research indicating a higher prevalence of substance use disorders among individuals with ADHD and BPD separately, there is a lack of comprehensive studies examining how ADHD and BPD symptoms correlate with specific substance use patterns (such as alcohol, tobacco, or illicit drugs) among university students. This gap is crucial for developing targeted intervention and treatment strategies.

5.AIMS AND OBJECTIVES

AIMS:

To determine the prevalence of adult ADHD and BPD in University students and determine their relationship with substance use patterns.

OBJECTIVE

Ø  Primary

1.      To find out the prevalence of adult Attention deficit hyperactivity disorder and Borderline personality disorder university students

2.      To find out the pattern of substance use among University students

3.      To determine the correlation between ADHD and BPD with substance use patterns.

Ø  Secondary

Ø  To compare the substance use patterns among students with ADHD, BPD, and the general student population.

NOVELITY

The previous research has separately examined the association between ADHD and BPD with substance use disorder. ADHD and BPD are two common mental health conditions that can significantly impact an individual’s academic performance, impulsivity, and social and personal functioning. As such, it is important to understand their prevalence in the student population.

These factors have not been studied in the context of the comparison between ADHD and BPD, as well as the correlation between these disorders and substance use patterns in university students.

6.METHODOLOGY

1.         Research Design

Cross sectional study

2.         Sampling method

Stratified random sampling was used to collect the data for this particular research study.

3.         Sample size

A sample size of 3000students was selected for this research study

4.Inclusion

•Undergraduate students of the age group 18-25 years were selected from SOA University.

• Student consent form.

•Participants must complete all assessment measures for ADHD and BPD

5. Exclusions

•Participants with a history of traumatic brain injury or neurological disorders that may impact cognitive functioning.

•Participants with a history of severe mental illness, such as schizophrenia or bipolar disorder, which may confound the results of the study.

•Systemic or neurological disorder affecting cognition, behaviour, or mental status.

Study duration: 3years

Tools To Be Used

Adult ADHD Self-report Scale V1.1  (ASRS V1.1)

The ASRS-v1.1 is a self-report form used to assess symptoms of ADHD based on the 18 DSM-IV symptom criteria [17]. The instrument is comprised of two parts: Part A (6 questions) and Part B (12 questions). For each item, respondents are asked to indicate how often the stated symptom occurred over the prior six months, with five options: never, rarely, sometimes, often, or very often. For all 18 items, responses of “often” or “very often” are considered positive (indicated by shaded boxes on the questionnaire). In addition, for items 1, 2, 3, 9, 12, 16 and 18, a response of “sometimes” is also scored positive. A patient is considered to screen positive on the ASRS-v1.1 if they endorse 4 or more of the Part A questions at these threshold levels. Although Part B is not used for diagnostic purposes, these items provide insight into the frequency of symptoms and can be used to help elicit other the symptoms the patient may suffer from [18].

McLean Screening Instrument for BPD

Each item in the McLean Screening Instrument for borderline personality disorder is rated as a "1" if it is present and a "0" if it is absent, and items are totaled for possible scores from 0 to 10. A score of 7 is generally considered a valid clinical cutoff, meaning that a score of 7 or higher indicates that a person likely meets the criteria for a BPD diagnosis. However, some researchers have proposed a lower cutoff[19].

WHO The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

ASSIST 1.0 began with an initial screening item that asked about life-time use of commonly used substances within the following 10 categories: tobacco products, alcoholic beverages, cannabis, cocaine, stimulants, inhalants, sedatives/hypnotics, hallucinogens, opioids and ’other drugs.’ If the respondent reported no psychoactive substance use, the interview was terminated. If the respondent admitted to life-time use of one or more substances, the remaining questions were asked only for those substances endorsed in the initial screening question. The 11 additional questions were selected from a large pool of items that had been used in previously developed scales to measure the frequency of substance use, dependence symptoms, substance-related problems, and injection drug use. Following the question about life-time use, the second question asked about drug use during the ’past 3 months’. The drug classes in this question were rated on a five-point frequency scale ranging from ’never’ (in the past three months) to ’daily’. This question provided critical information about the substances most relevant to the respondent’s current health status. If none of the substances had been used in the past 3 months, the interviewer skipped to questions 9–12 about problems and use patterns that occurred prior to the past 3 months. These questions inquired about a past history of harmful use or dependence that may increase the risk of future problems even in the absence of current use[20].

 Barratt Impulsiveness Scale (BIS-11)

For this questionnaire, the frequency of common impulsive (e.g., “I do things without thinking”) or non-impulsive (“I am self-controlled”) behavioral traits are rated on a scale from 1 = Rarely/Never to 4 = Almost Always/Always. The BIS-11 contains 30 items that measure three main domains: attention impulsivity, motor impulsivity, and no planning impulsivity. The three main domains can be fractioned into six dimensions of impulsivity: Scores range from 30 to 120, with higher scores indicating higher levels of impulsivity.

2nd Phrase Diagnostic Interview for ADHD in adults (DIVA 2.0)

The evaluation of each of the 18 symptom criteria for ADHD in childhood and adulthood, the interview provides a list of concrete and realistic examples, for both current and retrospective (childhood) behaviour. The examples are based on the common descriptions provided by adult patients in clinical practice. Examples are also provided of the types of impairments that are commonly associated with the symptoms in five areas of everyday life: work and education; relationships and family life; social contacts; free time and hobbies; self-confidence and self-image. The sum score is based on the total number of symptoms ranging from 0 to 9, where higher scores indicate more ADHD symptoms. The DIVA 2.0 is a semi-structured diagnostic interview for the assessment of ADHD in adults.

Severity Of Alcohol Dependence Questionnaire (SADQ-C)

The Severity of Alcohol Dependence Questionnaire (SADQ-C) is a tool used to assess the severity of alcohol misuse. The SADQ-C scores range from 0–60, with a score of 31 or higher indicating severe alcohol dependence, 16–30 indicating moderate dependence, and less than 16 indicating mild dependence. he SADQ-C uses a four-point Likert scale for each item, with the responses recorded as numeric values of 0–3:Almost never: 0,Sometimes: 1,Often: 2,Nearly always: 3.

Fagerstrom Nicotine Dependence Scale Smokeless Tobacco (FTND-ST)

In scoring the Fagerstrom Test for Nicotine Dependence, yes/no items are scored from 0 to 1 and multiple-choice items are scored from 0 to 3. The items are summed to yield a total score of 0-10. The higher the total Fagerström score, the more intense is the patient’s physical dependence on nicotine.

Variables

Independent: 1- Google form, and Hard copy questionnaires 2-Student consent form

Dependent :

1.      ADHD with Substance use pattern(SUP)

2.      BPD with substance use pattern

3.      Correlation with substance use pattern in ADHD and BPD

4.      Compare with substance use pattern in ADHD  ,BPD ,and general student population.

·         Inferential Statistics: Correlation Analysis, Regression Analysis. Chi-square Test, ANOVA or T-tests

8.EXPECTED OUTCOMES:

·         Comparison of Prevalence Rates: Determine and compare the prevalence rates of ADHD and BPD among a University students.

·         Demographic Comparisons: Analyze demographic differences between students with ADHD, BPD, and those without these disorders, including age, gender, ethnicity, socio-economic status, and academic major.

·         Substance Use Patterns Comparison: Investigate and compare substance use patterns among students with ADHD, BPD, both disorders, and those without either disorder, including frequency, quantity, types of substances used, and motivations for use.

·         Correlation Analysis: Examine the correlations between ADHD symptoms, BPD symptoms, and substance use patterns, assessing whether certain subgroups of students are more likely to engage in substance use based on their symptom profiles.

·         Impact on Academic Performance: Compare the impact of ADHD, BPD, and substance use on academic performance of a university students from other institutions.