The specificity of clinical characteristics in adults with attention-deficit/hyperactivity disorder: a comparison with patients with borderline personality disorder

Tattoos, piercings, and symptoms of ADHD in non-clinical adults: a cross-sectional study

Introduction

Tattoos and piercings are associated with impulsive and risk-taking personality traits, which are also common along the ADHD continuum. However, studies on ADHD and body modification are lacking. Thus, this study aimed to assess the association between body modification and subclinical ADHD symptom severity and to investigate if body modification can serve as an indication for ADHD examination.

Methods

A total of 762 adults (529 women and 233 men) without a diagnosis of ADHD completed the adult ADHD Self-Report Scale (ASRS) and answered questions concerning body modification. Two different ASRS versions were utilized: the 18-item ASRS Symptom Checklist and the 6-item ASRS Screener. Three categorizations of body modifications were analyzed: (i) having at least one tattoo, (ii) having at least one piercing other than ear piercing, and (iii) the combination of simultaneously having at least one tattoo and one piercing. Mean 18-item ASRS total and subscale scores and the proportion of positive results on the 6-item ASRS Screener were compared between those with and those without body modifications while adjusting for covariates age and sex. Additional analyses were performed for ≥2 and ≥3 body modifications.

Results

In our cohort, 26% had a tattoo, 14% had a piercing other than ear piercing, and 8% had a combination of tattoo and piercing. Having any kind of body modification was associated with more pronounced symptoms of ADHD and with a cutoff score on the ASRS screener indicating ADHD. Whereas, the effect sizes were small for tattoos, medium to large effect sizes were seen for ≥2 piercings in the ASRS. Moreover, moderately strong associations emerged for ≥1 piercing and a positive ASRS screening result.

Conclusion

Our results suggest that acquiring a body modification, especially a tattoo, is entering the mainstream in Sweden. Correspondingly, differences in subclinical ADHD symptomatology between non-clinical adults with and without body modifications are subtle. Having ≥2 piercings other than ear piercings, on the other hand, is associated with clinically relevant differences in ADHD symptoms. Moreover, piercing status may serve as an indicator, among others, for further ADHD assessments. However, more research is needed to ascertain the possible signaling functions of body modifications in clinical settings.

Divergent mentalization types in adolescent borderline personality disorder and attention deficit/hyperactivity disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have several similarities and it is difficult to distinguish these disorders in adolescents. We aimed to identify the unique correlates of mentalization abilities that may distinguish these two disorders, and to investigate the mentalization abilities of adolescents with ADHD, BPD and ADHD + BPD in an inpatient sample to determine the effect of co-morbidity on mentalization abilities.

METHODS

We have explored the relationship between Child Eye Test (CET) scores, Movie for the Assessment of Social Cognition (MASC) subscales, and ADHD and BPD symptoms in adolescent inpatients. In addition, we compared ADHD, BPD and ADHD + BPD groups in terms of their mentalization abilities.

RESULTS

Correct MASC scores were negatively associated with both ADHD and BPD symptoms in girls, and negatively associated with ADHD symptoms in boys. In addition, hypermentalization scores were associated with BPD symptoms in girls, and hypomentalization and no mentalization scores were associated with ADHD symptoms in girls. CET scores were negatively associated with ADHD symptoms in girls, but no relations with BPD were found. Group comparisons revealed no significant difference among groups.

LIMITATIONS

We included only inpatient sample without considering their medication condition, we did not compare the mentalization scores of the patient groups with healthy controls and we used self-report measures for several assessments.

CONCLUSION

Mentalization patterns in ADHD and BPD are distinct. ADHD may be related to hypomentalization, instead, BPD may be related to hypermentalization.

Borderline personality disorder and attention deficit/hyperactivity disorder in adolescence: overlap and differences in a clinical setting

BACKGROUND

With increased consensus regarding the validity and reliability of diagnosing Borderline Personality Disorder (BPD) in adolescents, clinicians express concern over the distinction between BPD and Attention-Deficit/Hyperactivity Disorder (ADHD), and its co-morbidity in clinical settings. The goal of this study was to evaluate differences between BPD, ADHD and BPD + ADHD in terms of co-morbid psychiatric disorders and a range of self-reported behavioral problems in adolescents.

METHODS

Our sample consisted of N = 550 inpatient adolescents with behavioral and emotional disorders that have not responded to prior intervention. We took a person-centered approach (for increase clinical relevance) and compared adolescents with ADHD, BPD and ADHD+BPD in terms of co-occurring psychiatric disorders and behavioral problems. We performed a regression analysis to test whether BPD symptoms make an incremental contribution to the prediction of psychiatric symptoms over ADHD symptoms.

RESULTS

The severity of almost all co-occurring disorders, aggression, self-harm, suicidal thoughts, and substance use, were higher in the ADHD+BPD group. Borderline symptoms made an incremental contribution to the prediction of psychiatric symptoms beyond the contribution of ADHD.

CONCLUSION

Severity and co-morbidity may be helpful factors in distinguishing between ADHD and BPD in clinical practice and the co-morbidity of these two disorders may indicate a worse clinical outcome.

Attention Deficit Hyperactivity Disorder And Borderline Personality Disorder In Adults: A Review Of Their Links And Risks

Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are particularly common disorders, that are highly comorbid in adult populations. The symptomatic overlap between adult ADHD and BPD includes impulsivity, emotional dysregulation and interpersonal impairment, which makes the differential diagnosis difficult. Our review aims at focusing on recent data on the comorbid ADHD+BPD form, as well as the risk factors involved in the emergence of the two disorders. While adult ADHD and BPD share some genetic and temperamental risk factors, adult ADHD is characterized by more severe trait-impulsivity compared to non-comorbid BPD; BPD patients display more severe trait-emotion regulation symptoms compared to non-comorbid ADHD. Patients with the comorbid ADHD+BPD form have severe symptoms in both dimensions. Early-life exposure to adverse events is a shared risk factor for the development of ADHD and BPD, but type and timing of adversity seem to play a differential role in the development of BPD and ADHD symptoms. Age of onset used to be a discriminative diagnostic criterion between ADHD, an early-onset neurodevelopmental disorder, and BPD, a late-onset psychological disorder. However, this distinction has been recently called into question, increasing the need for more research aiming at delineating the disorders from a developmental and clinical standpoint. Clinicians should carefully consider the comorbidity, and consider ADHD and BPD dimensionally, in order to provide more effective patient management. This might improve early preventive interventions, and treatment for comorbid conditions in adulthood.

Comorbidity of personality disorders and attention-deficit hyperactivity disorder in adults

INTRODUCTION

A high comorbidity has been observed among attention-deficit hyperactivity disorder (ADHD) and categorical personality disorders (PD). A study is conducted on the dimensional traits associated with ADHD and PD, in order to determine whether there are any differences.

METHODOLOGY

A cross-sectional study was conducted on 78 outpatients attending a Mental Health Clinic in Arganda (Madrid) from January 2013 to June 2015. ADHD diagnosis was evaluated with the CAARS, the CAADID, and the WURS scales, and the PD with the SCID-II-DSM-IV questionnaire. None of the patients were receiving any stimulant or atomoxetine before the study, and all patients signed the informed consent before the study.

RESULTS

A high comorbidity was found with all PD clusters, especially with hyperactive and combined type ADHD. Depressive PD was associated with inattentive ADHD.

CONCLUSIONS

In spite of using a questionnaire to evaluate PD, some differences can be observed between specific ADHD types and PD. More studies are needed to investigate dimensional personality traits in order to improve the diagnosis and therapeutics goals.

Rapid emotional response and disadvantageous Iowa gambling task performance in women with borderline personality disorder

BACKGROUND

Adults with Borderline Personality Disorder (BPD) manifest poor performance on tasks of decision making which may be congruent with their decisional and interpersonal conflicts in real life. Poor decision making is often assumed to be due to impulsive behaviour or weak inhibitory control despite inconsistent evidences of these relationships, leaving questions about the specific nature of these decisional deficits. Decision making in BPD may be compromised by different domains of impulsivity, affective dysregulatory processes or unknown co-morbid ADHD which is considered a developmental precursor to BPD.

FINDINGS

Iowa Gambling Task (IGT) decision making, 2 tasks of inhibitory control and a self report of ADHD symptoms consisting of 9 subscales were administered to 41 BPD women and 41 healthy controls. No group differences in inhibitory control were present. Net decision making performance and all ADHD subscale ratings differed significantly among BPD women and healthy controls. BPD women did not meet the threshold indicative of moderate to severe ADHD. Three subscales of attention, behaviour/ disorganized and emotive were significantly associated with poor IGT performance in 26 women with BPD. Of these 3 variables, the emotive subscale, representing a rapid emotional response, was the only significant predictor contributing 49% to the variance in poor DM.

CONCLUSIONS

This is the 1st evidence of an emotive type of impulsivity, representing a type of affective instability that is linked to poor IGT DM in BPD. Findings support the Somatic Marker Hypothesis of IGT DM and may reflect the affective dysregulation that characterizes the disorder.

Diagnostic profiles of adult psychiatric outpatients with and without attention deficit hyperactivity disorder

OBJECTIVE

Despite growing recognition that attention deficit/hyperactivity disorder (ADHD) is a highly prevalent, impairing, and comorbid disorder that persists into adulthood, reports on the nature and extent of its psychiatric comorbidities have been mixed to date. This study compared the prevalence rates of all major Axis I disorders as well as borderline personality disorder in an unselected sample of adult psychiatric outpatients with and without ADHD.

METHODS

As part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we administered a DSM-IV-based semi-structured diagnostic interview assessing ADHD and other psychiatric disorders to 1134 patients presenting for initial evaluation at an outpatient psychiatric practice. Logistic regression analyses were used to compare the rates of each disorder in patients with versus without an ADHD diagnosis (both overall and by Combined and Inattentive type).

RESULTS

Patients with (versus without) any ADHD diagnosis had significantly higher rates of bipolar disorder, social phobia, impulse control disorders, eating disorders, and BPD, and significantly lower rates of major depressive disorder and adjustment disorder (all p<.05). Patients with (versus without) ADHD-Inattentive type had significantly higher rates of social phobia and eating disorders, whereas those with (versus without) the ADHD-Combined type had significantly higher rates of bipolar disorder, alcohol dependence, and BPD (all p<.05).

CONCLUSION

In this novel investigation of the psychiatric profiles of an unselected sample of treatment-seeking adult outpatients with versus without ADHD, a distinct pattern of comorbidities emerged across subtypes, with implications for the accurate assessment and treatment of patients presenting for psychiatric care.

Characterizing adult attention-deficit/hyperactivity-disorder and comorbid borderline personality disorder: ADHD symptoms, psychopathology, cognitive functioning and psychosocial factors

OBJECTIVE

To characterize adults with comorbid attention-deficit/hyperactivity-disorder (ADHD) and borderline personality disorder (BPD) with regard to ADHD symptoms, psychopathology, cognitive functioning and psychosocial factors.

METHOD

A between-group design compared a group of individuals diagnosed with ADHD (n=40) with a group diagnosed with BPD and who also met the criteria for ADHD (ADHD+BPD) (n=20).

RESULTS

Significant differences were observed for both childhood and current impulsivity symptoms, whereby ADHD+BPD exhibited increased impulsivity; no differences on self-report and cognitive measures of impulsivity were reported. The ADHD+BPD group scored significantly higher on measures of depression, anxiety and numerous other axis I and II conditions. The ADHD+BPD group scored significantly lower on most measures of intellectual functioning and attention, however largely not on those relating to response inhibition. Furthermore, group differences were observed for psychosocial factors, including education, substance use and criminal record.

CONCLUSION

Comorbid ADHD and BPD is characterized by more symptoms of impulsivity, additional psychopathology, comparatively lower intellectual and attentional functioning and increased psychosocial difficulties.

Borderline personality disorder: Prevalence and psychiatric comorbidity among male offenders on probation in Sweden

INTRODUCTION

Borderline personality disorder (BPD) is a severely disabling condition, associated with substantially increased risk of deliberate self-harm and, particularly in men, also with interpersonal violence and other criminal behavior. Although BPD might be common among prison inmates, little is known about prevalence and psychiatric comorbidity in probationers and parolees.

METHOD

In 2013, a consecutive sample of 109 newly admitted adult male offenders on probation or parole in all three probation offices of Stockholm, Sweden, completed self-report screening questionnaires for BPD and other psychiatric morbidity. Participants scoring over BPD cut-off participated in a psychiatric diagnostic interview.

RESULTS

We ascertained a final DSM-5 BPD prevalence rate of 19.8% (95% CI: 12.3-27.3%). The most common current comorbid disorders among subjects with BPD were antisocial personality disorder (91%), major depressive disorder (82%), substance dependence (73%), attention deficit hyperactivity disorder (ADHD) (70%), and alcohol dependence (64%). Individuals diagnosed with BPD had significantly more current psychiatric comorbidity (M=6.2 disorders) than interviewed participants not fulfilling BPD criteria (M=3.6). Participants with BPD also reported substantially more symptoms of ADHD, anxiety and depression compared to all subjects without BPD.

CONCLUSIONS

BPD affected one fifth of probationers and was related to serious mental ill-health known to affect recidivism risk. The findings suggest further study of possible benefits of improved identification and treatment of BPD in offender populations.

Co-occurrence of attention-deficit hyperactivity disorder symptoms with other psychopathology in young adults: parenting style as a moderator

The extent to which parenting styles can influence secondary psychiatric symptoms among young adults with ADHD symptoms is unknown. This issue was investigated in a sample of 2284 incoming college students (male, 50.6%), who completed standardized questionnaires about adult ADHD symptoms, other DSM-IV symptoms, and their parents' parenting styles before their ages of 16. Among them, 2.8% and 22.8% were classified as having ADHD symptoms and sub-threshold ADHD symptoms, respectively. Logistic regression was used to compare the comorbid rates of psychiatric symptoms among the ADHD, sub-threshold ADHD and non-ADHD groups while multiple linear regressions were used to examine the moderating role of gender and parenting styles over the associations between ADHD and other psychiatric symptoms. Both ADHD groups were significantly more likely than other incoming students to have other DSM-IV symptoms. Parental care was negatively associated and parental overprotection/control positively associated with these psychiatric symptoms. Furthermore, significant interactions were found of parenting style with both threshold and sub-threshold ADHD in predicting wide-ranging comorbid symptoms. Specifically, the associations of ADHD with some externalizing symptoms were inversely related to level of paternal care, while associations of ADHD and sub-threshold ADHD with wide-ranging comorbid symptoms were positively related to level of maternal and paternal overprotection/control. These results suggest that parenting styles may modify the effects of ADHD on the risk of a wide range of temporally secondary DSM-IV symptoms among incoming college students, although other causal dynamics might be at work that need to be investigated in longitudinal studies.

Is ADHD an early stage in the development of borderline personality disorder?

BACKGROUND

Several studies report associations between adults with borderline personality disorder (BPD) and a history of attention-deficit hyperactivity (ADHD) symptoms in childhood.

AIMS

To explore the association between BPD and a history of ADHD in childhood.

METHOD

A comprehensive search of EMBASE, PsychInfo and Medline and hand-searching yielded 238 "hits". Fifteen articles were found to have sufficient quality and relevance to be included in the final review. The data were considered in six possible explanatory psychopathological models of the association between ADHD and BPD.

RESULTS

Most of the 15 articles showed a statistical association between ADHD and BPD. The data, most strongly provided a basis for the hypotheses that ADHD is either an early developmental stage of BPD, or that the two disorders share an environmental and genetic aetiology. Furthermore, one of the disorders seems to give a synergic effect, reinforce the other or complicate the disorders. In one prospective study, the risk factor for children with ADHD to develop BPD was as high as odds ratio 13.16. No studies have looked at treatment of ADHD as a mediator of the risk for BPD.

CONCLUSIONS

Many studies pointed at shared aetiology or the risk for development of one disorder, when the other disorder is present. The data do not evaluate how treatment factors or other factors mediate the risk or how overlap of diagnostic criteria adds to the statistical association. More research is much needed, in particular studies looking at early intervention and which treatment of ADHD that might prevent later development of BPD.

Distinguishing borderline personality disorder from adult attention deficit/hyperactivity disorder: a clinical and dimensional perspective

Adult attention deficit hyperactivity disorder (ADHD) is frequently associated with borderline personality disorder (BPD). As both disorders share some core clinical features they are sometimes difficult to distinguish from one another. The present work aimed to investigate differences in the expression of impulsivity, anger and aggression, quality of life as well as the number and severity of the comorbidities between ADHD, BPD, comorbid BPD-ADHD and control subjects. ADHD and BPD-ADHD patients showed a higher level of impulsivity than BPD and control subjects. BPD-ADHD patients had higher levels of substance abuse/dependence and higher levels of aggression than the other groups. Comorbid BPD-ADHD patients showed high levels of impulsivity and aggression, a characteristic that should draw the attention of clinicians on the necessity of providing an accurate diagnosis. The question also arises as to whether they represent a distinct clinical subgroup with specific clinical characteristics, outcomes and vulnerability factors.

Subjective cognitive complaints and functional disability in patients with borderline personality disorder and their nonaffected first-degree relatives

OBJECTIVE

To examine the contributions of subjective cognitive complaints to functional disability in patients with borderline personality disorder (BPD) and their nonaffected relatives.

METHOD

Patients with BPD (n = 26), their first-degree biological relatives (n = 17), and nonpsychiatric control subjects (n = 31) completed a self-report measure of cognitive difficulties and rated the severity of their functional disability on the World Health Organization Disability Assessment Schedule 2.0.

RESULTS

After accounting for group differences in age and severity of depressive symptoms, patients and relatives endorsed more inattention and memory problems than control subjects. Whereas probands reported greater disability than relatives and control subjects across all functional domains, relatives described more difficulties than control subjects in managing multiple life activities, including domestic activities and occupational and academic functioning, and participating in society. For both probands and relatives, inattention and memory problems were linked primarily to difficulties with life activities, independent of depression and other comorbid psychiatric disorders.

CONCLUSIONS

Problems with inattention and forgetfulness may lead to difficulties carrying out activities of daily living and occupational or academic problems in patients with BPD, as well as their nonaffected first-degree relatives.

Do cognitive measures of response inhibition differentiate between attention deficit/hyperactivity disorder and borderline personality disorder?

This study examined whether cognitive measures of response inhibition derived from the AX-CPT are able to differentiate between adult attention deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD), and healthy controls (HC). Current DSM-IV-TR symptoms of ADHD and BPD were assessed by structured diagnostic interviews, and parent developmental interviews were used to assess childhood ADHD symptoms. Patients (14 ADHD, 12 BPD, 7 ADHD and BPD, and 37 HC) performed the AX-CPT. Seventy percent of AX-CPT trials were target (AX) trials, creating a bias to respond with a target response to X probes in the nontarget (AY, BX, BY) trials. On BX trials, context, i.e. the non-'A' letter, must be used to inhibit this prepotent response tendency. On AY trials context actually causes individuals to false alarm. The effects of ADHD and BPD on AX-CPT outcome were tested using two-way ANOVA. BPD was associated with higher percentage of errors across the task and more errors and slower responses on BX trials, whereas ADHD was associated with slower responses on AY trials. The findings suggest response inhibition problems to be present in both ADHD and BPD, and patients with BPD to be particularly impaired due to poor context processing.

Trajectories of attention deficit hyperactivity disorder and oppositional defiant disorder symptoms as precursors of borderline personality disorder symptoms in adolescent girls

Little empirical evidence exists regarding the developmental links between childhood psychopathology and borderline personality disorder (BPD) in adolescence. The current study addresses this gap by examining symptoms of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) as potential precursors. ADHD and BPD share clinical features of impulsivity, poor self-regulation, and executive dysfunction, while ODD and BPD share features of anger and interpersonal turmoil. The study is based on annual, longitudinal data from the two oldest cohorts in the Pittsburgh Girls Study (N = 1,233). We used piecewise latent growth curve models of ADHD and ODD scores from age 8 to 10 and 10 to 13 years to examine the prospective associations between dual trajectories of ADHD and ODD symptom severity and later BPD symptoms at age 14 in girls. To examine the specificity of these associations, we also included conduct disorder and depression symptom severity at age 14 as additional outcomes. We found that higher levels of ADHD and ODD scores at age 8 uniquely predicted BPD symptoms at age 14. Additionally, the rate of growth in ADHD scores from age 10 to 13 and the rate of growth in ODD scores from 8 to 10 uniquely predicted higher BPD symptoms at age 14. This study adds to the literature on the early development of BPD by providing the first longitudinal study to examine ADHD and ODD symptom trajectories as specific childhood precursors of BPD symptoms in adolescent girls.

Symptomatic overlap between attention-deficit/hyperactivity disorder and borderline personality disorder in women: the role of temperament and character traits

OBJECTIVE

There is substantial symptomatic overlap between attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults, but the nature of the relationship between these disorders needs further clarification. The role of temperament and character traits in the differentiation of classes of patients with similar ADHD and BPD symptom profiles was examined and possible pathways between early temperament and future ADHD and/or BPD were hypothesized.

METHODS

Structured diagnostic interviews were conducted in 103 female patients to assess current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of ADHD and BPD, and parent interviews were used to assess ADHD symptoms in childhood. Classes of subjects with homogeneous symptom profiles were identified using latent class analysis. Temperament and character traits were assessed using the Temperament and Character Inventory of Cloninger et al; scores were then compared across the latent classes.

RESULTS

Latent class analysis revealed 4 mutually exclusive classes of patients: 1 with only ADHD symptoms; 1 with BPD symptoms and ADHD symptoms of hyperactivity; 1 with BPD symptoms and ADHD symptoms of inattention, hyperactivity, and impulsivity; and 1 with BPD symptoms and ADHD symptoms of inattention and hyperactivity. High Novelty Seeking was found in all classes except for the class with symptoms of BPD and only the hyperactivity aspect of ADHD. The highest Novelty Seeking temperament scores were found in that class of patients with both symptoms of BPD and symptoms in all areas of ADHD. High Harm Avoidance, low Cooperativeness, and low Self-directedness were specifically related to classes containing BPD symptoms.

CONCLUSIONS

Classes of ADHD and BPD symptoms are associated with specific temperament and character configurations. Novelty Seeking was associated with the inattention symptoms of ADHD. An outspoken Novelty Seeking temperament suggests vulnerability for the development of ADHD and co-occurring BPD. Contrary to patients with combined ADHD and BPD symptoms, patients with only symptoms of ADHD showed normal character development and thus an absence of a personality disorder. Assessment of temperament and character traits can improve our understanding of the complex relationship between ADHD and BPD.

Lifespan attention deficit/hyperactivity disorder and borderline personality disorder symptoms in female patients: a latent class approach

Attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are frequently comorbid. To contribute to a better understanding of the associations regularly found between ADHD and BPD, on the one hand, and the developmental pathways for these disorders, on the other hand, latent class analyses (LCA) were undertaken to identify classes differing in profiles of childhood symptoms of ADHD and adult symptoms of ADHD and BPD. Diagnostic interviews with 103 female outpatients meeting the criteria for ADHD and/or BPD were used to assess current DSM-IV symptoms; childhood symptoms of ADHD were assessed in parent interviews. The latent classes were examined in relation to the DSM-IV conceptualizations of ADHD and BPD. And relations between childhood and adult classes were examined to hypothesize about developmental trajectories. LCA revealed an optimal solution with four distinct symptom profiles: only ADHD symptoms; BPD symptoms and only ADHD symptoms of hyperactivity; BPD symptoms and ADHD symptoms of inattention and hyperactivity; BPD symptoms and ADHD symptoms of inattention, hyperactivity and impulsivity. All patients with BPD had some ADHD symptoms in both adulthood and childhood. Hyperactivity was least discriminative of adult classes. Adult hyperactivity was not always preceded by childhood hyperactivity; some cases of comorbid ADHD and BPD symptoms were not preceded by significant childhood ADHD symptoms; and some cases of predominantly BPD symptoms could be traced back to combined symptoms of ADHD in childhood. The results underline the importance of taking ADHD diagnoses into account with BPD. ADHD classification subtypes may not be permanent over time, and different developmental pathways to adult ADHD and BPD should therefore be investigated.

Not always hyperactive? Elevated apathy scores in adolescents and adults with ADHD

OBJECTIVES

To investigate the presence of apathy symptoms in adolescents and adults with ADHD as a behavioral manifestation of underlying motivational deficits and to determine whether apathy symptoms were associated with a specific neuropsychological profile.

METHOD

A total of 38 ADHD participants (28 of the combined subtype [ADHD/C] and 10 of the inattentive subtype [ADHD/I]) and 30 healthy controls (Ctrl) were assessed on two measures of apathy administered to subjects and informants. As well, ADHD participants completed a comprehensive neuropsychological battery.

RESULTS

ADHD participants presented elevated scores on measures of apathy relative to controls (ADHD/I > ADHD/C > Ctrl). Informant-based ratings of apathy correlated significantly with behavioral measures of inattention. Apathy measures correlated significantly with executive tests, working memory, verbal fluency, and general intellectual abilities, only in the inattentive sample.

CONCLUSIONS

This study stresses the relevance of motivational deficits in adult ADHD as a significant clinical dimension closely linked to inattention and executive difficulties.

Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): a systematic review

Attention deficit hyperactivity disorder (ADHD) is prevalent in the adult population. The associated co-morbidities and impairments can be relieved with treatment. Therefore, several rating scales have been developed to identify adults with ADHD who may benefit from treatment. No systematic review has yet sought to evaluate these scales in more detail. The present systematic review was undertaken to describe the properties, including psychometric statistics, of the currently available adult ADHD rating scales and their scoring methods, along with the procedure for development. Descriptive synthesis of the data is presented and study quality has been assessed by an objective quality assessment tool. The properties of each scale are discussed to make judgements about their validity and usefulness. The literature search retrieved 35 validation studies of adult ADHD rating scales and 14 separate scales were identified. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners' Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. More research into these scales, with good quality studies, is needed to confirm the findings of this review. Future studies of ADHD rating scales should be reported in more detail so that further reviews have more support for their findings.

Attention deficit/hyperactivity disorder in female offenders: prevalence, psychiatric comorbidity and psychosocial implications

Attention deficit-/hyperactivity disorder (ADHD) is associated with social maladaptation and delinquency in later life. This study was conducted to determine the prevalence of ADHD and comorbid conditions in female prison inmates. One hundred and ten adult female prison inmates of a German prison for women were investigated. SCID-I and -II interviews and standardized German instruments for the assessment of ADHD in adults (HASE) were used. The lifetime prevalence of ADHD was 24.5 and 10% for persisting ADHD according to DSM-IV criteria. A decline of the prevalence of persisting ADHD with age from 17.9% (age <25 years) to 10% (age 26-45 years) and 0% (age >45 years) was observed. Female prisoners with ADHD were younger at their first conviction as compared with females without ADHD and they showed longer incarceration periods in relation to age. The prevalence of other axis I disorders was high in both the ADHD and the non-ADHD female population, but significantly higher in ADHD females. Mean number of axis I diagnoses was 3.6 in females with ADHD and 2.3 in females without ADHD. No differences were found between females with and without ADHD regarding the prevalence of psychotic, affective, anxiety, somatization and posttraumatic disorders. Substance use disorders and in particular the use of stimulants were more frequent in females with ADHD as well as borderline personality disorder and eating disorders. The results suggest a high prevalence of ADHD in female prisoners that exceeds the prevalence estimates from epidemiological studies in general female populations. Moreover, it appears that ADHD is particularly frequent in adolescent and young adult female offenders and increases the risk for further psychiatric morbidity. The results indicate the need of adequate psychiatric support of female prison inmates including therapeutic programs for ADHD.

Structural brain abnormalities in borderline personality disorder: a voxel-based morphometry study

Imaging studies using region-of-interest morphometry and positron emission tomography have contributed to our understanding of structural and functional abnormalities in borderline personality disorder (BPD); however, both methods have practical limitations to their usefulness for exploratory studies of brain-behavior relationships. We used voxel-based morphometry (VBM) in 34 subjects with BPD and 30 healthy control (HC) subjects to study effects of diagnosis, gender, childhood sexual abuse, depressed mood, impulsivity and aggression on group differences. VBM is a computer-based method for whole brain analysis that combines the advantages of a functional study with a structural method. The BPD subjects, diagnosed with the Diagnostic Interview for Borderline Patients and the International Personality Disorders Examination, were compared with 30 HC subjects, with age and gender covaried. Analyses were repeated separately by gender and, in women, by histories of childhood sexual abuse. Depressed mood, impulsivity, and aggression were covaried in separate analyses. Compared with HC, BPD subjects had significant bilateral reductions in gray matter concentrations in ventral cingulate gyrus and several regions of the medial temporal lobe, including the hippocampus, amygdala, parahippocampal gyrus, and uncus. BPD women (and abused BPD women), but not BPD men, had significant reductions in medial temporal lobe, including the amygdala. BPD men, but not BPD women, showed diminished gray matter concentrations in the anterior cingulate gyrus compared with findings in HC subjects. Covarying for depressed mood rendered group differences non-significant in the ventral cingulate but had little effect on differences in medial temporal cortex. Covarying for aggression (LHA) had relatively little effect on group differences, while covarying for impulsivity, as determined by the Barratt Impulsiveness Scale, rendered all previously noted voxel-level group differences non-significant. Diminished gray matter in the prefrontal cortex and the medial temporal cortex may mediate the dysregulation of impulse and affect in BPD. Group differences varied greatly by gender, levels of depression, and impulsivity. VBM is an efficient method for exploratory study of brain-behavior relationships.

Methylphenidate in the treatment of female adolescents with cooccurrence of attention deficit/hyperactivity disorder and borderline personality disorder: a preliminary open-label trial

Recent studies reported symptomatic overlap between attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD). Methylphenidate (MPH) is the most efficient treatment for ADHD. We assessed the efficacy and tolerability of MPH treatment in adolescent females who met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for both disorders. Fourteen BPD/ADHD female adolescents aged 14-19 years were treated with MPH for 12 weeks, targeting ADHD, BPD symptoms, and aggressive behavior, as rated by ADHD-rating scale (ADHD-RS) and Clinical Global Impression-Severity (CGI-S) scale for BPD and aggressive behavior severity. A significant improvement was detected in both ADHD and BPD severity (baseline vs. end point, ADHD-RS: 33.1+/-4.8 vs. 17.6+/-5.2, P<0.001; BPD CGI-S: 4.6+/-0.8 vs. 3.4+/-0.8, P<0.0005, respectively) as well as in aggressive behavior (Aggression CGI-S: 3.5+/-1.3 vs. 1.8+/-0.5, P<0.001). MPH was well tolerated. MPH may be useful and well tolerated in treating some shared symptoms of ADHD and BPD among female adolescents. Controlled studies are needed to substantiate these findings.

Neuropsychological and behavioural disinhibition in adult ADHD compared to borderline personality disorder

BACKGROUND

Although attention-deficit/hyperactivity disorder (ADHD) is thought to be an inhibitory disorder, the question remains of how specific the inhibitory deficit is in adults and whether it distinguishes ADHD from borderline personality disorder (BPD), with which it shares several clinical features, particularly impulsiveness.

METHOD

The study assessed various motor and cognitive inhibitory functions (inhibition of prepotent, ongoing and interfering responses) in addition to working memory in adult ADHD patients with and without BPD, compared to subjects with BPD alone and controls. In addition, questionnaire data on various aspects of impulsiveness and anger regulation were assessed in all groups.

RESULTS

ADHD patients performed worse than BPD individuals and controls in two inhibitory tasks: the stop signal task and the conflict module of the Attentional Network Task (ANT). In addition, they exhibited longer reaction times (RTs) and higher intra-individual variance in nearly all attentional tasks. The co-morbid group exhibited poor performance on the stop signal task but not on the conflict task. The BPD group barely differed from controls in neuropsychological performance but overlapped with ADHD in some behavioural problems, although they were less severe on the whole.

CONCLUSIONS

Impaired inhibition is a core feature in adults with ADHD. In addition, slow RTs and high intra-individual variance in performance may reflect deficits in the regulation of activation and effort in ADHD patients. ADHD and BPD share some symptoms of behavioural dysregulation without common cognitive deficits, at least in the attentional realm.

Atomoxetine improved response inhibition in adults with attention deficit/hyperactivity disorder

BACKGROUND

Atomoxetine, a highly selective noradrenaline reuptake inhibitor (SNRI), shows efficacy in the treatment of attention-deficit/hyperactivity disorder (ADHD). Compared with psychostimulants, atomoxetine has a distinct mode of brain action and potentially lower addictive potential. Studies have yet to assess whether atomoxetine improves cognition following a single oral dose in ADHD.

METHODS

Twenty-two adults with DSM-IV ADHD were administered a single oral dose of atomoxetine (60 mg) in a placebo-controlled double-blind crossover design. Cognitive effects were assessed using stop-signal, sustained attention, spatial working memory, and set-shifting paradigms. Normative cognitive data from 20 healthy volunteers were collected for comparison.

RESULTS

The ADHD patients under placebo conditions showed response inhibition and working memory deficits compared with healthy volunteers. Atomoxetine treatment in the ADHD patients was associated with shorter stop-signal reaction times and lower numbers of commission errors on the sustained attention task.

CONCLUSIONS

Atomoxetine improved inhibitory control, most likely via noradrenergically mediated augmentation of prefrontal cortex function. These results have implications for understanding the mechanisms by which atomoxetine exerts beneficial clinical effects and suggest novel treatment directions for other disorders of impulsivity.

Questionnaire ratings of attention-deficit/hyperactivity disorder (ADHD) in adults are associated with spatial working memory

OBJECTIVE

Data related to brain function may have the potential to improve the reliability and validity of assessments for the aetiologically and clinically heterogeneous syndrome of attention-deficit/hyperactivity disorder (ADHD). This study investigated associations between questionnaire assessments of behavioural features of adults with ADHD and an aspect of neurocognitive performance which has been reported to be impaired in adults with ADHD.

METHODS

Fifty-nine adult patients with a DSM-IV diagnosis of ADHD, and their informants, completed questionnaires related to aspects of severity of ADHD. Associations were examined between questionnaire ratings and performance on a computer-administered task of spatial working memory (SWM).

RESULTS

Correlations between ratings of ADHD and SWM indicated moderate but significant correlations for patients' ratings, but not for informants' ratings. Also, patients who reported a past history of 'self-harm' (N=33) had a significantly worse mean performance on both measures of SWM (p=0.004, 0.003).

CONCLUSIONS

The results indicate that aspects of impulsivity, i.e. self-ratings of 'emotive' behaviour (involving rapid response to stimuli and marked reactivity of mood) and of past 'self-harm', show relatively strong associations with SWM performance in adults selected on the basis of an ADHD diagnosis. A profile of neurocognitive performances may have a role in the assessment of ADHD.

Reconsidering the attention deficit paradigm

OBJECTIVE

To examine the inadequacies and criticisms of the current categorical paradigm of Attention Deficit Disorder both in children and adults.

CONCLUSIONS

An alternative, more dimensional paradigm linking executive functions is described and its advantage over categorical diagnostic paradigms is argued. Consideration of a more discriminating and dimensional behavioural model would help psychiatrists operating in this area.

Komorbidität der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Erwachsenenalter

Zusammenfassung: Der Verlauf der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung ist bereits in der Kindheit durch ein hohes Maß an komorbid auftretenden Störungen gekennzeichnet, was schon zu diesem Zeitpunkt hohe Anforderungen an den diagnostischen Prozess stellt. Betrachtet man die Symptomausprägung der ADHS im Erwachsenenalter, so sind hier einerseits vielfältige psychische Begleiterkrankungen zu verzeichnen, andererseits besteht eine hohe Symptomüberschneidung mit anderen Störungsbildern, wodurch eine eindeutige Diagnose häufig erschwert wird. Für die Diagnostik der ADHS im Erwachsenenalter ergibt sich demnach folgende Konsequenz: Außer den neuropsychologischen Beeinträchtigungen müssen Probleme auf der sozialen und Verhaltensebene erfasst werden, um eine möglichst valide Aussage über die individuelle Symptomausprägung und die differenzialdiagnostische Abgrenzung zu ermöglichen. Es wird ein Ausblick auf das neu entwickelte “Bremer ADHS-Screening für Erwachsene” (BAS-E) gegeben, mit dem die genannten Bereiche erfasst sowie retrospektiv ADHS-Symptome in der Kindheit abgefragt werden. Eine Zusatzskala ermöglicht die quantitative und qualitative (Selbstmedikation) Erfassung des Alkohol-, Drogen- und Medikamentenkonsums, was sowohl für den weiteren diagnostischen Prozess als auch für die Therapieplanung von Bedeutung ist.

Attention deficit hyperactivity disorder and borderline personality disorder

To evaluate the association between attention deficit hyperactivity disorder (ADHD) and the diagnosis of borderline personality disorder (BPD) in adulthood, a systematic review of published follow-up data, mainly from observational studies was done. Electronic databases Medline, PsychInfo and PSYNDEXplus were searched from their earliest entries. All studies suggested significant relationships between ADHD and BPD. From a phenomenological point of view there seem to exist some similarities between these two disorders: deficits in affect regulation and impulse control, substance abuse, low self esteem and disturbed interpersonal relationship are common in both conditions. From a neuropsychological point of view dissociation in BPD might be regarded as a special form of behavioral inhibition and sustained attention comparable to ADHD. Possible therapeutic strategies of comorbid ADHD and BPD are discussed.