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Personality and Individual Differences 45 (2008) 468–472

Personality and Individual Differences 45 (2008) 468–472 Contents lists available at <a href=ScienceDirect Personality and Individual Differences journal homepage: www.else vier.com/locate/paid Psychopathic traits in adult ADHD patients H. Eisenbarth , G.W. Alpers * , A. Conzelmann , C.P. Jacob , P. Weyers , P. Pauli Department of Psychology, University of Würzburg, Marcusstrasse 9-11, D-97070 Würzburg, Germany Department of Psychiatry, University of Würzburg, Germany article info Article history: Received 7 December 2007 Received in revised form 21 May 2008 Accepted 30 May 2008 Available online 22 July 2008 Keywords: Adult attention deficit and hyperactivity disorder (ADHD) Psychopathy (PPI-R) abstract Previous studies have shown that the prevalence of attention deficit and hyperactivity disorder (ADHD) is elevated in prison inmates and in forensic patients with psychopathic traits. However, it is not clear whether ADHD and psychopathy scores also correlate in adult non-incarcerated samples. Moreover, it has not been examined if this correlation is due to specific facets of psychopathy. We assessed psychop- athy in 30 adult ADHD patients and in 41 healthy participants using the psychopathic personality inven- tory revised (PPI-R). Male ADHD patients had higher scores compared to healthy male and female participants on the subscales blame externalization, rebellious nonconformity, and carefree nonplanful- ness. Irrespective of gender, ADHD patients had lower scores compared to healthy participants on stress immunity and coldheartedness. These data specify the previously documented correlation between ADHD and psychopathy, and suggest that only the behavioral features of psychopathy are affected in ADHD whereas, the emotional features are not. 2008 Elsevier Ltd. All rights reserved. 1. Introduction Psychopathy has frequently been associated with attention def- icit hyperactivity disorder (ADHD) because some of their symp- toms overlap. Both, patients with ADHD and individuals who score high on psychopathy, often show drug abuse, antisocial behavior, unstructured lifestyle, or sensation-seeking. There are also similarities in the neurobiological system, which have been implicated to underlie both ADHD and psychopathic tendencies. ADHD, which is characterized by inattention and hyperactivity or impulsivity, is manifested in childhood and symptoms persist into adulthood in approximately 30–60% of the children with ADHD, although symptom severity tends to decrease ( Biederman, Mick, & Faraone, 2000; Torgersen, Gjervan, & Rasmussen, 2006 ). Aside from the symptoms that are comparable to those of child- hood ADHD, adult patients with ADHD tend to show impaired aca- demic achievement, difficulties in employment, and criminality. In addition, the comorbidity of antisocial personality disorder and substance abuse, or dependency are elevated. Some of these symp- toms are similar to those of individuals who score high on psy- chopathy. Psychopathy, first described by Cleckley (1964) , is usually not considered to be a diagnostic category or disorder but rather a dimensional personality trait ( Edens, Marcus, Lilien- feld, & Poythress, 2006 ). Accordingly, psychopathic traits in the normal population signify the degree of interpersonal and emo- tional impairments as well as a devil-may-care lifestyle, and manipulative behavior. * Corresponding author. Tel.: +49 931 312840; fax: +49 931 312733. E-mail address: alpers@psychologie.uni-wuerzburg.de (G.W. Alpers). 0191-8869/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2008.05.022 Descriptively, individuals scoring high on psychopathy and pa- tients with ADHD share several symptoms that may be traced back to similar neuronal dysfunctions. In their observable behavior, both show impulsive actions, leading to interpersonal problems, delinquent behavior, substance abuse or living-in-the-fast-lane. Colledge and Blair (2001) suggested that overlapping character- istics of psychopathy and ADHD have to be considered as common risk factors for different aspects of the disturbances. Whereas, the dysfunction in the alerting system and the resulting inattention seem to be independent of delinquent behavior, the dysfunction in executive control and in violence inhibition are both related to conduct problems. Furthermore, the problems in executive control are linked with impulsivity. On this background, the lack in vio- lence inhibition is strongly related to callous and unemotional traits in psychopathy. However, in both cases the causality of the link is unclear. These developmental pathways could be the basis of two phenotypes, an inattentive one and an impulsive one asso- ciated with conduct disorders ( Colledge & Blair, 2001 ). The rela- tionship between psychopathy and ADHD has been the subject of a number of descriptive studies. One line of research examined children or adolescents with ADHD and matched control partici- pants. From this perspective ADHD is strongly related to psycho- pathic traits, especially to callous unemotional traits and impulsivity ( Barry et al., 2000; Colledge & Blair, 2001; Loeber et al., 2001; Frick, Bodin, & Barry, 2000 ). The very recent study by Mathias and colleagues ( Mathias et al., 2007 ) is concerned with the differential aspects of the relation between ADHD and psy- chopathy. The authors found that the impulsivity component of psychopathy is mainly related to the hyperactivity component of ADHD, whereas the narcissistic and unemotional traits were " id="pdf-obj-0-5" src="pdf-obj-0-5.jpg">

Contents lists available at ScienceDirect

Personality and Individual Differences

journal homepage: www.else vier.com/locate/paid

Personality and Individual Differences 45 (2008) 468–472 Contents lists available at <a href=ScienceDirect Personality and Individual Differences journal homepage: www.else vier.com/locate/paid Psychopathic traits in adult ADHD patients H. Eisenbarth , G.W. Alpers * , A. Conzelmann , C.P. Jacob , P. Weyers , P. Pauli Department of Psychology, University of Würzburg, Marcusstrasse 9-11, D-97070 Würzburg, Germany Department of Psychiatry, University of Würzburg, Germany article info Article history: Received 7 December 2007 Received in revised form 21 May 2008 Accepted 30 May 2008 Available online 22 July 2008 Keywords: Adult attention deficit and hyperactivity disorder (ADHD) Psychopathy (PPI-R) abstract Previous studies have shown that the prevalence of attention deficit and hyperactivity disorder (ADHD) is elevated in prison inmates and in forensic patients with psychopathic traits. However, it is not clear whether ADHD and psychopathy scores also correlate in adult non-incarcerated samples. Moreover, it has not been examined if this correlation is due to specific facets of psychopathy. We assessed psychop- athy in 30 adult ADHD patients and in 41 healthy participants using the psychopathic personality inven- tory revised (PPI-R). Male ADHD patients had higher scores compared to healthy male and female participants on the subscales blame externalization, rebellious nonconformity, and carefree nonplanful- ness. Irrespective of gender, ADHD patients had lower scores compared to healthy participants on stress immunity and coldheartedness. These data specify the previously documented correlation between ADHD and psychopathy, and suggest that only the behavioral features of psychopathy are affected in ADHD whereas, the emotional features are not. 2008 Elsevier Ltd. All rights reserved. 1. Introduction Psychopathy has frequently been associated with attention def- icit hyperactivity disorder (ADHD) because some of their symp- toms overlap. Both, patients with ADHD and individuals who score high on psychopathy, often show drug abuse, antisocial behavior, unstructured lifestyle, or sensation-seeking. There are also similarities in the neurobiological system, which have been implicated to underlie both ADHD and psychopathic tendencies. ADHD, which is characterized by inattention and hyperactivity or impulsivity, is manifested in childhood and symptoms persist into adulthood in approximately 30–60% of the children with ADHD, although symptom severity tends to decrease ( Biederman, Mick, & Faraone, 2000; Torgersen, Gjervan, & Rasmussen, 2006 ). Aside from the symptoms that are comparable to those of child- hood ADHD, adult patients with ADHD tend to show impaired aca- demic achievement, difficulties in employment, and criminality. In addition, the comorbidity of antisocial personality disorder and substance abuse, or dependency are elevated. Some of these symp- toms are similar to those of individuals who score high on psy- chopathy. Psychopathy, first described by Cleckley (1964) , is usually not considered to be a diagnostic category or disorder but rather a dimensional personality trait ( Edens, Marcus, Lilien- feld, & Poythress, 2006 ). Accordingly, psychopathic traits in the normal population signify the degree of interpersonal and emo- tional impairments as well as a devil-may-care lifestyle, and manipulative behavior. * Corresponding author. Tel.: +49 931 312840; fax: +49 931 312733. E-mail address: alpers@psychologie.uni-wuerzburg.de (G.W. Alpers). 0191-8869/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2008.05.022 Descriptively, individuals scoring high on psychopathy and pa- tients with ADHD share several symptoms that may be traced back to similar neuronal dysfunctions. In their observable behavior, both show impulsive actions, leading to interpersonal problems, delinquent behavior, substance abuse or living-in-the-fast-lane. Colledge and Blair (2001) suggested that overlapping character- istics of psychopathy and ADHD have to be considered as common risk factors for different aspects of the disturbances. Whereas, the dysfunction in the alerting system and the resulting inattention seem to be independent of delinquent behavior, the dysfunction in executive control and in violence inhibition are both related to conduct problems. Furthermore, the problems in executive control are linked with impulsivity. On this background, the lack in vio- lence inhibition is strongly related to callous and unemotional traits in psychopathy. However, in both cases the causality of the link is unclear. These developmental pathways could be the basis of two phenotypes, an inattentive one and an impulsive one asso- ciated with conduct disorders ( Colledge & Blair, 2001 ). The rela- tionship between psychopathy and ADHD has been the subject of a number of descriptive studies. One line of research examined children or adolescents with ADHD and matched control partici- pants. From this perspective ADHD is strongly related to psycho- pathic traits, especially to callous unemotional traits and impulsivity ( Barry et al., 2000; Colledge & Blair, 2001; Loeber et al., 2001; Frick, Bodin, & Barry, 2000 ). The very recent study by Mathias and colleagues ( Mathias et al., 2007 ) is concerned with the differential aspects of the relation between ADHD and psy- chopathy. The authors found that the impulsivity component of psychopathy is mainly related to the hyperactivity component of ADHD, whereas the narcissistic and unemotional traits were " id="pdf-obj-0-16" src="pdf-obj-0-16.jpg">

Psychopathic traits in adult ADHD patients

H. Eisenbarth a , G.W. Alpers a, * , A. Conzelmann a , C.P. Jacob b , P. Weyers a , P. Pauli a

a Department of Psychology, University of Würzburg, Marcusstrasse 9-11, D-97070 Würzburg, Germany b Department of Psychiatry, University of Würzburg, Germany

article info

Article history:

Received 7 December 2007 Received in revised form 21 May 2008 Accepted 30 May 2008 Available online 22 July 2008

Keywords:

Adult attention deficit and hyperactivity

disorder (ADHD)

Psychopathy (PPI-R)

abstract

Previous studies have shown that the prevalence of attention deficit and hyperactivity disorder (ADHD) is elevated in prison inmates and in forensic patients with psychopathic traits. However, it is not clear whether ADHD and psychopathy scores also correlate in adult non-incarcerated samples. Moreover, it has not been examined if this correlation is due to specific facets of psychopathy. We assessed psychop- athy in 30 adult ADHD patients and in 41 healthy participants using the psychopathic personality inven-

tory revised (PPI-R). Male ADHD patients had higher scores compared to healthy male and female participants on the subscales blame externalization, rebellious nonconformity, and carefree nonplanful- ness. Irrespective of gender, ADHD patients had lower scores compared to healthy participants on stress immunity and coldheartedness. These data specify the previously documented correlation between ADHD and psychopathy, and suggest that only the behavioral features of psychopathy are affected in ADHD whereas, the emotional features are not.

2008 Elsevier Ltd. All rights reserved.

1. Introduction

Psychopathy has frequently been associated with attention def- icit hyperactivity disorder (ADHD) because some of their symp- toms overlap. Both, patients with ADHD and individuals who score high on psychopathy, often show drug abuse, antisocial behavior, unstructured lifestyle, or sensation-seeking. There are also similarities in the neurobiological system, which have been implicated to underlie both ADHD and psychopathic tendencies. ADHD, which is characterized by inattention and hyperactivity or impulsivity, is manifested in childhood and symptoms persist into adulthood in approximately 30–60% of the children with ADHD, although symptom severity tends to decrease (Biederman, Mick, & Faraone, 2000; Torgersen, Gjervan, & Rasmussen, 2006). Aside from the symptoms that are comparable to those of child- hood ADHD, adult patients with ADHD tend to show impaired aca- demic achievement, difficulties in employment, and criminality. In addition, the comorbidity of antisocial personality disorder and substance abuse, or dependency are elevated. Some of these symp- toms are similar to those of individuals who score high on psy- chopathy. Psychopathy, first described by Cleckley (1964), is usually not considered to be a diagnostic category or disorder but rather a dimensional personality trait (Edens, Marcus, Lilien- feld, & Poythress, 2006). Accordingly, psychopathic traits in the normal population signify the degree of interpersonal and emo- tional impairments as well as a devil-may-care lifestyle, and manipulative behavior.

* Corresponding author. Tel.: +49 931 312840; fax: +49 931 312733. E-mail address: alpers@psychologie.uni-wuerzburg.de (G.W. Alpers).

0191-8869/$ - see front matter 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.paid.2008.05.022

Descriptively, individuals scoring high on psychopathy and pa- tients with ADHD share several symptoms that may be traced back to similar neuronal dysfunctions. In their observable behavior, both show impulsive actions, leading to interpersonal problems, delinquent behavior, substance abuse or living-in-the-fast-lane. Colledge and Blair (2001) suggested that overlapping character- istics of psychopathy and ADHD have to be considered as common risk factors for different aspects of the disturbances. Whereas, the dysfunction in the alerting system and the resulting inattention seem to be independent of delinquent behavior, the dysfunction in executive control and in violence inhibition are both related to conduct problems. Furthermore, the problems in executive control are linked with impulsivity. On this background, the lack in vio- lence inhibition is strongly related to callous and unemotional traits in psychopathy. However, in both cases the causality of the link is unclear. These developmental pathways could be the basis of two phenotypes, an inattentive one and an impulsive one asso- ciated with conduct disorders (Colledge & Blair, 2001). The rela- tionship between psychopathy and ADHD has been the subject of a number of descriptive studies. One line of research examined children or adolescents with ADHD and matched control partici- pants. From this perspective ADHD is strongly related to psycho- pathic traits, especially to callous unemotional traits and impulsivity (Barry et al., 2000; Colledge & Blair, 2001; Loeber et al., 2001; Frick, Bodin, & Barry, 2000). The very recent study by Mathias and colleagues (Mathias et al., 2007) is concerned with the differential aspects of the relation between ADHD and psy- chopathy. The authors found that the impulsivity component of psychopathy is mainly related to the hyperactivity component of ADHD, whereas the narcissistic and unemotional traits were

H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468–472

469

marginally related to the inattentive component of ADHD. In accor- dance with the model of Colledge and Blair (2001), these results point to a common underlying mechanism for the conduct prob- lems in psychopathy and ADHD. Another line of research studied the prevalence of ADHD and psychopathy in high-risk adult popu- lations. Torgersen et al. (2006) found an elevated percentage of

2. Method

inattentive type diagnosis. Two patients and one control group participant received antidepressants, four patients received ADHD-medication, four patients received psychotherapy for Axis-I-disorders, one for ADHD. One patient had a diagnosis of an antisocial personality disorder but none of the control participants.

antisocial personality disorder (ASPD, 44%) in an adult ADHD sam- ple as compared to a general population (3–5%). Similarly, Roesler

  • 2.2. Material

et al. (2004) found an elevated percentage of adult ADHD in prison populations (45%). To our knowledge the research concerning the specific person- ality trait psychopathy and ADHD in adults is limited to prison samples. It documents correlations between ADHD and the behav- ioral as well as lifestyle features of psychopathy (Soderstrom, Nils- son, Sjodin, Carlstedt, & Forsman, 2005), a high predictive value of self-reported childhood ADHD for conduct disorder and psychopa- thy (Abramowitz, Kosson, & Seidenberg, 2004), as well as a high predictive value of impulsivity for psychopathy in adolescent in- mates in a longitudinal study (Vitacco & Rogers, 2001). Studies including non-incarcerated populations are limited to children or adolescent samples and, so far, there are no studies on adult ADHD patients. In addition, the existing literature on adult inmates is lim- ited to male participants, which represents the prevalence of high psychopathy scores and criminal behavior. Although lower scores on the scales for psychopathy can be expected in women than in men (see Warren et al., 2003). It seems necessary to examine the correlation on the whole spectrum and extend our knowledge on psychopathy in women (see Eisenbarth, Alpers, Segrè, Calogero, &

All participants completed the psychopathic personality inven- tory revised (PPI-R, German version; Eisenbarth & Alpers, 2007; Al- pers & Eisenbarth, 2008), which is a self-report measure of psychopathy (Lilienfeld & Andrews, 1996). The questionnaire con- sists of 154 items that can be assigned to eight subscales and one virtual responding scale. The subscales are blame externalization, rebellious nonconformity, coldheartedness, social influence, care- free nonplanfulness, fearlessness, machiavellistic egocentricity, and stress immunity. This version has been validated in students and in incarcerated samples revealing a good internal consistency of r a = .85 (Alpers & Eisenbarth, 2008). Convergent validity has been shown on the basis of the kieler psychopathie inventar (KPI-R, Koehler, Hinrichs, & Huchzermeier, in preparation) and on the basis of the German version of the interpersonal relationship inventory (SPF, Paulus, 2000). In addition, patients answered 18 Likert-scaled questions (four steps) for each criterion of DSM-IV. Sum scores were calculated for inattention and for hyperactivity, and used as continuous mea- sures of symptom severity.

Angrilli, 2008). In sum, the aim of the present study was to investigate psycho-

  • 2.3. Statistical analyses

pathic traits in adult female and male ADHD patients compared to a matched healthy control group. We expected that ADHD patients show higher scores of psychopathy, especially the male patients. Furthermore, we expected to find differences on those subscales of a self-report questionnaire, which reflect specific impairments of ADHD patients. We expected that psychopathy and ADHD are both characterized by unstructured lifestyle and antisocial behav- ior (corresponding to Hare’s lifestyle factor, Hare, 2003) but, that ADHD patients do not express callous unemotional traits.

All analyses were done with SPSS 14 (SPSS Inc., Chicago). We conducted analyses of variance for group differences as well as a linear regression analysis with the subscales of the PPI-R and the total score of the PPI-R as predictors and group (patients vs. healthy control group) as criterion. Post-hoc tests were Bonferroni corrected. For a correlational analysis of sum scores of DSM-IV symptom related items and scores on the subscales of the PPI-R as well as the PPI-R total score, Pearson’s correlation coefficients were computed. Logistic regression analyses with a stepwise inclusion of predic-

3. Results

2.1. Sample

tors were conducted for all of the subscales and for the total score separately to predict group affiliation (patients vs. healthy

Participants were recruited for an experimental study on ADHD. Exclusion criteria were age below 18 or above 60, severe somatic disorders or hearing problems, and any lifetime or current psychi-

participants).

atric diagnosis in the healthy participants. Participants gave writ- ten informed consent and were paid 10 Euro for participation.

  • 3.1. Group differences

All participants were assessed with the structural clinical inter- view of DSM-IV (SCID-I and SCID-II for axis I and II psychiatric dis- orders, First, Gibbon, Spitzer, Williams, & Benjam, 1996, 1997). ADHD was diagnosed by DSM-IV criteria (American Psychiatric Association, 1994) with adjustment to adult symptomatology (Weiss, Hechtman, & Weiss, 1999) and by the Wender Utah Rating Scale (WURS, Ward, Wender, & Reimherr, 1993) for symptoms dur- ing childhood. A sub-sample of 28 adult ADHD patients, 16 females, and 12 males (M = 35.15 ± 8.50, range = 18–50 years) and 41 healthy par- ticipants, 21 females, and 20 males (M = 37.71 ± 10.14, range = 19–56 years) participated in this study. The groups were matched for age (t = 1.08, p = .28), gender and education (56% high school, 44% higher education). Eighteen of the patients had a combined type diagnosis, four patients had a predominantly hyperactive- impulsive type diagnosis and six patients had a predominantly

The multivariate ANOVA revealed significant main effects for group (patients vs. healthy participants) and for gender. Between ADHD patients and healthy participants there was no difference in the total score (F (1,67) = 2.14, p = .15). Patients had higher scores than healthy participants in blame externalization (F (1,67) = 4.82, p = .03), rebellious nonconformity (F (1,67) = 18.72, p < .001), and carefree nonplanfulness (F (1,67) = 18.68, p < .001) but lower scores for stress immunity (F (1,67) = 21.43, p < .001) (see Table 1). Differ- ences between male and female participants were found in terms of higher scores for male participants in the total score (F (1,67) = 10.97, p = .001) and the subscales blame externalization (F (1,67) = 4.45, p = .04), rebellious nonconformity (F (1,67) = 10.34, p = .01), machiavellistic egocentricity (F (1,67) = 8.36, p = .01), carefree non- planfulness (F (1,67) = 5.16, p = .03) as well as fearlessness (F (1,67) = 12.54, p = .001).

  • 470 H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468–472

Table 1

Means and standard deviations of ADHD patients and healthy participants on PPI-R

scales

 

Patients (N = 28)

Healthy participants (N = 41)

Blame externalization

33.05 ± 9.35

29.46 ± 9.35

Rebellious nonconformity

58.91 ± 16.53

48.01 ± 10.15

Stress immunity

47.63 ± 7.78

55.98 ± 6.61

Social influence

42.74 ± 8.56

43.54 ± 6.32

Coldheartedness

35.69 ± 4.24

38.43 ± 5.39

Machiavellistic egoism

31.16 ± 4.96

30.85 ± 4.32

Carefree nonplanfulness

31.17 ± 5.91

26.66 ± 3.71

Fearlessness

16.10 ± 7.03

16.30 ± 4.61

Total score

318.92 ± 41.00

313.93 ± 24.51

Interactions between diagnostic group and gender were found for the total score (F (1,67) = 9.15, p = .01) and for the subscales blame externalization (F (1,67) = 3.96, p = .05), rebellious nonconfor- mity (F (1,67) = 6.46, p = .01), machiavellistic egocentricity (F (1,67) = 6.75, p = .01), and fearlessness (F (1,67) = 3.65, p = .06). Inter- actions are due to higher scores in male patients on the total score, blame externalization, rebellious nonconformity, machiavellistic egocentricity, and fearlessness, as well as lower scores of both male and female patients on stress immunity. This shows that the group differences between patients and healthy participants mainly arise from differences between male patients and male healthy partici- pants (see Fig. 1). Bonferroni corrected analyses were done separately for male and female participants. Male patients have significantly higher scores than healthy men on blame externalization (F (1,37) = 4.96, p = .03), rebellious nonconformity (F (1,31) = 21.50, p < .001), carefree nonplanfulness (F (1,31) = 10.81, p = .01), and on the total score (F (1,37) = 7.15, p = .01), as well as lower scores on stress immunity (F (1,31) = 9.37, p = .01). Female patients only have lower scores in stress immunity (F (1,37) = 13.46, p = .001) as well as higher scores on coldheartedness (F (1,37) = 6.46, p = .02) and carefree nonplanful- ness (F (1,37) = 7.10, p = .01) compared to healthy female participants.

3.2. Correlational analyses

Considering the correlations for male and female participants separately reveals a significant correlation between symptom

470 H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468–472 Table 1 Means

Fig. 1. Means and standard deviations of mean raw scores of male and female ADHD patients and healthy participants on the subscales of the PPI-R (Significant differences between all four groups: *** p 6 .001, ** p 6 .05, * p 6 .10).

severity and blame externalization only in male participants (inat- tention: r = .50, p = .003; hyperactivity: r = .54, p = .001), whereas the correlation with carefree nonplanfulness is significant in fe- male participants (inattention: r = .63, p < .001; hyperactivity:

r = .55, p = .001). The correlation with stress immunity does not dif- fer for male and female participants. In male participants we also found significant correlations for machiavellistic egoism and ADHD symptom severity (inattention: r = .55, p = .001; hyperactivity:

r = .45, p = .01).

  • 3.3. Classification

Logistic regression analysis reveals that the PPI subscales can predict group affiliation correctly for 93% of the subjects (v 2 (8,N = 70) = 62.19, p < .001). Involving only the subscales that con- tribute significantly, i.e., rebellious nonconformity (b = .23, p = .004), stress immunity (b = .32, p = .004), machiavellistic ego- centricity (b = .68, p = .01), and carefree nonplanfulness (b = .39, p = .004), the percentage of correct classification of participants as patients or healthy participants is reduced to 90% (v 2 (4,N = 70) = 60.69, p < .001). Using only the total score as a predictor it further reduces the percentage of correctly classified participants to 64% (v 2 (1, N = 70) = 0.64, p = .42).

4. Discussion

Psychopathy and ADHD share several symptoms, and previous research has shown that the diagnoses are often comorbid in incar- cerated populations. A recent model, which was based on data from adolescents, suggests that the relationship may be specific to those features of ADHD, which are related to conduct disorder (Colledge & Blair, 2001; Mathias et al., 2007). This study is the first to examine the specific facets of psychopathy in adult ADHD pa- tients. In addition, we examined the influence of gender differences on this relationship. Dimensions of trait psychopathy were measured in adult ADHD patients and matched to healthy participants with the psychopathic personality inventory revised (PPI-R, German ver- sion, Eisenbarth & Alpers, 2007; Alpers & Eisenbarth, 2008). Total scores of psychopathy were higher only in male ADHD patients. As predicted by Colledge and Blair (2001), our adult ADHD pa- tients had psychopathic traits related to conduct problems but they were inconspicuous with respect to the emotional aspects of psychopathy. According to the model of Colledge and Blair (2001), the prob- lems in executive control that correspond to impulsivity and to a lack of violence inhibition, are present in both psychopathy and ADHD. While, in psychopathy anterior cingulate and amygdala dysfunctions could result in callous and unemotional traits, in ADHD right frontal lobe dysfunction could be the basis for the inat- tentive ADHD type (Colledge & Blair, 2001). The assumption that psychopathic traits can be differentiated from ADHD by its higher callous unemotional traits, whereas ADHD, at least the inattentive and the mixed subtype can be differentiated from psychopathic traits by the deficits in attention, agrees with our data.

  • 4.1. Gender differences

The gender specific results show that the PPI-R total score is higher in male ADHS patients compared with male healthy partic- ipants, whereas female patients do not show higher total scores than healthy women. Overall, male patients have substantially higher scores than female ADHD patients. Lower scores are typical for women in the general population (Benning, Patrick, Blonigen, Hicks, & lacono, 2005; Eisenbarth et al., 2008). This finding was fur- ther confirmed in our correlational analyses, and is a relatively new

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471

contribution because the overlap of ADHD and psychopathy was typically examined in samples of incarcerated males. On a different conceptual level, our findings are in line with pre- vious research, which found that male adult ADHD patients more often show antisocial and externalizing behavior compared to fe- male patients (e.g., Washburn et al., 2007). Although, the lowered risk for externalizing behavior in women could be an explanation for the low psychopathy scores of our female patients, there are also studies that did not find gender differences in psychopathy (Loney, Taylor, Butler, & Iacono, 2007). However, female ADHD seems not to correspond to psychopathic traits in the same way as male ADHD does in terms of less psychopathic features com- pared to the male patients.

  • 4.2. Facets of psychopathy

The differences with respect to subscale scores point to a spe- cific increase in behavioral aspects such as impulsivity, living in the fast lane or antisocial behavior (corresponding to Hare’s life- style factor, Hare, 2003), whereas other psychopathic features like coldheartedness or manipulating behavior do not discriminate ADHD patients from healthy participants. This corresponds with recent data published by Mathias and colleagues (Mathias et al., 2007) who studied the relationship of ADHD and psychopathic traits in adolescents with conduct disorder. Together, these data provide convincing evidence for the model of Colledge and Blair (2001), who suggested that psy- chopathy and ADHD share impulsivity and antisocial features but not the emotion processing deficit which is typical for psy- chopathy. Because the latter symptoms have been linked to amygdala dysfunction, this corresponds with the finding that this structure is not characteristically implicated in ADHD (Giedd, Blumenthal, Molloy, & Castellanos, 2001; Seidman, Val- era, & Makris, 2005). Previous data from younger populations and our data taken to- gether, suggest that ADHD in childhood and adolescence may lead to more impulsiveness (Mathias et al., 2007; Frick et al., 2000) and thus to more antisocial behavior even in adulthood. The link be- tween impulsivity and antisocial behavior seems to be a phenom- enon, which is present in men but not in women. Whether ADHD actually originates earlier and causes secondary psychopathy, as suggested by Lykken (1995) and Newman, MacCoon, Vaughn, and Sadeh (2005), needs to be examined in prospective studies. Our data suggests that even in male ADHD patients this is not a one to one relationship. Instead, our adult male patients did not show the complete syndrome of psychopathy but merely reported higher degrees of some psychopathic traits like nonplanfulness, rebellious nonconformity, fearlessness, and blame externalization, and therefore only include lifestyle but not callous unemotional features. These former dimensions closely correspond with the diagnostic criteria of ADHD.

  • 4.3. Strengths and limitations

Although our sample of ADHD patients was large enough for the global analyses, it was adequately characterized by an expe- rienced clinician’s assessment, and psychopathy was assessed with a reliable instrument, our findings clearly need to be repli- cated in larger samples. It would be most informative if future studies also included psychophysiological markers of psychopa- thy to indicate their reactivity to distress cues (for an overview see Blair, 2001) or impaired aversive conditioning (Birbaumer et al., 2005; Flor, Birbaumer, Hermann, Ziegler, & Patrick, 2002). More patients are needed for a comprehensive subtype analysis, which should further be informed by psychometric de- tails on ADHD.

Taken together, this study adds an interesting perspective to the discussion on ADHD and its relationship to psychopathy. We found specific relationships of these constructs for male ADHD patients, suggesting that Colledge and Blair’s model should be specified for gender aspects. Furthermore, our data could point to a better understanding of the prevalent delinquency in ADHD patients (Roesler et al., 2004). Although these patients seem to share char- acteristics with psychopaths, they do not show the callous unemo- tional and manipulative traits of psychopathy. A common underlying mechanism of conduct problems in both, ADHD pa- tients and high psychopathic individuals, as suggested by Colledge and Blair (2001), is very plausible.

Acknowledgements

The recruitment of participants was part of a grant by the Ger- man research foundation (DFG). We thank K.-P. Lesch, M.D., and his team as well as R. Mucha, Ph.D., for their support. The first author was supported by the Konrad-Adenauer-Stiftung.

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