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Curr Psychiatry Rep (2016) 18: 33

DOI 10.1007/s11920-016-0675-4

PERSONALITY DISORDERS (C SCHMAHL, SECTION EDITOR)

Comorbidity of Personality Disorders and Adult Attention Deficit


Hyperactivity Disorder (ADHD)—Review of Recent Findings
Swantje Matthies 1 & Alexandra Philipsen 2,3

Published online: 18 February 2016


# Springer Science+Business Media New York 2016

Abstract Children suffering from attention deficit hyper- high impact of personality disorders on daily functioning, it is
activity disorder (ADHD) may remit until adulthood. But, important to take them into account when treating patients
more than 60–80 % have persisting ADHD symptoms. with ADHD. Research on the developmental trajectories lead-
ADHD as an early manifesting neurodevelopmental disor- ing to personality disorders in adult ADHD patients might
der is considered a major risk factor for the development of open the door for targeted interventions to prevent impairing
comorbid psychiatric disorders in later life. Particularly, comorbid clinical pictures.
personality disorders are oftentimes observed in adult patients
suffering from ADHD. If ADHD and personality disorders Keywords ADHD . Comorbidity . Personality disorders .
share common etiological mechanisms and/or if ADHD as a Neurodevelopmental disorders
severely impairing condition influences psychological func-
tioning and learning and leads to unfavorable learning histo-
ries is unclear. The development of inflexible and dysfunc- Introduction
tional beliefs on the basis of real and perceived impairments
or otherness due to the core symptoms of ADHD is intuitively Prospective studies in the past have shown an association of
plausible. Such beliefs are a known cause for the development ADHD diagnoses in childhood and the later development of
of personality disorders. But, why some personality disorders personality disorders in adulthood [1•]. Retrospective studies
are more frequently found in ADHD patients as for example in adults with ADHD in recent years confirm these findings
antisocial and borderline personality disorder remains subject even if these studies are problematic because the assessment
of debate. Because of the high prevalence of ADHD and the of ADHD symptoms in childhood is retrospective in nature
and therefore of limited accuracy. Nevertheless, these studies
point to the importance of having in mind these comorbidities
This article is part of the Topical Collection on Personality Disorders
when diagnosing ADHD and planning therapeutic steps.
* Swantje Matthies
Percentages of personality disorder diagnoses in adult
swantje.matthies@uniklinik-freiburg.de ADHD patients range from 10 to 75 % depending on sample
characteristics [2–5, 6•]. Especially personality disorders from
Alexandra Philipsen cluster B and to a lesser extent cluster C have frequently been
Alexandra.Philipsen@uni-oldenburg.de found in ADHD populations [1•, 2, 5, 6•, 7–10]. The literature
concerning the most prominent association of ADHD with
1
Department of Psychiatry & Psychotherapy, University Medical
antisocial and borderline personality disorder has been reca-
Centre Freiburg, Hauptstr. 5, D-79104 Freiburg, Germany pitulated in the articles published by Storebo and Simonsen,
2
Medical Campus University of Oldenburg, School of Medicine and
and Matthies and Philipsen [6•, 11•].
Health Sciences, D-26111 Oldenburg, Germany Until 2012 prospective studies following children suffering
3
Psychiatry and Psychotherapy – University Hospital,
from ADHD into adulthood had not been extended beyond
Karl-Jaspers-Klinik, Hermann-Ehlers-Straße 7, D-26160 Bad early adulthood. Then, Klein et al. [12•] presented data from a
Zwischenahn, Germany 33-year follow-up study in which they re-assessed the original
33 Page 2 of 7 Curr Psychiatry Rep (2016) 18: 33

sample at mean age 41. They compared 135 males with ADHD AND (PD OR (personality disorder)*). The search included
in childhood and without conduct disorder at mean age of all fields in PubMed, Embase, Medline, and PsychInfo data-
8 years with 136 males without childhood ADHD (65 and bases and abstract, title, and keywords in the Central bibliog-
76 % of the original sample). Almost a fifth of the investigated raphy (number of hits: PubMed 3579, Embase
ADHD sample had ongoing antisocial personality disorder (ScienceDirect): 11611, Medline (ME95) see PubMed,
(vs. no case of antisocial personality disorder in the comparison Psychinfo 921, Central (The Cochrane Central Register of
sample). In the subsample which had developed conduct Controlled Trials) 49, NCBI Web site 13). Studies were
disorder at some point during adolescence even more, almost screened and categorized in the following categories: research
a quarter of patients were diagnosed with antisocial personality on genetic links, personality, and temperament characteristics,
disorder at follow-up. Unfortunately, data on other personality environmental variables such as parenting style and personal-
disorders have not been reported in this study. Klein et al. [12•] ity disorders in the context of neurodevelopmental disorders.
5-HTT) were compared in children with ADHD and for new
psychopathology during the life-time course of ADHD is Prevalence
highest in adolescence and persisted then into adulthood. This
is in line with the concept of Bdevelopmental comorbidity^ Both conditions, ADHD and personality disorders, are fre-
mentioned by Taurines et al. [13]. According to their concept, quent mental disorders. Adult ADHD affects an estimated
specific comorbidity patterns are found during the life-time 3.4 % of the adult population [16, 17]. The prevalence of
course of ADHD, and the majority of comorbid conditions personality disorders has been estimated between 4.4 and
begin in adolescence and early adulthood [13]. This corre- 21.5 % [18]. In samples of adult ADHD patients, personality
sponds to the traditionally conceptualized onset of personality disorders have been found in 10 to 75 % of the investigated
disorders in adolescence. Emergent personality disorders in cases [2–5, 6•]. ADHD was associated with a significantly
adolescence are relatively rarely studied. Recently, a sample increased risk of personality disorders with a hazard ratio of
of 85 adolescents suffering from borderline personality disorder 5.80 in a large longitudinal population-based study [19].
was investigated by Speranza et al. [14]. Eleven percent of their Fossati et al. [20] studied childhood ADHD in adult patients
sample had an ADHD diagnosis. with personality disorders and found ADHD diagnoses in
The comorbid association between ADHD and personality 10.5 % of patients with personality disorders from clusters A
disorders seems rather uncontroversial in the literature, but the and C, in 10.6 % of patients with any personality disorder
mechanisms responsible for the development of different per- from cluster B, but in 59.5 % of the investigated borderline
sonality disorders in individuals with ADHD are subject of patients. Later on, the strong comorbid association of ADHD
debate and object of the latest publications in this field. and borderline personality disorder has been confirmed by
Different developmental trajectories particularly with regard Philipsen et al. [21], who reported a high prevalence of
to the association between ADHD and borderline personality ADHD in childhood (41.5 %) and adulthood (16.1 %) in
disorder have been hypothesized [15]. The broader concept of women with borderline personality disorder.
neurodevelopmental disorders including ADHD and autism
spectrum disorders has become an interesting field of discus- Genetic Links
sion with regard to possible links to the later development of
personality disorders. Multifaceted mechanisms seem to play Based on some phenotypic similarities and the comorbid as-
a role in the association between ADHD and personality dis- sociation between ADHD and personality characteristics/dis-
orders including biological mechanisms on the genetic and orders, different genetic polymorphisms have been hypothe-
neural level, innate temperament characteristics, and unfavor- sized to represent common underlying risk factors. Research
able environmental conditions as mediators. in this area has its origin in the fact that some polymor-
phisms—for example DAT1, DRD4, DRD5, 5HTT,
HTR1B, and SNAP25—have been found significantly asso-
Method ciated to childhood ADHD even if the effects are small [22],
whereas for other polymorphisms, conflicting results have
In this article, we summarize findings concerning the comor- been reported suggesting the possible effect of other comorbid
bidity of ADHD and personality disorders. We performed a conditions. A study conducted by Silva de Cerqueira et al.
search for studies dealing with ADHD and personality disor- [23] studied polymorphisms in the Alpha-2A adrenergic re-
ders covering studies published in the last 5 years. The fol- ceptor gene (ADRA2A), which contains the information for
lowing bibliographic databases were searched: PubMed, the most frequent noradrenergic receptor in the prefrontal cor-
Embase, Medline, PsychInfo, Central (The Cochrane Central tex, in relation to Cloningers temperament and character di-
Register of Controlled Trials). The following search terms mensions in adult ADHD patients and controls. ADRA2A
were used: (ADHD OR (attention-deficit) OR hyperactivity*) gene polymorphisms were associated with the temperament
Curr Psychiatry Rep (2016) 18: 33 Page 3 of 7 33

dimensions higher novelty seeking and lower harm avoidance No general conclusion on a common genetic basis for per-
as well as less persistence. These results might point to a sonality traits and ADHD is deducible from these data, but it
mediation of gene effects on ADHD by temperament di- seems plausible that genes that influence genetic risk for
mensions [23]. Reif et al. [24] studied the association be- ADHD also have an influence on personality traits and/or
tween the DIRAS2 gene, implicated in the regulation of comorbid personality disorders.
neurogenesis, and ADHD as well as personality disorders
from clusters B and C. The authors reported an association Personality Traits and Temperament
between polymorphisms of the DIRAS2 gene and ADHD
as well as cluster B personality disorders and a tendency Seen the comorbidity pattern of personality disorders and
for an increased association risk also for cluster C person- ADHD, the recently published literature pays attention to tem-
ality disorders. Furthermore, they found associations with perament and personality traits in ADHD patients. A recent
the personality traits extraversion, novelty seeking, lower meta-analytic report on ADHD and personality comes to the
conscientiousness, and higher harm avoidance [24]. conclusion that some personality variables are robustly inter-
Another candidate gene, the protein phosphatase 2, regu- woven with ADHD [31•]. Studies investigating on this issue
latory subunit B, gamma (PPP2R2C) situated in the 4p16 use different measures of temperament and personality char-
region which is candidate locus for ADHD and bipolar acteristics and ask different research questions beyond the fact
disorder, has been proposed as a common underlying risk that adults and children with ADHD have been found consis-
factor for the association between ADHD and personality tently to score high in the novelty-seeking domain indepen-
traits by Jacob et al. [25]. The authors report preliminary dent of impulsivity [2, 8, 32–39]. Instanes et al. [40] assessed
evidence that PPP2R2C might increase vulnerability for personality traits in adult ADHS patients and controls with
ADHD and certain personality traits connected to ADHD Cloninger’s Temperament and Character Inventory asking
as openness to experience, extraversion, and novelty seek- the question if the inconsistent results concerning harm avoid-
ing. They propose to regard pronounced personality pro- ance, persistence, and reward dependence as well as self-
files as endophenotypes of ADHD [25]. In other studies directedness and cooperativeness in previous studies on
from the same research group, the authors conducted can- ADHD and personality disorders might be attributable to co-
didate gene-based association studies in patients suffering morbid conditions. In Cloniger’s model, the four temperament
from ADHD and patients suffering from personality disor- dimensions (harm avoidance, novelty seeking, reward depen-
ders and healthy controls. The gene for the Kv channel- dence, persistence) are presumed to be heritable and relatively
interacting protein 4 (KCNIP4) and the SPOCK3 gene stable qualities, whereas the three character dimensions (self-
were found to play a role in the association between directedness, cooperativeness, self-transcendence) are consid-
ADHD and personality disorders and particularly cluster ered to be influenceable by learning and development. The
B personality disorders [26, 27] even if data were consid- dimensions low self-directedness and low cooperativeness
ered preliminary. seem to indicate a personality disorder [41]. Instanes et al.
A twin study from the Netherlands assessed ADHD [40] found higher scores on the dimensions harm avoidance
symptoms and borderline personality traits in 7233 twins and novelty seeking in the ADHD patient group. When con-
and their siblings. The study revealed a high phenotypic trolling for comorbid disorders (particularly anxiety and de-
correlation between ADHD and borderline symptoms and pression), the result for harm avoidance was no longer signif-
reported that 49 % of this correlation can be explained by icant. Novelty seeking was clearly correlated with antisocial
genetic factors, whereas 51 % were attributed to environmen- personality disorder diagnoses. Other personality disorders
tal influences. A shared etiology between a part of ADHD were not assessed. Novelty seeking was considered a vulner-
symptoms and borderline traits was considered probable by ability marker for the co-occurrence of ADHD and borderline
the authors [28]. Another twin study from Sweden investigat- personality disorders in women according to van Dijk et al.
ing on the association between neurodevelopmental disorders [42]. In a study published by Carlotta et al. [43], action-
(ADHD and autism spectrum disorders) and personality char- oriented personality traits have been found to mediate the
acteristic assumed a Bstrong genetic effect^ with regard to the relationship between retrospectively assessed ADHD symp-
covariation of neurodevelopmental disorders and personality toms in childhood and borderline features in 447 adult patients
characteristics [29]. admitted for psychotherapy. Possible mediator variables were
One study reported on gene environment interactions in chosen based on their correlation to ADHD symptomatology
ADHD children and found no differential susceptibility to and borderline trait measuring scores. A combination of mea-
maternal expressed emotion concerning prosocial and antiso- surements of juvenile conduct problems, novelty seeking, im-
cial behavior when the effects of susceptibility genes (DAT1, pulsivity, and aggression mediated the relation between
DRD4, 5-HTT) were compared in children with ADHD and ADHD symptomatology in childhood and borderline traits
their siblings [30•]. in adulthood. Another study of the same research group
33 Page 4 of 7 Curr Psychiatry Rep (2016) 18: 33

reported a significant association between childhood ADHD symptoms in a sample of 2284 college students. The
symptoms and borderline features only in female participants Parental Bonding Instrument (PBI) was used to assess parent-
mediated by impulsivity and emotion dysregulation [44]. ing styles. The instrument has two subscales: affection/care
The subject of sex-specific comorbidity profiles has been and overprotection/authoritarian control. A high score on the
treated in other studies. Martel et al. [45] suggested that sex care scale reflects affection and warmth, a low score rejection,
differences in common comorbidity patterns in childhood coldness, or indifference. A high score on the protection scale
ADHD might be explained partly by mediating personality indicates discouragement of the child’s freedom or overpro-
traits. For example, high neuroticism was important to explain tective parenting. Ni and Gau [52] reported an OR of 25.31 for
the co-occurrence of ADHD and oppositional defiant disorder the association of ADHD with borderline personality disorder
in girls [45]. Borderline traits at age 14 were predicted by which was the highest OR found in their study which consid-
aggression, depressive, and ADHD symptoms in girls from ered also the comorbid conditions anxiety, depression, ODD,
a community sample of 484 youth followed at ages 10, 11, 12, conduct disorder, PTSD, schizophrenia, and antisocial person-
13, and 14 to identify early precursors of borderline features ality disorder. Increased parental care and decreased parental
[46]. Soendergaard et al. [47] reported more personality dis- protection were protective with regard to psychiatric symp-
order diagnoses in females than in males suffering from adult toms and personality disorders. Interactions of ADHD and
ADHD. Jacob et al. [48] found sex-specific differences in the parenting styles revealed that having ADHD or sub-
comorbidity profile of 910 adults suffering from ADHD. The threshold ADHD symptoms in addition to male gender and
most prevalent personality disorders among these adult decreased maternal care was associated with more severe an-
ADHD patients were narcissistic personality disorder for tisocial and borderline personality symptoms. Also, paternal
males and histrionic personality disorder for females. The protection was associated with more severe borderline symp-
finding of histrionic personality traits in women with ADHD toms. Furthermore, maternal protection interacted significant-
was supported by a study published by Edvinsson et al. [4]. ly with ADHD and subthreshold ADHD symptoms to predict
Men with ADHD were reported to suffer from antisocial per- a high level of borderline symptoms [52]. The interesting fact
sonality disorders and conduct problems more often than in this study is the reported interaction between ADHD symp-
women with ADHD [4]. Women with ADHD had higher toms and parenting style even if the retrospective study cannot
scores of neuroticism, openness to experience, agreeableness, answer the question if unfavorable parenting styles are char-
harm avoidance, and reward dependence compared to males acteristics of the parents or occur in reaction to the difficult
with ADHD [48]. behavioral patterns of a child suffering from ADHD. On the
ADHD subtype-related differences in personality traits have other hand, given the fact that ADHD is heritable, a consider-
been reported in different studies. Narcissistic and antisocial able percentage of parents suffer from ADHD themselves and
personality disorder had the highest prevalence in the hyperac- have noticeable personality profiles and also personality dis-
tive subtype and borderline personality disorder in the com- orders possibly leading to unfavourable parenting behaviours
bined subtype [48]. In children, hyperactivity/impulsivity was [53, 54]. Steinhausen et al. [55] found a high burden of psy-
associated with rule-breaking/aggressive behavior, social prob- chopathology in parents of children with ADHD which suf-
lems, extraversion, and disagreeableness, whereas inattention fered from ADHD themselves. Concerning personality, these
was linked to withdrawal/depression, introversion, and agree- parents had also high neuroticism and low conscientiousness
ableness [49]. Also in an adult sample, impulsivity predicted scores. Interestingly, parents with remitted ADHD were not
lower agreeableness, whereas hyperactivity predicted extraver- different from the parent group without ADHD. The authors
sion and inattention was positively associated with neuroticism interpreted this finding as an indicator that the ADHD in the
and negatively with conscientiousness [50]. In young adults, parents themselves rather than the reaction to the ADHD in
inattention seemed to predict personality disorders to a mark- the child has an impact on psychopathology and personality in
edly lesser extent than hyperactivity/impulsivity [51]. parents with ADHD children [55]. Another point of view is
that of the influence of parenting practices on ADHD symp-
Parenting Styles toms in the child. Ullsperger et al. [56] report that ADHD
symptomatology in the child is negatively influenced by in-
A multifaceted etiological explanation is suggested for the consistent parenting style and practices of poor parental su-
observed co-occurrence of ADHD and personality disorders. pervision via the temperamental dimension of low conscien-
Environmental conditions are considered important risk fac- tiousness in the child [56].
tors for the development of personality disorders. In recent
years, notably parenting styles have been focused by different Neurodevelopmental Disorders
research groups. Ni and Gau [52] report the results of a retro-
spective investigation on parenting styles and their influence A recent development is the interesting discussion about person-
on comorbid psychiatric symptoms in addition to ADHD ality disorders in the broader context of neurodevelopmental
Curr Psychiatry Rep (2016) 18: 33 Page 5 of 7 33

disorders particularly autism spectrum disorders and Novelty seeking seems to be an outstanding trait and
ADHD. Neurodevelopmental disorders share the follow- possible vulnerability marker for the development of
ing characteristics: Their onset is in infancy or childhood, personality problems in ADHD patients even if novelty
maturation of central nervous system is assumed to be seeking comprises also possible positive traits as curiosity,
affected or impaired, and they are permanent conditions generosity, and extraversion in social contexts. Thus, the
persisting into adulthood. Autism spectrum disorders and existence of these traits is not enough to explain the emer-
ADHD are the most frequent neurodevelopmental disor- gence of personality disorders in the life time course of
ders and have been found to have a high genetic overlap ADHD. Parenting styles are one possible environmental
and natural co-occurrence [57]. A considerable proportion factor contributing to the development of personality disor-
of patients suffering from autism spectrum disorders do ders and interacting with ADHD as a risk factor itself.
also meet the diagnostic criteria for personality disorders Parental care was found protective, and parental authoritar-
[58]. Clegg et al. [59•] state that overlaps between ian controls a risk factor for the development of cluster B
neurodevelopmental disorders are the rule rather than the personality disorders. The discussion on parenting styles is
exception and propose three underlying uniting concepts controversial, as the question of the origin of unfavorable
for research purposes and to tailor interventions: atypical parenting styles is unclear. Are such parenting practices
neural connectivity, dysregulation, and failed sociality reactions to difficult behavior of the ADHD child or prob-
[59•]. These concepts link neurodevelopmental disorders lematic behaviors of parents frequently suffering from
closely to later personality disorders and might be starting ADHD and consecutive personality disorders themselves?
points for future research directions. In this field, prospective studies concerning the interplay
One example of a research field which picks up the idea of between parenting practices and their fitting to demands
problems with self-regulation as a common feature in of the difficult to manage problem behaviors of ADHD
neurodevelopmental disorders and stressing the regulative children are lacking. Future studies might also focus on
abilities of the autonomic nervous system is Stephen Porges’ the group of ADHD patients with remitted or remitting
work [60]. He and his coauthors published interesting stud- ADHD and their learning histories to identify protective
ies linking autonomic nervous system activity to social biological and environmental factors.
function in autism spectrum disorders [61]. He reported An interesting subject of future research will be the field of
also on alterable auditory processing related to altered au- neurodevelopmental disorders. To look on personality
tonomic responses in these patients [60]. As the regulation disorders from the perspective of neurodevelopmental
of physiological responses is learned early in close contact disorders and conceptualize personality disorders as re-
to parents in a sort of coregulation, the importance of par- sults of unfavorable learning histories based on biological
enting on a bodily level seems evident. Therefore, Porges’ otherness and resulting in inflexible behavior patterns
theories might provide a framework for future studies of might open doors for new therapeutic approaches focus-
associations between neurodevelopmental disorders and ing on the one hand on the embodied nature of
regulatory problems leading to later personality disorders. neurodevelopmental disorders [59•] and on the other hand
Clegg et al. [59•] consequentially stress the role of the on approaches stressing acceptance and self-validation.
body and its reactions when methods of treatment are Research on the role of significant others and their possi-
concerned. ble influence on the developmental trajectories is needed
to enable support and favorable outcomes for affected
individuals and their families.
Conclusion

ADHD and personality disorders frequently co-occur in


Compliance with Ethical Standards
adulthood. Studies indicate genetic effects behind the
overlapping phenotypic features even if results of genetic Conflict of Interest Swantje Matthies received a speakers’ fee from
studies are preliminary to date because large sample sizes Jansen-Cilag and was involved in clinical trials conducted by Janssen-
Cilag and Lilly in the years 2007–2009.
and replication are necessary for sound statements.
Alexandra Philipsen has received advisory board fees from Lilly, ad-
Characteristics of temperament and personality dimensions visory board, and lecture fees from Medice, Novartis, and Shire, congress
in ADHD patients, children, and adults have been studied in support from Servier, and a travel grant from Lundbeck. Dr. Philipsen has
numerous studies and point to the fact that personality also authored books and articles on adult ADHD published by Elsevier,
Hogrefe, Schattauer, MWV, Kohlhammer, and Karger.
variables and ADHD are complexly intertwined.
Particularly, the impulsivity and hyperactivity domain of
Human and Animal Rights and Informed Consent This article does
ADHD symptomatology seems to predispose to the devel- not contain any studies with human or animal subjects performed by any
opment of later personality accentuations and disorders. of the authors.
33 Page 6 of 7 Curr Psychiatry Rep (2016) 18: 33

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