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-
activity disorder (ADHD) may remit until adulthood. But,
more than 60–80 % have persisting ADHD symptoms.
ADHD as an early manifesting neurodevelopmental disor-
der is considered a major risk factor for the development of
comorbid psychiatric disorders in later life. Particularly,
personality disorders are oftentimes observed in adult patients
suffering from ADHD. If ADHD and personality disorders
share common etiological mechanisms and/or if ADHD as a
severely impairing condition influences psychological func-
tioning and learning and leads to unfavorable learning histo-
ries is unclear. The development of inflexible and dysfunc-
tional beliefs on the basis of real and perceived impairments
or otherness due to the core symptoms of ADHD is intuitively
plausible. Such beliefs are a known cause for the development
of personality disorders. But, why some personality disorders
are more frequently found in ADHD patients as for example
antisocial and borderline personality disorder remains subject
of debate. Because of the high prevalence of ADHD and the
This article is part of the Topical Collection on Personality Disorders
* Swantje Matthies
swantje.matthies@uniklinik-freiburg.de
Alexandra Philipsen
Alexandra.Philipsen@uni-oldenburg.de
1
Department of Psychiatry & Psychotherapy, University Medical
Centre Freiburg, Hauptstr. 5, D-79104 Freiburg, Germany
2
Medical Campus University of Oldenburg, School of Medicine and
Health Sciences, D-26111 Oldenburg, Germany
3
Psychiatry and Psychotherapy – University Hospital,
Karl-Jaspers-Klinik, Hermann-Ehlers-Straße 7, D-26160 Bad
Zwischenahn, Germany
high impact of personality disorders on daily functioning, it is
important to take them into account when treating patients
with ADHD. Research on the developmental trajectories lead-
ing to personality disorders in adult ADHD patients might
open the door for targeted interventions to prevent impairing
comorbid clinical pictures.
Keywords ADHD . Comorbidity . Personality disorders .
Neurodevelopmental disorders
Introduction
Prospective studies in the past have shown an association of
ADHD diagnoses in childhood and the later development of
personality disorders in adulthood [1•]. Retrospective studies
in adults with ADHD in recent years confirm these findings
even if these studies are problematic because the assessment
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
when diagnosing ADHD and planning therapeutic steps.
Percentages of personality disorder diagnoses in adult
ADHD patients range from 10 to 75 % depending on sample
characteristics [2–5, 6•]. Especially personality disorders from
cluster B and to a lesser extent cluster C have frequently been
found in ADHD populations [1•, 2, 5, 6•, 7–10]. The literature
concerning the most prominent association of ADHD with
antisocial and borderline personality disorder has been reca-
pitulated in the articles published by Storebo and Simonsen,
and Matthies and Philipsen [6•, 11•].
Until 2012 prospective studies following children suffering
from ADHD into adulthood had not been extended beyond
early adulthood. Then, Klein et al. [12•] presented data from a
33-year follow-up study in which they re-assessed the original
33 Page 2 of 7
sample at mean age 41. They compared 135 males with ADHD
in childhood and without conduct disorder at mean age of
8 years with 136 males without childhood ADHD (65 and
76 % of the original sample). Almost a fifth of the investigated
ADHD sample had ongoing antisocial personality disorder
(vs. no case of antisocial personality disorder in the comparison
sample). In the subsample which had developed conduct
disorder at some point during adolescence even more, almost
a quarter of patients were diagnosed with antisocial personality
disorder at follow-up. Unfortunately, data on other personality
disorders have not been reported in this study. Klein et al. [12•]
5-HTT) were compared in children with ADHD and for new
psychopathology during the life-time course of ADHD is
highest in adolescence and persisted then into adulthood. This
is in line with the concept of Bdevelopmental comorbidity^
mentioned by Taurines et al. [13]. According to their concept,
specific comorbidity patterns are found during the life-time
course of ADHD, and the majority of comorbid conditions
begin in adolescence and early adulthood [13]. This corre-
sponds to the traditionally conceptualized onset of personality
disorders in adolescence. Emergent personality disorders in
adolescence are relatively rarely studied. Recently, a sample
of 85 adolescents suffering from borderline personality disorder
was investigated by Speranza et al. [14]. Eleven percent of their
sample had an ADHD diagnosis.
The comorbid association between ADHD and personality
disorders seems rather uncontroversial in the literature, but the
mechanisms responsible for the development of different per-
sonality disorders in individuals with ADHD are subject of
debate and object of the latest publications in this field.
Different developmental trajectories particularly with regard
to the association between ADHD and borderline personality
disorder have been hypothesized [15]. The broader concept of
neurodevelopmental disorders including ADHD and autism
spectrum disorders has become an interesting field of discus-
sion with regard to possible links to the later development of
personality disorders. Multifaceted mechanisms seem to play
a role in the association between ADHD and personality dis-
orders including biological mechanisms on the genetic and
neural level, innate temperament characteristics, and unfavor-
able environmental conditions as mediators.
Method
In this article, we summarize findings concerning the comor-
bidity of ADHD and personality disorders. We performed a
search for studies dealing with ADHD and personality disor-
ders covering studies published in the last 5 years. The fol-
lowing bibliographic databases were searched: PubMed,
Embase, Medline, PsychInfo, Central (The Cochrane Central
Register of Controlled Trials). The following search terms
were used: (ADHD OR (attention-deficit) OR hyperactivity*)
Curr Psychiatry Rep (2016) 18: 33
AND (PD OR (personality disorder)*). The search included
all fields in PubMed, Embase, Medline, and PsychInfo data-
bases and abstract, title, and keywords in the Central bibliog-
raphy (number of hits: PubMed 3579, Embase
(ScienceDirect): 11611, Medline (ME95) see PubMed,
Psychinfo 921, Central (The Cochrane Central Register of
Controlled Trials) 49, NCBI Web site 13). Studies were
screened and categorized in the following categories: research
on genetic links, personality, and temperament characteristics,
environmental variables such as parenting style and personal-
ity disorders in the context of neurodevelopmental disorders.
Prevalence
Both conditions, ADHD and personality disorders, are fre-
quent mental disorders. Adult ADHD affects an estimated
3.4 % of the adult population [16, 17]. The prevalence of
personality disorders has been estimated between 4.4 and
21.5 % [18]. In samples of adult ADHD patients, personality
disorders have been found in 10 to 75 % of the investigated
cases [2–5, 6•]. ADHD was associated with a significantly
increased risk of personality disorders with a hazard ratio of
5.80 in a large longitudinal population-based study [19].
Fossati et al. [20] studied childhood ADHD in adult patients
with personality disorders and found ADHD diagnoses in
10.5 % of patients with personality disorders from clusters A
and C, in 10.6 % of patients with any personality disorder
from cluster B, but in 59.5 % of the investigated borderline
patients. Later on, the strong comorbid association of ADHD
and borderline personality disorder has been confirmed by
Philipsen et al. [21], who reported a high prevalence of
ADHD in childhood (41.5 %) and adulthood (16.1 %) in
women with borderline personality disorder.
Genetic Links
Based on some phenotypic similarities and the comorbid as-
sociation between ADHD and personality characteristics/dis-
orders, different genetic polymorphisms have been hypothe-
sized to represent common underlying risk factors. Research
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-
ciated to childhood ADHD even if the effects are small [22],
whereas for other polymorphisms, conflicting results have
been reported suggesting the possible effect of other comorbid
conditions. A study conducted by Silva de Cerqueira et al.
[23] studied polymorphisms in the Alpha-2A adrenergic re-
ceptor gene (ADRA2A), which contains the information for
the most frequent noradrenergic receptor in the prefrontal cor-
tex, in relation to Cloningers temperament and character di-
mensions in adult ADHD patients and controls. ADRA2A
gene polymorphisms were associated with the temperament
Curr Psychiatry Rep (2016) 18: 33
dimensions higher novelty seeking and lower harm avoidance
as well as less persistence. These results might point to a
mediation of gene effects on ADHD by temperament di-
mensions [23]. Reif et al. [24] studied the association be-
tween the DIRAS2 gene, implicated in the regulation of
neurogenesis, and ADHD as well as personality disorders
from clusters B and C. The authors reported an association
between polymorphisms of the DIRAS2 gene and ADHD
as well as cluster B personality disorders and a tendency
for an increased association risk also for cluster C person-
ality disorders. Furthermore, they found associations with
the personality traits extraversion, novelty seeking, lower
conscientiousness, and higher harm avoidance [24].
Another candidate gene, the protein phosphatase 2, regu-
latory subunit B, gamma (PPP2R2C) situated in the 4p16
region which is candidate locus for ADHD and bipolar
disorder, has been proposed as a common underlying risk
factor for the association between ADHD and personality
traits by Jacob et al. [25]. The authors report preliminary
evidence that PPP2R2C might increase vulnerability for
ADHD and certain personality traits connected to ADHD
as openness to experience, extraversion, and novelty seek-
ing. They propose to regard pronounced personality pro-
files as endophenotypes of ADHD [25]. In other studies
from the same research group, the authors conducted can-
didate gene-based association studies in patients suffering
from ADHD and patients suffering from personality disor-
ders and healthy controls. The gene for the Kv channel-
interacting protein 4 (KCNIP4) and the SPOCK3 gene
were found to play a role in the association between
ADHD and personality disorders and particularly cluster
B personality disorders [26, 27] even if data were consid-
ered preliminary.
A twin study from the Netherlands assessed ADHD
symptoms and borderline personality traits in 7233 twins
and their siblings. The study revealed a high phenotypic
correlation between ADHD and borderline symptoms and
reported that 49 % of this correlation can be explained by
genetic factors, whereas 51 % were attributed to environmen-
tal influences. A shared etiology between a part of ADHD
symptoms and borderline traits was considered probable by
the authors [28]. Another twin study from Sweden investigat-
ing on the association between neurodevelopmental disorders
(ADHD and autism spectrum disorders) and personality char-
acteristic assumed a Bstrong genetic effect^ with regard to the
covariation of neurodevelopmental disorders and personality
characteristics [29].
One study reported on gene environment interactions in
ADHD children and found no differential susceptibility to
maternal expressed emotion concerning prosocial and antiso-
cial behavior when the effects of susceptibility genes (DAT1,
DRD4, 5-HTT) were compared in children with ADHD and
their siblings [30•].
Page 3 of 7 33
No general conclusion on a common genetic basis for per-
sonality traits and ADHD is deducible from these data, but it
seems plausible that genes that influence genetic risk for
ADHD also have an influence on personality traits and/or
comorbid personality disorders.
Personality Traits and Temperament
Seen the comorbidity pattern of personality disorders and
ADHD, the recently published literature pays attention to tem-
perament and personality traits in ADHD patients. A recent
meta-analytic report on ADHD and personality comes to the
conclusion that some personality variables are robustly inter-
woven with ADHD [31•]. Studies investigating on this issue
use different measures of temperament and personality char-
acteristics and ask different research questions beyond the fact
that adults and children with ADHD have been found consis-
tently to score high in the novelty-seeking domain indepen-
dent of impulsivity [2, 8, 32–39]. Instanes et al. [40] assessed
personality traits in adult ADHS patients and controls with
Cloninger’s Temperament and Character Inventory asking
the question if the inconsistent results concerning harm avoid-
ance, persistence, and reward dependence as well as self-
directedness and cooperativeness in previous studies on
ADHD and personality disorders might be attributable to co-
morbid conditions. In Cloniger’s model, the four temperament
dimensions (harm avoidance, novelty seeking, reward depen-
dence, persistence) are presumed to be heritable and relatively
stable qualities, whereas the three character dimensions (self-
directedness, cooperativeness, self-transcendence) are consid-
ered to be influenceable by learning and development. The
dimensions low self-directedness and low cooperativeness
seem to indicate a personality disorder [41]. Instanes et al.
[40] found higher scores on the dimensions harm avoidance
and novelty seeking in the ADHD patient group. When con-
trolling for comorbid disorders (particularly anxiety and de-
pression), the result for harm avoidance was no longer signif-
icant. Novelty seeking was clearly correlated with antisocial
personality disorder diagnoses. Other personality disorders
were not assessed. Novelty seeking was considered a vulner-
ability marker for the co-occurrence of ADHD and borderline
personality disorders in women according to van Dijk et al.
[42]. In a study published by Carlotta et al. [43], action-
oriented personality traits have been found to mediate the
relationship between retrospectively assessed ADHD symp-
toms in childhood and borderline features in 447 adult patients
admitted for psychotherapy. Possible mediator variables were
chosen based on their correlation to ADHD symptomatology
and borderline trait measuring scores. A combination of mea-
surements of juvenile conduct problems, novelty seeking, im-
pulsivity, and aggression mediated the relation between
ADHD symptomatology in childhood and borderline traits
in adulthood. Another study of the same research group
33 Page 4 of 7
reported a significant association between childhood ADHD
symptoms and borderline features only in female participants
mediated by impulsivity and emotion dysregulation [44].
The subject of sex-specific comorbidity profiles has been
treated in other studies. Martel et al. [45] suggested that sex
differences in common comorbidity patterns in childhood
ADHD might be explained partly by mediating personality
traits. For example, high neuroticism was important to explain
the co-occurrence of ADHD and oppositional defiant disorder
in girls [45]. Borderline traits at age 14 were predicted by
aggression, depressive, and ADHD symptoms in girls from
a community sample of 484 youth followed at ages 10, 11, 12,
13, and 14 to identify early precursors of borderline features
[46]. Soendergaard et al. [47] reported more personality dis-
order diagnoses in females than in males suffering from adult
ADHD. Jacob et al. [48] found sex-specific differences in the
comorbidity profile of 910 adults suffering from ADHD. The
most prevalent personality disorders among these adult
ADHD patients were narcissistic personality disorder for
males and histrionic personality disorder for females. The
finding of histrionic personality traits in women with ADHD
was supported by a study published by Edvinsson et al. [4].
Men with ADHD were reported to suffer from antisocial per-
sonality disorders and conduct problems more often than
women with ADHD [4]. Women with ADHD had higher
scores of neuroticism, openness to experience, agreeableness,
harm avoidance, and reward dependence compared to males
with ADHD [48].
ADHD subtype-related differences in personality traits have
been reported in different studies. Narcissistic and antisocial
personality disorder had the highest prevalence in the hyperac-
tive subtype and borderline personality disorder in the com-
bined subtype [48]. In children, hyperactivity/impulsivity was
associated with rule-breaking/aggressive behavior, social prob-
lems, extraversion, and disagreeableness, whereas inattention
was linked to withdrawal/depression, introversion, and agree-
ableness [49]. Also in an adult sample, impulsivity predicted
lower agreeableness, whereas hyperactivity predicted extraver-
sion and inattention was positively associated with neuroticism
and negatively with conscientiousness [50]. In young adults,
inattention seemed to predict personality disorders to a mark-
edly lesser extent than hyperactivity/impulsivity [51].
Parenting Styles
A multifaceted etiological explanation is suggested for the
observed co-occurrence of ADHD and personality disorders.
Environmental conditions are considered important risk fac-
tors for the development of personality disorders. In recent
years, notably parenting styles have been focused by different
research groups. Ni and Gau [52] report the results of a retro-
spective investigation on parenting styles and their influence
on comorbid psychiatric symptoms in addition to ADHD
Curr Psychiatry Rep (2016) 18: 33
symptoms in a sample of 2284 college students. The
Parental Bonding Instrument (PBI) was used to assess parent-
ing styles. The instrument has two subscales: affection/care
and overprotection/authoritarian control. A high score on the
care scale reflects affection and warmth, a low score rejection,
coldness, or indifference. A high score on the protection scale
indicates discouragement of the child’s freedom or overpro-
tective parenting. Ni and Gau [52] reported an OR of 25.31 for
the association of ADHD with borderline personality disorder
which was the highest OR found in their study which consid-
ered also the comorbid conditions anxiety, depression, ODD,
conduct disorder, PTSD, schizophrenia, and antisocial person-
ality disorder. Increased parental care and decreased parental
protection were protective with regard to psychiatric symp-
toms and personality disorders. Interactions of ADHD and
parenting styles revealed that having ADHD or sub-
threshold ADHD symptoms in addition to male gender and
decreased maternal care was associated with more severe an-
tisocial and borderline personality symptoms. Also, paternal
protection was associated with more severe borderline symp-
toms. Furthermore, maternal protection interacted significant-
ly with ADHD and subthreshold ADHD symptoms to predict
a high level of borderline symptoms [52]. The interesting fact
in this study is the reported interaction between ADHD symp-
toms and parenting style even if the retrospective study cannot
answer the question if unfavorable parenting styles are char-
acteristics of the parents or occur in reaction to the difficult
behavioral patterns of a child suffering from ADHD. On the
other hand, given the fact that ADHD is heritable, a consider-
able percentage of parents suffer from ADHD themselves and
have noticeable personality profiles and also personality dis-
orders possibly leading to unfavourable parenting behaviours
[53, 54]. Steinhausen et al. [55] found a high burden of psy-
chopathology in parents of children with ADHD which suf-
fered from ADHD themselves. Concerning personality, these
parents had also high neuroticism and low conscientiousness
scores. Interestingly, parents with remitted ADHD were not
different from the parent group without ADHD. The authors
interpreted this finding as an indicator that the ADHD in the
parents themselves rather than the reaction to the ADHD in
the child has an impact on psychopathology and personality in
parents with ADHD children [55]. Another point of view is
that of the influence of parenting practices on ADHD symp-
toms in the child. Ullsperger et al. [56] report that ADHD
symptomatology in the child is negatively influenced by in-
consistent parenting style and practices of poor parental su-
pervision via the temperamental dimension of low conscien-
tiousness in the child [56].
Neurodevelopmental Disorders
A recent development is the interesting discussion about person-
ality disorders in the broader context of neurodevelopmental
Curr Psychiatry Rep (2016) 18: 33
disorders particularly autism spectrum disorders and
ADHD. Neurodevelopmental disorders share the follow-
ing characteristics: Their onset is in infancy or childhood,
maturation of central nervous system is assumed to be
affected or impaired, and they are permanent conditions
persisting into adulthood. Autism spectrum disorders and
ADHD are the most frequent neurodevelopmental disor-
ders and have been found to have a high genetic overlap
and natural co-occurrence [57]. A considerable proportion
of patients suffering from autism spectrum disorders do
also meet the diagnostic criteria for personality disorders
[58]. Clegg et al. [59•] state that overlaps between
neurodevelopmental disorders are the rule rather than the
exception and propose three underlying uniting concepts
for research purposes and to tailor interventions: atypical
neural connectivity, dysregulation, and failed sociality
[59•]. These concepts link neurodevelopmental disorders
closely to later personality disorders and might be starting
points for future research directions.
One example of a research field which picks up the idea of
problems with self-regulation as a common feature in
neurodevelopmental disorders and stressing the regulative
abilities of the autonomic nervous system is Stephen Porges’
work [60]. He and his coauthors published interesting stud-
ies linking autonomic nervous system activity to social
function in autism spectrum disorders [61]. He reported
also on alterable auditory processing related to altered au-
tonomic responses in these patients [60]. As the regulation
of physiological responses is learned early in close contact
to parents in a sort of coregulation, the importance of par-
enting on a bodily level seems evident. Therefore, Porges’
theories might provide a framework for future studies of
associations between neurodevelopmental disorders and
regulatory problems leading to later personality disorders.
Clegg et al. [59•] consequentially stress the role of the
body and its reactions when methods of treatment are
concerned.
Conclusion
ADHD and personality disorders frequently co-occur in
adulthood. Studies indicate genetic effects behind the
overlapping phenotypic features even if results of genetic
studies are preliminary to date because large sample sizes
and replication are necessary for sound statements.
Characteristics of temperament and personality dimensions
in ADHD patients, children, and adults have been studied in
numerous studies and point to the fact that personality
variables and ADHD are complexly intertwined.
Particularly, the impulsivity and hyperactivity domain of
ADHD symptomatology seems to predispose to the devel-
opment of later personality accentuations and disorders.
Page 5 of 7 33
Novelty seeking seems to be an outstanding trait and
possible vulnerability marker for the development of
personality problems in ADHD patients even if novelty
seeking comprises also possible positive traits as curiosity,
generosity, and extraversion in social contexts. Thus, the
existence of these traits is not enough to explain the emer-
gence of personality disorders in the life time course of
ADHD. Parenting styles are one possible environmental
factor contributing to the development of personality disor-
ders and interacting with ADHD as a risk factor itself.
Parental care was found protective, and parental authoritar-
ian controls a risk factor for the development of cluster B
personality disorders. The discussion on parenting styles is
controversial, as the question of the origin of unfavorable
parenting styles is unclear. Are such parenting practices
reactions to difficult behavior of the ADHD child or prob-
lematic behaviors of parents frequently suffering from
ADHD and consecutive personality disorders themselves?
In this field, prospective studies concerning the interplay
between parenting practices and their fitting to demands
of the difficult to manage problem behaviors of ADHD
children are lacking. Future studies might also focus on
the group of ADHD patients with remitted or remitting
ADHD and their learning histories to identify protective
biological and environmental factors.
An interesting subject of future research will be the field of
neurodevelopmental disorders. To look on personality
disorders from the perspective of neurodevelopmental
disorders and conceptualize personality disorders as re-
sults of unfavorable learning histories based on biological
otherness and resulting in inflexible behavior patterns
might open doors for new therapeutic approaches focus-
ing on the one hand on the embodied nature of
neurodevelopmental disorders [59•] and on the other hand
on approaches stressing acceptance and self-validation.
Research on the role of significant others and their possi-
ble influence on the developmental trajectories is needed
to enable support and favorable outcomes for affected
individuals and their families.
Compliance with Ethical Standards
Conflict of Interest Swantje Matthies received a speakers’ fee from
Jansen-Cilag and was involved in clinical trials conducted by Janssen-
Cilag and Lilly in the years 2007–2009.
Alexandra Philipsen has received advisory board fees from Lilly, ad-
visory board, and lecture fees from Medice, Novartis, and Shire, congress
support from Servier, and a travel grant from Lundbeck. Dr. Philipsen has
also authored books and articles on adult ADHD published by Elsevier,
Hogrefe, Schattauer, MWV, Kohlhammer, and Karger.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
33 Page 6 of 7
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