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 RESEARCH ARTICLE

Personality disorders in ADHD Part 3: Personality disorder, social adjustment, and their relation to dimensions of adult ADHD

Frederick W. Reimherr, MD

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

Barrie K. Marchant, MS

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

Erika D. Williams, MSW

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

Robert E. Strong, DO

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

Corinne Halls, MS

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

Poonam Soni, MD

Mood Disorders Clinic, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA

BACKGROUND: This study explored the relationship between the dimensions of adult attention-deficit/hyperactivity disorder (ADHD), personality disorder (PD), and adverse social adjustment.

METHODS: In a controlled trial of osmotic release oral system methylphenidate, PD was assessed using the Wisconsin Personality Disorders Inventory IV (WISPI-IV), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and a final consensus diagnosis. Participants were categorized 2 ways: (1) ADHD alone, ADHD with emotional dysregulation (ADHD + ED), and ADHD plus emotional dysregulation plus oppositional symptoms (ADHD + ED + ODD); and (2) those with no PD (PD-negative), 1 (PD-positive), and 2 or more (PD-plus) PDs.

RESULTS: None of the ADHD-alone patients had a PD compared with 33% of ADHD + ED patients and 68% of ADHD + ED + ODD patients. The level of ADHD-related emotional and oppositional symptoms correlated significantly with the severity of PD dimensions as assessed by WISPI-IV z scores and the number of items endorsed on the SCID-II screening questionnaire. Complex presentations (define by both ADHD and personality categories) were associated with high childhood ADHD ratings and problems in work, extended family, and economic functioning.

CONCLUSION: The ADHD symptoms of emotional dysregulation and oppositional symptoms were associated with increased Axis II disorders. Adverse outcomes were concentrated in patients with ADHD combined with emotional and oppositional symptoms, and in those with comorbid PDs.

KEYWORDS: attention-deficit/hyperactivity disorder, personality disorder, emotional dysregulation, oppositional

ANNALS OF CLINICAL PSYCHIATRY 2010;22(2):103–112

  INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood illness that frequently continues into adulthood. Studies have documented that ADHD patients are likely to develop a confusingly wide array of other disorders, including oppositional defiant disorder (ODD); conduct disorder; specific learning disabilities (eg, dyslexia); substance abuse1; various anxiety disorders, including obsessive-compulsive disorder; major depression; dysthymia; and bipolar disorder.2,3 ADHD may be thought of as having 4 symptom dimensions: attention/organization, hyperactivity/impulsivity, emotional, and symptoms of oppositional personality.4,5 Although only the first 2 symptom dimensions are included in the DSM-IV diagnostic criteria, it is probable that all 4 significantly influence the long-term development of ADHD patients.

A frequently reported area of association is ADHD and PD. ADHD has been reported to occur with conduct disorder in adolescence and with antisocial disorder in adults.6-12 Beyond this, there is a gradually expanding literature connecting ADHD to PDs within cluster B,13,14 a range of personality traits,15-18 as well as other PDs.19-23 Unfortunately, the assessment of PD in adults with ADHD is fraught with uncertainty,24 and as part of this study we have used multiple methods to rigorously confirm this association.

Not only is ADHD associated with a variety of psychiatric diagnoses, it is also associated with the development of variety of psychosocial impairments.25-30 For example, one study showed greater disruption at work, lower academic achievement, poor driving, and relationship difficulties associated with ADHD.31 There is also an increase in legal problems, including substance abuse,32 arrests, and vehicular accidents. ADHD is associated with worse performance in simulated driving tests.33 A study of a large health-claims database showed increased medical costs34 and greater absenteeism10 among adults with ADHD.

This assortment of disorders and associated areas of psychosocial impairment makes it important to investigate the ways in which ADHD serves as a precursor for their expression in adulthood. This study was designed to explore the intersection between these 4 ADHD symptom dimensions, psychosocial impairment, and adult PD.

In a previous analysis of these data, we found that a large percentage of adults in this study did have personality disorders.35 We found that 24% had a single PD, and we labeled these patients as PD-positive. An additional 21% had 2 or more PDs, and we labeled these patients as PD-plus. Those without a PD were labeled PD-negative. An alternative analysis explored the impact of oppositional defiant symptoms5 identified using adult-oriented descriptors.

These earlier observations led us to the hypothesis that social maladjustment and Axis II diagnoses may not be evenly distributed across all ADHD patients, but that these impairments might be concentrated in ADHD patients with certain characteristics. Several earlier reports have suggested that clustering of adverse outcomes in ADHD is associated with ADHD symptom clusters. For instance, Fischer et al36 found that conduct problems among children with ADHD were predictive of adult antisocial PD and/or depression. Murphy et al25 reported that patients with ADHD in combination with another disorder had a distinctly worse outcome than those with inattentive ADHD alone. Further, substance abuse was more related to hyperactivity/impulsivity as opposed to inattention.32 Another report suggested that substance abuse in ADHD patients was a critical element in leading to antisocial activities and other social problems.37 The authors suggested that the increase in antisocial outcomes was mediated by the higher level of impulsivity in such patients. Alternatively, childhood ODD has been predictive of adolescent conduct disorder.38 Oddly, one study has reported that the number of DSM-IV symptoms shows very little relationship with impairment.39

This article explores the following specific questions.

  1. Was increased complexity of ADHD (including symptoms of emotional dysregulation and oppositional symptoms) associated with increased frequency of PD (ADHD-negative, ADHD-positive, or ADHD-plus)?

  2. Were underlying measures of PD severity using the Wisconsin Personality Disorders Inventory IV (WISP-IIV) z scores and number of endorsed SCID-II items associated with specific dimensions of ADHD?

  3. Was social impairment associated with more complex ADHD, or PD, or both?

  METHODS

The University of Utah Institutional Review Board reviewed and approved this study. The study was conducted in accordance with the 1975 Declaration of Helsinki. It consisted of a placebo-controlled trial of osmotic release oral system (OROS) methylphenidate (MPH) and included a screening/baseline phase, followed by a double-blind crossover phase with two 4-week arms. Patients completing the crossover phase entered the 6-month open-label treatment phase.

Following an initial screening interview, informed consent was obtained. Evaluation of PDs was conducted as follows. Patients completed the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) screening questionnaire and SCID-II interviews, which were administered by the same clinician (E.D.W.), who is experienced in both initial evaluations and use of programmed interviews. Patients next completed the self-report WISPI-IV. Last, patients were assessed using the Iowa Personality Disorder Screen (IPDS) by one of the study psychiatrists. Assessment using the IPDS was repeated at the end of each double-blind arm plus the open-label period, with the intent to maintain awareness of the patient’s personality characteristics during the course of the study. Following the conclusion of the patient’s participation in the study, all available information was reviewed and a consensus decision regarding the patient’s PD (final PD) was made.

Study population

Participants were required to meet the Utah Criteria for ADHD in adults and the DSM-IV-TR criteria for current ADHD based on the Conners’ Adult ADHD Diagnostic Interview for DSM-IV. Patients were between age 18 and 65. The following DSM-IV Axis I diagnoses were exclusionary: obsessive-compulsive disorder, posttraumatic stress disorder, current diagnosis of major depressive disorder, panic disorder, current or lifetime bipolar disorder, schizophrenia, and other psychotic disorder. Although current substance abuse or dependence (including alcohol) was exclusionary, a past history of abuse or dependence was not. A more complete description of the selection process has been previously reported.5

Measures

The Parent Rating Scale (PRS) and the Wender Utah Rating Scale (WURS) were used to verify that participants met the childhood criteria. The PRS consists of 10 items to be filled out by the patient’s parent or parental figure. The WURS consists of 61 items to be filled out by the patient. It provides documentation regarding symptoms consistent with a history of childhood ADHD. It has been standardized in multiple languages and other psychiatric populations. Both scales have been validated, and scores above the 90th percentile on the PRS are associated with a positive treatment outcome.

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), and the Clinical Global Impressions–Improvement scale (CGI-I) were used to assess the efficacy of OROS MPH on ADHD symptoms. The WRAADDS is an interviewer-administered scale assessing the adult ADHD symptoms from the “Utah Criteria.”40 The scales of attention and disorganization are quite similar to the DSM-IV item inattention. The scales of hyperactivity/restlessness and impulsivity are quite similar to the DSM-IV item hyperactivity/impulsivity. The scales of temper, affective lability, and emotional overreactivity have been combined and called emotional dysregulation. Although this last grouping does not contain symptoms recognized in the DSM-IV, there is significant evidence that it is an integral part of ADHD, including its ubiquity within DSM-defined adult ADHD samples and the fact that it responds to treatment in parallel with the DSM-IV symptoms. When treated as a categorical item, emotional dysregulation was defined using previously published criteria5,41 of scores ≥7.

The Adult ADHD Self-Report Scale is an interviewer-administered scale that assesses the 18 items of the DSM-IV. It includes a total score and the subscales of inattention and hyperactivity/impulsivity.

The Self-Report ADHD Scale was used to assess oppositional symptoms. Addressing these symptoms is problematic for 2 reasons. First, ODD has never been considered an adult illness. Second, the symptoms of ODD can be seen as more similar to PD than an Axis I disorder. The Adult ADHD Self-Report Scale was augmented by a post hoc review of all available information by both the treating psychiatrist and the staff to confirm the assessment. The scale is available upon request. It is an amalgam of the WURS, WRAADDS, and the Utah Criteria and includes a subset of ODD symptoms.

The SCID-II is an interview-based assessment system for PDs using a 2-step system. The patient completes a screening questionnaire and then a follow-up interview is conducted, checking on areas that the patient has rated over a threshold level. Patients were segregated into 3 categories: PD-negative (patients not meeting full criteria for any diagnosis), PD-positive (patients meeting full criteria for 1 PD), and PD-plus (patients meeting criteria for at least 2 diagnoses). We also used the SCID-II screening questionnaire items endorsed as a dimensional measure of the severity of PD symptoms. This has not been reported on previously as a method to assess the severity of PD.

The WISPI-IV is a self-administered, computer scored scale consisting of 214 items derived from the interpersonal perspective of Lorna S. Benjamin,42 with demonstrated validity.43 Patients were categorized as meeting full criteria for a PD if they met the test developer’s criteria for a diagnosis consisting of: (a) meeting 100% of DSM “necessary items;” and (b) the percentage of “necessary items” exceeded the percentage of “exclusionary items” by at least 50%. Again, patients were segregated into 3 categories: PD-negative (patients not meeting full criteria for any diagnosis), PD-positive (patients meeting full criteria for 1 diagnosis), and PD-plus (patients meeting diagnostic criteria for at least 2 diagnoses). The WISPI also generates z scores, compared with normative data, for each diagnostic category. The z scores were used in some analyses but did not play a direct role in diagnosis.

A final PD was agreed upon for each patient at the end of their participation. This was completed by the treating psychiatrists considering all data sources (including SCID-II and WISPI-IV). This final PD was used as our “gold standard” of the patients’ personality status. Using it, patients were segregated into 3 post hoc categories: PD-negative (patients without a PD), PD-positive (patients meeting full diagnostic criteria for only 1 disorder), and PD-plus (patients meeting diagnostic criteria for 2 or more disorders).

The Weissman Social Adjustment Scale–Self-Report (SAS-SR)44 was used to assess social adjustment. This scale consists of 54 questions addressing work, extended family, and marital, parental, and economic issues. Although there is minor variability, most ratings range from 1 to 5. A score of 1 always indicates no impairment, and higher ratings indicate more impairment. In general, a score of ≥3 indicates impairment that is clinically significant, and we defined scores ≥3 as impaired in our categorical descriptions of this scale. Our analysis included 2 groupings of these questions that are not commonly used. Eight items of the SASSR addressed conflicts (eg, frequent arguing) within various social relationships, which we have combined and titled conflicts. Another 5 items within the SAS-SR addressed feelings of strong emotion within various social relationships, which we have combined and titled emotionality.

The Hamilton Rating Scale for Depression (HAMD) is a commonly used investigator-rated measure of depression. The 17-item version was used in this study.

Treatment procedures

During the double-blind phase, patients were seen weekly. Medication was started at 18 mg/d, and the dose was increased every 2 to 3 days by 9 mg, based on response and tolerance, up to a maximum dose of 90 mg/d. After a patient was rated as much improved or better on the CGI-I, or improved ≥50% on the WRAADDS, the dose remained constant for the remainder of that treatment arm. In the event of unacceptable side effects, dose reductions were allowed. Generally, a stable dose was obtained in 2 weeks and held constant the last 2 weeks. During the open-label extension phase, dose levels were determined by clinical judgment dose and generally remained consistent after the first 4 weeks.

Data analysis and statistical procedures

Chi-square was used to compare the number of patients with a PD in the 3 ADHD groups.

The relationships between WISPI-IV z scores (for individual diagnostic categories), the number of SCID-II items endorsed ADHD symptoms (attention/disorganization, hyperactivity/impulsivity, and emotional dys-regulation), and oppositional symptoms were analyzed using the Pearson correlation coefficient.

Baseline differences between the 3 PD groups in social adjustment were assessed using a simple analysis of covariance (ANOVA) with group category as the primary variable for continuous variables and chi-square for categorical variables. Similarly, a simple ANOVA was used to compare social adjustment for the 3 ADHD groups.

All analyses were done using the SPSS 13.0 statistical package. All statistics were 2-tailed, with P < .05. Given the exploratory nature of the study, Bonferroni corrections were not applied.

  RESULTS

Forty-seven patients entered the study. Four patients were eliminated during the baseline phase. Forty-one patients completed the double-blind trial. Thirty-four patients entered the open-label phase and were observed for as long as 6 months.

At baseline, 8 (17%) patients were experiencing only the ADHD symptoms of the DSM-IV and were classified as ADHD alone. Eighteen (38%) patients also had symptoms of emotional dysregulation and were classified as ADHD + ED. Finally, 19 (40%) patients were categorized as having both symptoms of emotional dysregulation and oppositional impairment (ADHD + ED + ODD).

The final PD assessment indicated that 26 (55%) patients were PD-negative, whereas 11 (23%) patients were PD-positive and 10 (21%) patients were PD-plus.

As seen in TABLE 1, the 3 ADHD groups differed significantly in the number of patients meeting Axis II criteria for PD and in the number of patients meeting criteria for 2 or more PDs. Patients in the ADHD-only group experience no PDs, whereas 7 (39%) of the ADHD + ED patients had at least 1 Axis II diagnosis, and 13 (68%) of the ADHD + ED + ODD patients had at least 1 Axis II diagnosis (χ2=13.9; df=2; P=.005). There were also significant differences in the numbers of PD-positive and PD-plus patients among these 3 groups of ADHD patients (χ2=10.4; df=4; P=.05). Conversely, although there were significant differences in the presence of PD, the ADHD + ED and the ADHD + ED+ ODD groups did not differ regarding which PDs were present or even which personality clusters were represented.

The relationship between PD and the dimensions of ADHD was also assessed by correlating the total scores within each of the 3 groupings of WRAADDS ADHD symptoms (attention/disorganization; hyperactivity/impulsivity, and emotional dysregulation) as well as the ODD score of the Self-Report ADHD Scale with WISPI-IV z scores and number of SCID-II items endorsed for each diagnostic cluster. As seen in TABLE 2, the DSM symptoms of attention/disorganization and hyperactivity/impulsivity, with one exception (relationship between the SCID-II number of cluster B items endorsed and hyperactivity/impulsivity), were not significantly correlated with the specorder-PDs dimensions. This lack of relationship was replicated with the 2 Conners’ Adult ADHD Rating Scales (CAARS) subscales of inattention and hyperactivity/impulsivity. In contrast, emotional dysregulation and symptoms of ODD were significantly associated with all 3 clusters, passive-aggressive and depressive PD for both the WISPI-IV z scores, and number of SCID-II items endorsed.

Previous analysis of these data indicated that patients with ADHD + ED or ADHD + ED + ODD were more likely to experience social maladjustment. This reanalysis found that PD status was similarly related to social maladjustment. As indicated in TABLE 3 and TABLE 4, complex presentations (using both ADHD and personality categories) were significantly associated with high childhood ADHD ratings and, to a lesser extent, social adjustment in work, extended family, economic functioning, and our unique groupings of items addressing conflicts and emotionality. Not all patients could be assessed in all social adjustment categories, which affected the P values. Given that the 3 PD groups differed significantly in 5 of the WSAS categories, whereas the 3 ADHD groups differed in only 2 WSAS categories, it is clear that PD has an impact on social functioning beyond that of the ADHD symptoms.


TABLE 1

Final personality diagnosis for all 47 subjects, ADHD alone, ADHD + ED, and ADHD + ED + ODD: Number and percentage of patients meeting DSM-IV criteria for each Axis II diagnosis

  Totala ADHD only ADHD + EDb ADHD + ED + ODDc  
  n % n % n % n % P value
CLUSTER A
Paranoid 4 9% 0 0% 2 11% 2 11%  
Schizoid 0 0% 0 0% 0 0% 0 0%  
Schizotypal 0 0% 0 0% 0 0% 0 0%  
Any cluster A diagnosis 4 9% 0 0% 2 11% 2 11% χ2=.95; df=2; P=ns
CLUSTER B
Antisocial 4 9% 0 0% 2 11% 2 11%  
Borderline 7 15% 0 0% 3 17% 4 21%  
Histrionic 1 2% 0 0% 1 6% 0 0%  
Narcissistic 1 2% 0 0% 0 0% 1 5%  
Any cluster B diagnosis 8 17% 0 0% 3 17% 5 26% χ2=2.69; df=2; P=.30
CLUSTER C
Avoidant 9 19% 0 0% 3 17% 6 32%  
Dependent 3 6% 0 0% 3 17% 0 0%  
Obsessive-compulsive 4 9% 0 0% 2 11% 1 5%  
Any cluster C diagnosis 13 28% 0 0% 6 33% 6 32% χ2=3.55; df=2; P=.20
Passive-aggressive 4 9% 0 0% 2 11% 2 11%  
Depressive 5 11% 0 0% 3 17% 2 11%  
NOS 3 6% 0 0% 1 2% 0 0%  
ANY DIAGNOSIS 21 45% 0 0% 7 39% 13 68% χ2=13.9; df=2; P=.005
PD-positived 11 23% 0 0% 3 17% 7 36%  
PD-pluse 10 21% 0 0% 4 22% 6 32% χ2=10.4; df=4; P=.05
ADHD: attention-deficit/hyperactivity disorder; ED: emotional dysregulation; NOS: not otherwise specified; ODD: oppositional defiant disorder; PD: personality disorder.
aTwo patients did not meet criteria for any of the 3 groups but were included in the total column.
bADHD + ED: Patients met criteria for ADHD as well as ED.
cADHD + ED + ODD: Patients met criteria for ADHD and ED, and had significant ODD symptoms.
dPD-positive: Patients met criteria for 1 PD;
ePD-plus: Patients met criteria for ≥2 PDs.

TABLE 2

Correlations between WISPI-IV z scores or SCID-II items endorsed and ADHD symptoms of attention/disorganization, hyperactivity/impulsivity, emotional dysregulation, and oppositional defiant disorder items*

  WRAADDS Attention/disorganization ADHD-RS Inattention WRAADDS Hyperactivity/impulsivity ADHD-RS Hyperactivity/impulsivity WRAADDS Emotional dysregulation Oppositional defiant disorder items
  Correlation P value Correlation P value Correlation P value Correlation P value Correlation P value Correlation P value
Cluster A
WISPI-IV .235 .116 .019 .908 .209 .163 .253 .116 .306 .039 .446 .002
SCID-II –.030 .845 –.089 .586 .128 .398 –.026 .875 .543 .000 .318 .036
Cluster B
WISPI-IV .220 .142 .073 .654 .213 .155 .305 .056 .378 .01 .478 .001
SCID-II .226 .130 .023 .887 .332 .024 .081 .621 .551 .000 .558 .000
Cluster C
WISPI-IV .155 .305 –.079 .628 .113 .453 .136 .401 .370 .011 .421 .004
SCID-II .160 .287 .132 .418 .207 .168 .072 .657 .506 .000 .314 .038
Passive-aggressive
WISPI-IV .195 0.41 .135 .405 .217 0.15 .291 .069 .374 .012 .443 0.003
SCID-II .187 .214 –.233 .207 .202 .177 –.158 .396 .428 .003 .417 .005
Depressive
SCID-II –.076 .618 –.018 .918 .121 .421 .034 .850 .586 .000 .403 .007
Total
WISPI-IV .207 .167 –.023 .890 .202 .178 .054 .740 .434 .003 .493 .001
SCID-II .133 .378 .014 .929 .285 .055 .053 .744 .683 .000 .554 .000
ADHD: attention-deficit/hyperactivity disorder; ADHD-RS: ADHD Rating Scale; SCID-II: Structured Clinical Interview for DSM-IV Axis II Personality Disorders; WISPI-IV: Wisconsin Personality Disorders Inventory IV; WRAADDS: Wender-Reimherr Adult Attention Deficit Disorder Scale.
*All correlations involve 47 patients and thus 46 degrees of freedom.

TABLE 3

Demographics, ADHD symptoms, and social adjustment as a function of ADHD categories

  ADHD alone ADHD+EDa ADHD+ED+ODDb Statistic
Patients, n 8 18 19  
Age 29.4±5.5 32.2±14.3 29.6±8.6 F(2,42)=0.27; P=.766
Male/female 6/2 11/7 14/5 χ2=0.52; df=2; P=.773
PRS 16.1±8.2 19.3±5.5 23.1±4.4 F(2,31)=3.74; P=.035
WURS 38.6±16.8 52.7±13.7 65.6±13.4 F(2,42)=13.30; P=.001
Drug/alcohol history 2 (25%) 4 (22%) 5 (26%) χ2=0.86; df=2; P=.958
HAMD-17 6.9±3.3 10.5±5.4 13.2±5.9 F(2,42)=3.68; P=.034
ADHD Rating Scale 36.0±10.0 38.2±8.7 32.5±2.1 F(2,42)=0.64; P=.530
  Attention 21.4±3.1 20.5±4.4 20.0±2.8 F(2,42)=.011; P=.900
  Hyperactivity/impulsivity 14.6±7.2 17.7±5.3 12.5±4.9 F(2,42)=1.68; P=.200
Social Adjustment—WSAS-SR average±SD (% at least moderately impaired)
  Work 1.4±0.5 (5%) 2.2±1.1 (33%) 2.5±1.3 (43%) F(2,34)=4.86; P=.014
  Extended family 1.6±0.6 (0%) 1.7±0.5 (0%) 2.0±0.7 (12%) F(2,35)=1.47; P=.243
  Marital 1.3±0.2 (0%) 2.2±.5 (30%) 2.1±0.7 (35%) F(2,17)=2.05; P=.160
  Parental 2.0±na (14%) 1.7±0.4 (0%) 1.8±0.2 (50%) F(2,7)=0.13; P=.878
  Economic 2.0±1.4 (40%) 2.2±1.4 (33%) 2.6±1.6 (56%) F(2,35)=0.48; P=.622
  Conflicts 1.5±0.7 (12%) 1.5±0.7 (8%) 2.0±1.1 (32%) F(2,36)=3.67; P=.035
  Emotionality 1.3±0.2 (0%) 1.7±0.8 (15%) 2.0±0.8 (25%) F(2,35)=1.63; P=.211
ADHD: attention-deficit/hyperactivity disorder; ED: emotional dysregulation; na: not applicable; ODD: oppositional defiant disorder; PRS: Parent Rating Scale; WURS: Wender Utah Rating Scale; HAMD-17: 17-item Hamilton Rating Scale for Depression; WSAS-SR: Weissman Social Adjustment Scale–Self-Report.
aADHD + ED: Patients met criteria for ADHD as well as ED.
bADHD + ED + ODD: Patients met criteria for ADHD and ED, and had significant ODD symptoms.

TABLE 4

Demographics, ADHD symptoms, and social adjustment as a function of PD categories

  PD-negativea PD-positiveb PD-plusc Statistic
Patients, n 26 11 10  
Age 32.0±12.5 29.2±8.6 28.7±8.5 F(2,42)=0.41; P=.667
Male/female 16/10 6/5 9/1 χ2 =3.44; df=2; P=.179
PRS 17.9±6.3 21.6±4.0 24.6±4.6 F(2,33)=4.26; P=.023
WURS 48.0±15.8 65.0±10.0 64.8±17.5 F(2,44)=7.32; P=.002
Drug/alcohol history 6 (23%) 1 (9%) 5 (50%) χ2=4.93; df=2; P=.085
HAMD-17 8.5±5.3 14.4±6.1 13.3±2.7 F(2,44)=6.22; P=.004
ADHD Rating Scale 35.0±9.6 34.9±6.5 41.0±8.8 F(2,44)=1.89; P=.205
  Attention 20.5±4.7 19.7±3.1 21.4±3.1 F(2,44)=0.63; P=.540
  Hyperactivity/impulsive 14.4±5.8 15.2±5.1 19.1±6.2 F(2,44)=2.10; P=.128
WRAADDS total 21.2±2.8 25.2±1.4 25.4±2.2 F(2,44)=16.64; P < .001
  Attention + disorganization 3.7±0.5 3.6±1.3 3.9±1.3 F(2,44)=0.72; P=.492
  Hyperactivity + impulsivity 3.0±0.8 3.6±0.3 3.5±0.6 F(2,44)=4.10; P=.024
  Emotional dysregulation 2.6±0.7 3.6±0.3 3.6±0.5 F(2,44)=10.99; P < .001
Self-Report ADHD Scale
  Attention + disorganization 3.0±0.6 3.1±0.6 3.0±0.6 F(2,44)=0.28; P=.754
  Hyperactivity + impulsivity 2.4±1.0 2.9±0.6 3.1±0.7 F(2,44)=2.39; P=.104
  Emotional dysregulation 1.9±1.0 2.8±0.4 2.7±0.8 F(2,44)=4.68; P=.015
  Oppositionality 1.5±0.8 2.2±0.5 2.6±1.1 F(2,44)=7.37; P=.002
  Academic problems 2.0±1.1 1.7±1.0 1.7±1.4 F(2,44)=0.39; P=.677
Social Adjustment—WSAS-SR average±SD (% at least moderately impaired)
  Work 2.1±0.6 (14%) 2.3±0.8 (0%) 2.9±0.9 (56%) F(2,35)=4.07; P=.026
  Extended family 1.6±0.3 (0%) 2.1±0.5 (11%) 2.1±0.5 (11%) F(2,37)=3.98; P=.027
  Marital 1.9±0.3 (8%) 1.9±0.5 (0%) 2.5±0.7 (0%) F(2,18)=2.42; P=.118
  Parental 1.8±0.2 (0%) 1.5±1.0 (0%) 2.0±0.4 (33%) F(2,7)=0.18; P=.838
  Economic 1.8±1.2 (30%) 3.0±1.5 (66%) 3.0±1.6 (55%) F(2,37)=3.45; P=.042
  Conflicts 1.5±4.3 (0%) 1.8±0.6 (11%) 2.5±1.2 (22%) F(2,38)=5.66; P=.007
  Emotionality 1.5±0.5 (4%) 1.7±0.5 (0%) 2.6±1.0 (33%) F(2,37)=7.95; P=.001
ADHD: attention-deficit/hyperactivity disorder; HAMD-17: 17-item Hamilton Rating Scale for Depression; PD: personality disorder; PRS: Parent Rating Scale; WRAADDS: Wender-Reimherr Adult Attention Deficit Disorder Scale; WSAS-SR: Weissman Social Adjustment Scale–Self-Report; WURS: Wender Utah Rating Scale.
aPD-negative: Patients did not meet criteria for personality disorder.
bPD-positive: Patients met criteria for 1 personality disorder.
cPD-plus: Patients met criteria for ≥2 PDs.

  DISCUSSION

As we have previously reported, 45% of the patients in this trial met criteria for PD. We found that PD was more frequent in ADHD patients with more complicated symptoms, eg, emotional and/or oppositional traits. Numerous (39%) ADHD + ED patients had at least 1 Axis II diagnosis, and 68% of the ADHD + ED + ODD patients had at least 1 Axis II diagnosis. In this small sample, no patients in the ADHD-only group were identified as having a PD. Consequently, we would conclude that complexity of ADHD, particularly symptoms of emotional dysregulation and oppositional symptoms, is associated with PD. We found that this also applied to patients who had 2 or more PDs, whom we labeled as PD-plus.

Although there is a significant relationship between the ADHD dimensions of emotional dysregulation and ODD with the symptoms of PD, several observations differentiate them: (1) emotional dysregulation has consistently responded to ADHD treatment in parallel with the DSM symptoms of inattention and hyperactivity/impulsivity; (2) ODD symptoms also respond to ADHD treatment; (3) in contrast, stimulants have never proven useful in treating PDs, and in this trial patients with 2 or more PDs did not respond to treatment45; (5) emotional dysregulation and ODD were not associated with any specific PD or even a specific cluster.

Next, we were interested in whether PD severity as measured by the WISPI-IV z scores and/or the number of endorsed SCID-II items was associated with specific dimensions of ADHD. This was done by calculating the correlation coefficients between each of the 3 groupings of the WRAADDS ADHD symptoms (attention/disorganization, hyperactivity/impulsivity, and emotional dysregulation) as well as the ODD score of the Self-Report ADHD Scale with these personality measures for each diagnostic cluster. We also calculated correlation coefficients for the entire test for both measures. The intensity of DSM symptoms of attention/disorganization and hyperactivity/impulsivity, with one exception, was not correlated with the specific PDs dimensions. In contrast, emotional dys-regulation and symptoms of ODD were significantly associated with all 3 clusters, as well as passive-aggressive and WISPI-IV z scores and number of SCID-II items endorsed.

The level of the correlation was moderate, suggesting that a relationship was identified, but we were not measuring identical dimensions. Generally, the highest correlation coefficients were between the overall WISPI z score average (and/or average SCID-IV items endorsed) and each ADHD dimension, not to a particular cluster. These findings contrast with beliefs expressed by Adler et al46 that children with ODD are at risk for cluster B disorders in adulthood. Although adults with ODD symptoms are at risk for cluster B disorders, they are also at risk for other PDs.

Previous analysis of these data indicted that patients with ADHD + ED or ADHD + ED + ODD were more likely to experience social maladjustment. This reanalysis found that PD status was similarly related to social maladjustment. As indicated in TABLE 4, complex presentations (using both ADHD and personality categories) were significantly associated with high childhood ADHD ratings and, to a lesser extent, social adjustment in work, extended family, economic functioning, and our unique measures of conflicts and emotionality. The relationship might be viewed as a related process. Social impairment is concentrated in ADHD patients with emotional and oppositional symptoms. In such patients, the additional presence of PD increases the level of social impairment.

This led us to conclude that adverse outcomes in ADHD, both psychosocial problems and PD, are concentrated in patients with more complex ADHD symptoms. This has particularly important implications for studies of long-term outcome of ADHD and current surveys of conditions associated with ADHD. Without careful assessment of the type of ADHD patients included in the sample, the results will be open to question.

Limitations

The initial study was designed as a clinical trial of OROS MPH in adult ADHD, and the assessment of PD was planned as a core part of the clinical trial. Further, although the inclusion and exclusion criteria are typical of adult ADHD clinical trials, they may have influenced the PDs exhibited in this sample compared with the total ADHD population. Most patients in this study were Caucasian and, given the exploratory nature of the study, we did not control for multiple comparisons. As noted earlier, assessment of PD in ADHD is problematic at best. However, we believe that the consistent findings between 2 validated personality assessments as well as clinical judgment give strong support to these findings.

  CONCLUSION

Numerous patients (45%) in this clinical sample met DSM-IV criteria for 1 or more PDs. Almost all PDs and clusters were represented in this sample. The data identified an association between ADHD and PD that was mediated primarily via the ADHD dimensions of emotional dysregulation and oppositional symptoms, rather than the ADHD dimensions of attention + disorganization and hyperactivity + impulsivity. Finally, poor psychosocial functioning was concentrated in 2 groups of patients: (1) those with emotional dysregulation and oppositional symptoms, and (2) patients with PDs.

ACKNOWLEDGEMENT: The authors would like to acknowledge Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa, for his careful review of an earlier version of this paper.

DISCLOSURES: Mr. Marchant receives grant/research support from Ortho-McNeil Pharmaceuticals. Drs. Reimherr, Williams, Soni, and Strong and Ms. Halls report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

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CORRESPONDENCE: Fred W. Reimherr, MD, Mood Disorders Clinic, Department of Psychiatry, 30 N 1900 E Rm 5R218 University of Utah Health Sciences Center, Salt Lake City, UT 84132 USA E-MAIL: fred.reimherr@hsc.utah.edu