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Curr Psychiatry Rep (2016) 18: 33 DOI 10.1007/s11920-016-0675-4

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

Alexandra Philipsen

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


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 [25, 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, 710]. 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

Then, Klein et al. [ 12 • ] presented data from a 33-year follow-up study in


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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 wh ich 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 B developmental 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.


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*)

were used: (ADHD OR (attention-deficit) OR hyperactivity*) AND (PD OR (personality disorder)*). The search included all

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.


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 [25, 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 SNAP25have 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

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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 in crease 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 (KC NIP4) 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 B strong 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].

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 tha t 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, 3239]. 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

between ADHD symptomatology in childhood and borderline traits in adulthood. Another study of the same research


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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

on comorbid psychiatric symptoms in addition to ADHD symptoms in a sample of 2284 college students.

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 childs 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

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disorders particularly autism spectrum disorders and ADHD. Neurodevelopmental disorders share the follow- ing characteristics: Their ons et 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 Porgeswork [60]. He and his coauthors published interesting stud- ies linking autonomic nervou s 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 l earned 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 neurode velopmental 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.


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 ac centuations and disorders.

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. A re 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 accep tance 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 speakersfee from Jansen-Cilag and was involved in clinical trials conducted by Janssen- Cilag and Lilly in the years 20072009. 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.

Informed Consent This article does not contain any studies with human or animal subjects performed by


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Papers of particular interest, published recently, have been highlighted as:

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