Psychiatry Research 217 (2014) 107–114

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Distinguishing borderline personality disorder from adult attention deficit/hyperactivity disorder: A clinical and dimensional perspective Paco Prada a,1, Roland Hasler b,1, Patrick Baud a,1, Giovanna Bednarz a, Stefano Ardu c, Ivo Krejci c, Rosetta Nicastro a, Jean-Michel Aubry a,d, Nader Perroud a,d,n a

Department of Mental Health and Psychiatry, Service of Psychiatric Specialties, University Hospitals of Geneva, Switzerland Department of Medical Genetic and Laboratories, Psychiatric Genetic Unit, University Hospitals of Geneva, Switzerland c Department of Cardiology and Endodontology, Treatment Plan Unit and Division of Operative Dentistry, Dental School, University of Geneva, Geneva, Switzerland d Department of Psychiatry, University of Geneva, Geneva, Switzerland b

art ic l e i nf o

a b s t r a c t

Article history: Received 24 July 2013 Received in revised form 10 February 2014 Accepted 2 March 2014 Available online 12 March 2014

Adult attention deficit hyperactivity disorder (ADHD) is frequently associated with borderline personality disorder (BPD). As both disorders share some core clinical features they are sometimes difficult to distinguish from one another. The present work aimed to investigate differences in the expression of impulsivity, anger and aggression, quality of life as well as the number and severity of the comorbidities between ADHD, BPD, comorbid BPD-ADHD and control subjects. ADHD and BPD-ADHD patients showed a higher level of impulsivity than BPD and control subjects. BPD-ADHD patients had higher levels of substance abuse/dependence and higher levels of aggression than the other groups. Comorbid BPDADHD patients showed high levels of impulsivity and aggression, a characteristic that should draw the attention of clinicians on the necessity of providing an accurate diagnosis. The question also arises as to whether they represent a distinct clinical subgroup with specific clinical characteristics, outcomes and vulnerability factors. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Impulsivity Psychiatry ADHD Anger Aggression Child maltreatment

1. Introduction Attention deficit/hyperactivity disorder (ADHD) is seen as a neuro-developmental disorder starting before the age of seven, according to the DSM-IV. Approximately 50% of the children suffering from ADHD still displayed clinically relevant symptoms when reaching adulthood, with a high degree of psychiatric comorbidities (Kessler et al., 2006), among which borderline personality disorder (BPD) is encountered more often than expected by chance (Bernardi et al., 2012; Philipsen et al., 2008). Several hypotheses can be raised to explain this greater-thanchance co-occurrence of the two disorders: (a) BPD and ADHD are different expressions of the same disorder rather than two distinct clinical entities; (b) ADHD may be an early manifestation (precursor) of BPD; (c) ADHD and BPD are distinct disorders sharing common genetic and environmental risk factors; (d) the presence of one disorder increases the risk of developing the other. This last hypothesis is strongly supported by the fact that ADHD appears

n Corresponding author at: Program TRE, Service of Psychiatric Specialties, Department of Mental Health and Psychiatry, University Hospitals of Geneva, 20b rue de Lausanne, 1201 Geneva, Switzerland. E-mail address: [email protected] (N. Perroud). 1 These three authors contributed equally to the work.

http://dx.doi.org/10.1016/j.psychres.2014.03.006 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

earlier than BPD, as highlighted by several studies (Bohus et al., 2004; Davids and Gastpar, 2005; Matthies et al., 2011; Philipsen, 2006; Speranza et al., 2011). Whichever hypothesis proves correct, a substantial clinical overlap is frequently observed between the two disorders. In fact, several symptoms such as impulsivity, mood liability, irritability, difficulty in controlling anger and impaired stress tolerance are found in ADHD patients as well as in BPD subjects. Among these symptoms, impulsivity has been identified as one of the most common traits occurring within this behavioral overlap (Davids and Gastpar, 2005). Impulsivity and related dimensions, such as inhibitory deficits, are part of the impaired executive functions that have been found in ADHD subjects leading researchers to consider ADHD as an “executive disorder”(Willcutt et al., 2005). These dimensions represent such a core phenomena in ADHD, that ADHD has historically been considered as an inhibitory disorder (Barkley, 1997; Nigg, 2001; Willcutt et al., 2005). Metaanalyses have shown that deficiency in inhibitory functions, especially motor inhibition, features among the most robust findings that distinguish ADHD patients from control subjects and other clinical populations (Nigg, 2001; Willcutt et al., 2005). Some studies on BPD also suggest that patients suffering from that disorder exhibit inhibitory dysfunctions similar to those observed among ADHD subjects. This is possibly explained by a dysfunction of the prefrontal

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P. Prada et al. / Psychiatry Research 217 (2014) 107–114

cortex and of the inhibitory systems mediated by frontal-striatal circuits (Bazanis et al., 2002; Dalley et al., 2008; Rentrop et al., 2008). The few studies that investigated impulsivity and related traits in both disorders suggest that ADHD patients have higher levels of impulsivity than BPD subjects (Lampe et al., 2007; Speranza et al., 2011). Lampe et al. (2007) have shown that ADHD patients do not perform as well as BPD subjects in two inhibitory tasks, namely the stop signal task relating to motor and cognitive impulsivity, and the conflict module of the Attention Network Task relating to cognitive impulsivity. Although ADHD patients may be distinguished from BPD subjects by attention deficits and organizational difficulties (Dowson et al., 2004), impulsivity may appear to be different in the two disorders. According to Lampe et al. (2007), ADHD patients and comorbid BPD-ADHD patients scored higher than BPD subjects on impulsivity ratings and some facets of anger expression. Moreover, temperamental analyses showed that, compared to patients displaying predominantly BDP symptoms, comorbid BPD-ADHD patients scored above average on Novelty Seeking, a dimension closely related to impulsivity. This suggests that high Novelty Seeking is more strongly linked to ADHD than it is to BPD itself (van Dijk et al., 2012). Therefore, impulsivity and inhibitory deficit appear more specifically associated with ADHD and should help distinguish BPD from ADHD. However, studies addressing this issue remain scarce and often fail to integrate other relevant dimensions such as aggression and/or anger expression. The aim of the present study was to examine impulsivity-, aggression- and anger-related traits, along with other relevant clinical features such as comorbid disorders and quality of life among adult ADHD patients, BPD patients, comorbid BPD-ADHD patients and healthy control subjects. We hypothesized that ADHD and comorbid BPD-ADHD patients would display a higher level of impulsivity and higher comorbid impulsivity-related disorders or behaviors, such as bipolar disorder and/or substance use disorder, than BPD patients. In addition, based on previous reports (Herpertz et al., 1997, 1999), the comorbid group should demonstrate poorer affect regulation (poorer anger control and higher aggression) than each disorder alone. Thus, the main purpose of our study was to better distinguish these two closely-related disorders. In addition, we were also interested to know if the behavioral and dimensional differences found between controls and the clinical samples may differently impact on the quality of life of these subjects. We here hypothesized that high levels of impulsivity and poor affect regulation may correlate with low levels of quality of life.

(DIGS) (Preisig et al., 1999), which assesses childhood ADHD, and the Screening Interview for Axis II disorders (SCID-II) BPD part (First et al., 1994), conducted by trained psychologists (RA, RN and GB). Only subjects with at least five criteria out of nine on the SCID-II were included in the current study as suffering from BPD. For ADHD subjects, SCID-II was only performed when the first assessment suggested the presence of BPD. If DSM-IV criteria were fulfilled, the subject was included in the comorbid group (BPD-ADHD), and if not, he/she was assigned to the ADHD group. For ADHD subjects, the existence of the disorder before the age of seven was required and was based on both the DIGS and the Wender Utah Rating Scale (WURS) (Ward et al., 1993), featuring a subset of 25 questions on a five point Likertscale. Following Fossati et al. (2002), we used a very stringent cut-off score of 46 to indicate the existence of ADHD in childhood. In addition, all subjects completed the following questionnaires: the Adult ADHD Self-Report Scale (ASRS v1.1) (Romo et al., 2010), which assesses severity of adult ADHD, the Barrat Impulsiveness Scale (BIS-10), which measures the three components of impulsivity: motor (behavior), attentional (cognitive) and nonplanning (Bayle et al., 2000), the State-Trait Anger Expression (STAXI), which measures the experience and expression of anger (Spielberger, 1998); the Lifetime History of Aggression (LHA), a nine-item interview that assesses lifetime aggressive behaviors in adolescence and adulthood (Brown et al., 1979); the Beck Depression Inventory II (BDI-II) (Beck et al., 1996) to assess the current severity of depression, the Beck Hopelessness Scale (BHS) (BHS; Beck et al., 1974), to estimate the degree of pessimism and negativity about the future, the shorter version of the World Health Organization Quality of Life Instrument (WHOQOL-BREF) questionnaire to test the quality of life (Baumann et al., 2010), the Questionnaire de Fonctionnement Social (QFS – Social functioning questionnaire), which is a 16-item self-report questionnaire assessing the frequency of, and the satisfaction with social behavior (Zanello et al., 2006), and the Childhood Trauma Questionnaire (CTQ), which examines five types of trauma (sexual abuse, physical abuse, physical neglect, emotional abuse and emotional neglect) (Bernstein and Fink, 1998) to assess childhood traumatic experience.

2.2.2. Controls All control subjects completed the following questionnaires: BIS-10, STAXI, BDI-II, LHA and BHS. The CTQ, ASRS v1.1, QFS and WHOQOL-BREF were only completed by control subjects recruited at the School of Dentistry at the University of Geneva (n ¼50). Finally, the assessment of Axis I disorders, using the Mini International Neuropsychiatric Interview (Preisig et al., 1999; Sheehan et al., 1998), was only performed for 228 control subjects.

2.3. Statistics Between-group comparisons were carried out using logistic regression and linear regression for categorical and continuous variables with adjustment on age and gender when appropriate. As several tests were performed for different independent samples, in order to take into account issues pertaining to multiple testing, we applied the Bonferroni correction. We conducted 31 tests (despite the fact that some of them were not entirely independent, we considered them as such in order to definitely rule out false positives) and six comparisons. The threshold for significance was therefore set at p ¼ 0.05/(31  6) ¼ 0.00027.

2. Methods

3. Results 2.1. Participants One hundred and fourteen outpatients suffering from adult ADHD were recruited in a specialized center for the diagnosis and care of adult ADHD patients at the University Hospitals of Geneva. In addition, 99 outpatients with BPD and 67 comorbid BPD-ADHD subjects were recruited in the same center, which also provides specialized care to BPD subjects, using dialectical behavior therapy as the main means of treatment (Perroud et al., 2010, 2012). Finally, 415 control subjects were recruited, either from the Blood Donor Center of the University Hospitals of Geneva, or from the School of Dentistry at the University of Geneva. The study was approved by the ethics committee of Geneva University Hospital. Informed written consent was obtained from all participants.

2.2. Measures 2.2.1. Patients During an initial assessment, which in some cases consisted of several interviews, all patients underwent a clinical evaluation carried out by a trained psychiatrist (NP, PP or PB), to ascertain the diagnosis of BPD and/or ADHD and to exclude any organic condition and/or Axis I disorders that might better explain the disorder. During a second assessment, participants were evaluated for Axis I and Axis II disorders using the French version of the Diagnostic Interview for Genetic Studies

Table 1 displays the clinical and demographic characteristics of the samples. Not surprisingly, BPD and BPDþ ADHD subjects were generally younger and more often female than the control subjects. The gender difference was also apparent when comparing ADHD to BPD and BPD-ADHD patients, with the former group being predominantly male. With the exception of eating disorders when comparing ADHD to control subjects, the latter significantly distinguished themselves from ADHD, BPD and ADHD þBPD subjects in all the clinical variables. BPD patients, with or without ADHD, showed a higher rate of Axis I disorders than both the ADHD patients and the control subjects. Unsurprisingly, they also showed a higher rate of suicidal behaviors, anxiety and eating disorders than ADHD patients and control subjects. Worthy of note, BPD-ADHD showed a significantly higher rate of substance use disorder than ADHD subjects (62.69% vs. 32.46%; p ¼7.50  10  5), although there was no difference in the rate of substance use disorder between ADHD and BPD subjects.

Table 1 Clinical characteristics of BPD, ADHD and BPDþ ADHD subjects. MDD ¼Major depressive disorder; BD ¼Bipolar disorder; Suicidal behav. ¼Suicidal behavior; Subst. use disord.¼ Substance use disorder; Anx. disor. ¼ Anxiety disorder; Eating disord. ¼ Eating disorder; Behav. probl. ¼Behavioral problems.

Age

ADHD (N ¼ 114)

BPD (N¼ 99) BPDþ ADHD (N ¼ 67)

Controls (N ¼415)

Mean

S.D.

Mean S.D.

Mean

S.D.

Mean

S.D.

36.66

10.45

32.86 10.62 29.42

8.30

45.58

12.63

Controls vs ADHD β;p

Controls vs BPD β;p

Controls vs BPD þADHD ADHD vs BPD β;p β;p

ADHD vs BPDþ ADHD BPD vs BPDþ ADHD β;p β;p

0.67; 7.28  10  11

0.96; 5.02  10  19

1.22; 5.62  10  22

0.55; 3.72  10  6

0.26; 0.027

χ2;p

χ2;p

2

2

2

0.28; 0.011 2

N

%

χ ;p

χ ;p

χ ;p

χ ;p

91.92 62

92.54

153

36.87

0.756; 0.385

97.15; 6.43  10  23

72.35; 1.79  10  17

78.12; 9.67  10  19 61.47; 4.48  10  15

0.012; 0.884

– – –

– – –

36 26 5

53.73 38.81 7.46

– – –

– – –

–

–

–

–

–

38.6 7.89 6.14 47.37

71 23 2 3

71.72 23.23 2.02 3.03

41 18 3 5

61.19 26.87 4.48 7.46

49 4 25 150

21.49 1.75 10.96 65.79

21.93; 6.74  10  5

150.81; 1.76  10  32 106.36; 6.64  10  23

60.11; 5.55  10  13 35.59; 9.11  10  8

3.29; 0.348

11

9.57

57

67.05 43

66.15

4

1.46

18.95; 1.34  10  5

197.29; 8.15  10  45 183.51; 8.30  10  42

57.38; 3.58  10  14 50.19; 1.39  10  12

0.01; 0.907

37

32.46

39

39.39 42

62.69

4

1.75

67.89; 1.72  10  16 85.63; 2.17  10  20

%

N

%

Female

37

32.46

91

ADHD type Attentional Hyp./impul. Combined

37 69 8

32.46 60.53 7.02

Axis I disord.a (lifetime) MDD 44 BD 9 Others 7 None 54 Suicidal behav.b Subst. use disord.

N

6

139.64; 3.18  10

 32

146.07; 1.25  10  33 142.15; 8.99  10

 33

8.54; 0.014

15.68; 7.50  10  5

1.11; 0.292 43.99; 3.29  10

 11

48.32; 3.62  10

8.67; 0.003

 12

1.35; 0.245

Anx. disor.

31

27.19

72

72.73 54

80.6

20

8.77

20.32; 6.53  10

Eating disord.

7

6.14

44

44.44 34

50.75

2

2.3

8.2162; 0.004

108.38; 2.21  10  25 120.20; 5.72  10  28

42.69; 6.41  10  11 47.92; 4.43  10  12

0.64; 0.425

– – –

– – –

26 15 58

26.26 22 15.15 14 58.59 29

33.85 21.54 44.62

– – –

– – –

–

–

–

3.21; 0.210

Behav. probl. Self-cutting Other behaviors Anger “crisis” a b c

c

–

–

P. Prada et al. / Psychiatry Research 217 (2014) 107–114

%

N

Only 228 controls fulfilled the DIGS. Missing data encountered. Including: burning itself, biting itself, vomiting, banging against a wall.

109

110 Table 2 Dimensions in BPD, ADHD and BPDþ ADHD subjects. BIS-10¼ Barrat Impulsiveness Scale; STAXI ¼State-Trait Anger Expression; LHA ¼ Lifetime History of Aggression; ASRS v1.1¼ Adult ADHD Self-Report Scale; QFS ¼Social functioning questionnaire; WHOQOL-BREF ¼World Health Organization Quality of Life Instrument; BDI-II ¼ Beck Depression Inventory II; Hopelessness ¼Beck Hopelessness Scale. BPD (N ¼99) BPDþ ADHD (N ¼67)

Controls (N ¼ 415)

Mean S.D.

Mean S.D.

S.D.

Mean

S.D.

16.53 7.50 5.64 8.01

45.46 12.44 16.82 16.20

Mean

Controls vs ADHD Controls vs BPD β;p β;p

Controls vs BPD þADHD ADHD vs BPDβ;p β;p β;p

ADHD vs BPDþADHD BPD vs BPD þADHDβ;p β;p β;p

13.12 5.99 5.77 5.90

1.60; 2.04  10  75 1.51; 1.38  10  69 1.42; 4.27  10  50 1.05; 1.22  10  28

0.94; 0.95; 0.73; 0.68;

1.32  10  26 6.65  10  29 4.39  10  13 2.32  10  11

1.56; 6.27  10  50 1.63; 5.32  10  54 1.19; 6.66  10  25 1.04; 3.93  10  18

0.66; 7.06  10  8 0.56; 1.79  10  6 0.60; 0.0005 0.13; 0.487

0.03; 0.792 0.12; 0.367 0.15; 0.381 0.02; 0.916

0.63; 0.68; 0.46; 0.36;

1.24; 1.79  10  28 1.55; 3.89  10  47 1.02; 1.00  10  18 1.19; 1.57  10  27 1.14; 6.79  10  21

1.32; 4.32  10  26 1.63; 3.94  10  47 1.11; 6.24  10  16 1.48; 1.09  10  31 1.18; 6.21  10  18

0.06; 0.34; 0.39; 0.20; 0.23;

0.16; 0.405 0.45; 0.033 0.46; 0.028 0.60; 0.0002 0.33; 0.093

0.03; 0.870 0.12;0.529 0.05; 0.772 0.25; 0.180 0.02; 0.880

BIS-10 Total score Motor Attentional Non-planning

77.18 16.44 64.06 16.72 76.50 26.27 7.72 21.12 7.05 27.34 26.96 6.12 22.03 6.75 25.33 23.95 7.51 21.17 7.06 23.82

STAXI Trait anger State anger Anger in Anger out Anger control

26.40 21.27 19.93 16.96 20.25

6.45 27.45 7.02 23.60 5.26 21.54 4.89 18.67 4.84 18.81

27.69 24.17 21.82 20.06 18.72

6.64 8.00 6.08 5.79 4.68

19.41 12.99 16.02 12.47 24.56

4.89 4.05 4.64 3.45 4.15

1.03; 3.93  10  32 1.02; 2.10  10  39 0.77; 4.48  10  14 0.81; 6.11  10  19 0.75; 4.10  10  13

12.86 49.50

9.76 15.44 8.91 20.36 9.98 38.10 10.71 45.73

8.60 11.79

3.76 24.08

4.14 8.10

0.89; 1.49  10  18 1.31; 3.20  10  26 1.81; 2.40  10  38 2.01; 2.56  10  29 0.97; 9.84  10  9 1.67; 4.58  10  14

0.36; 0.058 0.79; 2.64  10  6 1.09; 2.98  10  10 0.43; 0.035

0.49; 0.001 0.58; 0.0001

0.48; 0.028 0.49; 0.017

0.03; 0.833 0.04; 0.800

0.59; 0.71; 0.45; 0.71;

0.002 0.0001 0.025 0.0003

0.12; 0.423 0.01; 0.937 0.02; 0.889 0.16; 0.344

0.88; 4.79  10  7 0.88; 1.82  10  5

0.01; 0.960 0.07; 0.620

LHA ASRS v1.1 total scorea

QFSa Frequencies of activities 28.49 Satisfaction with activities 26.03 WhoQoL-Brefa Physical Psychological Social Environment BDI-IIa Hopelessnessa a

22.21 16.70 8.78 29.32 20.41 8.54

6.77 8.77 4.62 5.54 4.77

0.759 0.094 0.019 0.302 0.187

5.07 26.80 5.40 23.62

5.93 26.78 6.22 23.87

5.43 6.07

33.39 33.27

2.62 3.47

0.85; 9.19  10  8 1.15; 1.39  10  12

1.12; 3.78  10  8 1.22; 6.65  10  9 1.49; 3.54  10  13 1.46; 2.65  10  11

0.47; 0.028 0.50; 0.012

4.53 18.80 4.22 13.42 2.51 8.22 5.11 26.36

4.82 19.59 4.26 13.46 2.87 8.28 6.73 25.43

5.21 4.52 2.85 5.37

29.98 24.22 11.98 34.06

3.33 3.06 2.11 4.15

1.43; 6.87  10  20 1.42; 1.40  10  20 1.11; 4.13  10  11 0.79; 4.82  10  7

1.95; 1.27  10  22 1.88; 5.14  10  24 1.30; 3.63  10  10 1.14; 9.11  10  8

1.77; 1.07  10  15 2.05; 5.97  10  21 1.39; 1.37  10  9 1.35; 6.81  10  11

0.75; 0.64; 0.31; 0.49;

11.29 34.03 11.68 33.99 4.69 11.11 4.44 11.42

12.95 5.38

5.59 3.85

5.26 2.42

1.10; 4.00  10  16 1.87; 1.12  10  25 0.92; 1.49  10  9 1.33, 2.02  10  14

2.02; 2.11  10  21 1.59; 7.48  10  13

0.80; 1.89  10  7 0.67; 0.0001

Only 50 controls did fulfill this questionnaire.

1.16  10  5 0.0001 0.150 0.018

1.33  10  5 6.22  10  7 0.002 0.034

P. Prada et al. / Psychiatry Research 217 (2014) 107–114

ADHD (N ¼114)

1.74; 0.186 0.403; 0.525 4.40; 0.036 0.05; 0.824 1.93; 0.165

BPD vs BPDþ ADHD β;p

22.72; 1.87  10  6 6.22; 0.013 5.40; 0.020 4.41; 0.036 6.96; 0.008

ADHD vs BPD þADHD β;p

13.87; 4.03; 0.02; 4.47; 2.07;

0.0002 0.045 0.886 0.035 0.150

ADHD vs BPD β;p

12.29; 0.0004 18.56; 1.64  10  5 10.23; 0.001 38.42; 5.69  10  10 20.94; 4.71  10  6

19.28; 1.12  10  5 21.31; 3.90  10  6 22.19; 2.46  10  6 34.39; 4.50  10  9 28.13; 1.12  10  7

Controls vs BPDþ ADHD β;p

9 5 7 14 20 60.32 52.38 58.73 84.13 88.89 a

Only 48 controls fulfills the CTQ.

38 33 37 53 56 49.43 47.13 41.38 82.76 80.46 43 41 36 72 70 23.85 33.03 40.37 69.72 71.56 26 36 44 76 78 CTQa SA PA PN EA EN

% N % N %

18.75 10.42 14.58 29.17 41.67

0.501; 0.479 8.83; 0.003 10.10; 0.001 22.41; 2.20  10  6 12.69; 0.0004

Controls vs BPD β;p Controls vs ADHD β;p Controls (N ¼ 415)

N

Although the specificity (0.98) and the sensitivity (0.87), using the 4-point cut-off of the ASRS v1.1, were both very high when comparing control and ADHD subjects, this was not the case when comparing BDP patients to comorbid BPD-ADHD patients (specificity¼0.51; sensitivity¼0.67; negative predictive value¼ 0.70; positive predictive value¼0.48). Nevertheless, the total score for ASRS v1.1 significantly

%

3.3. Specificity and sensitivity of the ASRS-v.1.1 in BPD

N

Broadly speaking, control subjects reported less child maltreatment than the other clinical groups. This was particularly true when compared to BPD-ADHD patients. Emotional abuse is the form of maltreatment that best differentiates the control subjects from the clinical groups. It is relevant that ADHD subjects reported significantly less sexual abuse than both BPD and BPD-ADHD patients (Table 3).

BPDþ ADHD (N ¼67)

3.2. History of child maltreatment

BPD (N ¼ 99)

Table 2 shows the results derived from the abovementioned questionnaires. Control subjects displayed lower impulsivity, anger problems, aggression, depression, hopelessness, attention deficit-hyperactivity/impulsivity symptoms and higher quality of life and social functioning than all the clinical groups. ADHD subjects distinguished themselves from BPD subjects by a higher level of impulsivity (M¼77.18 (S.D.¼16.44) vs. M¼64.06 (S.D.¼16.72), β¼ 0.66, p¼7.06  10  8), which was mainly accounted for by higher levels of motor impulsivity (M¼26.27 (S.D.¼7.72) vs. M¼21.12 (S. D.¼ 7.05), β¼0.65, p¼1.79  10  6), a higher ASRSv1.1 total score (M¼49.50 (S.D.¼9.98) vs. M¼38.10 (S.D.¼ 10.71), β¼1.09, p¼2.98  10  10), better physical health (M¼ 22.21 (S.D.¼4.53) vs. M¼18.80 (S.D.¼4.82), β¼0.75, p¼1.16  10  5), better psychological health (M¼16.70 (S.D.¼4.22) vs. M¼ 13.42 (S.D. ¼4.26), β¼0.64, p¼0.0001), lower severity of depression (M¼20.41 (S.D.¼11.29) vs. M¼34.03 (S.D.¼ 11.68), β¼0.80, p¼1.89  10  7) and lower hopelessness (M¼8.54 (S.D.¼4.69) vs. M¼11.11 (S.D.¼4.44), β¼0.67, p¼0.0001). Moreover, ADHD patients distinguished themselves from BPD-ADHD by overall lower aggression levels (M¼ 12.86 (S.D.¼9.76) vs. M¼20.36 (S.D.¼8.60), β¼ 0.79, p¼2.64  10  6) and reduced depression severity (M¼ 20.41 (S.D.¼11.29) vs. M¼ 33.99 (S.D.¼ 12.95), β¼0.88; p¼ 4.79  10  7). Also worthy of mention and in keeping with the lower aggression levels detected among ADHD subjects when compared to BPD-ADHD patients, ADHD patients showed lower outwards anger (M¼16.96 (S.D.¼4.89) vs. M¼20.06 (S.D.¼ 5.79), β¼0.60; p¼0.0002). Finally BPD-ADHD patients showed, compared to BPD subjects, higher levels of impulsivity (M¼64.06 (S.D.¼16.72) vs. M¼76.50 (S.D.¼16.53), β¼ 0.63, p¼1.33  10  5), a fact that was mainly explained by higher motor impulsivity (M¼21.12 (S.D.¼7.05) vs. M¼27.34 (S.D.¼7.50), β¼ 0.68; p¼6.22  10  7). In the whole sample, there was an inverse correlation between level of impulsivity (BIS-10 total score) and all the subscales of the WHOQOL-BREF (from Pearson's r ¼  0.39; p ¼9.63  10  12 for the social relationships to Pearson's r ¼ 0.51; p ¼4.07  10  20 for the psychological health) and the two subscales of the QFS (Pearson's r ¼  0.45; p ¼1.02  10  15 for the frequency of activities and Pearson's r ¼  0.46; p ¼1.68  10  16 for the satisfaction with activities). In the same way lower were the control of anger and higher the aggression levels lower were the scores at the WHOQOL-BREF and QFS subscales (from Pearson's r¼  0.25; p ¼1.35  10  5 for the correlation between anger control and social relationships to Pearson's r ¼  0.52; p ¼3.28  10  20 for the correlation between “anger in” and psychological health).

111

ADHD (N ¼114)

3.1. Questionnaires

Table 3 History of childhood maltreatments in BPD, ADHD and BPDþ ADHD subjects. CTQ ¼ childhood trauma questionnaire; SA¼sexual abuse; PA ¼physical abuse; PN¼ physical neglect; EA¼ emotional abuse; EN¼ emotional neglect.

P. Prada et al. / Psychiatry Research 217 (2014) 107–114

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distinguished BPD-ADHD patients from BPD subjects (β¼0.58, p¼ 0.0001) (Table 2).

4. Discussion The present study compared ADHD, BPD and BPD-ADHD patients with control subjects for psychopathological and behavioral dimensions relating to impulsiveness, anger and aggression. As expected, the clinical samples showed higher scores of impulsivity, anger-related traits and lifetime aggression than controls. They also displayed more comorbid Axis I disorders. In addition, ADHD, BPD and BDP-ADHD subjects were more depressed, showed greater hopelessness, and had a poorer quality of life. These results support numerous studies showing that emotional deregulation and poor impulse control may severely affect the interpersonal relationships and quality of life of ADHD and BPD patients (McCloskey et al., 2009; Murphy and Barkley, 1996; Sanislow et al., 2012). The comparisons of psychopathological and behavioral dimensions between clinical samples confirm and extend the results of the few studies conducted in this field. As already reported (Lampe et al., 2007; Speranza et al., 2011), ADHD and BPD-ADHD patients differed from BPD subjects by a higher level of impulsivity. Our results highlight the contribution of motor impulsivity to this difference. As motor impulsivity – the tendency to act on the spur of the moment – is a main characteristic of ADHD, it is not surprising to find that this dimension is the one that best separates ADHD from nonADHD subjects. Lampe et al. (2007) using the BIS-10, also found that comorbid and pure ADHD patients achieved a higher total score than BPD patients, especially in terms of motor impulsivity, with BPDADHD patients scoring the highest of all groups. These results may also be in agreement with the findings of van Dijk et al. (2012), showing that high Novelty Seeking – a tendency towards exploration in response to novel stimuli which comprises among others a subdimension measuring impulsiveness – was more strongly linked to ADHD than to BPD. Impulsivity is frequently associated with bipolar, eating, and substance use disorders and is considered a risk factor for suicidal behavior. One may therefore expect to find higher rates of these disorders, as well as of suicidal behavior, in the BPD-ADHD sample than in the BPD group, given the higher level of impulsivity of the former. However we found no difference between the two samples neither for suicidal behavior nor for bipolar and eating disorders, and the only trend identified was for substance use disorders. These results are very similar to the one found by Ferrer et al. where comorbid BPD-ADHD group was found to be more frequently associated to substance abuse disorder but not to bipolar disorder or suicidal behavior even if for the latter a trend was observed (Ferrer et al., 2010). These results may suggest that impulsivity alone may not be the only dimension that increases suicidal behavior. Other dimensions such as decision making, for instance, that has been shown to be impaired in suicidal patients, may play a crucial role and may be more linked to BPD than ADHD (Jollant et al., 2005). Of note, the BPD group was associated with a significantly higher rate of comorbidities than ADHD subjects. This certainly reflects the fact that in our study BPD had a more devastating effect on the general quality of life. Anger expression and aggression were also more severe among BPD-ADHD patients. Indeed, we found higher levels of outwardlydirected anger and lifetime aggression in BPD-ADHD subjects than in ADHD patients and a similar trend was found when compared to BPD patients. In the light of these results, Lampe et al. (2007) found that comorbid BPD-ADHD patients achieved the highest scores in terms of anger temperament and outward anger scores. These results are supported by the study by Ferrer et al. (2010),

showing that BPD-ADHD patients are more impulsive and show a trend towards higher rates of substance abuse disorders, suicidal behaviors, and antisocial personality disorders than the BPD patients. Altogether, these data show that BPD-ADHD patients may differ from either BPD or ADHD subjects in a clinically significant way. Indeed, they display a specific profile of high impulsiveness, anger and aggression-related traits, and possibly a larger spectrum of comorbid Axis I disorders associated with these psychopathological dimensions (Ferrer et al., 2010; Philipsen, 2006; Philipsen et al., 2008; Speranza et al., 2011). Our results, as well as those of several other studies, also suggest that being able to distinguish this subgroup of patients may have an impact on treatment (Andrulonis et al., 1982). Childhood maltreatment is common among BPD patients and has been considered to be an etiological factor involved in the development of the disorder (Zanarini, 2000; Zanarini et al., 1997). Histories of childhood maltreatment among ADHD patients have undergone far less research. Some studies suggested that ADHD patients experience more stressful life events during childhood than control subjects (Rucklidge et al., 2006) or that childhood ADHD is associated with emotional abuse (Philipsen et al., 2008). Our results support these findings, with emotional abuse being the kind of maltreatment best distinguishing ADHD patients from control subjects. Surprisingly, the rates of maltreatment were found to be roughly similar among ADHD and BPD patients, with the exception of sexual abuse which was more frequent in the latter group. Moreover, BPD-ADHD subjects reported the highest levels of maltreatment. These results are in opposition to the largely accepted idea that BPD is the only disorder to show a high rate of abuse and neglect. The number of studies investigating the relationships between BPD and child maltreatment is in this perspective more than convincing, whereas ADHD has mainly been thought as an inherited and genetically driven disorder and thus received far less attention concerning this point. Among BPD patients, trauma is thought to play an important role in the development of impulsivity by altering key neural mechanisms involved in inhibition (Teicher et al., 1993, 2003). As inhibition deficit is considered a core psychopathological feature of ADHD, one can wonder if it is also linked to the high rate of maltreatment found in these patients. Further investigations are required to untangle the relationships between childhood adverse events and the development of ADHD, BPD and comorbid BPD-ADHD. Whether some forms of maltreatment should be considered a cause or a consequence of these disorders is still unknown. Impulsivity in ADHD subjects may indeed precede the apparition of the maltreatment and even be, in some cases, responsible for it. While sexual abuse clearly distinguishes BPD from ADHD patients, it remains difficult to draw any firm conclusion about the complex interactions that exist between these disorders and various types of maltreatment. Since BPD and ADHD share several clinical features, we were interested to know whether the ASRS-v1.1 would help distinguish BPD patients from the comorbid BPD-ADHD subjects. Our results show that the specificity and sensitivity of the scale (with the usual 4 item cut-off for the six first items of the scale (Romo et al., 2010)) to detect ADHD in the context of BPD are quite poor. One must therefore rely on clinical evaluation rather than on this scale to screen for ADHD in BPD patients, although ASRS-v1.1 has been shown to be valuable with other comorbid disorders (Daigre Blanco et al., 2009). This observation confirms the results of a recent study showing that BPD and/or bipolar disorder type II patients displayed elevated scores at the ASRS v1.1 (Edebol et al., 2012), in the range between ADHD patients and control subjects. It also raises some doubts as to the results of previous studies that investigated the link between ADHD and BPD by using a selfreport questionnaire to assess ADHD (Philipsen et al., 2008).

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This study has several limitations, which reside partly in the specificities inherent to the populations studied. For one thing, the BPD and comorbid BDP-ADHD patients are nearly exclusively women, and our study therefore lacks the male portion of the BPD population. One of the treatment's requirement is that the clinical state of the patients must be sufficiently stable for them to undergo an outpatient program. In terms of impulsivity, it is likely that highly impulsive BPD patients were not included in the treatment, and are thus excluded from the study. Secondarily, our results are limited to the dimensions measured by the scales used in this study. In this perspective, BIS-10 is based on Barrat's model of impulsivity and thus does not cover the entire facets of impulsivity; other scales such as the UPPS, measuring for instance sensation seeking, may have been used for a more detailed investigation of this topic (Whiteside and Lynam, 2001). Moreover BIS-10 is a self-report measure of impulsivity and may possibly differ from behavioral tests or more objectives measures (Jacob et al., 2009). Other limitations that are inherent to the diagnostic assessment of ADHD are also to be considered: childhood symptomatology rests in this case on personal memories and may be remembered in the light of current problems; thus without information provided by relatives there is a risk of under- or over-evaluation. Furthermore, the currently used DSM-IV criteria have not been validated for adult diagnosis, and symptoms related to executive dysfunctions contributing to the clinical picture are not taken into account. Finally, our article is based on the assumption that BPD and ADHD may be considered as separate entities and our results may suggest that this could be the case. But one has to keep in mind that the co-existence of the two disorders may be seen as an indirect measure of the severity of either ADHD or BPD and thus, the overlap between these two disorders may be larger than the one suggested in the current article. BPD is characterized by elevated impulsiveness and poor affect regulation. However, when compared to ADHD and comorbid BPD-ADHD subjects, BPD patients display lower BIS-10 scores, suggesting that impulsivity, and more specifically motor impulsivity, is essentially an ADHD characteristic. Interestingly, our study shows that affect deregulation and maladaptive modes of coping with anger characterize as much ADHD as BPD patients, a fact suggesting that the overlap between the two disorders might be stronger than previously suspected. Moreover, comorbid BPD-ADHD patients display specific psychopathological characteristics distinguishing them from ADHD and from BPD subjects. Whether BPD-ADHD represents a specific clinical entity remains a matter of debate and a question for future investigations. Nevertheless, BPD-ADHD patients represent a homogeneous subgroup with marked impulsivity and difficulties to control anger, which may take the form of aggressive reactions. In a clinical perspective, these findings should be taken into account in order to achieve the best quality of care. The way methylphenidate and other drugs used to treat ADHD act on this particular subgroup of patients, and more specifically on their impulsive and aggressive behaviors, requires further research.

Conflict of interest Nader Perroud has received honoraria for participating in expert panels from Lundbeck.

Acknowledgment We thank Dominique Mouthon for data management. We also thank Gérald Bouillault, Jean-Jaques Kunckler, Brigitte Blanchon, Venus Kaby, Mara Albom and Caroline Waeber for the data collection.

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