Symptoms of Attention Deficit , Hyperactivity and Impulsivity in a Sample of Personality Disorder Patients

Background: ADHD and personality disorders can show several common clinical characteristics. When evaluating individuals more closely it can be found that there are several specifi c attention features and also hyperactivity and impulsivity features that can differentiate these diagnostic categories, as well as functionality in different areas of life. Material and methods: In this study a sample of 140 individuals with a personality disorder has been evaluated in order to determine the proportion of symptoms of attention defi cit and hyperactivity/impulsivity by using the scale DIVA. Two groups were formed: A – the ADHD group and B – the nonADHD group. The ADHD group has three subgroups depending on the most frequent disabilities (inattentive, hyperactive/impulsive and combined). A global assessment has been made by using the scales CGIs, GAF and WFIRS (Weiss Scale). Results: Average scores have been calculated on the attention and hyperactive/impulsive domain in the two groups and then in the subgroups. The hyperactive/ impulsive domain is better represented in each group. A comparative approach referring to all the groups has been realized. Then, it has been studied the prevalence of the 18 items from the DIVA scale in the groups identifi ed above and the proportions in which they differentiate the two populations. The items A6,A4,H1,H8 differentiate best the ADHD and non ADHD patients. The differentiation using the scales CGI, GAF, WFIRS (Weiss Scale) has been studied. Then, the personality disorders in the initial diagnosis have been interpreted. The most frequent personality disorders identifi ed in the ADHD group are: mixed (29%), antisocial (24%), borderline (20%), avoidant (7%) and histrionic (7%). Conclusions: The study has been successful in evaluating the difference between ADHD and nonADHD patients not only by differentiating symptoms, but also functionality and the initial diagnostic perspective.

In terms of evolution and prognosis of the individuals, personality disorder has been shown to have an important infl uence on the outcome of other mental disorders when present as a comorbid condition.
Many studies have approached the correlation between the personality disorders and ADHD.Miller et al. found that the risk of developing a personality disorder is increased in the individuals with ADHD.In his study he showed that the most frequent were borderline, antisocial, avoidant and narcissistic personality disorders 11,12 .
Some ADHD individuals show an increase in risky behaviours.Antisocial activity and possible detention are also found.A study by Torgerson (2007) found 44% of ADHD in a population of antisocial personality disorder patients.Roesler (2004) found 45% ADHD in a population of antisocial personality disorder 13 .
One of the most used instruments that assesses the clinical picture in order to diagnose the ADHD in adults is the DIVA 14,15 .
Th e scale is based on the DSM IV criteria.It has been developed by J.J.S. Kooij and M.H. Francken and is the fi rst structured Dutch interview for ADHD in adults.Th e scale has 18 items meant to evaluate the two domains: attention defi cit and hyperactivity/impulsivity. Th e symptoms are evaluated both in childhood and adulthood.Information from family members is considered useful when possible.Th e presence of possible comorbidities has to be evaluated separately using other instruments.
An ADHD diagnosis according to DSM-IV-TR requires that six or more symptoms from one symptom domain must be present for at least six months, must be inappropriate for the individual's developmental level, interfere with functioning, be evident before seven years of age and be present across settings (e.g. at home and at school).

BACKGROUND
ADHD and personality disorders are known to have clinical presentations that sometimes share diff erent symptoms.Th eir characteristics are pervasive, relatively stable over the years.Th is study tries to determine the prevalence of attention defi cit and hyperactivity/impulsivity symptoms in a population of individuals with a personality disorder.
ADHD in adults is a disorder that presents symptoms that start early in life, usually observed at the age when the individual is faced with the educational environment.Later on, symptoms persist also in other domains of life, from family life to academic or social environment.
If we refer to personality disorders in general, the diagnostic criteria suggest traits that are persistent and infl exible.Problems in social functioning among people with personality disorder are clinically signifi cant.
Th ere are several descriptions of the main dimensions of personality disorder in studies carried out with diff erent populations.Th ree or four dimensions are uniformly reported [1][2][3][4][5] , in addition to the well-known fi ve-factor model 6,7 .
Th e fi ve factors have been defi ned as openness to experience, conscientiousness, extraversion, agreeableness and neuroticism.Beneath each global factor, there are a number of more specifi c primary factors 8 .
Th e categorical description of the various personality disorders is considered poorly specifi c.A diff erent approach is a dimensional one that refers to core features and enables a more specifi c characterization of each of the types of the personality disorders.
Th e DIVA consists of 9 items in the attention domain and 9 items in the hyperactive/ impulsive domain, the last being represented by 6 items of hyperactivity and 3 of impulsivity.Th e ADHD diagnosis is made after the DSM IV classifi cation.Th is diagnosis is present when more than 6 from 9 criteria from the inattentive or from the hyperactive/impulsive domain are met.
The 18 items are the following:

A1.
Often fails to pay close attention to details, or makes careless mistakes in schoolwork, work or during other activities A2.
Often has diffi cultly sustaining attention in tasks or play A3.
Often does not seem to listen when spoken to directly A4.
Often does not follow through on instructions and fails to fi nish schoolwork, chores, or duties in the workplace A5.
Often has diffi culty organizing tasks and activities A6.
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental eff ort (such as school of homework) A7.
Often loses things necessary for tasks or activities A8.
Often easily distracted by extraneous stimuli A9.
Often forgetful in daily activities H/I 1.
Often fi dgets with hands or feet or squirms in seat H/I 2.
Often leaves seat in classroom or in other situations in which remaining seated is expected H/I 3.
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults this may be limited to subjective feelings of restlessness) H/I 4.
Often has diffi culty playing or engaging in leisure activities quietly H/I 5.
Is often on the go or often acts as if 'driven by a motor' H/I 6.
Often talks excessively H/I 7.
Often blurts out answers before questions have been completed H/I 8.
Often has diffi culty awaiting turn H/I 9.
Often interrupts or intrudes on others 16 .Symptoms of inattention are characterized several behaviours such as making careless mistakes, forgetfulness, being easily distracted, diffi culty with organizing tasks, failure to begin or complete tasks.Symptoms of hyperactivity are characterized by behaviours such as fi dgeting with hands or feet, failure to sit still when required, talking excessively and symptoms of impulsivity by interrupting or intruding on others and having diffi culty waiting one's turn.
Th e inclusion criteria used have been a previous diagnosis of a personality disorder, the consent to being further investigated.Th e criteria used in the evaluation have been the DSM IV classifi cation.Th e exclusion criteria have been the refuse to sign the informed consent, the diagnostic scales left incomplete and acute symptoms at the time of the evaluation.
Th e 140 individuals have been evaluated using the scale DIVA (Th e Diagnostic Interview for ADHD in Adults).More of six symptoms in one or both domains (innatentive or hyperactive/impulsive) suggested a positive diagnosis of ADHD.Two groups were formed: A -the ADHD group and B -the non ADHD group.
Other scales used in the evaluation have been the CGIs (Clinical Global Impression severity), the GAF Scale (Global Assessment of Functioning), the WFIRS Scale (Weiss Functional Impairment Rating Scale Self-Report, WFIRS-S) 17 .
Th e demographic and medical data have been collected and inserted into an Excel table.
In this study the 18 items of the DIVA scale have been analysed in the two groups (ADHD and no-nADHD) in terms of percentage of response at each RESULTS 1.The DIVA scale -average scores and item analysis a. Average scores in the attention defi cit and hyperactive/impulsive domain First, it has been determined the mean number of items in the attention defi cit domain and then in the hyperactive/impulsive domain in the two groups: ADHD and nonADHD.
Th e average and SD are 5.20±1.9776number of attention items and respectively 2.25±1.4731for attention defi cit domain and 6.66±1.4766number of hyperactivity/impulsivity items and respectively 3.17±1.4359for hyperactivity/impulsivity domain.
As an observation, the average scores in the hyperactivity/impulsivity domain are higher than the attention defi cit domain in both the ADHD group and the no-nADHD group.Th is can be interpreted in the way that the initial population is by defi nition characterized by such traits, like impulsivity and hyperactivity because item, mean number of items in every domain -attention defi cit and hyperactivity/impulsivity, the signifi cance of the diff erence between the two groups.
Th e ADHD group is divided in three subgroups: predominantly inattentive (ADHD a), combined (ADHD c) and predominantly hyperactive/impulsive (ADHD hi).Th e items of the DIVA scale have been studied across the three subgroups.
Th e individuals have been also evaluated using some global clinical scales: the Weiss scale (the total score and the risk score), the CGIs scale and the GAF scale.Th e scores are evaluated in the two groups.
Another aspect studied has been the frequencies of the types of personality disorders in the initial diagnosis of the individuals evaluated.
Th ere can be identifi ed some limits of the study.Th e retrospective assessment of a childhood diagnosis can be subjective.It is known that usually the information from the patient can be subjective, the period assessed being several years before.Moreover, the information from the family members is usually absent.Medical records are also diffi cult to be found.score higher for items A6, A1, A2 (avoids sustained mental eff ort, fails to pay close attention to details, diffi cultly sustaining attention).Th e most frequent items in the hyperactivity/impulsivity domain are: H1, H3, H8 for the ADHD group and H3, H7, H8 for the nonADHD group.So, ADHD patients score high on items H1, H3, H8 (fi dgets with hands, subjective feelings of restlessness, diffi culty awaiting turn).
Th en a comparison between the percentage of response of every item (A1-A9, H1-H9) between the two groups (ADHD and nonADHD) has been made.Th e statistical test used has been the Pearson Chi-Square.Each comparison generated a p value shown below.
As observed the diff erence between the two groups is statistically signifi cant for items A1, A4, A5, A6, A7, A8, A9 and H1-H9.Th e diff erence is not important for items A2, A3 (diffi cultly sustaining attention, does not seem to listen), that means that they are less specifi c for ADHD symptomatology.these are traits common in the individuals with a personality disorder.
Th e average number of items in the two domains is compared between the two groups and it is shown an important statistical diff erence (p value=0.000000,Independent Samples T Test) for both domains.
Th en, it has been determined the average scores in the attention defi cit and hyperactive/impulsive domain in the ADHD subgroups.
A comparative approach referring to all the groups identifi ed by the evaluation using the DIVA Scale is shown below:

b. Item analysis
Th e percentage of response at every item (A1-A9, H1-H9) has been illustrated below referring to the ADHD and nonADHD group Th e most frequent items in the attention defi cit domain are A6, A1, A2 for the ADHD group and A2, A1, A6 for the nonADHD group.So, ADHD patients Graphic 2. Average scores in the attention defi cit and hyperactive/impulsive domain in the ADHD subgroups: a (predominantly inattentive), c (combined) and hi (hyperactive/impulsive).

Graphic 3. Average scores -comparative approach.
Th e order of the relevance of the items A1-A9 in terms of the way they can be used in diff erentiating the ADHD from the nonADHD patients is: A6, A4, A5, A8, A1, A9, A7, A2, A3.  c, ADHD hi).Th e results have been graphically illustrated.Th e results from the statistical analysis show that the subgroups can be diff erentiated by several items.Th e combined type can be diff erentiated from the hyperactive/impulsive type by items A2 and A5 (diffi cultly sustaining attention in tasks or play and diffi culty organizing tasks) and the inattentive subgroup from the hyperactive/impulsive subgroup by items H5, H6, H9 (acts as if 'driven by a motor', talks excessively, interrupts others).

CGIs scale, GAF scale and WFIRS (Weiss) scale
Th e scores of the Weiss scale, CGIs scale and GAF scale have been analysed between the two groups.
Th e average values of the scales CGI, GAF, Weiss (total score and risk domain) have been calculated.Th ey are shown below.Th e diff erences between the two groups -ADHD and nonADHD -have been studied using the Independent Samples T Test.
Th e average values of the CGI and GAF scale do not diff er statistically between the ADHD and no-nADHD patients (p_value=0.807587 for CGI and p value=0.206424 for GAF).Th at means that the global evaluation of the patients using nonspecifi c clinical scales does not discriminate between the ADHD pathology and the personality disorders.
Th e average values of the Weiss Functional Impairment Rating scale (WFIRS) diff er statistically betwe-Th e most relevant in diff erentiating the two pathologies are items A6 (avoids tasks that require sustained mental eff ort), A4 (does not follow through on instructions and fails to fi nish duties).
Th e less useful items for diff erentiation but still statistically signifi cant are A9 (being forgetful), A7 (losing things).
It can be observed that item A6 (avoids tasks that require sustained mental eff ort) is both the most frequent but also the most useful in diff erentiating the two subgroups.
Likewise, in the hyperactivity/impulsivity domain, the order of the items in terms of the way they can be used in diff erentiating the ADHD from the no-nADHD patients is: H1, H8, H6, H2, H9, H4, H5, H7, H3.
Th e most relevant in diff erentiating the two pathologies are items H1 (fi dgets with hands or feet), H8 (diffi culty awaiting turn).
Th e less useful items for diff erentiation H7 (answers before questions have been completed), H3 (restlessness).
It can be observed that the item H1 (fi dgets with hands or feet) is the most frequent but also the best to diff erentiate the two subgroups.

Th e ADHD subgroups -ADHD a, ADHD c, ADHD hi
Th e percentage of response at every item has been studied across the three subgroups (ADHD a, ADHD

The personality disorders in the initial diagnosis
Th e frequencies of the types of personality disorders in the initial diagnosis of the individuals evaluated has been determined and analysed across the two groups en the two groups (p value=0.002912for Weiss scale total score, 0.031711 for Weiss risk.Th is result shows that the Weiss scale is an instrument that can discriminate between the two pathologies especially the total score.Th e risk score can also diff erentiate them but the p value is smaller in this case, meaning that the diff erence is smaller than the global evaluation in all the domains, easy to understand taking into account that Graphic 6.The percentage of response at every item across the three subgroups (ADHD a, ADHD c, ADHD hi).
Graphic 7. The attention domain in the three subgroups.
both the ADHD group and the nonADHD group.A possible explanation is that we initially selected patients from a category that has as core features the impulsivity, the low frustration tolerance.Th e most frequent items in the attention defi cit domain are A6, A1, A2 for the ADHD group and A2, A1, A6 for the nonADHD group.
Th e most frequent items in the hyperactivity/impulsivity domain are: H1, H3, H8 for the ADHD group and H3, H7,H8 for the nonADHD group.
From the attention domain the most relevant in diff erentiating the two pathologies are items A6 (avoids tasks that require sustained mental eff ort), A4 (does (ADHD and nonADHD).Th ere have been also graphically illustrated.

CONCLUSIONS
Th e prevalence of response to the items of the DIVA scale from the two domains (A1-A9 and H1-H9) have been determined in the ADHD and nonADHD population and the diff erence between the two groups has been statistically evaluated.Th e average scores that have been calculated show the way the symptoms vary across the selected groups and subgroups.
Th e average scores in the hyperactivity/impulsivity domain is higher than the attention defi cit domain in Table 6.Scores of the Weiss scale, CGIs scale and GAF scale not follow through on instructions and fails to fi nish duties).
From the hyperactive/impulsive domain the most relevant in diff erentiating the two pathologies are items H1 (fi dgets with hands or feet), H8 (diffi culty awaiting turn).
Th e ADHD group can be divided in 3 subgroups.Th ey can be diff erentiated by several items of the DIVA scale.
Th e average values of the CGI and GAF scale do not diff er between the two groups.
Th e average values of the Weiss scale diff er statistically between the two groups.Th ere is a signifi cant sta-  the patients can be reconsidered as ADHD patients.So, at a closer and more attentive approach, characteristics of the personality can be reframed in another more specifi c syndrome that starts actually from childhood and go further in the adult life.Th is perspective off ers the clinician other clinical and therapeutic opportunities that are useful in the psychiatric practice.

Compliance with ethics requirements:
Th e authors declare no confl ict of interest regarding this article.Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law.Informed consent was obtained from all the patients included in the study.tistical evidence for both the total score and the risky behaviour domain.
Th e most frequent personality disorders identifi ed in the ADHD group are: mixed (29%), antisocial (24%), borderline (20%), avoidant (7%) and histrionic (7%).In the nonADHD group the most frequent personality disorders are mixed (55%), antisocial (18%), borderline (11%), histrionic (9%) and avoidant (3%).We notice that the types found more frequent are the same in the two groups, the proportion being diff erent.Th e best represented are the cluster B types, probably because the individuals from this diagnosis category would seek medical assistance more frequently.
Th e study evaluated a sample of patients initially diagnosed with a personality disorder.By using specifi c scales that test the domains of attention, hyperactivity and impulsivity, it has been found that a proportion of Graphic 12.The personality disorders in the initial diagnosis -comparative approach.

Graphic 8 .
The hyperactivity/impulsivity domain in the three subgroups.

Table 1 .
Average scores in ADHD and nonADHD patients Graphic 1.Average scores in the attention defi cit and hyperactive/impulsive domain in the ADHD and nonADHD group.

Table 4 .
Comparison between the percentage of response of every item (A1-A9, H1-H9) between the two groups (ADHD and nonADHD)

Table 5 .
Response at every item across the three subgroups

Graphic 9 .
The average values of the scales CGI, GAF, Weiss Scale (WFIRS -total score and risk domain).