Adult ADHD , Comorbidities and Impact on Functionality in a Population of Individuals with Personality Disorders – DSM IV and DSM 5 Perspectives

Background: ADHD and personality disorders show a considerable symptom overlap. Sometimes these disorders are complicated by comorbidities, the most frequent being depression, alcohol and drug abuse or dependence. Their presence impact the functionality of patients. The introduction of DSM 5 brought a new perspective on the approach of these disorders. Material and methods: The study consists of the evaluation of a sample of 140 individuals with personality disorders. From this sample it has been determined the proportion of the ADHD patients by using a specifi c scale (DIVA). First the analysis has been made using the DSM IV criteria. Two groups were formed: A the ADHD group and B – the personality disorder non ADHD group. The possible comorbidities in the two groups A and B have been determined using the instrument MINI. The impact on functionality was evaluated with the scale WFIRS and the overall severity with the presence of hospitalizations. The same analysis has been made using the DSM 5 criteria. Then a comparison between the two classifi cations has been made. Results: The prevalence of ADHD in the initial sample of the personality disorder patients has been 29.3% after the DSM IV classifi cation and 44.3% after the DSM 5. Moreover, the prevalence of depression, alcohol, drug abuse and dependence and other comorbidities has been determined in the ADHD and non-ADHD group, fi rst using the DSM IV criteria, then using the DSM 5 criteria. A comparison between the two situations has been made, as well as an evaluation of the impact on functionality. Conclusions: The presence of depression, substance use disorders other than alcohol and alcohol use disorders are not signifi cant in the differentiation of ADHD patients from the population of personality disorder nonADHD patients. The overall severity and the impact on functionality as assessed with the presence of hospitalizations and the WFIRS scale show a signifi cant importance in differentiating the intensity of ADHD symptomatology.

Some ADHD individuals show an important behavioral dimension that includes risky behaviors.Some show antisocial activity and then possible detention.Th ere has been an interest in studying individuals in detention.Torgersen et al. found a proportion of 44% ADHD in a population of antisocial personality disorder patients (2007) 7 .Another study by Roesler (2004)  identifi ed 45% ADHD in a population of antisocial personality disorder 8 .
Th e DSM 5 classiffi cation changed the pespective on the ADHD pathology.Th e number of the criteria necessary is smaller and the age of the onset of the symptomatology has changed.Th e diagnosis is therefore easier.Th e age of the onset has changed from 7 to 12 years old, the number of symptoms are 5 instead of 6 in the adults 1 .
Th is study tries to assess the presence of ADHD symptomatology in a sample of individuals diagnosed with a personality disorder.Moreover, the evaluation can identify several comorbidities that can modify the clinical presentation.
Mood disorders are frequent comorbidities of ADHD.Th eir presence can be episodic and symptoma tology can be fl uctuating across the life span.ADHD symptomatology can often associate an aff ective dimension.Sometimes we can fi nd emotional liability, impulsivity, irascibility, anxiety.Other symptoms are reduced self-esteem, sadness, depressive ideas 9,10 .
Other possible diagnoses that can overlap with ADHD are substance use disorders and alcohol use disorders [11][12][13] .Alcohol abuse and dependence can often add some behavioral modifi cation and determine risky behaviors like driving intoxicated, fi ghting, violent behavior or other antisocial actions.
Substance use disorders can also be discussed in relation to the ADHD treatment strategies.Th ere has BACKGROUND Th e DSM 5 perspective made psychiatrists turn their attention towards some disorders like personality disorders or ADHD.Having in mind the diff erent approaches regarding these pathologies we can say that there are some issues regarding the diagnostic process that can be discussed 1 .
According to the DSM IV, personality disorders are enduring, pervasive behavioral and thinking patterns that are infl exible and maladaptive.Described not as episodic mental or emotional states that correspond to Axis I disorders, personality disorders show stable characteristics that cause distress or impairment in multiple environments 2,3 .
In ADHD we fi nd inattention, hyperactivity and impulsivity in all aspects and environments of everyday life.Time often produces a reduction of this symptomatology.Th ere have been many correlations in literature regarding ADHD in the adult population and personality disorders, the relationship being explained in multiple ways.An aspect that can be discussed is the fact that in many cases this symptomatology that persists longitudinally with possible fl uctuations can be complicated by the emergence of other comorbidities 4,5 .
Many studies have been conducted to evaluate the relationship between the personality disorders and ADHD.Miller et al. conducted a longitudinal study that assessed the possible relationship between ADHD in childhood, personality disorders in adult life and other comorbidities and concluded that the risk of developing a personality disorder is increased in the individuals with ADHD.Th e most frequent were borderline antisocial, avoidant and narcissistic personality disorders 6 .
Substance abuse and dependence has been extensively studied in relation to ADHD pathology [15][16][17][18][19] .Some studies compared the alcohol and drug abuse and dependence pathologies and found that the drug abusers show greater ADHD pathology compared to the alcohol abusers 15,16 .
Th e ADHD medication is represented by the stimulant and non-stimulant substances.Th e stimulant medication are MTH (methylphenidate) or AMPHbased medications (amphetamine), substances that present an addictive risk.Th is is why many studies studied the risks and benefi ts of prescribing stimulants to ADHD patients 20 .
Other comorbidities present in ADHD patients can be anxiety, impulse-related behaviors like gambling, somatoform disorders.

MATERIAL AND METHODS
Th e study is designed as a cross-sectional, non-interventional one.Th e sample of patients studied consists of 140 individuals diagnosed with a personality disorder from cluster A, B or C. Some of them were hospitalized, some of them were outpatients.
Th e inclusion criteria used have been a previous diagnosis of a personality disorder, after the DSM IV criteria, the consent to being further investigated.Th e exclusion criteria have been the refuse to sign the informed consent, the impossibility of fi nishing the diagnostic scales and symptoms that represent an emergency at the time of the evaluation.From this sample it has been determined the proportion of the ADHD patients by using a specifi c scale for the ADHD pathology: DIVA (Th e Diagnostic Interview for ADHD in Adults) 21 .Two groups were formed: A -the ADHD group and B -the personality disorder non ADHD group.Th e possible comorbidities in the two groups A and B have been determined using the instrument MINI (Mini International Neuropsychiatric Interview).Th e impact of functionality has been determined using the scale WFIRS (Weiss Functional Impairment Rating  Scale).
Th e diagnosis of ADHD in adults is made initially after the DSM IV classifi cation, when more than 6 from 9 criteria from the inattentive or from the hyperactive/impulsive domain are met.Moreover, the diagnosis of ADHD in adults is revaluated using the DSM 5 criteria, that is when 5 from 9 criteria are met.Th en, a comparison between the two perspectives is made, having in mind the comorbidities and their impact on functionality.
Th e patients have been evaluated and the demographic and medical data has been collected.Th e standardized instruments used were the following rating scales: DIVA, WFIRS, ASRS, CGIs, GAF, MINI.Th e DIVA evaluation gives us a total score, that means the total number of positive items, the DIVA attention score or the DIVA hyperactive/impulsive score.From the evaluation with the WFIRS we use the total score and the risk score.
Some demographic data are: age, education, marital status, children.Other elements are the medical pathology, somatic or psychiatric, hospitalizations, treatments, employment, use of substances (coff ee, smoking, alcohol).
Th e data has been collected and inserted into an Excel table.Data analysis provided information about the prevalence of ADHD, and then the prevalence of other comorbidities (depression, alcohol and drug pathology) in the two groups (ADHD and personality disorder nonADHD group), as well as the impact on functionality.
Some limits of the study are: the retrospective assessment of a childhood diagnosis that can be problematic, the information from the patients that can be subjective, the diffi cult access to medical and the absence of the information from the family members.Th e transversal approach can also be a problem in assessing the comorbidities present retrospectively.

RESULTS
Th e initial sample of patients consisted of 140 individuals diagnosed with a personality disorder.

A. The DSM IV perspective
First, we referred to the ADHD diagnosis.Th e evaluation using the DIVA gave the following results: from the 140 of the individuals with a personality disorder, 41 could be diagnosed with adult ADHD.
Th e sample was divided into two groups: A-the ADHD group (individuals with a personality disorder and ADHD), B -the personality disorder group (individuals with a personality disorder without ADHD).
Alcohol abuse and dependence has been found to have a prevalence of 24% in ADHD group and 30% in the personality disorder nonADHD group.
Other drug abuse and dependence has been found to have a prevalence of 32% in ADHD group and 44% in the personality disorder nonADHD group.
Other disorders have been found in a proportion of 39% in ADHD group and 27% in the personality disorder nonADHD group.
If we look for the diff erence between the two groups (the ADHD and the nonADHD group) in terms of the variables represented by the comorbidities depression, alcohol, drugs and other pathologies, we fi nd the statistical results presented in the table below.
When evaluating the diff erence between the ADHD group and the nonADHD group in terms of the comorbidities present, it has been found a p value of 0.8201 for depression, that means that the presence of depression does not represent a risk factor for ADHD symptomatology.Th e same analysis revealed a p value of 0.2483 for alcohol and of 0.4541 for drugs.In the case of other comorbidities p=0.1702, that the presence of these comorbidities doesn't discriminate between Th e ADHD group has three subgroups: the predominantly inattentive type, the hyperactive/impulsive type and the combined type.We found that 17% are predominantly the inattentive type, 46% predominantly hyperactive/impulsive type and 37% the combined type.
Th e data shows us the increased proportion of the symptoms in the hyperactive/impulsive domain.Th is is concordant with the classic characteristics of the psychopath: impulsivity, reduced tolerance, emotional disregulation, irritability, restlessness are some of the symptoms that are frequently identifi ed in the individuals with a personality disorder.
Th e comorbidities were assessed using the MINI.Th e most representative disorders were depression, alcohol dependence and drug dependence.Th e other disorders present have been anxiety disorders, psychotic disorders, impulse disorders, somatoform disorders.
Th e prevalence of ADHD and comorbidities have been evaluated in the initial sample and in the groups identifi ed above: A and B (A -the ADHD group, Bthe personality disorder group).
If we refer to depression, the evaluation showed a prevalence of 56% of depression in the ADHD group    the combined type.Th e predominant type is the combined one, followed by the hyperactive/impulsive one.
Th e prevalence of ADHD and comorbidities have been evaluated in the initial sample and in the groups identifi ed above from the DSM 5 perspective: A and B (A -the ADHD group, B -the personality disorder group).
Th e evaluation showed a prevalence of 63% of depression in the ADHD group and of 58% in the personality disorder nonADHD group.
Alcohol abuse and dependence has been found in 29% of cases in ADHD group and 33% in the personality disorder nonADHD group.
Other drug abuse and dependence has been found in 42% of cases in ADHD group and 41% in the personality disorder nonADHD group.the two groups, the ADHD individuals and the personality disorder patients (nonADHD).We can say that the two categories can present these disorders independently from attentional or hyperkinetic symptoms.

B. The DSM 5 perspective
Using the DSM 5 perspective, the initial sample divided into two groups, with a greater proportion of ADHD individuals compared with the DSM IV classifi cation.
A -the ADHD group -62 patients (44.3%)B -the personality disorder nonADHD group -78 patients (55.7%)Th e proportion of the types has changed.We found that 6% are predominantly the inattentive type, 42% predominantly hyperactive/impulsive type and 52%

C. Comparison DSM IV -DSM 5
With the intention of making an analysis of the diff erences between the two classifi cations, DSM IV and DSM 5 regarding the ADHD pathology and the relation with the possible comorbidities, the initial sample can be divided into three groups: Group I -ADHD positive patients after the DSM IV classifi cation, but also after DSM 5 Group II -ADHD positive patients after DSM 5, ADHD negative after DSM IV Group III-ADHD negative after both DSM IV and 5.
Groups I, II and III can be interpreted as diff erent levels of severity of ADHD symptomatology (group I Other disorders have been found in a proportion of 31% in ADHD group and in the same proportion in the personality disorder nonADHD group. Looking for the diff erence between the two groups (the ADHD and the nonADHD group) in terms of the variables represented by depression, alcohol, drugs and other pathologies, we fi nd the statistical results presented in the table below.
It has been found a p value of 0.5318 for depression.Th e same analysis revealed a p value of 0.5861 for alcohol and of 0.9136 for drugs.In the case of other comorbidities p=0.9874 , that means that the presence of depression, alcohol, drugs or other comorbidities do not represent risk factors for ADHD symptomatology.sis.It has been found that hospital admissions does not seem an important factor in diff erentiating ADHD population and personality disorder nonADHD population in the DSM IV perspective (p=0.1762),not even in the DSM 5 perspective (p=0.0870),but it seems important in diff erentiating groups I, II, III (p=0.0326)Groups I,II and III can be interpreted as diff erent levels of severity of ADHD symptomatology.Th e statistical analysis revealed a diff erence when comparing the three groups (I, II, III) identifi ed when analyzing the DSM IV and 5 classifi cation.A possible explanation could link the presence of hospital admissions (as showing an overall severity) and the severity of ADHD symptomatology.
Another approach regarding functionality has been investigated using the WFIRS Scale.Th e total scores and the risk score of t/he ADHD and nonADHD population.Th e results are relevant in the case of the DSM IV classifi cation (p=0.0029,p=0.0317) but also in the case of the DSM 5 classifi cation (p=0.0052,p=0.0016).Moreover the statistical tests showed a relevance between the two classifi cations DSM IV and DSM 5, evaluating the diff erence among groups I,II,III: p=0.0077, p=0.0069.Th e results are shown below.
Th at means that the functionality evaluation with the WFIRS is able to diff erentiate the ADHD from has more ADHD symptoms than group II and group II more than group III).
Th e results presented in the table above have been statistically interpreted.
Th e statistical tests used to determine the diff erence between the prevalence of depression, alcohol use, drug use and other pathologies in the three groups (I, II, III) was the Pearson Chi-Square test.
Th e p values calculated above showed that the diff erence is not statistical signifi cant when we refer to depression (p=0.4962).Likewise, the results in the case of drug and alcohol use show the same absence of statistical signifi cance (p=0.4899,p=0.4640).In the case of other comorbidities the p value is smaller (p=0.1141),but not enough to detect a statistical signifi cance.
In conclusion, the identifi cation of depression, drug and alcohol pathology and other comorbidities in a population of personality disorder patients does not seem to be associated with the detection of ADHD symptomatology.
Another aspect investigated has been the impact of the overall pathology on the functionality of the patients.From this point of view the necessity of hospital admissions have been studied.
Hospitalizations generally indicate a degree of severity.Following this idea, the presence of hospitalizations has been studied in relation to the ADHD diagno-  Th e same evaluation is made between the DIVA total score and the WFIRS risk score.Pearson Correlation is R=0,212.Th at means that there is a weak uphill (positive) linear relationship between the DIVA total score and the WFIRS risk score.
So, individuals show increasing dysfunctionality as evaluated with the WFIRS (in all the domains but also specifi c in the risk domain) with increasing number of symptoms in the attention or hyperactive/impulsive domain.

CONCLUSIONS
ADHD is a diagnosis that is found in a considerable proportion in a population of individuals with a personality disorder -29% when considering the DSM IV classifi cation and 44% when referring to the DSM 5 criteria.
the nonADHD patients, both in the DSM IV perspective and in the DSM 5 perspective.Moreover, the WFIRS score can be linked to the ADHD severity.Th e WFIRS scores (both total and risk score) diff erentiate groups I, II, III, that means that they are linked to the severity of the ADHD symptomatology.
Moreover, to support the idea of the relevance of the WFIRS in detecting ADHD symptomatology, we tried to detect correlations between the intensity of ADHD symptomatology and WFIRS scores.
Th e Pearson Corellation has been calculated for the DIVA total score and the WFIRS total score, R=0.278.Th at means that there is a weak uphill (positive) linear relationship between the DIVA total score and the WFIRS total score.So, when the individuals score high in the attention or hyperactive/impulsive domain, the impact on functionality evaluated with the WFIRS also increases, but the correlation is defi ned as rather weak.Th e results of this study show that a psychiatric evaluation of personality disorder patients should also point towards a diagnosis like ADHD, in the DSM IV perspective, but especially in the DSM 5 perspective, where the prevalence is higher.Sometimes comorbidities like depression, alcohol and drug abuse and dependence can complicate the clinical picture and aff ect the prognosis.

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.

Abreviations: GAF
Global Assessement of Functioning CGI Clinical Global Impression WFIRS Weiss Functional Impairment Rating Scale DIVA Diagnostic Interview for ADHD in adults MINI Mini-International Neuropsychiatric Interview Depression, drug and alcohol dependence are the most frequent comorbidities identifi ed within the ADHD group, but also in the personality disorder no-nADHD group.
From these, the most frequent diagnosis in the ADHD group but also in the personality disorder no-nADHD group is depression, followed by substance pathology other than alcohol and then alcohol.More than half of the individuals in both groups had depression.Th e diff erence in the prevalence of these comorbidities in the ADHD and nonADHD group is not statistically signifi cant when referring to the DSM IV but also DSM 5 classifi cation.
When comparing the two perspectives, the DSM IV and the DSM 5 classifi cation, in terms of the association between the ADHD symptomatology, the comorbidities and the impact on functionality, the following results were found: comorbidities cannot be considered risk factors for ADHD symptomatology in the population of personality disorder patients; on the other hand, the overall severity and the impact on functionality as assessed with the presence of hospitalizations and the WFIRS scale show a signifi cant importance in diff erentiating the ADHD symptomatology.

Figure 1 .
Figure 1.ADHD in the sample of personality disorder patients -DSM IV.

Figure 3 .
Figure 3. ADHD and other comorbidities in the initial sample of patients with a personality disorder-DSM IV.

Figure 4 .
Figure 4. Number of patients with different comorbidities in groups A (ADHD) and B (Personality disorder nonADHD) -DSM IV.

Figure 6 .
Figure 6.ADHD in the sample of personality disorder patients -DSM 5.

Figure 8 .
Figure 8. ADHD and other comorbidities in the initial sample of patients with a personality disorder -DSM 5.

Figure 9 .
Figure 9. Number of patients with different comorbidities in groups A (ADHD) and B (Personality disorder nonADHD) -DSM 5.

Figure 11 .
Figure 11.Correlation between DIVA score and WFIRS total score.Figure 12. Correlation between DIVA score and WFIRS risk score.

Figure 12 .
Figure 11.Correlation between DIVA score and WFIRS total score.Figure 12. Correlation between DIVA score and WFIRS risk score.

Table 1 .
Prevalence of comorbidities in ADHD and nonADHD group and statistical signifi cance -DSM IV

Table 2 .
Prevalence of comorbidities in ADHD and nonADHD group and statistical signifi cance -DSM 5

Table 4 .
Hospitalizations of ADHD patients

Table 5 .
Functional assessement with WFIRS in ADHD patients