Originally published in: Gisli H. Gudjonsson, June Wells and Susan Young (2012). Personality Disorders and Clinical Syndromes in ADHD Prisoners. Journal of Attention disorders, DOI: 10.1177/1087054710385068
Personality Disorders and Clinical Syndromes in ADHD Prisoners Gisli H. Gudjonsson, June Wells and Susan Young Journal of Attention Disorders 2012 16: 304 originally published online 26 October 2010DOI: 10.1177/1087054710385068 The online version of this article can be found at: http://jad.sagepub.com/content/16/4/304
JAD1641 0.1177 /10870 547103 85068G u sorders
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Personality Disorders and Clinical Syndromes in ADHD Prisoners 1
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Gisli H. Gudjonsson , June Wells , and Susan Young
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Abstract Objective: The main objective of this article is to investigate the type of personality disorders and clinical syndromes (CSs)that were best related to ADHD symptoms among prisoners. Method: The authors screened for childhood and adult ADHD symptoms and administered the Millon Clinical Multiaxial Inventory–III (MCMI-III) to 196 serving prisoners. Results: Childhood and adult ADHD symptoms were most strongly related to the compulsive (negative relationship) and borderline (positive relationship) scales on the MCMI-III with large and medium effect sizes, respectively. Hierarchical multiple regressions revealed that the absence of compulsive personality disorder traits (i.e., a low score as a dimension) was the single best Axis II predictor of childhood and adult ADHD symptoms. CSs did not add significantly to the variance in childhood ADHD beyond that of the personality disorder dimensions, but it did so for current ADHD symptoms in relation to alcohol dependence. Conclusion: The findings demonstrate the relative absence of compulsive personality disorder traits in prisoners withADHD symptoms as core maladaptive traits involving disorganization. (J. of Att. Dis. 2012; 16(4) 304-313)
Keywords ADHD, personality disorders, maladaptive traits, disorganized personality traits, alcohol dependence
ADHD is a developmental disorder that occurs in about 7% of children (Faraone, 2005). The three key symptoms are inattention, hyperactivity, and impulsivity (American Psychiatric Association [APA], 2000). Many children continue to be symptomatic into their adolescence and adulthood (Brassett-Grundy & Butler 2004a, 2004b). It is estimated that up to 4.4% of adults meet the diagnostic criteria for ADHD (Kessler et al., 2006), whereas others are partly in remission of their symptoms (Faraone, Biederman, &Mick, 2006; Young & Gudjonsson, 2008). Psychiatric comorbidity, conduct disorder, delinquency, and psychosocial problems are commonly reported, and some children are at risk of developing antisocial personality disorder (Biederman, Newcorn, & Sprich, 1991; Young & Gudjonsson, 2005; Young, Gudjonsson, Ball, & Lam, 2003; Young, Wells, & Gudjonsson, in press). Substance misuse is also commonly found among adults with ADHD, but it mainly occurs when there is comorbid antisocial personality disorder (Lynskey & Hall, 2001; Young et al., in press). Symptoms of ADHD among college students are positively associated with social rejection (Paulson, Buermeyer, & Nelson-Gray, 2005) and negatively with reported satisfaction with life experiences (Gudjonsson, Sigurdsson, Eyjolfsdottir, Smari, &Young, 2009). Several studies have investigated the prevalence of ADHD among adult prison inmates (e.g., Dalteg, Lindgren,
& Levander, 1999; Eyestone & Howell, 1994; Gudjonsson, Sigurdsson, Einarsson, Bragason, &Newton, 2008; Gudjonsson, Sigurdsson, Eyjolfsdottir, et al., 2009; Rasmussen, Almik, & Levander, 2001; Retz et al., 2004; Young et al., 2009). As these studies used screening measures for assessing ADHD, the studies indicate that childhood ADHD among adult prison inmates ranges from 24% to 67% and adult ADHD ranges from 13% to 45%. Rates for juvenile offenders are estimated to be higher (e.g., Dalteg & Levander, 1998). Thus, ADHD is much more common among offenders than found in the general population. Rasmussen et al. (2001) found in a study of 82 Norwegian prisoners that childhood and adult ADHD symptoms shared a substantial amount of the variance with measures of personality disorders. The different personality disorders were significantly correlated, but antisocial and borderline personality disorders appeared to be best predicted by ADHD symptoms. In another study, borderline personality 1
King’s College London, London, UK Robert GordonUniversity, Aberdeen, UK
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Corresponding Author: Gisli H. Gudjonsson, Professor, Department of Psychology (PO 78), King’s College London, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, SE 5 8AF, United Kingdom
Email:
[email protected]
disorder was associated with ADHD (Rey, Morris-Yates, Singh, Andrews, & Stewart, 1995), which is not surprising in view of the fact that impulsivity is a core component of this disorder (Links, Heslegrave, & van Reekum, 1999). Recently, Einarsson, Sigurdsson, Gudjonsson, Newton, and Bragason (2009) found that antisocial personality disorder and substance dependence were powerful predictors of meeting criteria for full or partial symptoms of adult ADHD among prisoners. However, substance dependence was not discriminative when controlling for antisocial personality characteristics because of the strong relationship between the two disorders. May and Bos (2000) assessed the personality disorders of four distinct types of ADHD presentation from an outpatient ADHD clinic in the United States (ADHD only, ADHD comorbid disorder, ADHD oppositional defiant disorder, and ADHD comorbid and oppositional defiant disorder). Of the four groups, the ADHD comorbid and oppositional defiant disorder probably comes closest to matching that of the offenders. This group had a high rate of passive-aggressive and aggressive-sadistic disorders and a very low rate of compulsive disorder. The May and Bos study emphasized the need to understand the personality of adults with ADHD within the context of comorbid problems. This is particularly important among offender populations where comorbid Axis I as well as Axis II disorders are commonly found (Gudjonsson & Main, 2008). A meta-analysis of 20 studies found a strong relationship between ADHD measures and delinquent/criminal behavior (Pratt, Cullen, Blevins, Daigle, & Unnever, 2002). A key to understand the offending of people with ADHD is poor behavioral control (Barkley, 1997) and dysfunctional affect regulation (Maedgen & Carlson, 2006). Young et al. (2009) found that current symptoms of ADHD were a much better predictor of critical incidents within prison than antisocial personality disorder as measured by the Millon Clinical Multiaxial Inventory–III (MCMI-III; Millon, 1997). In another prison study, Gudjonsson, Sigurdsson, Young, Newton, and Peersen (2009) found that adult ADHD symptoms were better explained by emotional lability than anti-social personality traits. The authors suggested that one way of interpreting this finding is that emotional instability involves high drive propensities that exacerbate existing propensities for poor behavioral inhibition. Mental health and personality problems are commonly found among prisoners. Fazel and Danesh (2002) reviewed 62 surveys that were based on psychiatric interviews of unselected prisoners in 12 countries involving 22,790 prisoners of whom 81% were men. Of them, 3.7% had psychotic illnesses, 12% suffered from major depression, and 65% were personality disordered—the most common type of personality disorder being antisocial (47%). The authors concluded that there was heterogeneity across studies with
regard to the rate of personality disorder with prisoners being about 10 times more likely than members of the general population to have antisocial personality disorder. Similar findings were reported by Singleton, Meltzer, and Gatward (1998) among prisoners in England and Wales; they found that antisocial personality disorder was the most common type, followed by paranoid and borderline. Coid, Yang, Tyrer, Roberts, and Ullrich (2006) found that among offenders, antisocial, borderline, and narcissistic are the three most commonly reported personality disorders.
What these previous studies have not focused on specifically is the relationship between ADHD symptoms and disorganization as a personality trait. There is evidence that disorganization, which includes the failure of the individual to organize his or her personal, social, and occupational life, is an important feature of ADHD. Indeed, Barkley, Murphy, and Fischer (2008) proposed seven key symptoms that ―characterize the phenomenology of adults with ADHD‖ (p. 14). One of these key symptoms is ―disorganization.‖ Asherson, Chen, Craddock, and Taylor (2007) also drew attention to the importance of disorganization of children and adults with ADHD, stating as follows: ―Disorganization is prominent, tasks are not completed, problem-solving is lacking in strategy and time management is particularly poor‖ (p. 5). A personality disorder dimension that appears to be theoretically, but reversely, related to ADHD is compulsive, as measured by the MCMI-III (Millon, 1997). This personality disorder dimension measures rigid conformity to rules, moral codes, and orderliness. According to Craig (2005), a compulsive personality is positively correlated with measures of mental health and negatively with measures of maladjustment, including social problems, disorganization, inefficiency, irritability, and acting out behavior. Elevated scores on the compulsive scale are absent in most clinical groups, but it has been found to be correlated with life success (Ullrich & Marneros, 2007). The general theme of a very low score on the MCMI-III compulsive personality disorder suggests a disorganized and dysfunctional lifestyle (i.e., the person does not follow rules or a routine in daily life, feels aimless in life, does not take responsibility seriously, is not good with money, displays erratic behavior, and tends to make excuses when getting into trouble). These are the kinds of behaviors commonly seen in people with ADHD and can be described as a disorganized personality style (Young & Bramham, 2007; Young, Morris, Toone, & Tyson,2007) or maladaptive functional capacities (Gudjonsson, Sigurdsson, Gudmundsdottir, & Sigurjonsdottir, 2010). The aim of the present study was to investigate the relative importance of personality disorders (Axis II) and clinical psychopathology (Axis I) in predicting ADHD symptoms among prisoners. It was hypothesized that both personality disorders and clinical psychopathology would
be correlated with childhood and adult ADHD symptoms but that clinical psychopathology would not predict ADHD symptoms above or beyond personality disorders after controlling for response style. It was also hypothesized that the primary personality disorder dimensions related to ADHD symptoms would be antisocial (positive relationship), borderline (positive relationship), and compulsive (negative relationship).
Method Participants The sample comprised of 196 male prisoners with a mean age of 30.1 (SD= 8.2, range = 19-68). The ethnic background was known for 190 of the sample, of whom 180 (95%) were White European. The main groups of index offences were theft/burglary/deception, assault/murder/ armed robbery, and serious traffic violation. Two participants had to be excluded because they had invalid MCMI-III profiles.
Measures Diagnostic Statistical Manual IV–TR Checklist of Symptoms (DCS). The DCS (American Psychiatric Association, 2000)is an 18-item self-report questionnaire measuring symptoms of ADHD. Nine items relate to problems with inattention and another nine relate to problems with hyperactivity and impulsivity. In addition to categorizing frequency of symptoms, each item was scored on a 3-point rating scale (0 = never, 1 = sometimes, 2 = often). The possible score range was 0 to 36. Participants completed the questionnaire twice, once self-reporting on childhood symptoms and again reporting on symptoms in the past 6 months. The childhood and current scores on the DCS can also be used as a dimension rather than a diagnostic category for correlation and regression analysis (Thapar, Langley, O’Donovan, & Owen, 2006). For the purpose of the present study, childhood criteria for Diagnostic and StatisticalManual of Mental Disorders (4th ed., Text Revision; DSM-IV; APA, 2000) ADHD were applied when six or moreinattentive items (rated as ―often‖) or six or more hyperactive/ impulsive items (rated as ―often‖) were present. No classification in childhood means that there can be no classification in adulthood. For those who were classified in childhood but did not fulfill criteria for full symptomatology in adult-hood, we applied the following criteria for ADHD in partial and in full remission: (a) ADHD in partial remission indicated by a classification of ADHD in childhood, plus a total score of ≥17 for symptoms in the past 6 months on the DCS; a score of 17 represents one standard deviation above the mean score obtained by a normal population (Young, 1999) and (b) ADHD in full remission indicated by a classification
of ADHD in childhood, plus a total score of
