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Personality and Individual Differences 45 (2008) 468472

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Personality and Individual Differences


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Psychopathic traits in adult ADHD patients


H. Eisenbarth a, G.W. Alpers a,*, A. Conzelmann a, C.P. Jacob b, P. Weyers a, P. Pauli a
a
Department of Psychology, University of Wrzburg, Marcusstrasse 9-11, D-97070 Wrzburg, Germany
b
Department of Psychiatry, University of Wrzburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Previous studies have shown that the prevalence of attention decit and hyperactivity disorder (ADHD) is
Received 7 December 2007 elevated in prison inmates and in forensic patients with psychopathic traits. However, it is not clear
Received in revised form 21 May 2008 whether ADHD and psychopathy scores also correlate in adult non-incarcerated samples. Moreover, it
Accepted 30 May 2008
has not been examined if this correlation is due to specic facets of psychopathy. We assessed psychop-
Available online 22 July 2008
athy in 30 adult ADHD patients and in 41 healthy participants using the psychopathic personality inven-
tory revised (PPI-R). Male ADHD patients had higher scores compared to healthy male and female
Keywords:
participants on the subscales blame externalization, rebellious nonconformity, and carefree nonplanful-
Adult attention decit and hyperactivity
disorder (ADHD)
ness. Irrespective of gender, ADHD patients had lower scores compared to healthy participants on stress
Psychopathy (PPI-R) immunity and coldheartedness. These data specify the previously documented correlation between
ADHD and psychopathy, and suggest that only the behavioral features of psychopathy are affected in
ADHD whereas, the emotional features are not.
2008 Elsevier Ltd. All rights reserved.

1. Introduction Descriptively, individuals scoring high on psychopathy and pa-


tients with ADHD share several symptoms that may be traced back
Psychopathy has frequently been associated with attention def- to similar neuronal dysfunctions. In their observable behavior,
icit hyperactivity disorder (ADHD) because some of their symp- both show impulsive actions, leading to interpersonal problems,
toms overlap. Both, patients with ADHD and individuals who delinquent behavior, substance abuse or living-in-the-fast-lane.
score high on psychopathy, often show drug abuse, antisocial Colledge and Blair (2001) suggested that overlapping character-
behavior, unstructured lifestyle, or sensation-seeking. There are istics of psychopathy and ADHD have to be considered as common
also similarities in the neurobiological system, which have been risk factors for different aspects of the disturbances. Whereas, the
implicated to underlie both ADHD and psychopathic tendencies. dysfunction in the alerting system and the resulting inattention
ADHD, which is characterized by inattention and hyperactivity seem to be independent of delinquent behavior, the dysfunction
or impulsivity, is manifested in childhood and symptoms persist in executive control and in violence inhibition are both related to
into adulthood in approximately 3060% of the children with conduct problems. Furthermore, the problems in executive control
ADHD, although symptom severity tends to decrease (Biederman, are linked with impulsivity. On this background, the lack in vio-
Mick, & Faraone, 2000; Torgersen, Gjervan, & Rasmussen, 2006). lence inhibition is strongly related to callous and unemotional
Aside from the symptoms that are comparable to those of child- traits in psychopathy. However, in both cases the causality of the
hood ADHD, adult patients with ADHD tend to show impaired aca- link is unclear. These developmental pathways could be the basis
demic achievement, difculties in employment, and criminality. In of two phenotypes, an inattentive one and an impulsive one asso-
addition, the comorbidity of antisocial personality disorder and ciated with conduct disorders (Colledge & Blair, 2001). The rela-
substance abuse, or dependency are elevated. Some of these symp- tionship between psychopathy and ADHD has been the subject of
toms are similar to those of individuals who score high on psy- a number of descriptive studies. One line of research examined
chopathy. Psychopathy, rst described by Cleckley (1964), is children or adolescents with ADHD and matched control partici-
usually not considered to be a diagnostic category or disorder pants. From this perspective ADHD is strongly related to psycho-
but rather a dimensional personality trait (Edens, Marcus, Lilien- pathic traits, especially to callous unemotional traits and
feld, & Poythress, 2006). Accordingly, psychopathic traits in the impulsivity (Barry et al., 2000; Colledge & Blair, 2001; Loeber
normal population signify the degree of interpersonal and emo- et al., 2001; Frick, Bodin, & Barry, 2000). The very recent study
tional impairments as well as a devil-may-care lifestyle, and by Mathias and colleagues (Mathias et al., 2007) is concerned with
manipulative behavior. the differential aspects of the relation between ADHD and psy-
chopathy. The authors found that the impulsivity component of
* Corresponding author. Tel.: +49 931 312840; fax: +49 931 312733. psychopathy is mainly related to the hyperactivity component of
E-mail address: alpers@psychologie.uni-wuerzburg.de (G.W. Alpers). ADHD, whereas the narcissistic and unemotional traits were

0191-8869/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.paid.2008.05.022
H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468472 469

marginally related to the inattentive component of ADHD. In accor- inattentive type diagnosis. Two patients and one control group
dance with the model of Colledge and Blair (2001), these results participant received antidepressants, four patients received
point to a common underlying mechanism for the conduct prob- ADHD-medication, four patients received psychotherapy for
lems in psychopathy and ADHD. Another line of research studied Axis-I-disorders, one for ADHD. One patient had a diagnosis of
the prevalence of ADHD and psychopathy in high-risk adult popu- an antisocial personality disorder but none of the control
lations. Torgersen et al. (2006) found an elevated percentage of participants.
antisocial personality disorder (ASPD, 44%) in an adult ADHD sam-
ple as compared to a general population (35%). Similarly, Roesler 2.2. Material
et al. (2004) found an elevated percentage of adult ADHD in prison
populations (45%). All participants completed the psychopathic personality inven-
To our knowledge the research concerning the specic person- tory revised (PPI-R, German version; Eisenbarth & Alpers, 2007; Al-
ality trait psychopathy and ADHD in adults is limited to prison pers & Eisenbarth, 2008), which is a self-report measure of
samples. It documents correlations between ADHD and the behav- psychopathy (Lilienfeld & Andrews, 1996). The questionnaire con-
ioral as well as lifestyle features of psychopathy (Soderstrom, Nils- sists of 154 items that can be assigned to eight subscales and one
son, Sjodin, Carlstedt, & Forsman, 2005), a high predictive value of virtual responding scale. The subscales are blame externalization,
self-reported childhood ADHD for conduct disorder and psychopa- rebellious nonconformity, coldheartedness, social inuence, care-
thy (Abramowitz, Kosson, & Seidenberg, 2004), as well as a high free nonplanfulness, fearlessness, machiavellistic egocentricity,
predictive value of impulsivity for psychopathy in adolescent in- and stress immunity. This version has been validated in students
mates in a longitudinal study (Vitacco & Rogers, 2001). Studies and in incarcerated samples revealing a good internal consistency
including non-incarcerated populations are limited to children or of ra = .85 (Alpers & Eisenbarth, 2008). Convergent validity has
adolescent samples and, so far, there are no studies on adult ADHD been shown on the basis of the kieler psychopathie inventar
patients. In addition, the existing literature on adult inmates is lim- (KPI-R, Koehler, Hinrichs, & Huchzermeier, in preparation) and on
ited to male participants, which represents the prevalence of high the basis of the German version of the interpersonal relationship
psychopathy scores and criminal behavior. Although lower scores inventory (SPF, Paulus, 2000).
on the scales for psychopathy can be expected in women than in In addition, patients answered 18 Likert-scaled questions (four
men (see Warren et al., 2003). It seems necessary to examine the steps) for each criterion of DSM-IV. Sum scores were calculated
correlation on the whole spectrum and extend our knowledge on for inattention and for hyperactivity, and used as continuous mea-
psychopathy in women (see Eisenbarth, Alpers, Segr, Calogero, & sures of symptom severity.
Angrilli, 2008).
In sum, the aim of the present study was to investigate psycho- 2.3. Statistical analyses
pathic traits in adult female and male ADHD patients compared to
a matched healthy control group. We expected that ADHD patients All analyses were done with SPSS 14 (SPSS Inc., Chicago). We
show higher scores of psychopathy, especially the male patients. conducted analyses of variance for group differences as well as a
Furthermore, we expected to nd differences on those subscales linear regression analysis with the subscales of the PPI-R and the
of a self-report questionnaire, which reect specic impairments total score of the PPI-R as predictors and group (patients vs.
of ADHD patients. We expected that psychopathy and ADHD are healthy control group) as criterion. Post-hoc tests were Bonferroni
both characterized by unstructured lifestyle and antisocial behav- corrected.
ior (corresponding to Hares lifestyle factor, Hare, 2003) but, that For a correlational analysis of sum scores of DSM-IV symptom
ADHD patients do not express callous unemotional traits. related items and scores on the subscales of the PPI-R as well as
the PPI-R total score, Pearsons correlation coefcients were
computed.
2. Method Logistic regression analyses with a stepwise inclusion of predic-
tors were conducted for all of the subscales and for the total score
2.1. Sample separately to predict group afliation (patients vs. healthy
participants).
Participants were recruited for an experimental study on ADHD.
Exclusion criteria were age below 18 or above 60, severe somatic
disorders or hearing problems, and any lifetime or current psychi- 3. Results
atric diagnosis in the healthy participants. Participants gave writ-
ten informed consent and were paid 10 Euro for participation. 3.1. Group differences
All participants were assessed with the structural clinical inter-
view of DSM-IV (SCID-I and SCID-II for axis I and II psychiatric dis- The multivariate ANOVA revealed signicant main effects for
orders, First, Gibbon, Spitzer, Williams, & Benjam, 1996, 1997). group (patients vs. healthy participants) and for gender. Between
ADHD was diagnosed by DSM-IV criteria (American Psychiatric ADHD patients and healthy participants there was no difference
Association, 1994) with adjustment to adult symptomatology in the total score (F(1,67) = 2.14, p = .15). Patients had higher scores
(Weiss, Hechtman, & Weiss, 1999) and by the Wender Utah Rating than healthy participants in blame externalization (F(1,67) = 4.82,
Scale (WURS, Ward, Wender, & Reimherr, 1993) for symptoms dur- p = .03), rebellious nonconformity (F(1,67) = 18.72, p < .001), and
ing childhood. carefree nonplanfulness (F(1,67) = 18.68, p < .001) but lower scores
A sub-sample of 28 adult ADHD patients, 16 females, and 12 for stress immunity (F(1,67) = 21.43, p < .001) (see Table 1). Differ-
males (M = 35.15 8.50, range = 1850 years) and 41 healthy par- ences between male and female participants were found in terms
ticipants, 21 females, and 20 males (M = 37.71 10.14, range = of higher scores for male participants in the total score (F(1,67) =
1956 years) participated in this study. The groups were matched 10.97, p = .001) and the subscales blame externalization (F(1,67) =
for age (t = 1.08, p = .28), gender and education (56% high school, 4.45, p = .04), rebellious nonconformity (F(1,67) = 10.34, p = .01),
44% higher education). Eighteen of the patients had a combined machiavellistic egocentricity (F(1,67) = 8.36, p = .01), carefree non-
type diagnosis, four patients had a predominantly hyperactive- planfulness (F(1,67) = 5.16, p = .03) as well as fearlessness (F(1,67) =
impulsive type diagnosis and six patients had a predominantly 12.54, p = .001).
470 H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468472

Table 1 severity and blame externalization only in male participants (inat-


Means and standard deviations of ADHD patients and healthy participants on PPI-R tention: r = .50, p = .003; hyperactivity: r = .54, p = .001), whereas
scales
the correlation with carefree nonplanfulness is signicant in fe-
Patients (N = 28) Healthy participants (N = 41) male participants (inattention: r = .63, p < .001; hyperactivity:
Blame externalization 33.05 9.35 29.46 9.35 r = .55, p = .001). The correlation with stress immunity does not dif-
Rebellious nonconformity 58.91 16.53 48.01 10.15 fer for male and female participants. In male participants we also
Stress immunity 47.63 7.78 55.98 6.61 found signicant correlations for machiavellistic egoism and ADHD
Social inuence 42.74 8.56 43.54 6.32
Coldheartedness 35.69 4.24 38.43 5.39
symptom severity (inattention: r = .55, p = .001; hyperactivity:
Machiavellistic egoism 31.16 4.96 30.85 4.32 r = .45, p = .01).
Carefree nonplanfulness 31.17 5.91 26.66 3.71
Fearlessness 16.10 7.03 16.30 4.61 3.3. Classication
Total score 318.92 41.00 313.93 24.51

Logistic regression analysis reveals that the PPI subscales can


Interactions between diagnostic group and gender were found predict group afliation correctly for 93% of the subjects
for the total score (F(1,67) = 9.15, p = .01) and for the subscales (v2(8,N = 70) = 62.19, p < .001). Involving only the subscales that con-
blame externalization (F(1,67) = 3.96, p = .05), rebellious nonconfor- tribute signicantly, i.e., rebellious nonconformity (b = .23,
mity (F(1,67) = 6.46, p = .01), machiavellistic egocentricity p = .004), stress immunity (b = .32, p = .004), machiavellistic ego-
(F(1,67) = 6.75, p = .01), and fearlessness (F(1,67) = 3.65, p = .06). Inter- centricity (b = .68, p = .01), and carefree nonplanfulness (b = .39,
actions are due to higher scores in male patients on the total score, p = .004), the percentage of correct classication of participants
blame externalization, rebellious nonconformity, machiavellistic as patients or healthy participants is reduced to 90%
egocentricity, and fearlessness, as well as lower scores of both male (v2(4,N = 70) = 60.69, p < .001). Using only the total score as a
and female patients on stress immunity. This shows that the group predictor it further reduces the percentage of correctly classied
differences between patients and healthy participants mainly arise participants to 64% (v2(1, N = 70) = 0.64, p = .42).
from differences between male patients and male healthy partici-
pants (see Fig. 1). 4. Discussion
Bonferroni corrected analyses were done separately for male
and female participants. Male patients have signicantly higher Psychopathy and ADHD share several symptoms, and previous
scores than healthy men on blame externalization (F(1,37) = 4.96, research has shown that the diagnoses are often comorbid in incar-
p = .03), rebellious nonconformity (F(1,31) = 21.50, p < .001), carefree cerated populations. A recent model, which was based on data
nonplanfulness (F(1,31) = 10.81, p = .01), and on the total score from adolescents, suggests that the relationship may be specic
(F(1,37) = 7.15, p = .01), as well as lower scores on stress immunity to those features of ADHD, which are related to conduct disorder
(F(1,31) = 9.37, p = .01). Female patients only have lower scores in (Colledge & Blair, 2001; Mathias et al., 2007). This study is the rst
stress immunity (F(1,37) = 13.46, p = .001) as well as higher scores to examine the specic facets of psychopathy in adult ADHD pa-
on coldheartedness (F(1,37) = 6.46, p = .02) and carefree nonplanful- tients. In addition, we examined the inuence of gender differences
ness (F(1,37) = 7.10, p = .01) compared to healthy female on this relationship.
participants. Dimensions of trait psychopathy were measured in adult
ADHD patients and matched to healthy participants with the
3.2. Correlational analyses psychopathic personality inventory revised (PPI-R, German ver-
sion, Eisenbarth & Alpers, 2007; Alpers & Eisenbarth, 2008). Total
Considering the correlations for male and female participants scores of psychopathy were higher only in male ADHD patients.
separately reveals a signicant correlation between symptom As predicted by Colledge and Blair (2001), our adult ADHD pa-
tients had psychopathic traits related to conduct problems but
they were inconspicuous with respect to the emotional aspects
of psychopathy.
According to the model of Colledge and Blair (2001), the prob-
lems in executive control that correspond to impulsivity and to a
lack of violence inhibition, are present in both psychopathy and
ADHD. While, in psychopathy anterior cingulate and amygdala
dysfunctions could result in callous and unemotional traits, in
ADHD right frontal lobe dysfunction could be the basis for the inat-
tentive ADHD type (Colledge & Blair, 2001). The assumption that
psychopathic traits can be differentiated from ADHD by its higher
callous unemotional traits, whereas ADHD, at least the inattentive
and the mixed subtype can be differentiated from psychopathic
traits by the decits in attention, agrees with our data.

4.1. Gender differences

The gender specic results show that the PPI-R total score is
higher in male ADHS patients compared with male healthy partic-
ipants, whereas female patients do not show higher total scores
than healthy women. Overall, male patients have substantially
higher scores than female ADHD patients. Lower scores are typical
for women in the general population (Benning, Patrick, Blonigen,
Fig. 1. Means and standard deviations of mean raw scores of male and female
ADHD patients and healthy participants on the subscales of the PPI-R (Signicant Hicks, & lacono, 2005; Eisenbarth et al., 2008). This nding was fur-
differences between all four groups: ***p 6 .001, **p 6 .05, *p 6 .10). ther conrmed in our correlational analyses, and is a relatively new
H. Eisenbarth et al. / Personality and Individual Differences 45 (2008) 468472 471

contribution because the overlap of ADHD and psychopathy was Taken together, this study adds an interesting perspective to the
typically examined in samples of incarcerated males. discussion on ADHD and its relationship to psychopathy. We found
On a different conceptual level, our ndings are in line with pre- specic relationships of these constructs for male ADHD patients,
vious research, which found that male adult ADHD patients more suggesting that Colledge and Blairs model should be specied for
often show antisocial and externalizing behavior compared to fe- gender aspects. Furthermore, our data could point to a better
male patients (e.g., Washburn et al., 2007). Although, the lowered understanding of the prevalent delinquency in ADHD patients
risk for externalizing behavior in women could be an explanation (Roesler et al., 2004). Although these patients seem to share char-
for the low psychopathy scores of our female patients, there are acteristics with psychopaths, they do not show the callous unemo-
also studies that did not nd gender differences in psychopathy tional and manipulative traits of psychopathy. A common
(Loney, Taylor, Butler, & Iacono, 2007). However, female ADHD underlying mechanism of conduct problems in both, ADHD pa-
seems not to correspond to psychopathic traits in the same way tients and high psychopathic individuals, as suggested by Colledge
as male ADHD does in terms of less psychopathic features com- and Blair (2001), is very plausible.
pared to the male patients.

Acknowledgements
4.2. Facets of psychopathy

The recruitment of participants was part of a grant by the Ger-


The differences with respect to subscale scores point to a spe-
man research foundation (DFG). We thank K.-P. Lesch, M.D., and
cic increase in behavioral aspects such as impulsivity, living in
his team as well as R. Mucha, Ph.D., for their support. The rst
the fast lane or antisocial behavior (corresponding to Hares life-
author was supported by the Konrad-Adenauer-Stiftung.
style factor, Hare, 2003), whereas other psychopathic features like
coldheartedness or manipulating behavior do not discriminate
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