Emotion dysregulation and impulsivity as overlapping symptoms in adult Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder: Differences in severity and their association with childhood traumatization and personality functioning

doi:10.21203/rs.3.rs-5146516/v1

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Research Article

Emotion dysregulation and impulsivity as overlapping symptoms in adult Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder: Differences in severity and their association with childhood traumatization and personality functioning

https://doi.org/10.21203/rs.3.rs-5146516/v1

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published 13 Jan, 2025

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Background

Increased levels of emotion dysregulation and impulsive behavior are overlapping symptoms in Attention-Deficit/Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD), both symptom domains reflect on inhibitory control, although from different angles. Our aims were to describe their differences in the above conditions, investigate their associations with childhood traumatization, and to explore the potential mediation of emotion dysregulation and impulsivity between childhood traumas and personality functioning.

Methods

Young adults between 18–36 years diagnosed with aADHD (n = 100) and BPD (n = 63) were investigated with structured clinical interviews, while age-matched healthy controls (n = 100) were screened for psychiatric disorders. Patients with aADHD-BPD comorbidity were excluded from the analyses. The Difficulties in Emotion Regulation Scale, the Barratt Impulsiveness Scale, the Childhood Trauma Questionnaire-Short Form and the Level of Personality Functioning Scale were administered to investigate trait measures and childhood traumatization. Behavioral impulsivity and delay aversion were assessed using selected tests of the Cambridge Neuropsychological Test Automated Battery, and a computerized decision-making paradigm based on the Rogers’ decision-making task, respectively.

Results

Significantly higher levels of emotion dysregulation and impulsivity were present both in the aADHD and BPD groups, however with different inhibitory profiles. Waiting and stopping impulsivity was selectively higher among aADHD patients compared to healthy controls. The BPD group demonstrated higher levels of delay aversion among uncertain conditions in the decision-making task. Higher levels of childhood trauma were associated with emotion dysregulation, trait impulsivity, and delay aversion across groups. Emotion regulatory capacity played a significant mediating role between childhood traumatization and the level of personality functioning.

Conclusions

Inhibitory control profiles of the aADHD and BPD groups were divergent. Childhood traumatization was associated with lower levels of personality functioning in adulthood, independently of diagnosis. In our models the effect of trauma was mediated more by emotion dysregulation, rather than impulsivity. These findings have various clinical implications for the diagnosis and treatment of aADHD and BPD.

adult Attention-Deficit Hyperactivity Disorder (aADHD)

Borderline Personality Disorder (BPD)

impulsivity

emotion dysregulation

inhibitory control

childhood traumatization

level of personality functioning

Elevated levels of emotion dysregulation (ED) and impulsivity are important symptoms and diagnostic criteria of Borderline Personality Disorder (BPD). Impulsive behavior constitutes a core feature in Attention Deficit Hyperactivity Disorder (ADHD) as well, while ED is only recognized in the Diagnostic and Statistical Manual of Mental Disorders 5th (DSM-5) as an associated symptom. Impulse control difficulties are also characteristic of several other mental disorders, including bulimia, substance use, behavioral addictions, non-suicidal self-harm, paraphilias and tic disorders [1], and constitute a risk factor of suicidal behavior [2]. The most widely used definition of impulsivity characterizes the symptom as a predisposition to rapid and unplanned reactions triggered by internal and external stimuli, regardless of their negative consequences for the individual or others. Computational modeling and empirical evidence has demonstrated that impulsivity is closely linked to the behavior of value-free random exploration, the tendency to forego high valued and known outcomes for unknown choice options [3]. ED is considered as difficulties with or the inability to modulate any aspects of the emotion regulation process, including emotion escalation, intensity, and de-escalation, to an extent that interferes with development or functioning [4].

Previous studies indicate that there is no global impulsiveness factor, rather, impulsivity is a multidimensional construct, best captured by at least three different factors [5]. The impulsivity profile consists of impulsive personality traits reflecting self-reported attributions of self-regulatory capacity, impulsive actions, i.e. the inability of withholding premature actions (waiting impulsivity) or stopping ongoing actions (stopping impulsivity), and impulsive choice pattern, the presence of delay aversion in decision making. Impulsive choice refers to a tendency to prefer smaller, immediate rewards over larger, delayed rewards [6].

Several lines of evidence demonstrate altered self-regulatory profiles in aADHD and BPD. BPD patients scored significantly higher on the Barratt Impulsiveness Scale than healthy control individuals, while the aADHD group scored significantly higher than the BPD and control groups [7]. In terms of waiting and stopping impulsivity most studies indicated intact levels in BPD individuals, however increased impulsive choice behavior characteristics were observed {8]. Behavioral impulsivity was clearly the most severe among patients with aADHD, and less severe among BPD patients without ADHD [9]. Delay aversion was found to be affected both in ADHD and BPD. Current evidence suggests that “cold”, i.e., emotionally neutral impulse control is less affected in BPD than “hot” impulse control, i.e., situations involving affective and/or motivational aspects. BPD individuals may be more prone to make decisions providing immediate gratification, but negative consequences in the long term.

Despite the clinical evidence of transdiagnostic similarities, to date, only four studies have directly compared ED in ADHD and BPD. Witt et al. compared the two patient groups with a healthy control group and found significantly higher levels of ED in BPD patients in comparison with aADHD patients [10]. Philipsen et al. compared aADHD, BPD, and healthy controls using the Borderline Symptom List. Significantly higher scores assessed by the Emotion Regulation subscale were reported for BPD than for ADHD participants [11]. Cavelti et al. used the Emotion Regulation Skills Questionnaire to assess perceived emotional regulation skills, adults with ADHD and BPD reported comparable difficulties in ED [12]. In a recent study aADHD patients had higher ED than people from the general population, however, they demonstrated lower ED levels, better control over their emotions with higher use of adaptive cognitive strategies and less use of non-adaptive strategies than BPD patients [13]. Research on impulsivity in aADHD and BPD is ongoing, and it remains unclear whether ED and impulsivity manifests itself differently in these conditions. Further studies and analyses are warranted to provide a clearer understanding of these relationships [14].

Several studies reflect on the role of childhood traumatization in the background of ED and impulsivity. Krause-Utz et al aimed to investigate associations between childhood trauma severity, emotion regulation difficulties, and impulsivity in women with BPD compared to healthy and clinical controls. They found, that childhood traumas, particularly emotional maltreatment, was positively associated with ED across all groups [15]. According to the results of Lepouriel et al trait impulsivity measured was significantly associated to childhood traumatization in the healthy control group, but not in the aADHD and BPD groups [7].

From a clinical point of view global severity of personality dysfunction is seen as an important measure informative about long-term prognosis regardless of primary diagnoses. The DSM-5 Level of Personality Functioning Scale-Self Report (LPFS-SR) gives a comparable framework to assess personality functioning [16]. ED and impulsivity are potential mediators between childhood traumas and personality functioning.

In summary, this study had three objectives: First, to compare factors of ED and impulsivity between the aADHD, BPD and healthy control (HC) groups, and to explore divergent inhibitory profiles. Second, to explore the association of childhood trauma and self-regulatory impairments at trait and behavioral levels. Third, to test the potential role of ED and impulsivity between childhood traumas and personality functioning. The rationale of our approach was to investigate ED and impulsivity both within and across diagnostic groups, and identify background factors and mediation effects.

Participants

100 and 63 young adult patients between 18–36 years diagnosed with aADHD and BPD were enrolled in the study, respectively, 100 healthy adults were matched according to age. All patients were recruited at the Department of Psychiatry and Psychotherapy of Semmelweis University in Budapest, Hungary. A board-certified psychiatrist or clinical psychologist interviewed all patients in the BPD and aADHD groups using the MINI 5.0 [17, 18] and the SCID-5-PD¹⁹ [19] structured interviews to validate the clinical diagnosis and to detect the potential comorbidities. Comorbid BPD cases detected by SCID-5-PD were excluded from the aADHD group, while the detection of ADHD symptoms resulted in the exclusion from the BPD group to avoid the presence of both disorders. HC individuals without psychiatric or substance use disorder history were recruited on social media platforms, and screened by the Derogatis Symptom Scale/Symptom Checklist-90 (SCL-90) [20] and the Conners’ Adult ADHD Rating Scales (CAARS, 66-item version) [21]. To meet inclusion criteria for the HC group t-scores of the SCL-90 Global Severity Index (GSI) measure and the CAARS Inattention, Hyperactivity and Impulsivity domains had to be lower than 70. General exclusion criteria in all groups included psychosis, mental, visual or reading impairment.

The three groups were balanced according to age, but a significant difference in gender ratios was observed due to the higher rate of women in the BPD group (Table 1). There was also a significant difference in education level, with lower levels of completed education in the BPD group. There Barratt Simplified Measure of Social Status (BSMSS) [22] indicated lower SES scores in the BPD group.

Table 1

Clinical and demographic characteristics of the aADHD, BPD, and HC groups.
	aADHD (N = 100)	BPD (N = 63)	HC (N = 100)	F / χ²/H	p
Age (years, SD)	26.31 (4.71)	26.19 (4.51)	26.61 (4.59)	0.187	0.829
Sex (M/F) % ^a	52.0/48.0	20.6/79.4	44.0/56.0	16.102	< 0.001
Level of education (E/S/H) % ^b	4.0/51.0/45.0	7.9/61.9/30.2	3.0/49.0/48.0	6.309	0.043
SES (BSMSS, SD)^c	50.07 (8.73)	43.63 (11.80)	48.55 (10.69)	17.103	< 0.001
Inattention/Memory problems (CAARS-A)	25.55 (6.35)	17.47 (5.80)	11.07 (5.94)	138.512	< 0.001
Hyperactivity/Restlessness (CAARS-B)	20.862 (6.74)	14.70 (5.96)	11.30 (5.86)	57.606	< 0.001
Impulsivity/Emotional lability CAARS-C)	18.98 (7.07)	18.57 (6.87)	9.61 (5.24)	61.921	< 0.001
Problems with self-concept (CAARS-D)	11.47 (4.06)	13.55 (3.524)	6.24 (3.75)	74.316	< 0.001
DSM-IV Inattentive Symptoms (CAARS-E)	19.01 (4.64)	12.50 (5.42)	6.59 (3.90)	179.782	< 0.001
DSM-IV Ha-Imp Symptoms (CAARS-F)	15.39 (5.39)	10.33 (4.34)	7.49 (4.64)	64.266	< 0.001
DSM-IV ADHD Sy Total (CAARS-G)	34.40 (7.62)	22.83 (8.12)	14.07 (7.21)	173.292	< 0.001
ADHD index (CAARS-H)	23.20 (5.20)	19.32 (5.78)	10.35 (5.47)	138.954	< 0.001
Borderline Symptom Checklist – Behavior	16.73 (4.23)	22.52 (6.64)	14.65 (2.94)	49.385	< 0.001
Comorbidity
Depression (%)	38.0	73.0	-
Dysthymia (%)	5.0	22.2	-
Suicidal risk: no/low/mid/high (%)	88.0/10.0/-/-	15.9/41.3/20.6/22.2	-
(Hypo)mania (%)	-	3.2	-
Anxiety (%)	27.0	76.2	-
OCD (%)	1.0	7.9	-
PTSD (%)	0.0	25.4	-
Substance related (%)	12.0	22.2	-
Anorexia (%)	0.0	7.9	-
Bulimia (%)	0.0	11.1	-
Medication data
No medication (%)	43	20.6	84
Methylphenidate (%)	49	-	-
Atomoxetine (%)	1	-	-
Bupropion (%)	2	-	-
Antidepressant (%)	4	55.6	-
Antipsychotic (%)	-	30.2	-
Mood stabilizer and Anticonvulsant (%)	-	30.2	-
Anxiolytic (%)	-	31.7	-
Other (%)	11	12.7	16
Abbreviations:: ^a M = Male, F = Female. ^b For completed education, E = elementary, S = secondary, H = higher education, ^c BSMSS = Barratt Simplified Measure of Socioeconomical Status (BSMSS), which accounts for an individual's parent's educational attainment and occupational prestige, OCD = Obsessive-compulsive disorder, PTSD = post-traumatic stress disorder.

Table 2

PID-5, DERS and BIS-11 subscale results in the aADHD, BPD and HC groups.
Variable	Group	N	M	S.D.	F (df1, df2)	p	partial η²	Contrasts	p
PID-5 Distractibility	aADHD	95	2.290	0.535	124.18 (2,249)	< .001	0.499	aADHD > HC	< .001
	BPD	60	1.707	0.778				BPD > HC	< .001
	HC	99	0.878	0.581				aADHD > BPD	< .001
PID-5 Impulsivity	aADHD	95	1.340	0.678	36.012 (2,249)	< .001	0.224	aADHD > HC	< .001
	BPD	60	1.484	0.783				BPD > HC	< .001
	HC	99	0.632	0.565				aADHD v BPD	1.000
PID-5 Irresponsibility	aADHD	95	1.358	0.619	37.854 (2,249)	< .001	0.233	aADHD > HC	< .001
	BPD	60	1.116	0.628				BPD > HC	< .001
	HC	99	0.651	0.469				aADHD > BPD	< .008
BIS Attention	aADHD	96	3.029	0.442	114.41 (2,248)	< .001	0.480	aADHD > HC	< .001
	BPD	60	2.527	0.514				BPD > HC	< .001
	HC	99	2.034	0.435				aADHD > BPD	< .001
BIS Motor	aADHD	96	2.224	0.441	22.071 (2, 248)	< .001	0.151	aADHD > HC	< .001
	BPD	60	2.106	0.526				BPD > HC	.003
	HC	99	1.815	0.351				aADHD v BPD	.092
BIS Nonplanning	aADHD	96	2.392	0.446	31.173 (2, 248)	< .001	0.201	aADHD > HC	< .001
	BPD	60	2.317	0.429				BPD > HC	< .001
	HC	99	1.937	0.390				aADHD v BPD	.164
DERS	aADHD	94	2.746	1.027	29.266 (2, 247)	< .001	0.192	aADHD > HC	< .001
Nonacceptance	BPD	59	3.218	1.096				BPD > HC	< .001
	HC	99	2.003	0.800				aADHD v BPD	0.069
DERS	aADHD	94	3.655	0.963	31.082 (2, 247)	< .001	0.201	aADHD > HC	< .001
Goals	BPD	59	3.736	0.891				BPD > HC	< .001
	HC	99	2.687	0.978				aADHD v BPD	1.000
DERS	aADHD	94	2.612	1.005	42.503 (2, 247)	< .001	0.256	aADHD > HC	< .001
Impulse	BPD	59	3.314	1.069				BPD > HC	< .001
	HC	99	1.857	0.706				aADHD < BPD	< .001
DERS	aADHD	94	2.572	0.723	13.017 (2, 247)	< .001	0.095	aADHD > HC	0.003
Awareness	BPD	59	2.896	0.823				BPD > HC	< .001
	HC	99	2.227	0.689				aADHD v BPD	0.125
DERS	aADHD	94	2.646	0.845	62.808 (2, 247)	< .001	0.337	aADHD > HC	< .001
Regulation	BPD	59	3.659	0.936				BPD > HC	< .001
	HC	99	2.023	0.732				aADHD < BPD	< .001
DERS	aADHD	94	2.261	0.764	40.820 (2, 247)	< .001	0.248	aADHD > HC	< .001
Clarity	BPD	59	3.048	1.011				BPD > HC	< .001
	HC	99	1.778	0.639				aADHD < BPD	< .001
Abbreviations: PID-5 = The Personality Inventory for DSM-5, BIS = Barratt Impulsivity Scale 11th version, DERS = Difficulties in Emotion Regulation Scale.

The CAARS and the Borderline Symptom Checklist’s behavioral items [23] were used to assess ADHD and borderline symptoms in each group, respectively. The Personality Inventory for DSM-5 (PID-5) [1, 24, 25] was also administered for the detailed measurement of personality traits in the domains of negative affectivity, detachment, disinhibition, antagonism, psychoticism. We found significant differences in every domain of the CAARS, Borderline Symptom Checklist, and PID-5, except for antagonism. The demographic and clinical characteristics of the three groups are presented in Table 1.

Online questionnaires

All questionnaires were administered online. The 36-item Difficulties in Emotion Regulation Scale (DERS) scale was administered yielding results in the dimensions of nonacceptance, goal-directed behavior, impulsive behavior, emotion regulation, emotional awareness, and emotional clarity [26]. The 11th version of the Barratt Impulsivity Scale (BIS-11) [27, 28] was used to investigate attentional, motor, and non-planning impulsivity. With the LPFS-SR we assessed personality function components of Identity, Self-Direction, Empathy, and Intimacy, and the global dimension of personality dysfunction [16]. The Hungarian version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) was used for the assessment of childhood traumatization [29, 30].

Neuropsychological tests measuring behavioral impulsivity and impulsive choice

To assess waiting and stopping impulsivity, selected tests of the Cambridge Neuropsychological Test Automated Battery [31, 32] (CANTAB, Reaction Time, RTI, and Stop Signal Task, SST) were used. Although the RTI is designed for measuring reaction time, it can also be used for measuring waiting impulsivity by analyzing the number and the probability of premature responses and false alarms, when the subject cannot wait until the presence of stimuli. The waiting impulsivity related outcome measures are the RTI Simple/Five choice Error Scores (premature responses), the total number of trials where the subject made a response before the presentation of the target stimulus. In the SST the main outcome measure is Stop Signal Task Reaction Time (SSRT), which is an average time required for successful stopping; longer SSRT indicates greater difficulty in interrupting actions, reflecting on stopping impulsivity or impulse control [32].

A computerized version of Rogers’ decision-making task [33], was used for measuring impulsive choice. This task is designed to measure decision-making under uncertainty and delay aversion, as participants must make probabilistic judgments and make bets based on their confidence in their choice. The more detailed description of the test, and the process of the outlier detection process, has been described elsewhere [34].

Statistical analysis

The SPSS version 27 [35] and JASP 0.19.1 [36] were used for all statistical analyses. Group differences measured by self-report scales, were compared between BPD, aADHD and control groups using ANOVA analyses and Bonferroni post hoc tests. Neuropsychological test results were compared by either ordinal/logistic regression, or univariate ANOVA analyses, depending on data structure. Delay aversion was analyzed by using repeated measures ANOVA using Bonferroni post-hoc tests. All analyses were controlled for gender and SES. Predictors in the background of trait impulsivity factors were analyzed by linear regression, SES and gender were included in the model as covariates. The mediator model was created in SPSS, according to Process v4 by Andrew F. Hayes.

ED and trait impulsivity measures

Total DERS and BIS-11 scores were significantly different in the three groups. The highest DERS total score was reported in BPD, followed by the aADHD group, and the lowest in the HC group (F(2,247) = 64.206; p < .001; part. η²=.342). BIS-11 total score was significantly higher in aADHD compared to BPD and HC groups, while the difference between BPD and HC was also statistically significant (F(2,248) = 36.744; p < .001; part. η²=.355). ED and impulsivity subscales are summarized in Fig. 1. The two patient groups were significantly different from the control group in each subscale, but they also differed from each other as well. In the ED subscales the BPD group reached the higher scores than the aADHD group, accept for the nonacceptance, goals, and awareness subscales, which showed no significant difference between the two patient groups. Attentional impulsivity was more characteristic to aADHD, motor and non-planning impulsivity was similar in the two patient groups.

Neuropsychological measures of impulsivity and impulsive choice differences

Waiting impulsivity was measured by CANTAB Reaction Time paradigm’s premature responses. No significant difference was found between the three groups in the RTI simple error score variable. The five choice error score differed significantly between the aADHD and HC groups, while there was no significant difference between the BPD and HC groups in premature responses. In the stopping impulsivity measures, which represent the ability to stop ongoing actions, the aADHD group performed below the HC group. The SSRT was significantly longer in the aADHD group than the HC group (Table 3). There was no significant difference between the BPD and HC groups.

Table 3

Comparison of impulsivity related CANTAB variables in the aADHD, BPD, and HC groups.
Variable name	aADHD	BPD	Control	Contrasts	Statistic value	p
RTI simple error score – premature responses ¹	M = 0.43 S.D. = 0.728	M = 0.30 S.D. = 0.638	M = 0.28 S.D. = 0.533	aADHD v HC BPD v HC aADHD v BPD	b = 0.321 b = 0.177 b = 0.144	.328 .664 .720
RTI five choice error score – premature responses ² /dichotomized because of skewness/	Percentage of error: 14%	Percentage of error: 6.3%	Percentage of error: 5%	Main effect of group aADHD > HC BPD v HC aADHD v BPD	χ² (2) = 4.836 R² = 1.9–4 .2% OR = 3.012 OR = 1/0.685 OR = 2.064	.089 .045 .599 .255
SST stop signal reaction time ³ (measured in ms)	M = 242.230 S.D. = 42.880	M = 228.147 S.D. = 47.222	M = 219.172 S.D. = 37.778	Main effect of group aADHD > HC BPD v HC aADHD v BPD	F(2,248) = 7.609	< .001 < .001 > .999 .081
SST Direction error – go trials¹	M = 2.83 S.D. = 4.568 Med: 1.00	M = 1.54 S.D. = 2.657 Med: 1.00	M = 1.31 S.D. = 2.509 Med. 0.50	aADHD > HC BPD v HC aADHD v BPD		.019 .658 .139
SST Direction error – stop trials¹	M = 43.17 S.D. = 4.725 Med: 43.00	M = 42.21 S.D. = 4.080 Med: 43.00	M = 41.37 S.D. = 3.762 Med. 41.00	aADHD > HC BPD v HC aADHD v BPD		< .001 .076 .258
Legend: 1. Ordinal regression - comparison contains logistic regression slopes and significance values. Descriptive statistics contains Mean and standard deviation and median. 2. Logistic regression – we used Cox & Snell and Nagelkerke R² as effect sizes of main the effect of group. Comparison contains odds ratios (OR) and significance values. Descriptive statistics contains percentages. 3. Univariate ANOVA - comparison contains the main effect of group and Bonferroni Post hoc. Descriptive statistics contains Mean and standard deviation. All analyzes are controlled for age, gender, and SES.
Abbreviations: RTI = Reaction Time, SST = Stop Signal Task.

Table 4

Sociodemographic predictors of emotion dysregulation and trait impulsivity.
DERS	B	SE	β	t	p	tolerance
Constant	66.281	11.636		5.696	< .001
Gender	7.235	3.383	.124	2.139	.033	.091
SES	− .288	.160	− .106	-1.797	.074	.963
CTQ total	.711	.121	.348	5.896	< .001	.960
BIS-11	B	SE	β	t	p	tolerance
Constant	66.604	5.519		12.069	< .001
Gender	− .859	1.617	− .032	− .531	.596	.092
SES	− .152	.076	− .124	-2.002	.046	.961
CTQ total	.208	.058	.224	3.603	< .001	.957
Legend: Linear regression models. Outcome variable: Emotion dysregulation (DERS): R^² = .170 R²_Adj = .160 F(3, 250) = 16.981 p < .001. Outcome variable: Trait impulsivity (BIS-11): R^² = .076 R²_Adj = .065 F(3, 250) = 6.840 p < .001. Abbreviations: DERS = Difficulties in Emotion Regulation Scale, BIS = Barratt Impulsivity Scale 11th version, SES = Socioeconomic status,, CTQ = Childhood Trauma Questionnaire.

The decision making task has several outcome measures, of which only delay aversion was used for further analyses. Delay aversion represents the tendency to impatiently accept larger bets. The interaction of group and winning probability was found to be significant (F(2,211) = 4.996; p = .008; part. η²=0.045), and subjects in the BPD group had the tendency of impatiently accept larger bets despite of the low probability of winning in comparison to the HC group (F(2,211) = 3.101; p = .047; part. η²=0.029), when the bets were presented in descending order (Fig. 2). Upon ascending conditions, there was no statistically significant difference between the three groups in delay aversion (F(2,211) = 0.344; p = .709; part. η²=0.003).

The association of childhood traumatization with ED, trait and behavioral impulsivity

A dimensional approach was used to detect associations between childhood traumas, ED and impulsivity factors, which offers powerful ways of assessing psychopathology, beyond the structures of current diagnostic categories. Our hypothesis was, that the different factors of inhibitory capacity are associated with childhood traumatization to a different extent. Besides the CTQ total score, a trauma severity score was derived, grouping subjects into low, medium and high trauma severity groups, based on the CTQ mean total score, and +/- 1 standard deviation as cut-off scores. As expected by clinical experience, the BPD group was characterized by the highest proportion of highly traumatized subjects. The distribution of traumatization levels was comparable between the aADHD and HC groups (Fig. 3).

The total impulsivity scores measured by the BIS-11 had significant correlations with the CTQ total score. Linear regression modeling was used to test to what extent gender, socioeconomic status (SES), and levels of traumatization predicts trait impulsivity and ED. The conditions of regression met standard criteria (Supplementary Tables 1 and 2) The level of traumatization predicted ED and trait impulsivity. Gender predicted ED, but had no significant correlation with total impulsivity scores, while socioeconomic status demonstrated significant correlation with trait impulsivity, but not with ED. Female subjects had higher DERS scores than males in each studied group. Waiting and topping impulsivity showed no differences as a function of the level of traumatization (F(2,252) = 0.703; p = 0.496; part. η²=0.006). Delay aversion level among uncertain conditions differed significantly according to the level of traumatization, namely, those who were the most traumatized, had the highest delay aversion scores (F(2,169) = 3.192; p = 0.044; part. η²=0.036).

ED and impulsivity as mediators between childhood traumas and personality functioning

To assess the role of ED and impulsivity in the background of personality functioning a mediator model was implemented. Childhood traumatization as predictor variable, ED and impulsivity as mediator variables, and personality functioning as outcome variable were predefined. Each variable was transformed to z-scores and corrected for sign for downstream analyses. Standardized coefficients demonstrated that traumatization has a significant total and direct effect on personality functioning. Among the indirect pathways, only those remained significant, which had ED as a mediator. The model also showed that the detected associations between trait impulsivity and childhood traumatization were mediated by ED (Fig. 5).

ED and impulsivity are overlapping symptoms of aADHD and BPD, however disorder-specific characteristics of these constructs have not been clearly defined yet. From a clinical point of view, DSM-5 diagnostic criteria show significant differences in the definition of impulsivity for these disorders. The DERS and BIS-11, measures of self-reported inhibitory capacity showed marked differences between the aADHD, BPD, and HC groups. The DERS total score was the highest in the BPD group, and the lowest in the HC group. The aADHD group demonstrated significant differences compared to both the BPD and HC groups. In each DERS subscale the BPD group reached the highest scores nominally, however the impulse (controlling impulsive behavior when distressed), regulation (limited access to effective emotion regulation strategies) and clarity (lack of emotional clarity) scales showed significant difference between the two patient groups. The impulse subscale of DERS has the most overlap with the “negative urgency concept”, affective instability driven impulsivity. In the study of Krause-Utz et al. not only the BPD, but also the clinical control group expressed elevated negative urgency [15]. Linhartová et al. found, that the only significant difference between BPD and aADHD patients was negative urgency, with higher scores in BPD patients [6]. The regulation and clarity subscale of DERS refers to the capability of recognizing emotions and the lack of adaptive regulation strategies. The elevated DERS scores found in BPD relative to aADHD are in line with previous findings of Rüfenacht et al., who found that aADHD patients have a better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients [13].

BIS-11 impulsivity total scores were the most characteristic for the aADHD group, the BPD group was in-between differing significantly from aADHD and HC groups as well. In the study of Lepouriel et al. a same distribution of the BIS-11 total scores were demonstrated [7]. BIS-11 attentional scores were significantly higher in aADHD compared to BPD and HC groups. In summary, the self-regulatory profile, measured by self-reported questionnaires differs in these groups. We found ED to be more prominent in BPD, while impulsivity was more characteristic to aADHD.

Waiting impulsivity was measured with RTI subtest of CANTAB. The aADHD group showed elevated level of waiting impulsivity, while the BPD group did not differ from healthy controls in premature responses of RTI. In former studies individuals with BPD have been found to exhibit heterogeneous results in neuropsychological tests because of the high rate of comorbidity, including affective disorders, substance use, and ADHD [37]. Recently, several studies have found intact waiting and stopping impulsivity in BPD under emotionally neutral circumstances [8, 38, 39]. Stopping impulsivity was increased in aADHD, but not in BPD, which corresponds to previous studies [9, 40]. Delay aversion measured by the Rogers’ decision making task was detected only in the BPD group. The difference was significant among ascending conditions, while the probability of winning was very low. In other words, despite the uncertain conditions the BPD patients took earlier, therefore larger bets than the HC group. The aADHD group was similar to the HC group and had a similar delay aversion profile. Our results support former results, which found delay aversion relevant to BPD [38–40].

Traumatic events in childhood, especially those that influence emotional maturation, are considered as a predisposing factor for the later development of ED and impulsivity (reviewed by Calvo et al.) (41). The results of our transdiagnostic linear regression analyses support these findings, with trauma scores predicting both ED and impulsivity traits. In the case of ED, gender was also a significant predictor, while for impulsivity, SES was a significant predictor.

We found no associations between waiting and stopping impulsivity and the level of traumatization, which might be a consequence of the sex-dependent nature of maltreatment-related reorganization of the brain inhibitory control network resulting in poorer response inhibition among males (42). In our sample females were overrepresented than males, which has a great ecological validity and might be the reason, why stopping impulsivity seems to be intact in different BPD samples throughout studies (8, 9). Delay aversion level among uncertain conditions differed significantly according to the level of trauma. Those who were most traumatized, had the highest delay aversion scores, regardless the diagnosis. This association gives a potential insight to coping with a chaotic, traumatizing milieu, which was characteristic to the BPD group to the greater extent. Where the future is not predictable, the short term gains becomes more important and therefore it can be considered as a relevant coping strategy.

Several studies have suggested that traumatic childhood experiences are associated with personality disorders, depression, anxiety, addictions, suicidal behavior, obesity (43–48), but according to our best knowledge, there has not been studies published about the mediating effect of ED and impulsivity between traumatization an DSM-5 personality functioning. Our aim was to assess the role of traumatization across diagnostic categories, and find potential mediators in a transdiagnostic analysis. In our sample childhood traumatization had a significant total and direct effect on adult personality functioning, but among indirect pathways only those were significant which contain ED as a mediator. ED seems to mediate the effects of traumatization on impulsivity as well. However, it is crucial to acknowledge that the correlational design applied does not allow causal conclusions to be drawn between childhood traumatization, ED, impulsivity, and personality functioning. Therefore, it is essential for future research to investigate theses phenomena in prospective, well-designed studies.

Limitations of our study need to be acknowledged. We cannot report about aADHD - BPD comorbid cases, because they were excluded from the analyses. The sex ratio was different in the aADHD and BPD group, but we included sex as cofactor in each analysis. However, our sample has high ecological validity, as there is a higher prevalence of women among BPD patients and men among aADHD patients in clinical samples. Results of self-reported scales are subjective, therefore can be distorted and there are more suitable self–reported scales, i.e. UPPS-P, which measures negative urgency, a factor which seems to be able distinguish BPD from aADHD. The concept of negative urgency combines affective instability and impulsivity, and the importance of this combination for BPD was stressed in previous studies (49).

In conclusion, assessing the inhibitory profile in aADHD and BPD help us to understand the different factors of ED and impulsivity in these two disorders, which can be taken into consideration as an important aspect in differential diagnostics and can serve as a basis for therapeutic approaches. Future research should explore longitudinal associations and the effect of clinical intervention in these patient groups.

ADHD

Attention-Deficit/Hyperactivity Disorder

aADHD

adult Attention-Deficit/Hyperactivity Disorder

ANOVA

analysis of variance

BIS-11

Barratt Impulsivity Scale

BSMSS

Barratt Simplified Measure of Social Status

BPD

Borderline Personality Disorder

CAARS

Conners’ Adult ADHD Rating Scales

CANTAB

Cambridge Neuropsychological Test Automated Battery

CTQ-SF

Childhood Trauma Questionnaire-Short Form

DERS

Difficulties in Emotion Regulation Scale

DSM-5

Diagnostic and Statistical Manual of Mental Disorders 5th Edition

emotion dysregulation

healthy control

LPFS-SR

Level of Personality Functioning Scale-Self Report

MINI

Mini-International Neuropsychiatric Interview

PID-5

Personality Inventory for DSM-5

RTI

Reaction Time

SCID-5-PD

Structured Clinical Interview for DSM-5 Personality Disorders

SCL-90 GSI

Symptom Checklist-90 Global Severity Index

SES

Socio-economic status

SPSS

Statistical Package for Social Sciencies

SSRT

Stop Signal Reaction Time

SST

Stop Signal Task, SST

Ethics approval and consent to participate

All procedures conformed with the 1964 Helsinki Declaration and its subsequent amendments. The study received ethical board approval from the Hungarian Health Science Council (Egészségügyi Tudományos Tanács, ETT) and the Semmelweis University Institutional Research Ethics Committee prior to data collection: IF-113908/2015 and IF-621-2/2017, and approved modifications: 25329-5/2018/EÜIG and 926-5/2018/EÜIG. All particpants gave written consent after receiving detailed information.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors declare that they have no competing interests. The research was funded by the Hungarian Brain Research Programme grant 2017-1.2.1-NKP-2017-00002, and the National Research Development and Innovation Office grants NKFI K129195 and TKP2021-EGA-25, all to JMR.

Authors’ contributions

EK took part in: conceptualization, methodology, investigation, project administration, data curation, writing – original draft, funding acquisition. LB took part in: conceptualization, methodology, investigation, project administration, data curation. SS took part in: methodology and investigation. EEL took part in: methodology and investigation. ZH took part in: methodology and investigation. ZN took part in: writing – review & editing, supervision, resources. ZSU took part in: conceptualization, methodology, formal analysis, writing - review & editing, supervision. JMR took part in: conceptualization, writing - review & editing, resources, supervision, funding acquisition, correspondence. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank to Klára Soltész-Várhelyi and Máté Baradits for supervising the statistical analyses, and Bettina Bajzát for the valuable contributions in data collection, data curation and project administration.

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Emotion dysregulation and impulsivity as overlapping symptoms in adult Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder: Differences in severity and their association with childhood traumatization and personality functioning

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Abstract

Background

Methods

Results

Conclusions

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Background

Methods

Participants

Online questionnaires

Neuropsychological tests measuring behavioral impulsivity and impulsive choice

Statistical analysis

Results

ED and trait impulsivity measures

Neuropsychological measures of impulsivity and impulsive choice differences

The association of childhood traumatization with ED, trait and behavioral impulsivity

ED and impulsivity as mediators between childhood traumas and personality functioning

Discussion

Conclusions

Abbreviations

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References

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