[Adult ADHD - recommendations for clinical management in general practice]. / Trouble du déficit d'attention/hyperactivité (TDAH) chez l'adulte - Recommandations de prise en charge par le médecin de premier recours.

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is frequently found in the general population and it negatively impacts the quality of life of those that suffer from this disorder. Although the general practitioner occupies a primordial role in the detection as well as in the management of this disorder, the lack of training as well as the stigma surrounding ADHD make it not always obvious how to approach the patient with or possibly suffering from ADHD. In this article, we propose to present a few lines of good clinical practice applicable in primary medicine for the detection, diagnosis and management of ADHD in adults.

Le trouble du déficit d'attention/hyperactivité (TDAH) chez l'adulte est fréquemment rencontré dans la population générale et impacte négativement la qualité de vie de celui qui en souffre. Bien que le médecin de premier recours occupe un rôle primordial dans la détection ainsi que dans la prise en charge de ce trouble, le manque de formations ainsi que le stigma qui entoure le TDAH font qu'il n'est pas toujours évident pour le médecin de premier recours de savoir comment aborder un patient souffrant ou possiblement souffrant d'un TDAH. Dans cet article, nous présentons quelques bonnes pratiques cliniques applicables en médecine de premiers recours pour une détection, un diagnostic et une prise en charge du TDAH chez le sujet adulte.

Insomnia in adult attention-deficit/hyperactivity disorder: A comparison with borderline personality disorder population in a clinical setting and control participants.

OBJECTIVES: Many adults with attention-deficit/hyperactivity disorder (ADHD) report sleeping difficulties. The relationship between sleep and ADHD is poorly understood, and shows discrepancies between subjective and objective measures. In order to determine the specificity of sleep-associated symptoms in ADHD, subjective sleep assessments among ADHD adult patients were compared with control subjects and with individuals suffering from borderline personality disorder (BPD). METHODS: 129 outpatients with ADHD, 70 with BPD (including 17 patients with BPD and ADHD comorbidity), and 65 control participants were assessed for sleep quality, insomnia, and sleepiness, using the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), and the Epworth Sleepiness Scale (ESS). RESULTS: ADHD- and BPD-sufferers achieved higher insomnia and lower sleep quality scores than control subjects. Clinical groups did not differ in terms of sleep quality, although insomnia was more severe among BPD patients. Depression scores explained most of sleep symptoms, but even when controlling for depression, ADHD sufferers showed higher sleep latency. Inattentive symptoms were associated with somnolence, while hyperactive/impulsive symptoms were associated with insomnia and lower sleep efficiency. CONCLUSION: Sleep-related symptoms associated with ADHD were partly explained by non-specific factors, especially depression symptoms. In a dimensional perspective, hyperactive and inattentive symptoms were associated with specific sleep symptoms.

METHYLATION OF SEROTONIN RECEPTOR 3A IN ADHD, BORDERLINE PERSONALITY, AND BIPOLAR DISORDERS: LINK WITH SEVERITY OF THE DISORDERS AND CHILDHOOD MALTREATMENT.

BACKGROUND: Serotonin 3A receptor (5-HT3A R) is associated at the genetic and epigenetic levels with a variety of psychiatric disorders and interacts with early-life stress such as childhood maltreatment. We studied the impact of childhood maltreatment on the methylation status of the 5-HT3A R and its association with clinical severity outcomes in relation with a functional genetic polymorphism. METHODS: Clinical severity indexes of 346 bipolar, borderline personality, and adult attention deficit hyperactivity disorders patients were tested for association with the DNA methylation status of eight 5-HT3A R gene CpGs. Relationship between the functional variant rs1062613 (C > T) and methylation status on severity of the disorders were also assessed. RESULTS: Childhood maltreatment was associated with higher severity of the disease (higher number of mood episodes, history of suicide attempts, hospitalization, and younger age at onset) across disorders and within each individual disorder. This effect was mediated by two 5-HT3A R CpGs. Compared to T allele carriers, CC carriers had higher methylation status at one CpG located 1 bp upstream of this variant. CONCLUSIONS: This study shows that epigenetic modification of the 5-HT3A R is involved in the mechanism underlying the relationship between maltreatment in childhood and the severity of several psychiatric disorders in adulthood.

Personality profiles in adults with attention deficit hyperactivity disorder (ADHD).

BACKGROUND: Previous studies suggested that the presence of ADHD in children and young adolescents may affect the development of personality. Whether or not the persistence of ADHD in adult life is associated with distinct personality patterns is still matter for debate. To address this issue, we compared the profiles of the Temperament and Character Inventory (TCI) that assesses personality dimensions in 119 adults ADHD and 403 controls. METHODS: ANCOVA were used to examine group differences (controls vs. ADHD and ADHD inattentive type vs. ADHD combined + hyperactive/impulsive types) in Temperaments and Characters. Partial correlation coefficients were used to assess correlation between TCI and expression and severity of symptoms of ADHD. RESULTS: High novelty seeking (NS), harm avoidance (HA) and self-transcendence (ST) scores as well as low self-directedness (SD) and cooperativeness (C) scores were associated with ADHD diagnosis. Low SD was the strongest personality trait associated with adult ADHD. Cases with the ADHD inattentive type showed higher HA and lower SD scores compared to the combined and hyperactive/impulsive types. High HA scores correlated with inattention symptoms whereas high NS and ST scores were related to hyperactive symptoms. Finally low SD and high NS were associated with increased ADHD severity. CONCLUSIONS: Distinct temperaments were associated with inattentive versus hyperactive/impulsive symptoms supporting the heterogeneous nature of the disorder.

CBT/DBT skills training for adults with attention deficit hyperactivity disorder (ADHD).

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is associated with marked impairments in familial, social, and professional functioning. Although stimulant treatments can be effective in adult ADHD, some patients will respond poorly or not at all to medication. Previous studies demonstrated that cognitive behavioural therapy- (CBT) and dialectical behavior therapy- (DBT) oriented interventions are effective in reducing the burden of the disease, which is mainly marked by depression, interpersonal difficulties, low self-esteem, and low quality of life. In order to determine the effectiveness of this intervention, we assessed the benefits of a CBT/DBT programme to reduce residual symptoms and help patients improve their quality of life. SUBJECTS AND METHODS: 49 ADHD-patients, poor responders to medication, were enrolled in a one-year programme where they received individual therapy, associated with weekly sessions of group therapy with different modules: Mindfulness, Emotion Regulation, Interpersonal Effectiveness and Distress Tolerance, Impulsivity/Hyperactivity and Attention. Each subject was assessed at baseline, at months 3 and 6, and at the end of the treatment for ADHD severity (ASRS v1.1), depression severity (BDI-II), hopelessness (BHS), mindfulness skills (KIMS), anger expression and control (STAXI), impulsivity (BIS-11), quality of life (WHOQOL-BREF), and social functioning (QFS). The 49 ADHD patients were compared with 13 ADHD subjects on a waiting list. Linear mixed models were used to measure response to treatment. RESULTS: Overall, the psychotherapeutic treatment was associated with significant improvements in almost all dimensions. The most significant changes were observed for BDI-II (b=-0.30; p<0.0001), ASRS total score (b=-0.16; p<0.0001), and KIMS AwA (b=0.21; p<0.0001), with moderate to large effect sizes. Compared with the waiting list controls, ADHD patients showed a better, albeit non-significant, pattern of response. CONCLUSIONS: Individual and structured psycho-educational DBT/CBT groups support existing data suggesting that a structured psychotherapeutic approach is useful for patients who respond partially or not at all to drug therapy.

Adult ADHD and pathological narcissism: A retrospective-analysis.

Adult attention deficit hyperactivity disorder (ADHD) is often associated with personality pathology. However, only few studies have been conducted on the link between ADHD and pathological narcissism (PN), with or without a diagnosis of narcissistic personality disorder (NPD). In order to fill this gap, PN and NPD were assessed in 164 subjects suffering from ADHD, with several other measures including ADHD severity, quality of life, depression, anxiety, impulsivity, and emotion dysregulation (ED). We found that a significant proportion of ADHD patients suffered from NPD, and that both narcissistic grandiosity and vulnerability were associated with ADHD hyperactivity and impulsivity symptoms, but not with inattentive symptoms. These two dimensions seemed to be negatively associated with well-being and positively associated with most of the other studied psychiatric dimensions except ED, the latter being only associated with vulnerability, even after adjustment on borderline symptoms. Overall, despite important limitations that limit the generalizability of our findings to the overall ADHD population (notably linked to selection bias), we believe that this exploratory study sheds light on the potential clinical relevance of narcissistic pathology in adult ADHD patients.

Association between pathological narcissism and emotion regulation: The role of self-mentalizing?

Pathological narcissism (PN) is a common psychopathological issue leading to maladaptive strategies to cope with self-esteem threats, including self-enhancement and exploitation (grandiose strategies) or internalized shame, depression, and social withdrawal (vulnerable strategies). Mentalizing is a key process for regulating self and other representations and their associated emotions. Patients with PN further struggle with emotion dysregulation (ED), which during development is intertwined with the growing capacity to mentalize. We seek to contribute to emerging empirical data documenting the associations between PN and ED and between PN and mentalizing, and to provide information on the nature of their mutual relationships. In the present study, we assessed PN, ED, and three mentalizing dimensions (mentalizing self, other, and motivation to mentalize) in 183 patients consulting in our outpatient unit specialized in ED. We found that narcissistic vulnerability was negatively associated with self-mentalizing and positively associated with overall ED, both even after adjustment for borderline and attention deficit hyperactivity disorder (ADHD) symptoms. However, the association with ED was not maintained after further adjustment for self-mentalizing or overall-mentalizing, which suggests that mentalizing may play a mediating role in this relationship. On the other hand, narcissistic grandiosity was positively associated with other-mentalizing and ED and negatively associated with self-mentalizing in bivariate analyses, but these last two associations were not maintained after adjustment for comorbid borderline and/or ADHD symptomatology. This study provides new information on the link between PN and ED and on key mentalizing dimensions meaningfully relating to PN, notably through a potential role of self-mentalizing processes between PN and ED.

Body modifications in borderline personality disorder patients: prevalence rates, link with non-suicidal self-injury, and related psychopathology.

BACKGROUND: Borderline Personality Disorder (BPD) is a potentially severe personality disorder, characterized by difficulties in emotion regulation and control of behaviors. It is often associated with non-suicidal self-injury (NSSI). Borderline personality features have also been linked to body modifications (BMs). However, the prevalence of BMs, the link between BMs and NSSI, and between BMs and several psychopathology dimensions (e.g. borderline severity, emotion regulation, impulsivity …) remains understudied in patients with BPD. This study aims to fill this gap, and to provide further evidence on the link between NSSI and BMs. METHODS: We used data from a psychiatric outpatient center located in Switzerland (n = 116), specialized in the assessment and treatment of BPD patients. Patients underwent several semi-structured interviews and self-report psychometric scales at the arrival, and the data were retrospectively analyzed. RESULTS: We found that 70.69% of the patients had one piercing or more, and 69.83% were tattooed. The total score of body modifications and the total number of piercings score of piercings were significantly positively associated with NSSI and the SCID BPD total score. The association with the SCID score was mainly driven by the "suicide and self-damaging behaviors" item and the "chronic feeling of emptiness" item. A significant association was found between total number of piercings and emotion dysregulation. On the other hand, the self-reported percentage of body covered by tattoos score was specifically associated with the sensation seeking subscale of the UPPS-P. CONCLUSION: This study provides evidence on the prevalence of BMs in BPD patients, and on the link between BMs and NSSI in this population, suggesting a role of emotion regulation in the link between both constructs. These results also suggests that tattoos and piercings may be differentially linked to specific underlying psychological mechanisms. This calls for further considerations of body modifications in the assessment and care of BPD patients.

Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy: preliminary results.

OBJECTIVE: One of the components of dialectical behavior therapy (DBT) is the use of mindfulness skills as a core component of treatment for subjects with borderline personality disorder (BPD). In this study, we investigated changes in and correlates of mindfulness skills over a 1-year follow-up including a 4-week session of intensive DBT followed by 10 months of standard DBT. METHODS: Fifty-two BPD subjects were assessed several times using the Kentucky Inventory of Mindfulness Skills (KIMS) which describes mindfulness in four discrete dimensions: observing (Obs), describing (Des), acting with awareness (AwA) and accepting without judgment (AwJ). RESULTS: AwJ was the only dimension that increased significantly over time after adjustment for potential confounding factors (ß = 0.24; P = 0.0002). Increases in AwJ correlated with improvement in BPD symptoms. CONCLUSIONS: This study highlights the usefulness of investigating changes in mindfulness dimensions during DBT. AwJ is a possible mechanism for positive change. Encouraging this skill should lead to a more adaptive response to problematic situations and counteract impulsive and problematic behaviors. The lack of specific control groups means that these findings are preliminary and replication is required.

Anxiety disorders in adult ADHD: A frequent comorbidity and a risk factor for externalizing problems.

INTRODUCTION: ADHD is a common neurodevelopmental disorder and is highly prevalent in adults. It is associated with several negative outcomes, impacting well-being and global functioning. ADHD is highly associated with comorbidities, anxiety disorders being probably the most frequent. The goal of our study is to assess the prevalence of anxiety disorders and their impact in adults with ADHD. METHOD: 353 individuals diagnosed with ADHD were recruited. Severity of ADHD was assessed as well as lifetime anxiety disorders and other psychiatric comorbidities. We performed logistic and linear regressions to test the impact of lifetime anxiety disorders on demographic and clinical variables. RESULTS: More than half of the patients had at least one anxiety disorder. The presence of comorbid anxiety disorders was associated with worse clinical presentation (positive history of suicide attempts, higher disposition toward anger, higher rate of hospitalization and psychotic symptoms) and with a lower level of education. CONCLUSION: Anxiety disorders are highly prevalent in ADHD and are associated with higher levels of suicidality and disposition towards anger, more severe clinical presentation and lower functioning. Comorbid anxiety needs to be evaluated and treated by clinicians to limit distress, aggression towards self and others and to improve quality of life.

Validation of self-report measures of narcissism against a diagnostic interview.

The Pathological Narcissism Inventory (PNI) and the Narcissistic Personality Inventory (NPI) are often used to screen for pathological narcissism but have rarely been validated against a clinician-administered diagnostic interview. Our study evaluated the convergent validity of the PNI and NPI against a diagnostic interview for narcissistic personality disorder (NPD) in a clinical population. We used data from a psychiatric outpatient center located in Switzerland (n = 123). Correlations between PNI/NPI and NPD ranged between .299 and .498 (common variance 9.0-24.8%). The PNI and NPI should be used carefully to screen for NPD. We highlight a need to increase the compatibility between the conceptual underpinnings of the PNI, NPI and NPD.

Mindfulness Training for Adults with Attention-Deficit/Hyperactivity Disorder: Implementation of Mindful Awareness Practices in a French-Speaking Attention-Deficit/Hyperactivity Disorder Unit.

Introduction: Mindfulness-based programs are a promising option for patients with attention-deficit/hyperactivity disorder (ADHD), who face attention, hyperactivity, and emotion dysregulation issues in their daily life. Objective: To examine the implementation and impact of specific mindfulness training for adults with ADHD in a French-speaking unit. Methods: Thirty-eight adults with ADHD were included in an 8-week Mindful Awareness Practices (MAPs) program. Patients were assessed for ADHD symptoms, anxiety, depression, and mindfulness skills, before (T1) and after (T2) the eight sessions, and then 2 months later (T3). Results: The patients adhered to the program as the majority of them completed it. A significant decrease in ADHD, depression, and anxiety symptoms was found between T1 and T2. Regarding mindfulness skills, a significant increase was observed between T1 and T2 in Observing, Describing and Nonreactivity to inner experience cores, but not Acting with awareness and Nonjudging of inner experience scores. There was no significant change between T2 and T3. Conclusion: The MAPs program was successfully implemented and showed promising effects on ADHD symptomatology and related symptoms.

Link between History of Childhood Maltreatment and Emotion Dysregulation in Adults Suffering from Attention Deficit/Hyperactivity Disorder or Borderline Personality Disorder.

Childhood maltreatment (CM) may have a long-term effect on emotion regulation. This study aimed to explore the relationship between CM and emotion dysregulation (ED) in a heterogeneous population. Four hundred seventy French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 ADHD + BPD, N = 61 clinical controls) completed the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), the Childhood Trauma Questionnaire (CTQ), and the Relationship Scales Questionnaire (RSQ). Reports of childhood maltreatment experiences were significantly associated with increased levels of emotion reactivity in all our groups and in the whole population, with a greater use of non-adaptive cognitive emotion regulation strategies and insecure attachment patterns. Emotional abuse showed the strongest effect. Further analysis indicated that an anxious attachment style significantly mediated the relationship between CM and the use of non-adaptive cognitive emotion regulation strategies and emotion reactivity. The results of our study suggest an impact of CM on ED and a potentially marked effect of emotional abuse. They also indicate a potentially mediating role of insecure attachment in the relationship between a history of childhood abuse and emotion reactivity and a higher use of non-adaptive cognitive emotion regulation strategies in adulthood.

Impact of Childhood Maltreatment in Borderline Personality Disorder on Treatment Response to Intensive Dialectical Behavior Therapy.

Childhood maltreatment (CM), including emotional, physical, and sexual abuse and emotional and physical neglect, is associated with severity of borderline personality disorder (BPD). However, knowledge on the impact of CM on treatment response is scarce. The authors investigated whether self-reported CM or one of its subtypes affected treatment retention, depressive symptoms, and impulsivity throughout short-term intensive dialectical behavior therapy (I-DBT) in 333 patients with BPD. Data were analyzed with linear and logistic regressions and linear mixed models, using a Bayesian approach. Patients who reported childhood emotional abuse had a higher dropout rate, whereas it was lower in patients who reported childhood emotional neglect. Emotional neglect predicted a greater decrease of depressive symptoms, and global CM predicted a greater decrease of impulsivity. The authors concluded that patients with BPD who experienced CM might benefit from I-DBT in specific symptom domains. Nonetheless, the impact of emotional abuse on higher dropout needs to be considered.

Childhood maltreatment, anxiety disorders and outcome in borderline personality disorder.

INTRODUCTION: Anxiety disorders are a frequent in borderline personality disorder (BPD) and are associated with more severe symptomatology and poorer functional outcomes. Their presence in BPD is also believed to be the consequence of early life adversities. The aim of our study was to examine the relationship between comorbid anxiety disorders, childhood maltreatment and severity of BPD. METHODS: 388 BPD outpatients were assessed for lifetime anxiety disorders and history of childhood maltreatment. Severity of BPD was measured by the number of DSM-IV BPD criteria, history of suicide attempts, hospitalizations, psychotic symptoms, comorbid substance use disorder, other comorbid disorders, level of depression, hopelessness, impulsivity and trait anger. We used logistic regressions to test the association between childhood maltreatment and anxiety disorders and the effect of those factors on severity indicators RESULTS: More than half of the participants suffered from two or more anxiety disorders. The most common comorbidity was social phobia. Childhood maltreatment was associated with an increased number of anxiety disorders. Both anxiety disorders and childhood maltreatment had, independently from one another, an effect on severity indicators. Anxiety disorders were significantly associated with the number of DSM-IV BPD criteria, suicide attempts and psychotic symptoms. Anxiety disorders had an impact on the level of depression and hopelessness, whereas childhood maltreatment impacted impulsivity and anger trait. CONCLUSION: Our results show the importance of comorbid anxiety disorders in BPD, as well as their impact on severity. Anxiety disorders and childhood maltreatment should be considered by healthcare professionals to ensure optimal care. Furthermore, interventions targeting those issues need to be developed.

Internalized stigmatization in borderline personality disorder and attention deficit hyperactivity disorder in comparison to bipolar disorder.

INTRODUCTION: Internalized stigma constitutes a major concern in mental health illness. It has numerous repercussions on patients, including poor self-esteem, higher illness severity, poor adherence to care and reduced global functioning. The goal of this study was to compare internalized stigma between three diagnoses frequently seen in psychiatric practice: Borderline personality disorder (BPD), Attention deficit-hyperactivity disorder (ADHD) and Bipolar disorder (BD). METHODS: A total of 244 French-speaking patients were recruited in a specialized psychiatric center at University Hospitals of Geneva, Switzerland. 39 patients had a diagnosis of BPD, 136 had ADHD and 69 had BD. Every subjects completed the Internalized Stigma of Mental Illness (ISMI) scale, which is the most widely used scale employed to measure of internalized stigma. One way ANOVA analysis with adjustment on age and gender was done to compare the three groups (BPD, ADHD, BD). RESULTS: Participants with BPD reported higher ISMI score than subjects with ADHD and BD. BD experienced more internalized-stigma than ADHD. Higher ISMI score was also associated with higher severity of the respective disorder, poorer quality of life and unemployment. LIMITATIONS: Limitations of this research include the small sample, especially in BPD group. A disequilibrium between male and female subjects can also impact our results. Observational nature of our study mean that we can only make correlation between variables and not infer causality. Finally, other confounding factors not taken into account in this study may have had influence on stigma. CONCLUSIONS: Our findings are coherent with recent literature on BPD reporting high level of distress and of stigmatization. This has serious consequences on provided care and need to be address by mental health professionals to assure the optimal service to this population.

Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD).

BACKGROUND: Emotional dysregulation (ED) is now considered as an important symptom of attention deficit hyperactivity disorder (ADHD). It is believed to have a considerable impact on the severity of the disorder, one's global functioning, and the prognosis. Our research aimed to evaluate and compare ED and cognitive emotional regulation strategies between ADHD and borderline personality disorder (BPD) patients. METHODS: Four hundred six French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 BPD + ADHD) were assessed with the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), The Basic Empathy Scale (BES-A), the Adult ADHD Self-Report Scale (ARSV-v1.1) and the Beck Depression Inventory II (BDI-II). ADHD, BPD and comorbid patients were compared with each other and with samples of controls extracted from already published data. RESULTS: ADHD patients, although having higher ED than samples derived from the general population, had less ED, better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients. However, ADHD subjects had similar scores as BPD subjects when looking at difficulties in perceiving self and others. ED generated considerable distress in all groups and was also positively associated with ADHD symptomatology. ADHD patients with comorbid BPD had the highest scores of ED. CONCLUSIONS: Our results suggest that there may be similarly inefficient cognitive emotional regulation skills leading to ED in both disorders (ADHD and BPD). However, ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than BPD patients.

Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD.

Objective: Affective lability is an important dimension of adult ADHD, associated with marked impairments and worse outcomes. A valid and quick tool to measure affective lability may therefore be of interest. Method: In 187 adult ADHD patients, we explored psychometric properties of the Affective Lability Scale-Short Form (ALS-18 items). We analyzed the construct validity and the external validity of the scale. Patients were compared with 48 healthy adult controls. Results: The three-factor structure of the ALS-18 presented a good fit and a good internal consistency. The correlations between the ALS-18 and ADHD symptoms and other psychological dimensions were, respectively, low and moderate. ALS-18 scores were higher in patients than in healthy adults. Conclusion: ALS-18 showed good psychometric properties in ADHD adult patients, allowing us to recommend the implementation of ALS-18 in assessing affective lability for clinical and research purposes. Use of ALS-18 should improve the clinical assessment of affective lability in adult ADHD patients.

Strategies to Deal With Suicide and Non-suicidal Self-Injury in Borderline Personality Disorder, the Case of DBT.

One of the most problematic aspects of borderline personality disorder resides in repeated non-suicidal self-injury (NSSI) and suicide attempts. These behaviors constitute the prime therapeutic target and a factor that complicates patient care, namely in terms of therapeutic continuity. It has been demonstrated that Dialectical Behavior Therapy (DBT) is efficient in reducing the symptomatology of this disorder, as well as NSSI and suicide. DBT is a multi-component psychotherapeutic treatment, and the effectiveness of its individual constituents is therefore a relevant question. Studies comparing its various components (individual therapy, group therapy, and standard DBT) have not revealed any marked difference between them, other than a tendency toward improved patient retention rates in the standard version of the treatment. The aim of this study is to review the various components of DBT and their constituent parts, in order to highlight the importance of focusing on self-harm behaviors within the therapy as a whole. Although therapeutic strategies may differ and target directly suicide or NSSI, managing the quality of life, and the persistence of the therapeutic alliance (and of the interpersonal alliance) is equally important in terms of treatment efficacy.

Subjective Distress Associated with Adult ADHD: evaluation of a new self-report.

The current study aims at documenting the psychometric properties of the Subjective Distress Associated with Adult ADHD-Self-Report (SDAAA-SR), a newly developed instrument for the assessment of psychological suffering in ADHD adults. The SDAAA-SR was administered to 247 students and 142 ADHD adults. Factor structure, internal consistency, test-retest reliability, convergent validity and discriminant validity were assessed. Sensitivity to change was examined in a subsample of 25 ADHD patients who participated in a 1-year therapy. The initial pool of 62 items was reduced to 33 items distributed in a three-component structure. Internal consistency was excellent for the "distress due to inattention/disorganization" subscale and good for the "distress due to hyperactivity/impulsivity" and "distress due to self-esteem deficit" subscales. Test-retest reliability in a subsample of 98 students was substantial for all three subscales. ADHD patients scored significantly higher than students on distress due to "inattention/disorganization" and "hyperactivity/impulsivity," but no difference was observed for "self-esteem deficit." The components "inattention/disorganization" and "hyperactivity/impulsivity" displayed moderate to large correlations with the corresponding dimensions of the Adult Self-Report Scale for ADHD (ASRS-V1.1). Distress due to "inattention/disorganization" and "self-esteem deficit" was significantly associated with lower satisfaction with social behaviors (QFS, social functioning questionnaire) and quality of life (WHOQOL-BREF). Distress due to "inattention/disorganization" and "self-esteem deficit" significantly decreased after a 1-year therapy. The SDAAA-SR represents a reliable and valid measure of adult ADHD-associated distress, an important but often undocumented parameter in the clinical setting. Its use as an outcome variable in psychological interventions deserves further investigation.