Adult ADHD Diagnosis,Symptoms of Impulsivity,and Emotional Dysregulation in a Clinical Sample of Outpatients Consulting for a Behavioral Addiction

Abstract

Objective:

This study aimed to investigate ADHD in adult outpatients seeking treatment for a behavioral addiction and to identify the specificity of psychopathological features if the behavioral addiction cooccurs with adult ADHD.

Method:

Sixty-five outpatients consulting for a behavioral addiction were assessed for ADHD (DIVA-5), addictive disorder (alcohol, tobacco, cannabis, gambling, gaming, food, and sex), impulsivity (UPPS-P), and emotion dysregulation (DERS-36).

Results:

In our sample of outpatients seeking treatment for a behavioral addiction, adult ADHD was independently associated with higher compulsive sexual behavior disorder severity, “sensation seeking,” “positive urgency,” difficulties in “goal-directed behavior,” “impulse control,” and use of “emotion regulation strategies” in the context of intense emotions. A 29% of the sample was diagnosed for adult ADHD.

Conclusion:

The association of adult ADHD with specific dimensions of impulsivity and emotion dysregulation, pave the way for future clinical and research perspectives.

Keywords

adult ADHD behavioral addiction impulsivity emotional dysregulation

Introduction

For many years, ADHD, a neurodevelopmental disorder that involves symptoms of inattention, hyperactivity, and/or impulsivity, was considered to be a disorder present exclusively in children. Gradually, it has been shown that the disorder, or at least some of the symptoms, persists throughout life. The prevalence of ADHD in childhood and adolescence is approximately 5% (Sayal et al., 2018), and the prevalence of adult ADHD is 2.6% (95% confidence interval (CI): [1.51, 4.45]; Song et al., 2021).

One area of interest for adult ADHD diagnosis is its association with addictive disorder, including substance use disorders (SUDs) and behavioral addictions. According to the literature, adult ADHD is associated with a 1.9- to 3-fold higher risk of substance abuse and a 2.5-fold higher risk of polydrug use (Brandt et al., 2018; Capusan et al., 2019; Faraone et al., 2021; Vogel et al., 2016). Individuals with ADHD have an earlier age of first use and occurrence of a use disorder (Brandt et al., 2018). In addition, the likelihood of abstinence and treatment adherence is lower in these individuals (Katzman et al., 2017). There is much less data on the association between adult ADHD and behavioral addictions than about SUDs. Although the addictive nature of other behaviors has been investigated in the literature (e.g., gambling, gaming, sex, food, and shopping), international classifications currently recognize only two behavioral addictions: gambling disorder (DSM-5, American Psychiatric Association, 2013, and ICD-11, WHO, 2018) and gaming disorder (ICD-11, WHO, 2018). Moreover, the ICD-11 refers to compulsive sexual behavior disorder (CSBD) as an impulse control disorder. The prevalence of adult ADHD appears to be especially high among individuals with behavioral addiction, such as gaming or internet use disorder (28%, according to Bielefeld et al., 2017), pathological gambling (18.5%, according to Theule et al., 2019), and CSBD (23%, according to Korchia et al., 2022). Adult ADHD is associated with a 1.4-fold higher risk of food addiction (Brunault et al., 2019). According to the literature, the combined presentation of adult ADHD seems to predominate when cooccurring with a behavioral addiction. When considering the population of individuals with gambling disorder, the prevalence of adult ADHD in its combined presentation is approximately 18%, while it is 5.5% and 1.2% for the hyperactive/impulsive and inattentive presentations, respectively (Retz et al., 2016). However, CSBD is more highly associated with the predominantly inattentive presentation of adult ADHD (Soldati et al., 2021). Moreover, the literature highlights a positive association between adult ADHD severity and behavioral addictions (González-Bueso et al., 2018; Kim et al., 2017; Savard et al., 2021; Theule et al., 2019). However, as far as we know, few studies have investigated the specific psychopathological factors associated with the cooccurrence of adult ADHD and behavioral addiction in a clinical population.

In the context of pathological gambling, Nower et al. (2022) describes pathways model which identify etiological factors that distinguish the course of three specific subgroups of those with gambling problems: (1) a “behaviorally conditioned subgroup” with no psychopathology, in which gambling problems are a consequence of conditioning effects and distorted cognitions, (2) an “emotionally vulnerable subgroup” with a tendency to gamble to escape aversive mood states, and (3) an “antisocial impulsivist group” that exhibits additional elevated impulsivity when compared to the other groups. This model has also been tested for other behavioral addictions (Clark et al., 2022; Marchica et al., 2022). In our study, we focused on emotion dysregulation and impulsivity as risk factors for behavioral addictions because they are core components of the second and third subgroup, respectively. In addition, these two potential etiological factors are factors strongly involved in ADHD symptomatology: impulsivity and emotional difficulties. We assumed that both impulsivity and emotion dysregulation may be independent risk factors explaining the strong association between ADHD and behavioral addiction. As a first step toward the validation of such a model, one preliminary step is to investigate these psychopathological factors in the context of co-occurrence between ADHD diagnosis and behavioral addictions (both assessed using validated interviews).

Impulsivity is the tendency to express excessive and/or unplanned behavior (Billieux et al., 2014). It plays a key role in understanding many psychopathological conditions (e.g., obsessive-compulsive disorder and borderline personality) and problem behaviors (e.g., antisocial behavior and substance abuse; Billieux et al., 2014). According to Nower et al. (2022), impulsive traits promote the occurrence of maladaptive behaviors, affecting many aspects of the gambler’s psychosocial functioning and potentially leading to pathological gambling. Because impulsivity is one of the main symptoms of ADHD, individuals with adult ADHD have a delay aversion and a preference for immediate gratification. Activities such as video games, gambling, and internet use may meet this need (Fatseas et al., 2016; Li et al., 2016; Marmet et al., 2018; Stavropoulos et al., 2019). Among the different models that have been proposed to study impulsivity in patients with addictive disorders, we chose UPPS-P model because it provides a multidimensional approach of impulsivity that includes a more broad set of impulsivity-traits and because the UPPS-P has the ability to distinguish individuals according to both their ADHD and behavioral addiction status. The UPPS-P model indeed suggests that impulsivity involves five distinct dimensions: negative urgency, lack of premeditation, lack of perseverance, sensation seeking, and positive urgency (Cyders et al., 2007; Whiteside & Lynam, 2001). Thus, this model of impulsivity may identify the specific dimensions of impulsivity involved in the co-occurrence of ADHD and behavioral addictions. Previous studies showed that dimensions of the UPPS-P model can explain variance in externalizing behaviors such as pathological gambling and predict both ADHD and behavioral addiction status (Canale et al., 2017; Lopez et al., 2015). The UPPS-P dimensions would be differentially involved in addictive behaviors. According to Billieux et al. (2012), urgency could predict severity of addictive disorders, whereas lack of premeditation could predict engagement in harmful behaviors. Moreover, the literature suggested that urgency and lack of perseverance could mediate the association between adult ADHD and addictive behaviors (El Archi et al., 2022; Fatseas et al., 2016; Grall-Bronnec et al., 2011; Yen et al., 2017). Thus, the UPPS-P model of impulsivity seems to be a suitable model to assess impulsivity in individuals with both adult ADHD and behavioral addiction.

Emotional difficulties are so common in adults with ADHD that some authors argue emotional symptoms should be consider a core symptom of ADHD (Faraone et al., 2019). Emotional regulation difficulties could be greater when ADHD cooccurs with gambling disorder (Chamberlain et al., 2017; Mestre-Bach et al., 2021) and internet addiction (Evren et al., 2018). According to Evren et al. (2018), among adult gamers, there is a correlation between ADHD symptoms and higher emotion dysregulation, especially the tendency to have a negative secondary or nonaccepting reaction to one’s own distress. According to Cabelguen et al. (2021), as emotional regulation difficulties are part of the symptomatology of ADHD, the use of video games could be a way to fulfill an urgent need to calm negative emotions. This hypothesis has also been suggested in the context of hypersexuality, by Bőthe et al. (2019) and in the context of food addiction, by El-Ayoubi et al. (2021). This coping strategy, effective in the short term, would then bring unanticipated negative consequences in the longer term (Grall-Bronnec et al., 2011).

Thus, the literature shows impulsivity and emotional dysregulation are common psychopathological features of addictive behavior and ADHD. It tempts to investigate these features when the two disorders co-occur. One of the limitations of the studies conducted in adult populations is that they often use self-administered questionnaires rather than diagnostic interviews to assess ADHD, and few have addressed both emotional dysregulation and impulsivity dimensions. In addition, these studies often focus on a specific behavioral addiction rather than on a wide range of addictive behaviors. Finally, many studies have been conducted in nonclinical populations rather than in treatment-seeking persons. To our knowledge, there is a lack of studies investigating ADHD using a rigorous assessment of ADHD among patients consulting for a behavioral addiction. More specifically, to our knowledge, no study has investigated the psychopathological and addictive disorder correlates of adult ADHD among persons consulting for a behavioral addiction.

Therefore, the main objective of this study was to identify the specificity of psychopathological features (impulsivity according to the UPPS-P model, emotional dysregulation, and addiction severity) if the behavioral addiction co-occurs with adult ADHD. The secondary purpose was to assess the proportion of people with adult ADHD among those seeking treatment for behavioral addiction. We hypothesized that among outpatients seeking treatment for behavioral addiction (1) the co-occurrence of adult ADHD was associated with higher emotion dysregulation (especially “nonacceptance of emotional response,” “impulsivity in the context of intense emotions,” and “lack of emotion regulation strategies”) and impulsivity (especially “positive and negative urgency” and “lack of perseverance”) and (2) the proportion of outpatients seeking treatment for behavioral addiction who show adult ADHD criteria would be higher than that in the general population.

Method

Procedure and Population

Before recruitment began, this study was approved by an institutional review board in February 2020 (Research Ethics Committee Tours-Poitiers, no. 2020-01-04) and was the subject of a declaration of processing and collection of personal data to the French National Commission for Information Technology and Civil Liberties (Commission Nationale de l’Informatique et des Libertés).

This cross-sectional study was conducted from March 2020 to May 2022 within behavioral addiction outpatients from four French addiction care centers (University Hospital of Tours, Hospital Center of Versailles, and addiction care centers of Orléans (APLEAT-ACEP) and Châteauroux (Addictions France)). All outpatients who met the inclusion criteria and gave their consent participated in the study. The inclusion criteria were as follows: age over 18, consulting for addictive behaviors within one of the four addiction care centers included in the study, and diagnosed with a behavioral addiction (gambling disorder, gaming disorder, compulsive buying, CSBD, or food addiction) during a clinical interview by a professional of the above facilities. The exclusion criteria were having a psychotic disorder or a history of brain trauma or disease that could lead to attention deficit (possibly mistaken for adult ADHD).

After we gave them general information on the study and obtained their free and informed consent, they were first asked to answer self-administered questionnaires (to collect sociodemographic and clinical information and assess addictive disorders, impulsivity and emotion dysregulation). The second step of the study comprised an interview with a clinician (the clinician who conducted this interview was not the one responsible for the usual care in the outpatient center) to assess adult ADHD diagnosis.

Seventy-one outpatients gave their consent to participate in the study. We obtained complete and reliable data for 65 of them (6 outpatients were excluded because of missing self-administered questionnaires or poor-quality responses to the self-administered questionnaire (n = 2), errors in inclusion criteria (n = 2), and absence from the semistructured interview (n = 2)). Our final population was thus composed of 65 outpatients consulting for a behavioral addiction. The mean age was 38.4 years (standard deviation (SD): 12.6). Sixty-six percent of the participants were men. The sociodemographic data are presented in Table 1. The participants had been in the care addiction center for an average of 19 months (SD: 25.4). Thirty-two percent of the sample consulted for two or more behavioral addictions. A total of 41.5% of the sample was also treated for substance use disorder (details in Table 1). One outpatient reported being diagnosed with ADHD in childhood and treated with methylphenidate until adolescence. Two patients reported current adult ADHD, and one of them had a current methylphenidate treatment.

Table 1.

Sociodemographic Data and Initial Motive for Consultation.

	M or %	SD or (n)
Age (years)	38.42	12.59
Gender (male)	66.2%	(43)
Marital status
Single	41.5%	(27)
Divorced/separated	40.0%	(26)
Married/partnered	15.4%	(10)
Missing data	3.1%	(2)
Occupation
Employed	41.5%	(27)
Unemployed	27.7%	(18)
Student	15.4%	(10)
Other situations (e.g., retired)	15.4%	(10)
Addictive disorders for which the patient sought treatment^a
Behavioral addictions
All	100%	(65)
Gambling	36.9%	(24)
Gaming	21.5%	(14)
Sex	29.2%	(19)
Food	32.3%	(21)
Buying	24.6%	(16)
Others	6.2%	(4)
Co-occurrent substance use disorders
All	41.5%	(27)
Alcohol	23.1%	(15)
Tobacco	16.9%	(11)
Cannabis	18.5%	(12)
Cocaine	7.7%	(5)
Heroine	1.5%	(1)
Medication	3.1%	(2)
Others	4.6%	(3)
Duration of the follow-up since the first consultation (months)	19.23	25.24

All participants had at least one behavioral addiction, for some of them there was co-occurring substance use disorder.

Measures

The Diagnostic Interview for ADHD in Adults

The Diagnostic Interview for Adult ADHD-5 (DIVA-5; Kooij et al., 2019) is a tool used to diagnose adult ADHD through semistructured interviews. The DIVA-5 asks about the presence of DSM-5 ADHD symptoms in adulthood as well as childhood, the chronicity of these symptoms, and significant lifetime impairments due to these symptoms. This interview provides a number of pieces of information about ADHD in both childhood and adulthood: the number of significant inattentive and hyperactivity/impulsivity symptoms (a maximum of 9 for each), the number of affected settings (a maximum of 5), the diagnosis of adult ADHD and the predominant presentation of adult ADHD. The criteria for adult ADHD diagnosis are three or more symptoms of inattention and/or hyperactivity/impulsivity in childhood (before age of 12 years), five or more symptoms of inattention and/or hyperactivity/impulsivity in adulthood, and significant impairment in two or more areas of life. DIVA-5 is available in 29 languages, including French.

Addictive Disorder Severity: Substance Use Disorder

Tobacco Use Disorder

Nicotine dependence was assessed through the Fagerström Test for Nicotine Dependence (FTND; Heatherton et al., 1991). This self-administered questionnaire includes six items inquiring into nicotine use. The answer modalities and quotations are adjusted to each of the questions. The highest possible score is 10. The French version of this scale has acceptable internal consistency: .70 (Etter et al., 1999). In the current study, the Cronbach alpha was .83, and we assessed tobacco use disorder symptoms using the FTND total score.

Alcohol Use Disorder

The Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993) is a 10-item self-administered questionnaire that assesses the level of alcohol consumption, symptoms of dependence, and alcohol-related consequences. Each item is rated on a 5-point Likert scale (from 0 to 4). The total score ranges from 0 to 40. For the current study, we used the French version of the AUDIT, which showed high internal consistency (Cronbach’s alpha in the validated article = .97). In the current study, the Cronbach alpha was .93, and we assessed alcohol use disorder symptoms using the AUDIT total score.

Cannabis Use Disorder

The Cannabis Abuse Screening Test (CAST; Legleye et al., 2015) assesses cannabis use within the past 12 months. Six items ask about nonrecreational use, memory disorders, and unsuccessful attempts to quit related to cannabis on a 5-point Likert scale ranging from “0—never” to “4—very often.” The highest possible total score is 24. In the current study, the Cronbach alpha was .94, and we assessed cannabis use disorder symptoms using the CAST total score.

Addictive Disorder Severity: Behavioral Addictions

Gambling Disorder

The Canadian Problem Gambling Index (CPGI; Ferris & Wynne, 2001) assesses gambling problems through a self-administered questionnaire. Each of the nine items was rated on a Likert scale from “0—never” to “3—almost always” (Cronbach’s alpha: .86). In the current study, the Cronbach alpha was .98, and we assessed gambling disorder symptoms using the sum of the nine item scores that increased with gambling severity.

Gaming Disorder

The Game Addiction Scale (GAS; Lemmens et al., 2009) is a brief 7-item self-administered questionnaire that assesses video game behaviors among adolescents. The GAS’s authors draw their inspiration from gambling disorder DSM-IV criteria. Each item is scored on a Likert scale from “1—never” to “5—very often” and refers to addictive symptoms such as salience, tolerance, mood modification, and negative consequences. The highest possible score is 35. In the current study, we used the French version of the GAS, validated by Khazaal et al. (2016). The Cronbach alpha was .98, and we assessed gaming disorder symptoms using the GAS total score.

Compulsive Sexual Behavior Disorder

We assessed CSBD severity using the sexual addiction screening test (SAST). This questionnaire involves 25 dichotomous items that ask about sexual preoccupations, loss of control, and impairment associated with sexual behaviors. The participants answer each item with “yes” or “no.” “Yes” is scored as 1 point, and “No” is scored as 0 points. The French version, validated by Hegbe et al. (2021) showed very good psychometric properties (good specificity and sensibility, internal consistency: .90). The French version of the SAST showed a structure with a unique factor explaining 31% of the variance. In the current study, the Kuder Richardson-20 was .94, and we assessed CSBD symptoms using the SAST total score.

Food Addiction

The Yale Food Addiction Scale 2.0 (YFAS 2.0; Gearhardt et al., 2016) inquires into food behavior over the previous 12 months and assesses the clinically significant impairment or distress associated with consumption of high fat and/or sugar foods as well as possible addictive symptoms toward these foods. In the current study, we used a French short version of this scale, validated by Brunault et al. (2020): the modified Yale Food Addiction Scale 2.0 (mYFAS 2.0). The items were associated with a Likert scale ranging from “0—Never” to “7—Every day.” There are 11 items to assess the 11 criteria of addiction by extrapolating the DSM-5 substance use disorder criteria to food (two additional items assess associated impairment and distress, and two additional items identify what kinds of food are associated with eating problems). Each of the 11 items has its own threshold of significance. In the current study, we assessed food addiction symptoms using the number of significant FA criteria, and the Kuder Richardson-20 was .87.

Impulsivity

The UPPS-P Impulsive Behavior Scale—short version is a 20-item self-administered questionnaire (Cyders et al., 2014). The scale assesses five facets of impulsivity: negative urgency, positive urgency, lack of premeditation, lack of perseverance, and sensation seeking. Each item refers to one of these facets of impulsivity and is rated from “1—agree strongly” to “4—disagree strongly.” The UPPS-P provides a subscore for each facet. Higher scores indicate a higher intensity of impulsivity. The French version of the UPPS-P short version was validated by Billieux (2012), who showed that this scale has good psychometric proprieties (internal consistency: Cronbach’s alpha from .70 to .84). In the current study, Cronbach’s alpha was .80 for the dimension negative urgency, .72 for positive urgency, .82 for lack of premeditation, .88 for lack of perseverance, and .85 for sensation seeking.

Emotion Dysregulation

The difficulties in emotion regulation scale-36 (DERS-36; Gratz & Roemer, 2004) assesses six dimensions of emotion regulation difficulties through a 36-item self-administered questionnaire. Each of the items is rated on a 5-point Likert scale (from “1—almost never” to “5—almost always”) and refers to one of the six dimensions: nonacceptance of negative emotions (nonacceptance), inability to engage in goal-directed behaviors when distressed (goals), difficulty controlling impulsive behaviors when distressed (impulse), lack of emotional awareness (awareness), limited access to emotion regulation strategies perceived as effective (strategies), and lack of emotional clarity (clarity). The scale provides six subscores. Higher scores suggest greater emotion regulation difficulties. The French version of the DERS-36 used in the current study provides satisfying psychometric characteristics (all Cronbach’s alpha values are over than .80; Dan-Glauser & Scherer, 2013). In the current study, Cronbach’s alpha was .88 for the dimension nonacceptance, .85 for goals, .75 for impulse, .72 for awareness, .81 for strategies, and .68 for clarity.

Data Analysis

Analyses were conducted with SPSS^® version 22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0, IBM Corporation, Armonk, NY, USA) and were two-tailed. P-Values <.05 were considered statistically significant.

Descriptive statistics included percentages for ordinal variables and means and standard deviations (SDs) for continuous variables. Then, to investigate the symptoms of ADHD in the sample of interest, we analyzed the data obtained during the DIVA-5 semistructured interview. Binary logistic regressions were conducted to identify the psychopathological factors (addictive disorder symptoms, emotion dysregulation and impulsivity; and independent variables) independently associated with adult ADHD diagnosis (dependent variable).

Results

Investigating ADHD in Outpatients With Behavioral Addiction

According to the DIVA-5, 26 (40% of all the participants) participants had significant ADHD during childhood. Among them, 23 participants (88% of the participants who had ADHD in childhood) reported persistence of symptoms of inattention or hyperactivity/impulsivity in adulthood. Nineteen participants (29.2% of all the participants) were diagnosed with adult ADHD (with both childhood and adulthood ADHD diagnosis), and four participants (21.1% of participants who had ADHD in childhood) had persistent residual symptoms of ADHD in adulthood (two affected settings at least and two symptoms of inattention or hyperactivity/impulsivity at least). Thus, the persistence of ADHD diagnosis from childhood to adulthood was approximately 73%. Among the 19 participants who were diagnosed with adult ADHD, 12 participants (63.2%) had a combined presentation, 5 participants (26.3%) had a predominantly inattentive presentation, and 2 participants (10.5%) had a predominantly hyperactive/impulsive presentation. More details are presented in Figure 1 and Table 2.

Figure 1.

ADHD diagnosis according to DIVA-5 semistructured interview.

Table 2.

Descriptive Statistics of the ADHD Prevalence and Symptoms During Childhood and Adulthood, as Assessed by the DIVA-5.

	M or %	SD or (n)
Childhood symptomatology
Nb of inattentive criteria/9	3.46	2.66
Nb of hyper/imp criteria/9	2.89	2.88
Nb of affected settings/5	1.45	1.62
Significant symptomatology	40.0%	(26)
Combined	27.7%	(18)
Hyperactive/impulsive	3.1%	(2)
Inattentive	9.2%	(6)
Adulthood symptomatology
Nb of inattentive criteria/9	4.26	2.5
Nb of hyper/imp criteria/9	3.62	2.32
Nb of affected settings/5	2.08	1.8
Significant symptomatology	47.7%	(31)
Combined	20.0%	(13)
Hyperactive/impulsive	7.7%	(5)
Inattentive	20.0%	(13)
Both childhood and adulthood symptomatology
Significant symptomatology	29.2%	(19)
Combined	18.5%	(12)
Hyperactive/impulsive	3.1%	(2)
Inattentive	7.7%	(5)

Note. Nb = number; hyper/imp: hyperactive/impulsive; SD = standard deviation.

Psychopathological Factors Associated With Adult ADHD

Adult ADHD was not associated with different ages or sexes. See details in Table 3.

Table 3.

Comparison Between Patients With Versus Without Adult ADHD in Univariate Analyses.

	All (N = 65)		With adult ADHD (N = 19)		Without adult ADHD (N = 46)		Independent logistic regression
	M or %	SD or (n)	M or %	SD or (n)	M or %	SD or (n)	OR	[95% CI]	p-Value
Age (years)	38.42	12.59	37.58	10.86	38.76	13.34	.992	[0.95, 1.04]	.729
Gender (male)	66.2%	(43)	57.9%	(11)	69.6%	(32)	1.66	[0.55, 5.03]	.368
Substance use disorder symptoms
Tobacco use disorder^a	1.89	2.74	2.68	2.81	1.57	2.67	1.16	[0.96, 1.40]	.138
Alcohol use disorder^b	8.02	9.65	9.95	11.36	7.22	8.86	1.03	[0.98, 1.09]	.302
Cannabis use disorder^c	3.18	6.30	3.95	6.49	2.87	6.26	1.03	[0.95, 1.11]	.529
Behavioral addiction symptoms
Food addiction^d	2.14	2.82	2.95	3.21	1.80	2.60	1.15	[0.96, 1.38]	.142
CSBD^e	6.11	6.61	9.58	6.65	4.68	6.10	1.12	[1.03, 1.22]	.009
Gaming disorder^f	8.92	11.32	8.89	10.30	8.93	11.82	1.00	[0.95, 1.05]	.991
Gambling disorder^g	6.58	9.50	4.16	8.01	7.59	9.96	.96	[0.90, 1.02]	.191
Emotion dysregulation
Non acceptance	15.19	6.32	15.63	6.11	15.01	6.46	1.02	[0.93, 1.11]	.718
Goal	17.17	5.11	19.95	4.56	16.02	4.92	1.19	[1.05, 1.35]	.007
Impulse	14.82	4.56	17.49	5.40	13.72	3.69	1.23	[1.07, 1.42]	.005
Awareness	17.32	5.02	16.79	5.07	17.54	5.03	.97	[0.87, 1.08]	.579
Strategies	23.65	6.69	26.53	5.31	22.46	6.89	1.11	[1.01, 1.22]	.030
Clarity	12.63	4.23	13.05	4.50	12.46	4.15	1.03	[0.91, 1.17]	.607
Impulsivity
Negative urgency	10.15	2.91	10.21	3.74	10.13	2.54	1.01	[0.84, 1.22]	.919
Lack of premeditation	8.46	2.66	9.32	3.02	8.11	2.44	1.20	[0.97, 1.48]	.100
Lack of perseverance	8.91	3.18	9.32	3.46	8.74	3.07	1.06	[0.89, 1.26	.503
Sensation seeking	10.09	3.39	11.95	3.47	9.33	3.07	1.32	[1.08, 1.61]	.007
Positive urgency	12.11	2.50	13.16	2.59	11.68	2.35	1.31	[1.02, 1.68]	.033

Note. SD = standard deviation; CSBD = compulsive sexual behavior disorder; OR = odd ratio; bold = p < .05.

Assessed with the Fagerström Test for Nicotine Dependence total score.

Assessed with the alcohol use disorders identification test total score.

Assessed with the Cannabis abuse screening test total score.

Assessed with the modified Yale Food Addiction Scale 2.0 score.

Assessed with the sexual addiction screening test total score.

Assessed with the Game addiction scale total score.

Assessed with the Canadian Problem Gambling Index total score.

Addictive Disorder Symptoms

Adult ADHD was associated with higher CSBD symptoms (odds ratio (OR) = 1.12; 95% CI: [1.03, 1.22], p = .009) but was not associated with symptoms of tobacco use disorder, alcohol use disorder, cannabis use disorder, food addiction, gaming disorder, or gambling disorder. See details in Table 3.

Impulsivity and Emotion Dysregulation

Adult ADHD was associated with higher emotion dysregulation, especially in difficulties with “goal-directed behavior” (p = .007), “impulse control” (p = .005), and “emotion regulation strategies” (p = .030). It was also associated with impulsivity, especially “sensation seeking” (p = .007) and “positive urgency” (p = .033). See details in Table 3.

Discussion

As expected, the results showed a high proportion of adult ADHD in this clinical sample of individuals seeking treatment for behavioral addiction. In this sample, co-occurring adult ADHD was independently associated with higher CSBD symptoms, impulsivity (especially “sensation seeking” and “positive urgency”), and emotion regulation difficulties (especially difficulties in “goal-directed behavior,” “impulse control,” and use of “emotion regulation strategies” in the context of intense emotions).

The occurrence of hyperactivity/impulsivity or inattention symptoms was common in our sample of outpatients seeking treatment for behavioral addiction, as almost 50% of the participants showed significant current ADHD symptoms. A total of 29.2% of participants were diagnosed with adult ADHD. The main behavioral addictions present in this study were gambling disorder, food addiction, and CSBD. The literature reported a prevalence of adult ADHD in individuals with gambling disorder of 18.5% (95% CI: [10%, 31%]; Theule et al., 2019), in individuals with addictive-like eating (such as food addiction, binge eating, or bulimic symptoms) of 12% to 37% (assessed in women with bulimia nervosa; El Archi et al., 2020), and in individuals with hypersexuality of 23% (95% CI: [17%, 29%]; Korchia et al., 2022). Retz et al. (2016), who assessed adult ADHD through DSM-5 criteria in patients exclusively with gambling disorder, showed a prevalence of 25.2%. The proportion of individuals with ADHD we found is therefore consistent with the literature, though in the higher end of the range. In our sample of outpatients with behavioral addiction, we found that 88% of individuals who met the criteria for ADHD in childhood had residual or full criteria of ADHD in adulthood, higher than in the general population (40%–60% according to Faraone et al., 2006). The most common adult ADHD presentation was the combined form. A total of 18.5% of the participants had an adult ADHD combined presentation, equivalent to the prevalence suggested by Retz et al. (2016) in individuals with gambling disorder (18%). These results, obtained from a thorough assessment of adult ADHD within a clinical sample, corroborate the results obtained previously in other studies highlighting the strong comorbidity between ADHD symptomatology and behavioral addictions. This association seems particularly strong in the context of CSBD.

Our main aim was to identify impulsivity and emotion dysregulation dimensions associated with co-occuring adult ADHD in context of behavioral addiction. As expected, comorbid adult ADHD was associated with specific difficulties in emotional regulation and impulsivity. It was associated with difficulties engaging in goal-directed behavior, keeping in control, and using emotion regulation strategies when experiencing negative emotions. Consistent with ADHD symptomatology, it was also associated with higher impulsivity, resulting in a tendency to express strong and rapid reactions in the context of positive emotions and to seek activities involving excitement, new experiences, and risk-taking. These results are also consistent with the pathways model of pathological gambling submitted by Nower et al. (2022), who identified a profile of gamblers with high impulsivity and risk-taking. This profile of gamblers resorts to gambling as a strategy to avoid emotional states and in response to a search for meaning and purpose as well as to heightened levels of impulsivity and risk-taking behaviors. The emotional regulation difficulties identified seem to be related to impulsivity, and conversely, the identified impulsivity dimensions seem to be related to emotional regulation difficulties. This shows the close proximity of these concepts, especially in individuals with comorbid behavioral addictions and adult ADHD. Contrary to what was expected, adult ADHD was not associated with higher negative urgency but only with higher positive urgency. This finding is in line with Rogier et al. (2020), who pointed out that positive urgency should not be overlooked in the context of pathological gambling. They showed that impulsivity in the context of intense positive emotions predicts maladaptive behaviors such as severity of gambling disorder. Difficulty in managing positive emotions can lead to persistent engagement in pleasurable activities in an excessive manner, such as gambling. This may explain our findings that one of the factors most associated with ADHD is sensation seeking. Rogier et al. (2020) suggested that individuals with disordered gambling “may negatively judge their positive emotional states and/or avoid arousal related to positive emotions experienced as distressing throughout gambling activities. This converges with the conceptualization of gambling as a strategy to escape from aversive internal states.” This pattern may therefore be even more consistent for patients with cooccurring adult ADHD, which is associated with even higher difficulties in emotional regulation and impulsivity. This could be explain our results but our methodology does not allow us to demonstrate a causal link. Further investigations could be aimed at assessing this causal link and the mediational role of emotional dysregulation and impulsivity between behavioral addiction and ADHD.

This study has practical implications. In view of the high proportion of adult ADHD among individuals seeking treatment for behavioral addictions, it seems essential to include an adult ADHD assessment from the first steps of their management. It also seems relevant to assess behavioral addictions among adults with ADHD. Management of intense emotions and behaviors in this context may be an interesting psychological intervention to target both adult ADHD symptomatology and behavioral addictions. This is all the more important as difficulties in emotion regulation mediate the association between adult ADHD and quality of life (Ben-Dor Cohen et al., 2021) and impact functional status and treatment outcomes in individuals with adult ADHD (Faraone et al., 2019). In view of the current results, in context of co-occurrence between ADHD and behavioral addiction, it would be of interest to target specific dimensions of impulsivity and emotion dysregulation, such as goal-directed behavior, impulsivity in the context of intense emotions, and sensation seeking. Although the management of negative emotions is often addressed, it seems important to not neglect positive emotions, which can also lead to maladaptive behavior. Management could also involve the acquisition of effective emotion regulation strategies to deal with negative emotions to alleviate impulsivity in this context.

The results need to be interpreted in light of some limitations. The design of this study was cross-sectional and did not allow for the attribution of causal links. Future studies may investigate the associations between adult ADHD, behavioral addiction and psychopathological factors (such as emotion dysregulation and impulsivity) through suitable mediational methodology. We considered a sample of individuals seeking treatment for behavioral addiction. However, these people most likely have a high severity of behavioral addiction. The results obtained are therefore not extrapolable to the general population with an addiction but exclusively to those consulting for it. The number of participants was not sufficient to differentiate groups according to the nature of the behavioral addiction and thus to identify psychopathological specificities. Further study should investigate these specificities. To assess ADHD in childhood, we did not rely on a childhood diagnosis but, rather, on retrospective data. A longitudinal study with diagnosis in childhood and adulthood and investigating the impact of these symptomatology and psychopathological features on the occurrence and severity of behavioral progression into adulthood would provide even more reliable results. We did not take into account psychiatric comorbidities such as mood and anxiety disorders. However, according to Faraone et al. (2019), in individuals with adult ADHD, emotional dysregulation is distinct from mood disorders. “Although emotional symptoms occur in other psychiatric disorders, the emotional symptoms of ADHD cannot be adequately accounted for by the presence of comorbidity in individuals with ADHD” (Faraone et al., 2019). Difficulties in emotion regulation are so characteristic of adult ADHD that they could be present in the diagnostic criteria. This has been demonstrated in the general population, but it also seems to be the case for outpatients with behavioral addictions.

Conclusion

The current study investigated adult ADHD using a semistructured interview and its associated psychopathological factors among outpatients seeking treatment for a behavioral addiction. Our results confirm the high proportion of adult ADHD in this population, as well as the involvement of specific dimensions of impulsivity and emotion dysregulation in this association, which paves the way for interesting future clinical and research perspectives.

Footnotes

Acknowledgements

We would like to thank all the outpatients for their participation, all the healthcare professionals who supported this study by facilitating the recruitment of the participants (APLEAT-ACEP, Orléans, France: Nicolas Baujard, head of the youth department, Pascale Neveu, executive director, Azélie Brand, social worker, Céline Benoist, clinical psychologist; Association Addictions France, Châteauroux, France: Hervé Stipetic, CSAPA-36 executive director, Aurélie Chauvin, social worker; Versailles Hospital Center, France: Nadia Younès, head of the addiction care center, Mathilde Auclain, clinical psychologist), and the Psychology students of the University of Tours who contributed to the recruitment of the current study (Sophie Fernandez, Claire Barili, and Lucie Vossels).

Author Contributions

Study design and concept: PB and SBa; Data collection: SBa, SEA, SBr, PB, SEA, and MG; Writing-original draft preparation: SEA; Writing-review and editing: SEA, SBa, PB, NB, MG, SBr, and DM. Supervision and project administration: PB and SBa. All authors have read and approved the published version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: NB reports personal fees from Lundbeck, Astra-Zeneca, and D&A Pharma, unrelated to the submitted work. PB reports personal fees and non-financial support from Lundbeck, personal fees from Astra-Zeneca and D&A Pharma, unrelated to the submitted work. All other authors have nothing to disclose.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: SEA’s PhD work was funded by a Presidential University Grant (University of Tours). Qualipsy research team covered the costs of proofreading.

ORCID iDs

Sarah El Archi

Servane Barrault

Paul Brunault

Author Biographies

Sarah El Archi is a clinical psychologist and doctor in psychology. She is a contract teacher and researcher at the University of Tours belonging to the Laboratory QualiPsy (EE1901). His main research interests focus on addictive disorders, disordered eating and its association with adult ADHD.

Servane Barrault is a lecturer in clinical psychology in University of Tours belonging to the Laboratory QualiPsy (EE1901). She is the author of more than 35 scientific articles about addictions. She also works in addictology in CSAPA 37 (CHRU of Tours) and is a member of the Centre Val de Loire’s Pathological Gambling Group.

Manuel Garcia is a psychiatrist/addictologist. He works in addiction care center (CSAPA) of Loches and the Louis Sevestre Hospital Center.

Stéphanie Branger is a social worker in addiction center CSAPA 37 (CHRU of Tours) since 2015. She is a member of the Centre Val de Loire’s Pathological Gambling Group.

Damien Maugé is graduate of the Faculty of Medicine of Nancy (54), emergency doctor and psychiatrist/addictologist in the hospital of Tours (CHRU of Tours) since May 2000. He is head of department of the CSAPA 37 (Addiction care center of Indre et Loire, CHRU de Tours).

Nicolas Ballon, MD, PhD, is professor of psychiatry and addiction medicine at the University of Tours, France. He completed his MD in psychiatry at the University Descartes, Paris V (France)and his PhD in genetics of addictions at the University Pierre etMarie Curie, Paris VI (France). He previously worked as assistant professor of addiction/psychiatry at the University Antilles Guyane in the French West Indies. He is author/coauthor of more than 50 scientific publications.

Paul Brunault, MD, PhD, is a psychiatrist specialized in addiction medicine, assistant professor at the University of Tours, France. His main research interests focus on the association between ADHD and addictive disorders, eating disorders in patients with obesity (food addiction/addictive-like eating behavior/eating addiction, binge eating disorder), and behavioural addictions.

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