ADHD Comorbidities & Related Conditions

Is It Just ADHD? Comorbidities That Unlock an Accurate Mental Health Diagnosis

For patients with attention deficit, a mental health diagnosis almost always includes an ADHD comorbidity as well — autism spectrum disorder, generalized anxiety disorder, depression, and other conditions. To fully understand your mental health diagnosis and get the full benefit of ADHD treatment, you must factor co-occurring conditions into the medication equation.

Mental Health Diagnosis: ADHD, Anxiety, Autism, Bipolor, Depression

A mental health diagnosis is based almost entirely on the discussion of symptoms between a patient and his mental health provider. You might think being the diagnosis expert is your doctor’s job alone, but if you don’t thoroughly understand the diagnosis for yourself or your loved one, you may not get the treatment you need. You want to understand everything you can about how your diagnosis is made, and what it means, so you can communicate well with your prescriber and therapist.

For many people with attention deficit disorder (ADHD or ADD), understanding a single diagnosis isn’t enough. Many present with symptoms of two or more conditions. We call this “co-occurrence.” Great. Just when you thought nothing else could be wrong, you realize (or find out) you may have another psychiatric diagnosis.

While many disorders can co-occur with ADHD, six show up most often:

Each of these conditions can radically affect the approach to medication and therapy for people with ADHD. Here we’ll examine the first four in depth and show how each intertwines with ADHD.

To learn more about these conditions, check out our forthcoming book, ADD and Zombies: Fearless Medication Management for ADD and ADHD.

[Read: When It’s Not Just ADHD – Symptoms of Comorbid Conditions]

This short guide doesn’t supply enough information to set up your own co-occurring diagnosis shop. But it will let you see the complex interplay of several conditions that often intersect with ADHD, and to be a better consumer of those diagnoses and to partner with the providers who give them. This will make all the difference when you or someone you love is up for a diagnostic label.

Anxiety: Is It Primary or Secondary?

We like to think of ADHD and anxiety as being on a continuum. Anxious people care too much about the details of life, and people with ADHD care too little. When ADHD and anxiety appear in the same person, treatment is complicated.

The complication appears in one of three ways. Most commonly, a client who qualifies as having both ADD and anxiety is treated with an SSRI (selective serotonin reuptake inhibitor) or an SNRI (serotonin and norepinephrine reuptake inhibitor) before starting stimulants. This is because stimulants will reduce procrastination and improve on-task behavior by raising anxiety. For clients with both ADHD and anxiety, being prescribed stimulants first can push that anxiety to unproductive levels. Occasionally, we only realize a client has a mixed condition after trying stimulants and seeing this result, in which case we temporarily stop the stimulants and treat the anxiety first.

Sometimes, a client presents ADHD symptoms but is experiencing so much anxiety that he or she has problems concentrating and managing daily affairs. The client’s mind never stops running, in rare cases, to the point of obsessions and compulsions. This preoccupation prevents a person from getting anything done. We refer to this as “anxiety-primary.” However, even when we hypothesize this condition, it is tough to prove without a medication trial. If taking an SSRI or an SNRI reduces both anxiety and the ADHD symptoms, this is the best conceptualization.

[Click to Read: “I Feel Like I’m Losing My Grip.”]

Conversely, we may see a client whose anxiety is the result of ADHD. We call these cases “ADHD-primary.” Such individuals are so overwhelmed by managing ADHD symptoms that they are constantly on edge and fearful. By reducing their ADHD symptoms, their anxiety drops to a tolerable level. The quickest way to find out if this will happen with a given client is to initiate stimulant medication. If anxiety drops, we’ve nailed it. If it rises or remains the same, we’re back to the ADHD-anxious diagnosis. In that case, we typically add an SSRI or SNRI to the medication regimen.

Any differences in symptom presentation following a stimulant trial are critical for your prescriber to know about and understand. Unfortunately, we see many clients who started a stimulant trial with a previous prescriber, had poor results, and then had the prescriber errantly ignore the ADHD diagnosis and eschew a valuable course of treatment. Getting it right matters. Understanding how your anxiety and ADHD interact will make all the difference in successfully treating both conditions.

Bipolar Disorder: Tricky to Treat

Many bipolar disorder symptoms are overlooked because they closely resemble those of ADHD-combined inattentive/hyperactive type. Both disorders are marked by inattention, excessive energy, poor judgment, impulsivity, hyperkinesis, disconnected thoughts, irritability, mood dysregulation, sleep problems, racing and/or jumbled thoughts.

[Self-Test: Bipolar Disorder in Adults]

Bipolar disorder, however, typically brings broader and more severe changes in mood, excessive self-esteem, revved-up energy, impulsive or self-destructive behaviors, and even psychotic behavior. When people with ADHD and co-occurring bipolar disorder have a depressive episode, they may still be agitated or even grandiose, but this may be attributed to their ADHD, not to mania. Thus, they may be misdiagnosed as having unipolar depression rather than bipolar disorder.

Treating co-occurring ADHD and bipolar disorder is tricky because stimulants have the potential to trigger mania. While stimulant-related anxiety is often tolerable and quickly fixed, stimulant-induced mania can create serious trouble. Prescribers are aware of these dangers, so bipolar clients may be under-treated for ADHD symptoms.

The knack in ADHD-bipolar cases is to tightly integrate medication management and psychotherapy to keep up with and respond to the changes in personality, emotional state, and brain chemistry that come with any serious mood disorder. Staying attuned to those tides is the most important job for client, therapist, prescriber, and family. Whenever we use a stimulant in such cases, we start off with low doses, and see the client weekly for medication evaluation and therapy during the first month or two of treatment, then adjust the protocol slowly. We carefully increase the dosage, and introduce, or alter, mood-stabilizing medications as necessary.

Autism Spectrum Disorder: Closely Correlated with ADHD

Autism exists on a broad spectrum — from oddly helpful to debilitating — making it hard to compare one case to another. However, what these cases have in common, in varying degrees of severity, is difficulty with communication and interaction with others. Clients have restricted interests and repetitive behaviors, and impairment in the client’s functioning in school, at work, and in areas of life that involve human interplay.

[Self-Test: Autism Spectrum Disorder in Adults]

Rarely is ASD a differential diagnosis to ADHD because the two are so closely correlated. When a person has both, the diagnoses are especially tricky to treat. Stimulants can help people with ASD-ADD learn social rules and pay attention to the details that underlie them, but no medication can make them more socially adroit or disengage them from their interior worlds. Some patients with ASD-ADD have significant mood fluctuation and emotional breakdowns, particularly when external events overwhelm them. Some providers mistake mood swings for anxiety, and treat them as such, which serves to increase, rather than decrease, irritability.

Mood dysregulation can be as problematic for those with ASD as it is for those with bipolar disorder. In fact, stimulants can be so irritating to people with ASD that, at one time, it was recommended that doctors forgo them. Yet we find, time and again, that the correct combination of stimulants and mood stabilizers improves client functioning. Like bipolar clients, ASD-ADD clients may do well with mood stabilizers plus a slow, careful, and well-integrated treatment plan.

Depression and ADHD: Chicken and Egg

For many individuals, depression and ADHD go hand in hand. Their dual symptoms include a persistent, sad, or irritable mood, loss of interest in previously enjoyable activities, changes in appetite or weight, sleep problems (too much or too little), low energy, feelings of worthlessness, or inappropriate guilt. Some clients experience thoughts or acts of self-harm.

As with anxiety, there are three ways ADHD-depression present together. Most commonly, depression follows the ADHD. Managing ADHD symptoms is tough, so a person with ADHD may feel hopeless and ineffective, leading to diagnosable depression. Even with a good evaluation, the only way to test this is to address the ADHD with stimulants and cognitive behavioral therapy, and see if the depressive symptoms lessen. Frequently, they will.

In other cases, clients respond favorably to stimulants at first, only to have a quick drop-off in their impact. Stimulants raise energy and alertness, and increase productivity, which helps people feel better. However, that improvement may mask underlying depressive symptoms that exist in tandem with ADHD, and may last only as long as the stimulant is working, usually eight to 12 hours. Fortunately, these clients tend to be good candidates for adding an SNRI. Treating co-occurring depression and ADHD in this way allows the prescriber to try lower stimulant doses while maintaining treatment satisfaction.

Similarly, we may see a client presenting with symptoms of depression, treat that condition successfully, and then later realize that, despite improvements in mood, the client is still struggling in school, relationships, or career. The client is feeling better but not doing much better.

In a small number of cases, depression, and not ADHD, is the primary issue. These clients become so sad that they can’t focus. For them, depression management, usually with an SNRI (like Effexor or Cymbalta), or a norepinephrine–dopamine reuptake inhibitor (NDRI) (like Wellbutrin), may manage the ADHD symptoms well without a stimulant.

[Free Expert Resource: Is It ADHD or a Misdiagnosis?]

Wes Crenshaw, Ph.D., ABPP, s a licensed psychologist and coauthor of the forthcoming books Consent-Based Sex Education: Parenting Teens for Sexual Competence and ADD and Zombies: Fearless Medication Management for ADD and ADHD. Kelsey Daugherty, DNP, is licensed to prescribe psychopharmaceuticals, including stimulant medication, under protocol. She works with Dr. Crenshaw at Family Psychological Services LLC, in Lawrence, Kansas.


SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Updated on July 15, 2020

2 Related Links

  1. Fantastic article, but what about the comorbidity of dyslexia? I’m a 52-year-old male with inattentive ADD and dyslexia. I realize that the chicken and the egg in my personal scenario is – do I have generalized anxiety and depressive tendencies or are they a manifestation of my two stated underlying conditions? I have and can accomplish great things; however, they typically take me much longer than most neuro-typical people. I don’t delegate well because of my difficulty in explaining information to others in a logical and concise manner. Because I am such a concrete thinker, I am not a good multi-task thinker. I can do one thing to near perfection but keeping multiple balls in the air is difficult to say the least. IQ tests put me in the top 1% of the general population – and although I’ve done reasonably well for myself throughout my working career, I almost always fall to the bottom or near the bottom of the pecking order. The reason for this is multi-pronged; first, I have very little ability to politicize my abilities, efforts, and accomplishments in the workforce (I am easily pushed out of the good-old-boy circles).
    And, since things tend to take me a bit longer to muster through, in a dog-eat-dog world where speed is generally king, I’m not a top-tier (or most of the time even medium) performer anyway. The frustrating thing about all of this is the amount of effort needed to be average is exhausting. I feel like we are all treading the same water, but instead of having a speedo racer on like my peers, I have an all-cotton combination of sweatpants and hoodie that’s three sizes too large. I can do it but, in the end, I’m left exhausted with similar accomplishments. That’s all well and good – effort is a good thing, right? But what about the next endeavor – and the one after that – and the one after that – and so on? Sooner or later the inevitable complication of circumstances and exhaustion gets the best of me. This is when anxiety and depressive thoughts find their way into your consciousness. And really, how could they not find their way in? If I had an average IQ it would be easier to conceptualize (or lack thereof) because I wouldn’t be as intellectually aware. As it is, however, I am keenly in-tune with my pent-up capabilities. It takes a great deal of humility to keep things in perspective – and to allow the adversity to work for you instead of against you.

  2. I was taught that the most common co-occuring conditions (I hate the term co-morbid) are sleep disorders (over 60 percent) Learning Disorders (76 percent) Anxiety and Depression (10 to 47 percent) and Oppositional Defiance Disorder (35-50 percent)

    Of those, it’s understandable that sleep is disrupted and compromised – we have a really hard time shutting off our brains when they are working overtime to stimulate us and boost dopamine. I think that just assuming sleep issues are a common part of ADHD makes more sense than considering them a separate issue.

    Learning Disorders – The rate of these co-occuring with ADHD is significant, but the most common one is Disability of Written Expression and I’ve heard Dr. Tom Brown explain his belief that this really just should be considered part of ADHD because the challenges with written expression are largely explained by challenges with executive functioning.

    Anxiety – as above, is the anxiety a separate disorder – sometimes it is, but probably more often it’s because our brains have an abundance of information to deal with due to differences with our RAS and a brain that finds “what if” thoughts stimulating – even if our minds don’t find them all that pleasant. Depression – ok, sometimes, and sometimes what originally gets labelled depression turns out to be ADHD rumination and negative thinking. On top of that, throw in a big dose of ADHD emotional sensitivity. Historically, women in particular were told by Dr’s that they had anxiety and depression because their MD didn’t see the ADHD – it often takes years before women’s inattentive type ADHD is picked up on, if at all – and although I’m not a medical professional, I’ve been told by a leading Canadian psychiatrist specialising in this area that quite often if the ADHD is treated and managed the anxiety and depression symptoms resolve themselves.

    ODD – there’s a movement on the part of enlightened professionals to have oppositional defiance disorder removed from the DSM, because they believe it’s more of an indicator of something else going on (ADHD, anxiety, etc…) than a separate disorder. Do you know how many adults a kid needs to be defiant with in order to meet the criteria for ODD? Just one… With that criteria, who doesn’t have ODD?

    20-50 percent of people with ADHD have autistic tendencies which is not the same as having a diagnosis of ASD. However – the reverse is true, 30 to 80 percent of those on the spectrum have ADHD.

    Part of the reason that there is such a high rate of co-occurring disorders with ADHD is that we seem to love a lot of separate labels, when just one label – ADHD – will explain most of what’s happening.

    Definitely, there are co-existing mental illnesses or psychiatric disorders at times but this article makes it sound like most of us are walking basket cases of mood and personality disorders. That’s not the case for me and it’s not the case for most of the people with ADHD I work with.

Leave a Reply