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.
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: generalized anxiety disorder, depression, bipolar disorder, autism spectrum disorder, borderline personality disorder, and antisocial personality disorder. 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.
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.
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.
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.
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.
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.
Updated on February 11, 2020