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Diagnosed with ADHD? Comorbidity Might Be the Real Issue

Identifying signs of other mental health issues can help solve the overdiagnosis of ADHD.

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Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent behavior disorders in America…or at least, it’s diagnosed as if it were. Today, an increasing amount of doctors are identifying symptoms of inattention, hyperactivity, and impulsivity as a steadfast identifier of ADHD, catapulting the number of diagnosis in the process.

In the past two decades alone, the rate of ADHD diagnoses increased faster for adults during doctor’s visits, while the overall number of diagnosed youth remained far greater. By 2011, the Centers for Disease Control and Prevention (CDC) estimated that 11% or 6.4 million of American children had ADHD making it the most commonly diagnosed disorder in children under 18. In a 2017 Midwestern University study, ADHD increased by 36% among adults.

This increase is not just an American epidemic. In some countries, the rate rose more than tenfold making it on par with the amount of surging American diagnoses. Yet, the number of cases can be misleading. Health care providers from different countries often use different criteria to identify the disorder and there is no one test to diagnose ADHD. Countless studies show how cultural norms, including societal stigmas, and economic factors like cost evaluation and treatments affect analysis of the symptoms. For example, a 2010 U.S. National Health Interview study estimates that 1.1 million children receive an inappropriate diagnosis with over 800,000 prescribed stimulants due only to immaturity.

But what accounts for these upward trends, both nationally and globally in children and adults? There are a variety of political, social, and economic reasons for ADHD’s popularity. But ADHD often has many mental and psychiatric disabilities associated with it. When symptoms become blended, it’s harder to distinguish a disease correctly. Often, comorbidity, defined as the simultaneous presence of two chronic diseases or conditions, is an overlooked factor for overdiagnosed ADHD cases.

A Case of Comorbidity

Diagnosing symptoms of ADHD can be tricky. The time and care needed to make an accurate diagnosis isn’t always taken by medical practitioners. For example, inattention can signal a variety of disorders other than ADHD. When you’re anxious, don’t you have a hard time concentrating? A clinician diagnosing you must consider how patients attribute symptoms of inattention. Is it due to ADHD, anxiety, both, or something else? Given the prevalence of ADHD, it’s easy to assume that any symptoms in question are due to ADHD alone.

The National Comorbidity Survey Replication, among many other studies, showed a strong correlation between ADHD and other disorders. Approximately 70-80% of adult ADHD coexists with at least one other psychiatric condition. Studies also highlight that ADHD type strongly influences the specific type of comorbid psychiatric issue. For example, those diagnosed with ADHD, predominantly inattentive type, are more likely to have internalized disorders like anxiety or depression. Hyperactive types are likely to experience externalizing conditions like defiant behaviors. Closely associated but more prominent neurological disorders are often intertwined with ADHD, often going ignored or unchecked. ADHD becomes a go-to diagnosis, when in fact, symptoms of what is thought to be ADHD may be that of another disorder.

In other scenarios, ADHD could still be present when one or more comorbid issues are at play. Yet, these comorbid diseases like anxiety or depression are not as readily addressed or factored into the diagnoses and, as a result, patients suffer from a lack of beneficial treatment for their other mental disorders. However, often, the time, care, and testing is not occurring to assess for other diagnoses.

As a result, practitioners need to remain vigilant in ruling out other disorders or diagnosing them along with ADHD. This can be accomplished through more thorough psychological testing and exploring the research and observations made by others.

Below are other considerations you may want to explore with your doctor:

1. Depression

As one of the most commonly associated comorbid conditions with ADHD, depression or Major Depressive Disorder (MDD) is described as downtrodden moods and/or a loss of pleasure in everyday activities during most hours of the day nearly every day during a two-week period. Using a nuanced diagnostic interview process, the National Comorbidity Survey Replication found these results:

  • 31.4% of participants with ADHD reported depressive symptoms.

  • Another sample of outpatient ADHD participants identified 25.31% had Major Depressive Disorder with no noticeable differences between subtypes.

  • Requests for psychotherapy and medication for those with both MDD and ADHD was higher than those without MDD

  • Patients with or without MDD had similar symptoms of ADHD

In addition, a 2005 study showed that 35.9% of patients diagnosed with ADHD were also prescribed antidepressants, correlating the strong relationship between depression and ADHD.

Advice: If you are even mildly depressed, this may manifest as distraction or disengagement. Again, depression and ADHD are highly comorbid, but it’s important to consider that difficulty sustaining attention may be presumed to be a symptom of ADHD, rather than depression. Consider other symptoms you may be experiencing. Are you disengaged from previously enjoyed activities? Any changes in appetite? Feeling sad?

2. Anxiety

Anxiety is also a highly comorbid condition of adult ADHD. Up to 47.1% of diagnosed patients meet criteria for an anxiety disorder; the three most common are social phobia, specific phobia, and PTSD. A 2010 study found that:

  • From a comorbid ADHD standpoint, of those diagnosed with only anxiety disorder 27.9% met criteria for ADHD. So, even if ADHD is a second diagnosis, the relationship between the two is significant.

  • A 2012 Swedish study showed ADHD strongly correlated with generalized anxiety disorders, with differences among different types of anxiety. The hyperactive/impulsive types had lower risks for anxiety and depression, while the inattentive type was at a higher risk.

Advice: Anxiety can cause extreme stress, inattention, and, in its different forms, hyperactivity which is easily misdiagnosed as ADHD. However, focusing on the processes to diagnose ADHD separately from anxiety can identify if comorbidity exists with or without it. Psychological testing and a thoughtful interview should aid in determining if anxiety is also occurring or if you are only experiencing anxiety. A risk here is that a commonly prescribed medication to combat ADHD, stimulants, can exacerbate anxiety. Speak to your prescriber about other options if you feel anxious. Also, Cognitive Behavior therapy has proven to be highly effective at addressing anxiety symptoms.

3. Bipolar Disorder

Adults diagnosed with ADHD often have a high risk for bipolar disorder. But several symptoms for ADHD and bipolar disorder overlap and can often muddle the diagnosis. Common symptoms of bipolar disorder include distraction, increased activity, flighty ideas, and overly verbose. Often, these mania symptoms overlap with the identifying factors of ADHD.

Advice: A large difference between these two diagnoses is that bipolar disorder affects mood, while ADHD affects attention and behavior. People with bipolar disorder cycle through drastic changes of mania or hypomania, and depression. People with ADHD encounter chronic symptoms. If it’s predicted that both diseases are present then a mix of medication and psychotherapy should be administered.

4. Conduct Disorder/Oppositional Defiant Disorder

A commonly externalized disorder, Oppositional Defiant Disorder (ODD) is characterized by negativistic or hostile patterns of behavior including frequent arguments, blaming others for their mistakes, and actively refusing requests. On the other hand, Conduct Disorder (CD) is considered more extreme, usually categorized as a persistent pattern of violating the rights of others. Actions may include aggression towards people or animals, property destruction, theft, and serious violation of rules.

Research identified that adults who reported ODD alone or with ADHD experienced more severe self-reported symptoms of other psychiatric disorders than adults who only had ADHD. Yet, overall participants with ODD reported more violent and antisocial tendencies while ADHD-only patients only experienced more severe anxiety and depression than the ODD group. The patient diagnosed with both encountered the most severe emotional and behavioral patterns.

Advice: People diagnosed with ADHD, especially those with hyperactive or impulsive traits, may showcase symptoms that appear oppositional. They may have difficulty standing still, fidget with any object, blurt out inappropriate comments, have difficulty following rules, and interrupt others. This could be a result of their impaired executive functioning skills; their ability to think ahead and assess their behavior. But doctors should consider and test out the true hallmarks of ODD and CD to see if these actions are purposeful or not.

Diagnosing the Future

It’s evident that ADHD is drastically intertwined with other mental impairments. As more research is conducted in the field, the relationship between ADHD to comorbid diseases will unravel, so patients don’t feel as if they’re forced to unravel with it. As medical professionals diagnose patients with ADHD, they should remain dedicated to careful, thoughtful evaluation, while also including forms of psychological testing to help. With these efforts, they can obtain an accurate picture that encompasses every factor at play so that patients get the diagnoses they deserve.

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