Anxiety? Depression? Or ADHD? It Could Be All Three
ADHD is often missed when it co-exists with depression or anxiety, and vice versa. Here’s what to look for — and how to ensure you get a thorough and accurate diagnosis.
Studies find that 80 percent of people with attention deficit disorder (ADHD or ADD) will have at least one other psychiatric disorder in their lifetime. The two most common are depression and an anxiety disorder, like obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD).
ADHD without a comorbid disorder is the exception rather than the rule. Having ADHD is challenging enough, but the other disorders that accompany ADHD profoundly affect a person’s daily life. A patient of mine, Antonio, knows this well. Although his ADHD was diagnosed when he was in fifth grade, his anxiety disorder was not caught until his last year of college.
“Everyone assumed that my anxiety behaviors were just the hyperactivity part of my ADHD,” he says. Years of his life were spent suffering from paralyzing anxiety that resulted in his missing classes, being housebound for days, and not being able to work.
When ADHD and another disorder co-occur, there will likely be one of the following scenarios:
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1. The ADHD has been diagnosed, but the comorbid disorder has not been. Doctors sometimes mistakenly chalk up depressive and anxiety symptoms to the ADHD diagnosis, as in Antonio’s case. The comorbid disorder can be independent of the ADHD (primary) or a direct result of ADHD symptoms (secondary).
Corey was never an anxious person before he went to college. But, without the structure of high school and his parents’ support, he felt lost. His ADHD and executive functioning deficits stymied him. He had severe anxiety about taking tests and writing papers, which led to poor sleep. His sleeplessness caused him to feel “on edge” all the time. He met the criteria for having an anxiety disorder and needed treatment, even though it was secondary to his ADHD.
A secondary diagnosis does not make anxiety less challenging to live with. There is a parallel to substance abuse. Most people who abuse drugs or alcohol are depressed or anxious, yet the addiction is a separate entity that must be dealt with, in addition to its underlying causes.
2. The depression or anxiety has been identified and diagnosed, but the ADHD has not been. Doctors see ADHD symptoms as part of the comorbid disorder. Janice had a severe binge-eating disorder, and her doctor assumed that her impulsivity and lack of concentration were due to that disorder. Her previous therapist questioned whether she really wanted to get better because she was late for many of her appointments.
3. ADHD and the comorbid disorder are both diagnosed and treated — the ideal scenario. A patient’s doctor focuses on depression or anxiety’s effect on ADHD and vice versa. The ADHD affects the comorbid disorder and, in turn, is affected by depression or anxiety, whether or not the comorbid disorder results from ADHD. When someone struggles with two conditions, the symptoms of each disorder are more intense.
To avoid the plight of Antonio, Corey, and Janice, it is important that your doctor get the diagnosis right. Here is a checklist of symptoms you and she should be looking for, questions your doctor should be asking you, and some tools she should be using to assess you.
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Depression: Coming Out of the Darkness
About 30 percent of those with ADHD will experience a depressive episode at some time in their lives. Depression can be independent of the ADHD, or it can result from ADHD symptoms. ADHD has a significant impact on the course of depression. Studies always find more depressive symptoms in individuals with ADHD than in their counterparts without ADHD. Increased severity of ADHD symptoms is correlated with higher depressive symptoms. When you have ADHD and depression, the symptoms of both conditions are worse than if you had either disorder alone.
In making a proper diagnosis of depression, your doctor will assess the following criteria, and should make distinctions between depression and your ADHD symptoms.
- PERSISTENT SAD OR IRRITABLE MOOD When a person has ADHD alone, sadness or irritability is context- or environment-specific. Your doctor should find out if you are always feeling sad, or whether there are certain scenarios in which your ADHD symptoms always come to the fore.
- LOSS OF INTEREST IN ACTIVITIES ONCE ENJOYED With ADHD, it is common for someone to enjoy something intensely, and then grow bored with it, moving on to something new and more stimulating. With depression, a person finds no enjoyment in anything.
- CHANGE IN APPETITE OR BODY WEIGHT With depression, there might be weight gain or loss of 20 pounds or more. Someone may lose his appetite, despite being surrounded by food and unengaged in anything else. With ADHD, loss of appetite is caused by hyperfocusing on another activity or related to stimulant treatment.
- SLEEPING TOO LITTLE OR TOO MUCH Your doctor should assess your sleep patterns for a period of time, not just in the last week. With depression, tiredness is unrelated to how much sleep you are getting night after night. Jack slept 14 hours a night for weeks during the throes of his depression, and always felt tired the next day. This was not due to sleep deprivation. Many with ADHD do not sleep enough (hyperactive types) or sleep too much (inattentive types), but what qualifies sleeplessness as a depressive symptom is the episodic nature of it; it occurs without a context.
- PHYSICAL AGITATION OR SLOWING Your doctor will ask if you are feeling agitated or slow, even when engaged in something that interests you. She will want to know if the agitation is environmentally triggered (such as the presence of an ex-boyfriend) or is something that feels internally caused.
- FATIGUE Is this a new feeling for you, or have you always felt like you lacked some energy? How have you been sleeping in the last month? Have there been any particular new stressors in your life that could cause the fatigue? How have you been eating? Have you had a sleep study to rule out sleep apnea or other sleep disorders? Are you seriously overweight? Your doctor should ask these questions to determine if symptoms are caused by environmental or behavioral factors, such as malnutrition or sleep deprivation, or a looming depression.
– FEELINGS OF WORTHLESSNESS OR INAPPROPRIATE GUILT Many with ADHD feel guilt over not getting something done in time, interrupting a friend in conversation, or running through the house and breaking Mom’s favorite vase. With depression, this feels like a general sense of guilt and inadequacy.
- DIFFICULTY CONCENTRATING This is often one of the first symptoms of an emerging depression, and it usually gets lumped with the concentration challenges of ADHD. Is this concentration problem, to this degree, new for you, given your ADHD? Is it persistent? Does it occur during relaxing, enjoyable activities? Is the difficulty due to distractions from external (noises, people) or internal (thoughts or daydreams) stimuli?
- RECURRENT THOUGHTS OF DEATH OR SUICIDE It is always a serious clinical matter when someone has thoughts of suicide or a preoccupation with death. This should never be downplayed. Whether such thoughts are a result of ADHD-related struggles or not doesn’t matter. Tell your doctor immediately if you are experiencing these thoughts. Remember that depression brings on a mindset in which it seems rational to take one’s life.
- PSYCHOTIC FEATURES Hearing voices, visual hallucinations, paranoia, and delusional thinking are signs of something beyond ADHD. They can be part of a severe depressive episode, in which psychotic features are apparent. Do not be afraid to disclose this, even though you might feel ashamed to be talking about such symptoms.
In addition to these clinical criteria, your doctor will ask you about family history. Both ADHD and Major Depressive Disorder run in families. Studies find that depression in individuals with ADHD is often caused by relationship conflicts or social isolation related to ADHD symptoms.
Finally, your doctor should assess whether depressive symptoms are caused by, or exacerbated by, a medication you are taking or any side effects of a medication. A physical exam should also be conducted to rule out thyroid problems or other medical conditions.
Evaluating for Depression
Doctors often use empirically based surveys to add to a personal history.
> The Beck Depression Inventory or Automatic Thoughts Questionnaire (for adolescents and adults) or Children’s Depression Inventory (for children and adolescents) are quick, reliable surveys that could aid in the diagnosis of depression. The severity and course of a depressive episode may be charted if a patient monitors symptoms daily.
> The Structured Clinical Interview for DSM-V Disorders (SCID-5) (for adults) and Diagnostic Interview for Children and Adolescents-Revised are reliable instruments that use the DSM-V criteria to assess for clinical disorders.
Anxiety: Worry Less
One study found that 27 percent of children with ADHD had more than one anxiety disorder compared to 5 percent of children without ADHD. Other studies find that anywhere from 20 to 30 percent of individuals with ADHD will struggle with a clinical anxiety disorder in their lifetime.
Having ADHD itself can cause lots of stress. Executive functioning issues affect every part of a person’s life. Disorganization, time mismanagement, procrastination, and frustration over failed intentions create a state of anxiety for individuals with ADHD. Learning disabilities, which affect 50 to 60 percent of students with ADHD, are highly associated with academic anxiety.
Anxiety is defined as a feeling of unease, tension, or nervousness related to stressful or uncertain events. Most people have experienced a bout of anxiety (but not depression) at some point in their lives. The diagnosis of anxiety or having an anxiety disorder is made when the condition is more than a temporary state of being, it gets worse, and there is significant interference in the activities of daily living.
Getting a proper diagnosis for an anxiety disorder can be tricky, given that many symptoms mimic ADHD or are seen as related to ADHD. A physical examination should be conducted to rule out any other medical condition. You should report any medications or their side effects that cause anxiety. In addition, your doctor should inquire about the following to make a correct diagnosis.
- PERSISTENT WORRY Worry about paying bills, a job interview, or catching a flight are normal. If worry becomes constant and causes significant distress, it warrants clinical attention. When stress arises from ADHD symptoms, the treatment is focused on the ADHD. If it is clear that anxiety is beyond the ADHD, then anxiety disorder treatment is indicated.
- PHYSICAL SYMPTOMS Anxiety expresses itself in a variety of physical symptoms — cold or sweaty hands, shortness of breath, heart palpitations, dry mouth, flushed face, numbness or tingling in the hands and/or feet, nausea, muscle tension, migraine headaches, acid reflux, tics, erectile dysfunction, constipation or diarrhea, and dizziness. Your doctor should ask about all of these symptoms, as well as your history of panic attacks or phobias.
- SLEEP Anxiety makes it very hard to sleep. If you find it difficult to fall asleep or to slow your mind down, these things can occur without anxiety. In the case of anxiety, sleep problems are due to constant worry as well as fears and irrational thoughts.
- IRRATIONAL FEARS People with an anxiety disorder may know that their fears are irrational, but they cannot help taking them seriously.
- AVOIDANCE One of the common behaviors of anxious people is avoidance. Whether it is about things perceived as contaminated (OCD) or socially related situations (social anxiety disorder), avoidance is an attempt to prevent feeling anxious. However, avoidance only leads to more anxiety, since it prevents a person from practicing how to tolerate that situation.
- ATTENTION AND FOCUS With anxiety, a person finds it hard to stay focused because of worry, fear, and obsessive, unwanted thoughts. With ADHD, anxious thoughts can be a distraction, but they can also be pleasant.
- DEALING WITH CHANGE Those with ADHD often like change, as they get bored easily, but they may also find change stressful, since it requires new ways of engaging with their environment. People with anxiety are often wedded to routine, since it offers certainty in their lives. Your doctor should ask how well you deal with change and transition.
In addition to the above, as part of your evaluation, your doctor should always ask you about family history. Anxiety disorders run in families.
The following assessments are frequently used in diagnosing anxiety. Your doctor should be using one or more of these, or similar scales:
> SCID-5
> Yale Brown Obsessive-Compulsive Scale (Y-BOCS) for OCD symptoms
> Hamilton Anxiety Rating Scale
> Beck Anxiety Inventory
> Revised Children’s Manifest Anxiety Scale.
No assessment measure is empirically perfect, and none is a substitute for a comprehensive clinical interview and physical examination.
Knowledge is power. Dealing with ADHD symptoms is challenging enough. Dealing with depression or anxiety, too, is debilitating. Only with proper assessment and diagnosis can treatment for both, or either, be possible.
[What to Do When It’s More Than ADHD]
Roberto Olivardia, Ph.D., is a member of ADDitude’s ADHD Medical Review Panel.
The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude
- How can I better understand ADHD, its causes, and its manifestations?
- What do I need to understand about ADHD that is not fully represented in the DSM?
- How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
- How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
- What comorbidities are associated with ADHD?
- What are the key distinctions between ADHD and depression?
- How is ADHD distinct from oppositional defiant disorder and disruptive mood dysregulation disorder?
- How are the symptoms of ADHD and bipolar disorder often conflated?
- What are the shared and distinct characteristics of obsessive compulsive disorder (OCD) and ADHD?
- How can diagnosing clinicians differentiate between rejection sensitive dysphoria (RSD) – the emotional highs and lows associated with ADHD – and the similar ups and downs of bipolar disorder?
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- How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
- How can I best consider trauma and personality disorders through the lens of ADHD?
- What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?
