Dr Larry Klassen
ADHD and anxiety: detection, diagnosis and treatment
This interactive clinical seminar was led by Dr Larry Klassen (Eden Health Care Services, Canada) and discussed the presence and frequency of common anxiety disorders found with ADHD, differentiation of ADHD and anxiety disorder and the treatment of ADHD in the presence of anxiety.
Dr Klassen began by highlighting that anxiety and mood disorders develop progressively across the lifespan and peak during adulthood; and that there is considerable overlap between symptoms of ADHD and other psychiatric disorders, which may complicate the diagnosis of ADHD.1,2 He presented results from the National Comorbidity Survey (NCS; n=3199 adults), which showed that 47.1% of adults with ADHD have a 1-year prevalence of any anxiety disorder, and nearly 1 in 10 patients with any anxiety disorder had a 1-year prevalence of ADHD.3 Dr Klassen continued his review of the NCS data by showing that in all types of anxiety disorders (generalised anxiety disorder, post-traumatic stress disorder, panic disorder and social phobia), ADHD prevalence was higher in those with anxiety comorbidity compared with those without anxiety comorbidity and that prevalence of anxiety disorders was higher in those with ADHD compared with those without ADHD.3 He asserted that those patients with anxiety disorders and comorbid ADHD may exhibit more severe anxiety symptoms, earlier age of onset of anxiety and additional comorbid psychiatric conditions.4-6
Dr Klassen then described three questions (‘red flags’) which ought to be asked when diagnosing ADHD in complex patients:7
- Have you had long-standing and consistent problems with attention and distractibility?
- Have your current complaints been present over the last 10 or 20 years?
- If I could see you in the classroom when you were a child, what would you be like?
He noted the importance of adult patients providing clinicians with copies of their school report cards, as these may hold the key to a correct diagnosis.
Although restlessness and difficulty concentrating are both key features of ADHD and anxiety disorder, there are unfortunately no overlapping symptoms that can help distinguish between the two disorders; therefore, Dr Klassen recommended asking all patients with ADHD if they have feelings of nervousness, anxiety or uncontrollable worry and screening for anxiety (for example, using the Generalised Anxiety Disorder Questionnaire [GAD-7], or in the case of one audience member, they recommended the Hamilton Anxiety Rating Scale [HAM-A]).
Dr Klassen highlighted that the goals of treatment for all patients are to reduce core symptoms, improve stress resilience, improve quality of life, reduce disability, reduce comorbidity and prevent relapse. When discussing the question “Which disorder should be treated first, ADHD or anxiety?”, he explained that initially it would be important to distinguish anxiety disorders from performance anxiety and obsessions for order, as they can be secondary to ADHD and could resolve with successful treatment of ADHD; he explained that, in most cases, he recommended (based on Canadian ADHD Resource Alliance [CADDRA] guidelines) that treatment of ADHD should be prioritised, and that to avoid exacerbating symptoms of anxiety, it is generally advised to ‘start low and go slow’ when initiating treatment of ADHD.8 Choosing the right non-pharmacological/pharmacological treatment for anxiety disorder would be dependent on patient preference and motivation, the ability of the patient to engage in treatment, the severity of illness, the clinician’s skills and experience, treatment availability, prior treatment response and any comorbidities (medical and psychiatric).9 Using case studies as examples and treatment guidelines, Dr Klassen then discussed the non-pharmacological and pharmacological treatment approaches in adult patients with ADHD and anxiety disorder, demonstrating the effect of noradrenaline on the prefrontal cortex in patients with anxiety. Discussion between Dr Klassen and the audience gave insight into the importance of non-pharmacological treatments such as cognitive behavioural therapy (CBT), reliable books/internet resources and exercise, with one audience member explaining that patients at their hospital go running with their therapist (‘Dynamic Running Therapy’).
Dr Klassen concluded his presentation by summarising that comorbidity is the rule – not the exception – in ADHD and can complicate identification and diagnosis and that, in the face of comorbidities, it is generally preferable to stabilise the most severe condition first.
Dr Klassen: “Non-response to ADHD treatment should prompt re-evaluation of ADHD diagnosis and evaluation for comorbidities.”
Professor Luis Rohde
ASRS and risk scores: implications for epidemiology and management of adult ADHD
Professor Luis Rohde (Federal University of Rio Grande do Sul, Brazil) and Professor Joseph Sergeant (Vrije University, Amsterdam, The Netherlands) began this session with a stimulating debate surrounding the new Adult ADHD Self-Report Scale (ASRS v1.2) Symptom Checklist which is being launched this year. Professor Rohde began by describing the ASRS v1.1, highlighting that it is a simplified version of the 18-symptoms of DSM-IV, with the 6-question screener covering 2 impulsive/hyperactivity symptoms and 4 inattention symptoms from DSM-IV.10 Professor Rohde discussed the new 6-question screener of the ASRS v1.2, which was developed using the same sample group as ASRS v1.1, and outlined the questions included in the new ASRS v1.2 which relate to 4 questions from the DSM-5 (questions 1-4) and 2 symptoms which are not part of DSM-5 (questions 5 & 6):11
- How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? (DSM-5 A1c)
- How often do you leave your seat in meetings or other situations in which you are expected to remain seated? (DSM-5 A2b)
- How often do you have difficulty unwinding and relaxing when you have time to yourself? (DSM-5 A2d)
- When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves? (DSM-5 A2g)
- How often do you put things off until the last minute? (Non-DSM)
- How often do you depend on others to keep your life in order and attend to details? (Non-DSM)
Professor Rohde and Professor Sergeant concluded that, although the ASRS v1.2 could be used to initially screen for ADHD, a full in-depth assessment would still be required to diagnose ADHD, highlighting that it is not just about counting the symptoms; it is also the settings, age of onset, etc that are important.
Professor Rohde then examined the research which investigated whether young adults with ADHD symptoms have always had childhood-onset disorder. In his presentation, he showed using longitudinal study data that there are indeed two syndromes which have distinct developmental trajectories. Professor Rohde closed the clinical seminar by briefly describing the prospect of personalised medicine to predict both persistent and later-onset ADHD.
Professor Martin Katzman
Understanding the neurobiology of cognition, low hedonic tone, emotional lability and the comorbidity of depression and ADHD
Professor Martin Katzman (Stress, Trauma, Anxiety, Rehabilitation and Treatment [START] Clinic for Mood and Anxiety Disorders, Canada) gave a lively presentation covering the diagnosis of ADHD and comorbid major depressive disorder (MDD); the many manifestations of ADHD, including cognitive impairment and executive dysfunction, low hedonic tone, emotional instability and impulsivity; the role of top-down regulation; the catecholaminergic effects on the prefrontal cortex; and that selective serotonin reuptake inhibitor (SSRI)-induced side effects in depression may suggest the presence of ADHD.
He started by highlighting that the DSM-V criteria for MDD ought to be considered as ‘clusters’ of symptoms12 and that Tom Insel from the National Institute of Mental Health (NIMH) recommends to look not only at these clusters but also the forces that are driving these systems, such as cognitive symptoms, systems for social processes and arousal and regulatory systems.13 He emphasised the burden of depression with the following statistics:14,15
- ≥350 million people across the globe live with depression, and it is the leading cause of disability worldwide
- depression often starts at a young age and affects women more commonly than men – 1 or 2 mothers out of 10 have depression after childbirth
- almost 1 million people take their own lives each year – for every person who commits suicide, there are 20 or more who make an attempt.
He described the consequences of untreated depression, not only for the patient but also relationships with spouses and close family, and that without complete remission, future episodes are highly likely,16,17 and that the risk of suicidality (suicidal ideation and suicidal attempts) can increase in those patients who do not achieve remission.18
Professor Katzman presented results from the STAR*D study which showed that,19 even after 4 steps of treatment, remission rates in patients with MDD were <70%.20 He followed this with results from a 3-year prospective study of 267 initially depressed primary care patients, which showed that cognitive symptoms were present 85-94% of the time during depressive episodes and 39-44% of the time during remissions.20 Other residual symptoms following an acute manic depressive episode included: mood, diminished pleasure or interest, weight, sleep disturbance, psychomotor dysfunction, fatigue, guilt, concentration and suicidal ideation – all of which suggest prefrontal deficits.21 He commented that it is these residual symptoms of forgetfulness, inattention and word-finding difficulties that are associated with cognitive deficits, and sleepiness, fatigue and apathy that is associated with chronic anhedonia (low hedonic tone), which in turn brings the patient closer to becoming depressed.22
When diagnosing comorbid ADHD in patients with MDD, he explained the power of executive dysfunction on predicting ADHD in these patient populations. Professor Katzman explained that if you improve executive function in these patients with ADHD, you move them from just reacting to what is going on around them to planning and pursuing goals, and they are able to effectively problem-solve and analyse data.23,24 He discussed the default mode network (DMN), a network which activates when a person’s mind wanders when they are not fully involved in a task; in patients with ADHD, reduced inhibition of the DMN is found when performing cognitive tasks.25
Professor Katzman went on to summarise the role of the prefrontal cortex in impulse control, whereby the prefrontal cortex is more active when patients successfully inhibit an action (delayed gratification), and that those people who cannot achieve delayed gratification show exaggerated recruitment in ventral striatum.26 During the presentation, he explained how patients with low hedonic tone try to reach euthymia via internalising (e.g. day-dreaming) and externalising activities (e.g. taking cocaine). He then outlined the involvement of neural circuits in bottom-up and top-down systems in the prefrontal cortex and the role of dopamine, noradrenaline and serotonin in monoaminergic pathways in MDD.
Professor Katzman: “If you have a patient on an antidepressant who is flat or numb and is having difficulty feeling good, in these cases consider comorbidity with ADHD.”
Professor Susan Young
Non-pharmacological treatment strategies for adolescents and adults with ADHD
Professor Susan Young (Imperial College London, UK) and Dr Duncan Manders (University of Edinburgh, UK) hosted this engaging group discussion workshop that focused on practical techniques for breaking the cycle of negative reinforcement faced by patients with ADHD using non-pharmacological methods.
The resilience of patients with ADHD can be strained by patterns of failure and negative appraisal in response to situations or events throughout life. Reframing of experiences, symptoms and feelings by schema therapy, CBT or coaching can help promote positive thoughts and improve outcomes.
The group were encouraged to embrace behavioural experiments as a means of effecting change. As each patient is unique, it cannot be known what intervention will succeed. An empirical approach should therefore be adopted, where promising interventions are tested and outcomes noted.
Professor Young advocated the identification of ‘early warning signs’ by patients that could be used as triggers for behavioural intervention. These could be physical, cognitive or behavioural signals, such as increased heart rate, finger pointing or thoughts of, ‘I’m getting mad’. CBT was visualised as a three-legged table, supported by thoughts, feelings and behaviour. The objective of behavioural intervention should be to ‘knock out’ at least one of these legs. For example, relaxation techniques could help suppress feelings before they progress to anger or frustration.
The participants then split into small discussion groups and were provided with vignettes detailing the symptoms of two patients with ADHD from clinical practice. Using the techniques discussed in the workshop, the groups identified early warning signs, and specific behavioural experiments that could be used in each case. The importance of identifying practical and achievable goals was emphasised by the discussion leaders, as was the utility of simple organisational tools such as mobile phone alarms.
Professor Young: “Patients with ADHD have a sack on their back that gets heavier and heavier with negative reinforcement over the lifetime.”
Professors Mie Bonde and Marina Danckaerts
ADHD and families: strategies for success
This informative and interactive clinical workshop was co-hosted by Professor Mie Bonde (Frederiksberg, Denmark) and Professor Marina Danckaerts (University of Leuven, Belgium). Participants were invited to discuss the issues which they considered most important in the context of working with families affected by ADHD.
The first topic of discussion was the issue of intergenerational stigma and the scepticism associated with a diagnosis of ADHD, particularly in adults. The participating adult and child psychiatrists reported on the differing clinical picture across Europe, raising the following points:
- there are frequently inadequate, or no, systems in place to support adults with ADHD
- many families do not want to accept a diagnosis of ADHD
- in some cases, ADHD may be wrongly used to justify all behaviours
- in some countries, government ministers are also misinformed and unsupportive of ADHD treatment. Clear and prominent leadership is desirable
- changes in funding policies can have direct impact on patients
- in Belgium, there is a shortage of adult psychiatrists, due in part to other vocations being more popular career choices. There is also reluctance to label children as having ADHD in schools
- the UK has empowered nurses to prescribe for ADHD; this was seen as a progressive step by the group, but there is still resistance from some medical professionals.
On the subject of parenting with ADHD, practical suggestions were shared with the group for engaging the affected family with treatment regimens. These included family therapy and home visits by special educators; special educators sitting in at a family meal was also suggested as a good method of observing normal family behaviours. It was agreed that reducing the barriers to treatment for adults with ADHD should be a priority.
Professors Bonde and Danckaerts also highlighted the value of pragmatic organisational tools and advice for parents with ADHD. Suggestions included the use of calendars, schedules and daily routines.
The problems associated with siblings of children with ADHD were then debated among the participants. The importance of paying equal attention to each child was stressed, and the dangers of bullying by the child with ADHD were recognised. It was advocated that parents should be fair, personalise attention to the needs of each child and consider teaching empathy by first applying it to other people.
The particular issues that present when dealing with adolescents with ADHD were also discussed. A flexible approach was recommended; for example, respecting the decisions made by adolescents, but leaving the door open for them to return. The technique of paradoxical observation, where non-treatment is prescribed in response to non-adherence, can be useful in this regard.
Professor Bonde: “We need leadership to drive the recognition of adult ADHD.”
Professor Guy Goodwin
Unstable moods and comorbidity in ADHD in adults
Professor Guy Goodwin (University of Oxford, UK) led this lively seminar on variable mood as a potential treatment target in ADHD and other mental health disorders. After introducing the many comorbidities associated with ADHD, he focused on mood instability (MI) as a common feature of many mental health disorders, including ADHD, bipolar disorder, borderline personality disorder and Asperger syndrome. Unstable mood is characterised by sadness, anxiety, irritability/anger – and impaired decision-making, impulse control and relationships. It has been proposed that MI may resolve into other specific psychiatric disorders with time. One possible cause of MI is the failure of normal circadian homeostasis.
Drawing from his own clinical experience, Professor Goodwin described how diurnal synchronisation was often disturbed in patients with borderline personality disorder. Symptoms included:
- delayed heart rate rhythm
- delayed sleep relative to activity
- variability in heart rate and sleep was often associated with variable mood, especially irritability.
Similarly, in patients with bipolar disorder, variability in sleep may be associated with variable mood.
These observations led to a group discussion on the possibilities of targeting sleep deficiency as a means of addressing disorders of mood. Some participants reported that treatment of sleep deficiency was already used in their practice for some patients with ADHD. Professor Goodwin presented findings from a successful trial of online CBT for the treatment of chronic insomnia,27 and ended the seminar by proposing that digital solutions may offer real promise in treating sleep deficiencies and possibly other mental health conditions.
Professor Goodwin: “Variable mood is ripe for digital solutions.”
- Kooij JJ, Huss M, Asherson P, Akehurst R, Beusterien K, French A, Sasane R, Hodgkins P. Distinguishing comorbidity and successful management of adult ADHD. J Atten Disord 2012; 16(5 Suppl): 3S-19S.
- Turgay A. A multidimensional approach to medication selection in the treatment of children and adolescents with ADHD. Psychiatry (Edgmont) 2007; 4: 47-57.
- Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE, Zaslavsky AM. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163: 716-723.
- Mancini C, Van Ameringen M, Oakman JM, Figueiredo D. Childhood attention deficit/hyperactivity disorder in adults with anxiety disorders. Psychol Med 1999; 29: 515-525.
- Schatz DB, Rostain AL. ADHD with comorbid anxiety: a review of the current literature. J Atten Disord 2006; 10: 141-149.
- Alexander SJ, Harrison AG. Cognitive responses to stress, depression, and anxiety and their relationship to ADHD symptoms in first year psychology students. J Atten Disord 2013; 17: 29-37.
- Katzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry 2017; 17: 302.
- Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. eds. Toronto: Third edCADDRA, 2011.
- Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, Antony MM, Bouchard S, Brunet A, Flament M, Grigoriadis S, Mendlowitz S, O’Connor K, Rabheru K, Richter PM, Robichaud M, Walker JR. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014; 14 Suppl 1: S1.
- Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med 2005; 35: 245-256.
- Ustun B, Adler LA, Rudin C, Faraone SV, Spencer TJ, Berglund P, Gruber MJ, Kessler RC. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry 2017; 74: 520-526.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. eds. 2013.
- Insel T. Post by Former NIMH Director Thomas Insel: Research Domain Criteria — RDoC. Available at: https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2012/research-domain-criteria-rdoc.shtml. Last updated 2012. Accessed 28 September 2017.
- Smith K. Mental health: a world of depression. Nature 2014; 515: 181.
- Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459-1544.
- Sobocki P, Ekman M, Agren H, Runeson B, Jonsson B. The mission is remission: health economic consequences of achieving full remission with antidepressant treatment for depression. Int J Clin Pract 2006; 60: 791-798.
- Keller MB. Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA 2003; 289: 3152-3160.
- Judd LL, Akiskal HS, Paulus MP. The role and clinical significance of subsyndromal depressive symptoms (SSD) in unipolar major depressive disorder. J Affect Disord 1997; 45: 5-17.
- Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ, Rosenbaum JF, Sackeim HA, Kupfer DJ, Luther J, Fava M. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163(11): 1905-1917.
- Conradi HJ, Ormel J, de Jonge P. Presence of individual (residual) symptoms during depressive episodes and periods of remission: a 3-year prospective study. Psychol Med 2011; 41: 1165-1174.
- Nierenberg AA, Wright EC. Evolution of remission as the new standard in the treatment of depression. J Clin Psychiatry 1999; 60 Suppl 22: 7-11.
- Fava M, Graves LM, Benazzi F, Scalia MJ, Iosifescu DV, Alpert JE, Papakostas GI. A cross-sectional study of the prevalence of cognitive and physical symptoms during long-term antidepressant treatment. J Clin Psychiatry 2006; 67: 1754-1759.
- Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. eds. Guilford Press, 2006.
- Barkley RA, Murphy KR, Fischer M. ADHD in adults: what science says in: Guilford Press, 2008: 176-179.
- Silberstein RB, Pipingas A, Farrow M, Levy F, Stough CK. Dopaminergic modulation of default mode network brain functional connectivity in attention deficit hyperactivity disorder. Brain Behav 2016; 6: e00582.
- Casey BJ, Somerville LH, Gotlib IH, Ayduk O, Franklin NT, Askren MK, Jonides J, Berman MG, Wilson NL, Teslovich T, Glover G, Zayas V, Mischel W, Shoda Y. Behavioral and neural correlates of delay of gratification 40 years later. Proc Natl Acad Sci U S A 2011; 108: 14998-15003.
- Espie CA, Kyle SD, Williams C, Ong JC, Douglas NJ, Hames P, Brown JS. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep 2012; 35: 769-781.