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ADHD and Anxiety: Clinical Significance and Treatment Implications

  • Attention-Deficit Disorder (A Rostain, Section Editor)
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Abstract

In comparison to the DSM formulation of ADHD, we have proposed that ADHD in adults should be divided into Inattentive and Emotional Dysregulation Presentations. Under both systems, there is potential overlap with generalized anxiety disorder (GAD). We compared data from four distinct populations: ADHD clinical trials, GAD clinical trials, an ADHD clinic, and a forensic clinic. Approximately 25% of patients in each population had comorbid ADHD and anxiety. Comorbid subjects reported more childhood ADHD symptoms and higher scores on ADHD scales and were more likely to fit criteria for ADHD Emotional Dysregulation Presentation or DSM-IV combined type. Comorbid subjects did not drop out at a higher rate and showed significant drug-placebo differences on ADHD symptoms, including Emotional Dysregulation. Conversely, although symptoms of anxiety decreased, there was no drug-placebo difference in improvement.

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References

Papers of particular interest, published recently, have been highlighted as: • Of major importance

  1. Jacob C, et al. Internalizing and externalizing behavior in adult ADHD. Atten Defic Hyperact Disord. 2014;6(2):101–10. https://doi.org/10.1007/s12402-014-0128-z.

    Article  PubMed  Google Scholar 

  2. • Reimherr FW, et al. Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry. 2005;58(2):125–31. This is the first study documenting that high levels of emotional dysregulation can exist in adults with ADHD even when anxiety and depression disorders are carefully excluded. Emotional dysregulation improved even though measures of anxiety and depression did not

    Article  CAS  PubMed  Google Scholar 

  3. Kessler RC, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–23.

    Article  PubMed  PubMed Central  Google Scholar 

  4. • Piñeiro-Dieguez B, et al. Psychiatric comorbidity at the time of diagnosis in adults with ADHD: the CAT study. J Atten Disord. 2016;20(12):1066–75. In a large sample of adults ADHD ( n = 367), additional psychiatric diagnoses were present in 66.2% of the sample. The most common were substance use disorders (39.2%) and anxiety disorders (23%)

    Article  PubMed  Google Scholar 

  5. • Van Ameringen M, et al. Adult attention deficit hyperactivity disorder in an anxiety disorders population. CNS Neurosci Ther. 2011;17(4):221–6. https://doi.org/10.1111/j.1755-5949.2010.00148.x. In an anxiety clinic, a sample of 129 patients were assessed for the presence of adult ADHD; 27.9% had both disorders

    Article  PubMed  Google Scholar 

  6. Tannock R. Attention-deficit/hyperactivity disorder with anxiety disorders. In: Brown TE, editor. Attention-deficit disorders and comorbidities in children, adolescents, and adults. Washington, DC: American Psychiatric Press; 2000. p. 125–70.

    Google Scholar 

  7. Nigg JT, Goldsmith HH, Sachek J. Temperament and attention deficit hyperactivity disorder: the development of a multiple pathway model. J Clin Child Adolesc Psychol. 2004;33(1):42–53.

    Article  PubMed  Google Scholar 

  8. • Milberger S, et al. Attention deficit hyperactivity disorder and comorbid disorders: issues of overlapping symptoms. Am J Psychiatry. 1995;152(12):1793–9. In large sample of children, adolescents, and adults with ADHD and a comorbid psychiatric disorder, 75% maintained their diagnosis of generalized anxiety disorder when overlapping symptoms were removed

    Article  CAS  PubMed  Google Scholar 

  9. Cadman T, et al. Six-year follow-up study of combined type ADHD from childhood to young adulthood: predictors of functional impairment and comorbid symptoms. Eur Psychiatry. 2016;35:47–54. https://doi.org/10.1016/j.eurpsy.2015.08.007.

    Article  CAS  PubMed  Google Scholar 

  10. Jensen PS, et al. ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J. Am. Acad. Child Adolesc Psychiatry. 2001;40(2):147–58.

    Article  CAS  PubMed  Google Scholar 

  11. March JS, et al. Anxiety as a predictor and outcome variable in the multimodal treatment study of children with ADHD (MTA). J Abnorm Child Psychol. 2000;28(6):527–41.

    Article  CAS  PubMed  Google Scholar 

  12. Barrickman LL, et al. Bupropion versus methylphenidate in the treatment of attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1995;34(5):649–57.

    Article  CAS  PubMed  Google Scholar 

  13. Geller D, et al. Atomoxetine treatment for pediatric patients with attention-deficit/hyperactivity disorder with comorbid anxiety disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(9):1119–27.

    Article  PubMed  Google Scholar 

  14. Snircova E, et al. Anxiety reduction on atomoxetine and methylphenidate medication in children with ADHD. Pediatr Int. 2016;58(6):476–81. https://doi.org/10.1111/ped.12847.

    Article  CAS  PubMed  Google Scholar 

  15. Moshe K, Karni A, Tirosh E. Anxiety and methylphenidate in attention deficit hyperactivity disorder: a double-blind placebo-drug trial. Atten Defic Hyperact Disord. 2012;4(3):153–8. https://doi.org/10.1007/s12402-012-0078-2.

    Article  PubMed  Google Scholar 

  16. Ter-Stepanian M, et al. Clinical response to methylphenidate in children diagnosed with attention-deficit hyperactivity disorder and comorbid psychiatric disorders. Can J Psychiatr. 2010;55(5):305–12.

    Article  Google Scholar 

  17. Sciberras E, et al. Anxiety in children with attention-deficit/hyperactivity disorder. Pediatrics. 2014;133(5):801–8. https://doi.org/10.1542/peds.2013-3686.

    Article  PubMed  Google Scholar 

  18. Clemow DB, et al. A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatr Dis Treat. 2017;13:357–71. https://doi.org/10.2147/NDT.S115707.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Bloch Y, et al. Methylphenidate reduces state anxiety during a continuous performance test that distinguishes adult ADHD patients from controls. J Atten Disord. 2017;21(1):46–51.

    Article  PubMed  Google Scholar 

  20. Bouffard R, et al. The efficacy of 2 different dosages of methylphenidate in treating adults with attention-deficit hyperactivity disorder. Can J Psychiatr. 2003;48(8):546–54.

    Article  Google Scholar 

  21. Mattos P, et al. A multicenter, open-label trial to evaluate the quality of life in adults with ADHD treated with long-acting methylphenidate (OROS MPH): Concerta Quality of Life (CONQoL) study. J Atten Disord. 2013;17(5):444–8. https://doi.org/10.1177/1087054711434772.

    Article  PubMed  Google Scholar 

  22. • Gabriel A. The mixed amphetamine salt extended release (Adderall XR, Max-XR) as an adjunctive to SSRIS or SNRIS in the treatment of adult ADHD patients with comorbid partially responsive generalized anxiety: an open-label study. Atten Defic Hyperact Disord. 2010;2(2):87–92. https://doi.org/10.1007/s12402-010-0025-z. A sample of adults with ADHD and generalized anxiety who showed a partial response to a SSRI or a SNRI were then treated with extended mixed amphetamine salts. The HAMA, ADHD rating scale, and CGI all showed additional improvement

    Article  PubMed  Google Scholar 

  23. Gabriel A, Violato C. Adjunctive atomoxetine to SSRIs or SNRIs in the treatment of adult ADHD patients with comorbid partially responsive generalized anxiety (GA): an open-label study. Atten Defic Hyperact Disord. 2011;3(4):319–26. https://doi.org/10.1007/s12402-011-0063-1.

    Article  PubMed  Google Scholar 

  24. Horrigan JP, Barnhill LJ. Low-dose amphetamine salts and adult attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2000;61(6):414–7.

    Article  CAS  PubMed  Google Scholar 

  25. • Rösler M, et al. Twenty-four-week treatment with extended release methylphenidate improves emotional symptoms in adult ADHD. World J Biol Psychiatry. 2010;11(5):709–18. https://doi.org/10.3109/15622971003624197. In this large multi-center study, while there was a significant reduction in ADHD symptoms, there was no difference in change in anxiety symptoms between placebo and methylphenidate

    Article  PubMed  Google Scholar 

  26. Durell TM, et al. Atomoxetine treatment of attention-deficit/hyperactivity disorder in young adults with assessment of functional outcomes: a randomized, double-blind, placebo-controlled clinical trial. J Clin Psychopharmacol. 2013;33(1):45–54. https://doi.org/10.1097/JCP.0b013e31827d8a23.

    Article  CAS  PubMed  Google Scholar 

  27. Bilodeau M, et al. Duloxetine in adults with ADHD: a randomized, placebo-controlled pilot study. J Atten Disord. 2014;18(2):169–75. https://doi.org/10.1177/1087054712443157.

    Article  PubMed  Google Scholar 

  28. • Reimherr FW, et al. Types of adult attention-deficit hyperactivity disorder (ADHD): baseline characteristics, initial response, and long-term response to treatment with methylphenidate. Atten Defic Hyperact Disord. 2015;7(2):115–28. https://doi.org/10.1007/s12402-015-0176-z. We proposed that adult ADHD should be divided into ADHD Inattentive Presentation and Emotional Dysregulation Presentation

    Article  PubMed  Google Scholar 

  29. Bradley C. The Behavior of Children Receiving Benzedrine. Am J Psychiatry. 1937;94:577–81.

    Article  Google Scholar 

  30. Wender PH. Minimal Brain Dysfunction in Children: Wiley-Interscience; 1971.

  31. Reimherr FW, et al. Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry. 2005;58(2):125–31.

    Article  CAS  PubMed  Google Scholar 

  32. Wender PH. Attention-deficit hyperactivity disorder in adults. New York. NY: Oxford University Press; 1995.

    Google Scholar 

  33. Marchant BK, et al. Psychometric properties of the self-report Wender-Reimherr Adult Attention Deficit Disorder Scale. Ann Clin Psychiatry. 2015;27(4):267–77. 26554368

    PubMed  Google Scholar 

  34. Reimherr FW, et al. Bupropion SR in adults with ADHD: a short-term, placebo-controlled trial. Neuropsychiatr Dis Treat. 2005;1(3):245–51.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Wilens TE, et al. Atomoxetine treatment of adults with ADHD and comorbid alcohol use disorders. Drug Alcohol Depend. 2008;96(1–2):145–54. https://doi.org/10.1016/j.drugalcdep.2008.02.009.

    Article  CAS  PubMed  Google Scholar 

  36. Rosler M, et al. A randomized, placebo-controlled,24-week, study of low-dose extended-release methylphenidate in adults with attention-deficit/hyperactivity disorder. Eur Arch Psychiatry Clin Neurosci. 2008;259(2):120–9. https://doi.org/10.1007/s00406-008-0845-4.

    Article  Google Scholar 

  37. Wender PH, et al. One year trial of methylphenidate in adult ADHD. J Atten Disord. 2011;15(1):36–45.

    Article  PubMed  Google Scholar 

  38. Marchant BK, et al. Psychometric properties of the Wender-Reimherr Adult Attention Deficit Disorder Scale. Psychol Assess. 2013;25(3):942–50.

    Article  PubMed  Google Scholar 

  39. Conners CK, Erhardt D, Sparrow EP. Conners’ Adult ADHD Rating Scales (CAARS). Multi-Health Systems: North Tonawanda, NY; 1999.

    Google Scholar 

  40. Spencer TJ, et al. Validation of the adult ADHD investigator symptom rating scale (AISRS). J Atten Disord. 2010;14(1):57–68. https://doi.org/10.1177/1087054709347435.

    Article  PubMed  Google Scholar 

  41. Hamilton MA. The assessment of anxiety states by rating. Br J Med Psychology. 1959;32:50–5. https://doi.org/10.1111/j.2044-8341.1959.tb00467.x.

    Article  CAS  Google Scholar 

  42. Derogatis LR, Savitz KL. The SCL-90-R, brief symptom inventory and matching clinical rating scales. In: Maruish ME, editor. The use of psychological testing for treatment planning and outcomes assessment. Philadelphia: Lawrence Erlbaum; 1999. p. 679–724.

    Google Scholar 

  43. Victor MM, et al. Reasons for pretreatment attrition and dropout from methylphenidate in adults with attention-deficit/hyperactivity disorder: the role of comorbidities. J Clin Psychopharmacol. 2009;29(6):614–6. https://doi.org/10.1097/JCP.0b013e3181c00b1e.

    Article  PubMed  Google Scholar 

  44. Gift T, et al. Personality disorder in adult attention-deficit/hyperactivity disorder: attrition and change during long-term treatment. J Nerv Ment Dis. 2016;204(5):355–363.

  45. Victor MM, et al. Attrition and dropout from methylphenidate in adults with attention-deficit/hyperactivity disorder the role of comorbidities. J Clin Psychopharmacol. 2014;34(2):212–7.

    Article  CAS  PubMed  Google Scholar 

  46. Robison RJ, et al. Personality disorders in ADHD part 2: the effect of symptoms of personality disorder on response to treatment with OROS methylphenidate in adults with ADHD. Ann Clin Psychiatry. 2010;22(2):94–102.

    PubMed  Google Scholar 

  47. Segev A, et al. A possible effect of methylphenidate on state anxiety: a single dose, placebo controlled, crossover study in a control group. Psychiatry Res. 2016;214:232–5.

    Article  Google Scholar 

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Acknowledgments

This material is the result of work supported by GlaxoSmithKline; Eli Lilly & Company; Medice, Germany; NIMH, USA; Cephalon; Sandoz; Solvay; Astra-Zenica; Bristol Myers Squibb; and Ciba-Geigy. This reanalysis was funded independently.

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Authors and Affiliations

  1. Psychiatric & Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT, 84105, USA

    Frederick W. Reimherr, Barrie K. Marchant & Tammy A. Steans

  2. University of Utah Department of Psychiatry, Salt Lake City, UT, USA

    Frederick W. Reimherr

  3. University of Rochester School of Medicine, Rochester, NY, USA

    Thomas E. Gift

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  1. Frederick W. Reimherr
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Correspondence to Frederick W. Reimherr.

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Conflict of Interest

Frederick W. Reimherr reports research support from GlaxoSmithKline; Eli Lilly & Company; Medice, Germany; NIMH, USA; Cephalon; Sandoz; Solvay; Astra-Zenica; Bristol Myers Squibb; and Ciba-Geigy. Barrie K. Marchant, Thomas E. Gift, and Tammy A. Steans each declare no potential conflicts of interest.

Human and Animal Rights

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

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This article is part of the Topical Collection on Attention-Deficit Disorder

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Reimherr, F.W., Marchant, B.K., Gift, T.E. et al. ADHD and Anxiety: Clinical Significance and Treatment Implications. Curr Psychiatry Rep 19, 109 (2017). https://doi.org/10.1007/s11920-017-0859-6

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