Clinical Assessment and Diagnosis of Adults with Attention-Deficit/Hyperactivity Disorder

Jan Haavik; Anne Halmøy; Astri J Lundervold; Ole Bernt Fasmer

Disclosures

Expert Rev Neurother. 2010;10(10):1569-1580. 

In This Article

Differential Diagnoses

Depressive Disorders

Characteristic symptoms of a major depressive episode may be difficult to differentiate from ADHD symptoms.[15] For example, both disorders are characterized by a reduced ability to concentrate, an inner feeling of restlessness or physical agitation, low self-esteem and sleep disturbances. This makes it difficult to diagnose ADHD in the presence of an ongoing depressive episode. However, symptoms related to depression should remit in periods between depressive episodes, whereas symptoms of ADHD should be present continuously. Still, patients with chronic depressive symptoms may date these problems back to childhood. Furthermore, medication used in the treatment of ADHD may both mimic and exacerbate symptoms of depression. As a general rule, if a diagnosis of major depression is probable, this should be treated first, and ADHD treated thereafter if symptoms are still present. However, in some situations both disorders should be treated concurrently, for instance by combining medication and cognitive–behavioral therapy.[46]

Anxiety Disorders

Anxiety is clearly associated with inattention, and there are overlapping symptoms between ADHD and generalized anxiety disorder. ADHD patients will often have strong emotional reactions that may mimic panic attacks[15] and the symptoms associated with a post-traumatic stress disorder may be difficult to differentiate from ADHD. Many ADHD patients present with turbulent and traumatic experiences, and symptoms of post-traumatic stress disorder may resemble ADHD symptoms. Furthermore, onset of anxiety symptoms is common in childhood, and the age criterion may, therefore, be less useful in distinguishing anxiety disorder from ADHD. If possible, it may help to identify the direction of symptoms, for example, whether it is a primary inability to concentrate and not to get work done (ADHD) that causes the stress and anxiety or the opposite.

Bipolar Disorders

According to current diagnostic criteria,[22] both ADHD and bipolar disorder (BD) are characterized by symptoms involving dysregulation of energy, activity, affect and impulsivity. Unlike ADHD, classical BD (bipolar I disorder) is a well-established diagnosis in adult psychiatry, and clear, full-blown manic episodes are easily distinguishable from ADHD symptoms. Some family studies have not shown a strong relationship between susceptibility to bipolar I disorder and ADHD.[47,48] However, in recent years the concept of BD has been broadened, including patients who were formerly diagnosed with unipolar depression. The episodic versus the chronic nature of BD and ADHD, respectively, has been considered to be a main factor in differentiating the two disorders in adults. However, there is now increasing evidence that affective temperaments, life-long dysregulation of mood, and other chronic symptoms are important parts of the phenomenology of bipolar spectrum disorders.[49] Furthermore, increased motor activity has been found to be even more characteristic of hypomanic episodes than elevated mood.[50] A detailed history of symptom appearance may be helpful in differentiating the two disorders, as the age of onset is generally lower for ADHD than for BD. However, the phenotype of juvenile BD, including the age of onset criteria, is currently being discussed among child psychiatrists, parallel to the debate on the developmental course and phenotype of ADHD in adulthood.[51] Therefore, it has become increasingly difficult to categorize many patients with a mixture of mood instability, impulsivity, irritability and restlessness into clearly defined ADHD or bipolar disorder.[30]

Borderline Personality Disorder

There are a number of overlapping symptoms between ADHD and borderline personality disorder (BPD), and age of onset of symptoms may be of limited value in the differential diagnosis, since adults with BPD show high rates of symptoms and behavior typical for ADHD in retrospective assessment of childhood symptoms.[52] The two disorders also have a similar profile of comorbid disorders, such as drug abuse, anxiety, depressive and bipolar disorders.[9,53] However, symptoms such as suicidal or self-mutilating behavior, chronic feeling of emptiness and stress-related paranoid symptoms are not typically seen in ADHD patients, and may be used to differentiate the two disorders.[15,22] On the other hand, both longitudinal and cross-sectional studies have demonstrated high rates of comorbidity between BPD and ADHD, implying that the presence of one of the disorders should not necessarily exclude the other.[54–56]

Alcohol & Substance Abuse

It is difficult to evaluate psychiatric symptoms in patients with ongoing alcohol or drug abuse, and the substance use disorder should ideally be treated or stabilized before assessment of ADHD. Still, it may be difficult to determine whether the ADHD symptoms are related to early onset 'genuine' ADHD, or if they are a consequence of such abuse. Although special caution is required before prescribing stimulants to individuals with a history of substance abuse, it is important to recognize that the treatment of underlying ADHD could be protective against subsequent substance abuse.[57]

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