How to distinguish between ADHD and anxiety disorder?

April 14, 2010 9:58 AM

How to distinguish between ADHD and anxiety disorder, given that they (a) are frequently co-morbid and (b) have overlapping symptoms?

I've been reading quite a bit of the professional literature on ADHD, and the consensus seems to be that to qualify for a diagnosis, a person must not only exhibit relevant symptoms, but other diagnoses ought to be ruled out, too. It is apparently especially important to rule out anxiety disorder, since it manifests many of the same symptoms as ADHD. However, a high percentage of people who suffer from ADHD have a co-morbid anxiety disorder!

How, then, to distinguish between someone with an anxiety disorder, and someone who is ADHD-Inattentive type and has an anxiety disorder?

posted by limon to health & fitness (13 answers total)

How, then, to distinguish between someone with an anxiety disorder, and someone who is ADHD-Inattentive type and has an anxiety disorder?

IANADiagnostician, but... Treat one condition, and if symptoms of the other persists, ta-da!
posted by Sys Rq at 10:05 AM on April 14, 2010

Hmmm...I know that going into small parties and similar things makes me nervous, but crowds are totally awesome. I think my ADD might really love getting the stimulus-overload of people and noise and things to see that a crowd offers, but a smaller and more personal setting makes too many personal demands on my system. Whereas my partner dislikes crowds exponentially more than he dislikes parties, and is dealing more with an all-around social anxiety.
posted by redsparkler at 10:08 AM on April 14, 2010

There are specific tests for ADHD-Inattentive. The easiest is basically an attention test. Things like a connect-the-dots page with a *very* large number of dots, simple math problem sets, etc.

Now, if the "Drive to Distraction" causes an anxiety attack when a patient tries to stay focused and can't, you can still tell that it's the root cause by observing the patient properly during the test(s).

That's the best I've got...

Also, there's always the converse sort of test, where you dose the patient with a suitable stimulant (Ritalin, Adderall, etc.), and see if it has any beneficial effect. There are a lot of clinicians who don't like to do that, though. And, I can kind of see why.
posted by Citrus at 10:11 AM on April 14, 2010

For me, at least, my anxiety (which has not been diagnosed as a disorder) is caused by my ADHD. (In fact, I got my diagnosis for ADHD when I went to my doctor to see about treating my anxiety.) For my diagnosis, my doctor asked me lots of questions about my anxiety, trying to pinpoint where it was coming from. When she sussed out that it was my inability to get work done that was stressing me out, she suggested that I might have ADHD, and that the way to be sure was to start treatment for ADHD and see if it helped with the anxiety. So I started treatment, and sure enough, it helped.

Presumably, if it hadn't, we would have started treating the anxiety as the condition rather than a symptom of another underlying condition.
posted by ocherdraco at 10:14 AM on April 14, 2010 [1 favorite]

I was diagnosed with Seasonal Affective Disorder for a long time before a psychiatrist (to whom I went to talk about light boxen) suggested, "Have you ever been tested for ADHD? You seem to have particular problems with depression and anxiety presenting cyclicly, but perhaps that cycle is school instead of circadian-based."

I told him that Tom Cruise is the one who is jumping on couches, not me, but everything I heard about ADHD after that sounded very applicable to me, so I got tested--in an 8-hour barrage of testing*, oh my god. I sailed away with a diagnose for ADHD. I felt a lot better. I felt a lot smarter, for one, since now that I was medicated class discussion didn't sail over my head.

However, I have recently discovered that for me, ADHD & anxiety are definitely co-morbid, and medication for the one is exacerbating the other ten-fold. The muscles in my neck are like rope. I've had really strong anxiety five out of seven days this week. BUT BY GOD I CAN FOLLOW THE CLASS DISCUSSIONS.

Long story short: A trained professional can distinguish between ADHD & anxiety, sometimes. Typically what will happen is he will give you some tests and talk to you; if he is confused about whether your present symptoms are pointing to ADHD/anxiety/both, he will probably ask you which one causes you the most distress, treat that, and if problems are still present, tease those out and try to address them.

*on two separate days; don't worry.
posted by opossumnus at 10:36 AM on April 14, 2010

In my non-pro opinion,

My impression of this is that docs often just go by experience--they probably have known multiple people with ADHD so it becomes relatively easy to pick it out when it happens. Sorta like a dermatologist being able to tell the difference between chicken pox and poison ivy. Yes, you can get this with non-physical illnesses too. Go read the ADHD thread, a lot of people have similar experiences, and probably sound very similar to an experienced doc.

And now I am going to ramble for a while, maybe this will give you some insight.

The ruling out of anxiety and depression is because those things can cause ADHD-like symptoms. Not because they can't coexist, because they can.

Everyone I know with ADHD has had issues going back years with concentration, focus, etc. so the history is really important.

It is also important to tease out exactly what the anxiety is about. Again in my experience (and everyone I know with ADHD) there are a lot of very specific and real precursors to the anxiety and depression--i.e. I used to be really anxious about leaving my house because of a few horrible times when I locked myself out and had nowhere to sleep, no money to get on the train, etc. So it is situational anxiety and depression, but the situation pretty much NEVER CHANGES, so it is much less obvious that it is situation.

Or another common thing is to be depressed because you hate your job/feel like an underachiever. So if you go back to it and look at it over time, it's more obvious that the ADHD came first, not the depression causing attention issues.

But it is complicated because ADHD people seem to internalize negative self-talk that leads to depression and anxiety, but that negative self-talk is somewhat rooted in the every day reality of ADHD. When you're in that cycle it is very hard to figure out what came first. So then you have to look at objective things like school records, asking other people around you, job history, etc.

The above was muddled. There are books that describe this diagnosis issue better, including Driven to Distraction/Delivered from Distraction.
posted by internet fraud detective squad, station number 9 at 11:12 AM on April 14, 2010 [2 favorites]

also, opossumnus, try another med and avoid caffeine! but yeah stimulants can do a number on the anxiety, whew, but for me the overall effect is less anxiety. Yay!
posted by internet fraud detective squad, station number 9 at 11:14 AM on April 14, 2010

First, let’s do away with some of the problems introduced by other answers. There is no such thing as a test for ADHD. Indeed, there are no available tests for any mental disorders in the sense that we use the word test when we’re talking about medical diagnosis. There is no test for ADHD in the way that there’s a test for Strep throat. There are tools that measure self-reported aspects of one’s mental state (like the Beck Depression Inventory), and there are tools that measure things like attention. These various tools have different levels of validity and reliability. But, not being able to concentrate is not the same thing as having an ADHD diagnosis. There are many different reasons why someone might not be able to concentrate.

Which leads to the next point. Psychiatric diagnosis is much more art than science. There a several reasons for this. First, when you’re diagnosing you’re dealing with patient self-report. There are no tests for anxiety disorder or ADHD. There aren’t even tests for what we call “major mental illness,” that is, there aren’t tests for those things that we consider to take people the furthest from normal on the spectrum. So you can’t test someone for schizophrenia, even if you have the best brain imaging technology in the world. Second, it is true that a single symptom by itself might mean several different things. Psychiatric symptoms contribute to syndromes, rather than to concretely diagnosed illnesses. Third, there’s a lot of evidence that the Diagnostic and Statistical Manual for Mental Disorders is neither valid nor reliable, which means that 1) it may not be accurately describing things as they are (not valid), and 2) going to different practitioners does not guarantee the same diagnosis (no reliable).

But, to directly answer your question: The DSM is set up with lists of diagnostic criteria which must be met in order for someone to “qualify” for a given diagnosis. There are frequently subsets within given criteria only some of which must be present (3 out of 5, say). But all of the major criteria need to be there unless specified otherwise. In my experience untrained folks looking at those lists tend to pay attention to those that matter most to them, but a competent diagnostician pays attention to all of them. One always rules out medical conditions or intoxication, for instance, before considering that the symptoms might be due to a mental disorder. The only way to gather information about these criteria is to spend time learning about the patient. Things that seem of little import to the patient could easily change a diagnosis: a young child hallucinating a ghost is troubling, that same person hallucinating the ghost of the grandmother who died two months ago is much less troubling. Many psychiatric diagnoses explicitly list “rule out” diagnoses for which there is not enough current evidence to make a decision one way or the other. They’re listed in the same place, with a “r/o” in front of them.

In this specific case, I’m not sure what type of anxiety disorder you’re talking about, but in the case, for instance, of Generalized Anxiety Disorder, there really is not much overlap in diagnostic criteria (although, again, to a lay person who isn’t looking at the whole diagnosis there might appear to be). The only place of overlap is on criteria C:

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6.sleep disturbances (difficulty falling or staying asleep, or restless unsatisfying sleep)

One can see where 1, 2, and 4 appear to be symptoms that would mimic ADHD, but if you read the start of criteria C you’ll see that symptoms 1,2, and 4 are the result of anxiety or worry. In other words, there’s a causal relationship that is not present in ADHD. Further, criteria A & B, which are at least equally important, make clear that anxiety and worry are what’s to be paid attention to here.

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.

None of this means there won’t be a misdiagnosis, or confusion, but it’s actually much less likely than if you’re using selective attention when reading the criteria.
posted by OmieWise at 11:53 AM on April 14, 2010 [5 favorites]

OmieWise: thanks for the thoughtful response. However, causality as a diagnostic criterion doesn't seem to help much. According to one recent book, 25% of individuals with ADHD have a comorbid anxiety disorder. For some, it is a side effect of stimulant medication. For others, however, it is the result of persistent experience of failure, and the fear and shame that are its concomitants. As a result, according to this book, many adults develop "anticipatory anxiety" (= apprehensive expectation), which precedes certain activities and makes them more difficult to complete successfully. For an individual who experiences this debilitating apprehension, it may be difficult or even impossible to determine whether this apprehension causes or was caused by persistent distraction.

The DSM is remarkably unhelpful here. None of the studies that inform the diagnostic criteria for ADHD included adults, but it is precisely adults with ADHD in whom we would expect to find comorbid anticipatory anxiety, since it is they who would have the requisite persistent experience of failure. The DSM is therefore not at all useful (in my lay estimation) for individuating anxiety and ADHD.

Further, criteria A & B, which are at least equally important, make clear that anxiety and worry are what’s to be paid attention to here.

But this is circular. Suppose an individual reports inattention and anxiety in equal measure, and neither the individual nor anyone else is able to say which came first. How do you determine the direction of causality between the two? The causal relationship can only be derived from a correct diagnosis, so I fail to see how it can serve as a useful diagnostic criterion.

I've acquired a number of books on ADHD written for mental health professionals, and none address this question to my satisfaction. I take your point that diagnosis is an art. But even artists have a method. What method is being employed in such situations?
posted by limon at 1:29 PM on April 14, 2010

many adults develop "anticipatory anxiety" (= apprehensive expectation), which precedes certain activities and makes them more difficult to complete successfully. For an individual who experiences this debilitating apprehension, it may be difficult or even impossible to determine whether this apprehension causes or was caused by persistent distraction. (limon)

Anecdatum: I have this "anticipatory anxiety." For me, it feels like it has been caused by my, as you put it, "persistent distraction" because I only get it for the kinds of tasks that my ADHD makes it difficult for me to complete.
posted by ocherdraco at 1:54 PM on April 14, 2010

limon -- if you are a diagnostician looking for a the appropriate criteria for distinguishing between different DSM-IV diagnosis, this is probably not the right forum. its a question that should probably be taken up with the appropriate group at the APA.

However, if you are someone who is dealing with a constellation of symptoms in yourself or a loved one, this is probably the right forum, but you need to rephrase your question. The sad truth of psychiatric science is that the disease model used in most other medicine doesn’t (yet) really work very well. Identifying the “disease,” i.e., the DSM-IV classification, may provide a way of think about a set of symptoms, but it doesn’t provide a cure. Some meds work with one person and not with another and no one is really sure why. Talking therapies work for some, behavioral therapies for others, and sometimes medication is all that is required.

Anyway, what I am trying to get at is that if you or yours is suffering from a set of symptoms that looks like ADHD or an anxiety disorder, putting a name on it is far less important than finding workable treatment for the symptoms. Find someone good 9prpbalby the hardest part), and start ruling things out.
posted by UncleJoe at 2:59 PM on April 14, 2010

I am, of course, the person in question. No point being evasive about it.

Anyway, what I am trying to get at is that if you or yours is suffering from a set of symptoms that looks like ADHD or an anxiety disorder, putting a name on it is far less important than finding workable treatment for the symptoms. (UncleJoe)

You're right. But for some intractable, half-conscious reason, it's very important to me to have a clear diagnosis, since it makes a difference in how I understand my personal history. It shouldn't matter, perhaps, but it does.

The sad truth of psychiatric science is that the disease model used in most other medicine doesn’t (yet) really work very well.

I'm coming around to this conclusion. I desire a degree of clarity and certainty that simply isn't yet available. I'm finding it hard, though, to reconcile myself to this ambiguity. It feels somehow necessary to fix this in black and white terms. I'll get over it.

Thanks everyone.
posted by limon at 4:44 PM on April 14, 2010

Suppose an individual reports inattention and anxiety in equal measure, and neither the individual nor anyone else is able to say which came first. How do you determine the direction of causality between the two? The causal relationship can only be derived from a correct diagnosis, so I fail to see how it can serve as a useful diagnostic criterion.


I pretty much agree with UncleJoe. Your concern in this thread is about diagnosis, but the real issue is what helps you. In practice, what happens is that through exploration of symptoms and symptom abatement over time, a provider can arrive at a better diagnosis than they might first have been able to offer. There are certainly cases where the causal relationship is not clear, but treatments for neither condition are debilitating, and can be easily adjusted. For instance, if someone's anxiety does worse on stimulant medications, they would be discontinued on them.

However, I do think it's very difficult to diagnose yourself. Even if you feel like it's impossible to determine a causal relationship, it may well not be hard for a trained clinician.

I'm sorry to hear that you're struggling with this, and it isn't clear from what you've written where you are in the process of addressing it. At times it seems as if you may not have sought treatment, at others like you're dissatisfied with the diagnosis or reaction you've gotten. In either case, I'd urge you to get treatment. Either start it, or change to someone who suits you better. The really good news is that all the research suggests that people in mental distress respond very well to treatment (~80% do better than those who want treatment but do not receive it), and the type of treatment (and for the most part, the type of diagnosis) does not really matter.

Feel free to email me if you would like to discuss this further. I am a psychotherapist.
posted by OmieWise at 7:35 PM on April 14, 2010