ADHD with Comorbid Anxiety: What Clinicians Need to Know

Announcer:
You’re listening to ReachMD. This program, titled “ADHD with Comorbid Anxiety: What Clinicians Need to Know,” is sponsored by Otsuka America Pharmaceutical, Inc. Here are your hosts, Drs. Ann Childress and Jeffrey Strawn.

Dr. Childress:
Welcome to ReachMD. I'm Dr. Ann Childress, and I'm the President of the Center for Psychiatry and Behavioral Medicine in Las Vegas, Nevada.

With me today is Dr. Jeffrey Strawn, and together we'll discuss navigating ADHD when comorbid anxiety is present. Jeff, thanks for joining me today.

Dr. Strawn:
Thanks, Ann. It's really great to be speaking with you. 

Hi everyone, I'm Dr. Jeffrey Strawn. I'm a tenured professor of psychiatry, pediatrics, and clinical and translational pharmacology here at the University of Cincinnati, where I also serve as the Director of the Anxiety Disorders Research Program, which really focuses on anxiety disorders across the lifespan.

Now, we often treat ADHD with co-occurring anxiety in practice, and these clinical nuances really do matter. So, I'm looking forward to our discussion this morning, Ann.

Announcer:
Chapter 1: The Full Clinical Presentation of ADHD: Core Symptoms, Associated Features, and Major Comorbidities

Dr. Childress:
Jeff, let's start with the clinical presentation of ADHD.

You know, I think for most clinicians, inattention and hyperactivity come to mind immediately.¹ But tell us more about the full picture of ADHD and what you see in practice.

Dr. Strawn:
I think you're absolutely right, Ann. We always focus on inattention, distractibility, and hyperactivity, but I think it's very important for us to remember that ADHD rarely travels alone.¹

Beyond those core symptoms that you mentioned, many of our patients struggle with anxiety. They struggle with executive dysfunction. They struggle with emotional dysregulation. My patients certainly have a lot of sleep disturbances, and many of these individuals will also present with depressive symptoms.^1-3

Now, we sometimes differ in terms of what we call these additional symptoms, but regardless of the name, what's important to remember is that they really do drive functional impairment, and that can substantially complicate treatment.^1,4

Now, Ann, what's your experience been like managing co-occurring anxiety in patients with ADHD?

Dr. Childress:
My experience might be a little bit different than yours because I know you focus a lot on children and adolescents, and many of those with anxiety will come to you diagnosed with ADHD and the anxiety really hasn't been effectively managed or maybe it hasn't even been diagnosed.

What I see often are adults who come to me and they've been diagnosed with anxiety, but they haven't been diagnosed with ADHD and then a light bulb goes on when I'm treating their kids. 

Jeff, I'm thinking about a patient with ADHD and anxiety. She worked for the state as a case manager, had to do lots of reports. And she had really done pretty well. Her boss liked her a lot, and she had made it through her probationary period but she was still so worried that she would be fired if she badged in and the electronic lock on the door to the office didn't open right away.

Some days she was so sure that she would get fired that she even considered calling in sick. And again, this is even though people at her work were very supportive. She wasn't in trouble. She wasn't getting written up. It was purely the anxiety that she was having that was causing her problems.

Dr. Strawn: 
With all this in mind, Ann, I'm really curious, what do the data tell us just about the prevalence of anxiety in people with ADHD?

Dr. Childress:
Up to one half of individuals with ADHD have comorbid anxiety disorders^5-8 and will do a good job of parsing out maybe the ADHD symptoms, but not so much with the anxiety or vice versa. And we know with adults with ADHD, they have a fivefold increased risk of comorbid anxiety disorders,⁹ and the prevalence of GAD is about 13% in children, and for social anxiety disorder, it's about 5%.¹⁰

And we talked just a little bit about often what happens is the adult will come in with their child, I'm diagnosing their child with ADHD, and then all of a sudden the light bulb will go on that, “Oh my gosh, I had these symptoms as a child, and I've been diagnosed and treated for anxiety most of my life, but my anxiety really hasn't gotten better. You know, I was just like Sally was in middle school. I couldn't concentrate, and now I'm wondering, was it the anxiety, or do I have ADHD too?"

Announcer:
Chapter 2: ADHD with Comorbid Anxiety: Clinical Impact and Diagnostic Considerations

Dr. Childress: 
So Jeff, building on that, how can comorbid anxiety affect the burden of ADHD for patients and families?

Dr. Strawn:
Well, Ann, when I think about anxiety and ADHD, at least in terms of that co-occurrence, we know that patients frequently experience more impairment than would be expected from either condition alone. And also, I think that there are a number of sequelae of each of these.

For example, they may avoid challenging tasks, they may become more overwhelmed by everyday activities, they may struggle with uncertainty, and I think very importantly, they may spend a considerable amount of time really compensating for their difficulties with attention and organization and self-regulation. Now, over time, this really erodes the quality of life and probably produces worse long-term outcomes.

Now, this impact can be very, very significant because one of the things that we know when we look at the literature is that individuals with ADHD and co-occurring anxiety have lower occupational achievement. They have reduced quality of life. They have worse overall clinical presentation, meaning they have greater impairment associated with their anxiety and with their ADHD, in addition to other transdiagnostic comorbidity. And they also have greater rates of other specific psychiatric symptoms, as well as greater suicidality, greater risk for suicidal thinking and behavior. And they may also have greater irritability or a propensity for anger.^11,12

Now, in my clinical practice, co-occurring anxiety doesn't just present as excessive worry like we would think of in generalized anxiety disorder, but it also presents with avoidance, and I think that's something that's really important for us to think about as clinicians.

Our patients procrastinate. They resist new situations, they avoid academic tasks or work challenges, and they also, to alleviate their anxiety, tend to seek reassurance, a sense that everything is okay, that somebody's not disappointed in them, that they haven't done something wrong.

And very importantly, for many, they may look unmotivated. However, anxiety can actually be driving much of this behavior. And as I alluded to earlier, these patterns can actually amplify the functional impairment that we see with ADHD.

So if we take this one step further, I want to bring up something that really complicates things clinically, and that's the distinction between anxiety that's a co-occurring symptom of ADHD or something that is driven by undertreated ADHD.

Now, the most important question for me as a clinician treating patients day in and day out is not whether anxiety is there or not there, but why anxiety when it's there is present. Now, anxiety is, you certainly know, Ann, can be a comorbid condition, and you've mentioned those very high prevalence rates that we see in individuals with ADHD. But when it's a consequence or a sequelae of the ADHD itself, it becomes really a greater challenge. Now, this latter, in other words, when it's a consequence of the ADHD, we're gonna see chronic academic struggles.

We'll see executive dysfunction, we'll see emotional dysregulation, social difficulties, and that repeated internal experience of failure. And I think distinguishing between these is really critical because they require different treatment approaches.

And Ann, this is where I love to hear your thoughts in terms of how do you think about this in practice?

Dr. Childress:
I think about it the same way you do, Jeff. Comorbid anxiety can really complicate the diagnosis, the treatment, and my overall approach to ADHD management because those symptoms may be secondary to ADHD and you have to figure that out, just like my patient who was afraid she was gonna get fired.^13,14 Well, she makes a lot of mistakes on her reports, so that could be spot on that her boss is worried about it.

But she worries so much that each time she's called into the office, that her boss wants to talk with her for a minute, she's, "Oh, the hammer's coming down. I'm gonna get fired."

And that's more than just what you would expect for ADHD. You really have to work on that clinical differentiation, and the symptom overlap may contribute to that diagnostic uncertainty and affect treatment planning.^4,13

Emotional and anxiety-related symptoms may be more prominent in certain populations, including female patients.^14,15 And I said, often I'll have somebody who comes in with their child and a light bulb goes on because those symptoms just haven't been attributed to the right diagnosis.

And I don't fault any of the previous providers because it is really difficult, and you need to be able to have time to sit down with folks and really decide what's what. You really need to be a detective. 

For those of you who are just tuning in, you're listening to ReachMD. I'm Dr. Ann Childress, and today I'm speaking with Dr. Jeffrey Strawn about ADHD with comorbid anxiety.

Announcer:
Chapter 3: Challenges in Managing ADHD with Comorbid Anxiety

Dr. Strawn:
So Ann, when we're treating ADHD with co-occurring anxiety, many patients, as we've discussed, may experience a lack of improvement or even a potential worsening of the anxiety.^16-19 What does the current evidence tell us about the limitations of our pharmacologic treatments?

Dr. Childress:
Well, data show that fewer than 30% of patients will report full satisfaction with their current stimulant therapy.¹⁶ We may think they're doing pretty well, but they may not think that. And we know that ADHD medicines may fail to address that underlying anxiety, and it may lead to a waxing and waning course of impairment rather than sustained recovery.^20,21

Patients with comorbid anxiety are significantly more likely to show a poor or blunted response to stimulants compared to those with ADHD alone.²² And anxiety, again, may potentially worsen when on stimulants.¹⁹ And non-stimulants show inconsistent anxiolytic benefits.²³

Dr. Strawn:
So building on this, as we know, when anxiety or for that matter depression coexist with ADHD, treatment planning really does get complicated.¹³ Ann, what are some of the key considerations that clinicians are balancing when they're really managing these complex patients?

Dr. Childress:
It's certainly not a one-size-fits-all, and often the first medication or the first treatment you start with isn't gonna be the one that people are on a year from now.

Patients with comorbid anxiety and/or depression are 20 to 40% more likely to experience a change in their ADHD pharmacologic treatment. We're talking about switches or add-ons much more than those without comorbidities.²⁴

Clinician's face a dilemma where treating ADHD with stimulants may exacerbate anxiety while prioritizing only anxiety treatment may leave ADHD-driven functional stressors unaddressed.²¹

Inadequate symptom management and treatment-related complications are the leading causes for treatment discontinuation and dose adjustments.^19,25

Announcer:
Chapter 4: Clinical Approaches to Managing ADHD with Comorbid Anxiety

Dr. Childress:
Jeff, given the diagnostic complexity and the treatment limitations we've walked through, let's turn to the practical side. What's been your approach in helping patients who have ADHD with comorbid anxiety?

Dr. Strawn:
Well, I think one of the first things that I really try to figure out is where is the anxiety actually coming from. For example, does this patient have a co-occurring anxiety disorder? Is the anxiety emerging from challenges that are associated with the ADHD, or, as is probably all too often the case, is it actually both?

In other words, do we have anxiety symptoms that are reverberating with the ADHD symptoms and ADHD symptoms that are reverberating with the anxiety symptoms? Now, this probably, like a lot of things, becomes clearer if we consider an individual hypothetical patient.

So let's consider maybe a 15-year-old adolescent with ADHD, predominantly inattentive presentation, who's increasingly worried. She's struggling more at school, her grades are slipping, and in some cases, the anxiety is a consequence of her chronic struggles with organization, missed assignments. Am I going to be getting in trouble? Did I mess up on the math test because I skipped a process or didn't show my work? Is it because I'm falling behind academically? And how is the frustration that comes with all of these experiences also driving impairment?

Now, at other times, there's a clear co-occurring anxiety disorder that's actually contributing independently to the impairment. Most often, though, as I mentioned, the answer isn't an either/or. It's actually both, or maybe put another way, to what extent is ADHD driving anxiety and anxiety driving ADHD symptoms? Now, if I shift more to a treatment perspective, I usually try to focus on what is actually driving the impairment.

So in other words, what symptoms are getting in the way of functioning? Now, is the ADHD contributing to the anxiety, or is the anxiety making it harder to address the ADHD? 

Those questions are really critical because they help guide me in terms of where I'm going and how I'm sequencing various treatment options. Now, if ADHD-related difficulties are driving a lot of the distress, improving those symptoms is likely to improve the anxiety as well.

On the other hand, if the anxiety has really become severe enough that the patient can't engage in school or therapy or everyday activities, that may need to be addressed more directly.

Ultimately, though, as we've discussed, many patients will actually need a treatment for both the anxiety and the ADHD, but the sequence truly has to be individualized. Now, Ann, I spend a lot of time really trying to help patients as well as their families understand that ADHD and anxiety interact, and they interact in a way that really reinforces both of them. I'll often use the phrase reverberate, because the ADHD symptoms reverberate with the anxiety symptoms, and the anxiety symptoms reverberate with the ADHD symptoms. Now, the difficulties with executive functioning can create stress, uncertainty, and as we saw in that hypothetical example, that repeated expectation or experience of failure that we'll often see.

And while anxiety can further impair attention and working memory and task completion, over time, what we often see in many of these individuals who are struggling with ADHD and anxiety is that this becomes a self-perpetuating cycle unless we truly recognize and treat both conditions.

Ann, where do you really see the greatest area of uncertainty when managing ADHD with co-occurring anxiety? I'm curious what challenges you encounter beyond the initial treatment decisions.

Dr. Childress:
You know, Jeff, as you were talking, I was thinking, "This is really a chicken and egg kind of thing. Which came first? What do we do first? What, what makes the most sense? What can I do without making something else worse?" 

Hopefully both ADHD and anxiety will get better, but it doesn't always work out that way. And you're really trying to figure out what's anxiety, what's ADHD. We know that medications that we use for ADHD usually work pretty quickly, but it takes a lot longer for anxiety to get better. And I'm thinking about a young man, a 27-year-old, who was referred for a study we were doing by his primary care provider, and he was taking a stimulant for ADHD along with about 10 other medications.

And I'm thinking, "A 27-year-old? My gosh, what other medical comorbidities do you have, and is this gonna keep you from doing a study?" Well, he was on the stimulant, but he also had irritable bowel. He was on a medication for not ED, not executive dysfunction, but erectile dysfunction, and I'm thinking, "What 27-year-old is on a medication for erectile dysfunction if it's not anxiety?"

He was having shoulder issues, and he was having back issues, and he was having to take NSAIDs, and I thought, "Oh my gosh, you're 27 going on 90.

Anyway, he was somebody that was somewhat complicated, but the anxiety really jumped out at me when we were doing his initial evaluation.

Dr. Strawn: 
And it's interesting, Ann, because as I see some of those patients similarly who are on multiple medications for what we think of as co-occurring medical conditions, oftentimes as we get the anxiety under better control, they're no longer needing their proton pump inhibitor for their chronic recurrent abdominal pain or nausea as their tension in their shoulders and neck gets better.

If it's related to generalized anxiety disorder, for example, they're no longer needing a muscle relaxer, etc. My experience really does parallel yours.

Dr. Childress: 
And it's nice because when we get that anxiety treated and we're able to de-prescribe, the internal medicine docs think we're brilliant, right? 

Dr. Strawn: 
Absolutely.

Dr. Childress: 
Or maybe the pediatricians think we're brilliant. Well, as Jeff, as we come to the end of our program, what key takeaways would you like to share with our audience?

Dr. Strawn:
Well, as we've discussed, Ann, anxiety is one of the most common and clinically important comorbidities that we see in individuals with ADHD.^4-6,8 But one of the key challenges for clinicians is recognizing that anxiety in these patients is not always a separate anxiety disorder.

It may arise from consequences of the ADHD, including executive dysfunction, emotional dysregulation, and importantly, the cumulative effects of chronic impairment. Ultimately, though, effective management begins with understanding the relationship between ADHD and anxiety in a given patient.^{4,13,14,16,18,19}

And really by identifying what's driving impairment and addressing both the core symptoms and the broader clinical presentation, we can hopefully help our patients achieve better outcomes, whether we're talking about functional outcomes, symptom reduction, and improvement in quality of life. 

Ann, I'd also love to hear your final thoughts before we close.

Dr. Childress:
Oh, Jeff, you are spot on.

We know ADHD with comorbid anxiety represents a clinically complex presentation.^4,13,14 That symptom overlap between ADHD and anxiety can complicate assessment, diagnosis, and treatment planning.¹³ And our traditional treatment approaches may leave patients with unresolved or treatment-related worsening of anxiety.^16-19

Dr. Strawn:
As those insightful comments bring us to the end of today's program, I'd like to thank my good friend and colleague, Dr. Ann Childress, for sharing her expertise on navigating the complexities of ADHD with co-occurring anxiety.

Ann, thanks for a great discussion. I've really enjoyed it.

Dr. Childress:
Thank you, Jeff. It's been a pleasure.

And I'd like to thank Dr. Jeffrey Strawn for his real-world clinical perspectives on this important and often underappreciated topic.

Announcer:
This program was sponsored by Otsuka. If you missed any part of this discussion, visit Industry Features on ReachMD.com, where you can Be Part of the Knowledge.

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