Attention deficit hyperactivity disorder and co(morbidities).

Especially in adult attention-deficit/hyperactivity disorder, the issue of comorbidity/differential diagnosis plays a role that should not be underestimated. Experts assume that a large proportion of those affected also have other concomitant diseases. Not infrequently, however, only these are diagnosed and ADHD remains hidden behind the mask of comorbidity.

Symptoms of adult attention-deficit/hyperactivity disorder (ADHD) may be hidden behind comorbid medical conditions. In fact, in many cases, newly diagnosed patients first stand out because of other psychiatric illnesses. However, that comorbidities are the rule rather than the exception in adult ADHD patients was shown by a multicenter observational study in adults: At the time of ADHD diagnosis, psychiatric morbidity was 66.2%, with more males affected. The most common comorbidities of adult ADHD include addictive disorders (39%), anxiety disorders (23%), and affective disorders such as depression, mania, or bipolar (18%). The “big four” ADHD comorbidities include personality disorders. However, due to the great effort involved in recording these diagnoses, no reliable epidemiological data are available.

Symptom overlap possible

Recognition of the different diseases is complicated by the fact that symptom overlap is not uncommon. Core symptoms of ADHD are problems with attention, overactivity and impulsivity. These are chronically present. In bipolar disorder, for example, they also occur – but exclusively during episodes of illness. ADHD is classified as a developmental disorder and starts in childhood. Bipolar disorder, on the other hand, usually begins in late adolescence or adulthood. Similar to a manic episode, ADHD patients have increased drive, increased verbal fluency, increased impulsivity, and a tendency to engage in dangerous activities. In addition, ADHD patients are easily distracted, erratic in their formal thought process, and start many activities at once without finishing them.

A similar situation applies to depression. Both ADHD and a depressive episode have some of the same or similar symptoms – especially psychomotor agitation and difficulty concentrating. However, in extreme cases, depressive symptomatology can mask ADHD for years and prevent targeted therapy. As a rule, adults suffering from ADHD often seek psychiatric help “only” because of depression. Therefore, at the latest when the patient turns out to be resistant to therapy, one should also think in the direction of ADHD.

Which disease to treat first?

The decision about ADHD pharmacotherapy is based on the nature and severity of each comorbid condition. In principle, treatment with stimulants is indicated when ADHD is the primary condition. The drug of choice for this is methylphenidate. Pharmacotherapy in adult ADHD patients is now recommended not only for severe, but also for mild or moderate expression, provided this is consistent with the patient’s preferences. Often, reduction of ADHD symptom severity also improves symptoms of a comorbid condition. In the case of a comorbid depressive disorder, there is usually nothing to prevent concurrent drug treatment. However, in case of mania, it should be treated first. This is the prerequisite for making therapy of ADHD symptoms possible in the first place. Alcohol abuse and cannabis use are generally not strict contraindications for drug therapy. However, it is necessary to work toward abstinence during the course of treatment. In the case of abuse of cocaine, amphetamines or opiates or polytoxicomania, on the other hand, the focus is on detoxification.