ADHD Rarely Lives Alone

20. February 2018

Adults with ADHD often have other conditions as well. For more than 80 percent of these patients another psychiatric condition is present. These comorbidities make it difficult to treat the patient properly. What do psychiatrists, neurologists and psychologists advise?

Adults with an attention deficit / hyperactivity disorder (ADHD) often also have other illnesses. DocCheck spoke to psychiatrists, neurologists and psychologists who are experts in the field of ADHD. One of them is Bernhard Kis. He is deputy director of the Department of Psychiatry and Psychotherapy at the University Medical Center Göttingen (Germany), “ADHD in adults is associated with a variety of psychiatric disorders as comorbidities”, he says. “With more than 80 percent of patients there is an accompanying psychiatric comorbidity which makes management more difficult with respect to recognition, diagnosis and treatment”. These include affective disorders such as depressive illnesses, adjustment disorders, anxiety disorders, substance and personality disorders. ADHD is considered a prototype disorder with a very heterogeneous clinical manifestation. “It is said that ADHD is not just ADHD”, psychiatrist and neurologist Kis explains.

It’s in the family

Another expert is psychologist Christian Mette. He has led the ADHD research group for adults at the LVR-Clinic Essen (Germany) since 2014. He says there is a connection between these disorders. At the LVR clinic a study has shown that the serotonergic system is involved in ADHD, he explains. Moreover, there seems to be a genetic predisposition for ADHD and accompanying mental disorders.

“ADHD is independent of the phase of life in which the disorder is detected and treated, and is a disease with high familial frequency”, Kis underlines. Both genetic correlations and various environmental factors appear in large cohorts to be associated with the disorder: “A twin study showed for the first time a close connection between ADHD and emotional disorders in preschool children, which is largely explained by genetic causes. There are currently no comparable studies in adults that allow this theory to be transferred to adults”.

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Doctor Alexandra Lam works with patients who suffer from both ADHD and BPD.

What’s more the correlation between ADHD and borderline personality disorder (BPD) is associated with a genetic predisposition: “A family history should always be made available when seeking to produce a diagnostic explanation because ADHD has a high inheritance rate”, Alexandra Lam, a doctor at the University of Psychiatry and Psychotherapy in Oldenburg (Germany), says. Even when looking at BPD alone, one starts with the hereditary component. “However, the respective disorder does not necessarily have to be expressed in the next generation. A link between the two disorders at the genetic level cannot be clearly derived on the basis of currently available studies”.

A multifactorial etiopathogenesis is assumed for both the occurrence of BPD as well as ADHD, Lam says: “This means that a large number of factors play a role in both diseases. These include hereditary as well as environmental influences”. Environmental conditions are considered an important risk factor for the development of personality disorders, the doctor adds. Thus, for example, if the treatment of a child is trauma inducing and other conditions in the life of the child are unfavourable, the pathogenesis of a BPD can be triggered.

Research looks at parenting styles of children with ADHD and BPD

“What’s more results from studies suggest that severe childhood ADHD could increase vulnerability for BPD development”, Lam says. “There is also evidence that the environment has an impact on the severity of BPD among ADHD patients. A retrospective investigation by Ni & Gau in 2015 deduces among other things that a low level of maternal care of boys with ADHD was associated with greater symptoms of borderline disorder. “For this reason, the manner of upbringing of children with ADHD and/or BPD has increasingly become the focus of research in recent years.

“The upbringing of a child with ADHD presents parents with special challenges”, Alexandra Philipsen, clinic director of the Uniklinik Oldenburg, says. Due to the hereditary component of ADHD, there is an increased likelihood that at least one parent would be affected, she says: “In this case, this may result in the parenting style being less effective, for example if the parents, due to their ADHD, are less consistent or are even impulsive”. A study published in 2015 proves that particular parent-child training would have a positive outcome for the parents as well as the child, she says.

Two disorders – same clinical picture

“Clinically speaking, one usually has to deal with both BPD and ADHD simultaneously for diagnostic reasons”, Lam says. “Since there is an overlap in the symptoms range, differentiation can be made difficult. However, there is also a certain proportion of patients with BPD among ADHD patients and vice versa. “In studies, this proportion varies widely with the population studied; potential comorbidity is nonetheless of clinical and therapeutic relevance, Lam says.”Other studies indicate that the presence of both disorders may increase the risk of having another mental illness”.

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“First of all ADHD must be confirmed, everything else comes after that”, psychologist Christian Mette says.

“The problem is that the core symptoms – inattention, unrest and impulsiveness – are a part of almost every mental disorder in some way”, psychologist Christian Mette says. In order to diagnose the right disorder, the right causes need to be found: “We take our time with our clients and diagnose the disorders separately from one another according to the current norms. Then we look at whether and where there is a connection and what is prominent in order to get treatment”.

First, it is important to demonstrate the presence of ADHD, according to Mette: “If ADHD has been distinctly diagnosed, one can also diagnose the other disorders. So it all depends on this”. The symptoms need to be proven in childhood. This happens firstly through conversations with the clients and relatives, in which behaviour and childhood problems are recounted. “At the same time we try to improve the recall of events from memory and to control potential confounding variables and distortions when remembering”, Mette says.

Spotting ADHD can be blocked

From the point of view of the development of ADHD diagnostics, people born about 15 years ago and earlier would not have received treatment, says the psychologist. It could well be that they had developed depression due to experiences of failure in their life. Kis, on the other hand, points out that our ability to spot ADHD may be blocked: “Symptom overlap, for example due to depression, can lead to underdiagnosis and insufficient treatment”, he says.

Patients with ADHD experience failure and disappointment in their lives due to cognitive deficits, concentration problems in particular. These have an impact on school, professional and private life, which increases the risk of developing depression, Kis says. Both ADHD and co-morbid depression can appear together in familial form, Kis says. “In most cases, the child/youth psychiatrist then recommends that the previously undiagnosed parent visit a specialist in the field of ADHD screening”.

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The treatment of both diseases must be coordinated, says the Göttingen-based doctor, Bernhard Kis.

Treating ADHD and depression multimodally

Validated therapy of ADHD and concurrent depression involves the application of multimodal treatment principles, according to Kis, ie. the use of pharmacological, psychotherapeutic and complementary treatment measures. “A central question is the treatment hierarchy, whether ADHD or depression should first be treated,” he says. “It should be noted that certain antidepressants such as dual-acting antidepressants or tricyclics also have an effect on ADHD; conversely methylphenidate does not work as an antidepressant, but may positively influence certain depressive domains, such as emotional processing or apathy”.

Depression and BPS are however far from the only comorbid disorders of ADHD. “Substance use disorders must be considered, for example”, Mette says. “Alcohol, cannabis and amphetamines are predominant here. Anxiety and eating disorders are comparatively rare. Alcohol has a dampening effect, which helps to alleviate hyperactivity and cannabis has a similar effect. We see this above all in young adults”. With addiction there are several similar markers, according to the psychologist, such as impulsivity: “This occurs both in the ADHD patient group and in the group of patients with addiction problems”.

ADHD and narcissistic personality disorder

The ADHD outpatient clinic is also more likely to see people with a narcissistic basic psychological structure, according to Mette. “Their life story has often taught them that they are a failure and to be devalued in relationships. Clients often try to find explanations for failures in these cases”. Such a thing might happen, but it need not be the case, Mette says: “Some patients only have ADHD. But if a narcissistic personality structure is present with ADHD, then it pays to see if and how this came into being. Often this involves failures at school, at work, in the family, in interaction with other people. In the case of an interactional family structure, this can lead to an increase in the problems and to the disorders being sustained. “For this reason it is necessary when dealing with personality disorders to treat them in behavioural terms.

Lam has confirmed as much with regard to BPD, adding: “Where ADHD requires treatment in adulthood, treatment with stimulants is the first choice, according to guidelines”. These are methylphenidate-containing drugs, she says. “We can never look at the two disorders as separated”, Mette says. “You always have to look at them together and treat them together”.

To diagnose and treat all these subtleties and relationships as a general practitioner is certainly difficult, says the psychologist: “Patients with such problems do not necessarily go to the family doctor. Mental disorders are still stigmatised. I would always advise a family doctor to bring a psychiatrist on board or to refer to a special outpatient department”.

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