Chapter 10

UNDERSTANDING AND TREATING CONDITIONS THAT CAN COEXIST WITH ADHD

What mental health needs is more sunlight, more candor, and more unashamed conversation.

—Glenn Close

The term comorbidity is used in psychology to indicate that you have one disorder and, at the same time, you have one or more additional, different disorders. Usually, the disorders are thought to be unrelated to one another, like having a cold at the same time that you have poison ivy. Having the cold is totally unrelated to the fact that you walked in the woods and picked up poison ivy. But, even though they are unrelated, your suffering is increased because you have two different sets of symptoms at one time.

With attention-deficit/hyperactivity disorder (ADHD), comorbidity means that you have both ADHD and one or more other mental health issues going on simultaneously. The challenge can be to figure out what different conditions you actually have and how they may be related. Let’s say your primary symptom is lack of concentration. That can be a symptom of ADHD, depression, or anxiety. It’s possible that you have one of those disorders, or two, or even all three. It’s possible that you started as a child with ADHD, and then, because of your symptoms, you were constantly getting in trouble, which then caused you to become depressed about your life. Additionally, not doing well in school may have caused you some anxiety and worry about your schoolwork. So, you might have a situation in which the ADHD came first and actually caused the comorbid conditions. Or it’s possible that you have ADHD and depression and anxiety all at the same time, but they’re totally unrelated to one another. You can see how figuring out what might be going on can get tricky. But it’s important to have a clear picture of your diagnoses so that your treatment is appropriate. Sometimes alleviating the symptoms of one problem makes the other problems go away, and other times you need to independently treat everything. In this chapter, I discuss some common comorbid conditions and give suggestions for how you might deal with them.

WHAT THE EXPERTS SAY

Some of our best information about comorbid disorders comes from research done at Harvard Medical School. Researchers there conducted two very large surveys: the National Comorbidity Survey, in the early 1990s, and the National Comorbidity Survey Replication, 10 years later (Kessler & Walters, 2002). Researchers did intensive interviews with 10,000 people to find out what mental health and substance abuse problems tend to occur together. They found that adults with ADHD had numerous comorbid mental health disorders. The most common psychiatric comorbidities that co-occur with ADHD in adults are depression, anxiety disorders, bipolar disorder, substance use disorders, and personality disorders. Other researchers have looked at many more possible mental health problems and found that adults with ADHD also have significant comorbidity with oppositional defiant disorder, conduct disorder, agoraphobia, sleep problems, learning disabilities, and autism spectrum disorders. Researchers have estimated that between 65% and 89% of all individuals with ADHD will have one or more additional mental health disorders. More than 45% of adults with ADHD will have two or more comorbid mental health disorders.

As mentioned previously, the overlapping symptomatology between ADHD and many diagnoses (i.e., emotional dysregulation, restlessness, distractibility, etc.) presents several barriers to diagnosis and treatment, and a mental health professional can help to determine the proper diagnosis or diagnoses. In general, it’s somewhat disappointing to realize that having a second disorder at some time during your life appears to be the norm rather than the exception. So, it’s really important to look out for these symptoms, catch them early, and ask a qualified doctor or psychologist for help in treating them. You don’t want your symptoms of ADHD to be even more difficult to contend with because the long-term effects of other symptoms are making them worse. How can you avoid this? There are some important things to watch out for.

The wrong diagnosis can lead to the wrong medication. If you are being treated for ADHD and are on medication but your comorbid depression is undiagnosed, your doctor may think the ADHD medication isn’t working because you might still be distracted or unable to concentrate. But this could be due to depression, not to the ADHD. So, you might go through several months of trying out ADHD medications that don’t seem to work when actually you need to be using medication(s) designed for both ADHD and depression. So, it’s extremely important to have proper diagnoses to make sure you are medicating the right disorder. Similarly, concerns exist in regards to the potentially increased risk of stimulant-associated mania or hypomania in bipolar disorder patients (Wingo & Ghaemi, 2008).

The wrong diagnosis can mean that some symptoms remain untreated. On the other hand, suppose you have been diagnosed with anxiety or depression. There are some good, effective treatments for those. But if you have ADHD and don’t know it, your progress can be greatly hindered until you treat all of your symptoms (Seo et al., 2014). Think back to the example of having a cold and poison ivy. Suppose you thought you only had a cold, and you attributed your itchiness to the cold, so you took only a decongestant. You might stop sneezing and coughing, but your itch would probably get worse, and you wouldn’t feel much better overall until you put some cortisone ointment on the poison ivy rash.

The wrong diagnosis can make your symptoms worse. Finally, there are some instances in which the medication you might take for ADHD actually makes other undiagnosed disorders worse. The best-known case of this type occurs when a specialist treats a person’s ADHD with a stimulant, not realizing that the person also has an anxiety disorder. It’s possible that the stimulant medication can actually make the person’s anxiety much worse. So, in summary, it’s crucially important that you understand how disorders co-occur, keep an eye out for signs that you might have more than ADHD going on, and get good treatment that fits with your particular configuration.

In the following sections, I give you some in-depth information on the two most common comorbidities with ADHD: anxiety and depression. For each of these, I start with some easy questions to give you a “heads up” that you might want to pursue this further with your doctor, psychologist, or counselor. Then, I describe the disorder in detail and end with some suggestions about what you might do if you have comorbid anxiety or depression.

Be strongly advised that the material presented in this chapter does not make you an expert and should in no way help you to self-diagnose. Furthermore, even if you answer all the questions positively, it doesn’t mean you have another disorder. Instead, should any of the material ring true for you, it just means you might want to monitor yourself and definitely discuss any concerns with your doctor or a psychologist.

ANXIETY

The list of questions that follow can give you an idea of whether anxiety may be affecting you. There are many types of anxiety, so I have arranged the questions into four categories.

Category A: Panic Attacks:

Have you had, on more than one occasion, four or more of the following symptoms all at once: pounding heart, sweating, trembling, shortness of breath, feeling like you are choking, chest discomfort, nausea, dizziness or feeling faint, fear of losing control, fear of dying, numbness or tingling, chills, or hot flashes?
If you have had several of these symptoms, do you worry a lot about having this happen again?

Category B: Social Anxiety:

Do you worry about social situations with people you don’t know because you think you might embarrass yourself?
Do you avoid social situations with people you don’t know?
Do social situations with people you don’t know make you anxious?

Category C: Test Anxiety:

Do you get anxious when you are taking a test or being evaluated?
Do you get anxious just studying for a class or preparing for an evaluation?

Category D: Generalized Anxiety:

Do you worry consistently about a number of things, such as work, school, or life in general?
Do you find it difficult to control your worry?
When you worry, does it include three or more of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep problems?

Categories of Anxiety

You will see that the four categories tap into somewhat different types of worry or anxiety. (There are actually more types of anxiety, but the four I cover are the most common ones.) You should let your physician or psychologist know if you answered “yes” to all of the questions within a single category.

Category A inquires about panic attacks. These involve a very specific but short period of time in which you have very intense fear or discomfort. During this time, you have numerous physical symptoms, such as a pounding heart, sweating, trembling, or shortness of breath. You feel like you really want to escape from wherever you are, and, in severe cases, you might be fearful that you are dying, going crazy, or having a heart attack. Panic attacks can be unexpected and totally out of the blue, or they can be associated with specific events, like going to the doctor or public speaking. One of the worst things about panic attacks can be the subsequent worry about having another one.

Category B relates to social anxiety. This means you worry about being in situations or with people because you think you are going to do something to really embarrass yourself. So, you either avoid people and situations entirely, or you grit your teeth and get through them with a great deal of dread and apprehension, and you certainly don’t enjoy the experience. You can see how this would make it hard to go to a party, stand up in class and answer questions, or even give a presentation at work.

Category C focuses on test anxiety. In the work I do with college students, I find that test anxiety is the most common form of anxiety associated with ADHD. This seems to be the case because the symptoms of ADHD (disorganization, lack of concentration, and forgetfulness) are often associated with poor study skills. Therefore, many students with ADHD have test anxiety because they have had a difficult time preparing for a test, are often not ready, know from past experience that they will run out of time, and know that they will have difficulty concentrating during the test. So, their test anxiety is very realistic because of their past performance. This can also affect you in your job if you worry about assignments or presentations and get anxious when you have a specific task coming up.

Category D is for generalized anxiety. With generalized anxiety, you tend to worry almost every day about a variety of things, and you just can’t seem to get a handle on your worry or overcome it. You may worry about your job, finances, kids, your marriage, or car repairs; it just seems like you are in a constant, low-level state of anxiety.

What to Do About Anxiety

First, write down the things that you seem to worry about in Exhibit 10.1. Try to rank them, with one being your top worry.

EXHIBIT 10.1. Try It! Top Five Things You Worry About

1. ______________________________________________________

2. ______________________________________________________

3. ______________________________________________________

4. ______________________________________________________

5. ______________________________________________________

Second, consider whether these are things you can address on your own or whether you may require the help of a professional. There are a lot of effective treatments for anxiety. If your worries seem to be directly related to your symptoms of ADHD, then you might consider ADHD coaching or just trying some of the suggestions in this book. For example, are you worried about studying and taking tests (Chapter 8), your job performance (Chapter 9), your relationships with others (Chapter 6), or always being disorganized and feeling overwhelmed (Chapter 7)? Many of the suggestions in this book will help you deal directly with your symptoms, and your anxiety may be reduced as you learn better ways to deal with your symptoms of ADHD. If you have panic attacks or just seem overwhelmed by your worries, you might consider seeing a psychologist. There are some specific treatments that involve teaching you how to relax, developing a hierarchy of your fears and helping you face them one by one, using self-talk to counteract your negative thoughts, or just gaining insight into the nature of your fears and coming up with specific strategies to cope with them. If you are on medication for your ADHD, you should talk with your physician because you will likely benefit from medication that targets both your ADHD symptoms and your anxiety.

Finally, go back and review the things that make you worried or anxious. Do they seem to be stress related? Are you just overwhelmed by having too much to do in your life? Many of the clients we see are stressed out because their symptoms of ADHD (poor organization, forgetfulness, poor planning, and chronic lateness) cause them to be constantly doing things at the last minute. They wind up skipping appointments, classes, or events because they are behind on some other activity, which puts them behind on the activity they skipped. Again, it’s a vicious cycle.

Quick Tip: Align Your Time With Your Priorities

Although anxiety and stress are two different things, we often find that reducing stress in your life can reduce your anxiety also. Sometimes you are stressed because your priorities are out of whack and you spend too much time doing things that you don’t want to be doing. Let’s see if you can identify some ways that your time might be out of balance. Fill in the chart in Exhibit 10.2, listing the amount of time you actually spend in different activities and, then, the amount of time you would like to be spending in those activities.

EXHIBIT 10.2. Try It! Ways You Spend Your Time

Ways you spend your time	*How many hours per week (based on 100) do you currently* devote to this?**	*How many hours per week (based on 100) would you like* to devote to this?**	Check here if there’s more than a 5-hour difference in your two columns
Work
School and studying
Time with family
Exercise
Fun/social/entertainment
Personal (reading, TV, computer)
Church/volunteer/organizations
Other (list)

How many checks did you have in the last column? Think carefully about those activities. Can you say NO to anything you’re doing too much of? Can you include more of the activities that you want to be doing? Pick one of the activities that seems out of whack and make a conscious decision to rebalance. Set a goal for yourself over the next few weeks of changing the amount of time you’re spending on the activity you’ve selected.

Getting Back on Track: A Strategy to Reduce Your General Anxiety

Some days, or in some situations, you just feel anxious. It might be due to an upcoming evaluation, or a talk you have to give, or a social situation, or perhaps you can’t identify a reason—you just feel anxious. For generalized anxiety, many psychologists use a technique called progressive relaxation. There are many variations of this technique, and you can adapt it to fit your own needs. You can spend 30 minutes doing this, or do a shortened version in 5 minutes.

Find a quiet spot where you can dim the lights and won’t be distracted by noise. Sit in as comfortable a position as possible. One variation is to have quiet meditation music in the background, but you can do progressive relaxation with or without this. Close your eyes. Take a few minutes to let your thoughts flow freely. Imagine these thoughts draining out of your mind or floating off in the wind or simply becoming smaller and smaller. Take deep breaths, if it’s comfortable for you, and try to breathe in through your nose and out through your mouth. Try to breathe deeply into your abdomen. Imagine your abdomen is a tire or a balloon and each breath slowly fills it up. Some people do better if they count slowly (one, two, three, four) as they inhale and again as they exhale. Take a few minutes just to slow your breathing. Now, concentrate on your left hand. Clench your fist. Feel the tightness. Hold for a few seconds and then relax it. Feel it going loose and wiggle your fingers. Imagine your fingers feeling heavy and needing to rest on your leg. Repeat. If you have intrusive thoughts as you do this, don’t worry; let them flow through your mind and out. Push them out slowly with your breathing. You will usually find that if you are concentrating on your breathing and relaxing, there is not much space left for other thoughts. Now move up your arm, repeating the process with your elbow, your shoulders, your neck. When you do your neck, roll your head around after tensing your neck, feeling it very heavy and wanting to flop over. Repeat with your jaw, and then your facial muscles. Now, go to your toes, ankles, lower and upper legs, and lower back and buttocks. When you have tensed and released all your major muscles (or as much as you have time for), slump and relax your whole body for a minute. Focus on your breathing, counting to four as you inhale and exhale. Imagine all the tension flowing from your body. Finish by standing and gently stretching. Once you get the hang of this, it becomes easier and easier, and your body seems to automatically go through the steps.

Go back up to your list of worries. Was work one of them? If so, you might find the following 10 easy ways to reduce stress at work helpful:

Make your relationship with your boss a top priority. Do what it takes to get along with them; it will make your life infinitely better!
Avoid drinking coffee all day long. Try to substitute water or reduced sugar fruit juice.
Write a priority list every day. Don’t put too much on it. Make it manageable.
Try to make your workspace pleasant. Hang some pictures, buy a small throw rug, or bring in a plant.
Always try to take a lunch break. If you bring your own lunch, go outside or meet with a friend.
Take a couple of 10-minute exercise breaks each day; do yoga, go for a walk, or do some stretches.
Build pleasant, cooperative relationships with as many of your coworkers as possible.
Figure out ways to reduce distracting noise. Use a fan, a white noise machine, or low background music, or ask to move your office.
Learn to ignore, delegate, or procrastinate when faced with nonessentials. Trivialities can eat up your time, but if left alone, they often go away.
Learn when it’s okay to give less than 100% effort on a task. Sometimes that last 10% takes up hours of time, and 90% would have been just fine for that particular activity.

DEPRESSION

The second most common comorbidity with ADHD is depression. There are many levels of depression, ranging from mild feelings to something that can become life threatening. As with anxiety, there are many things you can do to avoid or lessen depression. The first is to be aware of the symptoms. Answer the questions below to see if you may be struggling with symptoms of depression.

Category A: Persistent Depression

Do you often have problems with your appetite—either you overeat, or you don’t feel like eating at all?
Do you often have problems sleeping—either you can’t sleep, or you want to sleep all the time?
Are you often tired or have no energy?
Do you have low self-esteem?
Do you find it hard to make decisions?
Do you feel hopeless?
Do you feel sad or empty?
Do you have little interest in doing things?
Do you feel worthless or guilty?
Do you think about dying a lot or think about suicide?

Category B: Depressive Episode

Have you experienced a sudden and rapid change in mood or loss of interest in most activities, tiredness, change of appetite, or feelings of worthlessness?

Category C: Bipolar Depression

Do you experience episodes of persistent depression mixed with episodes of the following:
1. Feeling wired, jumpy, or restless
2. Racing thoughts
3. Decreased need for sleep
4. Exaggerated sense of well-being
5. Distractibility

Categories of Depression

You should contact a psychologist or physician if you answered “yes” to four or more of the first nine questions or Question 10 in Category A. Again, keep in mind that this quiz is not meant to self-diagnose. And even if you answer all of the first nine questions positively, it doesn’t mean you are clinically depressed. It just means you might want to keep an eye on this and mention it to your doctor or psychologist. Answering “yes” to Question 10 indicates you may be severely depressed and in need of immediate professional help. Suicidal thoughts are not something to be taken lightly. If you answered yes to this question, you should put down this book and contact someone now.

Category A represents common symptoms of persistent depression (also called dysthymia). It’s very normal to have some of the symptoms from Category A and to feel down sometimes. It can be a problem if you experience many of these symptoms, a great deal of the time, over a long period of time, sometimes at low intensity, and to such a degree that it really begins to negatively impact your school, work, social relationships, or ability to enjoy life.

Category B represents a major depressive episode. A depressive episode tends to have more sudden onset and greater intensity than a dysthymia, also negatively impacting work, relationships, and other aspects of life.

Finally, Category C represents bipolar depression. As you can see, many of the symptoms of a manic episode can mimic ADHD symptoms. A person can be diagnosed with both bipolar disorder and ADHD or be misdiagnosed one for the other.

Take Rick, for example. Rick was in his 60s, and he came to my office with a previous diagnosis of ADHD. He had been married twice and reported always having difficulty in relationships. He had held numerous jobs and couldn’t seem to settle on a career. He reported having over 30 parking tickets and numerous driving citations. Rick had never done well in school, although he did better in subjects that he liked. However, he went on to say that he rarely slept more than 3 hours a night and would go through phases during which he would stay up for 2 days to work on a project that was going to “change his life.” He would then “crash” and spend a week or two not wanting to get out of bed and feeling angry and resentful toward the world. Because Rick’s executive function issues were consistent over time, I concluded that his ADHD diagnosis was accurate; however, the additional information about his sleep cycles and grandiose thoughts led me to an additional diagnosis of bipolar disorder.

Similar to anxiety, sometimes you need to work with a professional to work through depressive symptoms. However, just like anxiety, there are also some things you can do on your own.

Developing a Blues-Buster List

Many times, you can catch yourself sliding into a period of sadness or depression. Try to recognize the signs and be prepared to stop the cycle before it starts. Have on hand a list of proven strategies for you that typically perk you up. For example, buy a book you’ve wanted to read, a DVD you’ve wanted to watch, or take on a craft activity you’ve wanted to work on. Set the list aside and only take it out when you really need a blues buster. Plan a project (build something, plant something, or paint something). Set aside a recipe you’ve wanted to make. Buy something (a new shirt or a pair of running shoes), but leave it in the bag. Keep a list of rewarding charitable organizations (Habitat for Humanity or your local food pantry or homeless shelter) that you’ve been meaning to volunteer for, and have their phone numbers handy. Plan to visit a new store or museum or restaurant, but don’t go there yet.

Save these activities, but keep the list handy so that when you need an immediate pick-me-up, you don’t get bogged down in trying to think of something or don’t have the energy to get it started. Just go to your list and pick one! Write down some ideas for your list in Exhibit 10.3. During the next month, complete your blues-buster list and have it ready when needed.

EXHIBIT 10.3. Try It! Blues-Busting Ideas

Idea	What I need to do/buy to get it ready	Check off here when it’s ready
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Quick Tips: Addressing Minor Depression

In addition to having your blues-buster plan in place, the following tips are some fairly simple things you can do to avoid or reduce minor depression:

Follow my earlier suggestions for a healthy lifestyle and reducing stress. There is scientific proof that poor diet and exercise are linked to depression. Stress is also a major cause of depression.
Reach out to others by taking a class, joining a club, joining an online chat group, or renewing your contact with relatives. Social contact is an important component in alleviating depression. Isolation and loneliness generally make depression worse.
Keep a journal of positive affirmations. Each day, write down something you are thankful for or something positive about yourself or your life.
Volunteer. Use the internet to search the word “volunteer” and then the name of your city and state. You’ll probably get well over a hundred possibilities.
Make a plan for something you want to do. Having something to look forward to helps in two ways. One, the actual planning is enjoyable and keeps you busy. Two, the anticipation of the event can be exciting. So, plan a trip, vacation, or activity.
Change your attitude for just one day. Get out of bed and say thank-you for being alive. Expect a good day. When the first complaint enters your head, think of a way to improve the situation. Smile at least three times, at something in particular or for no reason at all. Say thank-you to someone, with feeling. Pay a compliment to someone during the day. If someone greets you with, “Hi, how are you?” respond with “I’m great!” and then make some positive comment about the day or the weather or the world.

If You Need More Help

Sometimes attempts to overcome depression by yourself are just not enough. You may want to consult a psychiatrist for medication or a psychologist for therapy. The good news is that depression is a disorder for which there are scientifically proven treatment methods. The most common therapy for depression is called cognitive behavior therapy (CBT). CBT combines two approaches: the cognitive part works on changing how you think about yourself, while the behavioral part teaches to actually alter your behaviors. Thoughts and behaviors can have a snowball effect. If you think more positive thoughts, you tend to act differently, both on your own and toward those around you. These positive actions make you feel better and also cause other people to respond to you more positively. So, then, you start interpreting things differently and view the world more positively, and then you behave differently . . . and so it goes in an upward spiral. This type of therapy is quite successful and relatively short term. You can expect to see changes in a matter of months. You can find more on CBT and other therapeutic interventions in Chapter 11.

WARNING: MEDICATION AND COMORBID DISORDERS

You need to be aware of a couple of cautions if you are taking, or plan to take, medication for ADHD, anxiety, depression, or bipolar disorder, and thoroughly read Chapter 11, in which medication options are covered in more detail. However, for the time being, just keep in mind that many symptoms and disorders are related and that the medications you take might interact. For example, some research has shown that a stimulant used to control ADHD symptoms might make anxiety symptoms worse. Stimulants can also make the manic phases of bipolar disorder worse. There are nonstimulant medications for ADHD that might be a better choice, as they can simultaneously help multiple symptoms. Some experts have suggested that you try to judge which disorder causes the most impairment and treat that first with medication before considering other medications for less impairing disorders.

CAN YOU RELATE TO THIS?

The following case example illustrates some of the issues that can coexist with ADHD. Alice was a young, single elementary school teacher trying to fulfill her dream of publishing a children’s book. However, Alice was unable to get much accomplished on her book beyond the title and was just barely able to keep up with the class she was teaching. The principal was upset by complaints from parents, and she had received an “unsatisfactory” on her most recent yearly evaluation. Alice was worried that she was going to be fired from her job.

Alice had done well in high school, although she reported always being disorganized and completing things at the last minute. She was very bright, took many honors and advanced placement courses, and worked hard to compensate for her lack of focus and difficulty paying attention. She had played on her high school soccer team and felt that the structure, discipline, and outdoor exercise had really helped her to do well overall. Her high school teachers and her mother (who was a college English professor) had been very supportive, and she received a great deal of help throughout high school in the form of individual attention, allowances for late work, and help organizing her time. Alice attended college in her hometown and continued to receive a great deal of support from her mother. She managed to graduate from college with a B average.

Alice reported that she had felt pressure from her mother to get a master’s degree in education, and she didn’t want to let her down after all her mother had done for her. After Alice barely made it through graduate school, the only school that offered her a job was in Florida, a long way from her home in New York. Alice was homesick from the time she began her job. She had difficulty adjusting to “small-town southern culture” and made few friends. She located a roommate through an online service but changed roommates every year because no one seemed to work out very well. Alice managed to “just get by” in her position, but she had to study all the time to keep up with the lesson planning. Her superiors frequently told her they thought she could do better, but she didn’t see how she could do more. Alice reported that she really would have liked to have a boyfriend but didn’t have the time and hadn’t met anyone anyway. She found most of the single young men to be “immature, slobs, interested in one-night stands, or not interested in girls.” Early in the school year, Alice had been told by the principal that she needed to prepare the kids for end-of-the-year state testing and follow strict guidelines. She wasn’t sure of the consequences of not following the guidelines but had been afraid to ask, and she had avoided the principal most of the school year. Now, with a month left to go, she was panicking. She had spent a great deal of time looking over the plans and had the children do some of the work here and there, but was not nearly as far as she should be with the tests looming in the next couple of weeks.

As the school year came to a close, Alice had become increasingly anxious. She felt she was letting her mother down, that she would be forced out of the school with nothing to show for the past 3 years, and that she was getting older and had no prospects of a serious relationship. She had quit working out at the gym, which made her feel even worse. The previous week, she had lost her wallet, which held her license, apartment building key card, cash, and ATM card. Rather than go get a new license and call the credit card company, she had taken to her bed and stayed there for 2 days. Her current roommate finally told her, “You look and smell like crap, you need to get counseling.” She went to a local psychologist and was subsequently referred for a psychoeducational assessment.

Alice was evaluated for ADHD, with possible comorbid anxiety and depression. It was determined that she met the criteria for ADHD, predominantly inattentive type. She also met the criteria for diagnoses of depression and anxiety. Because she was quite bright and had good coping skills, Alice had managed to cope quite well up to the present time by working hard and getting support from her mother and teachers. However, as her job demands became more intense, she could not keep up. Her stress was compounded by not having a strong social support network, loneliness, dropping her normal exercise routine, and feeling that she was a disappointment to her mother. Her anxiety and depression seemed secondary to her ADHD, and her inattention and lack of focus left her unable to keep up with the complex demands of lesson planning, test prep, and teaching.

Alice was encouraged to disclose her diagnosis to the principal, and, on the basis of her diagnosis of ADHD, she was entitled to receive reasonable accommodations under federal law. She met with the principal, who was understanding, and he agreed to meet with her twice each month to discuss her lesson plans. She signed up for ADHD coaching with a psychologist, which was offered at a local clinic, and worked with her coach to make a teaching schedule. Alice and her coach also decided that returning to a workout schedule at the gym would be helpful, so she signed up for a kickboxing class in the hopes that it would provide good exercise and also help her to engage in a group (rather than solitary) routine. Alice’s coach (a trained psychologist) also helped her to identify some of her negative cognitions (my mother won’t love me if I fail, writing a book is impossible, or I’ll probably never get married or have children). She was able to replace these with more realistic thoughts and reported that this change in thinking reduced her anxiety tremendously. Alice also met with a psychiatrist at the clinic, who determined that the first-line treatment for ADHD (a stimulant) might not be suitable. Together, they decided that her depression was having a bigger negative impact on her life than was her anxiety; after meeting with her principal and her ADHD coach, she was feeling much less panicky and anxious. Therefore, the psychiatrist prescribed the nonstimulant-based Strattera (atomoxetine), which is a good choice for someone with ADHD and symptoms of depression. After about a week, Alice began to see a difference in her ability to concentrate, and she reported feeling much more positive overall.

This case shows just how complex ADHD can be. For some individuals, impairment will not be apparent until adulthood, and it may initially look like something else is the primary issue, such as anxiety or depression. Alice was similar to many young adults who did reasonably well throughout high school, college, and even graduate school. However, when you look closely at how hard they have worked compared with others, you usually find that a parent or teachers (often both) have helped them to structure their time and worked with them as tutors or mentors. Many people are quite surprised when they learn of a late onset diagnosis of ADHD, but they are often relieved because, in retrospect, it seems to explain many events and struggles in their lives. Often, it’s the comorbid symptoms that really get the attention of referral sources. This case also shows how complex symptoms require a multimodal intervention. Any one of the interventions above would likely have been insufficient to get Alice back on track. But, by attacking her difficulties from several directions, she was able to successfully move forward.

SUMMARY

Here are the important points you will want to take away from this chapter. Use the following checklist to note the areas you have thoroughly studied. Leave the box empty if it is an area you would like to come back to and review further.

I understand the meaning and implications of the term comorbidity.
I have learned how to recognize the common comorbidities that I need to watch out for.
I have learned about the different types of anxiety.
I have discovered new ways to practice a healthy lifestyle.
I have learned new ways to reduce stress.
I understand the symptoms of depression.
I have tried some of the tips for helping depression.
I understand how bipolar disorder is different from depression.