Comorbidity in ADHD and Adult ADD

There is a very important concept in ADHD called comorbidity. Comorbidity means that there is a co-existing disorder that causes more ‘morbidity’, or in other words difficulties in one’s life.

It is very common for people with ADHD to have comorbid (or co-existing) conditions. Only about 25-40% of kids and teens with ADHD have ADD or ADHD alone. Most of the time (i.e. 60-75% of the time), there is a second, or third diagnosis as well.

The most common comorbid conditions with ADD or ADHD in kids and teens are: Learning Disabilities, Behavior Disorders (including Oppsitional Defiant Disorder and Conduct Disorder), Anxiety Disorders, Mood Disorders (commonly Depression, rarely Bipolar Disorder), tic disorders (like tourette’s), etc.

In adults – comorbidity in ADHD is very common. Research has shown that only about 14% of adult ADHD is simple ADHD, meaning that 86% of adults with ADD or ADHD actually have a second or third disorder.

While the list of comorbid conditions in adults is similar to the one in kids, it is important to note that there are some significant additions. These include: substance abuse and dependences (i.e. drug and alcohol addiction/dependence), and personality disorders. Adults still have high rates of Learning Disabilities, Behavior Disorders, Anxiety Disorders, Depression and even Bipolar disorder.

The reason that comorbidity in ADD or ADHD is so important relates to the fact that often times, the comorbid condition can be so important that it can completely dominate or change the treatment for the whole condition.

For example, if one has ADHD and an Anxiety disorder, there is research that shows that the response to medication may be different. For example, some studies show that the use of a stimulant (like Concerta, Ritalin, Adderall, Biphentin or Metadate CD) may actually worsen the anxiety. There are other studies that show that they don’t worsen the anxiety, but don’t help it. However, Strattera, the non stimulant for ADHD, has been shown to help the anxiety and the ADHD at the same time.

Another example is if a child has ADD and a Learning Disability. If this occurs, one needs to treat both in order to get a good effect. If one were to only treat the concentration, then there could still be problems with processing information (i.e. the learning disability). If there were academic supports and treatment put in place for the learning disability, but there was not effective treatment in place for the ADHD, then the child could struggle to pay attention in order to benefit from the help in place for academics.

The bottom line: a thorough assessment for ADD or ADHD will review whether there are any comorbid (or co-existing) conditions present. Knowing about these comorbid conditions is crucial because it can actually affect the primary treatment of the ADD or ADHD.

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Comments

  1. Hi,
    Many of the symptons of different conditions overlap, and also the depression could be from untreated ADHD, so of course we would try to treat both , but would treating one condition have priority over others ?

    Allan

  2. Hi Allan,
    Thanks for your insightful comment.
    The basic issue is that the doctor has to try to figure out what the primary concern is at the time.
    So, if the depression is the main issue -then it needs to be treated first, and the ADD later.
    If the ADD is the main issue (and the depression is more minor), then it will be treated first.
    Unfortunately, there is little science here.
    This comes down to the ‘art of medicine’, or the doctor’s clinical experience.
    Of course the experience and preferences of the patient are crucial in this type of discussion and treatment planning.
    I hope this helps.
    Dr. Kenny

  3. Comorbidity with Adult ADHD? NO SHIT!!!!

    (Excuse the French.)

    Here in Melbourne Australia there are LITERALLY two shrinks that will accept adult ADHD patients, and much less is it understoof that ADHD is never alone… there is always a “lurker” behind the scenes. I have experiences anxiety (mildly), but also teenage depression, terrible “life management” issues and the favourite: addictive tendencies. I only thank my good upbringing that this tendency never led to anything destructive.

    Man, I sure wish there was more said on adult ADHD and that I had more than ONE person in my entire city of 3 Million who claimed to be an ADHD coach (in her case so-so useful).

    Ranting now, but it feels good.

    :)

    -Alister

  4. Comorbidity seems to be my problem. ADD runs in my family, as well as depression. And I have been further blessed to have been diagnosed as learning disabled early in life. Depression reared its ugly head in my life at the young age of 12. Being diagnosed as ADD at the age of 17 was like a god-send and at the time, once medicated seemes to cure all three problems. However, now 27, after being on effexxor and adderall for ten years, the medication has lost its effect and all my problems have returned and I’m struggling to steer my life back on the right track and keep my head above water. But I don’t know what to do. I took myself off adderrall because I was worried it was causing more damage than good, but now I’m tempted to give it another shot. It’s hard to find a doctor who can address all my issues in a hopeful and practical way. Any advice?

  5. Hi Brigita,
    THank you for sharing your story.
    The best thing to do is find a Psychiatrist who is comfortable with Adult ADD. I know, this is easier said than done.
    A psychiatrist will be comfortable to help unravel which aspects are depression, which are ADD/ADHD, what psychological and social issues/stressors are having an impact, and which medications may be helpful.
    Where do you find a psychiatrist comfortable with Adult ADD/ADHD?
    Ask you family doctor, and if there is a medical school nearby – call them and ask for the department of psychiatry. You can then ask if they have any doctors who specialize in, or research adult ADHD.
    Regarding your medicine wearing off after 10 years – it is possible that a dosage adjustment is needed, or alternatively, a different medicine may be helpful. I can’t be any more specific – but I hope that you can find a doctor to help you out.
    All the best.

  6. so now I see I’m not alone. I’m 24 years old and it’s for 1 year that I’m diagonized with ADD after diagonizing for depression ganeral anxiety and in some periods dillusional dissorder.
    I’m a master student in physics and my big passionate is to continue study physics to PhD and higher but sometimes it seems that it’s quite impossible to be focussed or get realesd of my negative feelings.
    also in some period in my life I had experience of Hallusination and dillusion like schisophernic peaople that time I got Haloperidol to suppress the dellusion and I still use some anti-pschcotic medicine.

    It’s about two years that I leave in the Netherlands and in the first semester of university probably because too much pressure my dellusion came back and also I feel more and more restlessness and distracted in a way that I can’t be focussed that time I got so dissappoited that I decide to quit my study but after being refferd to neurologist I was diagonized first with Autism and then with ADD.

    now Im on medication and feel better but still feel distracted and restlees ….

    Is it ealy a way for me to live like a normal people and be successful in my study…..

  7. Hi Samira,
    Thank you for sharing your experiences.
    Having ADHD, plus depression, plus autism and sometimes hallucinations must be a challenge!
    I am glad that you are seeing a neurologist to get help with the medication.
    In this type of situation, medication will be a very important part of your treatment plan. In addition, you’d do well to learn coping strategies as well.
    If you feel like your symptoms aren’t controlled enough, be sure to speak to your doctor about whether the medicine can be adjusted.
    All the best,
    Dr. Kenny

  8. Dr. Kenny,
    I’m an adult with ADHD and have been sucessfully treated using Adderall, which given the research I’ve been doing, raises the seretonin level in my brain thus bringing about healthy nuerosynaptic transmission. Due to circumstances beyond my control, I had to apply to the VA to continue treatment. The doctor who interviewed me, prescribed and filled a drug called Risperodone. According to my research, this drug is an anti-psyshotic used primarily in the treatment of psychotic mental dissorders. Since my ADHD is a nuerologic dissorder and since I have had no psychotic episodes in my life, I fear rammifications this drug may give. I fear the doctor is not qualified to treat Adult ADHD or have the nuerological experience in understanding my former regimen. Is there a seperate certification for treating Adults with ADHD and apart from children? What steps do I take to find out what the certifications of this doctor are? Are my fears in taking this medication warrented?

  9. Hi,
    Thanks for your comments.
    A few comments for you:
    1) Adderall boosts the dopamine and norepinephrine. It does little to serotonin (just fyi).
    2) Risperidone is an atypical antipsychotic – and was developed originally for schizophrenia. It now has great evidence – and is approved for the treatment of Bipolar Disorder (Manic Depression). Although it is not approved for these, it is commonly prescribed also to help with hard to treat depression, and anger/irritability.
    Although I can’t give you the ‘green light’, at low doses, the side effects tend to minimal. I suggest that you go back to the doctor that you saw and ask more specific questions about what it is supposed to do for you.
    3) Regarding qualifications on adult ADHD – there aren’t any. It really depends on any one doctor’s experience and comfort in dealing with it.
    I hope this helps.
    Dr. Kenny
    p.s. I will be doing a course on medications in ADD/ADHD – and there will be section on Risperidone. You can sign up for the early notification list at: http://www.adhdmedicationcourse.com

  10. If anyone knows any psychiatrist in Melbourne, Australia that specialises and treats Adult ADHD please email me at susiejas@hotmail.com. I have been going crazy looking for someone and have had no luck. My brother- aged 23 really needs help and the whole family is falling apart. Please help if you can.
    I would appreciate any help

    Thank you Kindly

  11. I am looking for a doctor who works with low income adults with ADD/ADHD in San Diego, CA. Does anyone know of anyplace? I was taking adderall for several years and it worked perfectly, but have not had it for many months now. I have tried all the “natural” treatments, and none work. I just need some help. Thank you very much.

  12. This sounds like it could be my 14 yr old son’s problem. According to popular literature he seems to be more bipolar than ADHD. But, the usual bipolar meds have never worked well or at all with him. Especially lithium, very bad manic episode. He’s currently on gabapentin and adderall and very ODD. He was on concerta, but, Pdoc switched to adderall and he’s gotten worse. We’re thinking about trying strattera. We feel we have nothing to lose at this point. Its gotten to the point where we don’t even like having him in the house.

  13. My husband has mild tourette’s and ADHD. He was prescribed Strattera and it has had no impact on his significant ADHD symptoms. He recently was prescribed Ritalin and even up to 15 mg he has no noticeable or helpful change in symptoms. The Ritalin did not increase his tics. He is going to try Adderall XR, but we are feeling very discouraged. He is extremely earnest in finding the right med/dose/strategies to create more balance in his brain, but the process is rough. He is slightly irritable on the Ritalin and he is a slow processor as well. Any ideas?

  14. Hello, I have been taking Adderall xr 20 mg and at first Sertraline together for over a year.. When the winter came, it seemed as though I was zoning out and unable to focus.. Went back to my doctor and she prescribed Cybmalta 60 mg and upped my Adderall xr to 25mg..started to feel little more anxiety rather than focus–so then she switched me to Vyvanse 20mg–Still taking Cymbalta along with it..Feeling so tired and unfocused.. Get a little hyper and silly around 2pm like I am tired and cant think straight need coffee or a bed.. I called her today and asked her if she could please up the Vyvanse dose or something because I am so tired and my face feels heavy–not sure if that makes sense…She wants me to wait 2 weeks.. I think the Vyvanse dose is way too low due to be taking Adderall xr for a year?? Not sure what to do.. Just feel like crying and like I am going to fall apart for the next 2 weeks.. I feel like she has no idea what she is doing.. Please help.. Thanks, K

  15. Dr. Handelman,

    Two weeks ago, I was diagnosed with ADHD and started taking Adderall 10 mg bid, early am and early afternoon.

    At age 60, I now feel normal for the first time in my life, except for a short time – twenty years ago – when my doctor sent me to a weight loss physician due to a sudden weight gain as a side-effect of two medications (sinequan and a medrol dose pack) that were prescribed for eczema during a time of high stress.

    Since I’m so “hyper,” I asked the weight loss doctor to please not prescribe amphetamines, but she talked me into taking a short trial of low-dose phentermine – and the results were astounding. I felt relaxed and wonderful inside my skin. However, since I felt so wonderful, I did not pursue the treatment for long, because I felt so wonderful I knew I could easily get hooked on this medication!

    However, the effect I received from this medication somewhat confirmed in my mind what I’d suspected, that I was either dyslexic or had OCD or ADHD, possibly even bipolar disorder. I couldn’t determine which, because I had some symptoms of each disorder.

    Even though I worked as a nurse at the time (RN,C, now working in another, more creative, field), I held myself to much higher standards than I did my patients. They deserved compassion, but I had to be strong! In my heart, I felt that people who had such disorders were using these conditions as a crutch for ineffective coping skills.

    There was denial on my part, because I never had an “ergo” moment about the ADHD until my doctor had one, two weeks ago, when I told him I’d had a paradoxical reaction to phentermine, twenty years previous. That moment of “weakness” on my part (giving the doctor a hint of my problem) was truly a cry of desperation. Accepting the diagnosis and feeling calm and ‘normal’ was my ergo moment.

    Even after starting the Adderall, I alternated between happiness to be functioning, sleeping and feeling well – and thinking how terrible it is for a 60 year-old woman to take amphetamines!

    It just so happened that an acquaintance dropped by my house last week who used to have a medical practice in our area. He is an oriental physician who specialized in behavior disorders, They perform acupuncture and are big on holistic approaches, so I discussed the diagnosis and medication with him. Not only did he agree with my taking the Adderall, he also suggested that I mention resperidone to my doctor for impulse control, because he said that ADHD people almost always have co-mingling conditions and very often need additional medications (the co-morbidity you wrote about). When I told him how much better I was and that I did not feel the need for additional medication, he said, if I didn’t take the resperidone for myself, I should at least consider taking it for my husband! lol I must say that the obsessive-compulsive part of me was a huge factor in my somewhat-effectively coping with ADHD for sixty years! Working constantly at positive thinking, was probably the best thing I did to help myself. Apparently, I inherited ADHD from my Mom, whom I’ve always known was ‘mentally ill’.

    Mom used to have, on a fairly frequent basis, what I feel older people were describing when they’d say that someone had experienced a “nervous breakdown,” when she would go completely out of control, yelling, screaming, crying, ranting and raving for several days, then she’d have a few days of aloofness before getting back to her usual personality – overbearing, protective and smother-loving. We’d certainly tip-toe around her when she was in one of her hysterical states!

    I was never quite as severe as Mom because my personality is a bit more laid back, but controlling my temper was very difficult, and I certainly surprised many people, over the years, when they’d try to push this eager to please, pushover-seeming woman around. They had no idea, by my demeanor, that I’d ‘fight you to the death’ if you were too pushy, obnoxious or offensive, etc.! Did I mention that I’ve been married four times?!

    When my family was becoming increasingly worried about Mom getting more and more confused – with her domineering, angry and irrational personality – our making a family appointment with a psychiatrist induced Mom into one of her ‘nervous breakdowns!’ We finally took the advice/help of a lawyer friend to get Mother involuntarily admitted to a hospital psychiatric unit, when she became totally out of her mind due to a urinary infection. (Sadly, this sudden decline improved very little once her UTI cleared up.)

    It took about six months for her psychiatrist to try different combinations and dosages of drugs to get the optimum results for Mom, and she is now the happiest I’ve even seen her in my sixty years! God gave us a pleasant and loving mother/wife, just as he was taking her from us.

    Two years of spending every-other-month in another state caring for my Mom and Dad (who is legally blind and extremely passive – not to mention a supposedly reformed alcoholic who had started guzzling wine on the sly), plus working from my computer (my husband and I own/operate a small business) – and several other real (not perceived) problems had truly coped-out my coping mechanisms, and I was a simmering cauldron of anxiety – to the point I was sleeping very little, my heart was pounding, and I had a constant sense of dread, because I had so much to do, and everything took such a great effort on my part. At that point, I perceived my life as such a misery that I could barely endure it. (I was not suicidal, just miserable!) One day, I literally fell asleep at the wheel, due to total exhaustion. Luckily (for me and my parents who were also in the car), it was for only a split-second and happened while I was slowing down for a stop light.

    Now that I’m more informed about my condition, and it has clicked in my head that I AM a strong person, because I coped with my life extremely well, considering the level of difficulty I was working from, I will take the help of an extremely competent doctor and the Adderall!

    Now, this is my dilemma (you know us ADHD people always have one – lol):
    How long can a sixty year-old woman take a stimulant drug, considering the fact that my body is slowing cranking down? What about the non-stimulant drugs on the market?

    I must say, in the short time I’ve been on Adderall – feeling good, sleeping well and functioning without such great effort, I’ve been able to focus on eating healthy (whole foods) and plan to start back exercising (as soon as I complete the Effexor withdrawal; I’m almost completed with titrating the dosage down). Part of my effort is because I want to continue to feel good, the rest of my life!

    From my reading, knowing the problems I’ve encountered and experiencing a brief happiness on Adderall, I’m thinking/hoping that completing tasks without such great effort will stop the reason for my depression. I’m actually being productive, instead of having thoughts rushing-around in my head and my body running around in circles getting little accomplished. Much of my anxiety is from knowing how much I need to do, while sitting around not accomplishing anything. Then I’d feel badly about myself and become depressed, because everything was so overwhelming to me…

    I hope this is enough information to give you an idea of my history, but not so much you’re overwhelmed with details! Just reading over the letter for errors, I realize how typically ADHD it is – now that I’m out of denial and into treatment!

    Sincerely,
    Deb (former hyperactive maniac)

    • Deb,
      That’s a great story. I’m glad to hear you are feeling on track.
      I think one can continue with ADHD medications for years, even at the age of 60. The main thing to watch for is the cardiovascular side of things.
      All ADHD medications (even the non-stimulants) raise heart rate and blood pressure a little bit. So, if you develop any cardiac issues, you may have to stop the medicine.
      Good luck!

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