Mr. B, age 50, dreams of becoming a computer programmer but fears he will embarrass himself—as he has in many classrooms before. He is seeking evaluation because his teenage son was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD), and he recognizes similar symptoms in himself.
Mr. B received a college degree with great difficulty, putting off assignments until the last minute and “squeaking by.” For years he has changed occupations often, never progressing beyond entry level, and now works as a personal care provider and limousine driver. He reports problems keeping up with work and managing time.
His history includes early childhood hyperactivity, difficulty sitting through classes, sloppy handwriting, disorganization, short attention span, and distractibility. He is restless, fidgety, and has trouble staying on topic. His disorganization has caused marital difficulties, for which he has sought counseling.
After careful evaluation, you determine that Mr. B meets criteria for ADHD, combined type, and for anxiety disorder not otherwise specified. His treatment goals are to increase his ability to focus; procrastinate less; improve his planning, prioritizing, and self-esteem; and to become less sensitive to criticism and less anxious about handling work demands.
Like Mr. B, adults with ADHD need treatment for the disorder’s core symptoms as well as its psychiatric comorbidities and psychosocial consequences. Comprehensive treatment with medications, cognitive-behavioral therapy (CBT), and environmental adaptations is usually recommended.
Comorbidity rules
Core symptoms. ADHD is a lifespan disorder with multiple behavioral, cognitive, and emotional manifestations that impair relationships and academic and vocational functioning. ADHD-like symptoms are seen in other conditions such as mood disorders or substance abuse, but complaints of inattention, distractibility, procrastination, restlessness, and impulsivity—particularly when pervasive and chronic—are highly indicative of ADHD.
In treating adults with ADHD, we have noticed common behavioral patterns that contribute to their psychosocial problems (Table 1). Dysfunctional coping behaviors have short-term advantages, but patients readily admit they would rather accomplish tasks through greater thought and planning.
Chronic frustrations—often associated with deep shame—are typical of adult ADHD. Many patients have maladaptive core beliefs of failure, self-mistrust, and inadequacy (Table 2).
Table 1
Common dysfunctional behavioral patterns in adults with ADHD
| Behavior | Description | Short-term gain/long-term loss |
|---|---|---|
| Anticipatory avoidance | Magnifying the difficulty of a pending task and doubts about being able to complete it; results in rationalizations to justify procrastination | Defers short-term stress, but often creates a self-fulfilling prophecy because the task looms and may seem overwhelming when facing a deadline |
| Brinksmanship | Waiting until the last moment (eg, the night before) to complete a task, often when facing an impending deadline | Deadline-associated stress can be focusing, but this tactic leaves little room for error and may yield a substandard result |
| Pseudoefficiency | Completing several low-priority, manageable tasks (eg, checking e-mail) but avoiding high-priority tasks (eg, a project for work) | Creates sense of productivity by reducing items on to-do list but defers a more difficult project |
| Juggling | Taking on new, exciting projects and feeling ‘busy’ without completing projects already started | It is easier to become motivated to start a novel project than to complete an ongoing one; pattern usually results in several incomplete projects |
Table 2
5 common maladaptive core beliefs of adults with ADHD
| Self-mistrust | ‘I cannot rely on myself to do what I need to do. I let myself down’ |
| Failure | ‘I always have failed and always will fail at what I set out to do.’ |
| Inadequacy | ‘I am basically a bad and defective person.’ |
| Incompetence | ‘I am too inept to handle life’s basic demands.’ |
| Instability | ‘My life will always be chaotic and in turmoil.’ |
Psychiatric comorbidity is the rule in adults with ADHD (Table 3). For example, among 43 patients who received combined medication and CBT at the University of Pennsylvania Adult ADHD Treatment and Research Program, 75% reported at least one comorbid condition, including:
- 27 (63%) with mood disorder
- 23 (54%) with anxiety disorder
- 5 (12%) with substance abuse.1
Other treatment studies have reported similar comorbidity rates in adults with ADHD.2-4
Table 3
Psychiatric comorbidity in adult ADHD
| Disorder | Prevalence |
|---|---|
| Mood disorders | 50% to 65% |
| Recurrent depression | |
| Bipolar disorder | |
| Cyclothymia | |
| Dysthymia | |
| Depressive disorder NOS | |
| Anxiety disorders | 40% to 55% |
| Generalized anxiety disorder | |
| Anxiety disorder NOS | |
| Others | Various |
| Substance use disorder | |
| Learning disabilities | |
| Intermittent explosive disorder | |
| Tourette syndrome | |
| Antisocial personality | |
| Borderline personality disorder | |
| Dependent personality | |
| NOS: Not otherwise specified | |
Making the diagnosis
Diagnosis of adult ADHD is based on a comprehensive assessment, including:
- careful history of presenting complaints
- thorough review of educational, occupational, and family history
- standardized rating scales (such as the Barkley ADHD Behavior Checklists, the Conners’ Adult ADHD Rating Scale, or the Brown Attention Deficit Disorder Scales)
- collateral information
- assessment of mood, anxiety, substance use, and learning/organizational skills. For details, consult references on adult ADHD.5-8
Case continued: Self-fulfilling prophesies
On standardized rating scales, Mr. B meets criteria for combined ADHD for childhood and current symptoms. Information from his wife and brother also confirms the ADHD diagnosis.