Many disorders in our current classification system, the DSM-IV, subsume enough of the symptoms of ADHD to meet diagnostic criteria. For this reason, it is sometimes difficult to determine whether the individual is actually experiencing ADD or another disorder. Another factor is that ADD adults have often times developed other psychiatric symptoms and dual diagnoses are very common among this population. Each section below examines disorders which can either mimic or co-occur with ADD.

ADHD and Generalized Anxiety Disorder

by Susan Hill, Ph.D.

While discriminating between disorders within a category of the Diagnostic and Statistical Manual-fourth edition (DSM-IV) can be challenging, generally the child’s symptoms will match one disorder more than another, and selection of a single disorder can be determined. However, it is often more difficult to distinguish between disorders of two different categories than within a category since many of the disorders have similar symptoms which may occur for differing reasons. Determining whether symptoms are more reflective of one disorder than another, if meeting criteria for one disorder is the result of another disorder, or if comorbidity exists of the two disorders can be a humbling experience.

Two disorders in which such questions often arise are Attention Deficit Hyperactivity Disorder and Generalized Anxiety Disorder, or overanxious Disorder, (GAD). The term ADHD may also be referred to as ADD-H (Hyperactive-Impulsive Type) and/or ADD-WO (Inattentive Type) throughout this article when referring to research using the terms. According to several research investigations, children with ADHD and children with anxiety disorders often exhibit similar behaviors. However, since parents and teachers appear to have a greater awareness of ADHD, they generally refer the child to a psychologist in order to evaluate for ADHD who in turn requests them to complete rating scales. With the symptoms characteristic of ADHD in mind, the parents and teachers may inadvertently skew behavioral ratings toward a diagnosis of ADHD; thus, children with anxiety may be misdiagnosed as ADHD or children with both disorders may only be treated for ADHD. The distinction between the two disorders is important as the treatment modalities implemented are typically quite different. Currently, common interventions for children with ADHD include behavior management and stimulant medication; whereas, interventions for Generalized Anxiety Disorders consist of relaxation techniques, counseling services, and anti-anxiety medication such as benzodiazepine.

Using the DSM-IV criteria, some symptoms are listed under both disorders, including restlessness and difficulty concentrating; moreover, a child need exhibit only one of the symptoms in order to meet criteria for a generalized anxiety disorder (see Table). While not listed as criteria under anxiety, several of the ADHD symptoms may be seen in children who are anxious, such as fidgeting, talking excessively, and making careless mistakes. Thus, children with anxiety disorders may present as a child with ADHD. The presence of externalizing symptoms are often viewed as characteristic of ADHD-Hyperactive/Impulsive Type; however, children with anxiety may interrupt of move about excessively because they are anxious. The distinction is even more vague between ADHD-Inattentive Type and anxiety since a child may be distracted due to his/her worries, or a child may worry because they have difficulty attending. Furthermore, the presence of internalizing symptoms, including anxiety, are often viewed as characteristic of ADHD-Inattentive Type, although the DSM-IV states that it must be determined that the symptoms are not better accounted for by an Anxiety Disorder.

Current research in identifying characteristics of the two disorders indicates a high incidence of comorbidity, but does not clearly address how the two disorders may be distinguished from one another. In fact, questions have been raised regarding the validity of ADHD-Inattentive Type and whether or not the majority of children meeting criteria for this type can be accounted for by an anxiety disorder (Lahey & Carlson, 1991). A study of 119 children who were referred for an evaluation of ADHD confirmed that only 45 children had the disorder, while a large number of cases had anxiety disorders, suggesting an overinclusion of children being referred for ADHD (Desgranges, Desgranges & Karsky, 1995).

Due to the high rates of comorbidity, a subtype of ADHD with anxiety has been proposed; however, few studies have addressed whether one disorder may be the result of the other. Many studies have compared children with only ADHD to children with ADHD and anxiety. Children diagnosed as ADHD with anxiety were found to be less impulsive and/or hyperactive than those with only ADHD, indicating they are more likely to parallel the ADHD-Inattentive group (Pliszka, 1992). Biederman & Steingard (1989) proposed three symptoms of ADHD found among adolescents: those with conduct disorder, those with depression, and those with anxiety. The authors found that subjects in the ADHD with anxiety group had higher levels of life stresses and parental symptoms than subjects with only ADHD. The authors also recommended prescribing clonidine, a medication prescribed to anxiety patients, to subjects in the ADHD with anxiety group rather than methylphenidate (MPH) because the effectiveness of MPH tends to decline with this group. This suggests that a different area or pathway in the brain may be affected in children with ADHD with anxiety as compared to children with ADHD only, and that the affected area may be more closely linked to that of children with anxiety only.

In a study of 73 males between 6 and 17 years of age diagnosed with ADD/WO or ADD/H, 30% also met criteria for an anxiety disorder, with 60% of those children diagnosed with an overanxious disorder (Biederman, Faraone, Keenan, Steingard & Tsuang, 1991). The same study compared familial risks of children diagnosed with ADHD only and those diagnosed with both ADHD and an anxiety disorder. Questions were raised as to whether or not children who had an anxiety disorder were misdiagnosed as ADHD with anxiety; however, family members of both groups were equally at risk for developing ADHD. Both groups had a higher familial risk for anxiety disorders than the control group, but only the ADHD with anxiety group reached a level of significant difference from controls. The risk for one or more anxiety disorders, but not ADHD, among relatives was higher in the ADHD with anxiety group than the ADHD only group. For both groups, the presence of ADHD in a relative increased the risk for an anxiety disorder in that relative from 11 to 33 percent. No differences were found across SES groups for the risk of anxiety among relatives. In summary, the risk of ADHD was similar for both groups, and significantly higher than controls, the risk of anxiety was higher for the ADHD only group than controls, but relatives of the ADHD with anxiety group were at twice the risk of anxiety disorders than the ADHD only group.

In comparing children with only ADHD to those with ADHD with anxiety with regard to treatment, methylphenidate (MPH) seems to decrease activity levels in both groups; however, the medication increases working memory in the ADHD only group, but not in the group with anxiety (Tannock, Ickowicz & Schachar, 1995). Additionally, MPH increases heart rate, systolic blood pressure, and diastolic blood pressure in both groups, although the diastolic blood pressure is significantly increased further in the ADHD with anxiety group (Urman, Ickowicz, Fulford & Tannock, 1995). This finding further suggests physiological differences between the two groups, supporting evidence of this group representing either a subtype or having a different disorder (i.e. anxiety). Additionally, Buspirone was found to not only improve worry and anxiety in a group of children diagnosed with an anxiety disorder, but also to improve behavior and decrease hyperactivity in children with both ADHD and anxiety, suggesting a physiological link between the two diagnostic groups (Simeon, Knott, Dubois & Wiggins, 1994).

In the diagnosis of either ADHD or anxiety, using a battery of a variety of measures is recommended which includes primarily direct observation, behavior checklists, and parent, teacher, and self rating scales. Some instruments are designed to aid in differential or dual diagnosis, while others are designed to further analyze a specific disorder. In addition, several standardized cognitive and neurological instruments have been used to aid in the diagnosis of ADHD.

Direct observation in a variety of settings, either formally or informally, allows the examiner to note specific behaviors that occurred or did not occur and in what context. For example, when trying to differentiate between the two disorders or determine whether one, both, or neither disorder is present, it is helpful to note behaviors such as whether the child was squirming in his/her seat throughout the entire class period or only when s/he anticipated being called on, whether or not the child had difficulty maintaining attention during both structured and unstructured tasks, and whether the child often missed instructions because of external influences such as the child sitting beside him/her was constantly talking.

Common rating scales used to help differentiate between anxiety and ADHD, among other disorders, include the Behavioral Assessment Scale for Children (BASC) and the Child Behavior Checklist (CBCL). Both measures include a parent and teacher report which can be compared to one another, as well as a self report. However, caution is given with regard to administration of the CBCL for differential diagnostic purposes since it does not clearly define behaviors between disorders, but rather the scale clusters together similar behaviors which can be seen in a number of disorders (Reynolds & Kamphaus, 1990). For example, the scale does not separate behaviors related to anxiety and those related to depression; it also does not provide a distinct scale for hyperactivity. In addition, caution was raised regarding the insensitivity of the CBCL scale for diagnosing ADHD-Inattentive Type since such children may appear within normal limits due to items not reflective of attention difficulties which are included in the Attentional dimension, such as cannot sit still, clumsy, and acts young (Dumas & Guevremont, 1994). On the other hand, the BASC provides a more accurate scale for differentiating between anxiety and ADHD because it includes more distinct behaviors related to a specific disorder, as well as distinguishes among the disorders so that there is a separate scale for anxiety, a scale for attention problems, and a scale for hyperactivity (scales for other disorders are also included). Another benefit of the BASC is the inclusion of a lie scale to detect invalid responses.

Specific behavior rating scales which are used to gain additional insight regarding each disorder include the Attention Deficit Disorders Evaluation Scale (ADDES) and the Reynolds manifest Anxiety Scale (RMAS). Such scales are generally administered following the more comprehensive behavioral scales, such as the BASC, when significant areas of concern have been detected. With regard to ADHD, the ADDES presents a list of behaviors linked to the DSM-IV criteria and provides both a Home Version and a School Version to determine if the child meets criteria and if so, to pinpoint for which subtype. A number of other scales such as the ACTers, the CAAS-H, and the Conners are also used to aid in diagnosing ADHD. However, the ADDES was rated as one of the most favorable tools because it uses specific descriptors and observable behaviors; whereas, other scales tend to be vague, require the rater to draw conclusions, and/or include items unrelated to ADHD (Sharp, 1993). With regard to anxiety disorders, the RMAS provides an overall score which is derived from three subscales: Physiological, Worry/Oversensitivity, and Social Concerns/Concentration. Thus, critical areas can be determined from the subscales with regard to the nature of the anxiety. A lie scale is incorporated to indicate the validity of responses.

Several cognitive and neurological tests are often used in the evaluation of ADHD; however, there are minimal reports regarding the performance of children with anxiety disorders on these measures. Among the most common measures are the Processing Speed subtests on both the Wechsler Intelligence Scale for Children - III and the Woodcock Johnson Tests of Cognitive Abilities, the Stroop Color-Word Test, Continuous Performance Tests (CPT), and the Wisconsin Card Sorting Test. A number of studies have shown that children with ADHD generally perform more poorly on all the above measures in comparison to normal control groups. The small number of studies that have analyzed the performance of individuals with anxiety disorders on selective attention tasks indicate that these individuals also have difficulty maintaining focus and may perform similarly to the ADHD group (Fox, 1993; Mattia, 1993). Thus, such objective measures may not distinguish between the two disorders, although further research is needed.

Although many measurement tools exist to aid in diagnostic decision-making, discriminating between diagnoses or proposing dual or multiple diagnoses remains a challenge. Many symptoms are common to both ADHD and generalized anxiety disorders, making it difficult to determine which disorder a child may have or if multiple disorders are present. Therefore, further information is needed to aid in differentially diagnosing ADHD and anxiety, to determine whether or not subtypes of the disorders exist, or if the disorders are part of a spectrum of related disorders.

Suggestions for additional research include further comparisons between groups of children diagnosed with ADHD-Inattentive Type, ADHD-Hyperactive/Impulsive Type, ADHD-Inattentive Type with anxiety, ADHD-Hyperactivity/Impulsive Type with anxiety, and anxiety only. Comparison studies may include treatment effects of various medications, including MPH and Buspirone as previously mentioned, as well as Benzodiazepine and Clonazepam which are generally used in treating anxiety disorders (Biederman, 1990). With an increasing number of dual and multiple diagnoses, research is needed on the effectiveness of prescribing a combination of medication and to examine interaction effects (Wilens, Spencer, Biederman & Wozniak, 1995).

Other areas of research should include investigation of gender and age differences with regard to comorbidity of ADHD and anxiety. For example, it would be of interest to determine if comorbidity increases with age since one disorder may result from the other, as well as if comorbidity rates are higher among females since anxiety disorders are more prevalent among females.

References

Biederman, J., Newcorn, J. & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564-577.

Biedernan, J. & Steingard, R. (1989). Attention deficit hyperactivity disorder in adolescents. Psychiatric Annals, 19(11), 587-596.

Biederman, J. (1990). The diagnosis and treatment of adolescent anxiety disorders. Journal of Clinical Psychiatry, 51(5), 20-26.

Biederman, J., Faraone, S. V., Keenan, K., Steingard, R.; & Tsuang, M. T. (1991). Association between attention deficit disorder and anxiety disorder. American Journal of Psychiatry, 148(2), 251-256.

Desgranges, K., Desgranges, OL., & Karsky, K. (1995). Attention deficit disorder: Problems with preconceived diagnosis. Child and Adolescent Social Work Journal, 12(1), 3-17.

Duman, M. C. & Guevremont, D. C. (1994). Undifferentiated attention deficit disorder. ADHD Report, 2(1), 4-5.

Halperin, J. M., Newcorn, J. H., Matier, K., & Sharma, V. (1993). Discriminant validity of attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 32(5), 1038-1043.

Jensen, P. S., Shervette, R. E., Xenakis, S. N. & Richters, J. (1993). Anxiety and depressive disorders in attention deficit disorder with hyperactivity: New findings. American Journal of Psychiatry, 150(8), 1203-1209.

Lahey, B. B. & Carlson, C. L. (1991). Validity of the diagnostic category of attention deficit disorder without hyperactivity: A review of the literature. Journal of Learning Disabilities, 24(2), 110-120.

Pliszka, S. R. (1992). Comorbidity of attention deficit hyperactivity disorder and overanxious disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31(2), 197-203.

Reynolds, C. R. & Kamphaus, R. W. (1990). Handbook of psychological and educational assessment of children: Personality, behavior, and context. New York: Guilford Press.

Sharp, K. B. (1993). Comparing the technical aspects of attention deficit disorders rating scale. Columbia, MO: Hawthorne Educational Services.

Simeon, J. G., Knott, V. J., Dubois, C., & Wiggins, D. (1994). Buspirone therapy of mixed anxiety disorders in childhood and adolescence: A Pilot study. Journal of Child and Adolescent Psychopharmacology, 4(3), 159-170.

Tannock, R., Ickowicz, A. & Shachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 34(7), 886-896.

Urman, R., Ickowicz, A. & Fulford, P. (1995). An exaggerated cardiovasculoar response to methylphenidate in ADHD children with anxiety. Journal of Child and Adolescent Psychopharmacology, 5(1), 29-37.

Wilens, T. E., Spencer, T., Biederman, J., & Wozniak, J. (1995). Combined pharmacotherapy: An emerging trend in pediatric psychopharmacology. Journal of the American Academy of Child and Adolescent Psychiatry, 34(1), 110-112.

ADHD and PTSD

by Cindy Taylor, Ph.D.

One group of self-referred individuals actually have Post-Traumatic Stress Disorder. PTSD is a condition which develops in some people in response to a traumatic event - either directly experienced or witnessed by the person. Most typically they are from severely abusive homes, have been sexually assaulted, participated in wars, or have witnessed events outside the realm of normal human experience. These clients complain of difficulty sleeping, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response, and difficulty remembering things. Many alternate between an emotional numbness and overreactivity in relationships. Some have nightmares or flashbacks of the traumatic event, and avoid situations which remind them of the incident. Some of the symptoms are identical to those found in adults with ADD. Traumatic events are usually not part of the presentation of ADHD, although some have a history of fairly severe discipline. With ADHD, there is no avoidance although emotional sensitivity, low frustration tolerance, and overreactivity can be present. In a few cases, however, some clients, due to embarrassment over their childhood learning disabilities and attention problems, did experience school as traumatic and actually have nightmares about it. Some have a history of physical abuse; however, this is not common. One study examined parents’ treatment of ADHD children and their siblings by retrospective report. Whitmore (1993) and her colleagues found no difference in the ADHD subjects’ and their siblings’ reports of physical punishment, discipline, or parental rejection. Furthermore, the amount of physical punishment reported was unrelated to the degree of hyperactive and aggressive symptoms in the children. In an examination of comorbidity of these two disorders, Cuffe and his colleagues (1994) suggest that children with ADHD may be at higher risk for trauma due to their difficulties with impulse control, dangerous behaviors, and parents who may also respond impulsively. These researchers also acknowledge that the hyperarousal, hypervigilance, and poor concentration associated with PTSD may produce ADHD-like symptoms. Sufficient research has not been done to determine whether ADHD individuals are actually at greater risk for trauma. However, individuals with PTSD do seem more likely to be traumatized again, and one author suggests that this is possibly due to their inaccurate perception of environmental cues. If this is the case - that individuals with PTSD are at risk because they are not correctly attending to cues of possible danger, then it would seem that ADHD individuals may be at risk as well.

References

Cuffe, S. P., McCullough, E. L., and Pumariega, A. J. (1994). Comorbidity of attention deficit hyperactivity disorder and post-traumatic stress disorder. Journal of Child and Family Studies, 3(3), 327-336.

Matsakis, A. (1994). Post-Traumatic Stress Disorder: A Complete Treatment Guide Oakland, CA: New Harbinger Publications, Inc.

ADHD and Obsessive Compulsive Symptoms

by Cindy J. Taylor

Children with OCD will have a very difficult time adapting and will adopt a perfectionistic attitude toward schoolwork. Some children will not be able to complete work because they have made a mistake and either feel that they must redo it or become frustrated at the imperfection and will refuse to attempt it. Some adults report that their handwriting must be perfect which requires them to rewrite the assignment several times prior to turning it in. Some have a desire to go all the way back to the beginning and redo a task that was completed, but not completed in the correct sequence. These behaviors are very time consuming.

The main purpose of these compulsive behaviors is to relieve anxiety; and as we talked about in the previous section, people who have anxiety also have difficulty concentrating and can be quite restless and fidgety. Usually, the clients with either grouping of OC symptoms will report that they are unable to complete work on time and are very disorganized. Unfortunately, even with the focus on organization, lists, etc., the person may not actually be organized. Another symptom in common with ADHD is that these individuals have a tendency to analyze everything and say that their mind wanders. Additionally, individuals with OC Personality will frequently blurt things out and interrupt others in conversation. They are usually thinking far ahead in the conversation and will finish sentences or blurt out other thoughts. OC Personalities have other difficulties in communication as well due to their need to select the exact word and the need to over-explain things. Individuals with OC Personality will have difficulty with "yes" or "no" answers and with giving a direct answer to a question.

The key word in OC symptoms is "Control" - mental and interpersonal. Interestingly, the rigid control associated with the OC symptoms is the piece that is lacking for many people with ADHD. Often times, ADHD individuals develop some of the OC symptoms as a compensatory strategy. They compensate for forgetfulness by having a place for everything and everything in its place. This is a very helpful strategy - an example would be having a set, predetermined place to leave one’s keys so that they could easily be found. There is a fine line between using this strategy, let’s say, and compulsively patting pockets all day to check for keys. Another strategy for dealing with ADHD is schedule making, which works great until one is drawn off the schedule at which time he/she becomes anxious that he/she will never be able to return to it and then become frustrated and have trouble returning to the task at hand. For this reason, some individuals with ADD will be extremely rigid about staying on the schedule and will become angry when interrupted.

Another example of commonality in ADHD and OC symptoms is the perfectionistic standards. The sense that it’s "not enough" is a major piece of the OC Personality. Similarly, individuals with ADHD have usually suffered through years of teachers and parents telling them they are not doing as well as they should and could try harder, run faster, or jump higher. This history instills in the ADHD person that same sense of feeling like whatever he/she has achieved or wherever he/she is in life - it’s not enough. There could be more if he would only.... This kind of thinking leaves the person with a nagging, gnawing feeling that something is not quite right about him/her and what he/she is doing. The good news is that both the ADHD and the OC symptoms can be treated effectively. And with some behavior modification and a little reexamination of one’s expectations, these symptoms can be managed. OCD can be successfully managed with medication and therapy as well. It just takes correct identification of the problem so that you and your doctor know what you are treating and what treatments are most effective for that particular disorder, or combination of disorders.

ADHD and Borderline Personality Disorder

by Cindy J. Taylor, Ph.D.

Borderline Personality Disorder (BPD) looks a whole lot like ADHD...so much so in fact that when the original Utah criteria for diagnosing adult ADD came out it made ADD and BPD mutually exclusive. This is probably because the symptoms are so similar. The similarities, however, are more on the hyperactive- impulsive side than on the inattentive side. Folks with borderline personality feel restless, bored and mostly "empty" inside. In fact, one of he symptoms of BPD is chronic feelings of emptiness. Sometimes this is described as anxiety, boredom, or just a hole in the pit of their stomach. Another symptom of BPD is difficulty comtrolling temper, which is seen in a lot of adults who have ADD. Here are some other symptoms of BPD: they have a pattern of unstable and intense interpersonal relationships, affective instability, and impulsivity.

The impulsivity in BPD is similar to some of what you will see in ADD adults - spending, sex, substance abuse, reckless driving, and binge eating. Probably the one word that best characterizes individuals with BPD is instability -- in their mood, relationships, and even self image. These are the chameleons who will become like whoever they are around. They also have big trouble with what therapists call "boundaries." In case you don’t know what a boundary is, it’s basically an understanding of where you stop and another person starts. I heard one lady say that she didn’t want somebody to share her life, she wanted somebody to be her life. That’s a boundary problem. It’s trying to fill an inner emptiness with another person. These are the folks that may threaten to do something rash if you consider breaking off a relationship. They are terrified of being abandoned. Individuals with BPD also usually have intense underlying anger. ADD folks have impulse control problems, but you can be impulsive without being angry. In other words, the impulsivity doesn’t always have to be a temper outburst.

A lot of times, the individuals with BPD also have underlying depression which can cause difficulties with attention and concentration too. So this can get tricky. What about having BPD and ADD? Well, one study did report improvement in the cognitive processing of an individual with BPD and ADD. There have also been suggestions made that some individuals with ADD are prone to develop BPD in the future. The important issue here is not only differential diagnosis, but that the individual with BPD and ADD have the capacity to attend to the treatment. This can be done through proper medication for the ADD which enables them to attend to therapy and make the much desired changes in their lives.

Antisocial Personality Disorder

by Cindy Taylor, Ph.D.

Antisocial Personality Disorder is one of the most researched disorders in connection with ADHD and is the adult version of Conduct disorder. Cantwell (1988) discusses the relationship of ADHD to conduct, affective disorders and later substance abuse disorders. Dykman (1993) found that children with ADHD who were also hyperactive and aggressive were at increased risk to have oppositional and conduct disorders. Lilienfeld, (1990) reviewed the literature on ADHD and antisocial behavior. Findings from longitudinal, family and adoption, neuropsychological, psychophysiological, and other laboratory studies reviewed indicate that childhood ADHD is associated with adult disorders characterized by antisocial behavior. The relationship between ADHD and Conduct Disorder is also recognized, however, and there is still a question of whether this finding simply represents the continuation of conduct problems from childhood to adulthood. Manuzza's study of 91 adults diagnosed with ADHD as children found hyperactive subjects more than seven times more likely to have an antisocial personality disorder or a drug abuse problem than controls (1993). The previously mentioned work by Loney and colleagues (1991), however, indicates that aggressiveness rather than ADHD is the better predictor of antisocial behaviors in adulthood.

Antisocial Personality Disorder most closely resembles the hyperactive-impulsive type of ADHD. A couple of the symptoms I am frequently asked about are "lying" and "irresponsibility". Is lying a symptom of ADHD? No, "forgetting" is a symptom of ADHD which can look like lying if you said you were going to do something and didn’t follow through because you either got sidetracked or just plain forgot. Both ADHD and Antisocial personality have difficulties with impulse control. There is a risk taking, thrillseeker component to both, but the individual with Antisocial Personality disorder will typically have less regard for their own safety and the safety of others than the person with ADHD. I believe the most distinguishing feature is the lack of empathy found in persons with Antisocial Personality. There is a disregard for the feelings of others and a lack of appropriate guilt over their own inappropriate or hurtful behavior. The person with Antisocial Personality will seek treatment, but typically only when in trouble and can get out of it by seeming to seek help. Usually when the situation that caused the person to seek treatment clears up, he/she discontinues therapy. In contrast, the adult with ADHD is often times overly sensitive to the reactions and feelings of others and may feel remorseful to the point of becoming depressed over his/her impulsive actions. Unlike some of the other disorders we have been discussing in this column, Antisocial Personality disorder is not easily and quickly treated. The personality disorders in general are long standing patterns of behavior and personality that have developed over a life time. Individuals with personality disorders are so familiar with the symptoms and behaviors that they are not distressed by them. Many times it is a significant other who will request that the personality disordered individual seek treatment, or in the case of Antisocial Personality, it is often times due to legal difficulties. Relatively long term therapy can alter the patterns of behavior, and if the individual has ADHD and Antisocial Personality disorder, medications may help control the level of impulsive behavior.

ADHD and Dependent Personality Disorder

by Cindy Taylor, Ph.D.

We all handle our ADHD in different ways. We have found various coping strategies to deal with forgetfulness and general lack of effectiveness in certain areas of our lives. At times, however, those ways of compensating for deficits can become harmful themselves. Here’s one we see fairly often when dealing with couples, and it causes a lot of difficulty in the relationship. One partner has ADHD and the other partner is attempting to help by "coaching", reminding, etc. and instead of enabling the ADHD partner to better assume responsibility for his/her own behavior and function at a higher level, an unhealthy dependency develops. In these cases, the non-ADHD spouse usually begins assuming a parental role and initially the ADHD spouse will respond because of the novelty in the situation. As time progresses, however, the ADHD spouse often times becomes dependent on the coaching and reminders provided by his/her partner and resentments begin to form. The roles become confused and transactions and behaviors can become increasingly dysfunctional. Individuals with a dependent personality are particularly susceptible to this problem. According to the DSM-IV, here are the symptoms of Dependent Personality Disorder:

"A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:

1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

2) needs others to assume responsibility for most major areas of his or her life

3) has difficulty expressing disagreement with others because of fear of loss of support or approval

4) has difficulty initiating projects or doing things on his or her own (because of lack of self confidence in judgment or abilities)

5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

7) urgently seeks another relationship as a source of care and support when a close relationship ends

8) is unrealistically preoccupied with fears of being left to take care of himself or herself." (taken from DSM-IV, American Psychiatric Association, 1994)

In addition to seeing how some problems could develop, you also probably saw some similarities with ADHD. It’s not unusual for both groups to have difficulty making decisions and to let others take responsibility for things. A lot of the time, folks with ADHD will need reassurance when making decisions simply because of a long history of poor decision-making. And we all need a certain level of emotional support, but not in the same way as those individuals with a dependent personality style.

So, what’s the best way to help the adult with ADHD without enabling, or causing excess dependency? One is to encourage them to take responsibility for their own behavior. I prefer trading tasks or hiring someone outright rather than setting one person up to do the work of two. So, for example, if it’s the checkbook that is the problem, then trade for something that takes the same amount of time or skill level. If balancing the checkbook takes an hour and cleaning the kitchen takes a half hour, then trade two nights in the kitchen for the checkbook duty. Better yet, hire an accountant. You get the picture. Just make sure that things even out and one person does not end up doing everything. That’s how the dependency and also the resentments get started.

OK, one more thing to keep in mind is that there needs to be progress. ADHD is treatable! Medication, education, and psychotherapy should be working together to put improved brain chemistry and new strategies to work in your life so you should not have the same problems today as you did before you got diagnosed. If no progress is apparent you might need to reevaluate the process. Is medication providing better brain chemistry? Are you proficient at safeguarding your brain chemistry? Are you taking strides to be personally responsible as we’ve talked about in earlier issues? Are you open to risking new behaviors and looking at beliefs you have that may be undermining your efforts to function at a more independent level? Remember, there should be progress; however, progress can be a scary prospect if you’ve never been able to have it before...and it can be a very stressful experience for both spouses as change occurs. It’s a different way of doing things that is not familiar, and thus, can be threatening. It is also possible to minimize the changes that one or both have made and discount efforts and results. This is where a good support system or counselor can provide much needed balance in encouraging growth and validating efforts and results. It’s important to give each other hope and support and appreciation as efforts are made...and to hang in there! You can learn how to have loving, healthy interactions with each other that encourage and facilitate personal growth as well as relationship strengths.