Anxiety: an often-overlooked condition that may be present with ADHD

Trying to understand the impact of one condition can be a challenge, but some conditions tend to have a lot of other problems that “go with them.” ADHD is a disorder that has a tremendous amount of comorbidity. To help teachers understand that they need to be aware of “what else” the student with ADHD may have, I often use the following overhead:

Overwhelming, isn’t it?

With so much going on, it is somewhat understandable that teachers – and even parents – often overlook the presence of an anxiety disorder.  And yet anxiety may contribute to some of the worrisome behavior that they have been attributing to ADHD.   If a student becomes disruptive due to heightened levels of anxiety but their behavior is misunderstood as ADHD-related impulsivity or disinhibition, parents may think their child needs (more) medication for ADHD, when what they might really need is treatment for anxiety.  And increasing a stimulant medication to treat ADHD may make anxiety worse.

I came across an article online that may open some parents’ and teachers’ eyes about the relationship between ADHD and anxiety:

It’s not uncommon for individuals with attention deficit hyperactivity disorder (ADHD) to struggle with anxiety, whether it’s several symptoms or a full-blown disorder.

In fact, about 30 to 40 percent of people with ADHD have an anxiety disorder, which includes “obsessive-compulsive disorder, generalized anxiety disorder, phobias, social anxiety and panic disorder,” according to Roberto Olivardia, Ph.D, a clinical psychologist and clinical instructor at Harvard Medical School. The Anxiety Disorders Association of America even estimates the figure to be almost 50 percent.

Read more of this article on PsychCentral.

Join Me at an All-Day Workshop for Educators & Parents on December 5th

I’ll be conducting an all-day workshop for educators on Monday, December 5, 2011 at the Grappone Conference Center in Concord, New Hampshire. The event is sponsored by the University of New Hampshire Institute on Disability and is geared to regular and special education teachers, school psychologists and social workers, behavior specialists, occupational therapists, administrators, and parents.

Description:

Neurological disorders that emerge in childhood often have significant impact on students’ academic, behavioral, and social-emotional functioning. Participants will learn about the cardinal features of Tourette’s Syndrome, Obsessive-Compulsive Disorder, Attention Deficit Hyperactivity Disorder, Executive Dysfunction, Mood Disorders such as Depression and Bipolar Disorder, and the memory deficits, sensory issues and “storms” that sometimes accompany them. Strategies and assistive technology to accommodate symptom interference in activities such as handwriting, homework, math calculation, and written expression and big projects will be described. Pitfalls in behavioral interventions, and simple social skills and problem-solving interventions will also be identified.

For more information on the workshop and registration information, download the brochure or register online at www.iod.unh.edu.

Hope to see you there!

 

Long-term outcomes of OCD in patients with at least one other anxiety disorder

A new study looks at the rate of remission of Obsessive-Compulsive Disorder in patients who have at least one (other) anxiety disorder.  The results indicate that only 16% go into remission by one year after onset, but over 40% have gone into remission of their OCD by 15 years later. In some cases, those whose OCD has gone into remission experience a re-emergence of their OCD later on.

Although I haven’t yet obtained the full article, it would appear that this study was likely done using adult participants. If that’s the case, it’s not clear what the pattern or outcomes would be for those whose OCD had a childhood onset.

Here’s the abstract:

BACKGROUND: Although obsessive-compulsive disorder (OCD) is typically described as a chronic condition, relatively little is known about the naturalistic, longitudinal course of the disorder. The purpose of the current study was to examine the probability of OCD remission and recurrence as well as to explore demographic and clinical predictors of remission.

METHODS: This study uses data from the Harvard/Brown Anxiety Disorders Research Program, which is a prospective, naturalistic, longitudinal study of anxiety disorders. Diagnoses were established by means of a clinical interview at study intake. One hundred thirteen Harvard/Brown Anxiety Disorders Research Program participants with OCD were included in the study; all had a history of at least 1 other anxiety disorder. Assessments were conducted at 6-month and/or annual intervals during 15 years of follow-up.

RESULTS: Survival analyses showed that the probability of OCD remission was .16 at year 1, .25 at year 5, .31 at year 10, and .42 at year 15. For those who remitted from OCD, the probability of recurrence was .07 at year 1, .15 by year 3, and by year 5, it reached .25 and remained at .25 through year 15. In predictors of course, those who were married and those without comorbid major depressive disorder (MDD) were more likely to remit from OCD. By year 15, 51% of those without MDD remitted from OCD compared to only 20% of those with MDD.

CONCLUSIONS: In the short term, OCD appears to have a chronic course with low rates of remission. However, in the long term, a fair number of people recover from the disorder, and, for those who experience remission from OCD, the probability of recurrence is fairly low.

Source:

Compr Psychiatry. 2011 Feb 22.
Longitudinal course of obsessive-compulsive disorder in patients with anxiety disorders: a 15-year prospective follow-up study.
Marcks BA, Weisberg RB, Dyck I, Keller MB.

Brain Activity Patterns in Anxiety-Prone People Suggest Deficits in Handling Fear

Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron.

Background

Anxiety disorders are characterized by an excessive, irrational dread of everyday situations. Some people may experience general, chronic anxiety, while others become anxious in response to one or more specific triggers. Many studies have implicated two brain regions in anxiety—the amygdala in fear responses and the ventral prefrontal cortex (vPFC) in suppressing or regulating fear. Questions remain, however, about how trait anxiety—a person’s typical anxiety level on any given day—affects amygdala and vPFC functioning.

To explore these questions, Sonia Bishop, Ph.D., of the University of California Berkeley (at the University of Cambridge (UK) at the time of data collection), and colleagues designed a series of experiments to determine how the amygdala and vPFC responded in three types of situations:

• Cued fear—a neutral signal or cue is followed by an aversive event. In this study, the cue was an actor in a video placing his hands over his ears and the aversive event was a loud scream. The cue provided a reliable prediction of the aversive event. Cued fear can be compared to the situation-specific type of anxiety experienced by those with a specific phobia, such as a fear of heights.
• Contextual fear—a neutral cue and an aversive event occur independently of each other. The cue did not provide a reliable prediction of the aversive event. Contextual fear may be similar to the non-specific anxiety that affects people with generalized anxiety disorder.
• Safety—a neutral signal or cue occurs alone without an aversive event. The safety situation served as a comparison for the other two situations.

The researchers assessed the level of trait anxiety of 23 healthy study participants, ages 18 to 41. Each participant underwent a training session that exposed them to the above conditions. Two days after the training session, participants had their brain activity recorded through functional magenetic resonance imaging (fMRI), a noninvasive imaging method, while re-exposed to the cued fear, contextual fear, and safety conditions in the scanner.
Results from the Study

Participants with high trait anxiety showed greater amygdala response to cued fear situations compared to those with low trait anxiety. According to the researchers, this finding suggests that individual differences in amygdala response may contribute to differences in vulnerability to cue-specific anxiety disorders, such as specific phobia.

Participants with low trait anxiety showed increased vPFC activity in response to cued fear and more strongly sustained vPFC activity during contextual fear situations, compared to those with high trait anxiety. Notably, vPFC activity in participants with low trait anxiety occurred before the aversive event had ceased. The researchers suggest that this process—engaging brain areas that help to suppress fear even when the source of fear is still present—may help to protect against chronic anxiety disorders even when stressful life events are ongoing.
Significance

The study’s findings support a potential role of the amygdala in vulnerability to anxiety disorders and a potential role of the vPFC in protection against them.

“Individual differences in the functioning of one or both of these brain regions may help account for the variability in symptoms across different anxiety disorders,” said Bishop. “A better understanding of these processes may help inform treatment choice and predict treatment response.”

This study was supported in part by a Biobehavioral Research Award for Innovative New Scientists (BRAINS) from NIMH. Dr. Bishop was one of 12 researchers to receive this award in 2010.

Reference

Indovina I, Robbins TW, Núñez-Elizalde AO, Dunn BD, Bishop SJ. Fear-Conditioning Mechanisms Associated with Trait Vulnerability to Anxiety in Humans. Neuron. 2011 Feb 10;69(3):563-71.

Source: National Institute of Mental Health

Majority of United States Adolescents with Severe Mental Disorders Have Never Received Treatment for Their Conditions

A recent study by Merikangas and colleagues published in the January 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) shows that only half of adolescents that are affected with severely impairing mental disorders ever receive treatment for these conditions.

The researchers found that approximately one third of adolescents with any mental disorder received services for their illness (36.2%). Disorder severity was significantly associated with an increased likelihood of receiving treatment, yet only half of adolescents who were identified as having severely impairing mental disorders had ever received mental health treatment for their symptoms.

In the article titled “Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A),” Dr. Merikangas and colleagues examined the rates of treatment for specific mental disorders in the NCS-A. The NCSA is a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States.

The authors examined rates of treatment for DSM-IV disorders, and correlated the severity, number of disorders, and comorbidity in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Sociodemographic correlates were also evaluated.

Treatment rates were highest in those with attention-deficit/hyperactivity disorder (ADHD) (59.8%) and behavior disorders, such as oppositional defiant disorder (ODD) and conduct disorder (CD) (combined 45.4%). The picture is more discouraging for those adolescents with anxiety, eating, or substance use disorders for whom less than 20% received treatment.

Furthermore, the investigators found that Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. In the article, Merikangas and colleagues comment, “marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.”

Read the full press release on JAACAP.

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