Clifford Zeller MD

Complex ADHD and ADD

Complex ADHD and ADD are common in adults and occur when other symptoms such as anxiety, social phobia, panic attacks, excessive substance use, or mood disorders complicate the primary diagnosis. The clinical challenge is to find the right treatment that will balance the various biochemical mechanisms that modulate these diagnoses in a way that enhances the best response while avoiding medications or drug interactions that might benefit one condition at the expense of the other.

As you are aware, ADHD symptoms include: difficulty sustaining attention; careless mistakes; poor listening; leaving tasks unfinished; difficulty organizing; losing things; easy distractibility; avoiding tasks that require attention; and forgetfulness. However we are now recognizing that problems with emotional self-regulation are also part of the diagnosis. These include: becoming quick to anger or upset; easy frustration; emotional reactivity; impaired decision-making; and problems with inhibition. This new understanding is based on recognizing how” executive function” is affected by ADHD. Within this model ADHD is not primarily an attention disorder but primarily a problem maintaining consistent engagement in tasks that are unexciting or repetitive rather than exciting -even if one deeply cares about being successful in the task. Research indicates that individuals with ADHD change their jobs at least 20% more often than others and nearly 50% have left a job owing to symptoms.

The difference between ADD and ADHD is of course the letter H, standing for hyperactivity. In childhood about 75% of symptoms involve hyperactivity and are diagnosed ADHD. However as we grow into adulthood the ratio reverses and the majority of patients have primary problems with inattention and diagnosed as ADD. These problems are quite common – probably 6% of the population of children and up to 4% of the population and adults. ADHD usually starts in childhood but there are many individuals that have the intelligence and psychological resiliency to be unaware of having ADHD until they are older due to being able to ”push through the symptoms.” However there is some new research indicating that ADD can develop independently in adulthood and is more prevalent than previously thought.

The diagnosis may not become apparent until the demands of adult life including marriage, children, or work promotions finally creates expectations that even the resourceful and intelligent individual cannot overcome. By this time other psychological reactions such as low self-confidence, avoidance, and negative self-image may have been triggered by the efforts to compensate for the ADHD.

In the real world, ADHD or ADD can create a reactive rather than proactive pattern in life. Often stresses and pressures which increase attention become the main way to get things done. This creates a vicious cycle of ultimatums and deadlines at the last minute resulting in extra hours late nights and an exhausting crisis to crisis lifestyle. Sleep patterns can be disrupted with ADHD since late night is the time when ADHD symptoms can feel a bit improved and when work not done during the day can be done in a catch-up mode. This creates a cycle of sleep deprivation. The right medication and psychotherapy can work together to help individuals learn new habits that will allow for better self-care including changes in eating, exercise and structured work and study breaks.
A comprehensive understanding to ADHD and ADD includes working with the complex cofactors involved. Medication is the foundation for treating symptoms and should only be a prescribed after a thorough evaluation and diagnosis with understanding the complexity of the problems. Medications are available to not only address the primary ADHD but also associated anxiety, sleep dysregulation, or mood. Combining psychotherapy with medications results in better outcomes. Cognitive behavioral treatments include practicing alternative thoughts and actions, mental grounding; minimizing of emotional distractions; and optimizing thoughts before actions. Problem-solving psychotherapy includes integration of awareness of attitudes and beliefs towards oneself and others and emphasizes good decision-making regarding career and interpersonal values.

Successful outcomes flow from a good relationship with your treating psychiatrist with an open communicative and collegial approach.