Adult ADHD with Social Anxiety Disorder
by Richard Rubin, MD

ADHD adults commonly have combined Anxiety Disorders, with Social Phobia recently reported at 29% in a national community survey. These people suffer excessive embarrassment, fear talking to strangers, avoidance of social events, and panic distress in such situations. The addition of Social Anxiety Disorder to ADHD increases a person's impairments in life functioning. These combined problems often begin in childhood and increase through adolescence. Mild chronic depression, often called Dysthymia, commonly results from the disorder burden. The combined problems are often inadequately treated for several reasons: 1) Overt anxiety may obscure recognition of ADHD, 2) When ADHD has previously been diagnosed, the individual and clinician may assume the anxiety comes only from ADHD coping and performance problems, not another co-occurring disorder, and 3) Stimulant ADHD medicines, both methylphenidate and amphetamines, may increase anxiety symptoms. Even when tolerated adequately in ADHD treatment, an additional medicine is often required for anxiety relief. No careful large studies have been done on treatment of these combined disorders in adults.

Treatment with the non-stimulant atomoxetine was studied in 442 adults having both ADHD and Social Anxiety Disorder. I participated as one of the researchers and helped co-author the recent medical meeting presentation of results. Study participants were treated with standard doses of atomoxetine in blinded medication or placebo groups. Analysis of each group's responses showed that both ADHD core symptoms and quality of life impairments improved similarly to other atomoxetine studies. In other words, the anxiety disorder did not prevent ADHD response and the medicine did not increase anxiety problems. Significant improvements also occurred in the social anxiety symptoms compared to placebo. Both ADHD and anxiety changes were initially evident after two weeks and gradually increased through the study period. Atomoxetine dosing of 40 mg twice a day was usually well tolerated and no medical tests were abnormal.

While studies report statistical changes in group data, I observed that individuals varied in response. Follow up after the study showed that approximately half continued to do well for both ADHD and Social Anxiety on atomoxetine alone. Among the remainder, some achieved emotional and ADHD stabilizing benefit, but required stimulant augmentation for ADHD performance weakness. Others required different anxiety medicine for adequate benefit. Note that atomoxetine is not an approved treatment for anxiety disorders alone. Concurrent ADHD coaching and anxiety psychotherapy continue important components of full treatment.

Dr. Richard Rubin is a child and adolescent psychiatrist and Director of The Vermont Clinical Study Center, Burlington, Vermont.

A fascinating story found in The Republican by Nancy H. Gonter, reported on a school project that gave students a taste of what it might be like to have a learning disability.

Knowing what it's like to have a learning disability for just a few minutes gave eighth-grader Jon A. Hutton an idea of what it's like to live with one every day, all day.

"It was really confusing. I really had to concentrate," said Hutton, 14, a student at White Brook Middle School.

"It would be hard to do that every day. For one minute, it was hard enough," Hutton said.

Hutton was one of the nearly 100 fifth- through eighth-graders who got to experience what it's like to have different learning disabilities at the school's Learning Fair last month.

Students went to different stations that are based on the Public Broadcasting Service documentary "Misunderstood Minds" which discusses learning differences. More information can be found at www.pbs.org/.

The stations simulated what it's like to have learning problems related to paying attention as well as challenges in reading, writing and doing math. The event is part of a series being held at the school to inform students about learning disabilities.

"The goal is to demystify those differences and promote a sensitivity among students and teachers about kids who have these learning disabilities," said organizer and school counselor Ann Marie Zanfagna.

Feedback sheets from students who participated showed the event appeared to be working. "The learning fair changed my thinking. I used to think they were stupid," one wrote.

"Wow, this is crazy," eighth-grader Saovalom "D.J." Nhem, 14, said as he worked on an exercise that simulated what it would be like to have a disability such as Attention Deficit Disorder.

The experience made him appreciate the challenge of having a learning disability.

"It would be really hard, really complicated," he said.

Peer mediators helped students with each exercise. Dillon M. Serino, 12, a seventh-grader who has a writing disability, helped students with that exercise.

"I really liked seeing how people reacted. People kept saying, 'Wow, this is really hard.' I thought it was good for people to see what it's like," Serino said.

Peer mediator Tierney E.D. George, 12, a sixth-grader, learned from doing the exercises as well as by showing others how to do them.

"Now I understand what they go through and how hard it is in school," George said.

Below are some interesting articles on ADHD and related topics:

• Children, families learn to cope with
• More teens meddling with contents of
• What is fragile X syndrome?
• To enhance learning, read more and limit

Visit myADHD.com and use the follow tools this month to understand how cognitive behavior therapy works and how it can help with depression and anxiety:

• 1300 Introduction to Cognitive Therapy
• 1301 CBT for Depression
• 1302 CBT for Anxiety