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Walking the Stress Lines
All of her life, Nancy had been "high strung," clumsy, accident-prone and suffering from low self-esteem. As a child, she seemed bright but shy in school; at age 6, her teacher wanted to place her in a special class for slow learners.
But her parents fought the placement. They had her evaluated by a neurologist and a psychologist. The doctors made a diagnosis of attention deficit disorder and started her on Ritalin. It seemed to help.
In college, Nancy found that she learned better if she recorded her teacher's lectures and listened to them repeatedly. Now at 40, she decided on a psychiatric evaluation because she felt overwhelmed.
Married with two children, she was unhappy, irritable and worried about finances, work and her children. Her husband had recently lost his job; she was working full-time, but had difficulty completing tasks. She complained of fatigue and lower back pain.
It was obvious that she was frustrated and upset about her current life situation. However, I had to decide if her anxiety was secondary to her childhood attention deficit disorder, a primary anxiety disorder or both. This was my dilemma.
Adult patients, like Nancy, who come with a childhood history of attention deficit hyperactivity disorder and current anxiety, present a particular diagnostic problem. They may have a completely different physical or mental illness causing their anxiety, and medical conditions such as hyperthyroidism, seizure disorder, lead toxicity, sleep apnea and head injury can mimic ADHD.
Their ADHD may overlap with other psychiatric conditions, such as mood disorders, substance abuse, learning disabilities and personality disorders. They may have attention deficit disorder with secondary anxiety due to the frustrations, failures and negative feedback that they have experienced all of their lives. The anxiety may be primary, or they may be suffering from multiple problems.
The differential between these various disorders is particularly difficult. Let us look at the signs and symptoms of attention deficit disorder and generalized anxiety disorder, and see if we can tease out the differences.
Anxiety is pervasive. We have all experienced it, particularly in these stressful times. However, if it's chronic, causes significant distress and interferes with functioning, it may not just be a normal reaction to stress.
Instead, an individual may have generalized anxiety disorder, an inherited biologic illness. (Scientists even talk of a "worry gene.")
GAD often develops in childhood or adolescence, but can also begin in adulthood and is possible throughout the life cycle.
Patients with GAD have four cardinal complaints:
- Anxiety and nervousness
- Excessive unrealistic worry
- Avoidance behavior
- Vague physical symptoms
Such patients may say that they feel restless, keyed up or on edge, and they tend to worry too much about different things. They are prone to avoidance, complain of fatigue, difficulty concentrating or mind going blank.
What makes GAD harder to diagnose? It rarely exists as a single disorder. Patients may also have other psychiatric problems, which include social phobia or obsessive compulsive disorder.
Anxiety may overlap with mental-health conditions and medical disorders, such as irritable bowel syndrome, may have a component of anxiety. To make things even more confusing, the anxious person may not always have GAD at all. Anxiety can also be a normal reaction to stress.
ADHD patients show classic symptoms of:
- Inattention/easy distractibility
Anxiety may cause restlessness that one can interpret as hyperactivity. Persistent worries or concerns may cause a person to be inattentive and, as anxiety increases, people may act quickly or irrationally in order to minimize stress.
A hasty diagnosis can suggest that the person has ADHD when he or she really has an anxiety disorder or both. The differential is important; management choices vary based on diagnosis.
Back to Nancy, who had a family history of anxiety. I felt that Nancy had residual ADHD symptoms, as well as GAD. At this time, her primary anxiety disorder was causing most of the problem. Individual psychotherapy, as well as the short-term use of a benzodiazepine agent, was helpful in calming her down and giving her a new perspective on life.
Her history did not give us any clues that her anxiety was due to another physical or psychiatric disorder. She was happy to learn that she was not going crazy or losing her mind.
H. Michael Zal, D.O., FACN, FAPA, a board-certified psychiatrist in private practice in Norristown, is the author of Panic Disorder: The Great Pretender and The Sandwich Generation: Caught Between Growing Children and Aging Parents. He can be reached at: [email protected].