ADHD Misdiagnosed as Anxiety

ADHD and Its Symptoms

ADHD or Attention-deficit hyperactivity disorder is a neurodevelopmental disorder that exhibits striving symptoms of inattention, hyperactivity, and impulsivity that impact development and daily life. ADHD symptoms usually start during childhood years and usually persist into adulthood. The condition of ADHD affects one’s academic accomplishments, work performance, social relations, and quality of life (Faraone, Asherson, Banaschewski, et al., 2021).

Those with predominant inattentive ADHD usually have struggles maintaining attention, following instructions, organizing tasks, time management, distraction by unimportant stimuli, and trouble remembering responsibilities of daily activities (Faraone, Asherson, Banaschewski, et al., 2021).

Those with predominant hyperactive-impulsive ADHD usually feel restless, fidget, talk a lot, interrupt other people, struggle to wait their turn, and behave with no consideration for the consequences of their actions (Faraone, Asherson, Banaschewski, et al., 2021).

A lot of people with ADHD have the combined type. This type shows symptoms of inattention and hyperactivity-impulsivity simultaneously (Faraone, Asherson, Banaschewski, et al., 2021).

According to research, the condition of ADHD exhibits struggles with executive functioning. Such impacts include working memory deficits, planning struggles, issues with inhibition, cognitive flexibility and emotional self-regulation. Such symptoms cause impairment and daily struggles functioning (Faraone, Asherson, Banaschewski, et al., 2021).

Anxiety and Its Symptoms

Meanwhile, anxiety is marked by persistent and excessive fear, worry, and apprehension that are not in accordance with valid threats. Anxiety notably negatively impacts functioning on a daily basis (Craske et al., 2017).

Some psychological symptoms that are typical are those of excessive worrying, persistent nervousness, feelings of dread, irritability, difficulty concentrating, racing thoughts, and increased vigilance towards what are viewed as threats (Craske et al., 2017).

Some physical symptoms that are typical are those of an increased heart rate, sweating, trembling, muscle tension, shortness of breath, gastrointestinal discomfort, dizziness, fatigue, and sleep disturbances (Craske et al., 2017).

These anxiety symptoms persist past the normal anxiousness one may feel. An anxiety disorder has consistent symptoms that negatively impact occupational, academic, and social functioning (Craske et al., 2017).

Anxiety often impacts concentration, memory, and attention, which is similar to symptoms viewed in ADHD patients. This makes it difficult to make differential diagnosis and needs a comprehensive assessment (Schatz & Rostain, 2006).

Contributing factors

Also, when looking at ADHD and anxiety, we can see that they have a few symptoms in common such as problems paying attention, concentrating and executive functioning.

These overlapping symptoms can make it difficult for clinicians to diagnose and differentiate between ADHD and anxiety as the same symptoms arose from different underlying mechanisms. Clinicians can differentiate between the two conditions by viewing developmental history, symptom onset, and whether symptoms prevail across different environments. It is therefore important for accurate diagnosis that a comprehensive assessment is conducted.

Another phenomenon is that it is common for ADHD and anxiety to exist together (Faraone, Banaschewski, Coghill, et al., 2021; Katzman et al., 2017; Kooij et al., 2019). The diagnostic assessment should be comprehensive in that it looks at the developmental history, starting time of childhood symptoms, and negative impact looking at different environments is very important to differentiate between ADHD and anxiety. Looking at such factors closely decreases the occurrence of misdiagnosis (Koyuncu et al., 2022; Kooij et al., 2019; American Psychiatric Association, 2022).

Prevention and assessment

A comprehensive assessment can reduce misdiagnosis through viewing developmental history, symptom onset, and how symptoms appear across different environments. Symptoms of ADHD usually begin in childhood and prevail across environments. When it comes to concentration issues related to anxiety, they are best due to excessive worry or fear. Clinical consideration should also account whether ADHD and anxiety coexist.

ADHD and Anxiety as Distinct Disorders

Also, it is important to note that ADHD and anxiety are separate disorders that have distinct underlying mechanisms. ADHD is a neurodevelopmental disorder with symptoms of inattention, hyperactivity, and impulsivity. Anxiety is a disorder with symptoms of having excessive fear and worry that negatively impact functioning on a daily basis (Craske et al., 2017; Faraone, Asherson, Banaschewski, et al., 2021).

Real-World Example

A case report looks at a 13-year-old patient where anxiety and depression of the patient was identified while ADHD remained undiagnosed (Toole & Frank, 2024). After a comprehensive assessment was conducted which viewed the developmental history, attention and executive functioning, ADHD and coexisting anxiety was identified. This case shows how overlapping symptoms can cause ADHD to be missed and how important it is to do a comprehensive assessment diagnostic accuracy (Toole & Frank, 2024).

Conclusion

In conclusion, anxiety and ADHD have overlapping symptoms of difficulty concentrating, restlessness, and irritability, ADHD can be misdiagnosed as anxiety. Clinicians should assess developmental history, symptom onset, and symptoms across different environments to differentiate between the two disorders and identify when they coexist (Schatz & Rostain, 2006). The practical conclusion is that clinicians should be careful to not depend on overlapping symptoms when making a diagnosis.

An example of mismedicine would be misdiagnosing ADHD as anxiety as such diagnostic error can lead to inappropriate treatment and leaves the actual condition unattended to (Beigi, 2023).

Future research should focus on improving assessment tools that help clinicians distinguish anxiety from ADHD and lower diagnostic error.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.

Beigi, P. (2023). Mismedicine and medical error awareness [Video]. YouTube. https://youtu.be/yA7PpiNM600

Craske, M. G., Stein, M. B., Eley, T. C., Milad, M. R., Holmes, A., Rapee, R. M., & Wittchen, H.-U. (2017). Anxiety disorders. Nature Reviews Disease Primers, 3(1), Article 17024. https://doi.org/10.1038/nrdp.2017.24

Faraone, S. V., Asherson, P., Banaschewski, T., Biederman, J., Buitelaar, J. K., Ramos-Quiroga, J. A., Rohde, L. A., Sonuga-Barke, E. J. S., Tannock, R., & Franke, B. (2021). Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers, 7(1), Article 16. https://doi.org/10.1038/s41572-021-00269-0

Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., … Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. https://doi.org/10.1016/j.neubiorev.2021.01.022

Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

Kooij, J. J. S., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balázs, J., Thome, J., Dom, G., Kasper, S., Nunes Filipe, C., Stes, S., Mohr, P., Leppämäki, S., Casas, M., Bobes, J., McCarthy, J. M., Richarte, V., Kjems Philipsen, A., Pehlivanidis, A., … Asherson, P. (2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry, 56, 14–34. https://doi.org/10.1016/j.eurpsy.2018.11.001

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2022). Attention-deficit/hyperactivity disorder in adults with anxiety disorders: Clinical characteristics and diagnostic considerations. Psychiatry Investigation, 19(4), 268–277. https://doi.org/10.30773/pi.2021.0307

Schatz, D. B., & Rostain, A. L. (2006). ADHD with comorbid anxiety: A review of the current literature. Journal of Attention Disorders, 10(2), 141–149. https://doi.org/10.1177/1087054706286698

Toole, K. P., & Frank, C. (2024). A young adolescent with undiagnosed ADHD-inattentive presentation and co-morbid anxiety and depression: A case report. Journal of Pediatric Nursing, 78, e250–e259. https://doi.org/10.1016/j.pedn.2024.07.013

Young, S., Asherson, P., Lloyd, T., Absoud, M., Arif, M., Colley, W., Gudjonsson, G., Hollis, C., Hall, C. L., Jackson, G., Lambregts-Rommelse, N., Mason, O., Paliokosta, E., Pitts, M., Rafi, I., Schofield, J., Shanahan, M., & Woodhouse, E. (2020). Failure of healthcare provision for attention-deficit/hyperactivity disorder in the United Kingdom: A consensus statement. Frontiers in Psychiatry, 11, Article 649. https://doi.org/10.3389/fpsyt.2020.0064