Clinical Strategies for Distinguishing ADHD From Common Psychiatric Comorbidities

Attention-deficit/hyperactivity disorder (ADHD) often presents similarly to or alongside several psychiatric conditions, complicating the diagnosis process. In this video, Jo Hughes, DMSc, PA-C, CAQ-PSY, Steering Committee Partner, Psych Congress, offers an overview of the practical tools she uses to distinguish ADHD from other psychiatric disorders in clinical practice. In addition to highlighting the importance of a thorough clinical evaluation, Hughes underscores the role that screening tools and behavioral testing devices may play in teasing out whether symptoms are that of ADHD alone, ADHD and a comorbidity, or a separate diagnosis entirely.

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• ADHD shares symptoms with anxiety, depression, bipolarity, and autism spectrum disorder (ASD), but ADHD symptoms are typically persistent, whereas hypomania/bipolar symptoms are more periodic.
• DSM-5-TR ADHD assessment includes identifying symptoms before age 12 and reviewing personal and family history, and adult women may present with anxiety symptoms despite underlying undiagnosed ADHD.
• The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Qb Testing (a US Food and Drug Administration [FDA]-cleared medical device) can support differentiation of ADHD from anxiety and mood disorders when used alongside clinical evaluation.

Jo Hughes, DMSc, PA-C, CAQ-PSY: Hi, my name is Jo Hughes, and I'm a psychiatric physician associate out of Greensboro, North Carolina. I've been practicing since 2009, but I started in emergency medicine and then transitioned into psychiatry. I've been in this space for about 14 years. 

I currently own my own practice, Piedmont Partners for Mental Health, and I have to say, we're growing strong. I have 5 providers under me and 2 therapists. We're very excited about the community feedback, treating the populations we are, and helping folks in the psychiatric space.

Psych Congress Network NP Institute: What are some of the most commonly misunderstood or missed signs that could help distinguish ADHD from common co-occurring conditions, including anxiety, depression, ASD, and substance use disorder (SUD)?

Hughes: Some of the commonalities of ADHD across multiple psychiatric conditions are inattentiveness, impulsivity, mind wandering, difficulty staying on task. 

ADHD can be a part of all of these things, but the key thing is, how do we separate it, and how do we know what we're treating first? I think that is really the question mostly asked.

For me, I like to use screening tools to help me discern between a mood disorder, bipolarity, or depression or anxiety. Most adult women will come complaining of anxiety as their number 1 symptomology of why they're seeking treatment, but really, they have underlying ADHD that's never been diagnosed or treated. 

Now, conventional wisdom and the guidelines of DSM-5 TR all say [the patient has] to have some symptoms before the age of 12. Not everyone remembers that, but usually you can get some kind of history that will lead you into that. 

Then other questions to tease out: ADHD symptomology is persistent. Bipolarity, hypomania in mood disorder, is going to be periodic. So that's one thing. 

ADHD might have insomnia. Mood disorder with mania may have not needing to sleep. Asking those really detailed family history questions, when was their first depressive or anxiety episode? Before the age of 18? They're more likely to have a mood disorder on top of perhaps ADHD.

Don't discount that ADHD can be part of these other comorbidities, but it may not be the main one. So, you really have to tease out which symptomology we're trying to target and which diagnosis first, because it can make a difference on treatment outcomes.

PCN NPI: What practical assessment approaches or tools do you find most effective for differentiating ADHD symptoms from those of overlapping psychiatric disorders?

Hughes: Screening tools I like to use include the PHQ-9 and the GAD-7. Those are really simple and easy to do, and patients can do them really quickly before they come in or even while they're waiting for their appointment in office. 

To discern between anxiety sometimes, especially in those female adult women, I'm like, “Oh, is this anxiety or is this ADHD underlying?” I like to use Qb testing, which is a computer program where [the patient] sits and it's US Food and Drug Administration (FDA)-cleared as a medical II device. It distinguishes between the core symptomology of ADHD—impulsivity, inattentiveness, and hyperactivity. It does an infrared measurement of somebody who wears this funny thing on their head and it watches them move. Also, the task-oriented construct of it will help you determine about impulsivity and inattentiveness. 

It has a big comparative population for those that don't have ADHD in the same gender and age of the one being tested. I like to utilize that, as I find that to be a good distinction between ADHD, anxiety, and other mood disorders, at least one layer along with my clinical evaluation.

Jo Hughes, DMSc, PA-C, CAQ-PSY, of Greensboro, North Carolina is a psychiatric certified physician associate (PA) working in an outpatient setting with trained clinical team. She is the founder and lead clinician of Piedmont Partners for Mental Health, and provides treatment for a variety of psychiatric conditions, specializing in neurodevelopmental disorders in children, adolescents, and adults, and substance use disorders.

Hughes completed her PA training and Master of Medical Science at Wake Forest University School of Medicine and additionally holds a Doctor of Medical Science in psychiatry from Rocky Mountain University of Health Professionals. She is a certified PA with a Certificate of Added Qualification in Psychiatry.

She is currently the President with Association of PA's in Psychiatry (APAP) and is involved with North Carolina Association for PA’s (NCAPA) at the committee level in educating PA’s.

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