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Section 14
Comorbid Conditions

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In the last section, we discussed the challenges the ADHD family faces regarding boundaries and communication. We also discussed the "Message Center" tool.

4 Comorbid Conditions
In this section, we will discuss comorbidity in adults with ADHD

♦ Comorbid Condition # 1 - Learning Disabilities
According to Dr. Genel, approximately 65 percent of the ADHD population, both children and adults, will experience comorbidity, or the condition of having two or more diagnosable conditions simultaneously. As you know, the most common comorbid condition for ADHD adults is Learning Disabilities.

♦ Comorbid Condition # 2 - Substance Abuse
The second common comorbid condition for the ADHD adult is Substance Abuse. According to a study by Biederman, 52 percent of ADHD adults meet criteria for substance abuse, compared to only 27 percent of the non-ADHD adult population.

♦ Comorbid Condition # 3 - Antisocial Personality Disorder
Regarding Antisocial Personality Disorder, another common comorbid condition, according to Glenn Brynes, Ph.D., M.D., and Carol Watkins, M.D., between 18 and 25 percent of the ADHD population may also have Antisocial Personality Disorder, compared with two percent of the non-ADHD population.

♦ Comorbid Condition # 4 - Tourettes Syndrome
Regarding Tourettes Syndrome, also a common comorbid condition among ADHD individuals, there has traditionally been controversy regarding the use of stimulant medications to treat ADHD in an adult with the comorbid condition of Tourettes Syndrome. It was once thought that the use of stimulant medications to treat the ADHD would exacerbate, or even cause, tics.

However, recent studies have shown that for some ADHD adults with the comorbid condition of Tourettes Syndrome, stimulant medication for their ADHD has little effect on the presence of tics. I have found that in treating ADHD adults who are comorbid with Tourettes Syndrome, it is important to determine which symptoms are more troublesome to the client: the tics, the inattention, or another behavioral problem. Other comorbid conditions, as you know, include Conduct Disorder, Mood Disorders, and Anxiety.

♦ Treatment of ADHD vs. Effect on Comorbid Condition
Obviously, for ADHD adults with a comorbid condition, one concern regarding treatment of the ADHD is what effect the treatment for the ADHD will have on the comorbid condition. As you know, in ADHD adults with Mood Disorders or Anxiety, for example, the use of a stimulant medication for the ADHD could aggravate the client’s comorbid conditions. So how do you treat an ADHD adult client dealing with a comorbid condition that could be exacerbated by treatment of his or her ADHD? Let’s look at how Laura coped with her comorbid condition.

For Laura, age 29, the recent ADHD diagnosis caused her to develop the comorbid condition of Anxiety. Laura began worrying about nearly everything, especially anything related to her ADHD. Laura worried about how people would react if they found out she had ADHD, as well as what treatment she would need. Laura stated, "The thought of having to take medication for the rest of my life because of my ADHD worries me so much it actually makes me sick."

Laura explained that her anxiety kept her more distracted than she had been before the diagnosis. Laura had also recently upped her smoking habit to two packs a day from one to help her concentrate. Laura stated, "My need to smoke to maintain my concentration has never stopped. If anything, it’s gotten worse because now there are so many more distractions. There are just so many things I have to worry about because of my ADHD! Like, what if my co-workers find out? I don’t know what I’d do!" Sound like one of your recently diagnosed ADHD adult clients?

As you know, some ADHD adults develop smoking habits if they don’t have a prescribed medication for their ADHD. I find this unsurprising, as nicotine is a stimulant that may temporarily relieve some of the symptoms of ADHD. With Laura, I believed that the cigarette addiction had originally started as a method of controlling her undiagnosed ADHD and its symptoms. Now that Laura was diagnosed and had developed the comorbid condition Anxiety, though, the worry about the diagnosis caused her to start smoking more to stay focused. As you may have guessed, the nicotine stimulant was then, in turn, aggravating the anxiety that was distracting her.

♦ "Written Worries" Exercise - 3 Steps
Because I could see Laura was beginning a downward spiral with her smoking behavior for coping with her ADHD diagnosis, I suggested to her a simple activity to help her worry less and decrease her comorbid condition of anxiety. I suggested an exercise called "Written Worries." There are three steps to the "Written Worries" exercise.

-- Step # 1 - First, I gave Laura a notebook and asked her to write down a single worry. Laura wrote, "I’m worried that my co-workers will find out I have ADHD because of my behavior."

-- Step # 2 - Second, I asked her to evaluate her worry, in writing. I stated, "You could consider a few questions in this step, like what can I do to keep my co-workers from finding out about my ADHD? What might happen if they do find out? What is the worst that will happen if they do find out?" Laura wrote, "I can try to control myself and my ADHD tendencies, like disorganization and fidgeting. If they find out, I’m afraid they might think less of me. The worst that could happen is that they could tell my boss."

-- Step # 3 - For the third step, I asked Laura to visualize success. I stated, "Put your writing aside, close your eyes, and visualize managing your ADHD in your workplace." As you know, this visualization would help Laura because it works on the simple principle that people don’t do what they can’t see themselves doing. By having Laura visualize herself controlling her disorganization and fidgeting tendencies, she would be more likely to actually control them. Thus, she would also decrease the amount of time she spent worrying about her ADHD being discovered, and decrease her anxiety.
(Excess Baggage, Judith Sills, p. 147)

Do you have an ADHD adult client with one of the common comorbid conditions, like Antisocial Personality Disorder or Substance Abuse? Or is you ADHD adult client more like Laura, whose comorbid condition is Anxiety? Would your Laura benefit from the "Written Worries" exercise?

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