Clinical Effects of ADHD Subtypes in Patients With Social Anxiety Disorder

Poor face recognition predicts social anxiety in autism: A short report

LAY ABSTRACT

Research has shown that some autistic people have severe difficulties in recognising other people's faces. However, little is understood about how these difficulties impact the daily life and the mental well-being of autistic people. In this study, we asked 60 autistic adults with varying degrees of face recognition ability to complete two tests of face recognition, a questionnaire about social anxiety and a bespoke survey which asked participants about their experiences of face recognition and social interaction. We found that participants who had poor face recognition reported experiencing higher levels of social anxiety compared to those with average or better face recognition skills. More than half felt that their face recognition difficulties affected their social interactions, and over a third believed it hindered their ability to make friends. These findings suggest that face recognition difficulties may contribute to social anxiety among autistic individuals.

The Relationship Between Social Anxiety Disorder and ADHD in Adolescents and Adults: A Systematic Review

OBJECTIVE

This review aimed to systematically gather empirical data on the link between social anxiety disorder and ADHD in both clinical and non-clinical populations among adolescents and adults.

METHOD

Literature searches were conducted in PsycInfo, PubMed, Scopus, and Web of Science, resulting in 1,739 articles. After screening, 41 articles were included. Results were summarized using a narrative approach.

RESULTS

The prevalence of ADHD in adolescents and adults with SAD ranged from 1.1% to 72.3%, while the prevalence of SAD in those with ADHD ranged from 0.04% to 49.5%. Studies indicate that individuals with both SAD and ADHD exhibit greater impairments. All studies were judged to be of weak quality, except for two studies which were rated moderate quality.

DISCUSSION

Individuals with SAD should be screened for ADHD and vice versa, to identify this common comorbidity earlier. Further research is needed to better understand the prevalence of comorbid ADHD and SAD in adolescents.

The clinical, neuropsychological, and brain functional characteristics of the ADHD restrictive inattentive presentation

Objectives

There is an ongoing debate about the restrictive inattentive (RI) presentation of attention deficit hyperactivity disorder (ADHD). The current study aimed to systematically investigate the clinical, neuropsychological, and brain functional characteristics of children with ADHD restrictive inattentive presentation.

Methods

A clinical sample of 789 children with or without ADHD participated in the current study and finished clinical interviews, questionnaires, and neuropsychological tests. Those individuals with a diagnosis of ADHD were further divided into three subgroups according to the presentation of inattentive and/or hyperactive/impulsive symptoms, the ADHD-RI, the ADHD-I (inattentive), and the ADHD-C (combined) groups. Between-group comparisons were carried out on each clinical and neuropsychological measure using ANCOVA, with age and sex as covariates. Bonferroni corrections were applied to correct for multiple comparisons. Two hundred twenty-seven of the subjects also went through resting-state functional magnetic resonance imaging scans. Five ADHD-related brain functional networks, including the default mode network (DMN), the dorsal attention network (DAN), the ventral attention network, the executive control network, and the salience network, were built using predefined regions of interest (ROIs). Voxel-based group-wise comparisons were performed.

Results

Compared with healthy controls, all ADHD groups presented more clinical problems and weaker cognitive function. Among the ADHD groups, the ADHD-C group had the most clinical problems, especially delinquent and aggressive behaviors. Regarding cognitive function, the ADHD-RI group displayed the most impaired sustained attention, and the ADHD-C group had the worst response inhibition function. In terms of brain functional connectivity (FC), reduced FC in the DMN was identified in the ADHD-C and the ADHD-I groups but not the ADHD-RI group, compared to the healthy controls. Subjects with ADHD-I also presented decreased FC in the DAN in contrast to the control group. The ADHD-RI displayed marginally significantly lower FC in the salience network compared to the ADHD-I and the control groups.

Conclusion

The ADHD-RI group is distinguishable from the ADHD-I and the ADHD-C groups. It is characterized by fewer externalizing behaviors, worse sustained attention, and better response inhibition function. The absence of abnormally high hyperactive/impulsive symptoms in ADHD-RI might be related to less impaired brain function in DMN, but potentially more impairment in the salience network.

Multimodal treatment efficacy differs in dependence of core symptom profiles in adult Attention-Deficit/Hyperactivity Disorder: An analysis of the randomized controlled COMPAS trial

There is broad consensus that to improve the treatment of adult Attention-Deficit/Hyperactivity Disorder (ADHD), the various therapy options need to be tailored more precisely to the individual patient's needs and specific symptoms. This post-hoc analysis evaluates the multimodal effects of first-line medication (methylphenidate [MPH] vs placebo [PLB]) and psychotherapeutic (group psychotherapy [GPT] vs clinical management [CM]) treatments on the ADHD core symptoms inattention, hyperactivity and impulsivity. For the two-by-two factorial, observer-blinded, multicenter, randomized controlled Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS; ISRCTN54096201), 419 outpatients with ADHD were considered for analysis. ADHD symptoms were assessed by blind observer-rated and patient-rated Conners Adult ADHD Rating Scales before treatment (T1), 13 weeks (T2) and 26 weeks (T3) after T1, at treatment completion after 52 weeks (T4), and at follow-up (130 weeks, T5). MPH was superior to PLB in improving symptoms of inattention at almost all endpoints (observer-rated T2, T3, T4, T5; patient-rated T2, T3, T4), while a significant decrease in hyperactivity and impulsivity was at first found after 6 months of treatment. CM compared to GPT decreased inattention and impulsivity in the early treatment phase only (observer-rated T2, patient-rated T2, T3). In conclusion, while MPH seems to have a direct and sustained effect on inattention, premature medication discontinuation should particularly be avoided in patients with hyperactive-impulsive symptoms. Also, especially in high inattention and/or impulsivity presentations, initial individual patient management might be beneficial. Consequently, considering individual core symptom profiles may enhance the efficacy of treatments in adult ADHD.

ADHD-inattentive versus ADHD-Combined subtypes: A severity continuum or two distinct entities? A comprehensive analysis of clinical, cognitive and neuroimaging data

The current study aimed to explore the multimodal differences between the inattentive ADHD (ADHD-I) subtype and the combined ADHD (ADHD-C) subtype. A large sample of medication-naïve children with pure ADHD (i.e., without any comorbidity) (145 with ADHD-I, 132 with ADHD-C) and healthy controls (n = 98) were recruited. A battery of multiple scales and cognitive tests were utilized to assess the clinical and cognitive profiles of each individual. In addition, structural and diffusion magnetic resonance imaging (MRI) were acquired for 120 subjects with ADHD and 85 controls. Regional gray matter volume, white matter volume, and diffusion tensors, e.g., axial diffusivity (AD), were compared among the three groups in a whole-brain voxel-wise manner. Compared with healthy controls, both ADHD groups exhibited elevated levels of behavioral and emotional problems. The ADHD-C group had more behavioral problems and emotional liability, as well as less anxiety, than the ADHD-I group. The two ADHD groups were equally impaired in most cognitive domains, with the exception of sustained attention. Compared with healthy controls, the ADHD-C group showed a high gray matter volume (GMV) in the bilateral thalamus and a high white matter volume in the body of the corpus callosum, while the ADHD-I group presented an elevated GMV mainly in the left precentral gyrus and posterior cingulate cortex. Compared with participants with ADHD-C and healthy controls, subjects with ADHD-I showed increased AD in widespread brain regions. Our study has revealed a distinct, interconnected pattern of behavioral, cognitive, and brain structural characteristics in children with different ADHD subtypes.

ADHD and Anxiety Disorder Comorbidity in Children and Adults: Diagnostic and Therapeutic Challenges

PURPOSE OF THE REVIEW: In this review, we focus on overlapping features of ADHD and anxiety disorders, and will discuss how an anxiety disorder comorbidity leads to diagnostic and treatment challenges in patients with ADHD, in consideration of the accumulated available knowledge. RECENT FINDINGS: The presence of overlapping symptoms, changes in the diagnostic criteria, and the use of divergent diagnostic tools and informant effects can complicate the diagnosis of this comorbidity. Due to the ongoing debate about the etiology, psychopathology, and diagnostic features of the association between ADHD and anxiety disorders, choosing appropriate treatment options emerges as a challenge. A novel methodology, standardized interview tools, and new statistical analysis methods are needed to define the phenotype of this co-occurrence more clearly. It is important to uncover the developmental nature of this comorbidity with follow-up studies that may explain the etiology and underlying neurobiological basis, and ultimately lead to more effective treatment approaches.

Empathy in Social Anxiety Disorder: The Association with Attention Deficit Hyperactivity Disorder

Objectives: Our main hypothesis in this study was that patients with social anxiety disorder (SAD) and comorbid attention deficit hyperactivity disorder (ADHD) had lower empathy levels than those without ADHD. Also, after controlling for the severity of SAD and depression, we hypothesized that ADHD symptoms contributed to lower levels of empathy in SAD patients.Methods: 72 patients (46 females, 32 males) with SAD between the ages of 18-65 years were divided into two groups as those with (n = 32) and those without ADHD (n = 40). Participants were evaluated using the Liebowitz Social Anxiety Scale (LSAS), Turgay's Adult Attention-Deficit/Hyperactivity Disorder, Beck Depression Inventory (BDI), and Empathy Quotient. In this study, Mann Whitney-U test, Spearman correlation test, logistic and multiple regression analysis were used.Results: Education level (U = 371.5, p = .002) and empathy scores (U = 259.5, p < .0001) of SAD patients with ADHD were significantly lower than those without ADHD. BDI (U = 206.5, p < .0001), LSAS total (U = 454.5, p = .036), fear (U = 457.0, p = .038), and avoidance scores (U = 453.0, p = .034) were higher in SAD patients with ADHD than those without ADHD. Low levels of empathy (B = - 0.119, Exp(B) = 0.895, p = .014) and high severity of current depression (B = 0.119, Exp(B) = 1.127, p = .001) were significantly associated with comorbidity between SAD and ADHD. ADHD-inattention (β = -0.369, Exp(B) = -0.541, p = .004), and depression (β = -0.262, Exp(B) = -0.212, p = .036) negatively predicted empathy levels.Conclusions: Our findings may provide some evidence for the contribution of ADHD-inattention and depression to poor empathy in SAD patients. Therefore, it is recommended that symptoms of ADHD-inattention and depression should be carefully evaluated in SAD patients with low empathy.

The Mediating Effects of Self-Esteem and Harm Avoidance on the Association between Social Anxiety Symptoms and Adult Attention Deficit Hyperactivity Disorder Symptom Severity in Turkish Inpatients with Alcohol Use Disorder

Objective: The first objective of this research was to examine the association of the symptom severity of social anxiety with the adult attention deficit hyperactivity disorder (ADHD) symptom severity in Turkish patients with alcohol use disorder (AUD). The second objective was to examine if harm avoidance and self-esteem mediated this relationship.

Method: This cross-sectional analysis was performed among 151 inpatients with AUD at the Bakirkoy/AMATEM, a treatment center for substance use disorder, in Istanbul. Patients were examined with the Liebowitz Social Anxiety Scale (LSAS), the Adult ADHD Self-Report Scale (ASRS), the Rosenberg Self-Esteem Scale (SES), and the temperament dimension of Harm Avoidance (HA). Using SPSS-20 software, the data was analyzed using Pearson correlations, multivariate analysis of covariance (MANCOVA), and multiple linear regressions.

Results: The scales scores were mildly correlated with each other. The low self-esteem and high HA were related with the inattentive (IN) dimension of ADHD, whereas low self-esteem solely predicted hyperactivity/impulsivity (HI) dimension of ADHD in MANCOVA. In the linear regression analysis, the severity of social anxiety, particularly avoidance dimension, was associated with the symptom severity of ADHD. In the second step of the analysis, together with the avoidance dimension of social anxiety, self-esteem was associated with the symptom severity of ADHD. However, in the third step, after including HA as an independent variable in the analysis, the avoidance dimension of social anxiety was no longer associated with the severity of adult ADHD symptoms, whereas self-esteem together with HA (particularly “anticipatory worry and pessimism” [HA-1], and “asthenia and fatigability” [HA-4]) predicted.

Conclusion: Findings of the present study shows that although the symptom severity of social anxiety is associated with the severity of ADHD symptoms among inpatients with AUD, among dimensions of social anxiety, the avoidance dimension plays a main role in this relationship. Also, while the self-esteem partially mediates this relationship, HA seems to have a full mediator effect on this relationship.

Self esteem and clinical features in a clinical sample of children with ADHD and social anxiety disorder

OBJECTIVE

In this study, we aimed to investigate self-esteem and clinical features in clinically referred children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and comorbid Social Anxiety Disorder (SAD) and compare these to children and adolescents without SAD.

METHODS

One hundred and twenty child and adolescent drug-naïve outpatients (6-15 years of age) with a primary diagnosis of ADHD were included. Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL), was used to evaluate ADHD and comorbidities. Parents filled in clinical and sociodemographic data form, Conners Parent Rating Scale (CPRS) and patients filled in Rosenberg Self-esteem Scale (RSES) and Çapa Social Phobia Scale for children and adolescents (ÇESFÖ).

RESULTS

Forty-six of the 120 (38.3%) children had comorbid SAD. Forty-six patients with SAD (ADHD + SAD group) and 74 patients without SAD (ADHD without SAD group) were compared in terms of the sociodemographic and clinical features, rate of psychiatric comorbidities, and rating scale scores. The rate of inattentive subtype of ADHD (p = 0.009), and social anxiety symptom scores (p < 0.001) were higher and self-esteem was lower (p < 0.001) in the ADHD + SAD group. Additionally, there was a statistically significant correlation between ÇESFÖ scores and CPRS anxiety subscale scores (r = 0.300, p = 0.001), and also Rosenberg self-esteem scale scores (r = 0.470, p < 0.001).

CONCLUSION

Children and adolescents with ADHD who had comorbid SAD may differ from ADHD patients without SAD in terms of ADHD subtype, clinical features and self-esteem.

Psychopathologic Profiles and Clusters in Tertiary Clinic Referred Patients with Adult Attention Deficit Hyperactivity Disorder: A Person-Centered Analysis

OBJECTIVE

Adult attention deficit hyperactivity disorder (ADHD) has a heterogeneous clinical presentation with patients showing very frequent emotional problems. In the present study, patients with adult ADHD were subtyped based on their psychopathology using a person-centered approach.

METHODS

In the present chart review study, detailed findings of psychological evaluation conducted as part of routine care were utilized. A total of 77 subjects with adult ADHD were included in the analysis. Detailed ADHD symptoms, psychiatric comorbid Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses, and severity of mood and anxiety symptoms were evaluated in the person-centered analysis.

RESULTS

Three clusters were generated using clustering analysis. DSM comorbid conditions did not significantly impact the clustering. Cluster 1 consisted of ADHD combined presentation (ADHD-C) with less mood symptoms, cluster 2 of ADHD predominantly inattentive presentation and cluster 3 of ADHD-C with significant mood symptoms. Patients in cluster 3 had adulthood functional impairment more frequently compared with patients in cluster 1. Patients in cluster 3 showed recurrent thoughts of death and suicidal ideation more frequently compared with patients in cluster 1.

CONCLUSION

Further studies are needed to confirm the relationships observed in the present study.

Disentangling the effects of attentional difficulties on fears of social evaluation and social anxiety symptoms: Unique interactions with sluggish cognitive tempo

Although fears of negative and positive social evaluation are hallmark cognitive features of social anxiety, attentional difficulties may exacerbate the relation between fears of social evaluation and social anxiety. Thus, the goal of the current study was to test whether two different types of self-reported attentional difficulties, specifically sluggish cognitive tempo (SCT) and attention-deficit/hyperactivity disorder (ADHD) inattention symptoms, moderate the relation between fears of social evaluation and social anxiety. Participants (N = 4756; Mage = 19.28 years; 72.7% female) enrolled in five universities across the United States completed self-report measures of fears of negative and positive evaluation and psychopathology symptoms. Results indicated a significant two-way interaction of fear of negative evaluation and SCT in relation to social anxiety symptoms, as well as a significant two-way interaction of fear of positive evaluation and SCT in relation to social anxiety symptoms. In both instances, the associations between fears of negative and positive evaluation in relation to social anxiety became increasingly stronger at higher levels of SCT. Conversely, the interactions between fears of negative and positive evaluation with ADHD inattentive symptoms were non-significant. These results are the first to report that self-reported SCT, but not ADHD inattentive symptoms, exacerbate the relation between fears of social evaluation and social anxiety, and suggest that attentional difficulties characteristic of SCT may prolong engagement in fears.

Correlation between Taijin-Kyofu-sho and Attention Deficit Hyperactivity Disorder among University Students: A Self-Reported Assessment Study

Taijin-Kyofu-sho (TK) is regarded as a culture-bound anxiety disorder in East Asian counties. Despite its earlier discovery in Japan, fewer studies have focused on TK than on social anxiety disorder (SAD) and even fewer on TK comorbidity with developmental disorders. Thus, we examined the association between TK and attention deficit hyperactivity disorder (ADHD) among Japanese university students. A total of 673 students (500 male, 173 female) were assessed on the Japanese version of Liebowitz Social Anxiety Scale (LSAS-J), TK scale, and adult ADHD Self-Report Scale (ASRS; version 1.1). On the TK scale and LSAS-J, 17.4 and 10.3 percent of students, respectively, exceeded the cut-off value. Furthermore, ASRS scores more strongly correlated with TK scale than LSAS-J scores (TK scale: r = 0.427; LSAS-J: r = 0.330). To evaluate how TK or SAD with ADHD affects those scores, we divided subjects into four groups: healthy subjects, subjects with TK, those with SAD, and those with both disorders. The total ASRS score was significantly higher in TK-only subjects than in healthy subjects (p < 0.0001). However, there was no significant difference between scores of healthy and SAD-only subjects (p = 0.281). Our results indicate a possible link between ADHD and later development of TK in Japan.

Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges

Comorbid disorders are highly prevalent in patients with social anxiety disorder, occurring in as many as 90% of patients. The presence of comorbidity may affect the course of the disease in several ways such as comorbidity in patients with social anxiety disorder (SAD) is related to earlier treatment-seeking behavior, increased symptom severity, treatment resistance and decreased functioning. Moreover, comorbidities cause significant difficulties in nosology and diagnosis, and may cause treatment challenges. In this review, major psychiatric comorbidities that can be encountered over the course of SAD as well as comorbidity associated diagnostic and therapeutic challenges will be discussed.

Comorbidity of Attention Deficit Hyperactivity Disorder and Generalized Anxiety Disorder in children and adolescents

The aim of the study is to explore the impact of Generalized Anxiety Disorder (GAD) comorbidity in children with Attention Deficit Hyperactivity Disorder (ADHD). Six hundred children with ADHD (mean age = 9.12 years), recruited from 2013 to 2017, participated in the study. A total of 96 (16%) children with ADHD displayed a comorbidity with GAD. ADHD + GAD were compared to 504 ADHD children without GAD in terms of cognitive and psychiatric profile, ADHD subtype and family psychiatric history. The ADHD + GAD, predominantly represented from ADHD combined (72.6%), displayed higher psychiatry comorbidity, in particular with depressive disorders, and were associated with higher rates of maternal depression, of ADHD in fathers, and bipolar disorders in second degree relatives. Moreover, younger preschool-primary school age children with ADHD + GAD showed significant higher frequency of depressive disorders versus younger preschool-primary children with ADHD without GAD. ADHD + GAD comorbidity represents a more complex clinical condition compared to ADHD without GAD, characterized by the higher frequency of multiple comorbidities and by a psychiatric family with higher rates of mood and disruptive disorders.

Development of social anxiety disorder secondary to attention deficit/hyperactivity disorder (the developmental hypothesis)

Social anxiety disorder (SAD) may develop secondary to childhood attention deficit/hyperactivity (ADHD) in a subgroup of the patients with SAD. Patients pass through a number of identifiable stages of developmental pathways to SAD as they grow up. Patients with ADHD have maladaptive behaviours in social settings due to the symptoms of ADHD. These behaviours are criticized by their parents and social circle; they receive insults, humiliation and bullying. After each aversive incident, the individual feels shame and guilt. A vicious cycle emerges. The patients then develop social fears and a cognitive inhibition that occurs in social situations. The inhibition increases gradually as the fear persists and the individual becomes withdrawn. Patients start to monitor themselves and to focus on others' feedback. Finally, performative social situations become extremely stimulating for them and may trigger anxiety/panic attacks. If this hypothesis is proven, treatment of 'patients with SAD secondary to ADHD' should focus on the primary disease.

The relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder in Turkish university students; impact of negative affect and personality traits of neuroticism and extraversion

The aim of the present study was to evaluate relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder (ADHD) while controlling the personality traits of neuroticism and extraversion, anxiety and depression symptoms in a sample of Turkish university students (n=455). Participants were evaluated with the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Eysenck Personality Questionnaire Revised-Abbreviated Form (EPQR-A), the Adult ADHD Self-Report Scale (ASRS-v1.1) and the Liebowitz Social Anxiety Scale (LSAS). Severity of social anxiety, depression, anxiety and neuroticism were higher among those with probable ADHD, whereas extraversion score did not differ between the groups. The severity of ADHD score, particularly hyperactivity/impulsivity score, was related with the "fear or anxiety" together with low extraversion (introversion) and high neuroticism dimensions of personality, whereas the severity of ADHD score, both inatentiveness and hyperactivity/impulsivity scores, was related with "avoidence" together with low extraversion (introversion) dimension of personality. These findings suggest that probable ADHD and severity of ADHD symptoms are related with both "fear or anxiety" and "avoidance" of social anxiety, while personality dimensions of low extraversion (introversion) and high neuroticism may have an effect on this relationships among young adults.

Diagnostic profiles of adult psychiatric outpatients with and without attention deficit hyperactivity disorder

OBJECTIVE

Despite growing recognition that attention deficit/hyperactivity disorder (ADHD) is a highly prevalent, impairing, and comorbid disorder that persists into adulthood, reports on the nature and extent of its psychiatric comorbidities have been mixed to date. This study compared the prevalence rates of all major Axis I disorders as well as borderline personality disorder in an unselected sample of adult psychiatric outpatients with and without ADHD.

METHODS

As part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we administered a DSM-IV-based semi-structured diagnostic interview assessing ADHD and other psychiatric disorders to 1134 patients presenting for initial evaluation at an outpatient psychiatric practice. Logistic regression analyses were used to compare the rates of each disorder in patients with versus without an ADHD diagnosis (both overall and by Combined and Inattentive type).

RESULTS

Patients with (versus without) any ADHD diagnosis had significantly higher rates of bipolar disorder, social phobia, impulse control disorders, eating disorders, and BPD, and significantly lower rates of major depressive disorder and adjustment disorder (all p<.05). Patients with (versus without) ADHD-Inattentive type had significantly higher rates of social phobia and eating disorders, whereas those with (versus without) the ADHD-Combined type had significantly higher rates of bipolar disorder, alcohol dependence, and BPD (all p<.05).

CONCLUSION

In this novel investigation of the psychiatric profiles of an unselected sample of treatment-seeking adult outpatients with versus without ADHD, a distinct pattern of comorbidities emerged across subtypes, with implications for the accurate assessment and treatment of patients presenting for psychiatric care.