(Part 2 of 2) Anxiety-The Archnemesis of Attention, Focus, Concentration, Memory, & Learning
Unlock Your Mind - Understand Anxiety's Grip on Focus & Learning
Section IV: Anxiety and ADD/ADHD: Prevalence to Underdiagnosis
More so anxiety, but to a lesser degree, attention-deficit/hyperactivity disorder (ADD/ADHD) are two of the most common psychiatric disorders in the United States, affecting millions yearly. While anxiety and ADD/ADHD share similarities regarding symptoms in memory, new learning, and focus, as discussed previously, they are considered distinct disorders.
We have already reviewed that anxiety disorders, as an umbrella diagnostic group (i.e., Generalized Anxiety Disorder, Panic Disorder, PTSD, OCD, etc.), are characterized by excessive and persistent fear, worry, and anxiety (nervousness to an extreme). These disorders can be debilitating and interfere with daily life, including work, school, and social interactions. Some patients can also suffer restlessness and inability to concentrate or focus in the context of these feelings of fear and worry, leading to memory problems (as items in immediate memory are wiped clean from shift-in-focus to shift-in-focus: as if you over-wrote the contents of RAM before you sent them to the hard-drive for longer-term storage).
According to the National Institute of Mental Health, approximately 31% of adults in the United States will experience an anxiety disorder at some point —NIH, 2023.
According to the National Institute of Mental Health, approximately 31% of adults in the United States will experience an anxiety disorder at some point (NIH, 2023). Anxiety disorders are more common in women than men, with a lifetime prevalence of 33.7% in women and 22.8% in men (NIH, 2023).
ADD/ADHD, on the other hand, is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. According to the Centers for Disease Control and Prevention (CDC), approximately 6.1 million children in the United States have been diagnosed with ADD/ADHD, which continues to rise (CDC, 2023). The prevalence of ADD/ADHD is higher in boys than girls, with a male-to-female ratio of 2:1 (CDC, 2023).
Studies have shown that anxiety is often underdiagnosed as a CAUSE of attention, focus, concentration, memory, and learning problems, especially in children —Owens, M.J., et. al., 1994.
Despite the high prevalence of ADD/ADHD and anxiety disorders, these conditions are often underdiagnosed and under-treated (particularly in children). Both can cause difficulties with attention and concentration, making it difficult to distinguish between them. Studies have shown that anxiety is often underdiagnosed as a CAUSE of attention, focus, concentration, memory, and learning problems, especially in children (Owens, M.J., et. al., 1994).
One study found that anxiety disorders were present in 60% of children with ADD/ADHD and that anxiety was the most common comorbid disorder in this population (Connor, D.F., et. al., 2003). Another study found that children with anxiety disorders were likelier to have impaired attention and cognitive function than children without anxiety disorders, even after controlling for ADD/ADHD (Choudhury M.S. et. al., 2003).
As the adage goes in medicine: “Diagnosis is made for treatment and prognosis” —if we don’t get the diagnosis correct, then we are highly unlikely to achieve remission, as any positive effects of treatment may be by luck alone.
The reason for a sex discrepancy in the distribution of ADD/ADHD and anxiety cases is not entirely apparent. Some researchers suggest hormonal differences between males and females may play a role. For example, testosterone has been shown to have a protective effect against anxiety, while estrogen may increase anxiety (Bangasser D.A. et. al., 2014) even though it has been shown to potntially be neuroprotective of degenerative disorders (Behl, C, et al, 2000). Additionally, there may be differences in brain structure and function between males and females that contribute to the sex differences observed in the prevalence of these disorders (McCarthy M.M., et al., 2012).
“Psoriasis patients are 1.5 times more likely to show depressive symptoms and experience a higher prevalence of anxiety symptoms (20-50%) than individuals without psoriasis —Hedemann T.L., et al, 2022”.
From the immune perspective, inflammation is THE other main systems-mechanism implicated in the relationship between anxiety and cognitive impairment. As mentioned more specifically in a previously-published portion of this article, proinflammatory cytokines, produced by immune cells in response to infection or injury, have been shown to impair cognitive function, particularly in attention, working memory, and executive function (Marsland, A.L. et al., 2008). Additionally, evidence suggests that chronic inflammation may be a risk factor for developing anxiety disorders, more generally (Dantzer, R., et. al., 2008), and these patterns have played prominently in patients with more commonly established chronic pro-inflammatory states like psoriasis or other immune-activated disorders (Sanders, K.M., et al, 2018; Pollo, C.F., et al, 2021; Marek-Jozefowicz, L., et al, 2022; Hedemann T.L., et al, 2022).
I’ve mentioned this before, but it bares re-emphasizing it now:
Stimulant medications such as methylphenidate and amphetamine are effective treatments for ADD/ADHD. Yet, these very potent treatments are powerful because they do things within our physiology at multiple levels —in broad strokes neurochemically— and therefore they carry inherent risks, particularly in children.
These risks include increased heart rate and blood pressure, as well as the potential for abuse and addiction (Volkow, N.D., et al., 2020). Additionally, evidence suggests that long-term use of stimulant medications may be associated with changes in brain structure and function. However, the clinical significance of these changes is not yet clear (Frodl T., et al., 2012).
Alternative treatments for ADD/ADHD include behavioral interventions such as parent training and classroom-based interventions (potent indeed), improved nutrition, sleep hygiene, and non-stimulant medications such as atomoxetine and guanfacine (8). These treatments are effective for some individuals with ADD/ADHD, particularly those who cannot tolerate or do not respond to stimulant medications.
Millions of individuals suffer from these disorders each year, as they are two of the most common psychiatric disorders in the United States.
These disorders share some similarities in terms of symptoms.
They have different, overlapping —compounding, and confounding— underlying causes.
Healthcare providers must recognize the overlap in symptoms and evaluate patients to ensure an accurate and comprehensive problem list and diagnosis.
More research is needed to better understand the underlying causes of these disorders from a precision medicine perspective (systems biology, genomics, metabolomics, etc.) and therefore guide the development of more effective diagnostic measures and specific/targeted treatments.
Section V: The Dangers of Undertreatment
Anxiety is a common and treatable mental health condition that affects approximately 31.1% of individuals at some point (1). Anxiety can manifest as excessive worry, fear, and apprehension about everyday situations or events, significantly impairing an individual's ability to function in daily life.
One of the most significant dangers of undertreating anxiety is the increased lifetime morbidity associated with this condition.
One of the most significant dangers of undertreating anxiety is the increased lifetime morbidity associated with this condition. Studies have shown that individuals with untreated anxiety are more likely to develop other mental health conditions, such as depression, and physical health conditions, such as cardiovascular disease (2, 3).
It is essential for healthcare providers to recognize the overlap in symptoms between anxiety and ADD/ADHD and to thoroughly evaluate patients to ensure an accurate diagnosis —the risks of underdiagnosis, and under-treating either of these disorders are significant.
The medication management of both of these disease states also carries risks, and therefore measured steps should be taken to screen adequately for both in susceptible populations.
Have a high degree of suspicion for both in the context of overlap of symptoms of focus and learning difficulties.
Use medication when appropriate, while underscoring the elder statesman of corny attending one-liners: “Start low, Go slow.”
Despite the apparent need for more research and the overlap in symptoms between anxiety and ADD/ADHD,
it is unclear what the underlying causes are,
where we might find similarities or overlaps in therapy, and
where else they may need different ones.
As mentioned earlier, anxiety disorders are often associated with dysregulation of the stress response, which can lead to chronic activation of the hypothalamic-pituitary-adrenal (HPA) axis and subsequent immune system dysregulation. This chronic activation of the stress response can lead to impairments in attention, focus, concentration, memory, and learning and an increased risk for various physical health problems (McEwen, B.S. et al., 2008). Therefore no need to add to those risks unnecessarily or imprudently by not throwing the proverbial ‘kitchen sink’ at establishing as precise of a diagnosis as possible (this can be via multiple clinical exams by different providers, reviewing clinical records, certain lab measures, standardized questionaires by patient/by teachers-caregivers/by parents/by clinicians).
The undertreatment or missed diagnoses of either disorder is concerning because untreated anxiety can have significant long-term consequences, including increased risk for substance abuse, depression, and other psychiatric disorders (Kessler, R.C., et al., 2005).
"Alcohol use disorders share common genetic risk factors with several neuropsychiatric disorders, including depression, anxiety disorders, and ADHD" (Evangelou 2019).
Undertreated ADD/ADHD can impair academic and social functioning and increase the risk for substance abuse, depression, and other psychiatric disorders (Biederman, J. et. al., 2008).
"Identifying these shared genetic mechanisms may improve our understanding of the underlying pathophysiology of these disorders and facilitate the development of novel treatments” (Evangelou 2019).
Moreover, anxiety can harm an individual's social and occupational functioning. For example, anxious individuals may have difficulty forming and maintaining relationships, completing tasks at work or school, and participating in social activities.
Children with anxiety are especially vulnerable to the adverse effects of undertreatment. Remember, especially in children, anxiety is often underdiagnosed, as they may have difficulty communicating their symptoms effectively. This can significantly impair academic performance, social functioning, and overall quality of life.
In addition, anxiety in childhood can increase the risk of developing other mental health conditions, such as depression and substance use disorders, later in life.
Many individuals do not receive appropriate treatment despite the potential dangers of undertreating anxiety. One reason is the stigma associated with mental health conditions, which can prevent individuals from seeking help.
Furthermore, some individuals may not recognize that their symptoms are related to anxiety or may be reluctant to take medication for fear of side effects. However, effective treatments for anxiety are available, including cognitive-behavioral therapy, medications, and other complementary therapies —to include (but certainly not limited to): proper diet, nutrition, gut-microbiome considerations, vitamin D, B12 and folate optimization and improved glucose regulation.
Recognizing and treating anxiety in this population is especially crucial in children so as to improve their quality of life and long-term outcomes. Effective treatments for anxiety are available, and seeking appropriate treatment is essential to achieving optimal health and well-being.
In addition to the potential negative consequences of undertreating anxiety, there are potential risks associated with using medication to treat anxiety, particularly with stimulants commonly prescribed for Attention Deficit Hyperactivity Disorder (ADHD) (whether due to underdiagnosis or misdiagnosis of attentional and concentration problems — or with co-morbid ADD/ADHD patients).
Stimulant medications, such as methylphenidate and amphetamines, are commonly prescribed to treat ADHD. These medications can improve attention, focus, and concentration in individuals with ADHD but also have significant short-term and long-term risks, while at the same time have the potential to exacerbate anxiety symptoms in patients misdiagnosed or with co-morbid anxiety disorders. Moreover, there is evidence that individuals with anxiety may be more susceptible to the adverse effects of stimulant medication. This highlights the importance of carefully evaluating the risks and benefits of stimulant medication in individuals with anxiety and considering alternative treatments when appropriate. Short-term risks of stimulant use include appetite suppression, insomnia, and irritability. Long-term risks include high blood pressure, heart problems, and addiction and disruption of sleep —all of which can have deliterious effects on patients with ADHD and or anxiety.
Alternative treatments for ADHD and anxiety include non-stimulant medications, such as atomoxetine and guanfacine, and behavioral therapies, such as cognitive-behavioral therapy and mindfulness-based interventions (12). These treatments may be particularly beneficial for individuals with anxiety, as they do not carry the same risks as stimulant medication.
Undertreating anxiety can have significant negative consequences, including increased lifetime morbidity, impaired social and occupational functioning, and increased risk of developing other mental and physical health conditions. Children with anxiety are especially vulnerable to these adverse outcomes.
While medication can be an effective treatment for anxiety, particularly in the short term, it is essential to carefully evaluate the risks and benefits of medication use, particularly with stimulants commonly prescribed for ADHD.
Alternative treatments, such as non-stimulant medication and behavioral therapies, may be more appropriate for individuals with anxiety.
It is essential to recognize that anxiety, like ADD/ADHD, is a legitimate medical condition that can have significant consequences if left untreated.
By seeking appropriate treatment, individuals with anxiety can improve their quality of life, reduce their risk of developing other health conditions, and achieve their full potential.
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