Therapy of Social Anxiety Disorder (5)

Therapy-of-Social-Anxiety-Disorder-5-Christian-Jonathan-Haverkampf-psychotherapy-series

Therapy of Social Anxiety Disorder

Christian Jonathan Haverkampf, M.D.

Social anxiety disorder can significantly reduce an individual’s choices in life and the quality of life overall. Since communication is the process by which humans fulfil their needs, values and aspirations, its effectiveness is important for satisfaction, contentment and happiness in life. It is the main autoregulatory instruments, also in the psychotherapeutic process, to promote mental health. If interpersonal communication is interfered with by anxiety, these processes can no longer work effectively. As the individual withdraws further, the capabilities for needs fulfilment and autoregulation decline further.

Focusing on interpersonal and intrapersonal communication patterns can help to reverse the vicious cycle of social anxiety. Communication-Focused Therapy® (CFT®) provides a toolset, methodological and theoretical framework to facilitate the awareness for individual communication patterns and the interventions to improve them in line with the patient’s needs, values and aspirations.

Keywords: social anxiety, communication-focused therapy, CFT, CBT, psychodynamic psychotherapy, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Self-Image. 4

External Image. 5

Focus. 5

Experiencing the Interaction. 6

Transparency. 6

Habituation. 7

Social Network. 7

Social Exclusion. 7

Hierarchies. 8

Technology. 8

Symptoms. 9

Measurement 9

Neurobiology. 9

The Amygdala. 9

Identity. 10

‘Lost Opportunities’ 11

Judgment 11

Location. 11

Treatment 12

Cognitive-Behavioral Therapy (CBT) 12

Psychodynamic Psychotherapy. 13

Mindfulness-based stress reduction (MBSR) 13

D-Cycloserine. 13

Communication-Focused Therapy® (CFT®) 13

Introduction. 14

Communication as Autoregulation. 14

Communication Patterns. 14

Attention. 15

Communication to Participate in Life. 15

Understanding Social Anxiety and Shyness. 15

Internal Communication. 16

Uncertainty. 16

Communication Deficits. 16

Avoidance. 17

Meaning. 17

Awareness of Thought Patterns. 17

Flow of Information. 18

Emotional Reconnection. 18

Experiencing the World. 18

Communication Techniques. 19

Breaking the Cycle of Anxiety. 19

The Reward of Seeing More. 20

Values, Needs and Aspirations. 20

The Need for Communication. 20

Meaningful Messages as the Instrument of Change. 21

Embracing Change. 22

Living. 23

References. 24

Introduction

A person suffering from social anxiety disorder feels unwell in social situations and begins to avoid them, which can not infrequently lead to significant problems in daily life. Social anxiety is more than just shyness. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. (World Health Organization, 1992) The prevalence of 12-month and lifetime prevalence of social anxiety disorder is around 3% and 5%, respectively. (Grant et al., 2005) It is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. (Stein & Stein, 2008) In a study by La Greca and Lopez on adolescents, girls reported more social anxiety than boys, and social anxiety was more strongly linked to girls’ social functioning than to that of boys. Girls with higher levels of social anxiety reported fewer friendships, and less intimacy, companionship, and support in their close friendships. (La Greca & Lopez, 1998)   Social anxiety disorder is also sometimes referred to as social phobia.

Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (e.g., personality trait neuroticism) core phenotypes to identify risk loci. (Stein & Stein, 2008) There are several psychological and psychopharmacological treatments (Haverkampf, 2017h) available. Communication-Focused Therapy® (CFT®) as developed by the author is an approach that targets the processes and patterns which are underlying interpersonal interactions. (Haverkampf, 2013, 2017a, 2018f)

Self-Image

The sense of a stable self-image plays an important role in lowering social anxiety. The more confident one is oneself, and thus the more one is connected with oneself in a meaningful way, the lower the anxiety will be in interpersonal or social situations. Having a good and stable self-image requires connection with oneself, the ability to be open and receptive to information that originates within oneself, other than the information that is received from the external world through the sense, for example. Even though the distinction between the internal and the external maybe somewhat artificial, it is important to acknowledge that there are sources of information which are not in the external world. In some psychiatric conditions, such as in psychosis, this distinction between the external and the internal can get lost with potentially severe consequences.

How the internal self-image can affect the communication with others has been demonstrated by Hirsch and colleagues. One group was asked to hold in mind a negative self‐image, while the other held in mind a less negative (control) self‐image. When holding the negative image, the socially anxious volunteers felt more anxious, reported using more safety behaviors, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers’ performance as poorer in the negative image condition. Furthermore, both groups of participants rated its quality as poorer in the negative image condition. (Hirsch et al., 2004)

External Image

Social anxiety arises when individuals are motivated to make a preferred impression on real or imagined audiences, such as when one tries to portray an image to others one believes others want to see, or where a person believes there is an external benefit to making oneself appear with certain characteristics. This is inextricably linked to the fear that just being oneself is not good enough, that one will be judged in unpredictable and possibly harsh ways by everyone or a defined group of others.

The cognitive state of the individual can mediate both affective arousal and behavior. (Schlenker & Leary, 1982) At the same time, external factors within the environment can have an effect on how an individual thinks and feels in a given situation, which is also influenced by individual predispositions and traits. In clinical experience, the more an individual tries to adhere to portraying an external image that is believed to be required by external factors and other people, but which does not match with the individual’s communication styles and personality traits, needs, values and aspirations, the less stable the interaction will become, leading to more anxiety and a mutually less satisfying experience. (Haverkampf, 2010a, 2013)

Focus

When it comes to the important role of information dynamics in the epigenesis of social anxiety, focus is an important mediator because it selects the information that becomes available in an interaction. Since all forms of anxiety arise from a deficit of meaningful information or unhelpful ways of processing it, social anxiety can be improved by helping a patient to learn more helpful ways in selecting and focusing on particular types of information.

Socially anxious individuals are excessively concerned about negative evaluation by others. And they often focus more on threat cues or imagined threat cues. In a study by Mansell and colleagues, high socially anxious individuals when compared to low socially anxious individuals showed an attentional bias away from emotional (positive and negative) faces when under conditions of social-evaluative threat. (Mansell et al., 1999) As discussed above, this leads to a situation where less information is available to the socially anxious person, which does not help mitigate the social anxiety.

Socially-anxious individuals also have an increased number of negative cognitions and fewer positive cognitions, while situational factors appear to mediate the absolute level of reactivity. (Beidel et al., 1985) This probably turns the focus even more away from sources of information which could lead to a reduction in the anxiety, resulting in a vicious cycle in which social withdrawal and more negative interpretation of interpersonal interactions and the environment overall leads to even more social withdrawal. In Communication-Focused Therapy® this cycle can be broken by working on the communication patterns the individual uses, which are the structural entities that facilitate the information flow to him or her.

Experiencing the Interaction

Many people who are suffering from social anxiety are familiar with the feeling of continuously asking themselves what other people are thinking about them. In one study, anxious subjects were more likely to attribute more meaning to others’ thoughts. (Hezel & McNally, 2014) The same study interestingly also found that socially anxious individuals performed worse on theory of mind tasks. Theory of mind is the ability to attribute mental states — beliefs, intents, desires, emotions, knowledge, etc. — to oneself and to others. It is necessary to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own. In other words, to fully appreciate the separate mind of another person with its unique content and information processing requires a theory of mind, which seems impaired in individuals with social anxiety. However, to fully reflect on the information dynamics and communication patterns within an interaction it is important to have a basic working concept of an “I” and a “You”. Communication-Focused Therapy® also includes techniques aimed at strengthening this distinctions. (Haverkampf, 2017a, 2017e)

A person suffering from social anxiety takes great pains to not only try to follow the dynamics of an interaction but at the same time to interpret what the partners to an interaction are thinking and feeling about them. While individuals with social anxiety are often quite perceptive and sensitive to various channels of information, this can lead to an information overload, which as a result makes them turn away from the interaction, which increases the anxiety even to a higher level. Communication-Focused Therapy® attempts to reverse this vicious cycle by developing awareness for communication patterns and information flows and practicing communication in a way that leads to fulfilment of own needs, values and aspirations, which also lowers the anxiety.

Transparency

Being able to give oneself permission to practice greater openness in communicating with others is an important step towards overcoming social anxiety. The feedback and information from others help to lower the anxiety as others’ dreaded thoughts turn out to be untrue. However, many people suffering from social anxiety already believe that they are overly transparent to others, that others can see what they are thinking and feeling, such as the anxiety or negative feelings, such as anger or frustration, which could interfere with the social bond from the interaction. As the distinction between the inside and outside worlds of the mind are weaker, the socially anxious person tries even harder to control themselves. Individuals with social anxiety are often quite sensitive, but their interpretation of information is often more on the negative side. Depression with anxiety can mask as the ‘pure’ social anxiety disorder.

Interesting is that studies suggest that socially anxious individuals remember more negative memories than those less distressed. This may either have a biological explanation or be a learned phenomenon. However, since social anxieties do seem to run in families at least partially, there may be a biological explanation to it.  A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Habituation

Habituation is the process by which through a ‘getting used’ to an anxiety or fear inducing stimulus the psychological and physical reaction to it decreases. One becomes less anxious or fearful in the face of information that otherwise induced anxiety or fear, such as the visual input that one is looking out high up on a tall building, if one exposes oneself repeatedly to the information. Social anxiety involves social cues that can induce anxiety. The latency at which habituation occurs, however, seems to be different in individuals that are suffering from social anxiety. (Beidel et al., 1985)

From the perspective of Communication-Focused Therapy® (CFT), any information that is repetitive and has lost its characteristics of novelty will lead to a lesser response, whether in terms of feelings, emotions, thoughts or otherwise. Thus, the internal and external context matters whether habituation will take place. One may reach habituation in one type of situation and when experiencing a particular family of thoughts and perceptions, but conventional behavioural and cognitive methods in the form of CBT, for example, often lead to improvements that are limited in time and circumstance. However, changing one’s exposure to meaningful information, that is information which brings about a change in the recipient, through changes in communication patterns, can be highly effective. Changes in communication patterns also have a longer-lasting effect because the flow of information is permanently altered. CFT works to adjust the communication patterns in the session through awareness, reflection, experimentation and change. It is not primarily the change in perspective or learning new thought patterns that bring about change but changes in communication patterns that determine them through the information they make available, and how information is processed. (Haverkampf, 2010b, 2017a) Practising new communication patterns in the therapeutic session usually shows a significant over time with respect to anxiety, but also anxiety in general.

Social Network

Various aspects of social relations uniquely contribute to feelings of internal distress. In a study by La Greca and Harrison with adolescents, crowd affiliations (high and low status), positive qualities in best friendships, and the presence of a dating relationship protected adolescents against feelings of social anxiety, whereas relational victimization and negative interactions in best friendships predicted high social anxiety. In contrast, affiliation with a high-status peer crowd afforded some protection against depressive affect; however, relational victimization and negative qualities of best friendships and romantic relationships predicted depressive symptoms. (La Greca & Harrison, 2005)

Social Exclusion

Baumeister and Tice’s social exclusion theory of anxiety proposes that a primary source of anxiety is perceived exclusion from important social groups. The relationship between perceived social exclusion and social anxiety, jealousy, loneliness, and depression. Self-esteem can moderate reactions to perceived exclusion. (Leary, 1990) Relationships are expectations of future communication (Haverkampf, 2018c), and not being part of a web of communication increases anxiety. One of the reasons is that living organisms fulfil their needs, and in the case of humans also their values and aspirations, through communication, the exchange of meaningful information with others (Haverkampf, 2010a). Not just the shared reality, but even only the imagined reality can lead to significant anxiety.

Hierarchies

Social rank theory (Price and Sloman, 1987; Gilbert, 1989, 1992) argues that emotions and moods are significantly influenced by the perceptions of one’s social status or rank; that is the degree to which one feels inferior to others and looked down on. A common outcome of such perceptions is submissive behavior. Gilbert showed in a study that shame, social anxiety and depression (but not guilt) are highly related to feeling inferior and to submissive behavior. (Gilbert, 2000) Since these feelings develop from the workings of communication patterns as they determine the information that will ultimately reach various centers of the brain (Haverkampf, 2018c), an adjustment to these communication patterns changes feelings that can be associated with social anxiety. Especially with feelings that have a strong social context, such as shame, changes in communication patterns with the help of a therapeutic seeting can be very helpful. Shame is a result of internal and external communication patterns that are being used, while communication patterns can be influenced by a feeling of shame. Important is to remember that work with any communication pattern can be used to change the whole vicious cycle. (Haverkampf, 2017d, 2017a)

Technology

Increasing the number of available communication channels, such as adding communication via the Internet, can in theory help reduce the sense of isolation rather than increasing it. However, this has been hotly discussed. A study by Caplan supports the hypothesis that the relationship between loneliness and preference for online social interaction is spurious, and that social anxiety is the confounding variable. (Caplan, 2007) Communication means offered by the Internet are tools to interact with humans or human-designed programs in a meaningful way. It depends on what the individual makes out of them. How much one can use a technology to one’s advantage depends on the use of the right communication patterns and an insight into the own basic parameters, including one’s needs, values and aspirations. (Haverkampf, 2017f)

A ‘reduced channel’ communication offered, for example, by online chats or social networks may make it easier for a person suffering from social anxiety to connect with others, but to do in a less anxiety provoking and non-threatening way. As long as it is seen as steps on the way towards overcoming the social anxiety and adding more channels of communication, according to the individual needs, preferences and aspirations, it can be even helpful. For many people suffering from social anxiety the step from no communication to full interpersonal interaction in subjectively experienced high stakes settings can be too high. Online dating platforms, for example, can make it possible for people to go on dates who would otherwise never been able to do so.

Symptoms

Social anxiety often leads to physical symptoms that can worsen the vicious cycle of trying not to appear nervous and anxious, but by ‘fighting’ to do so the nervousness and anxiety just keep on getting worse. In adults, feelings of social anxiety may be associated with tears, blushing, excessive sweating, nausea, difficulty breathing, shaking, and palpitations. They are somatic manifestations, though often experienced much more intensely subjectively than observed objectively, of the fight-or-flight-response, which is largely hardwired into our brains. Since as we have discussed previously, social success is as much a matter of survival as finding food or warding off an attacker, anything that seems to interfere with it can lead to negative emotional states, such as anxiety.

Research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. It has even been shown that experimentally modifying interpretation in non-anxious individuals affected their anxiety. (Beard & Amir, 2008) Since how information is interpreted depends on external communication channels and on how the information is communicated internally, the techniques of Communication-Focused Therapy work with communication patterns to affect a change. As external and internal communication patterns reflect each other (Haverkampf, 2010a, 2010b, 2017a), the work on communication patterns in therapy has a direct effect on the internal information processing that leads to and maintains social anxiety.

Measurement

The clinically most commonly used questionnaire to assess social anxiety is the Liebowitz Social Anxiety Scale (LSAS). The LSAS has been empirically shown to be a reliable, valid and treatment sensitive measure of social phobia. (Heimberg et al., 1999) It lists a variety of different situations and asks to rate for anxiety and avoidance. This practical orientation is very helpful because it leads to greater insight into the underlying motives of the anxiety. For example, if the contexts of the anxiety provoking situations have in common that they are more of an interpersonal nature with people that are familiar (or strangers), awareness of it can lead to greater understanding of possible underlying causes. People adapt particular communication patterns as a reaction to the perceived need to manage interpersonal dynamics.

Neurobiology

The Amygdala

The amygdala is often implicated in social anxiety and the processing of social threats. In a quantitative meta-analysis, Etkin and Wager compared functional magnetic resonance imaging and positron emission tomography studies of posttraumatic stress disorder (PTSD), social anxiety disorder, specific phobia, and fear conditioning in healthy individuals. Patients with any of the three disorders consistently showed greater activity than matched comparison subjects in the amygdala and insula, structures linked to negative emotional responses. Hyperactivation in the amygdala and insula were, of interest, more frequently observed in social anxiety disorder and specific phobia than in PTSD. Only patients with PTSD, on the other hand, showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex—structures linked to the experience and regulation of emotion. (Etkin & Wager, 2007)

Amygdala activation to interpersonal threat has been linked to the severity of social anxiety symptoms. Phan and colleagues examined in a study the association between response to emotionally harsh faces in the amygdala and severity of social anxiety symptoms in patients with generalized social phobia. Relative to happy faces, activation of the amygdala in response to harsh (angry, disgusted, fearful) faces was greater in the patients than in controls, and the extent of amygdala activation was positively correlated with severity of social anxiety symptoms, but not general state or trait anxiety levels. (Phan et al., 2006)

However, it needs to be remembered in this context that information is stored in many areas of the brain which all contribute to the signals that then flow through and are integrated, compared, subtracted and processed in specific areas like the amygdala. (Haverkampf, 2018g) Thus, to understand the complexity, and at the same time simplicity of social anxiety one also needs to look at the actual communication patterns an individual uses, externally and internally, and how information is received, selected for, transported and stored. Meaning

Identity

An important question is why I as a socially anxious person feel as the center of attention if it is not what I want, or is it? Many people with social anxieties actually want to have good relationships and are often fond of people. The problem is how they see themselves or that in many cases they cannot really see who they are. Sometimes there may also be an ambivalence in one’s relationship with people, which might be a result of personal life experiences or some unresolved conflicts from another source.

The search for identity lies at the heart of any form of social anxieties. Often, if some fundamental questions about oneself can be answered the social anxiety decreases. Basic parameters are:

  • Needs
  • Values
  • Aspirations

(Haverkampf, 2018h)

An important method in therapy to have the client imagine a situation and run through it. This helps break down the distinction between reality and the imagined world. Many people suffering from social anxieties are very sensitive, which also contributes to the symptoms. Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. There may even be stammering and rapid speech. Panic attacks can also occur under intense fear and discomfort.

Many people with social anxieties have difficulties imagining the future because it is too painful. Here it helps to identify emotions and feeling that underlie the negative thoughts. Often the tensions and anxieties have underlying processes that need to be identified.

People with social anxiety often set high standards for themselves for social situations. Since they believe they cannot reach these standards they have a lot of negative thoughts about how they do in those situations and the outcomes. The sense of failure can be reinforced in the situation by very minor mishaps, such as a stutter or notices sweating. This leads to even greater self-consciousness and the likelihood actually of sweating or stuttering increases. Anxiety can increase to panic attacks.

‘Lost Opportunities’

It is also important to deal with the losses patients subjectively think they have incurred as a result of their social anxiety. People avoid situations where the social anxieties cause the symptoms. In more severe cases this can mean that the individual has no romantic relationships and does not take up jobs that could be interesting and enjoyable. Here the first step it to acknowledge the problem and realize that while one may not have done the preferred choice in the moment, social anxiety is often a problem of not knowing what one really wants. Finding this out can be a tremendous chance.

Judgment

The sense of being judged is quite common in social anxiety disorder. The judgment by others gets a relatively high significance. People with social anxieties can be very competitive in professional or academic situations. It seems easier to believe the judgment of others. The combination of a greater focus on oneself, being more alert to anything other people may see or perceive, and reduced trust in oneself and others frequently gives rise to the fear of being judged. If there is a greater disconnect from oneself and others, this can cause additional problems and potentially more anxiety.

There is a perceived need for a more complete control of one’s external communication, out of fear that the connection with the world could be lost, but this sought-after control by necessity also has to extend then to the internal communication, which destabilizes further can causes additional anxiety. The ultimate fear in social anxiety is not of social situations per se, but that connections and relationships could be lost forever. Fears of loss of relationships and loss of control is often at the heart of social anxiety. Helping people with social anxiety means exploring new ways of communicating, so that they learn that communication and relationships are in their essence quite predictable and stable.

Location

The setting can also play a problem and may be worthwhile to thematize. Instead of making a new friend at a bar, a person with social anxiety might find this task easier to accomplish via an online friendship or dating site. As patients develop a greater understanding of their wants, needs and aspirations, they also develop a better understanding of how they interact and communicate with their environment in ways that are more helpful, more efficient and better suited to their own needs and personality.

Treatment

he most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs). However, there are several other therapeutic approaches which have shown promising in the treatment of social anxiety disorder. There are also various psychopharmacological approaches which demonstrate effectiveness.

Medication can help. From clinical experience the selective serotonin reuptake inhibitors (SSRIs), such as be helpful, particularly in the form of selective serotonin reuptake inhibitors (SSRIs) or sometimes serotonin norepinephrine reuptake inhibitors (SNRIs) if needed over a longer interval. Selective Serotonin Inhibitors (SSRIs) are often used in generalized social anxiety disorders, if psychotherapy does not help fast enough or as a support. Historically, paroxetine and fluoxetine have often been used, but newer SSRIs, such as escitalopram, seem also to work. In clinical experience, some people benefit significantly from SSRIs, while others do not. One explanation is that it depends on the presence of other symptoms and psychiatric disorders, as well as how generalized the symptoms are, or how specific they apply to certain situations. Overall, there can be many different reasons, especially psychodynamic ones, that make up this diverse diagnosis, and they need to be carefully explored to increase the chances of therapeutic success.

Cognitive-Behavioral Therapy (CBT)

Meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. (Rodebaugh et al., 2004) On the behavioral side, exposure therapy, for example, involves exposing the patient to anxiety invoking interpersonal situations in a gradual fashion, beginning with less anxiety provoking scenarios, and moving up to the ones to which a greater level of potential anxiety is attached. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. (Craske et al., 2014) Exposure optimization strategies include the following:

  1. expectancy violation
  2. deepened extinction
  3. occasional reinforced extinction
  4. removal of safety signals
  5. variability
  6. retrieval cues
  7. multiple contexts
  8. affect labeling.

(Craske et al., 2014)

On the cognitive side, other techniques commonly used in CBT are to reflect on the negative thoughts and ruminations in interpersonal situations, identify unhelpful beliefs and biases, make more realistic probability estimates and use other more or less structured thought processes. The cognitive approach focuses mainly on intrapersonal rather than interpersonal processes. (Stangier et al., 2011)

Psychodynamic Psychotherapy

In a large multicenter study Leichsenring and colleagues used a manual-guided form of psychodynamic therapy that was specifically developed for their trial. (Leichsenring et al., 2013) It was based on Luborsky’s model of psychodynamic therapy, including supportive and expressive interventions. A secure helping alliance is an important element of the model. Expressive interventions relate the symptoms of social anxiety disorder to the patient’s underlying core conflictual relationship theme, such as a wish, an anticipated response and a response from the self, in order to reduce the symptoms of social anxiety disorder. (Leichsenring et al., 2013) The response from the self represents the symptoms of social anxiety disorder. The core conflictual relationship theme is worked through in present and past relationships as well as in the relationship to the therapist. (Leichsenring et al., 2013)

Mindfulness-based stress reduction (MBSR)

Mindfulness-based stress reduction (MBSR) has shown in several studies to reduce symptoms of stress, anxiety, and depression. MBSR is believed to alter emotional responding by modifying cognitive–affective processes. Since social anxiety disorder is characterized by emotional and attentional biases as well as distorted negative self-beliefs, this can be a helpful approach. MBSR training in patients with social anxiety disorder may reduce emotional reactivity while enhancing emotion regulation.

Goldin and Gross examined MBSR-related changes in the brain–behavior indices of emotional reactivity and regulation of negative self-beliefs in patients with social anxiety disorder. Compared with baseline, MBSR completers showed improvement in anxiety and depression symptoms and self-esteem. During the breath-focused attention task, they also showed decreased negative emotion experience, reduced amygdala activity, and increased activity in brain regions implicated in attentional deployment. (Goldin & Gross, 2010)

D-Cycloserine

Clinical data with specific phobias has suggested that the treatment effects of exposure therapy for SAD may be enhanced with D-cycloserine, an agonist at the glutamatergic NMDA receptor, and its use has been suggested for social anxiety disorder. In a study by Hofmann and colleagues, patients receiving D-cycloserine in addition to exposure therapy reported significantly less social anxiety compared with patients receiving exposure therapy plus placebo. Controlled effect sizes were in the medium to large range. (Hofmann et al., 2006)

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.

Introduction

We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal cords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life.

Communication as Autoregulation

Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

If one suffers from social anxiety, this autoregulation seems to fail. One reason why it fails is because communication is such an important and basic process that there is nothing that could hierarchically control it and put a problem in it right. Only changes in communication can put a communication failure right. This is why a therapy that focuses on communication by identifying communication patterns and reflecting on them is in a good position to treat social anxiety.

Communication Patterns

Communication patterns are sequences in which meaningful information flows between individuals who are interacting with each other. A question in one person leading to an answer in another person is an example, which also illustrates how one communication pattern gives rise to another one. Communication patterns exist as templates in a social or cultural setting. They are activated and modified by the person using them. In a therapeutic setting one may, for example, look with patients at which communication patterns they use and how. Since meaningful information can only flow if it is transmitted within the dynamics of communication patterns, no matter how simple and rudimentary they may be, improving one’s selection and use of communication patterns also leads to a more efficient transmission of meaningful information. This is particularly useful in anxiety conditions, which are characterized by a subjective lack of meaningful information. Since a socially anxious person may actually be very sensitive and perceptive, and thus have more information about interactional clues and the other person available, the focus in Communication-Focused Therapy®, for example, is not necessarily the quantity of information, but how the patient finds, absorbs and processes the information which is most helpful to further the own needs, values and aspirations. In clinical experience, the more competent a patient feels in this regard, the lower the anxiety usually is. This applies particularly to social anxiety, where the anxiety revolves around external communication.

Attention

Attention is the ability to notice new information within a defined space, but also the capability to attach relevance to it.  Both attention and focus are important in the acquisition of meaningful and relevant information form the environment. If they are interfered with or misdirected, there is less relevant information available, which can increase the experienced anxiety. The attention of highly anxious individuals is more automatically captured by sub-threshold cues.  (Mogg & Bradley, 2002) Attentional bias toward negative social cues is thought to serve an etiological and/or maintaining role in social anxiety disorder. As discussed above, anxiety in general is a result of the subjective perception of missing relevant information. (Haverkampf, 2010a, 2018f)

Schmidt and colleagues tested in their study whether training patients to disengage from negative social cues may ameliorate social anxiety in patients with a primary diagnosis of generalized social anxiety disorder. Patients who underwent attention training exhibited significantly greater reductions in social anxiety and trait anxiety, compared with patients in the control condition. At termination, 72% of patients in the active treatment condition, relative to 11% of patients in the control condition, no longer met the DSM-IV criteria for social anxiety disorder. At 4-month follow-up, patients in the attention training condition continued to maintain their clinical improvement. (Schmidt et al., 2009)

Communication to Participate in Life

Communication is important to be connected into the web of life. The exchange of meaningful messages helps one to get what one needs, wants and aspires to. This applies to communication with oneself and others. Finding out what one needs, wants and aspires to happens through communication with oneself. It requires openness and insight.

The feeling of being a part of ‘the whole thing’ is important to an individual, not jut because the individual is part of a chain of generations. When one exchanges meaningful messages with others, oneself and the world around become meaningful to oneself. Losing a part of oneself or a loss of meaning, however, represents an existential threat, which can induce anxiety. This is how social anxiety and a loss in meaningful connectedness with others can lead to more anxiety. To an extent, this can be compensated for with meaningful communication with oneself, but for most this is not enough.

Understanding Social Anxiety and Shyness

Social anxiety is often present from childhood. The fears already interfere with one’s development early on. Since some of the most experiences in a human life are the interpersonal ones, this can interfere with one’s personal development. As already mentioned, shyness is not a disorder, and a person may be happy about it. However, the potential loss to quality of life of social anxiety and shyness can be similar. Shy people often develop adaptive communication pathways, such as relying more heavily on the Internet and may be content with it. However, interpersonal communication is an important piece of change and of bringing about in the world, and without it some of this dynamic may be missed out on. Given the many possible channels of communicating with the world, it does not matter so much which one is used. The important factor is that it allows the exchange of meaningful messages, which aid the individual in becoming better connected with oneself and the world.

Internal Communication

Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Individuals with social anxiety are often very critical of themselves, and this is what is then projected into others, who then appear critical of oneself. An important, and often helpful, step is to become aware of this.

The internal and external communication go hand in hand. Thought patterns that are used in one’s communication with oneself are usually also used in the communication with others. If there are doubts and fears in the communication with oneself, they often will also be present in one’s communication with others.

Uncertainty

In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst-case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.

Studies have shown that the intolerance of uncertainty explains a significant amount of variance in social anxiety severity when controlling for several cognitive correlates of social anxiety, such as the fear of negative evaluation, and for neuroticism. Intolerance of uncertainty also seems to be related with symptom levels of GAD, OCD, and social anxiety, but not depression. (Boelen & Reijntjes, 2009) It seems to play a significant role in performance and interaction social anxiety, but probably a slightly greater role in the former. (Whiting et al., 2014) Intolerance of uncertainty also appears significantly associated with symptom levels of separation anxiety disorder. (Boelen et al., 2014)

Communication Deficits

Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.

In one study, hildren with social anxiety disorder scored significantly higher than anxious children without on the Social Communication Questionnaire (SCQ), reciprocal social interaction, communication and repetitive, restrictive and stereotyped behaviors subscales. They were also three times more likely to score above clinical cut-offs overall. (Halls et al., 2015) This shows that these children have difficulties with certain communication patterns. However, this may not be due to a social skills defict, but they may believe that they appear nervous during social encounters. (Cartwright-Hatton et al., 2005) It would further support the view that it is the flow of information, internally and externally, which is really at the base of social anxiety disorder and many other mental health conditions (Haverkampf, 2018b). These can, on the other hand, be influenced and changed through work on the communication petterns and individual uses.

Avoidance

Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run. While smaller skillsets seem to pla role, it is also important to keep in mind that the avoidance of internal and external flows in itself lowers the available quantity of meaningful information, which plays a significant role in increasing uncertainty about the world and oneself (Haverkampf, 2010a) and thus the levels of anxiety, while holding the tolerance for uncertainty constant.

Meaning

Individuals suffering from social anxiety do not see less relevance in social interactions, but often even more. It is not necessarily seeing more meaning, though, but a different kind. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

However, someone with social anxiety may see the meaning in things differently from someone what does not suffer from it. Approaching someone of the opposite sex may be seen differently because of life experiences. Also, if different meaning is seen in it, the expectations can be different. Expectations that are so high that they are self-defeating can be a problem. However, to set expectations that are not too high and not too low mean having a view of reality that works for oneself.

Awareness of Thought Patterns

An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty is quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing psychologically and the feelings of a dreaded uncertainty about oneself and one’s emotional states.

Awareness means observing the own thought patterns and gaining insight into them. This requires being receptive to this information from oneself and the ability to reflect on it. Important is being able to perceive the flow of information between the parts of oneself, and the ability to let the information flow freely.

Flow of Information

A free flow of information within oneself and with the environment is important to reduce the anxiety and physical symptoms associated with social anxiety. Often, such an openness has become difficult for people because of inadequate interaction patterns and a fear to change anything. In a therapeutic session, this can be changed in two ways. Interaction patterns can be experimented with in a therapeutic session and reflected upon. One objective should be to help the patient develop greater efficacy and confidence in his or her interactions with the environment.

Emotional Reconnection

If there have been adverse life experiences as a significant factor in the social anxiety, there can still be unresolved emotions underlying the anxiety. To resolve them means answering the hypothetical question, what one may have felt in the difficult situation, but then also seeing the strength that allowed one to pull through, which only becomes visible now. The goal is not necessarily to reconnect with only negative emotions form the past, but also the good ones, and emotions as a whole today.

If there is a disconnect, and emotional reconnection would be helpful, one should approach one’s feelings gradually. Especially in cases of social anxiety, it could be problematic trying this too fast. In any case, as internal and external communication go hand in hand, so do internal and external emotional connection. Someone who is disconnected from oneself will have a more difficult time to emotionally communicate with others or stay reflected and calm in situations where there is a potential for greater emotional communication, such as in romantic situations.

Experiencing the World

Social anxiety means potentially experiencing less of the world, although the higher sensitivity can at the same time let someone experience more. It is important again to note that many patients suffering from social anxiety disorder put themselves under an enormous pressure. Their more frequent feeling that they need to interact with others and live their lives in certain can add to the anxiety, rather than diminishing it. The more permanent solutions to this dilemma are, as outlined above, a greater connectedness with oneself and better insight into the own needs, values and aspirations. Work with the communication patterns a patient uses, as well as reflection on how she felt when engaged in activities and with other people in the past, sheds light on the ‘truer’ needs, values and aspirations. The focus is here completely on the patient and her experiences, not on the expectations of others. This focus establishes more meaning in the life of the patient and helps is the acquisition of more helpful communication patterns.

Communication Techniques

Various communication techniques can be helpful, not as an end in themselves, but to help the person have more confidence in oneself and to see communication not as something dangerous one needs to be guarded against, but as something that can help one meet one’s needs, wishes and expectations. Thus, the reason for communication techniques should be not an end in itself, but to increase one’s repertoire, ease and confidence in communicating with oneself and others.

Openness to others, a positive and welcoming attitude towards the messages of others and engaging in reflection on the interaction are some helpful approaches towards communication, but there are many others as well. Important is not to be deterred from the interaction when something unsuspected or disappointing happens, but to reflect on what it could mean, whether it is a message from outside or inside oneself. Genuinely new information is never meaningless and reflecting on it helps to gain more insight into the world. Social anxiety, on the other hand, is often a result of engaging with messages only superficially, rather than letting them resonate with oneself and determining what they might mean.

Technology can also play a useful role in gradually exposing oneself to potentially more anxiety provoking situations. For example, beginning with interactions with fewer communication channels, such as an online dating site, can make it easier to then move on to an in-person date. More information could already be screened in a less communication intensive setting before exposing oneself to the many communication channels of an actual physical date. Pierce demonstrated in a study a positive relationship between social anxiety (not comfortable talking with others face-to-face) and (1) talking with others online and (2) talking with others via text messaging. In contrast, there was a positive relationship between the lack of social anxiety (feeling “comfortable” talking with others) and making friends online. (Pierce, 2009) Gender differences were also pointed out in the study.

Breaking the Cycle of Anxiety

To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.

Insight and connectedness reduce anxiety. Openness and receptiveness to information and messages can lead there. This can be practiced in therapy and brought from there into everyday life. The sense of competence helps build confidence in dealing with oneself and the environment. Important is to connect with oneself to a level that there is greater insight into what is truly important to oneself.

The Reward of Seeing More

Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it. People with social anxiety often see less in an interaction, although they often have a greater sensitivity and perceptiveness to see more. This has to do with a different focus on where to find a relevant and meaningful message in the interaction. For example, in an interaction with a romantic love interest, the socially anxious person may be too focused on signals and own thoughts about a possible rejection rather than on information from the other person that could help in getting to know that person.

An important step is therefore to become aware that what may be behind some of the social anxiety, or much of it, is actually something quite positive, something that can be used to one’s advantage. Central is merely how to use a heightened percetiveness and sensitivity to certain information signals for one’s benefit rather than to one’s detriment. In Communication-Focused Therapy, through work on communication patterns, within and without oneself, the selection and steering of information flows can be changed, which also directly impacts the information and meaning a person is exposed to. Since anxiety is tightly linked with the flow of information and the available information, changing internal and external communication patterns can lower anxiety quite substantially (Haverkampf, 2013, 2017i, 2017b).

Values, Needs and Aspirations

Beyond food, drink, a roof over one’s head and basic safety, humans have values, needs and aspirations that drive much of what they are doing throughout their lives. None of us is born to live the life of a Robinson Crusoe, and just like the fictional character, interpersonal interactions with others, as well as the intrapersonal communication that is tightly lined with it, are the main instruments to get these needs, values and aspirations met. The exchange of meaningful information is what brings about positive and lasting change in oneself and in the environment (Haverkampf, 2010b). The author has referred to the own needs, values and aspirations before as basic parameters because they can determine whether some information that has become available in a person is meaningful or not (Haverkampf, 2018h).

One of the most painful elements of social anxiety is that a person finds it more difficult to find the own needs met. It interferes with dating, in workplace situations or in academia. People suffering from this condition, do so in silence, which tends to make it even worse. To escape this vicious cycle, a new orientation towards the own values, needs and aspirations is needed (Haverkampf, 2013, 2017e). What helps to achieve this is through a better connectedness with oneself and others. The work on communication patterns in Communication-Focused Therapy can here be very helpful (Haverkampf, 2017e).

The Need for Communication

Living organisms constantly need to communicate within themselves and with others, and humans are not an exception. Close relationships in humans, for example, have been linked to a wide variety of psychological and other processes, including physical and mental health (Jones et al., 1990). Communication with others is needed to grow, innovate and propagate. Most of the human accomplishments in the arts, sciences and professions are based on the exchange of meaningful messages, communication. But communication is also to have one’s needs met and to survive in general. Even a hermit in the mountains needs to interact with his or her living mountain environment. People who enjoy nature usually do not want to shun communication but focus on an exchange with a nonhuman environment. Communication is fundamental to life itself.

Suffering from social anxiety does not mean a disinterest in people or an objection to being with them, rather the opposite. An indifference ot something does not lead to anxiety or the feelings that are commonly experienced by indidividuals with social anxiety. The latter are testamount to the importance a person with social anxiety attaches to interpersonal connections and the social realm. People with social anxiety may even be more sensitive and perceptive to social signals, though they may be minterpreted, and to the importance of social interactions. In one study, perceived closeness was greatest when the most socially anxious individuals interacted with each other (Kashdan & Wenzel, 2005). At the same time, in another study, when asked how an investigator viewed them based on that person’s facial expressions, socially anxious subjects made ratings that were consistently less favorable than the ratings made by subjects lower in social anxiety (Pozo et al., 1991). In other words, we have the semmingly paradoxical findings that people with social anxiety may experience social connections even mor eintensely, while possibly doubting them more in other situations. One explanation would be the fear of losing something very important. The more important social connections are to a person, the higher may also be the apprehensiveness about doing something wrong and losing it. Adding in higher anxiety levels to begin with, might give us a fairly adequate representation of the underlying dynamic in social anxiety.

Experimentation with adjustments to existing communication patterns and the development of new ones is the road that leads to less social anxiety (Haverkampf, 2017e, 2018d). The first steps can often be quite small for good reasons. It often helps people with social anxiety and shyness to connect with and appreciate their need and joy in communicating. Once communication is seen as a potential source of pleasure rather than a necessary task, it can become much easier, as ‘I want’ replaces ‘I should’. It often helps to take on a more investigatory perspective, donning a lab coat so to speak, and having fun observing the communication dynamics as they unfold in an interaction. The benefit is often twofold. Once one takes on an observer role it is easier to extricate oneself from the emotional vortex of being caught up insight a problematic interaction, while being able to better reflect and understand the dynamics. The greater awareness and space to experiment with new communication elements and patterns either in the current or a future situation can lead to a massive change in how effectively and satisfyingly one interacts with oneself and the world and thereby fulfils the own needs, values and aspirations.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change, and meaning drives it. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings about change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist. Over time, changes and sjudtments to in internal and external communication patterns facilitate a greater awareness for and processing of meaning (Haverkampf, 2010a, 2017c, 2018i).

Information underlies practically everything from physical quantum states and classical processes to psychological ones (Haverkampf, 2018g). Information Perceived emotions are also communicated information (Haverkampf, 2012b). In an interpersonal conext, meaning is generated from the information carried by signs.  Creation of meaning events in-therapy, for example, are change episodes that occur when a patient seeks to understand the meaning of an emotional experience (Clarke, 1996). Meaningful information is information which can bring about a change in the recipient of the information (Haverkampf, 2010a, 2018a). It has also been argued that information is objective, but inaccessible to humans, who exist exclusively in a world of meaning, while meaning is intersubjective, or based on shared agreement and understanding, rather than purely subjective (Mingers, 1995). However, the description of meaning as information that carries the potential to effect change may allow for a broader and more generally applicable delineation of the term. In Communication-Focused Therapy it is an important means of change dependent on the effective communication of the information that codes for it. Social anxiety illustrates quite brightly what happens when the process at one or more points affected by other factors, either within or outside the person. Social anxiety is primarily a communication problem, often alongside or based on generally higher levels of anxiety.

Embracing Change

In the case of social anxiety, embracing change can be associated with anxiety, while it can also be liberating because it means that there are no rigid rules one needs to adhere to other than those linked to the communication process itself, which has clear laws. Understanding these laws of communication, on the other hand, which humans subconsciously operate on and use as they accumulate experience in their interactions with others is essential to gain greater confidence in tolerating and working towards change. Basic communication concepts, such as what constitutes communication, how meaning is created, how information flows, and how communication processes are influenced, is usually not conscious. Reflecting on it and beginning to use it, however, can be especially helpful to sensitive people, who quite frequently have experienced social at some point in their lives. One might say that only those who do not care about people and themselves are entirely free from social anxiety, but this tantamount to the description of a sociopathic personality disorder.

Change should thus not be understood as changing oneself or one’s ability to perceive and be sensitive to the nuances of daily interactions, but to develop new communication patterns. Some of the techniques used in Communictaion-Focused Therapy have been described elwhere (Haverkampf, 2017a, 2017e, 2017i, 2018e). Important is the concept that external and internal communication patterns are closely related to each other, and that work on communication in therapy leads to change on both sides. Several of the techniques involve the use of certain communication elements and structures, such as a variety of the question (Haverkampf, 2017g) and other functional concepts.

Living

It is not the number of social contacts which is relevant. Having a few good friends is often worth more than thousands of contacts in an online social network. However, this does not mean friends have to be always physically present. Meeting friends online also allows for communication, while close physical contact in an intimate relationship is to most people important on a regular basis.

Important is that the communication patterns, the frequency and the interaction style fit the needs, values and aspirations of the individual. People who are shy can be quite happy with the intensity and frequency of their interactions, those with social anxiety are usually not. It is thus important to help individuals with social anxiety discover what is important to them and how they want to live their lives. Communication patterns change more easily when the change creates more meaning in the world of the patient (Haverkampf, 2012a). Communication-Focused Therapy thus aims first at creating greater awareness for the basic parameters of needs, values and aspirations to support the process of change in communication patterns (Haverkampf, 2010b, 2017a).

In the end, communication is an activity. One ultimately needs to do it. However, when one has worked on the own communication, developed awareness for them, gained insight into them and made it a habbit to experiment with them, communication becomes something to look forward to rather than something that causes apprehensiveness and anxiety.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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The Misdiagnosis of ADHD in Adults (1)

The-Misdiagnosis-of-ADHD-in-Adults-1-Christian-Jonathan-Haverkampf-psychiatry-series-1

The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11

CAADID.. 12

DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25

 

Introduction

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)

Attention

When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)

Communication

The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).

Autism

Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).

Trauma

Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).

OCD

Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).

Symptoms

Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.

Subtypes

It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)

Assessment

The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.

Communication

How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.

CAADID

The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)

DIVA

Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.

Questionnaires

Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.

Malingering

Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).

Comorbidity

High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).

Conclusion

Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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