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1 Reference Rationale/Prior Research Subjects/ Participants Tests/Measures Results Discussion/ Conclusions Pehlivanidis, A., Papanikolaou, K., Mantas, V., Kalantzi, E., Korobili, K., Xenaki, L. -A., Vassiliou, G., & Papageorgiou, C. (2020). Lifetime co - occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD). BMC Psychiatry , 20 (1) , 1 - 12 . https://doi.org/10.11 86/s12888 -020 - 02828 -1Â • Need has increased for accurate assessments for adults seeking an Autism Spectrum Disorder (ASD) or Attention deficit hyperactivity (ADHD) disorder due to increased awareness, interest in seeking a diagnosis, and a change in criteria in the DSM -5 • Psychiatric disorders often “overshadow” a diagnosis of ADHD or ASD • Psychiatric disorders co - ocurring with ASD and ADHD contributes to burden on available healthcare services • The rate of ADHD in adults is between 2 and 5% • ADHD is frequently associated with • 326 patients met the criteria (excluded patients with urgent psychiatric issues and active substance use disorders) • Demographic and diagnostic breakdown of participants: • 217 men • 109 women • average age: 31.7 years • ADHD: 151 participants • ASD: 58 participants • Dual ASD+ADHD: 29 participants • No neurodevelopment (NN) disorder: 88 participants • Questionnaire is used to gather demographic, educational, occupational, and clinical data from patients and their relatives • Autis m Quotient: subjective self - assessment questionnaire measuring expression of autistic traits • Empathy Quotient: subjective self - assessment questionnaire to measure empathy • Barkley Adult ADHD Rating Scale -IV: questionnaire to measure current ADHD traits and the impairments caused, as well as childhood symptoms • Two hour interview using MINI: questionnaire developed by psychiatrists to • ~73% of subjects with ADHD, 50% of subjects with ASD, ~73% of subjects with ADHD+ASD, and ~76% of the subjects with no neurodevelopmen t disorder reported lifetime occurrence of psychiatric diagnoses • The NN group had a significantly higher rate of bipolar disorder than the ASD only group • The ADHD groups had a significantly higher rate of substance use disorder than non - ADHD groups (NN & ASD) • ~37% of all ADHD subjects had three or more co - occuring disorders • Depression was the most common disorder reported: 37.3% of ADHD, 29.3% of ASD, 24.1% in • The high rate of psychiatric disorders found in the ADHD groups is consistent with prior research • The ASD only group showed a lower rate of psychiatric disorders when compared with prior research, possibly explained by prior research including both ADHD+ASD subjects and ASD only subjects, whereas this study separated these groups • The group of subjects who did not receive a neurodevelopment al disorder diagnosis also showed a high rate of psychiatric disorders and researchers believe this group of patients may seek a neurodevelopment al explanation 2 co -existing psychiatric disorders • In a study including 20 countries, 23% of ADHD cases are comorbid with one psychiatric disorder, 14% of cases with two disorders, and 14% with three disorders • Most common psychiatric disorders associated with ADHD are mood disorders, anxiety disorder, substance use disorder, and behavioral disorders (22%,34%,11%,1 5%, respectively) • A population study of 40k adults showed ADHD patients have anxiety, depression, substance use disorder, and other disorders 4x to 9x more often than non -ADHD adults • Co -occuring depression in ADHD leads to assess for psychiatric disorders (including depression, bipolar disorder, panic disorder, social phobia, pbsessive compulsive disorder, anxiety disorder, psychotic disorder, alcohol dependence, substance use disorder, and antisocial personality disorder • Psychiatrist assessment of subject • Final diagnoses use data obtained with above tests, team meeting of clinicians, and DSM -5 ADHD+ASD, and 31.3 in NN • Bipolar disorder was found in 9.3% of ADHD, 3.5% in ASD, 13.8% in ADHD+ASD, and 19.3% in NN • Panic disorder(PD), social phobia(SP), and generalized anxiety(GAD): ADHD - 4.6% with PD, 16.7% with GAD, 3.3% with SP. ASD - 6.9% with PD, 13.8% with GAD, 1.7% with SP. • ADHD+ASD - ~10% for each disorder. NN - 10.2% with PD, 12.3% with SP, and 12.5% with GAD • Obsessive Compulsive disorder: 10% of ADHD, 10% of NN, 8.6% of ASD, and 24.1% in ADHD+ASD • Psychotic disorder: 10% of ADHD, 6.9% of ASD, ~20% of ADHD+ASD, and 5.7% of NN • Substance use disorder: 26.6% of when their conditions don’t improve with treatment • Depression: subjects had a higher rate of depression when compared to prior research, probably explained by prior research being population studies and this research is on psychiatry patients. Clinicians should be aware of overlapping symptoms in depression and ADHD when assessing patients, and should be aware ASD patients may have more diﬃculty explaining or describing depression • Bipolar disorder: lower rates of co - occuring BD in this study may be explained by the features of the subjects. The subjects were adults seeking a first time ADHD and/or ASD 3 poorer quality of life • Among psychiatric patients, 10 -20% of the patients will have ADHD • Rate of ASD is about 1-2% in developed countries • ASD signs in in high functioning individuals may go unnoticed and these individuals have a higher rate of psychiatric disorders • Research estimates 73 -81% of ASD individuals will meet criteria for at least one other psychiatric disorder • Most previous research on adults with ASD has focused on depression, anxiety, OCD, ADHD, and personality disorders • Other diagnoses are also common, and patients seen clinically will have a higher rate than general popuation • Diagnostic criteria for ASD and ADHD, 3.5% of ASD, 20.7% of ADHD+ASD, and 11.4% of NN • Antisocial personality disorder: 7.3% of ADHD, 2.5% of ASD, 13.8% of ADHD+ASD, and 11.4% of NN. diagnosis, possibly meaning those individuals were less impaired to begin with leading to delay in diagnosis. Manic episodes in BD may be mistaken for ADHD symptoms, and clinicians should take a thorough history to diﬀerentiate ADHD and BD symptoms • Anxiety disorders: ADHD findings were consistent with prior research (except social phobia was lower), ASD findings were consistent except for lower social phobia. The authors believe this may be explained by their own diﬃculty diﬀerentiating diagnoses, prior research participant s may have been misdiagnosed with ASD vs SP, and participants of this study are assumed to be 4 ADHD has changed to allow a dual diagnosis of ADHD and ASD in the DSM -5, which was previously exclusionary • Data on adults with both ASD and ADHD is limited but evidence shows 37 -43% of adults with ASD have had or have an ADHD diagnosis • 10% of patients who were first diagnosed wtih ADHD in adulthood had an ASD diagnosis at some point • Large Swedish study showed that ASD and ADHD are rarely diagnosed together, with 86% of only 14 dual diagnosis patients having other psychiatric disorders • Only two population studies researching ASD, ADHD, and other comorbid diagnoses in adults, one of high functioning. The authors conclude that more research is needed to better diagnose anxiety in ADHD and ASD individuals, and to diﬀerentiate between anxiety symptoms and ADHD/ASD symptoms. • OCD: ADHD and NN findings were consistent with prior research, ASD had a higher rate than previous research, and authors had no comparison data for the ADHD+ASD group. Diﬀerence in ASD findings might be explained by population studies underestimating ASD and OCD rates. OCD presentation can be confused with ADHD and/or ASD symptoms. Authors conclude that thorough evaluations are necessary to parse out OCD and 5 which in Norway • Previous population studies show adults with both ASD and ADHD have higher rates of co - morbid psychiatric illness than in adults with only ADHD or only ASD • Substance Use Disorder is more common in adults with ADHD than without ADHD • Individuals with ADHD and/or ASD who do not receive a diagnosis until adulthood are a unique patient population • ADHD is underdiagnosed and patients are often misdiagnosed or do not receive adequate treatment • 7-16% of Adult patients in psychaitric facilities are diagnosed with ASD for the first time (vs 1-2% in general population) neurodevelopment al disorders. • Psychotic disorder: ADHD findings are consistent, ASD findings are low but prior research has shown wide ranging rates, and ADHD+ASD findings are consistent with prior research, but not statistically significant. Authors conclude that similar presenting symptoms in ADHD, ASD, and psychotic disorder highlight the need for thorough assessments to prevent misdiagnosis. • Substance use disorder: ADHD findings were consistent, ASD findings showed a lower rate, and ADHD+ASD findings showed a higher rate of SUD compared to prior research. These diﬀerences may be explained by cultural diﬀerences of 6 • Adults with ASD often go to their primary care giver first when seeking help • Adults with undiagnosed ADHD and ASD are often high functioning with the cost of high rates of co -morbid psychiatric illnesses • Diagnostic criteria for adults referred for an ADHD or ASD diagnosis are lacking . research subjects and by the exclusion of patients with an active SUD from this study. • Features of SUD can present similarly to ADHD and/or ASD symptoms. Authors conclude that patients with ADHD are at higher risk of having SUD. However, they also conclude that similar symptoms makes diﬀerential diagnosis diﬃcult. • Antisocial personality disorder: ADHD findings were lower than prior research which authors attribute to the participant characteristics, while ASD findings were consistent. Authors conclude that clinicians may mistake ADHD or ASD for antisocial personality disorder, and may refer patients with ASPD diagnosis for an ADHD 7 evaluation. • Overall, authors conclude that evaluation of patients for neurodevelo pment al disorders should be thorough and performed by experienced clinicians. Clinicians should be aware of the high rate of co - occuring psychiatric disorders in ADHD and autism, as well as the diﬀerences, to correctly diagnose patients. A correct diagnosis or diagnoses is “essential [to] changing the prognosis” of the disorder(s). • Limitations of the study include a small sample size, uneven sex/ gender distribution, investigating only 10 psychiatric disorders co - occuring with ADHD or ASD, and lack of a general population 8 control group. Findings may not be generalizable to all ADHD and ASD patients, and more, larger scale research on these patients should be performed.