Clinical Case Discussion Extended-release Methylphenidate Treatment and Outcomes in Comorbid Social Anxiety Disorder and Attention-deficit/ Hyperactivity Disorder: 2 Case Reports Social anxiety disorder is frequently comorbid with attention-deficit/hyperactivity disorder (ADHD). However, treatment recommendations are not clear in the presence of such comorbidity. A few studies in the literature have reported improvement in symptoms of both disorders with treatment specific for ADHD (ie, stimulants and atomoxetine). In this report, we present cases of 2 adults with social anxiety disorder and ADHD who were treated with methylphenidate monotherapy. Both cases responded well in terms of not only their ADHD symptoms but also the social anxiety disorder symptoms. Methylphenidate was well tolerated with no significant side effects. More studies are needed to better establish the potential of ADHD medications to be effective for comorbid social anxiety disorder symptoms. (Journal of Psychiatric Practice 2015;21; 225–231) KEY WORDS: social phobia, social anxiety disorder, attention-deficit/hyperactivity disorder, stimulants, methylphenidate
Case presentation: AHMET KOYUNCU, FAHRI ÇELEBI, ERHAN ERTEKIN, Case discussion: DAVID A. KAHN,
MD MD MD MD
association between the inattentive type of ADHD and social anxiety disorder. The use of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version’s (K-SADS-PL), a highly reliable semistructured interview, is a possible explanation for the high rates of ADHD found in that study. Moreover, the study sample consisted primarily of patients with a relatively high educational level who applied to 3 hospitals in the same group, specifically for treatment of social anxiety disorder through personal referrals or Internet searches. Koyuncu et al3 also found that the presence of a history of childhood ADHD was associated with more severe symptoms of social anxiety disorder. Mancini et al4 reported that 19.5% of patients with anxiety disorders had a history of ADHD in childhood, and they also found that 12 of 34 patients with social anxiety disorder (35.3%) had a history of childhood ADHD. Van Ameringen et al5 reported a frequency of adult ADHD of 27.9% among 129 patients with anxiety disorders. Finally, in a childhood study, generalized-type social anxiety disorder and ADHD were found to be associated among patients aged 7 to 18 years.6 Data are limited not only about the characteristics of comorbidity between social anxiety disorder and ADHD, but also concerning treatment approaches for this type of comorbidity. In a study
CASE PRESENTATION Background Little research exists concerning comorbidity of social anxiety disorder and attention-deficit/hyperactivity disorder (ADHD). In 2 studies conducted with small samples of patients with social anxiety disorder, Safren et al1 reported that the frequency of childhood ADHD among 33 patients was 3%, and Mörtberg et al2 reported childhood symptoms of ADHD in 7.8% of participants. Koyuncu et al3 reported 72.3% of 130 patients with a primary diagnosis of social anxiety disorder had a history of childhood ADHD, and they noted a particular
KOYUNCU: Academy Social Phobia Center, Istanbul, Turkey; ÇELEBI: Department of Child and Adolescent Psychiatry, Zonguldak Women and Children Hospital, Zonguldak, Turkey; ERTEKIN: Department of Psychiatry, Istanbul Medical School, Istanbul University, Istanbul, Turkey; KAHN: Columbia University College of Physicians and Surgeons, New York, NY. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Please send correspondence to: Fahri Çelebi, MD, Department of Child and Adolescent Psychiatry, Zonguldak Women and Children Hospital, Zonguldak, 67100 Turkey (e-mail: [email protected]). The authors declare no conflicts of interest. DOI: 10.1097/PRA.0000000000000070
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CLINICAL CASE DISCUSSION of adult patients with comorbid social anxiety disorder and adult ADHD, Adler et al7 compared atomoxetine (n=224) and placebo (n=218) and found that atomoxetine monotherapy effectively improved symptoms of ADHD and comorbid social anxiety disorder and was well tolerated. In a recent study, 21 patients with ADHD and comorbid social anxiety disorder, aged 8 to 18 years, received methylphenidate treatment, which was found to be associated with a significant decrease in scores on rating scales for both ADHD and social anxiety disorder. The improvement in ADHD symptoms with methylphenidate treatment was associated with a parallel improvement in social anxiety disorder symptoms, and methylphenidate treatment was found to be safe and effective in children with comorbid ADHD and social anxiety disorder.8 In this report, we present the cases of 2 adult patients with comorbid social anxiety disorder and adult ADHD who were treated with methylphenidate monotherapy.
Case 1 The patient was a 21-year-old single woman with a bachelor’s degree who works as a graphic designer. She was admitted as an outpatient to our clinic with social phobic complaints that she experienced at work and in social circles. She reported difficulty in interacting with her supervisors and also with people with whom she was unfamiliar. She stated that she had a feeling that people were watching her during her daily activities. She reported avoiding situations such as public speaking, speaking up in a meeting, eating with people, attending group activities, and meeting new people. When she was not able to avoid such situations, she experienced worsened anxiety symptoms, including sweating, fearfulness, heart pounding, flushing, quavering in her voice, and difficulty speaking accurately. She reported that such symptoms of social anxiety disorder had started 5 years earlier. On the basis of the Structured Clinical Interview for DSM-IV (SCID-I),9 the patient was diagnosed with social anxiety disorder, with no current or lifetime comorbid Axis I psychiatric disorder. During the SCID interview, the patient also reported having problems with attention since childhood. She had difficulties in her job because of forgetfulness and she made mistakes that affected
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the tasks she was performing. She stated that she was unable to start working on her tasks until deadlines were getting too close, which caused conflicts with her supervisors. She also reported that, when she had been in school, she had difficulty following the lessons and had made mistakes because of poor attention. Because of the attentional symptoms she reported, the K-SADS-PL ADHD module10 was administered, which revealed a history of ADHD, inattentive type in childhood. A validity and reliability study of the Turkish version of the K-SADS-PL was published by Gokler et al in 2004.11 The K-SADS-PL has also been used in previous studies to retrospectively assess childhood psychopathology.3,12–14 The current status of the patient’s ADHD symptoms was also evaluated by clinical interview in accordance with DSM-IV-TR criteria,15 and it was found that she also met criteria for a diagnosis of adult ADHD. (The SCID-I does not include a module for assessing for ADHD in adult patients. The diagnosis of ADHD in adults is therefore made by clinical interview on the basis of the DSM criteria.) When the patient was first evaluated in our clinic, her score on the Adult Attention-Deficit and Hyperactivity Disorder Self-Report Scale (ASRS)16 was 41 and her total score on the Liebowitz Social Anxiety Scale (LSAS)17 was 79 (marked social anxiety disorder), with a score of 41 on the fear subscale and a score of 38 on the avoidance subscale. Cardiology consultation and electrocardiography revealed no cardiac problems. The patient stated that at least part of her problems with social phobia stemmed from her inattentiveness. For example, she reported being teased by her peers because of the mistakes she made owing to poor attention. Therefore, we chose to prioritize ADHD rather than social anxiety disorder in her treatment. Extended-release methylphenidate was initiated at a dose of 18 mg/d and then titrated up to 36 mg/d in 1 week. Her ASRS score fell to 24 by the third week of treatment and decreased further to 21 by the tenth week. Her LSAS fear and avoidance scores also fell to 28 and 29 by the third week of treatment and decreased further to 17 and 15 by the tenth week, respectively. The patient’s subjective experience of the treatment was consistent with the reductions observed in her rating scale scores: she reported significant improvement in both social anxiety disorder and ADHD symptoms. After she had completed 10
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CLINICAL CASE DISCUSSION weeks of treatment, the patient reported improvement in most of the symptoms she initially had. She reported improvement in her performance at work and in her attention skills. She also reported increased social interactions with her friends and that she had become less avoidant in social situations and at work. In conclusion, with methylphenidate monotherapy 36 mg/d, the patient’s LSAS fear, avoidance, and total scores improved by 60% and her ASRS scores improved by 49%, which indicates response to treatment in line with clinically significant improvement by the tenth week of treatment (Table 1).
Case 2 The patient was a 28-year-old single man working at a university as a research assistant. He was admitted as an outpatient to our clinic with social phobic complaints, which he experienced particularly in academic settings. He reported that he had thoughts that everybody was watching him and he avoided going to the cafeteria and having lunch with his colleagues. He also stated that he was scheduled to give a speech at a conference next month, which was the main reason he was seeking treatment. His social phobia first occurred in primary school when he was 6 years old, but he never received treatment. While he was at school, he reported difficulty in speaking in front of his classmates and teachers, which caused him to avoid answering questions in the classroom, although he knew the answers. He reported that, when he had to perform
a task in public, he felt intense anxiety symptoms, including heart pounding, sweating, flushing, and forgetting what to say. His classmates had made fun of his behaviors, which worsened his anxiety symptoms in social situations. He complained about trouble talking to girls whom he liked, for which reason he had not had any romantic relationships. On the basis of the SCID-I, the patient was diagnosed with social anxiety disorder with no current or lifetime Axis I psychiatric comorbidity. The patient also reported difficulty in concentrating and severe distractibility at his job. He said that he would lose concentration if another person, a car, or even a fly passed by. When he was at school, he got lower grades than he should have because of mistakes on the easiest questions and concentration problems during class lessons and examinations. He stated that he had difficulty listening to anybody carefully, because he frequently found himself preoccupied with thinking about something else. He reported that he would start daydreaming after listening to the other person for a while. He avoided tasks that required efforts to engage with others. He did not mention having experienced any hyperactivity symptoms in the past. The ADHD module of the K-SADS-PL was administered, based on which the patient was diagnosed with a history of childhood ADHD, inattentive type. The current status of his ADHD was assessed by clinical interview based on DSM-IV-TR criteria, and the diagnosis of ADHD was found to have persisted into adulthood. When the patient was first evaluated in our clinic, his score on the ASRS was 34, and his total score on the LSAS was 97 (very severe social anxiety disorder), with a score
TABLE 1. Symptom Severity Scores for Social Anxiety Disorder and ADHD Before and After Monotherapy With Methylphenidate in Case 1 Rating Scales
Initial Scores
Scores at Week 3
Scores at Week 10
Improvement Rate at Week 10 (%)
LSAS fear LSAS avoidance LSAS total ASRS
41 38 79 41
28 29 57 24
17 15 32 21
60 61 60 49
ADHD indicates attention-deficit/hyperactivity disorder; ASRS, Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale; LSAS, Liebowitz Social Anxiety Scale.
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CLINICAL CASE DISCUSSION of 51 on the fear subscale and a score of 46 on the avoidance subscale. His cardiology examination was normal, and there was no history of epilepsy in the patient or his family. Extended-release methylphenidate 18 mg/d was initially prescribed, with the dose increased to 36 mg/ d after a week. By the third week of treatment, the patient’s ASRS score fell to 25 and his LSAS fear and avoidance subscale scores fell to 40 and 35, respectively. The dose of methylphenidate was increased to 54 mg/d after the third week of treatment. By the seventh week of treatment, the patient’s ASRS score fell to 17, and his LSAS fear and avoidance subscale scores fell to 20 and 11, respectively (Table 2). After treatment, the patient’s social anxiety disorder symptoms resolved, and he was able to give his first lecture in the conference without any concern. He started to attend peer group meetings and reported that he felt more comfortable in social circles. His problems with attention and work performance also improved. He stated that he was able to organize his everyday life better. To summarize, with a dose of 54 mg/d of extended-release methylphenidate, the patient’s LSAS fear, avoidance, and total scores improved between 61% and 76% (indicates response to treatment), and his ASRS scores improved by 50% at the seventh week of treatment. Just as in Case 1, the patient subjectively reported improvement in both social anxiety disorder and ADHD symptoms with no significant medication side effects.
DISCUSSION We have presented the cases of 2 patients with comorbid social anxiety disorder and ADHD who
responded well to extended-release methylphenidate monotherapy. In both cases, the social anxiety disorder and ADHD symptoms simultaneously responded to treatment with extended-release methylphenidate, without the use of medication approved for the treatment of social anxiety disorder. These findings are consistent with those reported by Golubchik et al8 in 2014 in a group of children and adolescents with comorbid social anxiety disorder and ADHD. Given the improvement with methylphenidate treatment in both ADHD and social anxiety disorder symptoms reported elsewhere and in the cases presented here, we suggest the need for further research in this area. ADHD symptoms can interfere with social functioning during childhood and it has been reported that this social impairment often persists in adolescence even if there is a reduction in ADHD symptoms.18 Therefore, at least in a subset of patients, social anxiety disorder may develop secondary to the problems of having ADHD, and the symptoms of both social anxiety disorder and ADHD in these patients may respond to monotherapy with medication for ADHD. The literature on the relationship between ADHD and anxiety disorders is limited and inconsistent. Pliszka suggested that children with anxiety disorders may have limited function in attention skills and because of that they may be erroneously diagnosed with ADHD. He also suggested that the children who are diagnosed with ADHD and comorbid anxiety disorders may have a different type of ADHD and that their ADHD symptoms emerge because of a primary anxiety disorder.19,20 Various studies have also found that atomoxetine and methylphenidate are effective for the treatment of both ADHD and anxiety symptoms in patients with ADHD and comorbid anxiety disorders.7,21–23
TABLE 2. Symptom Severity Scores for Social Anxiety Disorder and ADHD Before and After Monotherapy With Methylphenidate in Case 2 Rating Scales
Initial Scores
Scores at Week 3
Scores at Week 7
Improvement Rate at Week 7 (%)
LSAS fear LSAS avoidance LSAS total ASRS
51 46 97 34
40 35 75 25
20 11 31 17
61 76 68 50
ADHD indicates attention-deficit/hyperactivity disorder; ASRS, Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale; LSAS, Liebowitz Social Anxiety Scale.
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CLINICAL CASE DISCUSSION It has also been found that anxiety symptoms can worsen attention skills,24 and that attention deficit may have anxiogenic effects.25,26 Therefore, it is important to make an accurate differential diagnosis in these conditions. Because the onset of ADHD and social anxiety disorder symptoms occurred during childhood and adolescence in our cases, we used the K-SADS-PL to make reliable childhood diagnoses of ADHD and social anxiety disorder and delete. The K-SADS-PL also confirmed the diagnosis of social anxiety disorder that we had already made using the SCID-I. The cases presented here suggest that the finding by Golubchik et al8 of a parallel improvement in ADHD and social anxiety disorder with methylphenidate treatment in youth may also be valid in adults. Methylphenidate has been found to be associated with improvements in emotional recognition and in social adaptation.27 Treatment with methylphenidate is associated with a positive effect on school performance, academic achievement, and self-efficacy. All of these parameters may lead to improvement in social functioning, which may lead to a reduction in the symptoms of social anxiety disorder.8 Adler et al7 also found that atomoxetine monotherapy was more effective than placebo in patients with comorbid social anxiety disorder and ADHD. Taken together with these studies, our findings suggest that, in the presence of comorbid ADHD, a treatment specific to ADHD (eg, stimulants or atomoxetine) may be sufficient for the treatment of both ADHD and social anxiety disorder, at least in some patients.
CONCLUSIONS Extended-release methylphenidate treatment in 2 patients with ADHD inattentive type and social anxiety disorder led to clinical improvement and a decrease in scores on ratings scales for both social anxiety disorder and ADHD. Further comprehensive studies of the effects of stimulant and nonstimulant ADHD treatment in patients with comorbid social anxiety disorder and ADHD (particularly the inattentive type) are warranted.
COMMENTARY by David A. Kahn, MD I enjoyed reading this report because it lends credence to a clinical impression that I have held for a
long time. As an adult psychiatrist, I see a number of individuals who are emotionally scarred by the impact that childhood-onset learning problems have had on the trajectory of their lives. These early neurodevelopmental disorders include not only ADHD but also a wide variety of verbal and nonverbal learning disorders. Whereas some children, and the adults they become, are socially unaware of their limitations, others are quite sensitive to the knowledge that they miss cues and have trouble performing social and occupational tasks in both small and large ways. These problems range from difficulty following and contributing to everyday conversations at the book club or around the water cooler, all the way to achieving the kinds of major successes in school, work, and life generally that build confidence, particularly in interpersonal settings. The secondary impact of ADHD and related neurodevelopmental disorders on mood is multifold and can include depressive, anxiety, and personality disorders. These 2 cases are especially interesting because neither patient received typical first-line therapies for social anxiety, such as serotonin reuptake inhibitors or cognitive behavior therapy. We can think of 2 possible reasons why stimulant monotherapy was effective for these 2 adults, as well for many of the children with comorbidity described in the related studies referenced by the authors. One is that stimulants might be a good, if unrecognized, treatment for the underlying neurobiology of social anxiety disorder. There do not seem to be any studies testing the effects of stimulants in social anxiety disorder without ADHD. Results of 1 openlabel study of bupropion suggests that it may be helpful in social phobia,28 indicating that serotonergic mechanisms may not be the only pathway to target. It is also interesting to note the counterintuitive finding in another isolated study, by a very reputable group of researchers, that stimulants may improve obsessive-compulsive disorder,29 broadly considered an “anxiety” disorder even if quite unrelated to social anxiety disorder. (I can corroborate the observation, based on my own experience after reading the report, using amphetamine successfully in a patient with obsessivecompulsive disorder to markedly diminish crippling fears of contamination that were never fully responsive to a combination of clomipramine and serotonin reuptake inhibitors.)
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CLINICAL CASE DISCUSSION The other major explanation for the findings reported by Koyuncu and colleagues could be that social anxiety or other dysphoric symptoms develop as a comorbid but secondary response to cognitive difficulties. I would imagine this might be the case, especially in individuals with good self-perceptive capacities. As mentioned earlier, I have seen a number of adult patients in whom I believed this to be the case, and I have found that improvement in attention and other cognitive domains with the use of stimulants sometimes leads to a significant reduction in the fear of failing at interpersonal and occupational tasks. In some instances, after proper diagnosis of underappreciated comorbid ADHD and addition of a stimulant, I have been able to reduce or stop serotonin reuptake inhibitors that had only been partially effective and fraught with unpleasant side effects such as sedation, weight gain, and sexual dysfunction. Articulate patients can describe quite vividly how the improvement in focus melts through the anxiety they have been living with for so long. From the other side, anxiety can also lead to difficulty in focusing and learning, so that it is important to use a 2-tailed approach in evaluating children and adults with comorbid ADHD and social anxiety disorder in determining which, if either, is the primary problem and which is secondary. The widespread cultural concern that we are overdiagnosing ADHD (and overprescribing stimulants) in children who are merely under the stress of massive expectations for super achievement is another variation on this theme. We do not have nearly enough evidence to regard stimulants as a parallel option to serotonin reuptake inhibitors for the treatment of adults (or children) with social anxiety alone. However, in the presence of comorbid ADHD, we should certainly consider using stimulants, given that they are suggested by this report and other preliminary studies to be a valuable ingredient in a sequential approach to social anxiety symptoms.
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REFERENCES 1.
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Safren SA, Lanka GD, Otto MW, et al. Prevalence of childhood ADHD among patients with generalized anxiety disorder and a comparison condition, social phobia. Depress Anxiety. 2001;13:190–191.
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Mörtberg E, Tilfors K, Bejerot S. Screening for ADHD in an adult social phobia sample. J Atten Disord. 2012;16:645–649. Koyuncu A, Ertekin E, Yüksel C, et al. Predominantly inattentive type of ADHD is associated with social anxiety disorder. J Atten Disord. 2014. DOI: 10.1177/ 1087054714533193 [Epub ahead of print]. Mancini C, Van Ameringen M, Oakman JM, et al. Childhood attention deficit/hyperactivity disorder in adults with anxiety disorders. Psychol Med. 1999;29: 515–525. Van Ameringen M, Mancini C, Simpson W, et al. Adult attention deficit hyperactivity disorder in an anxiety disorders population. CNS Neurosci Ther. 2001;17: 221–226. Chavira DA, Stein MB, Bailey K, et al. Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample. J Affect Disord. 2004;80:163–171. Adler LA, Liebowitz M, Kronenberger W, et al. Atomoxetıne treatment in adults with attention-deficit/hyperactivity disorder and comorbid social anxiety disorder. Depress Anxiety. 2009;26:212–221. Golubchik P, Sever J, Weizman A. Methylphenidate treatment in children with attention deficit hyperactivity disorder and comorbid social phobia. Int Clin Psychopharmacol. 2014;29:212–215. First M, Spitzer R, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I). Washington, DC: American Psychiatric Press; 1997. Kaufman J, Birmaher B, Brent D, et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36:980–988. Gokler B, Unal F, Pehlivanturk B, et al. Okul Cagı Cocukları İcin Duygulanım Bozuklukları ve Şizofreni Gorusme Cizelgesi Simdi ve Yasam Boyu Sekli- Turkce Uyarlamasının Gecerlik ve Guvenirligi [in Turkish] [Reliability and Validity of Schedule for Affective Disorders and Schizophrenia for School Age ChildrenPresent and Lifetime Version-Turkish Version (K-SADSPL-T)]. Cocuk ve Genclik Ruh Sagligi Dergisi [Turk J Child Adolesc Ment Health]. 2004;11:109–116. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150:1792–1798. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry. 2005;162:1621–1627. Tamam L, Karaku G, Ozpoyraz N. Comorbidity of adult attention deficit hyperactivity disorder and bipolar disorder: prevalence and clinical correlates. Eur Arch Psychiatry Clin Neurosci. 2008;258:385–393. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC: APA; 2000. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35:245–256. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry. 1987;22:141–173.
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CLINICAL CASE DISCUSSION 18. Lee SS, Falk AE, Aguirre VP. Association of comorbid anxiety with social functioning in school-age children with and without attention-deficit/hyperactivity disorder (ADHD). Psychiatry Res. 2012;197:90–96. 19. Pliszka SR. Effect of anxiety on cognition, behavior, and stimulant response in ADHD. J Am Acad Child Adolesc Psychiatry. 1989;28:882–887. 20. Pliszka SR. Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder. J Am Acad Child Adolesc Psychiatry. 1992;31:197–203. 21. Diamond IR, Tannock R, Schachar RJ. Response to methylphenidate in children with ADHD and comorbid anxiety. J Am Acad Child Adolesc Psychiatry. 1999;38:402–409. 22. Sumner C, Sher L, Suttun V, et al. Atomoxetine treatment for pediatric patients with ADHD and comorbid anxiety. Paper presented at the annual meeting of the American. Academy of Child and Adolescent Psychiatry (AACAP), Toronto, ON, October 23, 2005. 23. Geller D, Donnelly C, Lopez F, et al. Atomoxetine treatment for pediatric patients with attention-deficit/ hyperactivity disorder with comorbid anxiety disorder. J Am Acad Child Adolesc Psychiatry. 2007;46: 1119–1127.
24. Roth RM, Wishart HA, Flashman LA, et al. Contribution of organizational strategy to verbal learning and memory in adults with attention-deficit/hyperactivity disorder. Neuropsychology. 2004;18:78–84. 25. Pliszka SR. Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am. 2000;9:525–540, vii. 26. Manassis K, Tannock R, Young A, et al. S. Cognition in anxious children with attention deficit hyperactivity disorder: a comparison with clinical and normal children. Behav Brain Funct. 2007;3:4. 27. Williams LM, Hermens DF, Palmer D, et al. Misinterpreting emotional expressions in attention-deficit/hyperactivity disorder: evidence for a neural marker and stimulant effects. Biol Psychiatry. 2008;63:917–926. 28. Emmanuel NP, Brawman-Mintzer O, Morton WA, et al. Bupropion-SR in treatment of social phobia. Depress Anxiety. 2000;12:111–113. 29. Koran LM, Aboujaoude E, Gamel NN. Double-blind study of dextroamphetamine versus caffeine augmentation for treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2009;70:1530–1535.
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Case presentation: AHMET KOYUNCU, FAHRI ÇELEBI, ERHAN ERTEKIN, Case discussion: DAVID A. KAHN,
MD MD MD MD
association between the inattentive type of ADHD and social anxiety disorder. The use of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version’s (K-SADS-PL), a highly reliable semistructured interview, is a possible explanation for the high rates of ADHD found in that study. Moreover, the study sample consisted primarily of patients with a relatively high educational level who applied to 3 hospitals in the same group, specifically for treatment of social anxiety disorder through personal referrals or Internet searches. Koyuncu et al3 also found that the presence of a history of childhood ADHD was associated with more severe symptoms of social anxiety disorder. Mancini et al4 reported that 19.5% of patients with anxiety disorders had a history of ADHD in childhood, and they also found that 12 of 34 patients with social anxiety disorder (35.3%) had a history of childhood ADHD. Van Ameringen et al5 reported a frequency of adult ADHD of 27.9% among 129 patients with anxiety disorders. Finally, in a childhood study, generalized-type social anxiety disorder and ADHD were found to be associated among patients aged 7 to 18 years.6 Data are limited not only about the characteristics of comorbidity between social anxiety disorder and ADHD, but also concerning treatment approaches for this type of comorbidity. In a study
CASE PRESENTATION Background Little research exists concerning comorbidity of social anxiety disorder and attention-deficit/hyperactivity disorder (ADHD). In 2 studies conducted with small samples of patients with social anxiety disorder, Safren et al1 reported that the frequency of childhood ADHD among 33 patients was 3%, and Mörtberg et al2 reported childhood symptoms of ADHD in 7.8% of participants. Koyuncu et al3 reported 72.3% of 130 patients with a primary diagnosis of social anxiety disorder had a history of childhood ADHD, and they noted a particular
KOYUNCU: Academy Social Phobia Center, Istanbul, Turkey; ÇELEBI: Department of Child and Adolescent Psychiatry, Zonguldak Women and Children Hospital, Zonguldak, Turkey; ERTEKIN: Department of Psychiatry, Istanbul Medical School, Istanbul University, Istanbul, Turkey; KAHN: Columbia University College of Physicians and Surgeons, New York, NY. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Please send correspondence to: Fahri Çelebi, MD, Department of Child and Adolescent Psychiatry, Zonguldak Women and Children Hospital, Zonguldak, 67100 Turkey (e-mail: [email protected]). The authors declare no conflicts of interest. DOI: 10.1097/PRA.0000000000000070
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CLINICAL CASE DISCUSSION of adult patients with comorbid social anxiety disorder and adult ADHD, Adler et al7 compared atomoxetine (n=224) and placebo (n=218) and found that atomoxetine monotherapy effectively improved symptoms of ADHD and comorbid social anxiety disorder and was well tolerated. In a recent study, 21 patients with ADHD and comorbid social anxiety disorder, aged 8 to 18 years, received methylphenidate treatment, which was found to be associated with a significant decrease in scores on rating scales for both ADHD and social anxiety disorder. The improvement in ADHD symptoms with methylphenidate treatment was associated with a parallel improvement in social anxiety disorder symptoms, and methylphenidate treatment was found to be safe and effective in children with comorbid ADHD and social anxiety disorder.8 In this report, we present the cases of 2 adult patients with comorbid social anxiety disorder and adult ADHD who were treated with methylphenidate monotherapy.
Case 1 The patient was a 21-year-old single woman with a bachelor’s degree who works as a graphic designer. She was admitted as an outpatient to our clinic with social phobic complaints that she experienced at work and in social circles. She reported difficulty in interacting with her supervisors and also with people with whom she was unfamiliar. She stated that she had a feeling that people were watching her during her daily activities. She reported avoiding situations such as public speaking, speaking up in a meeting, eating with people, attending group activities, and meeting new people. When she was not able to avoid such situations, she experienced worsened anxiety symptoms, including sweating, fearfulness, heart pounding, flushing, quavering in her voice, and difficulty speaking accurately. She reported that such symptoms of social anxiety disorder had started 5 years earlier. On the basis of the Structured Clinical Interview for DSM-IV (SCID-I),9 the patient was diagnosed with social anxiety disorder, with no current or lifetime comorbid Axis I psychiatric disorder. During the SCID interview, the patient also reported having problems with attention since childhood. She had difficulties in her job because of forgetfulness and she made mistakes that affected
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the tasks she was performing. She stated that she was unable to start working on her tasks until deadlines were getting too close, which caused conflicts with her supervisors. She also reported that, when she had been in school, she had difficulty following the lessons and had made mistakes because of poor attention. Because of the attentional symptoms she reported, the K-SADS-PL ADHD module10 was administered, which revealed a history of ADHD, inattentive type in childhood. A validity and reliability study of the Turkish version of the K-SADS-PL was published by Gokler et al in 2004.11 The K-SADS-PL has also been used in previous studies to retrospectively assess childhood psychopathology.3,12–14 The current status of the patient’s ADHD symptoms was also evaluated by clinical interview in accordance with DSM-IV-TR criteria,15 and it was found that she also met criteria for a diagnosis of adult ADHD. (The SCID-I does not include a module for assessing for ADHD in adult patients. The diagnosis of ADHD in adults is therefore made by clinical interview on the basis of the DSM criteria.) When the patient was first evaluated in our clinic, her score on the Adult Attention-Deficit and Hyperactivity Disorder Self-Report Scale (ASRS)16 was 41 and her total score on the Liebowitz Social Anxiety Scale (LSAS)17 was 79 (marked social anxiety disorder), with a score of 41 on the fear subscale and a score of 38 on the avoidance subscale. Cardiology consultation and electrocardiography revealed no cardiac problems. The patient stated that at least part of her problems with social phobia stemmed from her inattentiveness. For example, she reported being teased by her peers because of the mistakes she made owing to poor attention. Therefore, we chose to prioritize ADHD rather than social anxiety disorder in her treatment. Extended-release methylphenidate was initiated at a dose of 18 mg/d and then titrated up to 36 mg/d in 1 week. Her ASRS score fell to 24 by the third week of treatment and decreased further to 21 by the tenth week. Her LSAS fear and avoidance scores also fell to 28 and 29 by the third week of treatment and decreased further to 17 and 15 by the tenth week, respectively. The patient’s subjective experience of the treatment was consistent with the reductions observed in her rating scale scores: she reported significant improvement in both social anxiety disorder and ADHD symptoms. After she had completed 10
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CLINICAL CASE DISCUSSION weeks of treatment, the patient reported improvement in most of the symptoms she initially had. She reported improvement in her performance at work and in her attention skills. She also reported increased social interactions with her friends and that she had become less avoidant in social situations and at work. In conclusion, with methylphenidate monotherapy 36 mg/d, the patient’s LSAS fear, avoidance, and total scores improved by 60% and her ASRS scores improved by 49%, which indicates response to treatment in line with clinically significant improvement by the tenth week of treatment (Table 1).
Case 2 The patient was a 28-year-old single man working at a university as a research assistant. He was admitted as an outpatient to our clinic with social phobic complaints, which he experienced particularly in academic settings. He reported that he had thoughts that everybody was watching him and he avoided going to the cafeteria and having lunch with his colleagues. He also stated that he was scheduled to give a speech at a conference next month, which was the main reason he was seeking treatment. His social phobia first occurred in primary school when he was 6 years old, but he never received treatment. While he was at school, he reported difficulty in speaking in front of his classmates and teachers, which caused him to avoid answering questions in the classroom, although he knew the answers. He reported that, when he had to perform
a task in public, he felt intense anxiety symptoms, including heart pounding, sweating, flushing, and forgetting what to say. His classmates had made fun of his behaviors, which worsened his anxiety symptoms in social situations. He complained about trouble talking to girls whom he liked, for which reason he had not had any romantic relationships. On the basis of the SCID-I, the patient was diagnosed with social anxiety disorder with no current or lifetime Axis I psychiatric comorbidity. The patient also reported difficulty in concentrating and severe distractibility at his job. He said that he would lose concentration if another person, a car, or even a fly passed by. When he was at school, he got lower grades than he should have because of mistakes on the easiest questions and concentration problems during class lessons and examinations. He stated that he had difficulty listening to anybody carefully, because he frequently found himself preoccupied with thinking about something else. He reported that he would start daydreaming after listening to the other person for a while. He avoided tasks that required efforts to engage with others. He did not mention having experienced any hyperactivity symptoms in the past. The ADHD module of the K-SADS-PL was administered, based on which the patient was diagnosed with a history of childhood ADHD, inattentive type. The current status of his ADHD was assessed by clinical interview based on DSM-IV-TR criteria, and the diagnosis of ADHD was found to have persisted into adulthood. When the patient was first evaluated in our clinic, his score on the ASRS was 34, and his total score on the LSAS was 97 (very severe social anxiety disorder), with a score
TABLE 1. Symptom Severity Scores for Social Anxiety Disorder and ADHD Before and After Monotherapy With Methylphenidate in Case 1 Rating Scales
Initial Scores
Scores at Week 3
Scores at Week 10
Improvement Rate at Week 10 (%)
LSAS fear LSAS avoidance LSAS total ASRS
41 38 79 41
28 29 57 24
17 15 32 21
60 61 60 49
ADHD indicates attention-deficit/hyperactivity disorder; ASRS, Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale; LSAS, Liebowitz Social Anxiety Scale.
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CLINICAL CASE DISCUSSION of 51 on the fear subscale and a score of 46 on the avoidance subscale. His cardiology examination was normal, and there was no history of epilepsy in the patient or his family. Extended-release methylphenidate 18 mg/d was initially prescribed, with the dose increased to 36 mg/ d after a week. By the third week of treatment, the patient’s ASRS score fell to 25 and his LSAS fear and avoidance subscale scores fell to 40 and 35, respectively. The dose of methylphenidate was increased to 54 mg/d after the third week of treatment. By the seventh week of treatment, the patient’s ASRS score fell to 17, and his LSAS fear and avoidance subscale scores fell to 20 and 11, respectively (Table 2). After treatment, the patient’s social anxiety disorder symptoms resolved, and he was able to give his first lecture in the conference without any concern. He started to attend peer group meetings and reported that he felt more comfortable in social circles. His problems with attention and work performance also improved. He stated that he was able to organize his everyday life better. To summarize, with a dose of 54 mg/d of extended-release methylphenidate, the patient’s LSAS fear, avoidance, and total scores improved between 61% and 76% (indicates response to treatment), and his ASRS scores improved by 50% at the seventh week of treatment. Just as in Case 1, the patient subjectively reported improvement in both social anxiety disorder and ADHD symptoms with no significant medication side effects.
DISCUSSION We have presented the cases of 2 patients with comorbid social anxiety disorder and ADHD who
responded well to extended-release methylphenidate monotherapy. In both cases, the social anxiety disorder and ADHD symptoms simultaneously responded to treatment with extended-release methylphenidate, without the use of medication approved for the treatment of social anxiety disorder. These findings are consistent with those reported by Golubchik et al8 in 2014 in a group of children and adolescents with comorbid social anxiety disorder and ADHD. Given the improvement with methylphenidate treatment in both ADHD and social anxiety disorder symptoms reported elsewhere and in the cases presented here, we suggest the need for further research in this area. ADHD symptoms can interfere with social functioning during childhood and it has been reported that this social impairment often persists in adolescence even if there is a reduction in ADHD symptoms.18 Therefore, at least in a subset of patients, social anxiety disorder may develop secondary to the problems of having ADHD, and the symptoms of both social anxiety disorder and ADHD in these patients may respond to monotherapy with medication for ADHD. The literature on the relationship between ADHD and anxiety disorders is limited and inconsistent. Pliszka suggested that children with anxiety disorders may have limited function in attention skills and because of that they may be erroneously diagnosed with ADHD. He also suggested that the children who are diagnosed with ADHD and comorbid anxiety disorders may have a different type of ADHD and that their ADHD symptoms emerge because of a primary anxiety disorder.19,20 Various studies have also found that atomoxetine and methylphenidate are effective for the treatment of both ADHD and anxiety symptoms in patients with ADHD and comorbid anxiety disorders.7,21–23
TABLE 2. Symptom Severity Scores for Social Anxiety Disorder and ADHD Before and After Monotherapy With Methylphenidate in Case 2 Rating Scales
Initial Scores
Scores at Week 3
Scores at Week 7
Improvement Rate at Week 7 (%)
LSAS fear LSAS avoidance LSAS total ASRS
51 46 97 34
40 35 75 25
20 11 31 17
61 76 68 50
ADHD indicates attention-deficit/hyperactivity disorder; ASRS, Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale; LSAS, Liebowitz Social Anxiety Scale.
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CLINICAL CASE DISCUSSION It has also been found that anxiety symptoms can worsen attention skills,24 and that attention deficit may have anxiogenic effects.25,26 Therefore, it is important to make an accurate differential diagnosis in these conditions. Because the onset of ADHD and social anxiety disorder symptoms occurred during childhood and adolescence in our cases, we used the K-SADS-PL to make reliable childhood diagnoses of ADHD and social anxiety disorder and delete. The K-SADS-PL also confirmed the diagnosis of social anxiety disorder that we had already made using the SCID-I. The cases presented here suggest that the finding by Golubchik et al8 of a parallel improvement in ADHD and social anxiety disorder with methylphenidate treatment in youth may also be valid in adults. Methylphenidate has been found to be associated with improvements in emotional recognition and in social adaptation.27 Treatment with methylphenidate is associated with a positive effect on school performance, academic achievement, and self-efficacy. All of these parameters may lead to improvement in social functioning, which may lead to a reduction in the symptoms of social anxiety disorder.8 Adler et al7 also found that atomoxetine monotherapy was more effective than placebo in patients with comorbid social anxiety disorder and ADHD. Taken together with these studies, our findings suggest that, in the presence of comorbid ADHD, a treatment specific to ADHD (eg, stimulants or atomoxetine) may be sufficient for the treatment of both ADHD and social anxiety disorder, at least in some patients.
CONCLUSIONS Extended-release methylphenidate treatment in 2 patients with ADHD inattentive type and social anxiety disorder led to clinical improvement and a decrease in scores on ratings scales for both social anxiety disorder and ADHD. Further comprehensive studies of the effects of stimulant and nonstimulant ADHD treatment in patients with comorbid social anxiety disorder and ADHD (particularly the inattentive type) are warranted.
COMMENTARY by David A. Kahn, MD I enjoyed reading this report because it lends credence to a clinical impression that I have held for a
long time. As an adult psychiatrist, I see a number of individuals who are emotionally scarred by the impact that childhood-onset learning problems have had on the trajectory of their lives. These early neurodevelopmental disorders include not only ADHD but also a wide variety of verbal and nonverbal learning disorders. Whereas some children, and the adults they become, are socially unaware of their limitations, others are quite sensitive to the knowledge that they miss cues and have trouble performing social and occupational tasks in both small and large ways. These problems range from difficulty following and contributing to everyday conversations at the book club or around the water cooler, all the way to achieving the kinds of major successes in school, work, and life generally that build confidence, particularly in interpersonal settings. The secondary impact of ADHD and related neurodevelopmental disorders on mood is multifold and can include depressive, anxiety, and personality disorders. These 2 cases are especially interesting because neither patient received typical first-line therapies for social anxiety, such as serotonin reuptake inhibitors or cognitive behavior therapy. We can think of 2 possible reasons why stimulant monotherapy was effective for these 2 adults, as well for many of the children with comorbidity described in the related studies referenced by the authors. One is that stimulants might be a good, if unrecognized, treatment for the underlying neurobiology of social anxiety disorder. There do not seem to be any studies testing the effects of stimulants in social anxiety disorder without ADHD. Results of 1 openlabel study of bupropion suggests that it may be helpful in social phobia,28 indicating that serotonergic mechanisms may not be the only pathway to target. It is also interesting to note the counterintuitive finding in another isolated study, by a very reputable group of researchers, that stimulants may improve obsessive-compulsive disorder,29 broadly considered an “anxiety” disorder even if quite unrelated to social anxiety disorder. (I can corroborate the observation, based on my own experience after reading the report, using amphetamine successfully in a patient with obsessivecompulsive disorder to markedly diminish crippling fears of contamination that were never fully responsive to a combination of clomipramine and serotonin reuptake inhibitors.)
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CLINICAL CASE DISCUSSION The other major explanation for the findings reported by Koyuncu and colleagues could be that social anxiety or other dysphoric symptoms develop as a comorbid but secondary response to cognitive difficulties. I would imagine this might be the case, especially in individuals with good self-perceptive capacities. As mentioned earlier, I have seen a number of adult patients in whom I believed this to be the case, and I have found that improvement in attention and other cognitive domains with the use of stimulants sometimes leads to a significant reduction in the fear of failing at interpersonal and occupational tasks. In some instances, after proper diagnosis of underappreciated comorbid ADHD and addition of a stimulant, I have been able to reduce or stop serotonin reuptake inhibitors that had only been partially effective and fraught with unpleasant side effects such as sedation, weight gain, and sexual dysfunction. Articulate patients can describe quite vividly how the improvement in focus melts through the anxiety they have been living with for so long. From the other side, anxiety can also lead to difficulty in focusing and learning, so that it is important to use a 2-tailed approach in evaluating children and adults with comorbid ADHD and social anxiety disorder in determining which, if either, is the primary problem and which is secondary. The widespread cultural concern that we are overdiagnosing ADHD (and overprescribing stimulants) in children who are merely under the stress of massive expectations for super achievement is another variation on this theme. We do not have nearly enough evidence to regard stimulants as a parallel option to serotonin reuptake inhibitors for the treatment of adults (or children) with social anxiety alone. However, in the presence of comorbid ADHD, we should certainly consider using stimulants, given that they are suggested by this report and other preliminary studies to be a valuable ingredient in a sequential approach to social anxiety symptoms.
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