Opinions on using stimulants for anxiety

[Shikima]

I came across an interesting case, admittedly the first of a kind for me where a lady I saw in clinic with long history of what appears to be generalized anxiety disorder and social phobia has been doing extensive reading and convinced herself that she has ADHD based on symptoms.

She started using a low dose Adderall from an unknown source with self report improvement of symptoms when confronted by social stressors - ie: improvement in conversational skills most noticeably.

Any theories for these neurobiological interactions? I recognize this has been short, I am wanting to get a hand up over these these symptoms as anxiety seems to be popping up more and provide some sound treatment rationale. I've also done a pubmed search with limited responses back (Did I not hit the correct key words?)

Thanks.

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[dl2dp2]

This is common. Some people just call the symptom of unable to initiate a task and getting interrupted constantly "anxiety."

This is why structured interviews and screening instruments are so important. ADHD is under-diagnosed in some populations and over-diagnosed in others. If you are her primary psychiatrist you need to do a real screening instrument like ADHD-RS or adult ADHD rating scale and treat her based on that plus review with family.

If she also has GAD, then you need to screen her for that also with Ham-D, and treat her with an SSRI.

 

[nitemagi]

I think there's many possibilities, here.

Micro-anxiety and avoidance of anxiety-triggering stimuli can manifest as poor attention, as in PTSD.

Stimulants rev up the whole brain, including the frontal lobe, which leads to an increased sense of control, which improves attention and may also lessen anxiety in the context of fear of loss of control.

I am not convinced that all attention problems is ADHD, nor that improvement on stimulants in attention (or anxiety) is ADHD. Due to my experience with so much addiction, I personally consider stimulants as mostly a second or third line medication. They have a lot of risks and those shouldn't be blown off, despite what industry-pushed CMEs tend to recommend. And for anyone with attention problems regardless of the cause, I incorporate CBT for ADHD.

 

[birchswing]

I have had anxiety since very early childhood, but I always functioned quite well with it, especially in terms of doing very well in school. In 10th grade I went south very fast. I began taking college and AP classes. It's hard to pinpoint exactly what went wrong, but I started having debilitating anxiety and having to run out of the classrooms. I was put on Ativan which didn't ever really help much past the first week I was on it. I had none of these screenings that are being mentioned--this was the typical in-and-out diagnosis and prescription. I too considered ADHD and my psychiatrist told me that the only way to know if I had it was to try me on Adderall. If it made me anxious, then I didn't have it. If I was better, then I had ADHD. He took me off Ativan and on Adderall. I took it for one week. I was anxious but in a different way--shaking a little bit. But it was very easy for me to sit through my classes. I had two AP exams that week. I had recently taken the SATs and had to leave halfway through to anxiety. I sat through both AP exams easily and got a 5 on both. When I saw him after the week he thought that I was feeling "too good" and that people with ADHD would feel normal on Aderall not "euphoric" as I seemed to feel. So he put me back on Ativan.

I'm now 32 and still on benzos, and my psychologist who I've been seeing for 6 years keeps getting closer to the conclusion that I actually have ADHD. If you saw what I look like sitting in a class to this day you would agree. I've always explained that I can do "output" but not "input." For me, sitting through a lecture is torture. It's always been the classroom that is so difficult and still is.

Anyhow, none of this is to seek medical advice, only to say that the OP's client may very well be right. Unfortunately for me, my psychiatrist thinks it's impossible to determine what any of my real diagnoses are until I'm off the benzos altogether which will take a while. The more I think about it though the more it makes sense. In class I squirm, I can't sit still, I am fidgeting and dropping things. And I always called it anxiety because that's what my dad called it and what my psychiatrist called it, and so I just came to believe I had an anxiety disorder. But I had always been anxious--just never in a way that affected my life until it hit like lightning in 10th grade.

 

[Shikima]

I think there's many possibilities, here.

Micro-anxiety and avoidance of anxiety-triggering stimuli can manifest as poor attention, as in PTSD.

Stimulants rev up the whole brain, including the frontal lobe, which leads to an increased sense of control, which improves attention and may also lessen anxiety in the context of fear of loss of control.

I am not convinced that all attention problems is ADHD, nor that improvement on stimulants in attention (or anxiety) is ADHD. Due to my experience with so much addiction, I personally consider stimulants as mostly a second or third line medication. They have a lot of risks and those shouldn't be blown off, despite what industry-pushed CMEs tend to recommend. And for anyone with attention problems regardless of the cause, I incorporate CBT for ADHD.

Thanks for this insight. I've often had the similar deductions but could not 'read it in a book' to affirm my own suspicions.

 

[Shikima]

I have had anxiety since very early childhood, but I always functioned quite well with it, especially in terms of doing very well in school. In 10th grade I went south very fast. I began taking college and AP classes. It's hard to pinpoint exactly what went wrong, but I started having debilitating anxiety and having to run out of the classrooms. I was put on Ativan which didn't ever really help much past the first week I was on it. I had none of these screenings that are being mentioned--this was the typical in-and-out diagnosis and prescription. I too considered ADHD and my psychiatrist told me that the only way to know if I had it was to try me on Adderall. If it made me anxious, then I didn't have it. If I was better, then I had ADHD. He took me off Ativan and on Adderall. I took it for one week. I was anxious but in a different way--shaking a little bit. But it was very easy for me to sit through my classes. I had two AP exams that week. I had recently taken the SATs and had to leave halfway through to anxiety. I sat through both AP exams easily and got a 5 on both. When I saw him after the week he thought that I was feeling "too good" and that people with ADHD would feel normal on Aderall not "euphoric" as I seemed to feel. So he put me back on Ativan.

I'm now 32 and still on benzos, and my psychologist who I've been seeing for 6 years keeps getting closer to the conclusion that I actually have ADHD. If you saw what I look like sitting in a class to this day you would agree. I've always explained that I can do "output" but not "input." For me, sitting through a lecture is torture. It's always been the classroom that is so difficult and still is.

Anyhow, none of this is to seek medical advice, only to say that the OP's client may very well be right. Unfortunately for me, my psychiatrist thinks it's impossible to determine what any of my real diagnoses are until I'm off the benzos altogether which will take a while. The more I think about it though the more it makes sense. In class I squirm, I can't sit still, I am fidgeting and dropping things. And I always called it anxiety because that's what my dad called it and what my psychiatrist called it, and so I just came to believe I had an anxiety disorder. But I had always been anxious--just never in a way that affected my life until it hit like lightning in 10th grade.

Keep at it, you'll get off of them.

 

[birchswing]

Keep at it, you'll get off of them.

Thanks!

 

[Ceke2002]

I too considered ADHD and my psychiatrist told me that the only way to know if I had it was to try me on Adderall. If it made me anxious, then I didn't have it. If I was better, then I had ADHD.

I was only 3-ish or so when I was first diagnosed with ADHD, but even without my Mum filling me in on the details some years later, and a very limited recollection of the actual process at the time, I sure as heck know there was more to it than just 'here take these pills and see what happens'.

Keep at it, you'll get off of them.

Seconded.

 

[whopper]

If there's someone with GAD or ADHD and you ask them if they have "racing thoughts" they could realistically say yes.

There is a difficult place where GAD vs ADHD vs Bipolar Disorder (cyclothymia) can all look the same. In all you could realistically have poor sleep. While this is not a DSM-V criteria for ADHD, I've seen it in so many ADHD patients that did not have other comorbidities. All can look tense, all have thoughts and/or emotions that are frustratingly out-of-control.

People with ADHD will, unfortunately for us, describe their problems as if they're anxiety because no one ever trained them in memorizing a DSM-V.

Some of the methods I've used to discriminate between these are 1-when did the problems start? If they started very early such as grade school or earlier this suggests but does not prove ADHD 2-Are they episodic in nature? This suggest bipolar disorder though cyclothymia could present all throughout the year. 3-What helps the symptoms? If coffee helps this suggests ADHD. Unfortunately exercise could improve all three so it won't lead you anywhere.

A problem here is a benzo can help all three so it will not help you diagnostically. If you give one, you could put the patient in a place where they feel better so they will not want to move out of that safe place. We all know that "safe place" really will make them worse the longer they are on it. I'd recommend avoiding benzos altogether unless the case was severe, in which case it should only be given temporarily.

One other trick I've learned is you have to avoid the term "racing thoughts" and instead ask "Are the thoughts going so fast that they're uncomfortable? or "Are they so fast that by the time you started a sentence you're already ahead on the next thought" vs "Do you have problems focusing on a specific thought" vs "Do you feel as if you're scared all the time."

 

[Information Underload]

I see kids all of the time who develop anxiety disorders and often depression secondary to ADHD symptoms, and thus if you address a root cause of that anxiety, it makes sense that anxiety would improve. If you think about it, in school or work you are expected to perform well. Particulary as a child, you're going through the Eriksonian stages of Industry v. Inferiority in the ages where ADHD symptoms become most prominent. Of course you're going to get anxious if you're constantly forgetting things, constantly getting in trouble, constantly screwing up your work, and dare I say, getting told you're a bad kid. You annoy your friends because you're a flake or if you're hyperactive enough, because you're in their business, disrupting things and all over the place. You get rejected. You start to develop a low self-esteem. You have to be hypervigilent, or you're going to get reamed because you can't focus.

Then you take a stimulant, and all of the nebulous things that hampered normal development crystalize. I love treating ADHD. I find it one of the most rewarding psychiatric conditions to address because treating it well it can be so life-changing.

Does this fit the case with your lady? In my experience, dropping a stimulant on an anxious individual without ADHD often makes them only more anxious. Matter of fact, I find it more effective to treat anxiety often before the ADHD given stimulants can worsen anxiety and given a lot of that inattention may be secondary to anxiety.

 

[Therapist4Chnge]

Stimulant use can simply help a person do what they do…better, which can reduce anxiety related to performance issues. I think that is the explanation in a minority of cases, though still worth considering. More likely a person will struggle with the effect of poor attentional abilities (e.g. incomplete assignments, missing information told to them, etc). It isn't hard to develop poor habits and maladaptive beliefs based on the feedback of others when that feedback is constant (e.g. in school from teachers and then in the workplace from co-workers/bosses), so those areas both need to be addressed. The prevalence of co-morbidity of a mood disorder with someone dx'd w. ADHD is ridiculously high (anecdotally more than what I've seen in the research).

Going back to attention…..I think complicating "poor attention" are the executive dysfunction aspects of ADHD that are much more problematic in adulthood, as there isn't a parent to act as the child's frontal lobe. This aspect cannot directly be treated by medication, though a stimulant can help quiet the "noise" that often exacerbates the executive dysfunction. Coping strategies and behavioral interventions can then be implemented to help bring order and function back to the person. It's been a number of years since I've done ADHD research, but I know this is still a young body of literature. That said, we know that things like problem solving and organizational abilities are significantly different in the brain of someone who has ADHD, though the research still struggles to quantify this across subjects in a clean enough way to take it to the next level of work.

 

[Shikima]

I see kids all of the time who develop anxiety disorders and often depression secondary to ADHD symptoms, and thus if you address a root cause of that anxiety, it makes sense that anxiety would improve. If you think about it, in school or work you are expected to perform well. Particulary as a child, you're going through the Eriksonian stages of Industry v. Inferiority in the ages where ADHD symptoms become most prominent. Of course you're going to get anxious if you're constantly forgetting things, constantly getting in trouble, constantly screwing up your work, and dare I say, getting told you're a bad kid. You annoy your friends because you're a flake or if you're hyperactive enough, because you're in their business, disrupting things and all over the place. You get rejected. You start to develop a low self-esteem. You have to be hypervigilent, or you're going to get reamed because you can't focus.

Then you take a stimulant, and all of the nebulous things that hampered normal development crystalize. I love treating ADHD. I find it one of the most rewarding psychiatric conditions to address because treating it well it can be so life-changing.

Does this fit the case with your lady? In my experience, dropping a stimulant on an anxious individual without ADHD often makes them only more anxious. Matter of fact, I find it more effective to treat anxiety often before the ADHD given stimulants can worsen anxiety and given a lot of that inattention may be secondary to anxiety.

Interestingly enough, I've had 2 cases pop up this week (full moon?) for a guy in his 60s and a lady in her 40s. I recognize that one must resolve the stages lest be stuck, but what I struggle with is a bit of a different beast. The instant gratification problem is the white elephant which relates into an excessive amount of energy burned translating into lower productivity based on a principle where one damn well better give up the magic pill to solve all problems.

 

[Shikima]

Stimulant use can simply help a person do what they do…better, which can reduce anxiety related to performance issues. I think that is the explanation in a minority of cases, though still worth considering. More likely a person will struggle with the effect of poor attentional abilities (e.g. incomplete assignments, missing information told to them, etc). It isn't hard to develop poor habits and maladaptive beliefs based on the feedback of others when that feedback is constant (e.g. in school from teachers and then in the workplace from co-workers/bosses), so those areas both need to be addressed. The prevalence of co-morbidity of a mood disorder with someone dx'd w. ADHD is ridiculously high (anecdotally more than what I've seen in the research).

Going back to attention…..I think complicating "poor attention" are the executive dysfunction aspects of ADHD that are much more problematic in adulthood, as there isn't a parent to act as the child's frontal lobe. This aspect cannot directly be treated by medication, though a stimulant can help quiet the "noise" that often exacerbates the executive dysfunction. Coping strategies and behavioral interventions can then be implemented to help bring order and function back to the person. It's been a number of years since I've done ADHD research, but I know this is still a young body of literature. That said, we know that things like problem solving and organizational abilities are significantly different in the brain of someone who has ADHD, though the research still struggles to quantify this across subjects in a clean enough way to take it to the next level of work.

The kind of executive dysfunction I anticipate to find in an adult compared to a child would be along the lines of impulsive behaviors, unable to keep their employment, using drugs/ETOH as a means to slow the activity, etc. They haven't described the level of social disruption of their lives as classically found. Moreover, I've asked for neuropsych testing to be completed which would give an objective sense to the diagnosis.

In reading, low dosage stimulant medications are ok in controlling symptoms, both for mood, anxiety and concentration in relation to the ADHD. I believe stimulants are covering up the problem and that we often ignore and underestimate the individuals' intelligence for self-governance and correction.

 

[nitemagi]

Anecdotally, I had an OCPD guy with anxiety. Someone had put him on a stimulant briefly. He cleaned his front door until 3 in the morning.

Stimulants can make the dysfunction more dysfunctional sometimes, just give you more energy to feed it.