Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD)

Eur Arch Psychiatry Clin Neurosci (2006) 256 [Suppl 1] : I/26–I/31 DOI 10.1007/s00406-006-1004-4

■ Abstract Attention-deficit/hyperactivity disorder(ADHD) is a chronic, lifelong disorder with childhood-onset, which seriously impairs the affected adults in avariety of daily living functions like educational and oc-cupational functioning, partnership and parenting.

ADHD is associated with a high percentage of co-morbid psychiatric disorders in every lifespan. In adult-hood between 65–89 % of all patients with ADHD sufferfrom one or more additional psychiatric disorders,above all mood and anxiety disorders, substance usedisorders and personality disorders, which complicatesthe clinical picture in terms of diagnostics, treatmentand outcome issues. The present overview provides in-formation of comorbid psychiatric disorders in adultswith ADHD, underlying associations and clinical impli-cations.

■ Key words Adult attention-deficit/hyperactivitydisorder (ADHD) · comorbidity · depression · anxietydisorders · substance use disorders · personalitydisorders

Introduction

Attention-deficit/hyperactivity disorder (ADHD) ischaracterised by chronic problems in attention and im-pulse control, age-inappropriate hyperactive behaviouras well as emotional dysregulation like temper outburstsor mood swings. It was long thought to be a disorderlimited to childhood and adolescence until prospectivestudies clearly documented the continuation of the dis-

order into adulthood. This leads in this age-group to se-vere impairments in a variety of social functions like ed-ucational and occupational performance, partnershipand parenting (Weiss et al. 1985; Manuzza et al. 1993;Rassmussen and Gillberg 2000; Murphy et al. 2002; Sec-nik et al. 2005).According to data assessed in a large epi-demiological US-study prevalence in adults (18–44years) is about 4 % (Kessler 2006).

A significant proportion of patients with the disorderalso present with one or more comorbid conditions.This complicates the diagnostic picture of adult ADHD.According to data which result mainly from clinicalstudies, between 65 and 89 % of all adults with ADHDsuffer from one or more other psychiatric disorders dur-ing their lifespan including mood and anxiety disorders,substance use disorders and eating disorders (Kessler2004; Biederman et al. 1993; Kooij et al. 2004; Spenceret al. 2005) as well as personality disorders, mainly anti-social personality disorders (Manuzza et al. 1993; Ver-meiren et al. 2000; Rösler et al. 2004). The high percent-age of comorbid psychiatric disorders in adults withADHD parallels findings in children in which ADHD isassociated in about 60–100 % of all cases with at leastone other child psychiatric diagnosis including opposi-tional defiant disorders in 50–60 %, depressive syn-dromes in 16–26 % and anxiety disorders in about 15 %of all children with ADHD as well as tic disorders anddevelopmental disorders like reading and spelling dis-orders (Gillberg et al. 2004)

Furthermore there is evidence that the presence ofcomorbid disorders in adults with ADHD gives rise toadditive clinical effects, leading to a more global impair-ment,poorer outcome,greater resistence to treatment aswell as higher costs of illness (Marks and Biederman2004; Sobanski et al., submitted for publication).

The present overview provides findings about co-morbid psychiatric disorders in adults with ADHD, un-derlying associations – as far as there exist etiologicalhypotheses – as well as clinical implications.

Esther Sobanski

Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD)

Received: / Accepted: / Published online:

EAPC

N 1

004

E. Sobanski, M.D.Department of Psychiatry and PsychotherapyCentral Institute of Mental HealthJ 568159 Mannheim, GermanyTel.: +49-621/1703-2852Fax: +49-621/1703-1205E-Mail: [email protected]

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Comorbidity with mood disorders

■ Depression

All retrospective studies evaluating the lifetime preva-lence of major depression consistently show that35–50 % of all adult individuals with ADHD suffer fromone or more depressive episodes during the assessedlifespan (Kessler 2004; Biederman et al. 1993; Kooij et al.2004; Spencer et al. 2005), a percentage which is clearlyhigher than the risk in the general population of about15 %.

In a preliminary study Alpert et al. (1996) found that16 % of 116 depressed adult patients met full or thresh-old diagnostic criteria for childhood ADHD and that12 % had clinically meaningful persistence of ADHDsymptoms into adulthood. In a comparison of the adultswith major depression and ADHD (n = 19) and majordepression alone (n = 97) no differences in the clinicalpicture of the current depressive episode including gen-der, age of onset of the mood disorder, number of de-pressive episodes and response to pharmacologicaltreatment of the depression were found between the twogroups.

Contrary to the equally good response to the phar-macological treatment of the depressive symptoms ofpatients with ADHD and depressive episode comparedto patients with major depression alone there is prelim-inary evidence that patients with ADHD and a comorbiddepressive episode do not respond well to the stimulanttherapy of ADHD despite known responsiveness tostimulants in non-depressed states (Wender et al. 1985;Sobanski et al. 2006).

Some investigators have hypothesized that depres-sion in ADHD patients must be considered as an adjust-ment disorder representing a demoralizing response toassociated patterns of chronic social and academic fail-ure. But data from family studies of subjects with ADHDand depression demonstrating elevated rates of depres-sion in relatives of individuals with ADHD as well as el-evated rates of ADHD in individuals with depressionsuggest a familial link and shared genetic risks betweenADHD and depression (Faraone and Biederman 1997).

On a practical level the results discussed above pointout that clinicians must be aware of the possibility thata certain proportion of patients with major depressiveepisodes may suffer from comorbid ADHD. In the caseof a patient presenting with ADHD and clinically mean-ingful depressive symptoms the first priority in treat-ment should address the affective disorder.

■ Bipolar disorder

The possibility of a relationship between ADHD andbipolar disorder has recently attracted growing interest,especially since in children comorbidity rates of bipolardisorder and ADHD ranging from 60–90 % were re-

ported (Geller et al. 2000; West et al. 1995), a findingwhich did not pass unchallenged due to the considerablediagnostic overlap between the two disorders.

Until lately the possible co-occurence of bipolar dis-order and ADHD has been investigated much less ex-tensively in adults than in children. However, just re-cently a study was published which evaluates the overalllifetime prevalence rate of ADHD in a cohort of 1000adults with bipolar disorder (Nierenberg et al. 2005).Ac-cording to the obtained results the lifetime prevalencerate of ADHD in adult bipolar patients was 9.5 % withsignificant gender differences as 14.7 % of the patientswith bipolar disorder and lifetime ADHD were maleand only 5.7 % female. Patients with lifetime ADHD andbipolar disorder had the onset of their mood disorderapproximately 5 years earlier (13.9 vs. 18 years) than thepatients with bipolar disorder alone, which is consistentwith the findings of previous studies (Sachs and Thase2000). Lifetime ADHD and bipolar disorder were fur-ther associated with a more severe course of the mooddisorder with shorter periods of wellbeing, a higherpercentage of days rated as irritable and a higher pro-portion of patients with more than 20 manic or de-pressive episodes. Contrary to the relatively high per-centage of lifetime ADHD the percentage of patientsactually diagnosed as having bipolar disorder andADHD was 5.3 %, which does not exceed significantlythe prevalence rate in the general population of about4 % according to the results of an epidemiological study(Kessler 2004).

Thus at present it is still far from clear whetherADHD and bipolar disorder are related in any sense asco-occuring or comorbid disorders in adulthood. Actu-ally the most consistent view in the scientific literatureleads to the preliminary conclusion that there may be asubgroup of bipolar patients in which ADHD-like symp-toms are a developmental precursor of bipolar disorder.

■ Comorbidity with anxiety disorders

Data from retrospective clinical and epidemiologicalstudies point to an increased lifetime prevalence of anx-iety disorders with 40–60 % of all adult patients withADHD suffering from one or more anxiety disordersduring their lifetime. All studies report consistently ele-vated lifetime prevalence rates for social phobias in20–34 % of all adults with ADHD, whereas lifetimeprevalence rates for obsessive compulsive disorders donot consistently exceed the lifetime prevalence rates inthe general population. Prevalence rates for generalizedanxiety disorder vary considerably between the avail-able studies, providing prevalence rates between10–45 % (Alm and Sobanski 2005; Kessler 2004; Bieder-man et al.1993; Kooij et al.2004; Spencer et al.2005).Thisallows no clear conclusion concerning comorbidity butpossibly points to a diagnostic artefact resulting in anoverdiagnosis of general anxiety disorders in adultswith ADHD due to reduced stress tolerance in a sub-


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group of adults with ADHD resulting in feelings of fearand emotional dysregulation.

In general, the scientific literature of anxiety disor-ders and ADHD in adults is relatively sparse. To ourknowledge there are only three studies evaluating theimpact of comorbidity of the two disorders. Accordingto Fones et al. (2000) 9.5 % of patients with panic disor-ders were diagnosed with adult ADHD and representeda subgroup with more impaired educational and socialfunctions. Manchini et al. (1999) found that patientswith anxiety disorders and ADHD in childhood had anearlier age of onset and more severe course of the anxi-ety disorder as well as more additional psychiatric diag-noses including alcohol and substance use disorders. Inour own study we could show that patients with ADHDand anxiety disorder had significantly more pro-nounced attentional impairments but not more hyper-active and impulsive symptoms than patients withADHD without comorbid anxiety disorder (Alm andSobanski 2005).

■ Comorbidity with substance use disorders

The comorbidity of ADHD and substance use disordershas been consistently observed by various researcherswith up to 50 % of adult individuals with ADHD suffer-ing from an additional substance use disorder (Bieder-man et al. 1995, 1998; Wilens et al. 1997) and vice versawith 25–35 % of patients with substance use disordersuffering from ADHD (Clure et al. 1999; Schubiner et al.2000). Thus, it is assumed that adult ADHD is associatedwith a 2-fold risk for substance use disorder comparedto the general population.

Recent investigations have demonstrated that adultswith ADHD have elevated rates of substance abuseacross several different classes of drugs (Clure et al.1999). This appears reasonable because the variety ofsymptoms in ADHD probably poses susceptibility to avariety of different psychoactive substances.While stim-ulants, nicotine and cocaine may temporarily improvethe cognitive performance, alcohol, marijuana and opi-ates may be preferentially used to reduce emotional dys-regulation, inner restlessness and excessive arousal. Inan investigation comparing the pattern of psychoactivedrugs in adults with ADHD to healthy control persons,the most common drug of abuse in both groups wasmarijuana (67 %), followed by cocaine (23 %) and stim-ulants (18 %) (Biederman et al. 1995). Rates of alcoholabuse and dependence in adults with ADHD are re-ported to be up to 35 % (Murphy et al. 2002), whereasother investigators have found that the rate of alcoholabuse or dependence only without drug-use disordersdid not differ significantly between adults with ADHDand control subjects (Biederman et al. 1995).

It has been proved for various drugs and alcohol thatADHD affects the course of the substance use disorderin several ways: Leading to earlier age of onset, a shorterinterval between the onset of drug abuse and depen-

dence, a more severe course of the substance use disor-der and a lower remission rate (Biederman et al. 1997;Wodarz et al. 2004; Wilens et al. 1997; Carroll and Roun-saville 1993).

The associations between ADHD and substance usedisorders are complex and varied. Risk factors in pa-tients with ADHD include impulsivity, deviant peergroups, comorbid conduct or antisocial personality dis-order, later onset of the pharmacological treatment ofADHD, shared genetic risks in both disorders and self-medication of ADHD. According to the results of a 4-year follow-up study, the risk for a substance use disor-der in never-medicated adolescents with ADHD is fourtimes higher than in adolescents with ADHD who hadreceived pharmacotherapy since childhood (Biederman2003). Several studies have clearly documented a highlysignificant relationship between comorbid conduct dis-order or antisocial personality disorder and substanceuse disorder in individuals with ADHD (Biederman2003; Barkley et al. 2003).

As a clinical consequence of the findings presentedabove, all adults with ADHD should be systematicallyscreened about substance use disorders including aurinary drug screen, if necessary. The first priority intreatment should address the substance use disorder, in-cluding empirically based substance use disorders psy-chotherapy and pharmacotherapy and self-help groups.Although up to date no specific guidelines exist for eval-uating a patient with active substance use disorder, ac-cording to clinical consensus and to our own experienceone month of abstinence is sufficient for reliably assess-ing symptoms of ADHD (Wilens 2004).

The first line of pharmacological treatment in adultswith ADHD and recently remitted substance use disor-ders should be the non-stimulants such as atomoxetineor tricyclic antidepressants with a strong noradrenergiccomponent like desipramine or imipramine whose ef-fectiveness for treatment of adults with ADHD havebeen proven in preliminary studies (Wilens et al. 1996).The use of stimulants should be considered as secondchoice and strictly be restricted to medication with lowabuse liability like extended-release methylphenidate.

■ Comorbidity with eating disorders

There is preliminary evidence that the prevalence ofbinge eating disorders and bulimia nervosa is slightlyincreased in adults with ADHD compared to the generalpopulation. According to available data, 3–9 % of alladults with ADHD suffer from additional bulimia ner-vosa during their lifespan (Shekim et al. 1990; Kooijet al. 2002; Kessler 2004). A case report describes the ef-ficacy of methylphenidate in reducing binge eating in anadult female patient with bulimia nervosa and ADHD(Schweickert et al. 1997).


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■ Comorbidity with sleep disorders

There is clinical and scientific evidence that adult ADHDintrinsically involves sleep disturbances. In clinical set-tings adults with ADHD frequently complain aboutchronic difficulties falling asleep (often described as in-ability to taper gradually the level of activity and stimu-lation near the end of the day), poor sleep quality andproblems with maintaining adequate alertness andarousal during the day. (Brown and McMullen 2001;Sobanski and Alm 2004). A recently publishedpolysomnographic study indicates that unmedicatedadults with ADHD display significantly increased noc-turnal movements and are subjectively significantlymore impaired in their sleep quality and efficiency com-pared to healthy controls (Philipsen et al. 2005).

At present there is not much evidence that sleepingdisorders as such are associated with adult ADHD,whereas studies in children with ADHD suggest an ele-vated comorbidity of periodic limb movement disordersand ADHD in this age-group (Crabtree et al. 2003;Chervin et al. 2002). Actually there is only one studycomparing the prevalence of ADHD in adults with rest-less legs syndrome, insomnia and in healthy controlswhich shows that a significantly greater number of adultpatients with restless legs syndrome compared to pa-tients with insomnia and controls met DSM-IV criteriafor ADHD (26 % vs. 5 % vs. 6 %) (Wagner et al. 2004).

Inadequate sleep can significantly exacerbate cogni-tive and behavioural symptoms associated with ADHD.Thus at the clinical level the diagnostic setup for adultswith ADHD should comprise a systematic assessment ofsleep quality and sleep disturbances. If necessary, sleep-ing problems should be addressed with appropriatetreatment interventions, e. g. with sleep hygiene. Be-sides,preliminary data indicate that stimulant treatment(methylphenidate, d-amphetamine) during daytime im-proves the subjective quality of sleep and decreases thenocturnal activity level in adults with ADHD (Kooijet al. 2001).

Comorbidity with personality disorders

■ Antisocial personality disorder

Several lines of evidence suggest an increased risk ofdelinquency in adult ADHD. Longitudinal studies ofchildren with ADHD as well as retrospective studies inadults with ADHD consistently report elevated rates ofantisocial personality disorders in adult ADHD. In twoprospective studies comparing hyperactive children tohealthy control children the rate of those who had addi-tional antisocial personality disorder in their mid-twen-ties was 18–23 % compared to 2–2.5 % in the controlprobands (Weiss et al.1985; Manuzza et al.1993).Studiesin delinquent adolescents and young prisoners foundprevalence rates for ADHD between 4–72 % (Vermeirenet al. 2000; Rösler et al. 2004).

The following relationships between ADHD and an-tisocial behaviour seem probable: Hyperactivity, impul-sivity and early conduct problems, but not inattention,predict a greater likelihood of delinquency in males butnot in females (Babinski et al. 1999).

The risk for becoming an adult offender is associatedwith conduct problems in childhood and serious antiso-cial behaviour in adolescence and thus the endpoint of abehaviour pattern starting much earlier.

Children with ADHD who do not show conduct prob-lems or antisocial behaviour during childhood andadolescence are not at increased risk for criminality andantisocial personality disorder in adulthood. In accor-dance with this conclusion the literature indicates thatADHD is associated with an early onset of delinquentbehaviour and goes along with a high rate of crime priorto age 14 and thus contributes to life-persistent crimi-nality and not transient delinquency in adolescence andadulthood (Satterfield and Schell 1997).Results from ge-netic studies suggest that ADHD and antisocial person-ality disorder in adulthood or conduct disorder in child-hood, respectively, represent a more severe subtype ofADHD in terms of genetic loading (Thapar et al. 2000).

■ Other personality disorders

At present there is only one controlled study evaluatingthe prevalence of ADHD in different personality disor-ders which provides evidence that a high percentage ofsubjects with borderline personality disorders (BPD)but not with other cluster B, cluster A or cluster C per-sonality disorder or control subjects suffer from ADHDduring childhood (BPD: 59.5 %, cluster B without BPD:10.6 %, cluster A/C: 10.5 %, controls: 6.5 %).According tothese preliminary data, childhood ADHD must be con-sidered as a risk factor for adult borderline personalitydisorder (Fossati et al. 2002). Furthermore, according toBohus et al. (personal communication) there is evidencethat a subgroup of patients with borderline personalitydisorder suffer from comorbid ADHD as adults.

Summary and conclusions

Psychiatric comorbidity in adults with ADHD is ratherthe norm than the exception. Several studies have con-sistently revealed significantly elevated lifetime preva-lence rates for major depressive episodes, substance usedisorders, anxiety disorders, especially social phobia,antisocial personality disorder and ADHD-intrinsicsleep disturbances.

Additive clinical effects of ADHD and comorbid dis-orders have been reported. Compared to individualswithout ADHD, those with ADHD have an earlier age ofonset of substance use disorders and of delinquent be-haviour in antisocial personality disorder. Symptoms ofADHD, especially the inattentive cluster, are more pro-nounced in patients with comorbid anxiety disorders


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and sleeping disturbances. Patients with depressivesymptoms and ADHD do not respond well to stimulanttreatment despite known responsiveness in nonde-pressed states. The psychosocial outcome in patientswith ADHD and other comorbid psychiatric disorders ispoorer than with ADHD exclusively.

The elucidation of underlying mechanisms is still inits beginnings, but according to available evidenceADHD-intrinsic vulnerability and genetic factors mayplay a role.

In the daily clinical work comorbid psychiatric dis-orders in adults with ADHD need to be addressed in thediagnostic process and in the establishment of a treat-ment hierarchy. The decision whether to treat ADHD orcomorbid disorder first should be based on the extentADHD and comorbid disorders respectively contributesto the global clinical impairment. Basically, comorbidsubstance use disorders and depressive episodes shouldbe treated first before diagnosing and treating ADHD. Inthe future, controlled studies assessing the treatmentoutcome for both ADHD and comorbid disorders areneeded to develop improved treatment strategies foradults with complicated ADHD.

■ Acknowledgement With many thanks to Barbara Alm, MD, forcritical comments on the manuscript.

References

1. Alm B, Sobanski E (2005) Angststörungen und Komorbidität mitAufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) imErwachsenenalter. In: Bassler M, Leydig S (eds) Psychotherapieder Angsterkrankungen. Thieme, Stuttgart New York, pp143–154

2. Alpert JE, Maddocks A, Nierenberg AA et al. (1996) Attentiondeficit hyperactivity disorder in childhood among adults withmajor depression. Psychiatry Res 62:213–219

3. Babinski LM, Hartsough CS, Lambert NM (1999) Childhoodconduct problems, hyperactivity-impulsivity and inattention aspredictor of adult criminal activity. J Child Adolesc Psychiatry40:347–355

4. Barkley RA, Fischer M, Smallish L, Fletcher K (2003) Does thetreatment of attention-deficit/hyperactivity disorder with stim-ulants contribute to drug use abuse? A 13-year prospective study.Pediatrics 111:97–107

5. Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, LapeyKA et al. (1993) Patterns of psychiatric comorbidity and psy-chosocial functioning in adults with attention deficit hyperac-tivity disorder. Am J Psychiatry 150:1792–1797

6. Biederman J, Wilens T, Mick E et al. (1995) Psychoactive sub-stance use disorders in adults with attention deficit hyperactiv-ity disorder (ADHD): effects of ADHD and psychiatric comor-bidity. Am J Psychiatry 152:1652–1658

7. Biederman J et al. (1997) Is ADHD a risk factor for psychoactivesubstance use disorder. Findings from a four-year prospectivefollow-up study. J Am Acad Child Adolesc Psychiatry 36:21–29

8. Biederman J, Wilens TE, Mick E et al. (1998) Does attention-deficit hyperactivity disorder impact the developmental courseof drug and alcohol abuse and dependence. Biol Psychiatry44:269–273

9. Biederman J (2003) Pharmacotherapy of attention deficit hyper-activity disorder (ADHD) decreases the risk for substance abuse:findings from a longitudinal follow-up of youths with and with-out ADHDJ Clin Psychiatry 64 (Suppl 11):3–8

10. Brown TE, McMullen WJ (2001) Attention deficit disorders andsleep/arousal disturbance. Ann N Y Acad Sci 931:271–286

11. Carroll KM, Rounsaville KJ (1993) History and significance ofchildhood attention deficit disorder in treatment-seeking co-caine abusers. Compr Psychiatry 34:75–83

12. Clure C, Brady KT, Saladin ME et al. (1999) Attention-deficit/hy-peractivity disorder: symptom pattern and drug choice. Am JDrug Alcohol Abuse 25:441–448

13. Chervin RD, Dillon JE, Bassetti C, Ganoczy DA, Pituch KJ (1997)Symptoms of sleep disorder, inattention and hyperactivity. Sleep20:1185–1192

14. Crabtree VM, Ivanenko A, O’Brien LM, Gozal D (2003) Periodiclimb movement disorder of sleep in children. J Sleep Res 12:73–81

15. Faraone S, Biederman J (1997) Do attention deficit hyperactivitydisorder and major depression share familial risk factors? J NervMent Dis 185:533–541

16. Fones CS, Pollack MH, Susswein L, Otto M (2000) History ofchildhood attention-deficit/hyperactivity disorder (ADHD) fea-tures among adults with panic disorder. J Affect Disorder 58:99–106

17. Fossati A, Novella L, Donati D, Donini M, Maffei C (2002) Historyof childhood attention deficit/hyperactivity disorder symptomsand borderline personality disorder: a controlled study. ComprPsychiatry 43:369–377

18. Geller B, Zimmerman B,Williams M, Bolhoffer K, Craney JL et al.(2000) Diagnostic characteristics of 93 cases of a prepubertaland early adolescent bipolar disorder phenotype by gender, pu-berty and comorbid attention deficit hyperactivity disorder. JChild Adolesc Psychopharmacol 10:157–164

19. Gillberg C, Gillberg IC, Rasmussen P, Kadesjö, B, Söderstöm H,Rastam M (2004) Co-existing disorders in ADHD – Implicationsfor diagnosis and intervention. Eur Child Adolesc Psychiatry 13(Suppl 1):80–92

20. Kessler RC, Adler L, Barkley R, Biedermann J et al. (2006) Theprevalence and correlates of adult ADHD in the united States: re-sults from the National Comorbidity Survey Replication. Am JPsychiatry 163(4):716–723

21. Kooij JJS, Huub AM, Middelkoop AM, VanGils K, Buitelaar JK(2001) The effect of stimulants on nocturnal activity and sleepquality in adults with ADHD: an open-label case-control study. JClin Psychiatry 62:952–955

22. Kooij JJS, Burger H, Boonstra AM, Linden PD van der, Kalma LE,Buitelaar JK (2004) Efficacy and safety of methylphenidate in 45adults with attention-deficit/hyperactivity disorder. A random-ized placebo-controlled trial. Psychol Medicine 34:973–982

23. Manchini C,Ameringen M van, Oakman JM, Figueredo D (1999)Childhood attention-deficit/hyperactivity disorder in adultswith anxiety disorders. Psychol Medicine 29:515–525

24. Manuzza S, Klein RG, Bessler A, Malloy P, La Padula M (1993)Adult outcome of hyperactive boys. Educational achievement,occupational rank, and psychiatric status. Arch Gen Psychiatry50:565–567

25. Marks, Biederman J (2004) Impact of comorbidity in adults withattention-deficit/hyperactivity disorder. J Clin Psychiatry 65(Suppl 3):3–7

26. Murphy KR, Barkley RA, Bush T (2002) Young adults with atten-tion-deficit hyperactivity disorder: subtype differences in co-morbidity, education and clinical history. J Nerv Ment Dis 190:147–157

27. Nierenberg AA, Miyahara S, Spencer T,Wisniewski SR, Otto MWet al1. (2005) Clinical and diagnostic implications of lifetime co-morbidity of attention-deficit/hyperactivity disorder in adultswith bipolar disorder. Data from the first 1000 STEP-BD partici-pants. Biol Psychiatry 57:1467–1473

28. Philipsen A, Feige B, Hesslinger B, Ebert D, Carl C et al. (2005)Sleep in adults with attention deficit hyperactivity disorder: acontrolled polysomnographic study including spectral analysisof the sleep EEG. Sleep 28:738–745

29. Rasmussen P, Gillberg C (2000) Natural outcome of ADHD withdevelopmental coordination disorder at age 22 years: A con-trolled, longitudinal, community-based study. J Am Acad ChildAdolesc Psychiatry 39:1424–1431


I/31

30. Rösler M, Retz W, Retz-Junginger P, Hensch G, Schneider M, Sup-prian T (2004) Eur Arch Psychiatry Clin Neurosc 254:365–371

31. Sachs GS, Thase M (2000) Comorbidity of attention deficit hy-peractivity disorder with early- and late-onset bipolar disorder.Am J Psychiatry 157:466–468

32. Satterfield JH, Schell A (1997) A prospective study of hyperactiveboys with conduct disorder and normal boys: Adolescent and adult criminality. J Am Acad Child Adolesc Psychiatry 36:1726–1735

33. Shekim WO, Asarnow RF, Hess E, Zaucha K, Wheeler N (1990) Aclinical and demographic profile of a sample of adults with at-tention-deficit hyperactivity disorder, residual state. Compr Psy-chiatry 31:416–425

34. Schubiner H, Tzelepis A, Millberger S et al. (2000) Prevalence ofattention-deficit/hyperactivity disorder among substance usedisorders. J Clin Psychiatry 61:244–251

35. Schweickert LA, Strober M, Moslowitz A (1997) Efficacy ofmethylphenidate in bulimia nervosa with comorbid attention-deficit/hyperactivity disorder. Int J Eat Disord 21:299–301

36. Secnik K, Swenson A, Lange MJ (2005) Comorbidities and costsof adults with attention-deficit hyperactivity disorder. Pharma-coeconomics 23 (1):93–102

37. Sobanski E, Alm B (2004) Aufmerksamkeitsdefizit-/Hyperakti-vitätsstörung (ADHS) bei Erwachsenen: Ein Überblick. Ner-venarzt 75:697–715

38. Sobanski E,Alm B, Krumm B (2006) Methylphenidatbehandlungbei erwachsenen Patienten mit Aufmerksamkeitsdefizit-/Hyper-aktivitätsstörung (ADHS): Bedeutung von Störungssubtyp undpsychiatrischer Komorbidität. Nervenarzt Mar 17 (E pub aheadof print)

39. Spencer T, Biederman J, Wilens T, Doyle R, Surman C, Prince Jet al. (2005) A large double-blind, randomized trial ofmethylphenidate in the treatment of adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 57:456–463

40. Thapar A, Harrington R, McGuffin P (2001) Examining the co-morbidity of ADHD-related behaviours and conduct problemsusing a twin-study design. Brit J Psychiatry 179:224–229

41. Vermeiren R, de Clippele A, Deboutte D (2000) A descriptive sur-vey of Flemish delinquent adolescents. J Adolesc 23:277–284

42. Wagner ML, Walters AS, Fisher BC (2004) Symptoms of atten-tion-defict/hyperactivity disorder in adults with restless legssyndrome. Sleep 27 (8):1499–1504

43. Wender PH, Reimherr FW, Wood D, Ward M (1985) A controlledstudy of methylphenidate in the treatment of attention deficitdisorder, residual type, in adults. Am J Psychiatry 142:547–552

44. Weiss G, Hechtman L, Milroy T et al. (1985) Psychiatric status ofhyperactives as adults: A controlled prospective 15-year follow-up of 63 hyperactive children. J Am Acad Child Adolesc Psychia-try 24:211–223

45. West S, McElroy, Strakowski S, Keck P, McConville B (1995) At-tention-deficit hyperactivity disorder in adolesecent mania. J Af-fect Disord 51:145–151

46. Wilens TE, Biederman J, Prince J et al. (1996) Six-week, double-blind, placebo-controlled study of desipramine for adults withattention deficit hyperactivity disorder. Am J Psychiatry153:1147–1153

47. Wilens TE et al. (1997) Attention deficit hyperactivity disorder(ADHD) is associated with early-onset substance use disorders.J Nerv Ment Dis 185:475–482

48. Wilens TE (2004) Impact of ADHD and its treatment on sub-stance use disorders. J Clin Psychiatry 65:38–45

49. Wodarz N, Laufkötter R, Lange K, Johann N (2004) Aufmerk-samkeitsdefizit-/Hyperaktivitätsstörung (ADHS) bei erwachse-nen Alkoholabhängigen. Nervenheilkunde 9:527–533


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Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD)