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Mental Disorders: Differential Diagnosis

Mental Disorders: Differential Diagnosis

Last updated:

Author: Ulrich Brennecke
Review 08/2024: Waldemar Zdero, M.A. in Psychology

This article provides an overview of the mental disorders that should be considered in the differential diagnosis of ADHD.

1. Anxiety Disorders (Annual Prevalence: 22.9% (women), 9.7% (men))

Prevalence: 22.9% of all women, 9.7% of all men within one year.12
Prevalence among girls under 18: 7.85%.3
Anxiety disorders are comorbid in 25% of people with ADHD;4 16.7% of children with ADHD and 27.2% of adults with ADHD.5 Other sources cite figures ranging from 15% to 35%6 or 35.6% among adults in England in 2007.7

Performance anxiety is particularly common.8

Common symptoms of anxiety disorders and ADHD:9

  • Inner restlessness
  • Difficulty concentrating
  • Reduced attention
  • Mood swings
  • Sleep problems
  • motor restlessness
    • for anxiety disorders without ADHD10
      • Adults with anxiety disorders who do not have ADHD often exhibit small, repetitive hand movements or leg tremors. The hand movements are slower, more repetitive, and show less variation in movement patterns than those seen in ADHD.
      • In anxiety disorders, the intensity and frequency of restless leg movements vary more during stressful or emotionally charged parts of the conversation.
      • Restlessness decreases with relaxation
    • in cases of ADHD

ADHD symptoms that are atypical for anxiety disorders:

  • excessive talkativeness (logorrhea, polyphasia)
  • Racing thoughts, ruminating
  • Impulsivity (unusual for ADHD-I)
  • Impaired executive function11

Symptoms of anxiety disorders that are atypical for ADHD:

  • Fatigue
  • Muscle tension

Anxiety in ADHD can, in some cases, reduce impulsivity and deficits in response inhibition, exacerbate working memory deficits, and appears to differ qualitatively from anxiety alone. Comorbid anxiety in ADHD apparently manifests in different ways:612

  • appear to be higher
    • negative affect
    • Mood Disorders
    • disruptive social behavior
    • Attention problems
    • School phobia
  • seem to have decreased
    • anxious / phobic behavior
    • social skills

While ADHD symptoms can occur even in low-stress situations or at times when the person is not anxious, people who are distracted by anxiety are usually constantly aware of their anxiety even while distracted and feel miserable. An anxiety disorder is often accompanied by a sense of guilt, whereas people with ADHD generally report that they are unaware that their thoughts have wandered. When engaged in a pleasant distraction, people with ADHD can actually be quite happy during that time.10

While the fear of missing an appointment is not yet generally considered specific to ADHD, the fear of missing an appointment—because people with ADHD frequently miss appointments, forget them, double-book them, don’t allow enough time for the trip, or forget to request time off from work—is very typical of ADHD.10

1.1. Panic Disorder (3.2 to 3.6%)

Prevalence of panic disorder: 3.2% to 3.6%13

1.2. Generalized Anxiety Disorder (1.9 to 31.1%)

Prevalence of generalized anxiety disorder: 1.9% to 31.1%13

2. Elimination Disorders (Bedwetting, Soiling) (Children: 18.5%)

18.5% of children with ADHD are affected.5

3. Mood Disorders (10 to 17%)

Prevalence:
Lifetime: 10% to 17%14
Under 18: Girls 2.54%, Boys 1.10%.15

Mood disorders are reported in 27.9% of children with ADHD and in 57.9% of people with ADHD5. Furthermore, a prevalence of 37.1% for mood instability and 29.9% for depression among adults in England in 2007 is cited.7

3.1. Depression (10% (men), 20% (women))

Depression must be distinguished from mere dysphoria associated with inactivity, which is a typical symptom of ADHD and does not constitute depression. Treatment with antidepressants would be inappropriate in this case.
For more information, visit ⇒ Depression and Dysphoria in ADHD In this chapter.

Between 12% and 50% of children with ADHD also suffer from depression, which is five times more common than among children without ADHD.6 A study of young adults with depression reports a lifetime prevalence of ADHD of 25.9%,16 which is also about five times higher.
The lifetime prevalence of major depression is 15%17; women are affected twice as often as men—that is, 20% of women and 10% of men.

In children with ADHD, emotional dysregulation occurs prior to the onset of comorbid depression.1819 This is not surprising, since emotional dysregulation is a core symptom of ADHD, whereas depression can develop as a comorbid disorder. Nevertheless, the degree of emotional dysregulation in children with ADHD appears to moderate the likelihood of later depression.20

Common symptoms of depression and ADHD:9

  • Inner restlessness (typical of atypical depression, less common in melancholic depression)
  • Difficulty concentrating
  • Attention problems21
  • Memory problems21
  • Sleep problems
  • Daytime sleepiness (typical in atypical depression, atypical in melancholic depression, possible in ADHD)
  • negative self-image8

ADHD symptoms that are atypical of depression:

  • rapid mood swings
  • Dysphoria only when inactive
  • excessive talkativeness (logorrhea, polyphasia)
  • Racing thoughts, ruminating
  • Impulsivity (untypical for ADHD-I, untypical for melancholic depression)
  • Problems with cognitive control22

Symptoms of depression that are atypical for ADHD:

  • a persistent depressed mood (even when it comes to things that are actually of interest)
  • Low mood in the morning (melancholic depression)
  • Low mood in the evening (atypical depression)
  • Weight loss (in cases of ADHD, possibly as a side effect of stimulants)
  • Reduced interest in activities (in ADHD, this tends to manifest as withdrawal due to heightened sensitivity or social anxiety)
  • Suicidal thoughts
  • Low motivation to seek rewards22

For people with ADHD, depression typically develops years after the onset of ADHD symptoms.23 In such cases, it is essential to treat not only the existing depression but also the underlying ADHD, which is often the cause of the depression. Otherwise, treating the depression would merely address a secondary symptom of ADHD.242312
About 34% of all cases of treatment-resistant depression are caused by previously undiagnosed ADHD.

3.2. Bipolar Disorder (Annual prevalence: 3.1% (women), 2.8% (men))

Prevalence: 3.1% of all women, 2.8% of all men within one year1

Bipolar disorder is characterized in particular by an alternation between depressive and manic symptoms. These shifts can occur at varying rates. The condition does not always progress to a full-blown manic episode.

ADHD occurs at a higher-than-average rate among people with bipolar disorder; however, the comorbidity with ADHD is likely lower than with other mental disorders.6 The prevalence of ADHD among people with bipolar disorder varies depending on the age at which the bipolar disorder first appears:25

  • Childhood: 80 to 95% have comorbid ADHD
  • Adolescents: About 50% have comorbid ADHD
  • Adulthood: About 25% have comorbid ADHD

In a reaction time study, people with ADHD and bipolar disorder showed a significantly higher variability in infrequent slow reactions than controls, while people with bipolar disorder showed significantly higher speed and variability in typical responses during the flanker task compared to people with ADHD and the control group.26

3.2.1. Depressive Episode of Bipolar Disorder

The common and distinct symptoms of a depressive episode in bipolar disorder and ADHD are the same as those of depression and ADHD.

See the section on depression above, as well as ⇒ Depression and Dysphoria in ADHD In the section ⇒ In-depth discussion of individual ADHD symptoms in the chapter “*” ⇒ Symptoms.*

3.2.2. Manic episode of bipolar disorder

Common symptoms of a manic episode in bipolar disorder and ADHD:

  • Difficulty concentrating9
  • Attention problems219
  • Memory problems219
  • Sleep problems9
  • Daytime sleepiness (typical in atypical depression, atypical in melancholic depression, possible in ADHD)9
  • Rapid mood swings27 9
  • Racing thoughts, ruminating27 9
  • Impulsivity (unusual for ADHD-I)279
  • Difficulty relaxing (ADHD-HI, bipolar disorder in the manic phase)27
  • Regulating one’s own arousal. Inner restlessness, agitation27
  • Hypersexuality25

ADHD symptoms that are atypical for manic episodes:

  • Dysphoria only when inactive

Symptoms of bipolar disorder that are atypical for ADHD:

  • Alternation between depressive and manic episodes

In ADHD, mood swings tend to be triggered by specific factors (reactive) and subside quickly when the person is distracted, whereas manic episodes in bipolar disorder tend to be more consistent and longer-lasting.28

3.3. Cyclothymia (13%)

Cyclothymia is a chronic condition characterized by rapid shifts in mood and energy levels, without reaching the intensity of symptoms seen in bipolar disorder. Hypomanic and depressive phases alternate. Cyclothymia has a prevalence of 13% in the general population.

Cyclothymia has been found in 75% of all people with bipolar disorder and occurs at a significantly higher rate in people with ADHD and depression.29

4. Specific Learning Disorders (Specific Learning Disabilities) according to ICD-10 (approx. 10 to 15% (?))

Specific learning disabilities are said to be a common comorbidity (especially in the ADHD-I subtype without hyperactivity).
Dyspraxia, on the other hand, is a purely motor developmental disorder that is more often confused with ADHD-HI (without inattention).

4.1. Dyspraxia (5 to 6%)

Prevalence: 5 to 6%3031

Dyspraxia is also known as “clumsy child syndrome” or “uncoordinated child syndrome.”
Dyspraxia is a developmental disorder that lasts a lifetime.
Dyspraxia very often occurs alongside ADHD or ASD.
Children with dyspraxia show no differences in intelligence.

There are different forms of dyspraxia.

4.1.1. Motor Dyspraxia / Specific Developmental Disorder of Motor Skills (SDDMS)

Problems with:

  • motor slowing
  • Balance problems
    • Abnormal gait
    • Difficulty getting dressed while standing
  • Clumsiness when performing complex movements that require balance and agility32
    • Catching a ball
    • hop
    • jump
    • climbing
    • Cycling
    • swim
    • Partner dance
  • Impaired automation of fine and gross motor skills
    • illegible handwriting
      • Difficulty holding the pen with the right amount of pressure
      • Difficulty staying within the page margins.
      • Typing on a computer is much easier
    • Trouble tying shoelaces or bows
    • Trouble buttoning buttons
    • Difficulty eating with a knife and fork
    • Problems cutting out a shape neatly
    • frequently dropping things
    • Difficulty handling glasses or dishes with care
    • Difficulty pouring into glasses
    • Problems with crafting or wrapping gifts
  • Difficulty acquiring new motor skills
  • impaired eye-hand coordination
  • Frequently confusing right and left
  • Problems with the order of priority when putting on clothes
  • Fatigue during physical activity
    • sports
    • Hiking
    • active play
  • Easily distracted while working on tasks
    • Too much information on a single page can be confusing
    • Improved task performance with increased line spacing and larger font size

No problems with:

  • Hyperactivity.

4.1.2. Ideomotor Dyspraxia

Problems with:33

  • Implementation of one’s own action plan
  • Fill out the forms completely
  • Difficulties with writing
  • Difficulties in performing actions
  • Execution of understood instructions is impaired
  • The order of priority gets mixed up easily
  • Impairment of imaginative or creative play

No problems with:

  • Describe movement sequences
  • Recognize others’ mistakes
  • read
  • talk

4.1.3. Conceptual Dyspraxia

Difficulties in planning and describing motor actions, although they have no motor impairment.33

Problems with:

  • Forming sequences (associated with poor memory)
  • Describe sequences of actions
  • Reading words
  • work quickly
  • Keep things organized

No problems with:

  • imitate individual movement sequences
  • Write words

4.1.4. Verbal Dyspraxia

Approximately 30% of children with dyspraxia also have a verbal developmental delay, known as verbal dyspraxia.34

Verbal dyspraxia is a disorder affecting the planning of speech motor skills. The speech organs (tongue, vocal cords) are not impaired.

  • Problems with planning speech movements
  • Difficulty saying the right words at the right time and in the right Order of priority.
  • Frequent coughing or choking while eating
    • Difficulty with the sequence of sucking, swallowing, and breathing
    • Increased saliva production when switching from pureed foods to solid meals
  • Significant delay in language development
    • a significantly later onset of speech
    • At first, just a few “babbling sounds”
    • Later, often vowel sounds without consonants (“Oaaaa,” “Eeea”).
  • often accompanied by problems with gross motor skills (see motor dyspraxia)
    • stumble
    • bumping into things, getting lots of bruises
    • Learning difficulties
      • read
      • spell

The risk factors for the development of dyspraxia remain unclear. As with ADHD, environmental factors during pregnancy and childbirth appear to increase the risk.

4.2. Developmental Coordination Disorders

It is unclear to what extent the concept of development-related coordination disorders differs from that of specific developmental disorders of motor functions and Developmental Coordination Disorder (DCD).

There are said to be different subtypes with six main symptom groups:

  1. General instability / slight trembling
  2. decreased muscle tone
  3. Increased muscle tone
  4. Inability to perform a smooth movement or to integrate individual movement elements into a single, coordinated movement
  5. Inability to form written symbols
  6. Difficulties with visual perception related to the development of the eye muscles

It is estimated that 50% of people with developmental coordination disorders also have ADHD.

The risk of ADHD is also elevated in children aged 4 to 5 with a developmental coordination disorder.35 However, the DSM-5 criteria appear to apply less frequently in these cases.36

4.3. Specific Learning Disabilities

The prevalence of comorbid ADHD and learning disabilities is reported to range from 10% to 90%.6
Learning disabilities are said to correlate more frequently with ADHD-I than with ADHD-HI.37 Among people with ADHD, writing difficulties are said to be twice as common as reading, math, or spelling difficulties.38

4.3.1. Reading and Spelling Disorder (Dyslexia) (5%)

While dyslexia is a genetically caused disorder, reading difficulties are an acquired disorder and can be more easily improved through practice.
Dyslexia is present in 17.6% of children with ADHD5 and is thought to be more common in ADHD-I than in ADHD-HI.39
Analyses of neuropsychological test results suggest that the co-occurrence of dyslexia and ADHD may be attributable, at least in part, to deficits in cognitive processing speed and working memory. During a psychoeducational assessment of reading difficulties, attention should always be paid to ADHD and other emotional and behavioral difficulties.40
Cognitive profiles are better predictors of the development of reading and writing skills than diagnostic results in children with severe ADHD symptoms.41

4.3.2. Math Disorder (Dyscalculia) (5%)

Dyscalculia is a genetically caused disorder, whereas math difficulty is an acquired disorder and can be improved more easily through practice.
Dyscalculia is thought to occur more frequently in ADHD-I than in ADHD-HI.39

4.3.3. Delayed Speech Development

Delayed language development was associated with a 12.09-fold increased risk of ADHD (+1,100%) among children aged 6 to 9 in Saudi Arabia42

5. Tic disorders, Tourette syndrome (1% to 15%)

Source2

Prevalence: 1% among elementary school-aged children (varying degrees of severity), 15% among elementary school-aged children (including mild and transient forms).43
Tic disorders are present in 9.5% of children with ADHD.5
31%44 to 55%45 of children with tic disorders also have ADHD.

ADHD is the most common comorbidity associated with ADHD. ADHD often precedes a tic disorder. ADHD and tic disorders share a common genetic basis. In cases of comorbid tic disorder and ADHD, the neutrophil-to-lymphocyte ratio appears to be higher than in cases of ADHD alone.46

6. Post-Traumatic Stress Disorder (PTSD) (5% (men), 10% (women))

Prevalence: 10% of all adult women and 5% of all adult men suffer from post-traumatic stress disorder.4748

60% of all men and 50% of all women experience at least one potentially traumatic event in their lifetime.49
Of these, the following suffer from PTSD:

  • Rape victims: 49%50
  • Severe beatings or physical assaults: 31.9%50
  • Crime victims: 25%50
  • Sexual assaults other than rape: 23.7%50
  • Serious accident (car or train): 16.8%50
  • Shooting or stabbing: 15.4%50
  • Sudden death of a close friend or loved one: 14.3%50
  • Life-threatening childhood illness: 10.9%50
  • Victims of potentially traumatic experiences not involving a crime: 9.4%50
  • Witnesses to a murder or a violent assault: 7.3%50
  • Natural disaster: 3.9%50

Sleep problems are common in both ADHD and PTSD. In PTSD, these problems often arise within the first two weeks after the traumatic event and are frequently characterized by persistent nightmares,51 which is also not typical of ADHD. In ADHD, on the other hand, sleep disturbances usually persist throughout a person’s life.

The “Posttraumatic Stress Disorder” subscale of the Child Behavior Checklist (PTSD-CBCL) is effective at distinguishing PTSD from ADHD.52

While ADHD is associated with reduced dopamine and norepinephrine levels, an excessive release of norepinephrine is suspected in PTSD.53 Since norepinephrine (like dopamine) acts in the form of an inverted U-curve54, this could explain why ADHD medications (which increase dopamine and norepinephrine) do not produce any improvement in some people with ADHD.

Assessing the Severity of Trauma Using the IES-R (Impact of Event Scale—Revised). Sample graph from Semmler.

7. Complex PTSD (cPTSD)

kPTSD is characterized by a wider range of symptoms that are more severe and, as a result, more complex than those of PTSD.
According to ICD-11, c-PTSD is a distinct diagnosis (6B41) that is classified as a “sibling disorder” alongside PTSD (6B40). Consequently, kPTSD is not a subtype of PTSD. The two diagnoses are mutually exclusive: if kPTSD is diagnosed, PTSD cannot be diagnosed at the same time, and vice versa.5556

General population:
A representative German study estimates the 1-month prevalence of k-PTSD to be approximately 0.5%.
According to estimates, the point prevalence of complex PTSD is approximately 0.6% to 1%.
Studies often report the combined prevalence of classic PTSD and complex PTSD. A study in Germany found a combined 1-month prevalence of 2%.

Characteristic , ADHD (ICD-11; 6A05) , cPTSD (ICD-11: 6B41)
Etiology Neurodevelopmental Disorder Stress-Related Disorder55
Trauma Exposure Trauma can increase the risk of ADHD, but it is not a necessary cause A traumatic event (extremely threatening/terrifying) is absolutely necessary55
Onset of symptoms Typically in early to middle childhood (usually before age 12) Can occur at any age, typically following chronic or repeated trauma5557
Symptom Course Persistent and cross-contextual, independent of stressors PTSD symptoms are often intermittent and trigger-dependent; DSO symptoms are persistent and pervasive55
Core symptoms Inattention, hyperactivity, impulsivity, executive function problems, emotional dysregulation PTSD triad (re-experiencing, avoidance, hypervigilance) + self-regulation disorders (affect dysregulation, negative self-concept, relationship difficulties)55
Inattention Depends on intrinsic motivation. Arises from a preference for new, stimulating stimuli. Is not associated with rumination or worry. The consequences of concentration difficulties include hypervigilance, intrusive thoughts, and an increased perception of threat 55 57
Emotional dysregulation In our view, a primary, core symptom of ADHD. According to other views, a secondary feature resulting from impulsivity and executive dysfunction58 Primary core feature (affective dysregulation as a distinct symptom cluster)
Negative self-concept Not really an original ADHD symptom, at least not a prominent one Core feature of complex PTSD55
Relationship difficulties No fear of being abandoned59 Social dysfunction due to impulsivity/inattention Often views others with paranoia or suspicion. No fear of being abandoned. Possibly a conscious decision to enter into a relationship59 Profound difficulties in forming and maintaining relationships (separate cluster of symptoms)
Mood swings Can become angry quickly. Anger is almost always short-lived and not typically directed at interpersonal triggers59 No general tendency to act out, but chronic depression and constant tension59
Risk-Taking Behavior Internal Motivations: Having Fun or Relaxing Through Overstimulation59 Dangerous Situations Are Not Recognized as Such59
Reliving traumatic situations (flashbacks) Not an ADHD symptom Flashbacks and/or nightmares are typical symptoms of complex PTSD5557
Avoiding trauma-associated stimuli Not an ADHD symptom Core feature of c-PTSD symptoms5557

ADHD and complex PTSD can overlap in several areas of symptoms—particularly in terms of concentration difficulties, emotional dysregulation, impulsivity, and relationship difficulties.5557
Both diagnoses can occur concurrently. A systematic review reports a comorbidity prevalence of 28% to 36% among adults with ADHD and PTSD.60 A Mendelian randomization study showed a causally increased risk of PTSD by 137% in the presence of a genetic predisposition to ADHD (sibling comparison, HR 2.37).61 Comorbidity leads to more severe clinical courses with more psychiatric comorbidities and greater psychosocial impairment.6062

Differential diagnosis in children exposed to trauma is particularly challenging. Following trauma-specific treatment and symptom reduction, a reevaluation for ADHD is recommended. A comprehensive trauma history is essential to rule out PTSD/complex PTSD or to identify them as comorbid conditions.63

8. Conduct Disorder (1.5% to 5%)

Source2

Common symptoms:64

  • Aggressive behavior
  • Lies
  • Stealing
  • Arson
  • Running away from home and school

Conduct Disorder is usually supported by comorbid disorders. Common ones include:64

  • ADHD
    • Problems with cognitive control22
  • Oppositional Defiant Disorder (ODD)
    • a strong desire for rewards22
  • Depression (especially among adolescents)
    • low motivation for rewards22
  • Anxiety disorder (especially in adolescents)

Prevalence: approximately 1.5% among elementary school-aged children and approximately 5% among adolescents.65
Oppositional defiant disorder is estimated to be present in 46.9% of people with ADHD, and social behavior disorders in an additional 18.5%.5
Comorbidity between ADHD-HI and conduct disorder is reported in 15 to 85 percent of cases, depending on the study design and the direction of the association, making it 4.7 times more common overall than in the general population.66
Oppositional defiant behavior and other social disorders are considered by some experts to be a subtype of ADHD (rage type). We tend to view this as a distinct disorder that is highly comorbid with ADHD.

Distinction from ADHD: Aggression in people with (pure) ADHD is reactive, motivated by self-defense, and involves no intent to harm.6768 Aggression in people with ADHD often stems from a misjudgment of situations, leading them to defend themselves (supposedly justifiably). People with ADHD thus exhibit reactive, rather than proactive, aggression.69

9. Emotionally Unstable Personality Disorder / Borderline Personality Disorder (1–5% (women), 1% (men))

This section has been moved to a separate post: Emotionally Unstable Personality Disorder / Borderline Personality Disorder

10. Addiction Disorders

10.1. Substance-Related Addictions

About 20% of all patients undergoing substitution treatment for heroin or opiate addiction already had ADHD before developing the addiction. In these cases, the addiction is usually the consequence of unsuccessful self-treatment.
During substance withdrawal, the symptoms of acute withdrawal and ADHD are very similar. Nearly 100% of people with ADHD tested positive on ADHD screening questionnaires during acute withdrawal.70 The key factor, therefore, is the presence of symptoms prior to the onset of addiction. While ADHD symptoms—with normal daily fluctuations—occur continuously, addiction-related symptoms appear only intermittently. Poor social behavior as early as childhood and adolescence, which can be verified, for example, through school report cards or accounts from relatives, is indicative of ADHD.
People with ADHD are more likely than average to discontinue addiction treatment. 70

10.1. Internet Addiction (3.9%)

Prevalence: among college students in Germany, 3.9% (2019) to 7.8% (2020, the year of the COVID-19 lockdown)71
A study identified two subtypes of Internet addiction: one subtype that correlated with impulsivity and ADHD-HI, and another subtype that correlated with compulsivity.72

11. Obsessive-Compulsive Disorder (1 to 3%)

Compulsivity is sometimes viewed as the opposite dimension of impulsivity. Impulsivity is characterized as poorly planned, hasty reactions aimed at obtaining gratification, whereas compulsivity is described as repetitive behavior driven by the need to relieve anxiety. However, there are also overlapping aspects.73

Compulsions must be distinguished from ADHD.2

Prevalence: Lifetime prevalence of 1 to 3%;7475 ; according to other sources, 4.2% of all women and 3.5% of all men within one year.1
Girls under 18: prevalence 0.96%; boys 0.63%.15

Olfactory disorders (disorders of the sense of smell) are common in ASD and obsessive-compulsive disorder, but not in ADHD.76

Obsessive-compulsive disorder is classified into four subtypes that responded differently to SSRIs7778

  • Contamination/Cleaning
    • 78% response rate to SSRIs
  • aggressive/sexual/religious obsessions
    • 57% response rate to SSRIs
  • Order/Symmetry/Repetition/Counting
    • 77% response rate to SSRIs
  • Hoarding
    • 14% response rate to SSRIs

12. Antisocial Personality Disorder (0.2–3%)

Source79

  • High impulsivity
  • High Novelty Seeking / Sensation Seeking
  • Self-centeredness / egocentrism
  • a lack of empathy toward others
    • being unable to understand how others feel

Subtypes of antisocial personality disorder:

  • impulsive type
    • Frequent comorbidity with ADHD-HI / ADHD-C
    • highly emotionally sensitive / hyper-reactive
    • increased excitability
    • high impulsivity
    • reactive aggression – as an immediate response to triggers
    • low stress tolerance
  • psychopathic type
    • rare comorbidity with ADHD-HI / ADHD-C
    • emotionally insensitive / hyporesponsive
    • active aggression – purposeful, instrumental violence
    • no increased agitation when frustrated
    • no reduced stress tolerance

Distinction from ADHD: Aggression in people with (pure) ADHD is reactive, motivated by self-defense, and involves no intent to cause harm 67 68 Aggression in people with ADHD often stems from a misjudgment of situations, leading them to defend themselves (supposedly justifiably). We see a connection here to rejection sensitivity—an exaggerated sensitivity to perceived or actual rejection or the tendency to take offense. Thus, people with ADHD exhibit reactive, rather than proactive, aggression.69
People with ADHD often recognize their sudden aggressive or verbal outbursts or impulse control problems as inappropriate shortly after they occur and are usually able to apologize, unlike people with psychopathic personality traits.80

Common symptoms of antisocial personality disorder and ADHD:9

  • Impulsivity (unusual for ADHD-I)
  • rapid mood swings

ADHD symptoms that are atypical of antisocial personality disorder:

  • Inner restlessness (typical of atypical depression, less so in melancholic depression)
  • Difficulty concentrating
  • Attention problems
  • Dysphoria due to inactivity
  • excessive talkativeness (logorrhea, polyphasia)
  • Racing thoughts, ruminating

Symptoms of antisocial personality disorder that are atypical for ADHD:

  • Criminal behavior
  • Deceiving others
  • Disrespect for oneself and others
  • Lack of remorse

13. Narcissism (0.5 to 2.5%)

Prevalence: 0.5% to 2.5%.

Narcissism and ADHD share some possible symptoms. Similar symptoms include:

  • Symptoms of depression
    • A feeling of inner emptiness
    • Low spirits
  • nonspecific fears
  • Strained or disrupted relationships with others
    • Belittling others to emphasize one’s own worth (narcissism only)
  • Emotional problems
    • In cases of narcissism, as with ADHD, it makes it more difficult to recognize and act on one’s own feelings and needs
  • Disorder of self-esteem

14. Schizophrenia (1%)

The lifetime prevalence is approximately 1%.81
Girls under 18: prevalence 0.76%; boys 0.48%.15

Schizophrenia is highly hereditary (like ADHD, approximately 80%)82 and usually does not develop until after adolescence. However, it is typically preceded by early signs in childhood that do not resemble schizophrenia itself but appear to be genetic indicators of the disorder.83

The negative symptoms of schizophrenia are caused by a dopamine deficiency. They are similar to ADHD symptoms.
In contrast, positive symptoms are thought to result from excessive subcortical presynaptic dopamine transmission (dopamine hypothesis). Although this is reduced by antipsychotic dopamine D2 receptor antagonists, in schizophrenia, D2/D3 receptors appear to be only very slightly elevated and DAT levels appear to be completely unchanged, suggesting that other treatment approaches may be more appropriate.84
Excessive subcortical dopamine drive is likely due to changes in cortical function, particularly a reduction in cortical NMDA receptor-mediated glutamate signaling, which impairs cortical dopamine and GABA function. These cortical changes are thought to underlie the cognitive impairments and negative symptoms of schizophrenia.82

Schizophrenia is also believed to result from a combination of genetic factors, environmental influences, and physical and psychological factors. Emotional trauma, social stress, and hallucinogenic drugs have been identified as environmental influences contributing to schizophrenia.
⇒ Genes + Early Childhood Stress as Causes of Other Mental Disorders

The COMT rs4680 variant, which is involved in schizophrenia (as one of 50 or more candidate genes), enhances the breakdown of dopamine and norepinephrine by producing a more active and thermally stable COMT enzyme.85 This leads to more severe schizotypal symptoms.
This is consistent with the more recent dopamine hypothesis, according to which the positive symptoms of schizophrenia are not caused by a general increase in dopamine levels in the frontal cortex (and in the nucleus accumbens, a part of the striatum), but rather by increased activity (firing rate) of the mesolimbic system, which in turn is caused or influenced by a dopamine deficiency in the ventral tegmental area.85

Schizophrenia and Attention:

  • Increased sensitivity to sensory stimulation67
  • High sensitivity leads to sensory overload67
  • Impaired attention selection for individual events67
  • Difficulty focusing on or maintaining focus on relevant aspects of a task.67

Symptoms of schizophrenia that are atypical for ADHD:

  • Drawings are non-spatial; they are not three-dimensional representations
  • Irony and sarcasm are not understood (as with ASD, unlike ADHD)
  • Olfactory disorders.76
  • Onset usually follows a psychotic episode (ADHD: initial symptoms are usually already apparent in childhood)
  • episodic course (ADHD: consistent throughout life; in some cases, late onset = symptoms become apparent later in life)
  • flat, indifferent emotions; unrelated to the situation (ADHD: emotionally labile, overstimulated)86
  • Lack of interest, withdrawal (ADHD: avoidance of stimuli, avoidance of overwhelm, possibly due to a lack of structure; emotions and interests are present, but there are difficulties regulating or expressing them appropriately)86
  • Consistent daily performance, with few fluctuations86
  • Slowed, impoverished speech (ADHD: impulsive, associative, rich in detail)86
  • Low activity level, lack of motivation (ADHD: low stamina but high impulsivity; lack of motivation due to dysphoria when inactive)86

15. Psychoses (1%)

16. Autism Spectrum Disorder (ASD) (0.95% worldwide, 1.13% in the Americas, 1.16% in Europe)

Sources87882

Unlike with ADHD, the prevalence is distributed very unevenly worldwide (meta-analysis, k = 51, n = 548,413,748):89

  • 0.98% worldwide
    • 0.85% developed countries
    • 1.55% developing countries
  • 2.96% Africa (Note: only a single study; this could be due to differences in diet, particularly during pregnancy)90
  • 0.26% Oceania
  • 0.16% Europe
  • 0.13% Americas
  • 0.034% Asia

The percentage of people with ADHD who also exhibit ADHD symptoms has been reported to range from 2.6% to 95.5% (meta-analysis, k = 23)91. Some sources estimate that approximately 42%92 to 50%9394 of all people with ADHD also have ADHD.
More than 20% of people with ADHD have subclinical ADHD symptoms. Their social, functional, and executive functions were worse than those of people without ADHD but better than those with ADHD.95
A review concluded that ADHD and ASD may form a continuum.96
ADHD and autism likely share common neurological/genetic roots.97

A study using the AQ-10 found that 44% of people with ADHD also exhibited autistic traits. Comorbid ASD traits were associated with poorer overall clinical and functional outcomes, lower quality of life, reduced social skills, and poorer family functioning.98
According to the ADOS-2, people with ADHD show elevated ASS scores that fall between the scores of people with ADHD and people without.99

  • Pervasive Developmental Disorder
    Prevalence: approximately 0.6%100
  • Pathological Demand Avoidance (PDA)
    • extreme resistance to any tasks not chosen by oneself
      • affects more than just individual areas of life
      • even everyday tasks that would be easy to do (e.g., brushing teeth, personal hygiene, homework)
      • even activities that the person normally enjoys when choosing them for themselves
      • goes far beyond what is typical for someone of that age
      • not tied to specific stages of child development (the “terrible twos”)
      • Frequent use of a wide range of avoidance strategies (making up excuses, delegating tasks, extreme to violent outbursts of anger)
      • The effort required to avoid something often exceeds the effort required to complete the task
      • Avoidance patterns can be externalizing or internalizing in nature
        • externalizing: confrontational, aggressive
        • internalizing: silent resistance, masking, concealed
    • psychological explanatory model
      • an extreme compulsion to control, fueled by irrational fears
      • External demands would be perceived as a loss of control and cause massive stress
      • Resistance stems more from fear than from malice (as is the case, for example, with disorder, CD)
        • Praise can fuel anxiety about future expectations rather than alleviate it
        • Uncertainty about what is to come and what is happening intensifies PDA
    • Overlap with ADHD in that, in ADHD, attention problems and hyperactivity are strongly associated with a lack of self-motivation when it comes to tasks that are not intrinsically interesting
      • Specific behavioral profile associated with autism or other childhood developmental disorders
      • is not considered a diagnosis in its own right
    • Treatment
      • As we understand it, anxiety-relieving medications, such as CBD, should be able to help
  • Autism101
    Prevalence: approximately 0.3%100
  • Asperger’s
    Prevalence: approximately 0.084%100
  • Disintegrative Disorder101
    Prevalence: 0.008% (one person with ADHD per 12,500 people)100
  • Rett syndrome101
    Prevalence: 0.006% (one person with ADHD per 10,000 to 17,000 people)102100
    Applies only to girls
    Symptoms of Rett syndrome:102
    • Stereotypical hand movements (washing movements)
    • some autistic behaviors
    • Dementia
    • reduced head growth
    • epileptic seizures (later stage)
    • Spasticity (late stage)
    • Apraxia
    • Muscle wasting
    • Movement disorders in the thoracic region
    • Social behavior and play development are severely impaired
    • Social interest remains
  • ASS and ADHD both show downregulation of neuroligin genes, which was even more pronounced in ASD.103

Differential Diagnosis of ADHD:

Children with ASD had 15 or more of the 30 symptoms (average: 22 = 73%) on the Checklist for Autism Spectrum Disorder Symptoms, while children with ADHD had an average of 4 symptoms (13.3%), none of whom had 15 or more. In contrast, ADHD symptoms were widespread among children with ASD.104
Children with ADHD showed higher scores on the Social Responsiveness Scale (SRS), although these scores did not reach the levels seen in people with ADHD.105

In favor of ASS:106

  • Inattention in ASS tends to stem from an excessive focus on details (as opposed to overlooking details, as is the case with ADHD)94
  • Concentration breaks down when routines are disordered in ASD (in contrast to a lack of routines and rapidly switching between different tasks in ADHD)
  • The unexpected is more likely to be seen as an unpleasant annoyance and disorder to one’s own routine (rather than a welcome change in ADHD)
  • Routines based on one’s own need for structure (as opposed to the arduous process of establishing routines to avoid losing too much structure when living with ADHD)
  • Significant difficulties in social situations due to an inner sense of uncertainty about how to behave appropriately (as opposed to causing offense through thoughtless behavior in ADHD)
  • Difficulty understanding social norms (as opposed to difficulty adhering to well-understood social norms in ADHD)
  • An intense focus on detail causes tasks to exceed their time frames (as opposed to project abandonment due to a shift in interests in cases of ADHD)
  • Needs order to maintain their own internal structure, but tends to find things more easily in a mess (unable to maintain order due to other priorities in cases of ADHD)
  • Deviating from the plan causes frustration (as opposed to frequent deviations from the plan due to one’s own spontaneity and impulsiveness)
  • reduced flexibility (compared to the relatively minor impairment of flexibility seen in ADHD)
  • Concentration can be maintained during longer and repetitive tasks (in contrast to the difficulty in maintaining concentration during monotonous, boring tasks seen in ADHD)
  • Motor restlessness tends to occur in stressful situations as a way to release tension (as opposed to motor restlessness in calm situations, which serves as a means of stimulation in ADHD)
  • Motor restlessness tends to stem from aversion to something = running away (as opposed to interest in something = running toward it in ADHD)
  • Casual conversations or small talk are unpopular because they disrupt one’s own thought processes; this is sometimes compensated for by a rigid conversational style (in ADHD, this is said not to be present; in our view, it is present in ADHD, but to a lesser extent)
  • Lack of awareness of the situation and atmosphere (common in ADHD)
  • Rarely interrupt others (as in ADHD-I, unlike ADHD-HI / ADHD-C)
  • Having to wait in a relatively dark, completely low-stimulus room is a rather pleasant prospect (very unpleasant for ADHD-HI / ADHD-C; both possibilities exist for ADHD-I)

In ASD, intracortical facilitation appears to be unaffected, whereas in ASD with comorbid ADHD, intracortical facilitation appears to be impaired. This could serve as a biomarker for distinguishing between ASD and ADHD.107

From a neurophysiological perspective, facilitation is the enhancement of a reflex or nerve cell activity by lowering the stimulus threshold for the transmission of a nerve cell’s action potential. Facilitation occurs primarily through repeated stimulation of the same nerve pathways or through the summation of subthreshold stimuli.108

Individuals with ASD, like those with ADHD, showed slower orienting responses to relatively unexpected spatial target stimuli compared to controls; in ASD participants, this was accompanied by greater amplitudes of pupillary dilation. ADHD participants showed shorter cue-evoked pupillary dilation latencies than ASD participants and controls.109

Several studies have examined the differences between ASD and ADHD.

ADHD symptoms that are atypical for ADHD:

  • Verbal comprehension is lower in ASD than in ADHD110
  • smaller vocabulary in individuals with ASD110
  • reduced comprehension in individuals with ASD110
  • Poorer visual concepts at ASS110
  • Poorer image completion with ASS110
  • slower processing speed with ASS110
  • Impaired social judgment in individuals with ASD110
  • Poorer response to being called by name at 24 months of age in children with ASD111
  • Higher shifting with ASS112
  • Poorer emotional self-regulation in individuals with ASD112
  • ASD demonstrates deficits in global motion processing, unlike ADHD. ASD and dyslexia show a significantly lower flicker fusion frequency than healthy controls or ADHD participants.113
  • Self-soothing through repetitive behaviors and routines114
  • Highly nuanced need for relationships. It is important to be able to control the frequency and intensity of social interactions. Not resentful, but pragmatic.59
  • Shutdown: Freezing up and being unable to respond.59
  • Meltdown: An open, aggressive outburst, sometimes involving physical attacks or shoving, to defend one’s own boundaries.59
    • Self-harming behavior may also occur here at times as a way to relieve tension59

ADHD symptoms that are atypical for ASD:

  • Impaired working memory is typical of ADHD, but less so for ASD110112
  • Problems with attention regulation114
  • Planning and organizational problems (which are largely determined by working memory) are typical of ADHD, but less so for ASD112
  • Inhibition problems typical of ADHD, less common in ASD112
    • Response inhibition was slightly worse in ADHD than in ASD115
  • Lower scores on the Digit Span test for ADHD than for ASD110
  • Impaired graphomotor processing in ADHD110
  • Novelty seeking is typical of ADHD, but not of ASD114
  • Hyperactivity114
  • an above-average number of eye contacts with the other person, even compared to those not affected116
  • Risky behavior: Fun through overstimulation59

Both ADHD and ASD show structural abnormalities in the PFC, the cerebellum, and the basal ganglia. People with comorbid ASD and ADHD showed no significant differences in the volumes of the PFC, cerebellum, or basal ganglia. However, they exhibited significantly smaller volumes of the left postcentral gyrus—though this was true only for children, not adolescents.117
A review compared catecholaminergic and cholinergic neuromodulation in ASS and ADHD:118

  • Stimulants may be a viable treatment option for a (possibly genetically defined) subgroup of ASD patients
  • A disorder of the cerebellum is much more common in ASD than in ADHD
    • In both cases, this could open up a treatment option mediated by norepinephrine or acetylcholine
  • A deficit in the cortical salience network is significant in subgroups of ASD such as ADHD
    • Biomarkers such as blink rate or pupillometric data can predict the effectiveness of targeted treatment of an underlying deficit using dopamine, norepinephrine, or acetylcholine, in both ADHD and ASD

ASD is characterized by high levels of aggression and risky behavior. In addition, individuals with ASD are involved in child abuse at an above-average rate.119 Aggression and high-risk behavior are also hallmarks of the ADHD-HI subtype.

A review article found that blood levels of norepinephrine were approximately double in individuals with ADHD and approximately half in those with ASD, compared to those without these conditions. In contrast, blood serotonin levels were four times higher in individuals with ASD and more than four times lower in those with ADHD.120

Children with ADHD also showed impaired ability to recognize irony.121

17. Pervasive developmental disorders (PDD) (0.06%)

Prevalence: 60 per 100,000 (0.06%)

PDD is characterized by severe deficits in social behavior and communication, as well as repetitive and stereotyped interests and behaviors. It is often accompanied by comorbid conditions such as intellectual disability, ADHD, aggression, and obsessive-compulsive disorder.122

18. Behavioral problems primarily caused by environmental factors

Behavioral problems primarily caused by environmental factors include, for example, a lack of attention and stimulation, physical and/or emotional abuse, excessive media use, conflicts within the family, and conflicts among siblings.2
As we understand it, this description corresponds to the environmental factors underlying most mental disorders, such as ADHD, depression, anxiety disorders, borderline personality disorder, etc., all of which can arise when environmental factors—most commonly stressful experiences during the first six years of life—permanently trigger an existing genetic predisposition through epigenetic changes. Behavioral problems that are primarily environment-related are therefore unsuitable for defining a distinct disorder.
⇒ How ADHD Develops: Genes or Genes + Environment
⇒ Genes + Early Childhood Stress as Causes of Other Mental Disorders

19. Oppositional Defiant Disorder (ODD)

ADHD is characterized in particular by problems with cognitive control, whereas oppositional defiant disorder (ODD) is characterized by a strong desire for rewards.22

Among children with ODD, 77.2% had comorbid ADHD; among adults with ODD, 69.2% had comorbid ADHD.123

20. Auditory Processing and Perception Disorder (APPD)

English: Auditory Processing Disorders (APD)124
AVWS is a distinct clinical condition (ICD-10: F80.20).
Prevalence: 2 to 3%, boys 4 to 6%, girls 1 to 2%125

Even soft sounds and noises are heard normally. Peripheral hearing is intact.
This impairs the processing and perception of what is heard.
The impairment is not due to a decrease in intelligence. Nonverbal intelligence is unaffected.
Functional deficits in auditory information processing and perception:

  • Correct auditory perception is impaired or impossible - auditory agnosia
  • Neural transmission, preprocessing, or processing of acoustic or speech signals is impaired, e.g.:
    • Localization (direction and distance of the sound source)
    • Discrimination (distinguishing between changes in time, frequency, or intensity)
    • Selection (filtering out background noise)
    • Dichotic listening (binaural listening)

The consequences can include difficulties in challenging listening situations, such as

  • Understanding speech in the presence of background noise
  • Understanding speech from multiple speakers speaking at the same time

When this is accompanied by difficulty distinguishing between tones, speech sounds, and noises (which is often the case), reading and writing difficulties may arise.
Therefore, AVWS is considered a neurocognitive risk, particularly for academic learning.

Common comorbidities associated with AVWS include:124

  • Speech and Language Disorders
  • Specific learning disabilities
    • e.g., reading and spelling disorders
  • supramodal attention problems (attention disorders)
  • Pervasive developmental disorders (e.g., ASD)

21. Lack of sleep

Sleep deprivation can be caused by physical or psychological factors.
Severe sleep deprivation can trigger inattentive or hyperactive/impulsive10 symptoms that can be mistaken for ADHD, such as

  • severe fatigue
    • Micro-sleep
    • Feeling of exhaustion
  • Lack of drive
  • Difficulty concentrating
  • Memory problems, forgetfulness
  • Mood swings
    • increased irritability
    • depressive mood
  • Feeling unwell
  • increased susceptibility to infections
  • Headaches, migraines
  • Circulatory problems
  • Drowsiness upon waking
  • Weight gain, increased hunger, being overweight
  • Difficulty concentrating
  • Muscle pain
  • Skin problems
  • burning and/or dry eyes
  • increased sensitivity to cold

People who have suffered from sleep deprivation for many years (some have been dealing with it since their school days) cannot always definitively attribute their symptoms to sleep deprivation and may need several months of adequate sleep to overcome the consequences of sleep deprivation.10

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