The present study investigated ADHD comorbidity and clinical features, including hyperfocus, in women with depressive or anxiety disorders, addressing the diagnostic complexities arising from symptom overlap and the underdiagnosis of ADHD in this population.
Methods
Female patients from outpatient psychiatric clinics (n = 170) were assessed using the Beck Depression Inventory and Beck Anxiety Inventory. Participants meeting threshold scores underwent further evaluation with the Wender-Utah Rating Scale, Hyperfocus Scale and Adult ADHD DSM-IV-Based Diagnostic Screening Scale, complemented by structured clinical interviews.
Results
ADHD was identified in 19.6% (n = 33) of patients, 45.5% (n = 15) of whom were previously undiagnosed. ADHD was most prevalent in patients with social anxiety disorder (46.4%) and double depression (40.6%). In non-ADHD participants, (a) attention deficit scores correlated positively with depression (r = 0.236, p = 0.005), (b) hyperactivity with anxiety (r = 0.187, p = 0.029), and (c) hyperfocus with ADHD scores (r = 0.434, p < 0.001; r = 0.292, p = 0.001); no such correlations were seen in the ADHD group.
Conclusion
ADHD is common and frequently overlooked in women presenting with depression or anxiety. While hyperfocus is a relevant clinical feature, it is not diagnostic alone and correlates with ADHD symptoms in the absence of ADHD. Clinicians should conduct thorough screenings for ADHD and carefully interpret hyperfocus within the broader clinical context to ensure accurate diagnosis and timely, appropriate treatment.
FaraoneSVBiedermanJ. What is the prevalence of adult ADHD? Results of a population screen of 966 adults. J Atten Disord. 2005;9:384-391. doi:10.1177/1087054705281478
3.
KesslerRCAdlerLBarkleyR, et al.The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatr. 2006;163:716-723. doi:10.1176/ajp.2006.163.4.716
4.
WillcuttEG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9:490-499. doi:10.1007/s13311-012-0135-8
5.
GaubMCarlsonCL. Gender differences in ADHD: a meta-analysis and critical review. J Am Acad Child Adolesc Psychiatry. 1997;36:1036-1045. doi:10.1097/00004583-199708000-00011
6.
SoldenS. Women with attention deficit disorder. Grass Valley, CA: Underwood Books. 1995.
7.
BerryCAShaywitzSEShaywitzBA. Girls with attention deficit disorder: a silent minority? A report on behavioral and cognitive characteristics. Pediatrics. 1985;76:801-809.
8.
BiedermanJFaraoneSVSpencerT, et al.Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatr. 1993;150:1792-1798. doi:10.1176/ajp.150.12.1792
9.
FayyadJDe GraafRKesslerR, et al.Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402-409. doi:10.1192/bjp.bp.106.034389
10.
AdlerLASpencerTJSteinMANewcornJH. Best practices in adult ADHD: epidemiology, impairments, and differential diagnosis. CNS Spectr. 2008;13:1-19. doi:10.1017/S1092852900003217
11.
KesslerRCAkiskalHSAmesM, et al.Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. Am J Psychiatr. 2006;163:1561-1568. doi:10.1176/ajp.2006.163.9.1561
12.
SobanskiE. Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatr Clin Neurosci. 2006;256(Suppl 1):i26-31. doi:10.1007/s00406-006-1004-4
13.
AlpertJEMaddocksANierenbergAA, et al.Attention deficit hyperactivity disorder in childhood among adults with major depression. Psychiatry Res. 1996;62:213-219. doi:10.1016/0165-1781(96)02912-5
14.
WuZChenJYuanC, et al.Difference in remission in a Chinese population with anxious versus nonanxious treatment-resistant depression: a report of OPERATION study. J Affect Disord. 2013;150:834-839. doi:10.1016/j.jad.2013.03.012
15.
LamersFvan OppenPComijsHC, et al.Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry. 2011;72:341-348. doi:10.4088/JCP.10m06176blu
16.
FavaMRushAJAlpertJE, et al.Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report. Am J Psychiatr. 2008;165:342-351. doi:10.1176/appi.ajp.2007.06111868
17.
KesslerRCMerikangasKRWangPS. Prevalence, comorbidity, and service utilization for mood disorders in the United States at the beginning of the twenty-first century. Annu Rev Clin Psychol. 2007;3:137-158. doi:10.1146/annurev.clinpsy.3.022806.091444
18.
KooijJJHussMAshersonP, et al.Distinguishing comorbidity and successful management of adult ADHD. J Atten Disord. 2012;16:3s-19s. doi:10.1177/1087054711435361
19.
DoyleBB. Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder. American Psychiatric Association Publishing; 2006.
20.
ConnerM. Attention deficit disorder in children and adults: strategies for experiential educators. Experiential education: A critical resource for the 21 st century Proceedings manual of the annual international conference of the association for experiential education. 1994;22:177-182.
21.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.Washington, DC; 2013.
22.
GroenYPriegnitzUFuermaierABM, et al.Testing the relation between ADHD and hyperfocus experiences. Res Dev Disabil. 2020;107:103789. doi:10.1016/j.ridd.2020.103789
23.
AshinoffBKAbu-AkelA. Hyperfocus: the forgotten frontier of attention. Psychol Res. 2019;85(1):1-19. doi:10.1007/s00426-019-01245-8
24.
HupfeldKEAbagisTRShahP. Living “in the zone”: hyperfocus in adult ADHD. Atten Defic Hyperact Disord. 2019;11:191-208. doi:10.1007/s12402-018-0272-y
25.
GoldmanLSGenelMBezmanRJ, et al. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. Jama. 1998;279:1100-1107. doi:10.1001/jama.279.14.1100
26.
WenderPH.Attention-deficit hyperactivity disorder in adults. Psychiatr Clin North Am. 1998;21:761-774. doi:10.1016/s0193-953x(05)70039-3
27.
NewcornJHWeissMSteinMA. The complexity of ADHD: diagnosis and treatment of the adult patient with comorbidities. CNS Spectr. 2007;12: 1-14; quiz 15-16. doi:10.1017/s1092852900026158
28.
WilliamsonDJohnstonC. Gender differences in adults with attention-deficit/hyperactivity disorder: a narrative review. Clin Psychol Rev. 2015;40:15-27. doi:10.1016/j.cpr.2015.05.005
29.
FedeleDALeflerEKHartungCMCanuWH. Sex differences in the manifestation of ADHD in emerging adults. J Atten Disord. 2012;16:109-117. doi:10.1177/1087054710374596
30.
MowlemFDRosenqvistMAMartinJLichtensteinPAshersonPLarssonH. Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. Eur Child Adolesc Psychiatr. 2019;28:481-489. doi:10.1007/s00787-018-1211-3
31.
WaiteR. Women With ADHD: it Is an Explanation, Not the Excuse Du Jour. Perspect Psychiatr Care. 2010;46:182-196. doi:10.1111/j.1744-6163.2010.00254.x
32.
QuinnPWigalS. Perceptions of girls and ADHD: results from a national survey. MedGenMed. 2004;6:2.
MartinJTaylorMJRydellM, et al.Sex-specific manifestation of genetic risk for attention deficit hyperactivity disorder in the general population. JCPP (J Child Psychol Psychiatry). 2018;59:908-916. doi:10.1111/jcpp.12874
35.
RucklidgeJJ. Gender differences in attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2010;33:357-373. doi:10.1016/j.psc.2010.01.006
36.
RucklidgeJJ. Gender differences in ADHD: implications for psychosocial treatments. Expert Rev Neurother. 2008;8:643-655. doi:10.1586/14737175.8.4.643
37.
BedawiRMAl-FarsiYMirzaH, et al.Prevalence and clinical profile of adults with ADHD attending a tertiary care hospital for five years. Int J Environ Res Public Health. 2024;21:566. doi:10.3390/ijerph21050566
38.
AttoeDEClimieEA. Miss. Diagnosis: a systematic review of ADHD in adult women. J Atten Disord. 2023;27:645-657. doi:10.1177/10870547231161533
39.
HisliN. Beck Depresyon Envanteri'nin Geçerliği Üzerine Bir Çalışma. Psikoloji Dergisi. 1998;6(22):118-126.
40.
Beck ATSRA. BAI : Beck Anxiety Inventory : Manual. San Antonio (Tex.): Psychological Corp. Harcourt Brace; 1993.
41.
UlusoyMhisli sahinNErkmenH. Turkish version of the Beck Anxiety Inventory: psychometric properties. J. Cogn. Psychother: An International Quarterly. 1998;12:163-172.
42.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.Washington, DC; 1994.
43.
BeckATWardCHMendelsonMMockJErbaughJ. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571. doi:10.1001/archpsyc.1961.01710120031004
44.
BeckATEpsteinNBrownGSteerRA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893-897. doi:10.1037//0022-006x.56.6.893
45.
WardMFWenderPHReimherrFW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatr. 1993;150:885-890. doi:10.1176/ajp.150.6.885
46.
RossiniEDO'ConnorMA. Retrospective self-reported symptoms of attention-deficit hyperactivity disorder: reliability of the Wender Utah Rating Scale. Psychol Rep. 1995;77:751-754. doi:10.2466/pr0.1995.77.3.751
47.
ÖncüBÖlmezSSenturk cankorurV. Wender-Utah derecelendirme ölçeǧi Türkçe formunun erişkin DEHB’nda geçerlik ve güvenilirlik çalişmasi. Türk Psikiyatri Dergisi. 2005;16:252-259.
48.
OzelKEDemirbasHBastugG, et al.A scale for the assessment of hyperfocusing in attention deficit and hyperactivity disorder. Eur Neuropsychopharmacol. 2013;23:S593. doi:10.1016/S0924-977X(13)70944-1
49.
GünayŞSavranCAksoyUM. Erişkin Dikkat Eksikliği Hiperaktivite Ölçeği’nin (Adult ADD/ADHD DSM IV- based diagnostic screening and rating Scale) dilsel Eşdeğerlilik, Geçerlik Güvenirlik ve norm çalışması. Marmara Üniversitesi Atatürk Eğitim Fakültesi Eğitim Bilimleri Dergisi. 2013;21:133-150.
50.
OsórioFLLoureiroSRHallakJEC, et al.Clinical validity and intrarater and test-retest reliability of the Structured clinical Interview for DSM-5 - Clinician Version (SCID-5-CV). Psychiatr Clin Neurosci. 2019;73:754-760. doi:10.1111/pcn.12931
51.
ElbirMAlp TopbaşÖBayadS, et al.[Adaptation and Reliability of the Structured Clinical Interview for DSM-5-Disorders - Clinician Version (SCID-5/CV) to the Turkish Language]. Türk Psikiyatri Derg. 2019;30:51-56.
52.
Almeida MontesLGHernández GarcíaAORicardo-GarcellJ. ADHD prevalence in adult outpatients with nonpsychotic psychiatric illnesses. J Atten Disord. 2007;11:150-156. doi:10.1177/1087054707304428
53.
DeberdtWThomeJLebrecJ, et al.Prevalence of ADHD in nonpsychotic adult psychiatric care (ADPSYC): a multinational cross-sectional study in Europe. BMC Psychiatry. 2015;15:242. doi:10.1186/s12888-015-0624-5
54.
FaraoneSVPerlisRHDoyleAE, et al.Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57:1313-1323. doi:10.1016/j.biopsych.2004.11.024
55.
FaraoneSVBiedermanJMickE. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med. 2006;36:159-165. doi:10.1017/s003329170500471x
56.
BiedermanJMickEFaraoneSV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatr. 2000;157:816-818. doi:10.1176/appi.ajp.157.5.816
57.
AbleSLJohnstonJAAdlerLASwindleRW. Functional and psychosocial impairment in adults with undiagnosed ADHD. Psychol Med. 2007;37:97-107. doi:10.1017/s0033291706008713
58.
BabinskiDEPelhamWEJr.MolinaBS, et al.Late adolescent and young adult outcomes of girls diagnosed with ADHD in childhood: an exploratory investigation. J Atten Disord. 2011;15:204-214. doi:10.1177/1087054710361586
59.
AdlerLCohenJ. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27:187-201. doi:10.1016/j.psc.2003.12.003
60.
QuinnPOMadhooM. A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. Prim Care Companion CNS Disord. 2014;16:PCC.13r01596. doi:10.4088/PCC.13r01596
61.
FaraoneSVBanaschewskiTCoghillD, et al.The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021;128:789-818. doi:10.1016/j.neubiorev.2021.01.022
62.
BarskyAJPeeknaHMBorusJF. Somatic symptom reporting in women and men. J Gen Intern Med. 2001;16:266-275. doi:10.1046/j.1525-1497.2001.00229.x
63.
KutscheidtKDreslerTHudakJ, et al. Interoceptive awareness in patients with attention-deficit/hyperactivity disorder (ADHD). Atten Defic Hyperact. Disord. 2019;11:395-401. doi:10.1007/s12402-019-00299-3
64.
BioulacSMicoulaud-FranchiJAPhilipP. Excessive daytime sleepiness in patients with ADHD--diagnostic and management strategies. Curr Psychiatry Rep. 2015;17:608. doi:10.1007/s11920-015-0608-7
65.
SobanskiESchredlMKettlerN, et al. Sleep in adults with attention deficit hyperactivity disorder (ADHD) before and during treatment with methylphenidate: a controlled polysomnographic study. Sleep. 2008;31:375-381. doi:10.1093/sleep/31.3.375
66.
GreenJGMcLaughlinKABerglundPA, et al.Childhood adversities and adult psychiatric disorders in the National Comorbidity Survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67:113-123. doi:10.1001/archgenpsychiatry.2009.186
67.
MirzaHAl-HuseiniSAl-JamoodiS, et al.Socio-Demographic and clinical profiles of adult attention deficit hyperactivity disorder patients in a university Hospital in Oman. Sultan Qaboos Univ Med J. 2022;22:206-211. doi:10.18295/squmj.5.2021.104
68.
TomitaNImaiSKanayamaYKumanoH. Relationships between cortically mediated attentional dysfunction and social anxiety, self-focused attention, and external attention bias. Percept Mot Skills. 2019;126:1101-1116. doi:10.1177/0031512519867798
69.
KoyuncuAÇelebiFErtekinEMemişÇÖTükelR. The presence of childhood attention Deficit/Hyperactivity disorder may be associated with interpersonal sensitivity in patients with social anxiety disorder. J Psychiatr Pract. 2017;23:254-259. doi:10.1097/pra.0000000000000246
70.
KoyuncuAAlkınTTükelR. Development of social anxiety disorder secondary to attention deficit/hyperactivity disorder (the developmental hypothesis). Early Interv Psychiatry. 2018;12:269-272. doi:10.1111/eip.12372
71.
MarchettaNDHurksPPDe SonnevilleLMKrabbendamLJollesJ. Sustained and focused attention deficits in adult ADHD. J Atten Disord. 2008;11:664-676. doi:10.1177/1087054707305108
72.
ParisJBhatVThombsB. Is adult attention-deficit hyperactivity disorder being overdiagnosed?Can J Psychiatry. 2015;60:324-328. doi:10.1177/070674371506000705
