In an adult female with markedly elevated ADHD self‑report scores, comorbid generalized anxiety disorder with panic symptoms, and severe alcohol‑use disorder (on fluoxetine and naltrexone), does she meet DSM‑5 criteria for ADHD and what diagnostic evaluation and treatment approach are indicated?

Does This Patient Meet DSM-5 Criteria for ADHD?

Yes, this patient meets DSM-5 criteria for ADHD, predominantly inattentive presentation with impulsive features, but the diagnosis cannot be definitively confirmed until her alcohol use disorder is in sustained remission and her anxiety symptoms are optimally treated. 1

Critical Diagnostic Barriers That Must Be Resolved First

Active Substance Use Disorder

• Alcohol use disorder can produce identical symptoms to ADHD, including impaired concentration, impulsivity, poor task completion, and memory problems. 1
• This patient had recent alcohol relapses (most recently on a specific date after one month of sobriety) and reports a pattern of drinking to blackout, hiding alcohol use, and consuming a fifth of vodka per week at her worst. 1
• The diagnostic algorithm for ambiguous cases requires reassessment after sustained abstinence from substance use before confirming ADHD. 1
• She is currently on naltrexone and engaged in a recovery program, which is appropriate, but ADHD diagnosis should be deferred until she achieves at least 3-6 months of documented sobriety. 1

Inadequately Treated Anxiety and Panic Disorder

• Generalized anxiety disorder can mimic ADHD symptoms, particularly mind-wandering, restlessness, difficulty concentrating, and racing thoughts. 1, 2
• She reports "excessive anxiety and worry with difficulties controlling the worry for at least 6 months" and a history of panic attacks with multiple somatic symptoms (trembling, chest discomfort, GI distress, numbness). 3
• Despite fluoxetine 80mg, she states "issues with mind wandering/racing is still very prominent" and describes constant rumination about tasks. 1
• Optimization of treatment for mood and anxiety symptoms must occur before diagnosing ADHD, as untreated anxiety can fully account for apparent inattentive symptoms. 1, 2

Evidence Supporting Provisional ADHD Diagnosis

Symptom Criteria Met

• She meets the threshold of ≥5 inattentive symptoms with a total inattention score of 24 (96-98th percentile) and 6 symptoms rated 3-4 ("often/very often"). 1
• She meets the threshold for impulsivity with a total impulsivity score of 15 (99th percentile) and 4 symptoms rated 3-4. 1
• Hyperactivity symptoms are borderline (score 10,84-92nd percentile) with only 1 symptom rated 3-4, which is consistent with adult ADHD where hyperactive symptoms typically decline while inattentive symptoms persist. 2

Childhood Onset Documented

• She reports symptom onset at age 10, which satisfies the DSM-5 requirement that symptoms must have been present before age 12. 1, 4
• Her childhood self-report shows borderline scores (section 1-2 total: 42,84-92nd percentile) with 7 symptoms rated 3-4, and she describes getting in trouble for talking in class, feeling burnt out by end of day, and parental frustration about not listening. 1, 4
• The collateral informant (relative) could not verify childhood symptoms because they did not know the patient during school years, which is a limitation but does not invalidate patient recall when it is detailed and consistent. 1

Functional Impairment in Multiple Settings

• She documents clear impairment in at least three settings: home (impulsivity causing relationship conflict, overthinking comments, not contributing to household tasks), social relationships (interrupting friends, forgetting plans, overwhelmed in social settings), and school (historical difficulty focusing, talking during class). 1, 4
• The collateral informant corroborates current impairment at home (difficulty recalling details, impulsive decision-making including drinking, needing multiple explanations, difficulty prioritizing tasks) and in social relationships (interrupting, asking about already-discussed topics, discomfort with silence). 1

Collateral Information Supports Diagnosis

• The relative's current symptom report closely matches the patient's self-report: inattention score 24 (96-98th percentile) with 6 symptoms rated 3-4, and impulsivity score 16 (99th percentile) with 4 symptoms rated 3-4. 1, 5
• This strong patient-informant agreement increases diagnostic confidence, as adults with ADHD tend to underreport symptom severity and collateral information is essential. 5

Diagnostic Algorithm for This Complex Case

Step 1: Stabilize Substance Use Disorder (Current Priority)

• Continue naltrexone and intensive outpatient program for alcohol use disorder. 1
• Document at least 3-6 months of sustained abstinence with regular urine drug screens before reassessing ADHD symptoms. 1, 2
• Non-stimulant ADHD medications should be considered first-line if ADHD treatment is initiated given her history of substance misuse and two DUIs. 1

Step 2: Optimize Anxiety Treatment

• Her current fluoxetine 80mg is insufficient given persistent mind-racing and rumination. 3
• Consider increasing SSRI dose, augmenting with buspirone, or adding cognitive-behavioral therapy specifically for GAD. 3
• Reassess ADHD symptoms after anxiety is adequately controlled, as approximately 10% of adults with recurrent anxiety have undiagnosed ADHD, but anxiety must be treated first. 2

Step 3: Reassess ADHD Symptoms After Stabilization

• Repeat CAARS self-report and collateral report after 3-6 months of sobriety and optimized anxiety treatment. 1, 6
• If inattentive and impulsive symptoms persist at similar severity despite abstinence and controlled anxiety, ADHD diagnosis can be confirmed. 1

Step 4: Initiate ADHD Treatment if Diagnosis Confirmed

• Atomoxetine, viloxazine, or bupropion are recommended first-line agents given her substance use history and concern for stimulant misuse. 1
• Stimulants should be avoided or used with extreme caution, prescription monitoring, and frequent follow-up given her two DUIs and pattern of impulsive substance use. 1
• Combination of medication plus psychotherapy is more effective than either alone for adult ADHD with complex comorbidity. 1

Critical Pitfalls to Avoid

• Do not start stimulant medication while she has active/recent substance use, as this creates risk for diversion, misuse, and worsening of impulsive behaviors. 1
• Do not diagnose ADHD definitively until anxiety and substance use are adequately addressed, as both conditions can fully account for her presenting symptoms. 1, 2
• Do not rely solely on rating scale scores without comprehensive clinical interview, as the CAARS identifies symptom burden but does not diagnose ADHD by itself. 1
• Do not dismiss the diagnosis simply because childhood symptoms were borderline, as retrospective recall is imperfect and her detailed functional impairment history supports early onset. 1, 2

Provisional Diagnosis and Management Plan

Provisional diagnosis: ADHD, predominantly inattentive presentation with impulsive features (deferred pending substance use remission and anxiety optimization); Generalized Anxiety Disorder (inadequately treated); Alcohol Use Disorder, severe, in early remission. 1, 3

• Continue current AUD treatment with naltrexone and intensive outpatient program, targeting 3-6 months documented sobriety. 1
• Optimize anxiety treatment by increasing fluoxetine dose or augmenting therapy, and add CBT for GAD. 3
• Reassess ADHD symptoms with repeat CAARS after stabilization period. 1
• If ADHD diagnosis is confirmed after stabilization, initiate atomoxetine or viloxazine rather than stimulants. 1
• Establish chronic disease management model with regular follow-up every 2-4 weeks initially, then monthly once stable. 1