What are the psychiatric and medical differential diagnoses for a patient diagnosed with major depressive disorder, social phobia (unspecified), generalized anxiety disorder, and attention‑deficit/hyperactivity disorder (unspecified)?

Differential Diagnosis for a Patient with Major Depressive Disorder, Social Phobia, Generalized Anxiety Disorder, and ADHD (Unspecified)

The primary differential diagnosis task is to determine whether these represent four distinct disorders, symptom overlap from a single underlying condition, or comorbid conditions with shared pathophysiology—and the most critical distinction is ruling out medical mimics (thyroid disease, sleep disorders, substance use) before confirming psychiatric diagnoses. 1, 2, 3

Psychiatric Differential Diagnoses

Primary Consideration: Diagnostic Overlap vs. True Comorbidity

• Major depressive disorder and generalized anxiety disorder share four overlapping DSM symptoms (concentration difficulties, sleep disturbance, fatigue, psychomotor changes), and approximately 85% of patients with depression experience significant anxiety symptoms while up to 90% of anxiety disorder patients develop comorbid depression 4, 5

• The "unspecified" ADHD designation suggests insufficient documentation of childhood onset before age 12 or inadequate verification of cross-setting impairment—this raises the possibility that inattention symptoms may be secondary to depression/anxiety rather than representing true ADHD 1, 3

• Concentration difficulties, restlessness, and task-incompletion occur in both ADHD and anxiety/depression, making differential diagnosis challenging without systematic evaluation of childhood onset, cross-setting persistence, and response pattern to initial treatment 1, 2, 6

Alternative Explanations to Consider

• Bipolar disorder must be ruled out, as mood instability can present with depressive episodes, anxiety, and apparent inattention; screening for hypomanic/manic episodes is mandatory 1

• Trauma-related disorders (PTSD, complex PTSD) produce hypervigilance, concentration problems, emotional dysregulation, and social withdrawal that closely mimic this symptom constellation 2

• Substance-induced anxiety/depression from marijuana, alcohol, stimulants, or caffeine can generate identical symptoms to this presentation 1, 2

• Personality disorders (particularly borderline, avoidant, or dependent types) may manifest with chronic anxiety, mood instability, social avoidance, and apparent inattention 1

Medical Differential Diagnoses

Thyroid Disorders

• Hypothyroidism produces fatigue, concentration difficulties, depressed mood, and psychomotor slowing that overlap substantially with depression and inattentive ADHD; prevalence of thyroid dysfunction in anxiety disorder patients ranges from 2-39% depending on the specific disorder 7

• Hyperthyroidism causes anxiety, restlessness, irritability, and concentration problems mimicking generalized anxiety disorder and hyperactive ADHD 7

• Obtain TSH, free T4, and TPO antibodies to screen for thyroid disease, as 9% of female panic disorder patients and 10.4% of generalized anxiety disorder patients have thyroid dysfunction 7

Sleep Disorders

• Obstructive sleep apnea produces daytime inattention, fatigue, irritability, and poor task completion that resolve after CPAP treatment; screen with STOP-BANG questionnaire and consider polysomnography 1, 3

• Insufficient sleep duration or irregular sleep-wake schedules generate concentration problems, mood dysregulation, and apparent hyperactivity 3

Substance Use Disorders

• Active marijuana, alcohol, or stimulant use produces concentration deficits, motivation problems, anxiety, and mood symptoms identical to this presentation 1, 2

• Obtain detailed substance-use history including caffeine, prescription medications, and over-the-counter stimulants; reassess after sustained abstinence before confirming ADHD diagnosis 1

Other Medical Conditions

• Cardiovascular conditions are associated with panic disorder and agoraphobia but not specific phobia 7

• Anemia, vitamin B12 deficiency, or other metabolic disorders can produce fatigue and concentration problems 1

Algorithmic Approach to Clarifying the Diagnosis

Step 1: Verify ADHD Childhood Onset

• Obtain collateral information from parents, old report cards, school records, or prior evaluations to document that inattention/hyperactivity symptoms were present before age 12 and caused impairment in multiple settings during childhood 1, 3

• If childhood onset cannot be verified, the ADHD diagnosis is invalid per DSM-5 criteria—symptoms are more likely secondary to depression, anxiety, or another condition 1, 3

Step 2: Rule Out Medical Mimics

• Order TSH, free T4, TPO antibodies to exclude thyroid disease 7

• Screen for sleep disorders with detailed sleep history and STOP-BANG questionnaire; refer for polysomnography if positive 1, 3

• Obtain comprehensive substance-use history and consider urine drug screen; if active use is present, reassess after 3-6 months of sustained abstinence 1, 2

Step 3: Determine Primary vs. Secondary Symptoms

• If depression is severe (suicidal ideation, marked functional impairment, vegetative symptoms), treat depression first with SSRI plus psychotherapy; reassess attention symptoms after 8-12 weeks of adequate antidepressant treatment 2

• If anxiety is severe and predates mood symptoms, treat anxiety disorder first with CBT and/or SSRI; many patients experience secondary improvement in concentration and mood 7

• If ADHD symptoms are equally severe and childhood onset is confirmed, initiate stimulant medication first—approximately 60-70% will experience improvement in both ADHD and secondary anxiety/depression 1, 2

Step 4: Assess for Trauma History

• Conduct detailed trauma assessment including childhood adversity, abuse, neglect, or significant losses; if trauma is present and symptoms began after trauma exposure, PTSD/complex PTSD is more likely than primary ADHD 2

• Trauma-focused therapy should be initiated first if trauma symptoms are primary or equally severe as ADHD symptoms 2

Step 5: Evaluate Symptom Overlap

• The comorbid group endorses overlapping symptoms (concentration, sleep, fatigue, restlessness) more than non-overlapping symptoms, suggesting that apparent comorbidity may reflect diagnostic criteria overlap rather than distinct disorders 5

• Use inattentive items only from ADHD rating scales when anxiety is present, as hyperactive/impulsive items overlap substantially with anxiety symptoms 6

Common Diagnostic Pitfalls to Avoid

• Diagnosing ADHD based solely on current adult symptoms without verifying childhood onset before age 12—this violates DSM-5 criteria and leads to inappropriate stimulant prescribing 1, 3

• Failing to screen for thyroid disease, sleep disorders, and substance use before confirming psychiatric diagnoses 7, 1, 3

• Attributing all concentration problems to ADHD when they may be secondary to depression or anxiety—optimize treatment of mood/anxiety disorders first and reassess attention symptoms 1, 2

• Relying on self-report rating scales alone without comprehensive clinical interview and collateral information from multiple sources 1, 3

• Missing trauma history that better explains the symptom constellation 2

• Overlooking personality disorders (particularly borderline, avoidant, or dependent types) that present with chronic anxiety, mood instability, and apparent inattention 1