understanding and treating adults with attention deficit hyperactivity disorder (adhd) brian b....
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Understanding and Treating Understanding and Treating Adults with Adults with
Attention Deficit Hyperactivity Attention Deficit Hyperactivity Disorder (ADHD)Disorder (ADHD)
Brian B. Doyle, MD Brian B. Doyle, MD
Adults with ADHDAdults with ADHD What is ADHD?What is ADHD?
How do you diagnose it in adults ? How do you diagnose it in adults ?
How do you treat with medication?How do you treat with medication?
What other treatments help?What other treatments help?
What is the impact of comorbid conditions?What is the impact of comorbid conditions?
How do you deal with treatment-refractory ADHD?How do you deal with treatment-refractory ADHD?
What is ADHD?What is ADHD?
A syndrome in which symptoms of A syndrome in which symptoms of inattention, of inattention, of hyperactivity/impulsivity, or both, hyperactivity/impulsivity, or both, significantly interfere with the significantly interfere with the capacity to work or to love, or both.capacity to work or to love, or both.
Diagnosing ADHDDiagnosing ADHD
Criterion A: At least 6 of 9 symptoms Criterion A: At least 6 of 9 symptoms of inattention, or at least 6 of 9 of inattention, or at least 6 of 9 symptoms of symptoms of hyperactivity/impulsivity, or both, hyperactivity/impulsivity, or both, have persisted for at least 6 months. have persisted for at least 6 months. Symptoms are maladaptive, Symptoms are maladaptive, inconsistent with developmental inconsistent with developmental level.level.
Symptoms of InattentionSymptoms of Inattention
Fails to attend to details Fails to attend to details Fails to sustain attention on taskFails to sustain attention on task Fails to listenFails to listen Fails to finish jobsFails to finish jobs Poor at planning and organizing Poor at planning and organizing Loses things frequentlyLoses things frequently Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli Often forgetfulOften forgetful Avoids sustained mental effortAvoids sustained mental effort
Hyperactive/Impulsive Hyperactive/Impulsive Symptoms Symptoms
Can’t sit quietlyCan’t sit quietly Has to get up and move aroundHas to get up and move around Subjective restlessnessSubjective restlessness Hard to engage in leisure quietlyHard to engage in leisure quietly ““On the go” or “driven”On the go” or “driven” Talks excessivelyTalks excessively Speaks without thinking; blurts outSpeaks without thinking; blurts out Has difficulty waiting his or her turnHas difficulty waiting his or her turn Interrupts or intrudes on othersInterrupts or intrudes on others
Criterion B: Symptoms causing Criterion B: Symptoms causing impairment were present impairment were present
before age 7 yearsbefore age 7 years
Criterion C: Impairment from Criterion C: Impairment from the symptoms is present in the symptoms is present in two two
or more settings or more settings (eg, work and home)(eg, work and home)
Criterion D: There is clear Criterion D: There is clear evidence of evidence of significantsignificant
impairment in social, academic impairment in social, academic or occupational functioningor occupational functioning
Criterion E: The symptoms are Criterion E: The symptoms are not better accounted for by not better accounted for by
another mental disorder (eg, another mental disorder (eg, mood or anxiety disorder, mood or anxiety disorder,
substance abuse, personality substance abuse, personality disorder)disorder)
Initial Evaluation Initial Evaluation 1: Clinical Interviews1: Clinical Interviews
Past and present ADHD symptomsPast and present ADHD symptoms How, where symptoms cause How, where symptoms cause
impairmentsimpairments Alternative and comorbid disordersAlternative and comorbid disorders Developmental history/impulsesDevelopmental history/impulses Strengths*Strengths* Mental status examinationMental status examination
Evaluation Evaluation 2: Standardized Rating Scales2: Standardized Rating Scales
Adult ADHD Self Report ScaleAdult ADHD Self Report Scale Barkley System of Diagnostic ScalesBarkley System of Diagnostic Scales Brown Attention-Deficit Disorder Brown Attention-Deficit Disorder
ScalesScales Conners Adult ADHD Rating ScaleConners Adult ADHD Rating Scale
Evaluation 4: FamilyEvaluation 4: Family
History of ADHD, results of treatmentHistory of ADHD, results of treatment History of other disordersHistory of other disorders
Evaluation 5: Information from Evaluation 5: Information from a significant other or parenta significant other or parent
DocumentationDocumentation Interview dataInterview data Rating scales Rating scales
Evaluation 7: Other Evaluation 7: Other assessmentsassessments
EducationalEducational Psychological testingPsychological testing Neuropsychological testingNeuropsychological testing NeuroimagingNeuroimaging VocationalVocational
ADHD Subtypes ADHD Subtypes
CombinedCombined Predominantly inattentivePredominantly inattentive Predominantly hyperactive/impulsivePredominantly hyperactive/impulsive Not otherwise specifiedNot otherwise specified
Prevalence of ADHD in Prevalence of ADHD in adults: 4.4%adults: 4.4%
(National(National Comorbidity Study, 2006) Comorbidity Study, 2006)
Differential Diagnosis of ADHD Differential Diagnosis of ADHD
PsychiatricPsychiatric MedicalMedical DietaryDietary MalingeringMalingering Normal behaviorNormal behavior
Psychiatric Disorders Psychiatric Disorders Associated with ADHDAssociated with ADHD
Anxiety disordersAnxiety disorders Affective disorders, uni- and bipolar*Affective disorders, uni- and bipolar* Learning disordersLearning disorders Substance abuse disordersSubstance abuse disorders Tourette’s Disorder Tourette’s Disorder Schizophrenia and other psychotic Schizophrenia and other psychotic
disorders disorders Mental retardationMental retardation Pervasive developmental disordersPervasive developmental disorders Personality disordersPersonality disorders
The Biology of ADHDThe Biology of ADHD
Attention is a complex state Attention is a complex state mediated by several areas of the mediated by several areas of the brainbrain
Frontal lobe dysfunction is central Frontal lobe dysfunction is central but not the only site of the disorderbut not the only site of the disorder
The Biology of ADHD, cont’dThe Biology of ADHD, cont’d
Less gray and white matter Less gray and white matter Decrements in the dorsal prefrontal Decrements in the dorsal prefrontal
cortexcortex Decrements in the cerebellumDecrements in the cerebellum Decrements in the striatumDecrements in the striatum
Biology: NeurotransmittersBiology: Neurotransmitters
Dopamine relates to attentionDopamine relates to attention Norepinephrine relates to Norepinephrine relates to
hyperactivity/impulsivity hyperactivity/impulsivity Current thinking: multiple Current thinking: multiple
neurotransmitter systems are neurotransmitter systems are involvedinvolved
Biology of ADHD: GeneticsBiology of ADHD: Genetics
Family studies: more first-degree Family studies: more first-degree relatives of affected individualsrelatives of affected individuals
Twin studies: higher concordance in Twin studies: higher concordance in identical than in fraternal twinsidentical than in fraternal twins
Adoption studies: nature>nurtureAdoption studies: nature>nurture Molecular studies: candidate genes Molecular studies: candidate genes
affect neurotransmitter systems affect neurotransmitter systems
Comprehensive Treatment for Comprehensive Treatment for ADHDADHD
Always starts with educationAlways starts with education Usually includes medicationUsually includes medication Usually includes psychotherapyUsually includes psychotherapy Good alliance with significant othersGood alliance with significant others May need other resources (coaches, May need other resources (coaches,
etc)etc)
Rx Goal : Enhance Rx Goal : Enhance Resilience Resilience
(Charney, 2005)(Charney, 2005) OptimismOptimism AltruismAltruism Moral compassMoral compass Faith and spiritualityFaith and spirituality HumorHumor Role modelRole model Social supportsSocial supports Face fearsFace fears Life missionLife mission TrainingTraining
Medication for ADHDMedication for ADHD
CNS stimulants and other CNS stimulants and other medicationsmedications
Result : moderate to marked Result : moderate to marked improvement in 60-70% of adult improvement in 60-70% of adult ADHD patientsADHD patients
Rarely “magic,” by itselfRarely “magic,” by itself
CNS Stimulants for ADHDCNS Stimulants for ADHD
Helpful, but less than in childrenHelpful, but less than in children Biggest problem in adults is Biggest problem in adults is
underdosingunderdosing Usual daily dosage range is Usual daily dosage range is
50-100 mg of methylphenidate, 50-100 mg of methylphenidate, 30-50 mg of dextroamphetamine 30-50 mg of dextroamphetamine
Try both, since 25% respond to one Try both, since 25% respond to one but not the otherbut not the other
CNS CNS Stimulants:Stimulants:
Active cardiovascular heart disease or Active cardiovascular heart disease or uncontrolled hypertensionuncontrolled hypertension
Active, untreated substance abuseActive, untreated substance abuse Drug-abusing patients with less than Drug-abusing patients with less than
three months of documented three months of documented abstentionabstention
Current symptoms or past history of Current symptoms or past history of bipolar disorder, especially maniabipolar disorder, especially mania
PsychosisPsychosis
Do Do NOTNOT UseUse
Methylphenidate stimulantsMethylphenidate stimulants
ConcertaConcerta DaytranaDaytrana FocalinFocalin Focalin XRFocalin XR Metadate CDMetadate CD Ritalin HClRitalin HCl Ritalin LARitalin LA
Amphetamine stimulantsAmphetamine stimulants
AdderallAdderall Adderall-XRAdderall-XR (Adderall-XXR)(Adderall-XXR) Dexedrine Dexedrine Dexedrine spansulesDexedrine spansules
Med Trial with Adderall XRMed Trial with Adderall XR
10 mg po each morning for 3-7 days10 mg po each morning for 3-7 days Raise by 10 mg increments each 3-7 days Raise by 10 mg increments each 3-7 days
until there is no further improvement, or until there is no further improvement, or there are bad side effects, or boththere are bad side effects, or both
Establish consistent use before prn useEstablish consistent use before prn use Seek lowest dosage with best efficacySeek lowest dosage with best efficacy Modulate dosage over 6 months to a yearModulate dosage over 6 months to a year
CNS Stimulant Trial: CNS Stimulant Trial: DangersDangers
Rise in blood pressure or pulseRise in blood pressure or pulse InsomniaInsomnia Irritability/signs of maniaIrritability/signs of mania Loss of appetiteLoss of appetite JitterinessJitteriness Hypersexuality Hypersexuality Worsened anxiety, depression, Worsened anxiety, depression,
psychosispsychosis
Stimulants, Abuse,Stimulants, Abuse,and ADHD Patientsand ADHD Patients
CNS stimulants are CNS stimulants are rarelyrarely abused by abused by ADHD patientsADHD patients
Used properly, they Used properly, they decreasedecrease the the likelihood of later substance abuse in likelihood of later substance abuse in these patientsthese patients
If there is comorbid substance abuse, If there is comorbid substance abuse, treat it first treat it first
Non-CNS Stimulants for Adult Non-CNS Stimulants for Adult ADHDADHD
Atomoxetine (Strattera): YesAtomoxetine (Strattera): Yes Bupropion (Wellbutrin): YesBupropion (Wellbutrin): Yes Tricyclic antidepressants: Yes Tricyclic antidepressants: Yes Monoamine Oxidase Inhibitors: YesMonoamine Oxidase Inhibitors: Yes SSRIs, SNRIs: NoSSRIs, SNRIs: No Alpha-agonists: No (?)Alpha-agonists: No (?) Nicotine and cholinergic agents: ?Nicotine and cholinergic agents: ? Modafinil (Provigil): Not alone, “layered” Modafinil (Provigil): Not alone, “layered”
Strattera (atomoxetine)Strattera (atomoxetine)
Titrate to 80-120 mg qd for 4-6 Titrate to 80-120 mg qd for 4-6 weeksweeks
Watch for irritability, nausea, Watch for irritability, nausea, sedation, delayed urination, less sedation, delayed urination, less libido, delayed orgasm, higher blood libido, delayed orgasm, higher blood pressure and pulsepressure and pulse
Hepatic symptoms: discontinue Hepatic symptoms: discontinue statstat Mild-moderate improvement Mild-moderate improvement
IneffectiveIneffective Treatments for Treatments for ADHDADHD
Meds: lithium carbonate; amantadine; l-Meds: lithium carbonate; amantadine; l-Dopa; D-,L-phenylalanine; tyrosine; Dopa; D-,L-phenylalanine; tyrosine; antiyeast medicationsantiyeast medications
Dietary supplements: acetylcarnitine; Dietary supplements: acetylcarnitine; gingko biloba; phosphatidylserine; gingko biloba; phosphatidylserine; essential fatty acids such as gamma-essential fatty acids such as gamma-linolenic acid and docosahexanoic acid; linolenic acid and docosahexanoic acid; megavitamins; DMAE megavitamins; DMAE (dimethylaminothanol)(dimethylaminothanol)
Dietary manipulations Dietary manipulations
Adult ADHD: Adult ADHD: Active Psychotherapy Active Psychotherapy
Support and psychoeducationSupport and psychoeducation Cognitive behavioral treatmentCognitive behavioral treatment Psychodynamic treatmentPsychodynamic treatment Couples treatmentCouples treatment Family treatmentFamily treatment ““Coaching”Coaching”
Comorbid ADHD: Comorbid ADHD: Be VigilantBe Vigilant
The The rulerule, not the exception, not the exception Look for ADHD in the anxious or Look for ADHD in the anxious or
depressed or substance-abusing depressed or substance-abusing patient; look for anxiety and patient; look for anxiety and depression and substance abuse in depression and substance abuse in the ADHD patientthe ADHD patient
““Treat what’s worst, first”Treat what’s worst, first” Personality disorders worsen prognosisPersonality disorders worsen prognosis
ADHD : Comorbid Affective ADHD : Comorbid Affective DisorderDisorder
At least 25% of ADHD patients are At least 25% of ADHD patients are depressed depressed
At least 25% of depressed patients At least 25% of depressed patients have ADHDhave ADHD
Strattera and the SSRIs: escitalopram Strattera and the SSRIs: escitalopram (Lexapro) or sertraline (Zoloft) don’t (Lexapro) or sertraline (Zoloft) don’t compete for the metabolic pathway compete for the metabolic pathway
ADHD and Bipolar DisorderADHD and Bipolar Disorder
An estimated 5-10% of adult ADHD An estimated 5-10% of adult ADHD patients have bipolar disorderpatients have bipolar disorder
Screen for it Screen for it by using a rating scale by using a rating scale
(eg, Mood Disorders Questionnaire) (eg, Mood Disorders Questionnaire) and data from significant others, and data from significant others, familyfamily
Stabilize mood before treating ADHDStabilize mood before treating ADHD
ADHD and Anxiety DisordersADHD and Anxiety Disorders
An estimated 50% of ADHD patients An estimated 50% of ADHD patients have 1 or more anxiety disordershave 1 or more anxiety disorders
Stimulants “worsen” anxiety, but full Stimulants “worsen” anxiety, but full treatment of ADHD lessens ittreatment of ADHD lessens it
Adult ADHD and Substance Adult ADHD and Substance AbuseAbuse
10% chance of current substance 10% chance of current substance abuse, 50% chance of past abuse, abuse, 50% chance of past abuse, 20-50% chance of 20-50% chance of future abusefuture abuse
Incidence higher in antisocial Incidence higher in antisocial personality disorderpersonality disorder
ADHD and Substance Abuse, ADHD and Substance Abuse, cont’dcont’d
Vigilance Vigilance Information from patient and othersInformation from patient and others Treat substance abuse firstTreat substance abuse first Document three or more months of Document three or more months of
abstinence before treating ADHDabstinence before treating ADHD Treat the abstinent patient with Treat the abstinent patient with
Strattera and/or stimulants, but stay Strattera and/or stimulants, but stay vigilantvigilant
Treatment-Refractory ADHDTreatment-Refractory ADHD
Lack of response to medicationLack of response to medication Many/severe comorbid disordersMany/severe comorbid disorders Unsupportive or hostile familyUnsupportive or hostile family Character pathology Character pathology
Treatment-Refractory ADHDTreatment-Refractory ADHD
Combine stimulants with Combine stimulants with atomoxetine or bupropionatomoxetine or bupropion
Combine atomoxetine or bupropion Combine atomoxetine or bupropion with a stimulant with a stimulant
Add modafinilAdd modafinil Try TCA (alone or with stimulant)Try TCA (alone or with stimulant) Alpha-agonistAlpha-agonist MAOI (alone)MAOI (alone)
ADHD and Women ADHD and Women
Girls have ADHD, Girls have ADHD, with significant with significant morbidity and higher risk of drug morbidity and higher risk of drug abuseabuse
Women with ADHD can founder when Women with ADHD can founder when they have childrenthey have children
Issues concerning pregnancy and Issues concerning pregnancy and breast-feeding require coordinated breast-feeding require coordinated carecare
ADHD and FamiliesADHD and Families
Problems are multi-generationalProblems are multi-generational The spouse can be unsupportive or The spouse can be unsupportive or
overburdened or bothoverburdened or both Think in terms of the family systemThink in terms of the family system
ADHD in Adults: Summary ADHD in Adults: Summary
Keep the diagnosis in mindKeep the diagnosis in mind Evaluate thoroughlyEvaluate thoroughly Assess for comorbidity, especially Assess for comorbidity, especially
affective disorder and substance affective disorder and substance abuse abuse
Identify strengthsIdentify strengths Treat what’s worst, firstTreat what’s worst, first Enhance resilienceEnhance resilience
Enhance ResilienceEnhance Resilience
OptimismOptimism AltruismAltruism Moral compassMoral compass Faith and spiritualityFaith and spirituality HumorHumor Role modelRole model Social supportsSocial supports Face fearsFace fears Life missionLife mission TrainingTraining
References: BooksReferences: Books
Doyle BB: Doyle BB: Understanding and Understanding and Treating Adults with ADHDTreating Adults with ADHD, 2006, 2006
Adler L: Adler L: Scattered MindsScattered Minds, 2006, 2006 Barkley RA: Barkley RA: Attention Deficit Attention Deficit
Hyperactivity DisorderHyperactivity Disorder, 3, 3rdrd Ed, 2006 Ed, 2006 Solanto MV, Arnsten AFT, Castellanos Solanto MV, Arnsten AFT, Castellanos
FX: FX: Stimulant Drugs and ADHDStimulant Drugs and ADHD, 2001, 2001