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Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD)

Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD). Brian B. Doyle, MD. Adults with ADHD. What is ADHD? How do you diagnose it in adults ? How do you treat with medication? What other treatments help?

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Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD)

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  1. Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD) Brian B. Doyle, MD

  2. Adults with ADHD • What is ADHD? • How do you diagnose it in adults ? • How do you treat with medication? • What other treatments help? • What is the impact of comorbid conditions? • How do you deal with treatment-refractory ADHD?

  3. What is ADHD? A syndrome in which symptoms of inattention, of hyperactivity/impulsivity, or both, significantly interfere with the capacity to work or to love, or both.

  4. Diagnosing ADHD Criterion A: At least 6 of 9 symptoms of inattention, or at least 6 of 9 symptoms of hyperactivity/impulsivity, or both, have persisted for at least 6 months. Symptoms are maladaptive, inconsistent with developmental level.

  5. Symptoms of Inattention • Fails to attend to details • Fails to sustain attention on task • Fails to listen • Fails to finish jobs • Poor at planning and organizing • Loses things frequently • Easily distracted by extraneous stimuli • Often forgetful • Avoids sustained mental effort

  6. Hyperactive/Impulsive Symptoms • Can’t sit quietly • Has to get up and move around • Subjective restlessness • Hard to engage in leisure quietly • “On the go” or “driven” • Talks excessively • Speaks without thinking; blurts out • Has difficulty waiting his or her turn • Interrupts or intrudes on others

  7. Criterion B: Symptoms causing impairment were present before age 7 years

  8. Criterion C: Impairment from the symptoms is present in two or more settings (eg, work and home)

  9. Criterion D: There is clear evidence of significantimpairment in social, academic or occupational functioning

  10. Criterion E: The symptoms are not better accounted for by another mental disorder (eg, mood or anxiety disorder, substance abuse, personality disorder)

  11. Initial Evaluation 1: Clinical Interviews • Past and present ADHD symptoms • How, where symptoms cause impairments • Alternative and comorbid disorders • Developmental history/impulses • Strengths* • Mental status examination

  12. Evaluation 2: Standardized Rating Scales • Adult ADHD Self Report Scale • Barkley System of Diagnostic Scales • Brown Attention-Deficit Disorder Scales • Conners Adult ADHD Rating Scale

  13. Evaluation 3: Medical history and assessments

  14. Evaluation 4: Family • History of ADHD, results of treatment • History of other disorders

  15. Evaluation 5: Information from a significant other or parent • Documentation • Interview data • Rating scales

  16. Evaluation 6: School and work assessments

  17. Evaluation 7: Other assessments • Educational • Psychological testing • Neuropsychological testing • Neuroimaging • Vocational

  18. ADHD Subtypes • Combined • Predominantly inattentive • Predominantly hyperactive/impulsive • Not otherwise specified

  19. Prevalence of ADHD in adults: 4.4%(National Comorbidity Study, 2006)

  20. Differential Diagnosis of ADHD • Psychiatric • Medical • Dietary • Malingering • Normal behavior

  21. Psychiatric Disorders Associated with ADHD • Anxiety disorders • Affective disorders, uni- and bipolar* • Learning disorders • Substance abuse disorders • Tourette’s Disorder • Schizophrenia and other psychotic disorders • Mental retardation • Pervasive developmental disorders • Personality disorders

  22. The Biology of ADHD • Attention is a complex state mediated by several areas of the brain • Frontal lobe dysfunction is central but not the only site of the disorder

  23. The Biology of ADHD, cont’d • Less gray and white matter • Decrements in the dorsal prefrontal cortex • Decrements in the cerebellum • Decrements in the striatum

  24. Biology: Neurotransmitters • Dopamine relates to attention • Norepinephrine relates to hyperactivity/impulsivity • Current thinking: multiple neurotransmitter systems are involved

  25. Biology of ADHD: Genetics • Family studies: more first-degree relatives of affected individuals • Twin studies: higher concordance in identical than in fraternal twins • Adoption studies: nature>nurture • Molecular studies: candidate genes affect neurotransmitter systems

  26. Comprehensive Treatment for ADHD • Always starts with education • Usually includes medication • Usually includes psychotherapy • Good alliance with significant others • May need other resources (coaches, etc)

  27. Rx Goal : Enhance Resilience (Charney, 2005) • Optimism • Altruism • Moral compass • Faith and spirituality • Humor • Role model • Social supports • Face fears • Life mission • Training

  28. Medication for ADHD • CNS stimulants and other medications • Result : moderate to marked improvement in 60-70% of adult ADHD patients • Rarely “magic,” by itself

  29. CNS Stimulants for ADHD • Helpful, but less than in children • Biggest problem in adults is underdosing • Usual daily dosage range is 50-100 mg of methylphenidate, 30-50 mg of dextroamphetamine • Try both, since 25% respond to one but not the other

  30. CNS Stimulants: Do NOTUse • Active cardiovascular heart disease or uncontrolled hypertension • Active, untreated substance abuse • Drug-abusing patients with less than three months of documented abstention • Current symptoms or past history of bipolar disorder, especially mania • Psychosis

  31. Methylphenidate stimulants • Concerta • Daytrana • Focalin • Focalin XR • Metadate CD • Ritalin HCl • Ritalin LA

  32. Amphetamine stimulants • Adderall • Adderall-XR • (Adderall-XXR) • Dexedrine • Dexedrine spansules

  33. Med Trial with Adderall XR • 10 mg po each morning for 3-7 days • Raise by 10 mg increments each 3-7 days until there is no further improvement, or there are bad side effects, or both • Establish consistent use before prn use • Seek lowest dosage with best efficacy • Modulate dosage over 6 months to a year

  34. CNS Stimulant Trial: Dangers • Rise in blood pressure or pulse • Insomnia • Irritability/signs of mania • Loss of appetite • Jitteriness • Hypersexuality • Worsened anxiety, depression, psychosis

  35. Stimulants, Abuse,and ADHD Patients • CNS stimulants are rarely abused by ADHD patients • Used properly, they decrease the likelihood of later substance abuse in these patients • If there is comorbid substance abuse, treat it first

  36. Non-CNS Stimulants for Adult ADHD • Atomoxetine (Strattera): Yes • Bupropion (Wellbutrin): Yes • Tricyclic antidepressants: Yes • Monoamine Oxidase Inhibitors: Yes • SSRIs, SNRIs: No • Alpha-agonists: No (?) • Nicotine and cholinergic agents: ? • Modafinil (Provigil): Not alone, “layered”

  37. Strattera (atomoxetine) • Titrate to 80-120 mg qd for 4-6 weeks • Watch for irritability, nausea, sedation, delayed urination, less libido, delayed orgasm, higher blood pressure and pulse • Hepatic symptoms: discontinue stat • Mild-moderate improvement

  38. Ineffective Treatments for ADHD • Meds: lithium carbonate; amantadine; l-Dopa; D-,L-phenylalanine; tyrosine; antiyeast medications • Dietary supplements: acetylcarnitine; gingko biloba; phosphatidylserine; essential fatty acids such as gamma-linolenic acid and docosahexanoic acid; megavitamins; DMAE (dimethylaminothanol) • Dietary manipulations

  39. Adult ADHD: Active Psychotherapy • Support and psychoeducation • Cognitive behavioral treatment • Psychodynamic treatment • Couples treatment • Family treatment • “Coaching”

  40. Comorbid ADHD: Be Vigilant • The rule, not the exception • Look for ADHD in the anxious or depressed or substance-abusing patient; look for anxiety and depression and substance abuse in the ADHD patient • “Treat what’s worst, first” • Personality disorders worsen prognosis

  41. ADHD : Comorbid Affective Disorder • At least 25% of ADHD patients are depressed • At least 25% of depressed patients have ADHD • Strattera and the SSRIs: escitalopram (Lexapro) or sertraline (Zoloft) don’t compete for the metabolic pathway

  42. ADHD and Bipolar Disorder • An estimated 5-10% of adult ADHD patients have bipolar disorder • Screen for it by using a rating scale (eg, Mood Disorders Questionnaire) and data from significant others, family • Stabilize mood before treating ADHD

  43. ADHD and Anxiety Disorders • An estimated 50% of ADHD patients have 1 or more anxiety disorders • Stimulants “worsen” anxiety, but full treatment of ADHD lessens it

  44. Adult ADHD and Substance Abuse • 10% chance of current substance abuse, 50% chance of past abuse, 20-50% chance of future abuse • Incidence higher in antisocial personality disorder

  45. ADHD and Substance Abuse, cont’d • Vigilance • Information from patient and others • Treat substance abuse first • Document three or more months of abstinence before treating ADHD • Treat the abstinent patient with Strattera and/or stimulants, but stay vigilant

  46. Treatment-Refractory ADHD • Lack of response to medication • Many/severe comorbid disorders • Unsupportive or hostile family • Character pathology

  47. Treatment-Refractory ADHD • Combine stimulants with atomoxetine or bupropion • Combine atomoxetine or bupropion with a stimulant • Add modafinil • Try TCA (alone or with stimulant) • Alpha-agonist • MAOI (alone)

  48. ADHD and Women • Girls have ADHD, with significant morbidity and higher risk of drug abuse • Women with ADHD can founder when they have children • Issues concerning pregnancy and breast-feeding require coordinated care

  49. ADHD and Families • Problems are multi-generational • The spouse can be unsupportive or overburdened or both • Think in terms of the family system

  50. ADHD in Adults: Summary • Keep the diagnosis in mind • Evaluate thoroughly • Assess for comorbidity, especially affective disorder and substance abuse • Identify strengths • Treat what’s worst, first • Enhance resilience

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