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ATTENTION DEFICIT DISORDER IN INTELLECTUALLY GIFTED ADULTS. Hal Elliott, MD Associate Professor Residency Program Director Department of Psychiatry East Tennessee State University. Wake Forest University : Middle 50% of Students With SAT between 1250-1390

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attention deficit disorder in intellectually gifted adults

ATTENTION DEFICIT DISORDER IN INTELLECTUALLY GIFTED ADULTS

Hal Elliott, MD

Associate Professor

Residency Program Director

Department of Psychiatry

East Tennessee State University

slide2

Wake Forest University:

  • Middle 50% of Students With SAT between 1250-1390
  • US NEWS and World Report: #25-30

Davidson College :

  • Middle 50% of Students With SAT between 1310-1440
  • US News and World Report: #5-11
dsm definition of adhd
DSM Definition of ADHD

“A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically found in individuals at a comparable level of development”

EXECUTIVE FUNCTIONING DISORDER

adhd neurobiologic basis
ADHD: Neurobiologic Basis

Attention Networks

EXECUTIVE CONTROL

ORIENTING (SELECTIVE ATTENTION)

ALERTING

Posner and Raichle. Images of the Mind. Scientific American Books; 1996.

neural networks of attention
Neural Networks of Attention
  • Prefrontal cortex
  • Parietal cortex
  • Cingulate gyrus
  • Limbic structures (amygdala-hippocampus)
  • Basal ganglia
  • Thalamus
  • Brainstem (reticular formation)
  • Cerebellum

Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272.

slide8

Normal Controls

ADHD

y = +21 mm

y = +21 mm

-2

1 x 10

1 x 10

-2

1 x 10

-3

1 x 10

-3

Anterior Cingulate Cortex Cognitive Division Fails to Activate in ADHD

Bush G et al. Biol Psychiatry. 1999;45:1542-1552.

heritability of adhd

ADHD

Heritability of ADHD

Schizophrenia

Panic Disorder

Height

Laarson( 2004)

Rietveld (2003)

Martin (2002)

Kuntsi(2001)

Coolidge (2000)

Thapar (2000)

Willcutt (2000)

Hudziak (2000)

Nadder (1998)

Levy (1997)

Sherman (1997)

Silberg (1996)

Gjone (1996)

Thapar (1995)

Schmitz (1995)

Stevenson (1992)

Edelbrock (1992)

Gillis (1992)

Goodman (1989)

Willerman (1973)

Matheny (1971)

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Heritability

Mean heritability of ADHD = .75

Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323.

neurobiology
NEUROBIOLOGY
  • Variation in basal ganglia symmetry and in corpus collosum
  • PET: Decreased brain glucose metabolism in basal ganglia of ADHD adults/adolescents (Zametkin et al)
  • SPECT: Increased striatal availability of a

dopamine transporter ( Krause et al)

  • Genetic Studies: Twin and sibling studies most convincing biologic evidence
slide11

Catecholamines and Brain Activity

DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; ACh, acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra.

lifetime course of adhd symptoms inattention domain
Lifetime Course of ADHD Symptoms: Inattention Domain

Childhood Adulthood

  • +

Difficulty sustaining attention

Doesn’t listen

No follow-through

Can’t organize

Loses important items

Difficulty sustaining attention (meetings, readings, paperwork)

Paralyzing procrastination

Slow, inefficient

Poor time management

Disorganized

Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37.

lifetime course of adhd symptoms hyperactivity impulsivity domain
Lifetime Course of ADHD Symptoms: Hyperactivity-Impulsivity Domain

Childhood Adulthood

  • +

Inefficiencies at work

Can’t sit through meetings

Can’t wait in line

Drives too fast

Self-selects very active job

Can’t tolerate frustration

Talks excessively

Interrupts others

Makes inappropriate comments

Squirming, fidgeting

Can’t stay seated

Can’t wait turn

Runs/climbs excessively

Can’t play/work quietly

On the go/driven by motor

Talks excessively

Blurts out answers

Intrudes/interrupts others

Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37.

traffic violations and mva among young adults with adhd
Traffic Violations and MVA Among Young Adults With ADHD

Negative Driving Outcomes From a Driving History Interview

P =.003

ADHD (n = 105)

Control (n = 64)

Subjects Responding Yes (%)

P=.007

P=.002

P=.001

P=.001

≥12 Traffic Citations

Drove Before Licensed

≥5 Speeding Citations

License Suspended or Revoked

≥3 Vehicular Crashes

MVA, motor vehicle accidents.

Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672.

driving problems
Driving Problems

“ OFFICER, I AM NOT INEBRIATED…I AM JUST INEPT.”

Britt Elliott ( 1988)

substance use disorders in adhd teens growing up overall rate of substance use disorder
Substance Use Disorders in ADHD Teens Growing Up:Overall Rate of Substance Use Disorder

P<.001

100

75

80

Individuals With Substance Use Disorder (%)

60

40

25

18

20

0

Non-ADHD

Medicated

ADHD

Unmedicated

ADHD

(n=137)

(n=19)

(n=56)

Biederman J et al. Pediatrics. 1999;104:e20

childhood add into adult add
Childhood ADD into Adult ADD
  • Spencer et al: 60% of children with ADHD meet criteria as adults
  • Spencer, Biederman, Williams: 663/1700 meet criteria
  • Borland and Heckman: 50% of ADHD kids meet criteria as adults as opposed to 5% of non-ADHD siblings
add symptoms in college grad students
ADD Symptoms In College/Grad Students:
  • Distractibility
  • Organizational problems
  • Poor task completion
  • Forgetfulness
  • Careless errors/ trouble with details
  • Sequencing problems
  • Hyper-focusing/ Prioritization Problems
  • “Deer in the Headlights”
add in college grad students continued
ADD in College/Grad Students (continued)
  • Authority Issues
  • Stubbornness
  • Intolerance of silly rules/ assignments
  • Relationship problems ( peer and sig. other)
  • Frequent changes in major/ schools
  • Poor frustration tolerance
  • Easily bored
  • Poor or inconsistent academic performance despite

adequate or even superior intellectual abilities

what add college gradstudents report
What ADD College/GradStudentsReport:
  • Scattered
  • Anxious/ “Scanning The Horizon”
  • Irritable
  • Chronically Late/ Poor Time Sense
  • Procrastination
  • Bored Easily/ Restless/ Impatient
  • Trouble with Math/Directions
  • Reading Comprehension Problems
  • Compensatory OC Behavior
overwhelmed
OVERWHELMED
  • Increase in distress/ anxiety/ disorganization when responsibility increases/ changes at work, home, or school.

EXAMPLES:

  • Birth of child
  • Promotion
  • Increase in academic workload
  • Transitions: First of School Year, Starting College or Grad School, Moving Rooms, Changing Classes, Weekday to Weekend, Weekend to Weekday, Awake to Sleep, Sleep to Awake
comorbidity in adults
COMORBIDITY IN ADULTS
  • Anxiety Disorders (50%)
  • Substance Abuse ( 27%-47%)
  • Antisocial Personality Disorder ( 12%-27%)
  • Affective Disorders (? %)
  • NO COMORBID DX: 40%
self rating scales
Self Rating Scales
  • Copeland Symptom Checklist For Adult ADHD
  • Brown Adult ADD Scale( BAADS II)
  • Amen Scale
psychoeducational testing
Psychoeducational Testing
  • While ADHD is a clinical diagnosis, consider psychometric testing if:
  • Diagnosis is unclear
  • Accommodations are needed
  • More details re: exact deficits are needed or if LD is suspected.
chronic vs new onset
CHRONIC vs. NEW ONSET
  • Childhood Prerequisite
  • New Onset: medical work-up indicated
  • Consider: endocrine, sleep apnea, drug interactions, hearing deficit, B12, head injury, heavy metal, seizure disorder.
  • MRI/CT, EEG, BP, EKG, baseline labs, etc.
controversy skepticism re adhd in young adults
Controversy/ Skepticism Re: ADHD in Young Adults

Why?

  • Childhood Onset – difficult to get accurate history, especially in individuals who have IQ in superior range.
  • By adulthood comorbidity clouds diagnosis
  • ADHD is a clinical diagnosis
  • Schedule II medications/fear of prescribing
  • Countertransference/Cultural Bias
why now if they didn t have trouble as small children doesn t that mean they are just lazy
WHY NOW?( If they didn’t have trouble as small children, doesn’t that mean they are just lazy?)
  • Many college students functioning in the intellectual ly superior range never had to study before college
  • Many students had parents to manage all of their details, scheduling, deadlines, etc
  • Some students attended exclusive private schools with very rigid day to day routines. External organization kept them structured and limited distractions.
compensatory anxiety
Compensatory Anxiety
  • It isn’t compulsive checking behavior if you really might forget
  • Anxiet y will increase catecholamines and can increase ability to attend
  • Procrastination creates anxiety when the work is imminently due….and can increase ability to attend
  • Classical conditioning model
  • But…too many catecholamines cause a shut down effect.
cause and effect
Cause and Effect
  • “Are you scattered because you are anxious or are you anxious because you are scattered”
  • “Are you depressed because you can’t get your work done or are you not getting your work done because you are depressed”
ocd and vs adhd
OCD and/vs ADHD
  • OC sxs as a compensatory mechanism. Ruminating. Lists. Excessive worry. Worst case scenarios.
  • Not usually repetitive over time. Tend to be day to day worries as opposed to intrusive ego dystonic obsessions
  • Thoughts jump from one thought to next as opposed to focusing on one obsession
  • Compulsive sxs are less likely to be linked to obsessive thinking.
bpad vs adhd
BPAD vs. ADHD
  • Genetic overlap
  • Hyperactivity vs. Mania/Hypomania
  • Discreet episodes vs. ongoing symptoms
adhd stimulant medications
ADHDStimulant Medications

Of pharmacologic options available for ADHD, stimulant medications are the:

  • Most studied
  • Most commonly used
  • Most effective
  • First-line agents for treatment

Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.

dopamine norepinehrine
DOPAMINE/NOREPINEHRINE
  • DOPAMINE: mediates “verbal fluency, serial learning, vigilance for executive functioning, sustaining and focusing attention, prioritizing behavior, and modulating behavior based on social cues” (Stahl)
  • NOREPINEPHRINE: plays role in “sustaining and focusing attention, as well as in modulating energy, fatigue, motivation and interest” ( Stahl)
psychopharmacology dopaminergic noradrenergic
PSYCHOPHARMACOLOGYDopaminergic/ Noradrenergic
  • STIMULANTS: Methylphenidate (Ritalin, Ritalin LA, Metadate CR, Concerta)
  • Mixed amphetamine salts ( Adderall, Adderall XR),
  • Dextroamphetamine( Dexedrine, Dextrostat),
  • Dextroamphetamine long acting ( Vyvanse)
  • d-methylphenidate ( Focalin)
  • Pemoline ( Cylert)…LFT’s
psychopharm cont
PSYCHOPHARM ( cont.)

ANTIDEPRESSANTS/ OTHER

Buproprion ( Wellbutrin)

Venlafaxine ( Effexor)

Duloxetine ( Cymbalta)

Desipramine/ Imipramine

Modafinil ( Provigil)

Clonidine ( catapress)

Atomoxetine(Strattera

SSRI’s for comorbidity….not for core symptoms

why nonstimulant treatments for adhd
Problems with the stimulants

Schedule II drugs (abuse liability, diversion, medicolegal concerns)

30% do not adequately respond or cannot tolerate stimulant treatment

Short duration of action (compliance, embarrassment)

Side effect profile adversely impacting sleep, appetite, mood, and anxiety

Concerns about cardiovascular effects, growth suppression, and tic development

Why Nonstimulant Treatments for ADHD?

Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432.

non medication intervention
Non- Medication Intervention
  • Education
  • Organizational Help (academic coaching)
  • Learning Assistance Center @ WFU
  • Individual and Couples Therapy
  • CHADD
  • SNL @ Davidson College
  • Exercise
  • Selection of occupation and need for novelty/ difficulty with change
academic accomodations
ACADEMIC ACCOMODATIONS

Leveling the playing field:

  • Quiet Environment
  • Extra Time
  • UC Berkeley Study:

Group Standard Time Extra Time

LD 13th percentile 76th percentile

Non-LD 82nd percentile 83rd percentile

accommodations for residents
Accommodations For Residents

Accommodations for Resident Physicians with Attention Deficit Disorder

Academic Psychiatry

Elliott, Arnold, Brenes, Silvia, Rosenquist

August 2007

thoughts re gifted adhd adults
Thoughts Re: Gifted ADHD Adults
  • Stimulants/ Schedule II drugs
  • Alteration of sense of self/ blunting of creativity
  • Non-linear thinkers in the academic environment.
  • Myth of Laziness. Twice the work for half the result.
  • “Left handed learners”
  • Responsibility
  • Square Pegs and Round Holes
family issues
Family Issues
  • “My parents and I have different ideas about what I should do after graduation. I want to go to Florence and study Art History. They want me to move into their pool house and become a dental hygienist”
  • Patient J, Senior at WFU
slide49

I was a peripheral visionary. I could see the future, but only way off to the side. Steven Wright

mindfulness and attentiveness
Mindfulness and Attentiveness
  • Attentiveness….does not characterize my brothers and me, all of whom were raised in SC and who have an air of abstraction and carelessness. None of us have a sense of direction. When something breaks, we fix it with duct tape…we tend to live in our own heads than in the actual physical world. We are more likely to get lost, to forget things, to stare blankly off in the distance for minutes at a time…at least part of the reason I resist ( taking something like Ritalin) is that I am not convinced the abstracted end of the mindfulness spectrum is such a bad place to be. In fact, I kind of like it here.

Sometimes I wonder whether it is an accident that of the three abstracted Elliott brothers, two have graduate degrees in philosophy and the other is a psychiatrist.

  • Carl Elliott, MD, PhD

Better Than Well. American Medicine Meets the American Dream

creativity and non linear thinking
Creativity and Non-Linear Thinking
  • “One must still have chaos within oneself to be able to give birth to a dancing star”

Nietszche

hearing the beat of a different drum
Hearing The Beat of A Different Drum
  • “ You can dream the American Dream, but you sleep with the lights on and wake up with a scream”

Warren Zevon ( Fistful of Rain)

pushing the envelope
Pushing The Envelope
  • “ Walk with me out on the wire…”

Bruce Springsteen ( Born To Run)

evaluation of adult adhd
Evaluation of Adult ADHD
  • What to evaluate
    • Current symptoms
    • Impairment
    • Establishing childhood onset
  • How to evaluate
    • Role of screening tools
    • Role of scales (diagnostic and symptom assessment)
    • Importance of prompts
  • Who should evaluate
    • Mental health professionals
    • PCPs

Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85-93; Wilens TE, et al. JAMA. 2004;292:619-623.

PCP, primary care physician.