ADHD AND ANXIETY AND DEPRESSION AN OVERVIEW
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1 ADHD AND ANXIETY AND DEPRESSION AN OVERVIEW A/Professor Alasdair Vance Head, Academic Child Psychiatry Department of Paediatrics University of Melbourne Telephone: Facsimile: Website:
2 Outline of Presentation - Definition of ADHD, anxiety and depressive disorders - The conceptual problem of comorbidity - The clinical problem of comorbidity - Future directions
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6 Attention Deficit Hyperactivity Disorder (ADHD) DSM-IV CRITERIA -six or more symptoms, at least six months, maladaptive/inconsistent with developmental level -inattention dimension and/or hyperactivity-impulsivity dimension -evident at least two settings -onset before seven years of age -impairment social, academic, occupational functioning -symptoms not due to a PDD, Psychotic, Mood, or Anxiety Disorder Dr A Vance
7 Definition (DSM-IV) Major depressive disorder one or more major depressive episode(s) characterized by the following: period of two weeks or more -depressed mood predominant and/or -loss of interest or pleasure -3 or 4 or more of the following; feelings of worthlessness or excessive or inappropriate guilt, >5% weight change in a given month, in/hyper somnia, psychomotor agitation/retardation, anergia (fatigue), decreased concentration or ability to think or decisiveness, recurrent thoughts of death, suicidal ideation, suicide plan or suicide attempt symptoms cause impairment in interpersonal, social, academic, occupational functioning not due to a substance, medical condition or bereavement
8 Definition (DSM-IV) Dysthymic disorder is characterized by the following: 2 years or more (most of the day, for more days than not), <2 months absence in a given year -depressed mood predominant -2 or more of the following: feelings of hopelessness, low self-esteem appetite change, in/hyper somnia, anergia (fatigue), decreased concentration or decisiveness no major depressive episode evident in first year of the symptoms symptoms cause impairment in interpersonal, social, academic, occupational functioning not due to a substance, medical condition or bereavement
9 Definition (DSM-IV) Anxiety disorders are characterized by the following: Generalized Anxiety Disorder: > 6 months anxiety/worries Specific Phobia: specific fear stimulus Social Phobia: interpersonal sensitivity Obsessive compulsive disorder: presence of obsessions/compulsions Panic disorder: panic attacks with characteristic cognitions symptoms cause impairment in interpersonal, social, academic, occupational functioning not due to a substance or medical condition
10 Types of ADHD -predominantly inattentive type (primarily) -combined type -predominantly hyperactive-impulsive type Dr A Vance
11 - all subtypes average prevalence 4% (9 years) 0.8% (20 years) (decrease 50%/5 years) - Controversy continues..diagnostic criteria and informants used
12 Comorbidity of ADHD -alcohol/substance abuse/dependence disorders -oppositional-defiant through to conduct disorders -anxiety and depressive symptoms through to disorders
13 Comorbidity of ADHD (continued) -males: increased rates of oppositional-defiant through to conduct disorders -females: increased rates of anxiety and depressive symptoms through to disorders -oppositional-defiant disorder increases risk of anxiety and depressive symptoms through to disorders
14 Comorbidity of ADHD (continued) - psychotic disorders primarily disorganized schizophrenia/ residual schizophrenia prominent thought blocking, formal thought disorder, confusion, personality disintegration, social and occupational impairment
15 The conceptual problem of comorbidity - comorbid disorders are separate disorders - comorbid disorders are secondary disorders ADHD ADHD anxiety disorders / depressive disorders anxiety disorders / depressive disorders - comorbid disorders share common antecedent ADHD anxiety disorders / depressive disorders working memory deficits
16 The conceptual problem of comorbidity - comorbid disorders are separate disorders - overwhelming evidence of a greater than chance association of ADHD and anxiety disorders / depressive disorders Dr A Vance
17 The conceptual problem of comorbidity - comorbid disorders are secondary disorders ADHD anxiety disorders / depressive disorders Dr A Vance
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20 The conceptual problem of comorbidity - comorbid disorders are secondary disorders ADHD anxiety disorders / depressive disorders Dr A Vance
21 Prefrontal cortex function Prefrontal cortex dysfunction Anxiety low/high Depression - low Behavioural symptom level
22 The conceptual problem of comorbidity - comorbid disorders share common antecedent ADHD anxiety disorders / depressive disorders working memory deficits Dr A Vance
23 BSE total score BSE 2 BSE 3 BSE 4 BSE 6 BSE 8 BSE - task difficulty Anxiety ADHD-CT and anxiety ADHD-CT Dr A Vance
24 80 BSE - total R 2 = R 2 = Anxiety ADHD-CT and anxiety ADHD-CT Age (months)
25 50 BSE total score Dysthymic disorder ADHD-CT and dysthymic disorder ADHD-CT 0-10 BSE 2 BSE 3 BSE 4 BSE 6 BSE 8 BSE - task difficulty
26 80 70 BSE - total R 2 = R 2 = Dysthymic disorder ADHD-CT and dysthymic disorder ADHD-CT Age (months)
27 The conceptual problem of comorbidity - comorbid disorders share common antecedent ADHD anxiety disorders / depressive disorders working memory deficits
28 The clinical problem of comorbidity -Summary to date: impairment governs referral comorbidity is common relatively specific and common risk factors emerging brain systems studied affected by biological and environmental factors
29 Developmental psychopathology -assessment and treatment involves [1] identifying biological, psychological, social, cultural and developmental risk and resilience factors and their relative importance in a given individual and [2] biological and psychological treatments used alone or in conjunction to achieve specific goals informed by the relative priorities of these risk and resilience factors -monitoring of treatment resides primarily with the clinician in association with the individual in the treatment process -clear biological risk factors or resilience factors identified
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32 Key targets of psychological and biological treatment Executive functioning Response inhibition: Working memory: motor and cognition optimise response speed and accuracy verbal and visuospatial optimise span and strategy Dr A Vance
33 Key targets of psychological and biological treatment Mood dysregulation: Arousal dysregulation: decrease irritability increase emotional salience optimise physiological arousal optimise habituation Dr A Vance
34 Useful medication approaches Response inhibition: motor and cognition speed and accuracy stimulant medication -linear dose response clonidine higher dose Working memory: span strategy stimulant medication -inverted parabolic response stimulant medication -linear dose response clonidine higher dose Dr A Vance
35 Useful medication approaches Mood dysregulation: irritability emotional salience stimulant medication SSRI TCA antipsychotic medication stimulant medication SSRI? TCA? Dr A Vance
36 Useful medication approaches Arousal regulation: physiological arousal habituation response clonidine benzodiazepines TCA antipsychotic medication clonidine benzodiazepines TCA? antipsychotic medication? Dr A Vance
37 Future directions - developmental stage dependent / independent risk and resilience factors determined - more specific psychological and medication treatments determined - more specific monitoring of these treatments determined Dr A Vance
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