Adult ADHD. Norm Costigan, M.D.

Transcription

1 Adult ADHD Norm Costigan, M.D. Department of Psychiatry, Alberta Health Services Clinical Professor, University of Alberta Faculties of Family Medicine and Psychiatry 1 1

2 Prevalence of ADHD Children Adults Ranges from 3-10% Only 45-72% receive treatment 4.4% Only ~ 10% receive treatment 2 Wender et al. NY Acad Sci, 2001; Wender H. Arch Pediatr Adolesc Med, 2002; Kessler et al. J Environ Med,

3 ADHD Grows Up Until recently, research focus: children Little known about ADULT ADHD: children would grow out of it 3 Weiss et al. J Psych Pract,

4 ADHD Grows Up Longitudinal studies now show: when children with ADHD reached adulthood > 65% reported ADHD symptoms significant enough to cause impairment 4 Weiss et al. J Psych Pract,

5 Course of the Disorder Hyperactivity Impulsivity Inattention Time 5 5

6 ADHD in the Spectrum of Psychiatric disease Adult ADHD is: common and often produces serious impairment. 12 month prevalence data (n=3,199): Major Depressive disorder 7.8 % Social phobias 7.8 % Substance use disorder 5.6 % ADHD 4.4 % PTSD 3.3 % Panic Disorder 3.1 % Bipolar disorder 3.1 % 6 Kessler et al. Am J Psych,

7 Adult ADHD: Symptoms Adult vs. child symptomatology Inattention: more frequent than hyperactivity Hyperactivity: often internalized as feelings of restlessness and tension Impulsivity: less common - consequences more enduring Executive dysfunction problems Weiss et al. J Psych Pract, 2002; Resnick. J Clin Psychology,

8 Presentation of ADHD Symptoms Children Inattentive Doesn t listen Can t organize Hyperactivity Squirms/Fidgets Runs/Climbs excessively Adults Inattentive Difficulty completing tasks Poor time management Hyperactivity Inner restlessness Selects active jobs Impulsivity Blurts out answers Can t wait turn Impulsivity Impulsive job changes Drives too fast, has traffic accidents 8 Adapted from Adler & Cohen. Psych Clin North Am,

9 Consequences of Untreated Adult ADHD: (Long-Term Implications) 9 9

10 Functional Impairment in ADHD Adults Adult ADHD patients: Lower education level Less annual income More job changes Higher rates of divorce Increased likelihood of being arrested Less satisfaction with family, social & professional lives 10 Biederman et al. J Clin Psych, 2006; Biederman et al. Psychol Med, 2006; Fischer et al. J Abnorm Child Psychol,

11 Relationship Impairments ADHD (N=500) Controls (N=501) Good relationship with parents * Fit in with peers * Ever divorced * Ever separated 5 10 * Stable relationship with partner * % of Subjects 11 Biederman et al. J Clin Psych,

12 Functional Impairments Repeat a grade ADHD < high school 0 32 Controls Teen pregnancy 4 38 STD 4 17 Substance abuse Accident prone Serious car accident Arrested Subjects (%) 12 Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. Third Edition, 2006 Wilens TE. Psychiatric Clin North Am, 2004; Biederman et al. J Clin Psych,

13 Adult ADHD Co-morbidities Co-morbidity: 70-87% Most frequent: depression, anxiety, ODD, CD, antisocial personality disorder (not all studies have shown risk of anxiety or depression) Substance abuse: Most common: alcohol & cannabis Much higher risk in for SUD in: untreated patients (3-4x risk) patients with co-morbid CD or bipolar disorder Higher rates of smoking Asherson. Exp Rev Neurotherap, 2005; Dodson. J Clin Psychology, 2005; Weiss et al. J Psych Pract, 2002; Kollins et al. Arch Gen Psych, 2005; McGough et al. Am J Psych, 2005; Wilens. Psychatr Clin N Amer, 2004; Biederman, J Clin 13 Psych, 2003; Bagwell et al. J Emot Behav Disord,

14 ADHD in Other Disorders Major depression 1 16% Bipolar disorder 2 9.5% Panic Disorder % Substance abuse 4 Up to 71% Obesity % BMI > % Prison inmates 6 25% 1. Alpert et al. Psychiatry Res, 1996; 2. Nierenberg et al. Biol Psych, 2005; 3. Fones et al. J Affect Disord, 2000; 4. Wilens et al. Psych Clin North Am, 2004; 5. Altfas JR. BMC Psychiatry, 2002; 6. Eyestone et al. Bull 14 Am Acad Psychiatry Law,

15 ADHD and Driving Drivers with ADHD: Significantly more drive without a license Greater number have license revoked/suspended» 48 % vs 9 % controls 3x more likely to have repeated violations (>3) 2-4 x to experience an MVA 4x to be found at fault 7x be involved in multiple MVAs (>2) 3x to suffer bodily injures from MVAs Barkley et al. Pediatrics, 1993 Barkley et al. Pediatrics, 1996 Murphy et al. Compr Psych Cox et al. J Nerv Ment Dis

16 ADHD vs. Adult ADD ADHD is the term currently used in DSM-5 diagnostic criteria ADD, with or without hyperactivity, is the older term originating in DSM-III 16 16

17 Diagnosis Adult ADHD is diagnosed on three components: Symptoms e.g. Lack of focus, disorganization, restlessness, losing things Impairment e.g. Difficulties at work, difficulties at home, difficulties in personal relationships History e.g. Must have had their symptoms prior to age seven, these must have continued for at least six months 17 17

18 DSM-5 Diagnostic Criteria for ADHD A. Either (1) or (2): 1. Six (or more) of the following symptoms of inattention have persisted for at least six months. Inattention a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b. Often has difficulty sustaining attention in tasks or play activities c. Often does not seem to listen when spoken to directly d. Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) 18 18

19 DSM-5 Diagnostic Criteria for ADHD Inattention continued: e. Often has difficulty organizing tasks and activities f. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) g. Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools) h. Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities 19 19

20 DSM-5 Diagnostic Criteria for ADHD 2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months. Hyperactivity a. Often fidgets with hands or feet or squirms in seat b. Often leaves seat in classroom or in other situations in which remaining seated is expected c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) 20 20

21 DSM-5 Diagnostic Criteria for ADHD Hyperactivity continued d. Often has difficulty playing or engaging in leisure activities quietly e. Is often on the go or often acts as if driven by a motor f. Often talks excessively Impulsivity g. Often blurts out answers before questions have been completed h. Often has difficulty awaiting turn I. Often interrupts or intrudes on others (e.g. butts into conversations or games) 21 21

22 DSM-5 Diagnostic Criteria for ADHD B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before seven years of age. C. Some impairment from the symptoms is present in two or more settings (e.g. at school, work, and home) D. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning

23 DSM-5 Coding Attention Deficit Hyperactivity Disorder, Combined Type Attention Deficit Hyperactivity Disorder, predominantly inattentive type Attention Deficit Hyperactivity Disorder, predominantly hyperactive impulsive type Attention Deficit Hyperactivity Disorder, not otherwise specified 23 23

24 Adult ADHD A neurological brain disorder manifesting as a persistent pattern of inattention and / or hyperactivity impulsivity that it is more frequent and severe than is typically observed About 60% of children with ADHD continue to have symptoms into adulthood; although, the disorder manifests differently as hyperactivity tends to diminish 24 24

25 Genetics Attention disorders often run in families therefore there are likely to be genetic influences Studies indicate that 25% of the close relatives in the families of ADHD children also have ADHD The rate in the general population is about 5% Twin studies show a strong genetic influence 25 25

26 Social Factors Child Rearing Methods There is little compelling evidence at this time that ADHD can arise purely from social factors or child rearing methods Most substantiated causes appear to fall in the realm of neurobiology and genetics Environmental factors may influence the severity of the disorder and especially the degree of impairment and suffering These factors do not seem to give rise to the condition of themselves 26 26

27 Environmental Agents Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and the risk for ADHD As a precaution it is best during pregnancy to refrain from both cigarettes and alcohol High levels of lead in the bodies of young preschool children may be associated with a higher risk of ADHD As lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is less prevalent 27 27

28 Brain Injury Some children who have suffered accidents leading to brain injury may show some signs of behaviour similar to ADHD: only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury 28 28

29 Food Additives and Sugar The National Institute of Health in 1982 found that dietary restrictions helped about 5% of children with ADHD, mostly young children who had food allergies A number of double blind studies have been conducted in children using sugar, aspartame, and placebo. These studies repeatedly show no significant effects of sugar on behaviour, hyperactivity or inattentiveness

30 Multi Modal Treatment Study of Children with ADHD NIMH funded Most intensive study ever undertaken for evaluating ADHD Compared four groups: 1. Medication management 2. Behavioral treatment 3. Combination of 1 and 2 4. Routine community care 30 30

31 Multi Modal Treatment Study of Children with ADHD Results: Long term combination treatments and medication management alone were superior In some areas anxiety, academic performance, oppositionality, parentchild relations, and social skills the combined treatment was usually superior Children in the combined group could usually be successfully treated with lower doses of medication 31 31

32 Diagnosing ADHD in an Adult Not considered an easy task Often a parent will recognize symptoms in himself / herself when their child is diagnosed Adults seeking help for depression or anxiety may discover their root cause is ADHD. May have a history of school failures of problems at work and are often involved in frequent automobile accidents 32 32

33 Differential Diagnosis in Adults Major Depression Features shared with ADHD: Subjective report reported poor concentration, attention, and memory: Difficulty with task completion and Distinctive features: Enduring dysphoric mood or anhedonia: Sleep and appetite disturbance 33 33

34 Differential Diagnosis in Adults Bipolar Disorder Features shared with ADHD: Hyperactivity, difficulty with maintaining attention and focus; mood swings Distinctive features: Enduring dysphoric or euphoric mood; insomnia; delusions 34 34

35 Differential Diagnosis in Adults Generalized Anxiety Features shared with ADHD: Fidgetiness, difficulty concentrating Distinctive Features: exaggerated apprehension and worries; somatic symptoms of anxiety 35 35

36 Differential Diagnosis in Adults Substance Abuse or Dependence Features shared with ADHD: Difficulties with attention, concentration and memory; mood swings Distinctive Features: Pathological pattern of substance use with social consequences; phsyiologic and psychological tolerance and withdrawal 36 36

37 Differential Diagnosis in Adults Personality Disorders Particularly Borderline and Anti-Social Personality Features shared with ADHD: Impulsivity; affective lability Distinctive Features: Arrest history (anti-social personality); repeated self endurious or suicidal behaviour (borderline personality); lack of recognition that behaviour is selfdefeating 37 37

38 Treatment Considerations Pros: 80% of patients experience relief Stimulants seem to decrease impulsiveness and sharpen focus Stimulants can reduce hyperactivity. Patients may feel calmer and more able to sit still When drug therapy is beneficial it can improve self-confidence and self-esteem and empower the patient Stimulants allow for more organized thinking and therefore more organized lives Stimulants allow patient s internal thoughts to be organized and in turn their external lives reflect these positive changes 38 38

39 Treatment Considerations Cons: 20% of people will not find relief from drug therapy A regimented pill schedule is often difficult to maintain Drug therapy does not cure ADHD and patients may require medication for many years Side effects: most common side effects are sleep disturbances and weight loss. Adults must also be concerned about high blood pressure, which may aggravate pre-existing cardiac problems, increased risk of heart attacks and strokes Lack of studies regarding long term effects of drug therapy Potential for drug abuse 39 39

40 Short Acting: Treatment with Stimulants Amphetamines Dexedrine Methylphenidates Ritalin Intermediate Acting: Dexedrine SR Ritalin SR 40 40

41 Long Acting Stimulants Long acting Methylphenidate: Concerta Mixed amphetamine salts: Adderrall XR These long acting formulations are equally efficacious as a matched multiple dose using immediate release forms and can be used initially barring no immediate obstacles to the family such as cost or availability The new or long acting mechanisms make diversion of the stimulant for substance abuse far less likely Compliance is anticipated to be better and these formulations simplify dosing schedules 41 41

42 Summery ADHD affects 40 60% of adults who had ADHD in childhood Accurate diagnosis is challenging and requires attention to early development and symptoms of inattention, distractibility, impulsivity, emotional lability 42 42

43 Summery There is significant overlap between the symptoms of Adult ADHD and common psychiatric conditions such as depression and substance abuse, anxiety or panic attacks, side effects of prescription or over the counter medicines and herbal medicines, thyroid problems or other hormone problems, alcoholism or street drug use and exposure to lead Most stimulant and non-stimulant drugs may be effective Cognitive behavioral skills and training in psychotherapy are useful adjunct to 43 pharmacotherapy 43

44 The End 44 44