Managing people with ADHD and psychosis. Peter Mason Consultant Psychiatrist Adult ADHD Service

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1 Managing people with ADHD and psychosis Peter Mason Consultant Psychiatrist Adult ADHD Service

2 Mr A Bipolar affective disorder (no insight) On Lithium and Quetiapine ADHD (late diagnosis age 44)

3 Mr A Bipolar affective disorder (no insight) On Lithium and Quetiapine ADHD (late diagnosis age 44) Treatment with Methylphenidate lead to rapid deterioration in mental state with paranoid delusions

4 Core symptoms of ADHD Inattention Distractible Difficulty maintaining attention / concentrating Not listening when spoken to Difficulty organising / following instructions Avoiding activities involving mental effort Forgetful

5 Core symptoms of ADHD Hyperactivity Fidgety Getting up when should be seated Running about when should be still Noisy doing leisure activities Often on the go as if driven by a motor Talking excessively

6 Core symptoms of ADHD Impulsivity Interrupting or intruding on others Blurting out answers to questions Trouble waiting in turn Risk taking Spending Fighting

7 Dysexecutive Syndrome Key features: Distractibility Impulsiveness Disinhibition Impaired ability to plan Apathy & inertia or euphoria Social insensitivity Lack of insight

8 Brain Imaging Findings consistent with: Neurodevelopmental abnormalitites in frontostriatal neural circuits Altered activity in sub-cortical dopamine pathways

9 Genetics of ADHD Over 50 different genes implicated in ADHD. Dopamine receptor genes appear to be the most important (especially dopamine transporter).

10 Dopamine transmission

11 Dopamine hypothesis of schizophrenia Different factors (aetiologies) result in striatal dopamine dysregulation Dopamine dysregulation most likely at the presynaptic dopamine control level. Dopamine dysregulation hypothesised to alter the appraisal of stimuli. Howes & Kapur (2009)

12 Stimulants and Psychosis Experimental studies show that a single dose of a stimulant drug can produce a brief increase in psychosis ratings in 50 70% of participants with schizophrenia and preexisting acute psychotic symptoms Curran, Byrappa & McBride (2004)

13 Mr X 26 year old single man Schizophrenia diagnosed at 19 (in prison) Auditory hallucinations Persecutory delusions Thought insertion Treatment resistant (Clozapine, Amisulpiride & Valproate)

14 Mr X continued ADHD diagnosed in adolescence Ritalin for a few months age 15 (stopped when imprisoned) Extensive forensic history - assaults

15 Mr X continued ADHD symptoms: Poor concentration Disorganisation Fidgety Impulsive Aggressive

16 Mr X continued Good response to Methylphenidate (Concerta XL) Calmer & less demanding Able to participate in psychology and education

17 Mr X continued Good response to Methylphenidate (Concerta XL) Calmer & less demanding Able to participate in psychology and education No more psychotic symptoms!

18 Miss Y 27 year old single mother of 2 Schizophrenia diagnosed at age 16 3 rd person auditory hallucinations Delusion of metal plate in skull Antipsychotics reduced intensity of symptoms Alcohol & stress exacerbated symptoms Cocaine, ecstasy & amphetamines little effect

19 Miss Y continued ADHD symptoms: Poor concentration Disorganisation Fidgety Impulsive Aggressive

20 Miss Y continued Rapid response to addition of Methylphenidate (Concerta XL) Concentration better Calmer & less impulsive

21 Miss Y continued Rapid response to addition of Methylphenidate (Concerta XL) Concentration better Calmer & less impulsive Auditory hallucinations disappeared!

22 Minimal Brain Dysfunction & Case report: Schizophrenia 23 year old chronic paranoid schizophrenia Delusions of reference Auditory hallucinations Childhood history of MBD On-going symptoms of MBD Anxiety Huey et al (1978)

23 Minimal Brain Dysfunction & Schizophrenia Intravenous methylphenidate Hallucinations faded into babbling & white noise Less anxious, calmer & more confident Huey et al (1978)

24 ADHD and Psychosis Huey et al; 1978: 1 adult case report Bellak et al; 1987: 3 adult case reports Pine et al; 1993: 2 adult case reports Tossell et al; 2004: 5 child case reports

25 ADD Psychosis A separate diagnostic category Rare or no hallucinations Concrete thinking (not FTD) Soft neurological signs Lack of response to neuroleptics Favourable response to stimulants Bellak, Kay & Opler (1987)

26 Frontal lobe dysfunction Schizophrenia: Reduced frontal blood flow Psychometrics imply prefrontal cortical dysfunction Impaired ability to perfuse frontal lobes in tests requiring prefrontal activation Opler, Frank & Ramirez (2001)

27 Psychostimulants ameliorate both attentional deficit and psychotic symptoms by increasing perfusion to the frontal lobes Neuroleptic refractory adult patients with psychosis and a history of ADD should receive a therapeutic trial of psychostimulants Opler, Frank & Ramirez (2001)

28 What about Dopamine? it is not the mere availability of dopamine in the synaptic cleft that is the primary mode of action for psychostimulant drugs, but rather their regulatory effects on post-synaptic cell firing Huber et al (2007)

29 Stress-vulnerability model of schizophrenia Vulnerability: Genetics Neurodevelopment etc. Stress: Relationships Bereavement Money etc.

30 Core symptoms of ADHD Inattention Hyperactivity Impulsivity

31 Prevalence Meta-analysis of international studies estimated prevalence of ADHD in adults to be 2.5%. Prevalence of ADHD in schizophrenia / treatment resistant schizophrenia not established

32 Drug treatment of ADHD Atomoxetine: Relatively safe in psychosis Can take months to work Methylphenidate: Contraindicated in psychosis Quick response Dexamfetamine

33 Mr A Bipolar affective disorder (no insight) On Lithium and Quetiapine ADHD (late diagnosis age 44) Treatment with Methylphenidate lead to rapid deterioration in mental state with paranoid delusions

34 Mr A Remains on Methylphenidate, Lithium and a higher dose of Quetiapine. No longer on CPA. Reduced support. Scoring > 90% Open University history degree and contemplating a career in teaching.

35 Neuroleptic refractory adult patients with psychosis and a history of ADD should receive a therapeutic trial of psychostimulants Opler, Frank & Ramirez (2001)

Interview for Adult ADHD (Parent or Adult Questionnaire)

Interview for Adult ADHD (Parent or Adult Questionnaire) (client s name here) is undergoing evaluation for Attention Deficit Hyperactivity Disorder (ADHD). You have been identified as someone who could