Impact of Unrecognized ADHD on Treatment of Anxiety & Depression

Transcription

1 Impact of Unrecognized ADHD on Treatment of Anxiety & Depression Thomas E. Brown, PhD Associate Director, Yale Clinic for Attention and Related Disorders Department of Psychiatry Yale Medical School

2 Psychiatric Comorbidities in adults with ADHD (prev 12 mos) ADHD Prevalence Other disorder in those with: in those with ADHD Any mood 13.1% 38.3% Any anxiety Any substance Intermittent Explo Many with ADHD have anxiety, mood or other comorbid disorder which may be more noticeable than their ADHD. 1 ( 1 Kessler, et al. 2006)

3 Comorbidity of ADHD in Children n=61k, ages 6-17 yrs (Larson, et al, 2011) Disorder ADHD% Non-ADHD% Conduct Disorder Anxiety Depression ADHD prevalence = 8.2% No. of Comorbid Disorders: 33% = 1, 16% = 2, 18% = 3 or more

4 Overview 1. Changes in understanding ADHD 2. Changes in understanding interaction of emotion & cognition 3. How ADHD may impact other disorders 4. Implications for dx and treatment

5 1. Changes in Understanding ADHD OLD: ADHD = disruptive behavior disorder of childhood NEW: ADHD = developmental impairments of brain s selfmanagement system-exec function

6 Executive Functions Wide range of central control processes of the brain Connect, prioritize, and integrate cognitive functions moment by moment Like conductor of a symphony orchestra TE Brown, Yale Medical School, 2013

7 Will you do it and, if so, how and when? (Lezak, 2004) Will you do it? Motivation/Activation How will you do it? Planning/Organizing When? Timing/Remembering TE Brown, Yale Medical School, 2013

8 Brown s Model of Executive Functions Impaired in ADHD Executive Functions Organizing, prioritizing, and activating to work Focusing, sustaining focus, and shifting focus to tasks Regulating alertness, sustaining effort, and processing speed Managing frustration and modulating emotions Utilizing working memory and accessing recall Monitoring and selfregulating action Activation Focus Effort Emotion Memory Action Brown TE. Manual for Attention Deficit Disorder Scales for Children and Adolescents; 2001.

9 Characteristics of ADHD Symptoms Dimensional, not all-or-nothing Everyone sometimes has some impairments in these functions; in ADHD: chronic, severe impairment Situational variability: If I m interested Most persons with ADHD have a few activities where ADHD impairments are absent ADHD looks like willpower problem, but it isn t! T.Brown, Attention Deficit Disorder: The Unfocused Mind in Children & Adults (2005)

10 The Mystery of ADHD: Situational Variability of Symptoms Why focus for this, but not that? If it really interests me (attraction) Why focus then, but not now? If I feel the gun to my head (fear) TE Brown, Ph.D., Yale Medical School

11 2 hypotheses re: motivation in ADHD Willpower vs Erectile Dysfunction of the Mind TE Brown, Ph.D., Yale Medical School

12 A Working Definition of ADHD (TEBrown, 2013) a complex syndrome of developmental impairments of executive functions, the self-management system of the brain, a system of mostly unconscious operations. These impairments are situationally-specific, chronic, and significantly interfere with functioning in many aspects of the person s daily life.

13 2. Changes in Understanding Emotion/Cognition OLD: Cognition is separate from emotions NEW: cognition and emotions are dynamically intertwined to guide our getting turned on or turned off by each perception, thought or task.

14 Cognition & Emotion are Integrated in learning history of each individual Emotion and cognition cannot be dissociated in the brain affective significance determines how the amygdala helps separate the significant from the mundane (L. Pessoa, 2013) Strictly speaking, there is no cognition without affect and emotion. (J. Fuster, 2008) All information processing is emotional emotion is the energy level that drives, organizes, amplifies and attenuates cognitive activity. (K. Dodge, 1991) TE Brown, Ph.D., Yale Medical School

15 Emotion Often Operates Uncsly the emotional signal can operate totally under the radar of consciousness. It can produce alterations in working memory, attention and reasoning the individual may not ever be cognizant of this covert operation. Antonio Damasio (2003)

16 How does brain determine what to ignore or attend to, to do or not do now? Each perception, thought or task is instantly screened by the brain s google search that pulls up relevant, usually unconscious memories throughout cortex; these compete to activate approach, avoidance and/or disinterest TE Brown, Ph.D., Yale Medical School

17 google search to guide responses how does the brain do it? Working memory is brain s search engine---fast, mostly uncs Response to any stimulus is shaped by search of relevant memories each of which is infused with emotion(s) Working memory draws on memories of past to anticipate what s likely to happen (+/-) if?

18 Amygdala is a major hub for connecting perceptions, thoughts, images to rest of the cortex Amygdala outputs to 64 of 72 regions In cortex. More recent studies show 1K separate cortical & subcortical pathways. Amygdala Schematic Graph of Amygdala Output by Young, et all. (1994) (Petrovich, et. al. 2001)

19 Output of Google Search The rapid-fire calculus of the amygdala and related networks sorts competing priorities emergent from the individual s learning history to mobilize, shape or defer action. Output from the amygdala reaching multiple brain regions quickly alters functional connectivity that activates (or doesn t) both body and brain. TE Brown, Ph.D., Yale Medical School

20 Amygdala s googling is filtered for context Amygdala responses are strongly context dependent Amygdala flexibly integrates stimulus valence with current goals, motivations, and contextual demands. Attar, H. et al (2010) TE Brown, Ph.D., Yale Medical School

21 Context Matters! Where we are and who we re with shapes which of our emotions are most intense in the moment: A clinical example: Would you like a cookie? TE Brown, Ph.D., Yale Medical School

22 Emotions May Shift as Context Shifts A student who works hard to get every term paper in on time may suddenly not care about a paper because his girlfriend broke up with him and is dating someone else. A student whose interest in completing papers is generally lukewarm may suddenly intensify interest and work hard on paper so he can maintain eligibility to stay on his team.

23 Bottom-Up Emotions arise from biological processes based on appraisal of perceptions ********************** each child is born with a profile of temperamental biases that creates initial tendencies to be vocal or quiet, vigilant or relaxed, irritable or smiling, energetic or lethargic with regard to particular events or situations 1 ( 1 J. Kagan, 2010)

24 Top-Down Executive Functions Process Memories In ways which can bias attention: to intensify to modulate AND/OR the way any given stimuli are appraised and responded to

25 A Dynamic Model Continuous Multi-Modal Scanning: of perceptions, sensations, thoughts, imaginings. To Detect: Differences from what is expected (dangers, frustrations, rewards) Identify: Search personal files of memories for anything relevant for me. Prioritize: according to how dangerous, frustrating, rewarding, conflicting Respond: by engaging, avoiding, monitoring, or ignoring Feedback: monitor & reappraise, continue or drop

26 Continuous Multi-Modal Scanning: Of perceptions, sensations, thoughts, imaginings

27 To Detect: Differences from what is expected (rewards dangers, frustrations)???

28 Identify: What is it? Search personal files of memories for anything relevant for me at this time.

29 Prioritize: Re: According to how dangerous, frustrating, rewarding, or conflicting it might be.

30 Respond: By engaging, avoiding, monitoring, or ignoring

31 A Dynamic Model Continuous Multi-Modal Scanning: of perceptions, sensations, thoughts, imaginings. To Detect: Differences from what is expected (dangers, frustrations, rewards) Identify: Search personal files of memories for anything relevant for me. Prioritize: according to how dangerous, frustrating, rewarding, conflicting Respond: by engaging, avoiding, monitoring, or ignoring Feedback: monitor & reappraise, continue or drop

32 3. How ADHD May Impact Other Disorders without basic attention and working memory there is no prospect of coherent mental activity (1) attention serves all the other functions. (2) Exec Functions are the operating system of the mind 1 Damasio (1994); 2 Fuster (2003)

33 In the clinic Patients who seek assessment and treatment for anxiety and/or depressive problems May have impairments due to excessive bottom-up intensity or ADHD-related problems with top-down modulation of those emotions---or both

34 3 ways persons with ADHD are likely to have problems with managing emotions 1. Difficulty with Working Memory, keeping multiple bits of info in mind, (flooding). 2. Difficulty with shifting focus, attentional bias (telescope). 3. Prioritizing for Present Moment/Context and Larger/Future contexts

35 Flooding While flooded with one emotion, persons with ADHD tend to forget about other relevant facts or emotions e.g. may forget their love & wish to protect the person friend, parent, child, co-worker who frustrated or angered them and say or do things that are too hurtful

36 Stuck in the Now Some with ADHD report that they often get stuck in the concerns of the moment and lose sight of the bigger picture, the longer term. e.g. Impulsive purchase using funds needed for a more important upcoming expense

37 Hyperfocus can block the bigger picture Focused too intensely on one goal or task, you may forget other goals you have or how actions of the moment may affect your bigger picture like one who is watching a basketball game through a telescope, you may miss other relevant aspects of the situation

38 Clinical Assessments Clinicians should know how to recognize and routinely screen for ADHD in every diagnostic eval Partial response, refractory sx, or patient non-compliance with usual tx for other disorders may be related to unrecognized ADHD (Barkley & Brown, 2008)

39 Treatments Most medications for anxiety or depression are designed to impact bottom-up processes Cognitive behavioral treatment may strengthen top-down control Stimulant medications used for ADHD may help to improve topdown control with or without usual meds for anxiety or depression

40 Reported Benefits of ADHD meds for treating anxiety & mood problems improved emotional lability as well as core ADHD sx in children improved depressive sx in MDD adults who failed SSRI trial improved stable bipolar pts as addon to their usual meds Adding stim reduced anxiety sx in pts unresponsive to SSRI alone. 1 ( 1 Sinita & Coghill, 2014)

41 Potential Risks of Treating Anxiety or Depression with Stimulants May increase anxiety May intensify depressive sx (rebound?) Often those problems are doserelated (Stims don t follow mg/kg!)

42 Key Points ADHD is developmental impairment of executive functions (EF) EF play important role in modulating emotions Anx/depressive disorders may be complicated by ADHD-related EF impairments Meds for ADHD may improve pt s anxiety or depressive disorders

43 Books by Thomas E. Brown, Ph.D. ( Smart but Stuck: Emotions in Teens and Adults with ADHD 2014 A New Understanding of ADHD in Children and Adults: Executive Function Impairments 2013 ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults 2009 Attention Deficit Disorder: The Unfocused Mind in Children and Adults