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some significant part of we who are gathered here together are so drawn because of an abiding interest in stimulants.

At least part of that interest derives from what is called "ADD", "ADHD", and other variants. Whatever it is called, it beats

"You lazy undisciplined brat"

as a descriptive, which is decidedly unhelpful, and leads to no good end for anyone. Therefore, the following information is provided, with a very excellent multi-phasic reference at the end, for those who wish to read more. ============== Historical Perspective 1. In a representative outpatient medical practice, few conditions cause as much consternation and controversy as attention deficit-hyperactivity disorder (ADHD). Although recent depiction and bias in the mainstream media paints ADHD as a purely 21st-century sociologic entity, deficits in attention and focus have been described in medical literature dating back as far as the American Civil War.[1] The bulk of research and insight into the condition has traditionally centered on the pediatric and adolescent populations, yet the notion that ADHD could continue as a clinically significant disorder into adulthood was proposed in 1902, when George Sill theorized that problems with "moral control" typical of the ADHD child were, in most cases, chronic.[2] Studies suggesting a genetic basis for ADHD began to appear in the late 1960s and early 1970s, along with outcomes data confirming the persistence of childhood hyperactivity into the adult years.[2] With the publication of Hallowell and Ratey's Driven to Distraction in 1994,[3] adult ADHD emerged as a unique malady in its own right; suddenly, it was not considered taboo to suffer from an attentional deficit,

and adults began to present -- some self-referred, others sent in by loved ones or employers -- to their psychiatric and primary care physicians alike for assessment. Barriers to Adult Diagnosis Despite this shift in attitude, a significant number of obstacles in the evaluation of the adult with ADHD remain (Table 1). The lack of cohesion and consensus regarding the criteria necessary to establish the diagnosis is a major barrier; the current edition of the Diagnostic and Statistical Manual of Mental Disorders does not even recognize "adult ADHD" as its own clinical entity.[4] Ward, Wender, and Reimherr[5] published a set of criteria in 1993 that still stand today as the primary diagnostic measures for adult ADHD, and multiple other rating scales exist as well (Table 2). Even so, many physicians, especially in the primary care disciplines, often do not know where to find these scales or are unsure how to implement them into their practices. This lack of familiarity may be related to the generally low level of consideration that ADHD receives in many pediatric, family medicine, and internal medicine residencies. Furthermore, given the higher incidence of substance abuse as a comorbidity in adults with ADHD, there may be a general reluctance among medical professionals to prescribe stimulants, discouraging both the provider from taking on ADHD patients and the adult patient from bringing up his or her concerns related to ADHD symptoms.

Wonder why "SELF MEDICATION" is not referenced here" MY useage and pursuit of such ancillary medicaments as I perceived to alleviate MY symptomology/ was GREATLY REDUCED upon the arrival of CERTAIN BLUE MUNCHABLE PILLS (aka "adderall") into my extensive pharmacological inventory. So which came first? The disgusting abuse of illegal drugs, or the symptoms thus expunged?

Table 1. Barriers to Diagnosis of Attention Deficit-Hyperactivity Disorder in Adults No DSM criteria specifically for adult ADHD Physicians are not well-trained in the diagnostic process for adult ADHD General disbelief of ADHD as a clinical entity Patient embarrassment Reluctance to treat with controlled substances -- high incidence of substance abuse in ADHD patients Cross-over symptoms with comorbidities Table 2. Scales for Adult Attention Deficit-Hyperactivity Disorder in Adults[6] Symptom Scales Adult Self-Report Scale Copeland Symptom Checklist Brown ADD Scale Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADS)

Diagnostic Scales Conners' Adult ADHD Rating Scale (CAARS) Barkley's Current Symptoms Scale--Self-Report Form (Barkley scales are available in Attention-Deficit Hyperactivity Disorder: A Clinical Workbook, Second Edition; Brown ADD Scale Diagnostic Form

Kiddie-SADS Diagnostic Interview

Addressing Comorbidity in the Patient With Attention Deficit-Hyperactivity Disorder The issue of comorbidity is the most important hurdle to overcome in the evaluation of a patient with a possible attention deficit disorder. For purposes of this discussion, we define a comorbid condition as any other neuropsychiatric disorder that can mimic or masquerade as an attentional deficit. Many of these conditions share diagnostic criteria with ADHD -- for example, difficulty with impulse control is seen in both ADHD and bipolar disorder -but they are often not treated with the same pharmacologic or behavioral approaches as ADHD. Moreover, medication used to treat ADHD or one of its comorbidities may adversely affect or exacerbate the other condition. This is of great clinical importance, because ample evidence demonstrates that the child, adolescent, or adult who has ADHD and no other recognized concurrent psychiatric diagnosis is a clinical rarity. The results of the Multimodal Treatment Study of Children with AttentionDeficit/Hyperactivity Disorder, published in 1999 by the National Institute of Mental Health,[7] showed that only one-third of the children studied had ADHD as their sole psychiatric diagnosis, and in the adult population that number may drop as low as 14%.[8] The most commonly seen comorbid conditions are listed in Table 3, and they must be ruled in or out during the initial evaluation of the patient with a possible attentional deficit. The age of the patient may come into play here, because certain conditions are more commonly encountered in a specific demographic group; for example, oppositional-defiant disorder may be the most common clinical comorbidity in the pediatric age population, occurring in up to one third of cases (60% boys, 30% girls),[9,10] whereas substance abuse -- although increasing in a disturbingly higher number of children and adolescents -- remains primarily an adult concern.

Table 3. Common Attention Deficit-Hyperactivity Disorder Comorbidities Oppositional-defiant disorder

Conduct disorder Depression Anxiety Bipolar disorder Learning disabilities Movement disorders (tic, Tourette's) Substance abuse disorder

Attention Deficit-Hyperactivity Disorder and Comorbid Anxiety Of the comorbid disorders that affect both children and adults, however, there is no more important condition to consider than anxiety. According to recent data, anxiety affects 1 of every 6patients: 30% of women, 19% of men, and 4% of children, or almost 40 million in the population at large.[11] Generalized anxiety, characterized by a gradual onset that waxes and wanes, has the highest prevalence among the anxiety disorders. More specific types of anxiety disorders include panic disorder, social anxiety, specific phobias, and obsessive-compulsive disorder. Posttraumatic stress disorder, another type of specific anxiety, may be the most common disorder mimicking ADHD, particularly if the trauma stems from physical or sexual abuse.[11] ADHD with comorbid anxiety appears to become more prevalent with age and may reach as high as 50% in the adult population[12]; furthermore, some have suggested that ADHD coexisting with anxiety may represent a different subtype of the disorder than that of ADHD without this comorbidity.[13] The presence of comorbid anxiety in addition to ADHD has been shown to not only predict a poorer clinical outcome in general,[12] but also a less robust response to the stimulant dextroamphetamine,[14] one of the more commonly used medications for ADHD in adults and children.

For years, investigators have studied the effects of ADHD on the ability to efficiently recall and access previously learned information, known as "working memory." It should come as no surprise that attentionally impaired adults often note significant problems in this area, and recent research has indicated that this may be related more to the stress and strain they feel when engaging in activities that require intense mental effort than to the primary neurochemical deficiencies that are at the root of ADHD. Several studies have shown that patients with ADHD plus anxiety have a greater impairment in working memory than those with ADHD alone, and a recent study concluded that ADHD with comorbid anxiety was correlated with "greater cognitive and academic vulnerability" with respect to working memory than anxiety alone.[15] There appears to be a strong neurochemical basis for this: stress impairs the operation of the prefrontal cortex, the part of the central nervous system responsible for a number of critical functions including sustaining attention, focus, filtering of unimportant material, and processing sensory input. Furthermore, the biologic degradation of norepinephrine -- one of the primary neurochemicals responsible for alertness, arousal, and memory storage/retrieval[16] -- is augmented with stress.[17] As their anxiety increasingly interferes with cognitive function, patients with ADHD may have difficulties in social settings that can be misinterpreted as social phobia, further blurring the diagnostic boundaries between the 2 conditions.[18] Adults with ADHD and comorbid anxiety frequently talk about feeling overwhelmed, and they experience difficulty with self-esteem. The term "emotional dysregulation" has been used by Reimherr and colleagues to define a symptom complex characteristic of these adults that includes problems with temper, affective lability, and an inability to deal with stress.[19] In general, these individuals spend more time worrying and/or focusing on matters irrelevant to the task at hand than they do on completion of said tasks, which understandably leads to poorer execution and performance.[20] These issues can cause devastating long-term consequences, not only for the patient's emotional health, but also for physical well-being and longevity. Barkley has shown that individuals with ADHD have significantly poorer

health and a less healthy lifestyle than others in the general community, which, when combined with emotional dysregulation, may shorten life expectancy.[2

Pharmacotherapy in the Adult With Attention Deficit-Hyperactivity Disorder and Comorbid Anxiety 1. As physicians become more and more pressed for time in their offices, the evaluation of the adult with a potential attentional deficit is a challenge, notwithstanding the complexities of comorbid conditions. The use of instruments such as the Hamilton-A Anxiety Scale can be useful in diagnosing comorbidity, but may also fail to identify patients who do not meet formal criteria for an anxiety disorder yet are still impaired by the sensation of feeling anxious.[12] If a diagnosis of ADHD and comorbid anxiety is reached, the physician and patient have a mutual decision to make. In recent years, pharmacotherapy of ADHD in adults has become more sophisticated. Studies have confirmed that certain stimulants and nonstimulants improve core ADHD symptoms. They work by enhancing levels of dopamine and norepinephrine.[16,17]

only 3 agents have received US Food and Drug Administration (FDA) approval for use in adults: 2 stimulants, extended-release mixed amphetamine salts and dexmethylphenidate XR, and the nonstimulant atomoxetine.
Nonetheless, Although generally well-tolerated and supported by roughly 7 decades of data indicating long-term safety, historically the stimulant class of medications has been believed to exacerbate anxiety. Whether this is an issue of primary causation, the specific anxiety disorder involved, or an increase in the restlessness than can be seen as part and parcel of ADHD is controversial. Earlier studies in children with ADHD indicated that stimulants were less effective in those with comorbid anxiety and caused more side effects, but this has not been verified by more recent

research.[12] For example, a number of trials published by Spencer and colleagues did not show the stimulants to be anxiogenic.[12] It is also worth noting that evidence exists, both in published pediatric guidelines and anecdotal experience with adults, that patients with ADHD

and comorbid mood disorders who take stimulants see improvements in their attentional complaints merely by virtue of the perception that, even in some small way, they are "getting better."[21,22]

No Firm Guidelines for Adult Attention Deficit-Hyperactivity Disorder + Anxiety There are no unanimously accepted guidelines for the treatment of adults with ADHD and comorbid anxiety, but in the pediatric population, one published algorithm recommends treating a mood disorder first if that disorder is severe and then adding on a second medication to treat the attentional deficit, if necessary.[21] Combining stimulants with other medications, such as buspirone or selective serotonin reuptake inhibitor (SSRI) antidepressants, which are used to treat anxiety, is a common tactic in clinical practice, although the literature does not universally endorse this. The use of these adjunctive medications may be off-label in some age groups. Moreover, Abikoff and colleagues have shown that the addition of the SSRI fluvoxamine was not superior to placebo for the treatment of comorbid anxiety in a sample of children with ADHD who were taking stimulants.[23] In a study of adults with ADHD and a comorbid mood disorder, the Adult ADHD Research group found that the addition of the SSRI paroxetine to dextroamphetamine was not better than either agent as monotherapy.[14]

Evidence-based Alternatives A relatively newer treatment option is atomoxetine, a selective norepinephrine reuptake inhibitor that is currently the only nonstimulant approved for use by the FDA in children, adolescents, and adults with ADHD. Since its introduction in the early part of the decade, atomoxetine has been looked at in a number of trials involving patients with ADHD and comorbid anxiety, and along with a clinical improvement in ADHD rating scores, it has also been found to have a benefit on emotional dysregulation in adults.

[19] In the pediatric population, atomoxetine improves ADHD symptoms without exacerbating anxiety.[24] Atomoxetine monotherapy may therefore be a viable first-line choice for ADHD, particularly when a comorbid anxiety disorder exists.[2,21] If monotherapy with either a stimulant or atomoxetine is not effective, the physician is left with few other evidence-based options. Combination therapy does pose certain risks; as the trial by Weiss and Hechtman indicated, couse of stimulants and SSRIs may increase adverse events,[14] and atomoxetine must be used cautiously with any medication that is an inhibitor of the cytochrome P450 2D6 enzyme. Other medications that have been studied and/or used for adults with ADHD, include bupropion,[25] modafinil,[26] and tricyclic antidepressants.[27] The use of these agents for the treatment of ADHD in adults is considered off-label, is not approved by the FDA, and has not demonstrated any proven benefit for comorbid anxiety. Thus, their use should be considered only on a case-by-case basis. Non-medication Options for the Adult With Attention Deficit-Hyperactivity Disorder and Comorbid Anxiety Nonpharmacologic interventions are an important component of any ADHD treatment plan, particularly when a comorbidity such as anxiety is present. Organizational skill-building is critical to reduce the anxiety that adults with ADHD often feel when performing even simple, mundane tasks such as paying bills or helping their children with their homework. To successfully treat a disorder, however, physicians and patients first have to acknowledge the presence of the disorder, and the most critical step in dealing with anxiety in the adult with ADHD may be the act of ruling it in or

out. Merely establishing the diagnosis is therapeutic for some patients, but when intervention is deemed necessary, randomized clinical trials have indicated that cognitive behavioral therapy (CBT) is an appropriate step. CBT is likely to be beneficial in the treatment of anxiety disorders,[28] and Safren has shown that CBT is superior to medication alone in reducing core ADHD symptoms.[29] Adults can pursue this type of therapy with a qualified counselor or on their own through self-mastery programs, and primary care providers should invest the time to educate their patients about these options. Final Comment The face of ADHD is an ever-changing one, presenting differently at age 7 than it will at age 17 or 37. As more adults ask to be evaluated for attentional deficits by their family doctors or internists, the diagnosis and treatment of ADHD has moved out of the exclusive realm of the specialist in psychiatry or neurology. A number of factors have caused primary care providers to be reluctant to get involved with the ADHD patient, including lack of in-depth training, little familiarity with the condition, and discomfort with prescribing controlled substances. History suggests that the majority of patients with ADHD can be treated successfully, and many therapeutic options are available for the physician to choose, from the pharmacologic (stimulants, atomoxetine) to the behavioral (skill-building, counseling, cognitive therapy). In the final analysis, however, clinical success begins with an appreciation for comorbidities like anxiety that can co-exist with, or confuse, the diagnosis. Paying more attention to the complexities of attentional deficits is critical to ensure satisfactory outcomes for all concerned. This activity is supported by an independent educational grant from Eli Lilly. ==================

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions

The questions on the back page are designed to stimulate dialogue between you and your patients and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD). Description: The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions. Instructions: Symptoms 1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X in the box that most closely represents the frequency of occurrence of each of the symptoms. 2. Score Part A. If four or more marks appear in the darkly shaded boxes within Part A then the patient has symptoms highly consistent with ADHD in adults and further investigation is warranted. 3. The frequency scores on Part B provide additional cues and can serve as further probes into the patients symptoms. Pay particular attention to marks appearing in the dark shaded boxes. The frequency-based response is more sensitive with certain questions. No total score or diagnostic likelihood is utilized for the twelve questions. It has been found that the six questions in Part A are the most predictive of the disorder and are best for use as a screening instrument.

Impairments 1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment associated with the symptom. 2. Consider work/school, social and family settings. 3. Symptom frequency is often associated with symptom severity, therefore the Symptom Checklist may also aid in the assessment of impairments. If your patients have frequent symptoms, you may want to ask them to describe how these problems have affected the ability to work, take care of things at home, or get along with other people such as their spouse/significant other.

History 1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have ADHD need not have been formally diagnosed in childhood. In evaluating a patients history, look for evidence of early-appearing and long-standing problems with attention or self-control. Some significant symptoms should have been present in childhood, but full symptomology is not necessary.

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during todays appointment.

Patient Name Todays Date 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When youre in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations

when turn taking is required? 18. How often do you interrupt others when they are busy? Part B Part A When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

Research suggests that the symptoms of ADHD can persist into adulthood, having a significant impact on the relationships, careers, and even the personal safety of your patients who may suffer from it.1-4 Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults.

The Value of Screening for Adults With ADHD

The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included the following team of psychiatrists and researchers: Lenard Adler, MD Associate Professor of Psychiatry and Neurology New York University Medical School Ronald C. Kessler, PhD Professor, Department of Health Care Policy Harvard Medical School Thomas Spencer, MD Associate Professor of Psychiatry Harvard Medical School As a healthcare professional, you can use the ASRS v1.1 as a tool to help screen for ADHD in adult patients. Insights gained through this

screening may suggest the need for a more in-depth clinician interview. The questions in the ASRS v1.1 are consistent with DSMIV criteria and address the manifestations of ADHD symptoms in adults. Content of the questionnaire also reflects the importance that DSM-IV places on symptoms, impairments, and history for a correct diagnosis.4 The checklist takes about 5 minutes to complete and can provide information that is critical to supplement the diagnostic process. References: 1. Schweitzer JB, et al. Med Clin North Am. 2001;85(3):10-11, 757777. 2. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. 1998. 3. Biederman J, et al. Am J Psychiatry.1993;150:1792-1798. 4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association. 2000: 85-93

Copeland Symptom Checklist for Attention Deficit Disorders - Adult Version 1. $50.00 0151 Designed to help health care professionals assess whether an adult has symptoms characteristic of attention deficit disorder, to what degree, and which areas of functioning are most seriously affected. The checklist covers eight areas, including: Inattention/Distractibility, Impulsivity, Activity Level Problems, Noncompliance, Underachievement/Disorganization/Learning Problems, Emotional Difficulties, Poor Peer Relations, and Impaired Family Relationships. Scoring instructions included.

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