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Adult ADHD (Final script from Dr Netto 28-2-2019)

Case report

It was a rude shock to find myself being manhandled and forcefully brought to the police station.
My parents were urgently summoned. I knew that my violent temper outbursts and mood swings
had caused it again. I had severely injured someone in a fight. He stood there before me and the
police bleeding profusely. It was frightening to see the scared look on my parents faces when they
arrived and the police team staring & interrogating me.

It all began when I was a child. Life has never been easy for me. I was a bright student, but my
teachers said I never performed up to my potential. My life took a turn for the worse when my
grades started falling in high school. I was taken to a Child psychiatrist who started me on
medication. I took it for some time. I felt much better so I gradually discontinued them. Things went
on well for some time.

After a terrible time of struggle I managed to get admission to an Engineering college. There it
took me 6 years to complete a course which normally takes 4 years. It was in college that I met
Alisha and we were going steady but then I started getting on her nerves. She found me too hot
tempered, nervous and moody. We fought often and I slapped her in rage. We both parted after
many attempts to patch up. I went through a surge of negative emotions – blame, guilt, hating
myself ....after she left me.

I secured a good job in a company but soon I changed my job as I could not concentrate. I was
like a rolling stone gathering no moss. Managing time was also a big hurdle. my thoughts
constantly drifted from one to another. I started using drugs to help me concentrate... it surely
calmed me down. Unfortunately, I was caught red handed and faced by disciplinary action. Yet
again, I lost my job.

Do you know how it feels to be corned on all sides? Rejected and unwanted? I felt helpless,
hopeless and useless.

Case conclusion

This is the story of Aditya, a 25 year old man whose life turned into a living hell because of Adult
ADHD.

What exactly is Adult ADHD?

The DSM 5 gives strict diagnostic criteria for the diagnosis of ADHD as follows:

The chief symptoms are inattentiveness and hyperactivity. The symptoms should be persistent for
more than 6 months and they should negatively impact the social, academic and professional life
of the patient.

When we think of ADHD, the picture of a hyperactive, inattentive and impulsive kid jumping around
comes to our mind.

Did you know that adults too can have ADHD? Did you know that symptoms of childhood ADHD
differ from those of Adult ADHD?
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ADHD was once thought to disappear as a child grew up. Attention-deficit/hyperactivity disorder
(ADHD) affects 30 to 50 percent of adults who had ADHD in childhood. It is estimated 5-8% of
global population suffers from adult ADHD. An accurate diagnosis of ADHD in adults is
challenging and requires attention to early development and symptoms of inattention,
distractibility, impulsivity and emotional lability. Diagnosis is further complicated by the overlap
between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions
such as depression and substance abuse.

Most of the information about the etiology, symptoms and treatment of this disorder comes from
observations of and studies in children. Research on adult ADHD is still in an early stage.

There is now growing and convincing evidence that the adult ADHD is different from childhood
ADHD.

The Utah Criteria has been designed for diagnosing ADHD in Adults

They are:

I. There is a Childhood history of ADHD

II. The Adult symptoms are usually: Hyperactivity and poor concentration

Along with two of the following:

Affective lability, Hot temper, Inability to complete tasks and disorganization, Stress intolerance
and impulsivity

Evaluating and treating patients with symptoms of ADHD, particularly adults without a previously
established ADHD diagnosis is confusing.

First, the criteria for ADHD are not objectively verifiable and require reliance on the patient's
subjective report of symptoms.

Second, the criteria for ADHD do not describe the subtle cognitive-behavioral symptoms that may
affect adults more than children.

Third, the most effective treatment is long-term use of a stimulants with has a potential for abuse.

The Adult ADHD Clinical Diagnosis Scale developed by WHO is a self administered questionnaire
is now being used to diagnose the disorder in adults.

History of ADHD

ADHD was earlier thought to be a disease affecting children and was first mentioned in 1902.

It was originally called hyperkinetic impulse disorder. In 1960s the American Psychiatric
Association (APA) formally recognized ADHD as a psychiatric disorder.

In DSM III which was released in1980. They changed the name of the disorder to attention deficit
disorder (ADD).

In the revised version of the DSM-III in 1987, it was renamed attention deficit hyperactivity disorder
(ADHD).
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ADHD cases began to increase significantly in the 1990s. There may be a few factors behind the
rise in diagnoses:Doctors were able to diagnose ADHD more efficiently and also more
medications were available to treat the disorder .

What makes adult ADHD even more confusing ?

It is estimated that 25% of patients with Adult ADHD develop co-morbid psychiatric disorders.
Oppositional Defiant Disorders, Mood disorders, Anxiety disorder, Borderline personality disorder
Antisocial personality disorders and conduct disorder are the common co-morbid psychiatric
disorders associated with Adult ADHD. These co –morbid disorders pose challenges in proper
diagnosis and treatment of ADHD.

We approached psychiatrist Dr David Wong PhD in a specialist in the field of ADHD from Canada
USA to understand what ADHD is all about. So let's see what he has to say

Survey

We conducted an online & offline survey, to understand the problem of Adult ADHD. We had a
sample of 60 respondents from the city of Pune. Our study got the approval of the Institutional
ethics Committee.

Our inclusion criteria were adults above 18 years of age, both male and female from medical &
non- medical professionals.

Our exclusion criteria included patients with diagnosed mental disorders.

The results of our study were as follows:

A shocking _____% of non-medical professional were unaware of adult ADHD. -----%- were
unaware of the treatment options available, ----- %said they would prefer not to approach a
psychiatrist or counsellor for being labelled as a mentally ill person

Among the medical professionals ----%- were unable to highlight the different in the clinical
symptoms in Childhood and in Adult ADHD, -----% were unable to describe the types of Adult
ADHD,------ % were unable to list the co-morbidities commonly associate with ADHD. -----%- were
unaware of the commonly available medication available to treat Adult ADHD. --------% were not
confident in the diagnosis or management of an Adult ADHD patient and would refer to a
Psychiatrist.

What Causes ADHD in adults?

Adult ADHD is known to have a strong genetic basis, one of the highest amongst the psychiatric
disorders. Parents and siblings of children with ADHD are 8 times more likely to have ADHD than
the general population.

Pre natal environmental factors such as drinking and smoking during pregnancy and postnatal
causes such as trauma, brain injury, minor infections, long labour and pre-eclampsia are also
reported to be causative mechanisms
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The neurobiology of ADHD

It describes and an ADHD brain like a TV, where the channels are constantly being changed and
the remote isn't in your hand. An ADHD brain may show Genetic polymorphism of the dopamine
receptor genes, raising the number of dopamine transporters on the pre-synaptic membrane. This
results in increased dopamine reuptake, causing less stimulation of neurons in the prefrontal
cortex which is the seat of judgement and planning. This is one of the most accepted
neurobiological hypothesis for ADHD.

What happens to adult ADHD is left untreated?

Adult ADHD decreases the overall quality of life of the patient. Due to inattention adults with ADHD
have their performance below their colleagues and hence they find difficulty in getting full time
jobs. Their temper flare up easily and they end up ruining family life and other social relationships.
They are shunned by people due to aggressive and destructive behaviour. Anxiety disorders,
severe depression, alcoholism and substance abuse disorders are the co-morbidities which
develop during the course of the ADHD the longer it remains untreated. Road accidents and
conflict with the law are some of the complications.

How adult ADHD is treated?

ADHD clearly has devastating effects on a person's everyday life. 80 percent of symptoms can be
easily managed by i proper treatment. Pharmacotherapy and psychotherapy are the main
treatment strategies for ADHD patients

Pharmacotherapy of ADHD in Adults

Stimulants:

Methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) are effective in improving attention

and concentration, and in reducing impulsivity in adults with ADHD. Caution should be exercised
in avoiding the use of stimulants in patients with a history of substance abuse. Adult patients may
require larger dosages than those usually prescribed to children. It is important to document the
patient's symptoms and the patient's response to each dosage as the amount is titrated upward.
Methylphenidate and dextroamphetamine are special schedule medication due to their abuse
potential and require careful monitoring.

Antidepressants:

Atomoxetine a norepinephrine reuptake inhibitor has also been found effective to treat ADHD.

Tricyclic antidepressants (TCAs) such as imipramine, desimipramine etc have also been used.
Bupropion an atypical antidepressant with more stimulant properties than the TCAs, may be
effective as well. Therapy with monoamine oxidase (MAO) inhibitors has produced variable
responses in patients with ADHD, but may be tried in patients who have responded poorly to other
therapies.

Some of the older medication such as Clonidine (Catapres) useful in children may not be effective
in adults
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Psychotherapy

Marital and individual counseling and self-help groups are often valuable adjuncts to
pharmacotherapy and skill training.

Low self-esteem, failure, frequent job changes and relationship problems are some of the
problems requiring counseling . Individual psychotherapy that focuses on core issues of self-worth
along with ways to improve the patient's ability to monitor work and social skills can be invaluable.

Married patients often have significant relationship conflicts stemming from forgotten
commitments, impulsive decisions and emotional outbursts. Working with the couple to enhance
communication skills, conflict resolution and problem solving, and educating the patient's spouse
about ADHD can dramatically improve the relationship.

Finally, self-help organizations such as Children and Adults with Attention Deficit Disorder provide
didactic information about the disorder.

At last Aditya's visited a psychiatrist who brought back hope into his life. Life was much better with
medications and therapy. He is now climbing the ladder of success in his company. He also got
into a serious and stable relationship He is now engaged to his girlfriend. His ADHD though not
cured was definitely treated and finally his energies got channelized in the right direction.

An ADHD patients have a lot to contribute to the world at large. Patients with ADHD can actually
hyperfocus at things which interests them. They are 300% more likely to start a new business.
Their brains are good at handling urgent and challenging situations. Many famous personalities
who have been diagnosed with ADHD, have addressed the disorder and are spreading awareness
regarding the same. So open your eyes, look around you. you know them, you might be one of
them.

There are a number of websites which provide information and guidance to people dealing with
ADHD. Also many NGOs like Latika Roy Memorial Foundation reach out to to help patients with
ADHD and their families.

Take home message

Adult ADHD is a disorder which can be diagnoised and treated effectively with medication &
psychotherapy. At times diagnosing adult ADHD is confusing due to the vagueness of symptoms
and due to the many co- morbidities. Lets us join hand in creating awareness about Adult ADHD
which is so little know especially among the young people. Let us make persons know the clinical
features signs of ADHD and its management. Let us fight the stigma associated with ADHD and
bring back hope into the lives and families of patients affected with adult ADHD

In those dark times

When nothing around shines

Let us be the guiding light

To help patients with Adult ADHD in their fight.