ADULT ADHD

Presenter: Dr. Karthik Prasanna

Chairperson: Dr. Abhiram
• ADHD is a genetic, neurobiological disorder that affects one’s ability to
regulate impulse control, motor activity and attentiveness (i.e. a disorder
of executive function)
Clinical Features

ADHD TYPES
• Predominantly inattentive presentation
• Predominantly impulsive/hyperactive presentation
• Combined presentation

In adults
• Symptoms of inattention are more common
• Hyperactivity and impulsivity present differently
 Inattention

• Frequent careless mistakes

• Poor attention to details
• Does not listen when spoken to
• Does not follow through on instructions and fails to finish schoolwork or
duties in the workplace (not due to oppositional behaviour or failure to
understand instructions)
• Has trouble organizing activities
• Avoids, dislikes, or doesn't want to do things that take a lot of mental
effort for a long period of time
• Loses things needed for tasks and activities (phone, keys, address books)
• Easily distracted
• Starts activities but leaves it midway
• Forgetful in daily activities
 Hyperactivity

• Fidgets with hands or feet or squirms in seat

• Gets up from seat frequently
• Restless, constantly moving
• Has trouble playing or doing leisure activities quietly
• Constantly shifts between tasks
• Is often "on the go" or often acts as if "driven by a motor"
• Talks excessively
 Impulsivity

• Blurts out answers before questions have been finished

• Has trouble waiting one's turn
• Interrupts or intrudes on others (e.g., butts into conversations or
games)
• Accident proneness
 DSM-5

• 5 or more of 9 inattentive symptoms, and/or 5 or more of 9

hyperactive / impulsive symptoms
• Interfere with social, academic, or occupational function
• Symptoms present prior to age 12 (rather than age 7, in DSM-IV) and
in 2 or more settings
 Core feature is disinhibition

Feelings of restlessness and difficulty

relaxing (as opposed to hyperactive)
Differences in Adult
ADHD Feelings of being on the go all the time

Desk is cluttered, and things are frequently

lost

Many projects are started and worked hard

on, but then abandoned before completion
• Patients with ADHD frequently come not only late to appointments,
but sometimes early or on the wrong day
• Frequent co-morbid substance abuse and psychiatric diagnoses
• Often in careers in which ADHD can be helpful (like sales, emergency
response)
 Epidemiology

• 2.5-4.4% of adult population (depending on the study)

• Childhood ADHD continues into adult life at >50% frequency
(depending on the study)
• Incidence of adult ADHD increasing as children diagnosed with it are
growing up
• Genetics: First degree relatives of people with ADHD have a 3-5 fold
increased risk
 Neurobiology

• Dysfunction of brain circuits which use catecholamines

• Hypoactive dopamine and norepinephrine in frontal subcortical
circuits
• Modulation of emotion and cognition, Vigilance, perceptual-motor
speed, working memory, verbal learning, processing speed, and
response inhibition

(J Clin Psychopharmacol. 2008 Jun;28(3 Suppl 2):S39-45)

• Related to the noradrenergic system
• Noradrenergic system regulates attention, alertness, executive
function
• Decreased Dopamine/ Increased Norepinephrine
• Dopamine DRD4 gene associated with short term memory, attention
 Assessment of specific
symptoms, including onset,
severity, frequency, situational
specificity, and duration
ASSESSMENT
A functional assessment that
covers school history,
employment history, and
performance
 Inattention

Hyperactivity
Key features
Impulsivity

Executive dysfunction

Emotional dysregulation
 CHILDREN
• Can’t pay close attention in class or
complete schoolwork
• Forgetful: chores, errands, schoolwork
• Loses things: pencils, paper, homework
Inattention
ADULTS
• Has difficulty concentrating at work
and finishing tasks
• Forgetful: returning calls, paying bills,
keeping appointments
• Loses things: wallet, keys, cell phone
HYPERACTIVITY IN CHILDREN
Can’t sit still, always on the go
Climbs or runs at inappropriate times
RESTLESSNESS IN ADULTS
Easily distracted, fidgety, impatient
Mood swings, relationship trouble
PHYSICAL IMPULSIVITY IN CHILD
Does things that result in injuries

VERBAL IMPULSIVITY IN ADULTS

Says the “wrong thing” or speaks out of turn
Interrupts, completes other’s sentences
 The ability to conceptualize all
facets of an activity and translate
that into appropriate and
effective behaviour

Struggle with time management

Executive dysfunction and have poorly organized lives

Emotional dysregulation: mood

lability, anger outbursts, low
frustration tolerance
 Mood lability

Emotional dysregulation Anger Outbursts

Low frustration tolerance

 Perceived: individual who is
working full time, married with
children, struggling to keep up
with an executive MBA
Real versus perceived program
impairment
Real: individual repeatedly
fired from jobs for failing to
turn in time sheets, complete
reports, or other job required
duties
 More than twice as likely to have been
arrested

Twice as likely to have been divorced

Adults with untreated

More than twice as likely to have dropped
ADHD are out of high school

Twice as likely to have held 6 or more jobs in

the past 10 years

"Survey of adults reveals life-long

consequences of ADHD," (Porter Novelli, May
6, 2004)
• ADHD is not an all or nothing condition
• People with ADHD can pay attention, exercise self-control, and
complete tasks
• When faced with a deadline, has a highly rewarding and interesting
task to complete, or is under close scrutiny their performance may be
quite good
• The key in diagnosing ADHD is determining whether symptoms are
typically present and are more pronounced when there is less
external structure and demand
 What information do you need?

• Much of the diagnosis of ADHD is by clinical interview and therefore

involves a fair number of conditions to rule out first
• Adult ADHD handouts can be helpful in screening (but not diagnosis)
(Greater than 40% false positive)
• Developmental history from multiple sources is very helpful as are
school records and grades. These may not be feasible.
• Assessment of Impact on work/study/relationships is critical more than
a list of symptoms
• Urine toxicology is essential on all patients
 SCREENING INSTRUMENTS
Adult ADHD self-report scale
• Current symptom check list based on frequency
• 18 items pulled from DSM-IV
• Shown to be effective in PC settings

Conners’ Adult ADHD rating scale

• Long (66 questions rating frequency), costly, self-report and observer report
time consuming
• Standardized scores across 9 domains
(J Am Board Fam Med November-December 2012 vol. 25 no. 6)
Wender Utah Rating Scale
• Helps to establish the diagnosis in childhood
• 61 questions, answered by the adult patient recalling their childhood
behaviour
• Free and available online
 Given the high prevalence of
Watching for amphetamine/ stimulant abuse, be
cautious of all patients seeking
stimulant stimulants, especially for the first time

seeking
behaviour Google “How do I get my doctor to
give me adderall?”
• The fact is that there is no standardized clinical test to diagnose the
disorder. No one knows what causes it
• The only thing the medical professionals know is that amphetamine/
stimulants delivered in small continuous doses relieves most
symptoms
• So, the trick is to convince your doctor that you have ADHD. And
what’s nice is that anyone can fool the system, as long as they know
what to say and how to act
• It’s all very simple, really, all it takes is a bit of memorization
 Stimulant Seeking Behaviour

• The study concluded that if properly coached by information available

on the internet, all standard screening tests could not differentiate
the students with ADHD from those without
• More specified tests, especially with scales to detect malingering
were far more effective (but not very available)

(Detection of feigned ADHD in college students. Sollman, Myriam J.;

Ranseen, John D.; Berry, David T. R. Psychological Assessment, Vol
22(2), Jun 2010, 325-335)
• Reasons people abuse stimulants: Academic performance, Athletic
performance, Weight loss, Euphoria (usually crushed/snorted,
occasionally IV use), Diversion
• Amphetamines are stimulants (effect somewhere between caffeine
and crystal meth/cocaine)
• Yellow flags: Patients with a rehearsed list of symptoms ; Medication
history with regular fills of amphetamines and not other medications;
Reluctance to give urine toxicology; Angry/ Accusative response to
questions.
 Differential Diagnosis

Besides malingering there are a number of conditions that get confused

as ADHD and need to get ruled out in making the diagnosis.
They include:
1. Substance abuse (especially Cannabis)
2. Bipolar Disorder
3. Depression/PTSD/ Anxiety
4. Personality Disorders- ASPD/BPD
5. Medical Conditions
 Substance Abuse

• Daily cannabis abuse (especially starting before 16) causes severe

impairment to frontal lobes/ inability to concentrate
• People using active opiates, cocaine and or alcohol will focus poorly
and not complete tasks. 3 months of sobriety is usually a minimum for
a confident ADHD diagnosis
• Patients need a lengthy substance abuse history and random urine
toxicology
• If history of being on stimulants, call pharmacy and get frequency of
fills of both the stimulant and the other medications they are taking
 Patients with bipolar disorder have periods
of time lasting weeks to month of
decreased need for sleep, increased goal
directed activity, racing thoughts, etc…

These are episodic and not chronic in

Bipolar Disorder nature and the impulsivity can be confused
with ADHD (and there is some
comorbidity)

Stimulants can worsen mania and

psychosis so should be used with extreme
caution
 Other disorders

• Patients with depression feel hopeless and cannot concentrate. They

cannot accomplish many activities because of their downward mood
(thus get confused as having ADHD)
• Patients with PTSD can be easily triggered, and switch from activity to
activity to avoid an emotional stimulus.
• Patients with generalized anxiety have chronic worries which distract
them
 Antisocial Personality Disorder: Some
patients lack a sense or remorse or
empathy. They seem indifferent to pain they
inflict on others. They lie, cheat and steal to
get ahead

Personality Disorders This subpopulation may seek stimulants,

but it tends to worsen these behaviours. Be
cautious

Borderline Personality –Emotional

dysregulation and impulsivity which can
sound like ADHD, but it is usually triggered
by a real or imagined abandonment or
interpersonal conflict
 Medical Conditions

• Hyperthyroidism
• Sleep apnoea
• Hearing Problems
• Neurological Disorders (including Traumatic Brain Injury)
• Partial-Complex Seizures
• Side effects of Drug treatments
 Treatment

• First, treat any comorbid psychiatric condition, once stable reassess

• If the patient has ADHD, the best treatment is stimulants +/- therapy
 Treatment

• Goal is to reduce ADHD symptoms and improve function

• Pharmacotherapy
Stimulants
Non-stimulants
• Cognitive therapy and environmental changes
 Stimulants
• Methylphenidate and Amphetamines
• Multiple formulations and delivery systems
• Work by increasing levels of dopamine and norepinephrine
• Randomization trials have shown that stimulants outperform placebo
(and non-stimulant medications), especially in short-term trials

N Engl J Med. 2013 Nov;369(20):1935-44

 Methylphenidate

Available in short and long-acting formulations

Average dose: 20 to 30 mg orally in 2 or 3 divided doses
preferably 30 to 45 minutes before meals
Maximum dose: 60 mg/day
• The time required for the immediate release formulations to show
their effect is 2 hours; for sustained-release formulations, it is 4-7
hours; and for extended-release formulations, it is 1-2 hours
• Issue of up/down effect too significant: switch to once-daily long
acting
• If effect doesn’t last long enough, add a low dose of a fast acting
stimulant in the afternoon
• Forgetful of afternoon dose: try long acting
 Adverse effects

• Dry mouth
• Insomnia
• Irritability
• Reduced appetite
• weight loss
• Headaches
• Elevation in blood pressure and pulse
• Psychosis
• Anxiety
• Tic disorder
• Hyperhidrosis
• Irritability
 Mixed Amphetamine salts

• Adderall is a combination of dextroamphetamine and amphetamine

• Dosing is 5-40mg/day divided usually BID
• Contraindications: Breastfeeding, active cardiovascular disease,
moderate to severe Hypertension, hyperthyroidism, glaucoma, past
cocaine abuse…
• Use caution: history of psychosis, seizures, elderly…
• Get familiar with one or two stimulants in each category (long and
short acting)
• No head-to-head trials comparing stimulants
General rule of thumb:
• 1mg/kg body weight of MPH
• 0.5mg/kg body weight of amphetamine preparations
• Average optimal daily dose for adults may be higher
(Spencer T, Biederman J, Wilens T, et al. Biol Psychiatry. 2005;57:456-
463)
 Outline guidelines for use

• Taken at dose and frequency prescribed

• The prescriptions can come from only one healthcare provider
• No early refills
• Medication cannot be given away or sold
• Random urine drug screens
 Non-Stimulant Drugs
• Issue of misuse
• substance use
Try a non-stimulant like
Atomoxetine
 Atomoxetine

• Dosing: 40mg qdaily for three days then 80mg qdaily

• Non-stimulant Selective Nor-epi RI
• Ideal choice for patients with substance abuse history, however…
• Many patients find it ineffective and unhelpful
• Contraindicated in cardiomyopathy
 Other medications
• Bupropion – must be taken daily, takes several weeks for effect
• TCA or venlafaxine
• Alpha-2 agonists
Clonidine
Guanfacine
• SSRIs are rarely helpful for ADD symptoms
 Therapy

• Cognitive behavioural therapy is very effective

• Attention enhancement skills
• Skills-based therapies is also effective
• Works well in addition to medication or on its own
 GOALS OF THERAPY
Practical strategies and instructions to solve three of the most common
ADHD problems
Time Management
Organization
Planning
• Maintain a daily schedule: Use a calendar, planner
• To-do list
• Limit distraction
• Schedule attention-demanding tasks
• Break down difficult tasks
• Dedicated quiet study space
 Conclusion

• Diagnosis of ADHD requires a thoughtful history taking and clinical

judgment as well ruling out most other possibilities
• Treatment can be very helpful to some people and frequently requires
treating other diagnoses first
• Abuse of stimulants is at an extremely high level, mostly in college
campuses and most screening tests can be faked
• Watch for mania and psychosis; these worsen significantly on
amphetamines/ stimulants
• A highly heritable condition
• Starts in childhood and persists into adulthood
• Diagnosis is made based on clinical presentation
• Treatment with stimulants, though second line medications are
available
THANK YOU