Attention Deficit Disorders In AdultsAmit Vijapura, M.D., Board Certified Psychiatrist
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Introduction:For many years, ADHD in adults remains a controversial diagnosis. Now, there is a collection of reputable studies that shows that more than 50 percent of children with ADHD have residual ADHD symptoms in adulthood, and about 11 percent will have symptoms that cause significant impairment in their daily life. Case Report:A 23-year-old female trying to finish her last year of college came to me because she was feeling overwhelmed by her studies. Since childhood, she was having a hard time concentrating in her class, but due to excellent I.Q. and a good family environment, she was able to maintain excellent progress. When she went to college and started becoming more independent, she could not maintain her finances or organize her daily activities. She was unable to finish lengthy projects in college. She changed her major in college three to four times due to her impulsiveness and inability to stay focused on her long-term goals. After she was given daily doses of stimulant medication, her life changed dramatically. At each visit, when she came for her follow-up, she would cry and she say to me “I feel bad about losing so many years of my life. This is my new life and I can accomplish so many things now which were impossible in the past.” Etiology:ADHD always starts before age seven. If a child has symptoms of hyperactivity and impulsiveness, he or she is likely to get diagnosed and receive treatment prior to age 10. However, very often they do not get any treatment if they have a problem with their attention span without hyperactivity. This is commonly seen in girls. (1) Catecholamine Hypothesis: In 1970, Kornetsky referred to suspected faulty function of dopamine and norepinephrine in brain structure. Since 1970, numerous animal and clinical studies have solidified the fact that impaired use of dopamine and norepinephrine is implicated in ADHD. (2) The Theory of Frontal Lobe Disinhibition: ADHD is the result of a disinhibition or dysregulation of the frontal lobes. The frontal lobe is responsible for executive function, which is defined as the ability to devise and maintain an appropriate problem-solving capacity to attain a future goal. The basic elements of executive function include the ability to initiate, sustain, inhibit, and shift attention. Zametkin at NIMH first published the landmark finding in November of 1990 in the New England Journal of Medicine, which suggested an integrated model. ADHD is a genetically based neurobiological disorder. ADHD is passed down from parent to child. Diagnosis and Symptoms:Like many psychiatric disorders, ADHD cannot be diagnosed by blood tests, EEG, or CT scan. We use guidelines from DSM-IV, which has specific diagnostic criteria. We inquire about typical symptoms, including inattention, distractibility, impulsivity, restlessness, disorganization, procrastination, and mood lability. We ask about childhood history, substance abuse, family history, and vocational history. A history of nonpsychiatric medical problems is also obtained. Next, we perform a mental status examination, and in few cases, psychological testing. Differential DiagnosisA good differential diagnosis is important because the symptoms of ADHD are very nonspecific and can be symptomatic of other psychiatric illnesses. Individuals with ADHD are at risk for developing maladaptive lifestyles which can lead to a variety of psychiatric conditions, including mood disorder, substance abuse, and antisocial behavior. Many adult patients with ADHD may also meet criteria for other psychiatric diagnoses. PrognosisIt has been very rewarding to help adults with ADHD in my practice. A significant number of patients have responded without any problems or complications. It is a life-long condition, which may require ongoing treatment, but they can maintain 100 percent of functioning. Full remission is difficult in cases with co-morbid substance abuse or other psychiatric disorder. Treatment1. Education: Perhaps the most important strategy for ADHD adults is to educate themselves as well as their families. The realization that many of their problems stem from neurological causes rather than from laziness or defects in their character or ability can begin to enhance self-esteem. Educating spouses, family members, and friends is also important. 2. Pharmacological Treatment: Several types of medications are used in treatment of adult ADHD. Any co-morbid psychiatric condition, including major depression, panic disorder, and bipolar disorder, can worsen symptoms of ADHD and needs to be treated first. Stimulants (Ritalin, Dexedrine, Adderall, Concerta) are the most commonly prescribed medications. These medications can cause increased availability of dopamine and norepinephrine in the brain. Ritalin is very effective, but a single dose lasts only three to four hours in most adults. Long-acting medications, such as Adderall XR are effective for 8 to 12 hours. All stimulant medications are schedule II drugs. Provigil can be used, but currently it is not FDA-approved for adult ADHD. Stimulants are very effective in calming the restless patient, improving the ability to focus, and improving their distractibility and impulsivity. Several antidepressant medications have been found to
be helpful. Desipramine, Effexor, and Wellbutrin have
been shown to have efficacy, but not as robust as stimulants.
They 3. Behavioral Therapies: Most adults with ADHD have suffered years of feeling demoralized, discouraged, and ineffective due to a history of frustration and failures in school, work, family, and/or social domains. Encouragement and positive reinforcement are crucial. It is helpful to take a problem-solving approach in which problems are isolated and analyzed jointly. There are several excellent books on adult ADHD available, which can provide an easy guide for the patient.
SummaryADHD in adults is a medical condition which affects many adults. It can be successfully treated with medication and therapy. March/April, 2002/ Jacksonville MedicineWhat's New
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