Presentation about ADHD in adults, symptoms, executive dysfunction and treatment.

1. ADHD in adults: diagnosis
and treatment
Dr Jaap Hamelijnck
Consultant Psychiatrist
Dr Somayya Kajee
Consultant Psychiatrist
Consultant to UEA Student Services
Founder Members Anchor Psychiatry Group
Consultant Psychiatrist; NSFT, Great Yarmouth and
Waveney Developmental Disorders Clinic
1

2. From Behavioural Syndrome to
ExecuNve DysfuncNon
Person burdened by a syndrome of chronic
difficulNes in focusing, geQng started on
tasks, sustaining effort, uNlising working
memory and modulaNng emoNons that
chronically impair their ability to manage
necessary tasks of daily life (Brown 2013)
2

3. • hYps://youtu.be/YmCc7dW6GVs
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4. A new working definiNon of ADHD
• A complex syndrome of
• Developmental impairments of execuNve funcNons
• The self-management system of the brain
• A system of mostly unconscious operaNons
• These impairments are situaNonally variable
• Chronic, and significantly interfere with funcNoning in
many aspects of the person’s daily life
4

5. • Epidemiology
• ADHD symptoms in adults
• Some theories the cause
• EmoNon dysregulaNon
• Medical management
• MedicaNon
5

6. Epidemiology
• Prevalence rates in childhood between 4 and 8%.
• For adults this is esNmated at 2.5%
• Male : Female = 3 : 1 in childhood
• For adults more like 1:1 as age increases.
• Males prevalence down with age.
• Females prevalence more stable
• Special populaNon prevalence much higher i.e. female prison
populaNon may be as high as 25%
Prevalence and correlates of adult ADHD: meta-analysis. BJPsych (2009) 194,
201-211
ADHD in female offenders: prevalence, psychiatric comorbidity and psychosocial
implicaNons. Eur Arch Psychiatry Neurosci. (2009) 259(2):98-105
6

7. Persistence of
Symptoms
• Persistence of symptoms is high
• 15% for 25 year olds full diagnosis of ADHD
• Up to 50% parNal remission
• ReducNon of symptoms more for males
Prevalence and correlates of adult ADHD: meta-analysis. BJPsych (2009) 194,
201-211
7

8. Core Symptoms
DSM-IV
InaYenNon (six or more of)
1. Oken fails to give close aYenNon to details or makes careless
mistakes
2. Oken has difficulty sustaining aYenNon in tasks or fun acNviNes
3. Oken does not seem to listen when spoken to directly
4. Oken does not follow through on instrucNons and fails to finish work
5. Oken has difficulty organizing tasks and acNviNes
6. Oken avoids, dislikes, or is reluctant to engage in tasks that required
sustained mental effort
7. Oken loses things necessary for tasks or acNviNes
8. Is oken easily distracted by extraneous sNmuli
9. Is oken forgenul in daily acNviNes
8

9. Core Symptoms DSM-IV
HyperacNvity / Impulsivity (six or more)
1. Oken fidgets with hands or feet or squirms in seat
2. Oken leaves seat in situaNons in which remaining seated is expected
3. Feelings of restlessness
4. Oken has difficulty engaging in leisure acNviNes or doing fun things
quietly
5. Is oken “on the go” or “driven by a motor”
6. Oken talks excessively
7. Oken blurts out answers before quesNons have been completed
8. Oken has difficulty awaiNng turn
9. Oken interrupts or intrudes on others
9

10. Associated symptoms
• ProcrasNnaNon
• Low tolerance of frustraNon; minor frustraNons cause catastrophic reacNons,
loss of temper or anger
• Mood lability; frequent changes, several Nmes a day, like a roller coaster
• Low self-esteem; expected given the lifelong problems with rejecNons and
failures
• Underachievement
• Frequent search for high sNmulaNon
• Intolerance of boredom
• Hyper-focusing
• Trouble going through proper procedures due to boredom and frustraNon
• Worry needlessly
• Sense of insecurity
• Inaccurate self-observaNon and assessment of their impact on others
10

11. Differences in adults
• InternalisaNon of symptoms
• HyperacNvity and impulsivity less evident
• EmoNon regulaNon and anger more prominent
• ExecuNve symptoms
• SituaNon specific (demands of adult life)
11

12. Other symptoms
ExecuNve funcNon
• Impaired concentraNon
• Poor planning
• Sleep problems
• Time keeping
• Memory problems
• DifficulNes puQng
problems in to words
• Poor self awareness
• Poor organisaNon
EmoNon regulaNon
• Anger
• Control of emoNons
• AgitaNon
• Mood problems and
fluctuaNons
12

13. 13

14. Impairments
1. Ac%va%on; excessive procrasNnaNon, put off geQng started on a task, even a
task they recognise as very important to them unNl the last minute. Keeping
track of plans, money or Nme. DifficulNes seQng prioriNes. Has a hard Nme
waking in the morning.
2. Focus; distracted easily by things going on around them and in their own
minds whilst at other Nmes they are stuck on one focus unable to shik to
another task. Reading very difficult to grasp the meaning. Mind driking all
the Nme and missing important informaNon. Spacing out. Easily side tracked,
only remembering some of the details. Doesn’t seem to be listening and
geQng complaints about it.
3. Effort; sustaining effort very difficult, moNvaNon wanes very quickly, needing
high levels of interest to keep going. Unable to conNnue tasks in alloYed
Nme, slacks of unless pressure is on. Requires others to keep them on task.
Chronic difficulty regulaNng sleep and alertness, stay up late because can’t
shut their head off, big problem geQng up in the morning.
14

15. Impairments
4. Emo%on; not recognised in DSM 5, chronic difficulNes managing frustraNon,
anger, worry, disappointment, desire, and other emoNons. EmoNons take
over, making it impossible to give aYenNon to anything else, short fused.
Excessively impaNent, sensiNve to criNcism from others, gets overly
defensive. Can appear apatheNc or unmoNvated.
5. Memory; oken great memory for things that happened long ago but not
what they have just done, or where they put something. Excessively
forgenul, intents to do things but forgets, making many mistakes or leaving
out words when wriNng. Always forgeQng to bring things or leaving the
house with necessary items.
6. Monitoring and regula%ng self-ac%on; too impulsive in what they say or do,
jumping in to quickly, not being able to interact appropriately. Fail to noNce
others are offended or puzzled and fail to modify their behaviour. Pacing of
acNons, slowing down or speeding up as required for a specific task. Monitor
one’s acNons and inhibit impulsive acNons.
15

16. Outcomes in ADHD
• Outcomes are poor despite treatment
• High psychiatric admission rates
• Personality disorder main outcome diagnosis
• Mood disorders
• Substance and alcohol abuse disorders
• AnNsocial behaviour and criminality
• Severe marital, occupaNonal and social difficulNes
Conduct problems, gender and adult psychiatric outcome of children with ADHD.
Dalsgard et.al. BJPsych (2002), 181,416-421.
Adolescent clinical outcomes for young people with ADHD. BriNsh Journal of
Psychiatry (2010) 196, 235-240.
16

17. ADHD and Co-Morbidity
Adapted from G D Kewley 1999: ADHD – Recogni%on, Reality and Resolu%on
17

18. ADHD and Co-Morbidity
Adapted from G D Kewley 1999: ADHD – Recogni%on, Reality and Resolu%on
18

19. Co-morbidiNes
1. Developmental disorders
– AuNsNc spectrum disorders
– Tic and ToureYes disorders
– Developmental delay
– Learning disabiliNes
– Specific learning disabiliNes (reading)
– (bipolar disorder)
19

20. Co-morbidiNes
2. Disorders first presenNng in adulthood
– Personality disorder (dissocial, borderline)
– Mood disorders (bipolar, depression)
– Anxiety disorders
– Substance abuse disorders (substance and alcohol)
– Sleep disorders
– Up to 90% of adults will have a co-morbid disorder
20

21. Aetiology
• Prefrontal cortex abnormalities
• Hypo-arousal affecting neural networks
• Prefrontal cortex – striatum – thalamus-
prefrontal cortex loops
• Thalamus - amygdala
Morphological abnormalities of the thalamus in youths with ADHD. The
American Journal of Psychiatry; April 2010; 167, 397-408.
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22. 22

23. Prefrontal cortex
• Dorsolateral prefrontal cortex
– DifficulNes sustaining aYenNon,
problem solving, planning and
organising
• Prefrontal motor cortex
– HyperacNvity
Stahl’s Essential Psychopharmacology. Neuroscientific basis and practical
applications. Cambridge University Press 2008
23

24. Prefrontal cortex
• Orbital frontal cortex (limbic
system)
– Impulsivity, selecNve
inhibiNon, noise/signal linked
to reward (dopamine release)
• Anterior cingulate cortex
– SelecNve inaYenNon, self-
monitoring
24

25. Other hypothesis
• Default Mode Network
• Impulse control disorder
• Reward deficiency disorder
• Mind Wandering
25

26. ADHD in adults: diagnosis
and treatment: Part 2
Dr Jaap Hamelijnck
Consultant Psychiatrist
Consultant to UEA Student Services
Founder Member Anchor Psychiatry Group
Consultant Psychiatrist; NSFT, Great Yarmouth
and Waveney Developmental Disorders Clinic
26

27. • hYps://youtu.be/hmBQ7RwBFDc
27

28. First appointment
• Screening tools; Connors, Barkley
• Clinical psychiatric interview, DIVA
• Mental State ExaminaNon
• Developmental history
• Family history
• Social and psychological factors
• Physical health
• Further invesNgaNons
• diagnosis
28

29. cAARS-self-Report: Long version (GAARS-s:L)
by G, K, Gonners, ph,D., D. Erhardt, ph:D,, & E. p. Sparrow, M.A.
Client ID:
Biffihdare; 4;Month hy ycr
Agslii=__ ,Today:sDrate:
-Mbhl}r ' Day yeil
Use the following scare: " o= Not at,all, neiier; r :'Just'ailittle,'on"" in u *hll";
2 .. Pretty much, oflen; and 3 : Very much, very frequently
Items continued an back page...
EMHS l,'i'J#.';#iiys:t'fli'?:ffi:#.6xlfiHili.fih;i,f .,l;H,ff]i,ii];ll-,.Tlr;:I,irylli,,&ry,,i,ff.?ii;1,,T*,.
29

30. Semi-structured Interview to establish
the symptoms
30

31. Non pharmacological
treatment
• Coaching
• ADHD focussed CBT
• CombinaNon with medicaNon
• Social support groups
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32. 32

33. 33

34. starNng treatment
• Physical invesNgaNons
• BP, Pulse, ECG, rouNne bloods
• Start low and go slow
• Monitor response (telephone/email) paNent and
significant other
• Monitor side-effects
• When stable GP to conNnue prescripNon
• Annual BP and pulse
• Specialist review
34

35. First Line Treatment
• SNmulants
– Methylphenidate
– Dexamfetamine
– Lis Dexamfetamine
• Slow conNnuous blockade
• Up to 100mg per day
• Not 24 hrs
• 70% response rate
Evidence based guidelines for management of ADHD in adults: recommendaNons
from the BriNsh AssociaNon of Psychopharmacology (2006)
35

36. • hYps://youtu.be/MeJRBsghMt8
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37. SNmulants
• BP, Pulse, ECG
• No significant tolerance
• Low abuse potenNal
• High dose and fast delivery euphoria, re-
enforcement and conNnuing abuse (nucleus
accumbens)
• Mild hypertension
• Headaches
• Sleep difficulNes
37

38. Methylphenidate
• Start low and go slow
– 5mg or 10mg two or three Nmes a day
– Monitor regularly (telephone/email contact)
– Adjust dose according to response
– Modified release preparaNons (Concerta, Equasym,
Medikinet)
– InformaNon from important other
– Psychological and social support
– Shared care with primary care
– Co-morbid disorders
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40. 40

41. Amphetamine
• Blocks NET and DAT
• Replaces NA and DA on the transporter molecule
• Inside the presynapNc nerve terminal leads to
further NA and DA release through blocking other
transporter molecules
– Higher abuse potenNal parNcularly immediate release
preparaNons
• Lisdexamfetamine
– Pro-drug, amphetamine and Lysine, split in red blood cell
– Slow onset, long acNng (10-14 hours)
41

42. Second line treatment
• Noradrenaline Reuptake Inhibitors
– AtomoxeNne (only licensed drug in UK for use in
adults when started in childhood)
– TCA (imipramine, nortriptyline, other)
– Buproprion
• NET inhibitors increase Dopamine in the
prefrontal cortex (avoiding increase of
dopamine in n accumbens)
42

43. NRIs side-effects
• Cardiovascular disease, hypertension, QT
interval
• Liver funcNon
• AnN-cholinergic side effects
• Sexual dysfuncNon
• SweaNng
• Suicidal ideaNon
• other
43

44. Noradrenaline agonists
• Clonidine/Guanfacine
– Alpha 2A (post synapNc) receptor agonist prefrontal
cortex mediate effects of NA on aYenNon, acNvity
and impulsivity
– Alpha 2B thalamus mediate sedaNng acNons of NA
– Imidazoline receptor acNon leading to sedaNon and
hypotension.
44

45. Clonidine/Guanfacine
• Useful for aggression, anger and sleep
disorder
• Tic disorder
• SedaNve
• Hypotension
• 25 mcg – 300mcg
45

46. Third line treatment
• SNmulants and NRIs
– Provide 24hr cover
• SNmulants and Clonidine
– Increased control of emoNons parNcularly anger and
aggression
• AnNpsychoNc drugs
– QueNapine (metabolite N-DesalkylqueNapine a
potent NET inhibitor)
N-DesalkylqueNapine: a potent norepinephrine reuptale inhibitor. Neuropsychopharmcology
(2008). Jensen et al, 33, 2303-2312.
46

47. Special condiNons
• Pregnancy
– Not enough data from studies on methylphenidate
– “Avoid unless benefit outweighs the risk”
– What are the risks to the foetus if mother is symptomaNc?
• Risk taking behaviour
• Impulsivity
• Safety
– Stop during first trimester
– Reduce the dose
– Change to methylphenidate (from amphetamines)
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