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ADHD	in	adults:	diagnosis	
and	treatment	
Dr	Jaap	Hamelijnck	
Consultant	Psychiatrist	
Dr	Somayya	Kajee	
Consultant	Psychi...
From	Behavioural	Syndrome	to	
ExecuNve	DysfuncNon	
Person	burdened	by	a	syndrome	of	chronic	
difficulNes	in	focusing,	geQng	...
•  hYps://youtu.be/YmCc7dW6GVs	
3
A	new	working	definiNon	of	ADHD	
•  A	complex	syndrome	of	
•  Developmental	impairments	of	execuNve	funcNons	
•  The	self-m...
•  Epidemiology	
•  ADHD	symptoms	in	adults	
•  Some	theories	the	cause	
•  EmoNon	dysregulaNon	
•  Medical	management	
• ...
Epidemiology	
•  Prevalence	rates	in	childhood	between	4	and	8%.	
•  For	adults	this	is	esNmated	at	2.5%	
•  Male	:	Female...
Persistence	of	
Symptoms	
•  Persistence	of	symptoms	is	high	
•  15%	for	25	year	olds	full	diagnosis	of	ADHD	
•  Up	to	50%...
Core	Symptoms		
DSM-IV	
InaYenNon	(six	or	more	of)	
1.  Oken	fails	to	give	close	aYenNon	to	details	or	makes	careless	
mis...
Core	Symptoms	DSM-IV	
HyperacNvity	/	Impulsivity	(six	or	more)	
1.  Oken	fidgets	with	hands	or	feet	or	squirms	in	seat	
2. ...
Associated	symptoms	
•  ProcrasNnaNon	
•  Low	tolerance	of	frustraNon;	minor	frustraNons	cause	catastrophic	reacNons,	
los...
Differences	in	adults	
•  InternalisaNon	of	symptoms	
•  HyperacNvity	and	impulsivity	less	evident	
•  EmoNon	regulaNon	and...
Other	symptoms	
ExecuNve	funcNon	
•  Impaired	concentraNon	
•  Poor	planning	
•  Sleep	problems	
•  Time	keeping	
•  Memor...
13
Impairments	
1.  Ac%va%on;	excessive	procrasNnaNon,	put	off	geQng	started	on	a	task,	even	a	
task	they	recognise	as	very	im...
Impairments	
4.  Emo%on;	not	recognised	in	DSM	5,	chronic	difficulNes	managing	frustraNon,	
anger,	worry,	disappointment,	de...
Outcomes	in	ADHD	
•  Outcomes	are	poor	despite	treatment	
•  High	psychiatric	admission	rates	
•  Personality	disorder	mai...
ADHD	and	Co-Morbidity	
Adapted	from	G	D	Kewley	1999:	ADHD	–	Recogni%on,	Reality	and	Resolu%on	
17
ADHD	and	Co-Morbidity	
Adapted	from	G	D	Kewley	1999:	ADHD	–	Recogni%on,	Reality	and	Resolu%on	
18
Co-morbidiNes	
1.  Developmental	disorders	
–  AuNsNc	spectrum	disorders	
–  Tic	and	ToureYes	disorders	
–  Developmental	...
Co-morbidiNes	
2.  Disorders	first	presenNng	in	adulthood	
–  Personality	disorder	(dissocial,	borderline)	
–  Mood	disorde...
Aetiology
•  Prefrontal cortex abnormalities
•  Hypo-arousal affecting neural networks
•  Prefrontal cortex – striatum – t...
22
Prefrontal cortex
•  Dorsolateral	prefrontal	cortex	
–  DifficulNes	sustaining	aYenNon,	
problem	solving,	planning	and	
orga...
Prefrontal cortex
•  Orbital	frontal	cortex	(limbic	
system)	
–  Impulsivity,	selecNve	
inhibiNon,	noise/signal	linked	
to...
Other	hypothesis	
•  Default	Mode	Network	
•  Impulse	control	disorder	
•  Reward	deficiency	disorder	
•  Mind	Wandering	
2...
ADHD	in	adults:	diagnosis	
and	treatment:	Part	2	
Dr	Jaap	Hamelijnck	
Consultant	Psychiatrist	
	
Consultant	to	UEA	Student...
•  hYps://youtu.be/hmBQ7RwBFDc	
27
First	appointment	
•  Screening	tools;	Connors,	Barkley	
•  Clinical	psychiatric	interview,	DIVA	
•  Mental	State	ExaminaN...
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:
B...
Semi-structured	Interview	to	establish	
the	symptoms	
30
Non	pharmacological		
treatment	
•  Coaching	
•  ADHD	focussed	CBT	
•  CombinaNon	with	medicaNon	
•  Social	support	groups...
32
33
starNng	treatment	
•  Physical	invesNgaNons		
•  BP,	Pulse,	ECG,	rouNne	bloods	
•  Start	low	and	go	slow	
•  Monitor	respo...
First	Line	Treatment	
•  SNmulants	
–  Methylphenidate	
–  Dexamfetamine	
–  Lis	Dexamfetamine	
•  Slow	conNnuous	blockade...
•  hYps://youtu.be/MeJRBsghMt8	
36
SNmulants	
•  BP,	Pulse,	ECG	
•  No	significant	tolerance	
•  Low	abuse	potenNal	
•  High	dose	and	fast	delivery											...
Methylphenidate	
•  Start	low	and	go	slow	
–  5mg	or	10mg	two	or	three	Nmes	a	day	
–  Monitor	regularly	(telephone/email	c...
39
40
Amphetamine	
•  Blocks	NET	and	DAT	
•  Replaces	NA	and	DA	on	the	transporter	molecule	
•  Inside	the	presynapNc	nerve	term...
Second	line	treatment	
•  Noradrenaline	Reuptake	Inhibitors	
– AtomoxeNne	(only	licensed	drug	in	UK	for	use	in	
adults	whe...
NRIs	side-effects	
•  Cardiovascular	disease,	hypertension,	QT	
interval	
•  Liver	funcNon	
•  AnN-cholinergic	side	effects	...
Noradrenaline	agonists	
•  Clonidine/Guanfacine	
– Alpha	2A	(post	synapNc)	receptor	agonist	prefrontal	
cortex	mediate	effe...
Clonidine/Guanfacine	
•  Useful	for	aggression,	anger	and	sleep	
disorder	
•  Tic	disorder	
•  SedaNve	
•  Hypotension	
• ...
Third	line	treatment	
•  SNmulants	and	NRIs	
– Provide	24hr	cover	
•  SNmulants	and	Clonidine	
– Increased	control	of	emoN...
Special	condiNons	
•  Pregnancy	
–  Not	enough	data	from	studies	on	methylphenidate	
–  “Avoid	unless	benefit	outweighs	the...
48
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Add norfolk presentation march 2016

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

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Add norfolk presentation march 2016

  1. 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. 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. 3. •  hYps://youtu.be/YmCc7dW6GVs 3
  4. 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. 5. •  Epidemiology •  ADHD symptoms in adults •  Some theories the cause •  EmoNon dysregulaNon •  Medical management •  MedicaNon 5
  6. 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. 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. 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. 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. 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. 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. 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. 13
  14. 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. 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. 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. 17. ADHD and Co-Morbidity Adapted from G D Kewley 1999: ADHD – Recogni%on, Reality and Resolu%on 17
  18. 18. ADHD and Co-Morbidity Adapted from G D Kewley 1999: ADHD – Recogni%on, Reality and Resolu%on 18
  19. 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. 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. 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. 21
  22. 22. 22
  23. 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. 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. 25. Other hypothesis •  Default Mode Network •  Impulse control disorder •  Reward deficiency disorder •  Mind Wandering 25
  26. 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. 27. •  hYps://youtu.be/hmBQ7RwBFDc 27
  28. 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. 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. 30. Semi-structured Interview to establish the symptoms 30
  31. 31. Non pharmacological treatment •  Coaching •  ADHD focussed CBT •  CombinaNon with medicaNon •  Social support groups 31
  32. 32. 32
  33. 33. 33
  34. 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. 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. 36. •  hYps://youtu.be/MeJRBsghMt8 36
  37. 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. 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 38
  39. 39. 39
  40. 40. 40
  41. 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. 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. 43. NRIs side-effects •  Cardiovascular disease, hypertension, QT interval •  Liver funcNon •  AnN-cholinergic side effects •  Sexual dysfuncNon •  SweaNng •  Suicidal ideaNon •  other 43
  44. 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. 45. Clonidine/Guanfacine •  Useful for aggression, anger and sleep disorder •  Tic disorder •  SedaNve •  Hypotension •  25 mcg – 300mcg 45
  46. 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. 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) 47
  48. 48. 48

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