Comorbidities in ADHD workshop (Norfolk and Suffolk NHS Trust)


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This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014.

The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

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Comorbidities in ADHD workshop (Norfolk and Suffolk NHS Trust)

  1. 1. ADHD and Co-Morbidity ADHD Attention  Deficit  Hyperactivity  Disorder Yasir Hameed (MRCPsych) Digitally signed by Yasir Hameed (MRCPsych) DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust ou=Norfolk and Suffolk NHS Trust Reason: I am approving this document Location: Date: 2014-03-31 22:19+01:00
  2. 2. ADHD and Co-Morbidity Proposed outline:  What is ADHD – and some concepts to consider  Co-morbidity  Stats  Selected Highlights:  ASD  Personality/?bipolar  Risk  Case vignettes with discussion on how you might manage and treat  (Including medication)
  3. 3. ADHD: what is it? The 3 musketeers:  Inattention/concentration  Impulsivity  Hyperactivity
  4. 4. ADHD: what is it? The 3 musketeers:  Inattention/concentration  Impulsivity  Hyperactivity And then there is the 4th one:  Emotional Dysregulation
  5. 5. ADHD: the Child Psychiatrist’s View Growth and Development  ‘Developmental Tasks’ (Neuro-) Developmental Disorders  Family Interaction  Schooling  Social Interaction  Disruptions Attachment’ Oppositional Defiant Disorder Others? The Whole of Psychiatry?
  6. 6. ADHD and Co-Morbidity: Concepts 1
  7. 7. ADHD and Co-Morbidity: Concepts 2
  8. 8. ADHD and Co--Morbidity: ‘All you ever wanted to know...’ Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution
  9. 9. ADHD and Co--Morbidity: ‘All you ever wanted to know...’ Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution
  10. 10. ADHD and Co--Morbidity: ‘All you ever wanted to know...’ Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution
  11. 11. What happens when ADHD grows up even more? Criminal behaviour Personality Disorders Oppositional School exclusion Defiant Mood Disorders Disruptive Disorder Behaviour Substance Bipolar?? Low Abuse ADHD only Self-esteem Poor Social Conduct Skills Disorder Drug & Alcohol Problems Learning Lack of Delay Challenging Motivation Criminality Behaviour Complex Relationships failures Learning Difficulties Underachieving Study /work problems 6y 10y 14-16y 17-35 Adapted and extended from G D Kewley 1999: ADHD – Recognition, Reality and Resolution
  12. 12. ADHD and Co-Morbidity: concepts 3 It is not : Can’t focus But: Can’t control the focus of attention - Executive Functions - Filtering Information - Signal Noise Ratio
  13. 13. ADHD and Co-Morbidity: concepts 4 Comorbidity: ‘Development related’  Autistic spectrum disorders  Tics and Tourette’s disorders  Developmental delay  Learning disabilities  Specific learning disabilities (reading, coordination) ‘Ordinary’  Sleep  Mood disorders (depression, ?bipolar)  Anxiety disorders  Substance abuse disorders (substance and alcohol)  Personality disorder (dissocial, borderline)
  14. 14. ADHD and Co-Morbidity: concepts 5 Underlying processing problems ‘push’ potential comorbidities towards clinical significance (E.g. John J. Ratey’s ‘Shadow Syndrome’ idea)
  15. 15. ADHD and Co-Morbidity: concepts 6 Utah Criteria for Adult ADHD A. Inattentiveness B. Hyperactivity With at least two of the following: 1. Mood fluctuations 2. Irritability and hot temper 3. Impaired stress tolerance 4. Disorganisation 5. Impulsivity
  16. 16. Is Adult ADHD Plain Vanilla ADHD, where …. hyperactivity has gone underground, but …. emotional dysregulation and co-morbidities have come to the fore?
  17. 17. Comorbidities: stats and a few selected highlights  ASD  Personality disorder, and what about Bipolar  Risk  DSH & Suicide  The Road
  18. 18. ADHD and Autistic Spectrum Disorders (ASD) • 41 % of the children with autistic spectrum disorders also had many ADHD characteristics, and 22 % of those with ADHD characteristics also had the diagnosis autistic spectrum disorder. • Suggested a joint genetic influence in both disorders (Ronald et al. 2008 ) .
  19. 19. ADHD and personality disorder: Miller, Nigg and Faranoe (2007) studies 363 adults with ADHD and compared them to non-ADHD controls in relationship to personality disorder. Adults with ADHD had a higher incidence of both cluster B and C. Controls % ADHD % Cluster A No difference Cluster B 9.5 24.4 Cluster C 4.3 21.0 The most frequent Cluster B personality disorder in ADHD was Borderline PD In Cluster C, the most common type was OC PD
  20. 20. In the differential diagnostic assessment, the following criteria are used: 1. The frequency of the mood swing (4–5 times a day in ADHD and cluster B personality disorders, a minimum of 2–3 days in a hypomanic episode) 2. The course (chronic in ADHD and cluster B personality disorder, episodic in bipolar disorder) 3. The age of onset (childhood in ADHD, usually later in the bipolar and personality disorders)
  21. 21. The incidence of death from suicide is nearly 5 times higher among adults who had had childhood ADHD compared with control participants (N = 367). Barbaresi et al. Mortality, ADHD, and Psychosocial Adversity in Adults With Childhood ADHD: A Prospective Study. PEDIATRICS Volume 131,Number 4, April 2013. The chance of suicidal tendencies in adolescents and adults with ADHD compared to controls is elevated mainly in the presence of hyperactivity/impulsivity, depression or dysthymia, and the antisocial behavioural disorder. Barkley and Fischer 2005 ; Semiz et al. 2008 In research, among adolescents 36 % of the patients with ADHD had suicidal thoughts before the age of 18, versus 22 % of a control group. For suicide attempts, these numbers were 16 % versus 3 %. Barkley and Fischer 2005 ADHD: DSH and Suicide
  22. 22. Young women diagnosed with ADHD, were three to four times more likely to attempt suicide and two to three times more likely to report injuring themselves than comparable young women in a control group. Hinshaw et al. Prospective Follow-Up of Girls With Attention- Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide Attempts and Self-Injury. Journal of Consulting and Clinical Psychology. American Psychological Association. 2012, Vol. 80, No. 6, 1041–105. This knowledge ought to change our thinking about DSH drivers, and also our working practices in trying to deal with this client group!! ADHD and (Female) DSH
  23. 23. Some Cases for Discussion
  24. 24. Case 1; Billy 41 years old, living on the street since age 15/16, multiple drug user, including iv heroin, Hep c positive. On methadone Now living in his own flat and finding it very difficult to cope When living on the street nobody cared about his hyper-activtiy, now he is driving everybody mad Diagnosis of ADHD, OCD, drug use on substitution therapy Physical health, slow pulse low BP
  25. 25. Case 2; Phillip • 63 year old man, initially diagnosed with bipolar disorder. Marked mood lability, anger/temper outbursts leading to loss of job ASDA, very low self-esteem, difficulties verbalising his problems • Diagnosis ADHD, sleep disturbance, emotional lability, anger • Mood very low at times. • Treated with stimulants + clonidine
  26. 26. Case 3; Ricky • Presented with OCD, ODD, ADHD, Ticks and substance misuse • Treated OCD with SSRIs and ADHD with atomoxetine, little effect, added risperidone. Severe sweating • Relationship difficulties, alcohol abuse leading to pacreatitis • Difficult to engage • Suicidal ideation; started on methylphenidate, good effect on suicidality and sweating, but not sustained.
  27. 27. Case 4; Susan • Multiple diagnosis including; bipolar, depression, BPD, anxiety • Antidepressants not working • Marked suicidality and DSH • Mum believed may have ADHD, assessment confirmed this • Stimulant medication marked improvement on suicidality.