Ó
2000 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 35 ± 39
35
Adult Attention Deficit Hyperactivity Disorder and comorbidity
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
PAULA ROSCA-REBAUDENGO,1 RIMONA DURST2 AND MOSHE DICKMAN,3 1
Talbieh Mental Health Cenre, affiliated with the Hebrew University, Hadassah Medical School, Jerusalem; 2Kfar Shaul Mental Health Centre, affiliated with the Hebrew University, Hadassah Medical School, Jerusalem and 3 University of Pittsburgh Medical Center, Pennsylvania, USA
Attention Deficit Hyperactivity Disorder (ADHD) is a chronic and incapacitating mental disorder characterized by overactivity, inattention and impulsiveness. The syndrome is usually diagnosed in childhood and it continues into adulthood. However, because the symptoms of ADHD frequently overlap with other categories of psychopathology, in adults it is often underdiagnosed or neglected, and left untreated. This paper emphasizes the importance of recognizing this syndrome in adulthood. To this end, we provide a review of the literature and four illustrative cases of our own. Appropriate treatment is also discussed. (Int J Psych Clin Pract 2000; 4: 35 ± 39)
Correspondence Address Dr Rimona Durst, Kfar Shaul Mental Health Centre, Jerusalem, Israel, 91060 Fax: 972-2-6512274
Received 10 September 1998; revised 20 May 1999; accepted for publication 25 May 1999
Keywords adult ADHD comorbidity psychosis
INTRODUCTION
T
he object of this paper is to draw attention to the occurrence of Attention Deficit Hyperactivity Disorder (ADHD) in adults, and to highlight the overlay and interplay of ADHD when it coexists with various other psychiatric conditions. According to the DSM-IV classification, ADHD is a psychiatric condition, usually first diagnosed in infancy, childhood or adolescence. It is currently viewed as a chronic disorder, originating in childhood but with symptoms frequently continuing into adult life, causing distress and psychiatric comorbidity. Wender and colleagues 1 were the first to describe the adult form of ADHD and its core symptoms, namely inattention, hyperactivity and impulsiveness. ADHD has previously been labelled with various headings such as hyperkinetic reaction, minimal brain dysfunction, minimal brain damage, and attention deficit disorder. 2 From the aetiological point of view, it has been attributed to genetic factors, alterations of cerebral glucose metabolism rate,3,4 and other pathophysiological disturbances. The main pathophysiological theory links the syndrome to dopaminergic mechanisms in the ventral tegmental DA neurons and their ascending fibers projecting to nucleus accumbens and prefrontal areas. Involvement of
drug abuse methylphenidate
norepinephrine (NE) and epinephrine in the locus coeruleus has also been suggested, 2 as well as dysfunction of other brain areas, including the diencephalon, caudate nucleus, fornix and septal region, and the reticular activating system. 5 However, to date, findings are inconclusive and it is possible that subtypes exist, depending on the neural systems involved. ADHD has been associated with a host of adult psychiatric conditions: antisocial personality disorder, 6 borderline personality disorder, 7 ± 9 a tendency to alcoholism,10,11 drug abuse,12 major depression, bipolar affective disorder, 13,14 and generalized anxiety disorder. 15,16 The possible link between psychotic disorders, schizophrenia and prolonged ADHD has led to new, nontraditional therapeutic strategies. 8,17 According to the literature, psychosis linked with ADHD (generally characterized by paranoid ideation without hallucinations) responds poorly to neuroleptics but symptoms are ameliorated quite promptly (within days) by psychostimulants.8 Prospective studies have demonstrated that at least half of children diagnosed as suffering from ADHD continue to show significant symptoms of the syndrome in adult life, 18,19 with concomitant repercussions on their social status, level of achievement, and sense of well-being. Adults may exhibit various behavioural problems such as
36
P Rosca-Rebaudengo et al
antisocial conduct, violation of the law, poor academic performance, etc. Their rate of employment is not affected but their rank is usually lower than average.20
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
THERAPEUTIC APPROACH The best outcome in the treatment of ADHD is achieved via a multimodal approach consisting of pharmacotherapy, educational ± cognitive therapy, and individual and family intervention. 21,22 Most of the experience in treating ADHD patients has been gathered in children, but the main principles apply to adults as well. The first-line pharmacological agents for the treatment of ADHD are CNS stimulants such as dextroamphetamines, methylphenidate and pemoline; at the moment, the action mechanism of these drugs is not quite clear. The second line of choice is provided by antidepressants such as imipramine (Tofranil), desipramine, and nortriptyline, all of which have been shown to be quite effective. 23 However, in children suffering from ADHD but without comorbid depression and anxiety, these are less effective than psychostimulants. Selective serotonin re-uptake inhibitors (SSRIs) are not considered beneficial in alleviating the cognitive symptoms of ADHD. Among the more recent treatments that have shown beneficial results are clonidine; 24 in cases of impulsivity and aggressiveness, a combination of a stimulant such as methylphenidate together with an antidepressant; MAO-A inhibitors25 (contraindicated in cases of drug abuse); and bupropion, an atypical antidepressant which seems to reduce the intensity of depressive as well as cognitive symptoms in hyperkinetic patients.2 The treatment of ADHD and its concomitant psychopathology is complicated and requires thorough acquaintance with the possible interaction of psychostimulants with other medications. Although, theoretically, psychostimulants have the capacity to trigger psychosis, prompt reduction of psychotic symptoms has been achieved with psychostimulants in some cases of psychosis or schizophrenia unresponsive to traditional neuroleptics. 8,17 With regard to bipolar disorders, although the combination of antidepressants and psychostimulants is often effective in the depressive phase, the use of psychostimulants in the manic phase seems to be hazardous. We believe that in the manic phase, an adjuvant of a mood stabilizer such as carbamazepine or valproic acid may bring about amelioration of symptoms, allowing psychostimulant administration to ADHD patients. Addition of clonidine for impulsivity or aggressive outburst should also be considered. In addition to the use of pharmacological agents, it is of utmost importance to address the psychological needs of the patient and the repercussions of the syndrome for him/ her as well as for those in his/her surroundings. This multimodality regimen requires the simultaneous use of individual and family psychotherapy ± mainly behavioural and cognitive in orientation ± and counselling.
ILLUSTRATIVE CASE REPORTS CASE 1 Y, a 23-year-old university student, was referred to psychotherapy due to interpersonal difficulties. He was diagnosed as suffering from depression superimposed on a narcissistic personality disorder. His depression remitted after 2 months of treatment with fluoxetine. During psychotherapy, he complained of difficulty in sustaining attention for more than few minutes at a time, resulting in underachievement and low self-esteem. In addition, he complained of being impatient, careless, unable to organize routine and leisure activities, easily distracted and forgetful. During sessions, he appeared restless, fidgety, and unable to focus his attention on the issue at hand. After detailed inquiry, it became clear that these symptoms had been present since early childhood, unnoticed and untreated. The administration of the Wender Utah Rating Scale (WURS),26 a structured clinical interview (SCID), neurological assessment, and psychological tests confirmed the suspected diagnosis of ADHD, and treatment with methylphenidate up to 20 mg/day (in two divided dosages) was initiated. The patient was assessed weekly for progress and adverse side-effects. This drug regimen resulted in distinct improvement in his powers of concentration and level of achievement, and a progressive increase in self-esteem. His mood changes stabilized, with no depressive relapses. Six months later, due to side-effects (insomnia and appetite loss), the patient decided to interrupt the methylphenidate treatment, and to use it intermittently according to the severity of ADHD symptoms. Follow-up, 2 years later showed the patient to be in a stable mental condition, with improved insight and acceptance of his difficulties.
CASE 2 D, 22 years old and unemployed, had been hyperactive, stubborn and impulsive since infancy. Her father died when she was 5 years old and at around the same time she immigrated to Israel from Europe and had to cope with acculturation and adjustment. Her learning (underachievement) and behavioural problems were ascribed to these major stress factors, and psychological treatment was initiated. Her main clinical manifestations were lack of concentration, high emotionality, impulsiveness, difficulty in focusing and maintaining attention, and hyperactivity. During adolescence, relations with her mother deteriorated and it became almost impossible to set limits to her behaviour. She was referred to a psychiatrist, who diagnosed borderline personality disorder, and she was treated accordingly. At the age of 16, she had a psychotic episode and left school. Prompt remission was obtained with haloperidol (up to 10 mg/day) and she was referred to
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
Adult ADHD
a community rehabilitation centre for adolescents, where she was treated until the age of 20. Thereafter, she moved into a flat, sharing with other young people, and although, in general, she was able to function, she was unable to sustain a job for more than a few months at a time; socially she was isolated and felt rejected. She embarked on a new course of psychotherapy in a rehabilitation centre, where she had been discouraged from academic pursuits in order to avoid stressful experiences and frustration. In the new psychotherapeutic setting, D expressed a desire to complete her high school studies. She was encouraged to do so and succeeded in completing an additional class. However, in view of the tremendous effort required on her part, it was suggested that her longstanding difficulties might be secondary to ADHD. The diagnosis of ADHD was established by WURS, SCID, neurological examination and neuropsychological assessment, which elicited dyslexia, serious concentration problems, disinhibition, high distractibility and planning difficulties. Methylphenidate treatment was initiated and gradually the dosage of 40 mg/day (divided thrice daily, 20 mg given in the morning on waking) was reached. The patient was monitored weekly. She developed side-effects, mainly restlessness and insomnia, and refused to continue with the medication. She was then sent to a cognitive therapist, who focused on her ADHD symptoms. She is currently at a boarding school program for young ADHD adults.
CASE 3 R, a 49-year-old professional/academic, married for the second time and father of five, was referred to psychotherapy because of lack of self-esteem, mood swings, and a sense of detachment from others. His past history revealed a reactive depressive episode following his father’s death, a hypomanic episode after his divorce which drove him into a new marital relationship, new fatherhood and a repeat pattern of marital discord. Lithium treatment was only partially beneficial and was discontinued due to side-effects (tremor and obesity) and psychological opposition. During psychotherapy, it transpired that he had a long history of inattentiveness and lack of concentration, especially at school and later at university. He recalled being impulsive and undertaking various tasks simultaneously, never to be completed. He was highly talkative and impatient with others, and described himself as ``emotionally distant’’. Following tremendous effort, driven by the motive not to disappoint his father, he succeeded in graduating, but was unable to specialize in his field of choice because of his incapacity to read required texts. He was referred to a neuropsychologist for diagnostic evaluation and probable ADHD was diagnosed on the basis of SCID and WURS. A trial with a psychostimulant (methylphenidate, 40 mg/day in three divided dosages) proved beneficial without any sign of mood elevation toward hypomania. As a result, for the first time in his life
37
he was able to read professional literature through to the end. Unfortunately, he feared dependency on the drug and decided to discontinue it. R is well aware that when in need he could re-approach this medication regimen.
CASE 4 I, 34 years old, living on her own, was referred for psychiatric treatment due to reactive depression. Her learning disorders, appearing in first grade, were attributed to psychological difficulties against a background of family discord. She was referred to a child psychologist but treatment was interrupted a few months later, with no improvement in school performance. Behavioural problems emerged around the same time, mainly hyperactivity and impulsiveness, inability to concentrate and complete either games or school assignments, loss of interest in activities, and distractibility. She was unable to sit still in one place for more than a few minutes at a time. She often seemed `detached’ from her surroundings, her social conduct was marked by impulsive acts and lack of boundaries, resulting in social rejection by her peers. She complained of pressure in her head and of being overwhelmed by external stimuli. During adolescence she started using drugs (hashish and marijuana) as a way to reduce her tension and restlessness. Later on, she turned to LSD and MDMA (Ecstasy) and soon became addicted and dependent, using drugs on a daily basis. The drug abuse led to further deterioration in her school performance and social interactions. She quit school but could not hold down jobs and her social contacts continued to be unsatisfying, especially in the romantic domain. In her mid-twenties she was referred to a day care unit, due to depression with suicidal ideation, which was attributed to an underlying borderline personality disorder and drug abuse. Treatment with nortriptyline up to 150 mg/day was ineffective and replaced by carbamazepine up to 800 mg/day which reduced her depression and eased her psychic agitation. After discharge, she was treated at an outpatient clinic and received psychotherapy concomitantly with carbamazepine. However, her impulsiveness and hyperactivity persisted and prevented her from engaging in academic activities, even though her intelligence and cognitive potential were high. In reviewing her case, the diagnosis of ADHD was proposed, and was confirmed by SCID, WURS and neuropsychological testing, which showed cognitive deficits, problems in sustaining attention and concentration. Methylphenidate treatment was initiated and evaluated weekly (with dosage titrated and adjusted to 40 mg/day). The response was dramatic: she was finally able to control her behaviour, concentrate and focus on tasks, and read texts to the end. She embarked on a formal professional course in which she excelled. In parallel with this improvement, she gradually stopped using drugs, aware of the possible danger of the
38
P Rosca-Rebaudengo et al
concomitant use of drugs and psychostimulants. At followup 3 years later, the patient was not on drugs and her mental condition was stable.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
DISCUSSION Comorbidity of ADHD and bipolar affective disorder is frequently reported, especially in children and adolescents.15 Genetic studies have shown higher rates among first-degree relatives of subjects affected by comorbid ADHD and bipolar disorder. 13 It is therefore suggested that when ADHD is combined with bipolar disorder, it should be treated as a distinct nosological entity.27 Manic patients frequently reveal a history of ADHD, and manic episodes of previously ADHD patients tend to be particularly severe. The history of young manic patients should, therefore, be searched for previous underlying ADHD manifestations.16,27 Similarly, there may be neglect of a superimposed manic episode in a patient diagnosed as hyperactive, 28 and inappropriate treatment may be given. Although mood and anxiety episodes are frequently associated with ADHD and increased risk of substance abuse, ADHD by itself is a significant risk factor in drug abuse disorders. 29 In children, ADHD often appears together with reading disabilities or dyslexia: reading disabilities affecting the cognitive domain, and ADHD affecting the behavioural field.30 Monozygotic and dizygotic twin studies point to two different disturbances but the possibility of a comorbid subtype should not be ruled out.31 The cognitive form of ADHD (20% of all cases) seems to share information processing deficits with dyslexia. 32 This cognitive impairment seems to continue into adult life, resulting in underachievement in academic and social contexts. The more disabling neuropsychological issues in adults are executive dysfunction and social imperception/ineptitude, the latter often attributed to personality traits or disorders and hence wrongly treated. In such cases, neuropsychological evaluation and subsequent cognitive treatment are indispensable.33 In the cases presented above, different associations of comorbidity frequently encountered in clinical practice are described. The various combinations call for different treatment strategies and therefore therapeutic programmes should be individualized. In Case 1 ± comorbidity of personality disorder, ADHD, and depression ± methylphenidate treatment was found to be effective in improving the patient’s academic performance. However, due to side-effects (appetite loss and insomnia), the treatment had to be interrupted, to be reinstated intermittently according to need. In Case 2 ± association between borderline personality disorder, ADHD and acute paranoid psychosis ± although methylphenidate caused side-effects, no exacerbation of the psychosis was elicited, and the ascription of many of the cognitive symptoms to ADHD opened up new possibilities for the
patient’s rehabilitation and resocialization. In Case 3 ± comorbidity of bipolar disorder, personality disorder and ADHD ± although lithium followed by carbamazepine proved to be effective in stabilizing the patient’s mood, his symptoms of inattentiveness persisted. Psychostimulant treatment proved effective but, due to fear of dependence, the patient stopped the treatment. In Case 4 ± concomitant borderline personality disorder, ADHD and drug abuse ± the effect of methylphenidate was dramatic: only when symptoms were correctly diagnosed as ADHD and appropriately treated by a psychostimulant (methylphenidate), did a significant improvement appear: the characteristics of the personality disorder lessened, academic achievement was attained, and drug abuse ceased.34
CONCLUSIONS The diagnosis of the adult form of ADHD calls for a broader perspective and understanding in both evaluation and treatment. Once the case is diagnosed, the physician should be prepared to consider other therapeutic modalities should first-line psychostimulants such as methylphenidate fail to improve symptoms. Furthermore, the patient’s awareness of the disorder may in itself assist therapy by allaying guilt for failure and concomitant low self-esteem. In cases of comorbidity with psychosis, mood disorders, personality disorders or drug abuse, it is important to ascertain which of the concomitant conditions is primary. If ADHD is diagnosed, then even if it is masked by other major psychiatric disorders, it should be treated promptly following alleviation of the major problem. Finally, as pharmacological treatment with CNS stimulants may be required indefinitely, there has to be close monitoring for response, side-effects and drug abuse. Moreover, in our experience, psychostimulants may provide much-needed stabilizing effects for the patients and, therefore, they may even be used, albeit with great caution, in treating drug abuse or psychosis.
KEY POINTS
· · · · ·
Adult ADHD with co-morbidity is frequently underdiagnosed or neglected Psychiatric comorbid conditions include: affective and anxiety disorders, personality disorders, alcohol and drug abuse and even psychosis Therapy of adult ADHD with comorbidity is complicated and both conditions should be treated Treatment strategy is multi-modal and individualized Psychopharmacological therapy requires a trial with psychostimulants alone or in combination with other medications, according to the comorbid condition
Adult ADHD
39
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
REFERENCES 1. Wender PH, Reimherr FW, Wood DR (1981) Attention deficit disorder (minimal brain dysfunction) in adults. A replication study of diagnosis and drug treatment. Arch Gen Psychiatry 38: 449 ± 56. 2. McCracken JT (1991) A two part model of stimulant action on Attention Deficit/Hyperactivity Disorder in children. J Neuropsychiatry 3: 201 ± 8. 3. Zametkin AJ, Nordahl TE, Gross M et al (1990) Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl J Med 323: 1361 ± 6. 4. Gur S, Granek A, Apter A (1996) Adult attention deficit hyperactivity disorder (in Hebrew). Harefuah 130: 851 ± 854. 5. Voeller KKS (1991) What can neurological models of attention, intention and arousal tell us about Attention Deficit/Hyperactivity Disorder? J Neuropsychiatry 3: 209 ± 216. 6. Mannuzza S, Klein RG, Bessler A et al (1993) Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 50: 565 ± 76. 7. Andrulonis P, Glueck B, Stoebel C et al (1981) Organic brain dysfunction and borderline syndrome. Psychiatr Clin North Am 4: 47 ± 66. 8. Pine DS, Klein RG, Lindy DC et al (1993) Attention Deficit/ Hyperactivity Disorder and comorbid psychosis: A review and two clinical presentations. J Clin Psychiatry 54: 140 ± 5. 9. Hooberman D, Stern TA (1984) Treatment of attention deficit and borderline personality disorder with psycho stimulants: case report. J Clin Psychiatry 45: 441 ± 2. 10. Manshadi M, Lippmann S, O’Daniel RG et al (1983) Alcohol abuse and attention deficit disorder. J Clin Psychiatry 44: 379 ± 80. 11. Glenn SW, Parsons OA (1991) Prediction of resumption of drinking and post treatment alcoholics. Int J Addict 26: 237 ± 54. 12. Wilens TE, Biederman J, Spencer TJ et al (1994) Comorbidity of Attention-Deficit Hyperactivity and psychoactive substance use disorders. Hosp Commun Psychiatry 45: 421 ± 3. 13. Biederman J, Munir K, Knee D et al (1987) High rate of affective disorders in probands with attention deficit disorder and in their relatives: A controlled family study. Am J Psychiatry 144: 330 ± 3. 14. Biederman J, Faraone SV, Keenan K et al (1991) Evidence of familial association between attention deficit disorder and major affective disorders. Arch Gen Psychiatry 48: 633 ± 42. 15. Milberger S, Biederman J, Faraone SV et al (1995) Attention Deficit Hyperactivity Disorder and comorbid disorders: Issues of overlapping symptoms. Am J Psychiatry 152: 1793 ± 9. 16. West SA, Strakowski SM, Sax KW et al (1995) The comorbidity of Attention Deficit Hyperactivity Disorder in adolescent mania: potential diagnostic and treatment implications. Psychopharmacol Bull 31: 347 ± 51. 17. Bellak LA (1976) A possible subgroup of schizophrenic syndrome and implications for treatment. Am J Psychotherapy 30: 194 ± 205. 18. Hechtman L, Weiss G, Perlman T (1984) Young adult outcome of hyperactive children who received long term stimulant treatment. J Am Acad Child Psychiatry 23: 261 ± 9.
19. Schubiner H, Tzelepis A, Isaacson JH et al (1995) The dual diagnosis of Attention Deficit/Hyperactivity Disorder and substance abuse: Case reports and literature review. J Clin Psychiatry 56: 146 ± 50. 20. Mannuzza S, Klein RG, Bonagura N et al (1991) Hyperactive boys almost grown up. V. Replication of psychiatric status. Arch Gen Psychiatry 48: 77 ± 83. 21. Kaplan HI, Sadock BJ, Grebb JA (eds) (1994) Synopsis of psychiatry (7th edn.) 1067 ± 8. Williams & Wilkins. Baltimore, MD. 22. Satterfield JH, Satterfield BT, Cantwell D (1981) Three-year multimodal treatment of 100 hyperactive boys. J Pediatr 98: 650 ± 5. 23. Levin GM (1995) Attention Deficit/Hyperactivity Disorder: the pharmacist’s role. Am Pharmacist 35: 10 ± 20. 24. Hunt RD, Minderra R, Cohen DA (1985) Clonidine benefits in children with attention deficit disorder: a report of a double blind placebo crossover trial. J Am Acad Child Adol Psychiatry 24: 617 ± 29. 25. Zametkin A, Rapoport JL, Murphy DL et al (1985) Treatment of hyperactive children with monoamine oxidase inhibitors. II. Plasma and urinary monoamine findings after treatment. Arch Gen Psychiatry 42: 969 ± 73. 26. Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 150: 885 ± 90. 27. Wozniak, Biederman J, Mandy E et al (1995) A pilot family study of childhood onset mania. J Am Acad Child Adol Psychiatry 34: 1577 ± 83. 28. Isaac G (1992) Misdiagnosed bipolar disorder in adolescents in a special educational school and treatment program. J Clin Psychiatry 53: 133 ± 6. 29. Biederman J, Newcorn J, Sprich S (1991) Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry 148: 564 ± 77. 30. Shaywitz BA, Fletcher JM, Shaywitz SE (1995) Defining and classifying learning disabilities and attention-deficit/hyperactivity disorder. J Child Neurol 1: 50 ± 57. 31. Gilger JW, Pennington BF, DeFries JC (1992) A twin study of the etiology of comorbidity: Attention-deficit hyperactivity disorder and dyslexia. J Am Acad Child Adol Psychiatry 31: 343 ± 8. 32. August GJ, Garfinkel BD (1989) Behavioral and cognitive subtypes of ADHD. Am Acad Child Adol Psychiatry 28: 739 ± 48. 33. Denckla MB (1993) The child with developmental disabilities grown up: adult residua of childhood disorders. Clin Neurol 11: 105 ± 125. 34. Durst R, Rosca-Rebaudengo P (1997) Adult attention deficit hyperactivity disorder as a possible underlying condition facilitating alcohol and drug abuse (in Hebrew). Harefuah 132: 618 ± 22.
2000 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 35 ± 39
35
Adult Attention Deficit Hyperactivity Disorder and comorbidity
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
PAULA ROSCA-REBAUDENGO,1 RIMONA DURST2 AND MOSHE DICKMAN,3 1
Talbieh Mental Health Cenre, affiliated with the Hebrew University, Hadassah Medical School, Jerusalem; 2Kfar Shaul Mental Health Centre, affiliated with the Hebrew University, Hadassah Medical School, Jerusalem and 3 University of Pittsburgh Medical Center, Pennsylvania, USA
Attention Deficit Hyperactivity Disorder (ADHD) is a chronic and incapacitating mental disorder characterized by overactivity, inattention and impulsiveness. The syndrome is usually diagnosed in childhood and it continues into adulthood. However, because the symptoms of ADHD frequently overlap with other categories of psychopathology, in adults it is often underdiagnosed or neglected, and left untreated. This paper emphasizes the importance of recognizing this syndrome in adulthood. To this end, we provide a review of the literature and four illustrative cases of our own. Appropriate treatment is also discussed. (Int J Psych Clin Pract 2000; 4: 35 ± 39)
Correspondence Address Dr Rimona Durst, Kfar Shaul Mental Health Centre, Jerusalem, Israel, 91060 Fax: 972-2-6512274
Received 10 September 1998; revised 20 May 1999; accepted for publication 25 May 1999
Keywords adult ADHD comorbidity psychosis
INTRODUCTION
T
he object of this paper is to draw attention to the occurrence of Attention Deficit Hyperactivity Disorder (ADHD) in adults, and to highlight the overlay and interplay of ADHD when it coexists with various other psychiatric conditions. According to the DSM-IV classification, ADHD is a psychiatric condition, usually first diagnosed in infancy, childhood or adolescence. It is currently viewed as a chronic disorder, originating in childhood but with symptoms frequently continuing into adult life, causing distress and psychiatric comorbidity. Wender and colleagues 1 were the first to describe the adult form of ADHD and its core symptoms, namely inattention, hyperactivity and impulsiveness. ADHD has previously been labelled with various headings such as hyperkinetic reaction, minimal brain dysfunction, minimal brain damage, and attention deficit disorder. 2 From the aetiological point of view, it has been attributed to genetic factors, alterations of cerebral glucose metabolism rate,3,4 and other pathophysiological disturbances. The main pathophysiological theory links the syndrome to dopaminergic mechanisms in the ventral tegmental DA neurons and their ascending fibers projecting to nucleus accumbens and prefrontal areas. Involvement of
drug abuse methylphenidate
norepinephrine (NE) and epinephrine in the locus coeruleus has also been suggested, 2 as well as dysfunction of other brain areas, including the diencephalon, caudate nucleus, fornix and septal region, and the reticular activating system. 5 However, to date, findings are inconclusive and it is possible that subtypes exist, depending on the neural systems involved. ADHD has been associated with a host of adult psychiatric conditions: antisocial personality disorder, 6 borderline personality disorder, 7 ± 9 a tendency to alcoholism,10,11 drug abuse,12 major depression, bipolar affective disorder, 13,14 and generalized anxiety disorder. 15,16 The possible link between psychotic disorders, schizophrenia and prolonged ADHD has led to new, nontraditional therapeutic strategies. 8,17 According to the literature, psychosis linked with ADHD (generally characterized by paranoid ideation without hallucinations) responds poorly to neuroleptics but symptoms are ameliorated quite promptly (within days) by psychostimulants.8 Prospective studies have demonstrated that at least half of children diagnosed as suffering from ADHD continue to show significant symptoms of the syndrome in adult life, 18,19 with concomitant repercussions on their social status, level of achievement, and sense of well-being. Adults may exhibit various behavioural problems such as
36
P Rosca-Rebaudengo et al
antisocial conduct, violation of the law, poor academic performance, etc. Their rate of employment is not affected but their rank is usually lower than average.20
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
THERAPEUTIC APPROACH The best outcome in the treatment of ADHD is achieved via a multimodal approach consisting of pharmacotherapy, educational ± cognitive therapy, and individual and family intervention. 21,22 Most of the experience in treating ADHD patients has been gathered in children, but the main principles apply to adults as well. The first-line pharmacological agents for the treatment of ADHD are CNS stimulants such as dextroamphetamines, methylphenidate and pemoline; at the moment, the action mechanism of these drugs is not quite clear. The second line of choice is provided by antidepressants such as imipramine (Tofranil), desipramine, and nortriptyline, all of which have been shown to be quite effective. 23 However, in children suffering from ADHD but without comorbid depression and anxiety, these are less effective than psychostimulants. Selective serotonin re-uptake inhibitors (SSRIs) are not considered beneficial in alleviating the cognitive symptoms of ADHD. Among the more recent treatments that have shown beneficial results are clonidine; 24 in cases of impulsivity and aggressiveness, a combination of a stimulant such as methylphenidate together with an antidepressant; MAO-A inhibitors25 (contraindicated in cases of drug abuse); and bupropion, an atypical antidepressant which seems to reduce the intensity of depressive as well as cognitive symptoms in hyperkinetic patients.2 The treatment of ADHD and its concomitant psychopathology is complicated and requires thorough acquaintance with the possible interaction of psychostimulants with other medications. Although, theoretically, psychostimulants have the capacity to trigger psychosis, prompt reduction of psychotic symptoms has been achieved with psychostimulants in some cases of psychosis or schizophrenia unresponsive to traditional neuroleptics. 8,17 With regard to bipolar disorders, although the combination of antidepressants and psychostimulants is often effective in the depressive phase, the use of psychostimulants in the manic phase seems to be hazardous. We believe that in the manic phase, an adjuvant of a mood stabilizer such as carbamazepine or valproic acid may bring about amelioration of symptoms, allowing psychostimulant administration to ADHD patients. Addition of clonidine for impulsivity or aggressive outburst should also be considered. In addition to the use of pharmacological agents, it is of utmost importance to address the psychological needs of the patient and the repercussions of the syndrome for him/ her as well as for those in his/her surroundings. This multimodality regimen requires the simultaneous use of individual and family psychotherapy ± mainly behavioural and cognitive in orientation ± and counselling.
ILLUSTRATIVE CASE REPORTS CASE 1 Y, a 23-year-old university student, was referred to psychotherapy due to interpersonal difficulties. He was diagnosed as suffering from depression superimposed on a narcissistic personality disorder. His depression remitted after 2 months of treatment with fluoxetine. During psychotherapy, he complained of difficulty in sustaining attention for more than few minutes at a time, resulting in underachievement and low self-esteem. In addition, he complained of being impatient, careless, unable to organize routine and leisure activities, easily distracted and forgetful. During sessions, he appeared restless, fidgety, and unable to focus his attention on the issue at hand. After detailed inquiry, it became clear that these symptoms had been present since early childhood, unnoticed and untreated. The administration of the Wender Utah Rating Scale (WURS),26 a structured clinical interview (SCID), neurological assessment, and psychological tests confirmed the suspected diagnosis of ADHD, and treatment with methylphenidate up to 20 mg/day (in two divided dosages) was initiated. The patient was assessed weekly for progress and adverse side-effects. This drug regimen resulted in distinct improvement in his powers of concentration and level of achievement, and a progressive increase in self-esteem. His mood changes stabilized, with no depressive relapses. Six months later, due to side-effects (insomnia and appetite loss), the patient decided to interrupt the methylphenidate treatment, and to use it intermittently according to the severity of ADHD symptoms. Follow-up, 2 years later showed the patient to be in a stable mental condition, with improved insight and acceptance of his difficulties.
CASE 2 D, 22 years old and unemployed, had been hyperactive, stubborn and impulsive since infancy. Her father died when she was 5 years old and at around the same time she immigrated to Israel from Europe and had to cope with acculturation and adjustment. Her learning (underachievement) and behavioural problems were ascribed to these major stress factors, and psychological treatment was initiated. Her main clinical manifestations were lack of concentration, high emotionality, impulsiveness, difficulty in focusing and maintaining attention, and hyperactivity. During adolescence, relations with her mother deteriorated and it became almost impossible to set limits to her behaviour. She was referred to a psychiatrist, who diagnosed borderline personality disorder, and she was treated accordingly. At the age of 16, she had a psychotic episode and left school. Prompt remission was obtained with haloperidol (up to 10 mg/day) and she was referred to
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
Adult ADHD
a community rehabilitation centre for adolescents, where she was treated until the age of 20. Thereafter, she moved into a flat, sharing with other young people, and although, in general, she was able to function, she was unable to sustain a job for more than a few months at a time; socially she was isolated and felt rejected. She embarked on a new course of psychotherapy in a rehabilitation centre, where she had been discouraged from academic pursuits in order to avoid stressful experiences and frustration. In the new psychotherapeutic setting, D expressed a desire to complete her high school studies. She was encouraged to do so and succeeded in completing an additional class. However, in view of the tremendous effort required on her part, it was suggested that her longstanding difficulties might be secondary to ADHD. The diagnosis of ADHD was established by WURS, SCID, neurological examination and neuropsychological assessment, which elicited dyslexia, serious concentration problems, disinhibition, high distractibility and planning difficulties. Methylphenidate treatment was initiated and gradually the dosage of 40 mg/day (divided thrice daily, 20 mg given in the morning on waking) was reached. The patient was monitored weekly. She developed side-effects, mainly restlessness and insomnia, and refused to continue with the medication. She was then sent to a cognitive therapist, who focused on her ADHD symptoms. She is currently at a boarding school program for young ADHD adults.
CASE 3 R, a 49-year-old professional/academic, married for the second time and father of five, was referred to psychotherapy because of lack of self-esteem, mood swings, and a sense of detachment from others. His past history revealed a reactive depressive episode following his father’s death, a hypomanic episode after his divorce which drove him into a new marital relationship, new fatherhood and a repeat pattern of marital discord. Lithium treatment was only partially beneficial and was discontinued due to side-effects (tremor and obesity) and psychological opposition. During psychotherapy, it transpired that he had a long history of inattentiveness and lack of concentration, especially at school and later at university. He recalled being impulsive and undertaking various tasks simultaneously, never to be completed. He was highly talkative and impatient with others, and described himself as ``emotionally distant’’. Following tremendous effort, driven by the motive not to disappoint his father, he succeeded in graduating, but was unable to specialize in his field of choice because of his incapacity to read required texts. He was referred to a neuropsychologist for diagnostic evaluation and probable ADHD was diagnosed on the basis of SCID and WURS. A trial with a psychostimulant (methylphenidate, 40 mg/day in three divided dosages) proved beneficial without any sign of mood elevation toward hypomania. As a result, for the first time in his life
37
he was able to read professional literature through to the end. Unfortunately, he feared dependency on the drug and decided to discontinue it. R is well aware that when in need he could re-approach this medication regimen.
CASE 4 I, 34 years old, living on her own, was referred for psychiatric treatment due to reactive depression. Her learning disorders, appearing in first grade, were attributed to psychological difficulties against a background of family discord. She was referred to a child psychologist but treatment was interrupted a few months later, with no improvement in school performance. Behavioural problems emerged around the same time, mainly hyperactivity and impulsiveness, inability to concentrate and complete either games or school assignments, loss of interest in activities, and distractibility. She was unable to sit still in one place for more than a few minutes at a time. She often seemed `detached’ from her surroundings, her social conduct was marked by impulsive acts and lack of boundaries, resulting in social rejection by her peers. She complained of pressure in her head and of being overwhelmed by external stimuli. During adolescence she started using drugs (hashish and marijuana) as a way to reduce her tension and restlessness. Later on, she turned to LSD and MDMA (Ecstasy) and soon became addicted and dependent, using drugs on a daily basis. The drug abuse led to further deterioration in her school performance and social interactions. She quit school but could not hold down jobs and her social contacts continued to be unsatisfying, especially in the romantic domain. In her mid-twenties she was referred to a day care unit, due to depression with suicidal ideation, which was attributed to an underlying borderline personality disorder and drug abuse. Treatment with nortriptyline up to 150 mg/day was ineffective and replaced by carbamazepine up to 800 mg/day which reduced her depression and eased her psychic agitation. After discharge, she was treated at an outpatient clinic and received psychotherapy concomitantly with carbamazepine. However, her impulsiveness and hyperactivity persisted and prevented her from engaging in academic activities, even though her intelligence and cognitive potential were high. In reviewing her case, the diagnosis of ADHD was proposed, and was confirmed by SCID, WURS and neuropsychological testing, which showed cognitive deficits, problems in sustaining attention and concentration. Methylphenidate treatment was initiated and evaluated weekly (with dosage titrated and adjusted to 40 mg/day). The response was dramatic: she was finally able to control her behaviour, concentrate and focus on tasks, and read texts to the end. She embarked on a formal professional course in which she excelled. In parallel with this improvement, she gradually stopped using drugs, aware of the possible danger of the
38
P Rosca-Rebaudengo et al
concomitant use of drugs and psychostimulants. At followup 3 years later, the patient was not on drugs and her mental condition was stable.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
DISCUSSION Comorbidity of ADHD and bipolar affective disorder is frequently reported, especially in children and adolescents.15 Genetic studies have shown higher rates among first-degree relatives of subjects affected by comorbid ADHD and bipolar disorder. 13 It is therefore suggested that when ADHD is combined with bipolar disorder, it should be treated as a distinct nosological entity.27 Manic patients frequently reveal a history of ADHD, and manic episodes of previously ADHD patients tend to be particularly severe. The history of young manic patients should, therefore, be searched for previous underlying ADHD manifestations.16,27 Similarly, there may be neglect of a superimposed manic episode in a patient diagnosed as hyperactive, 28 and inappropriate treatment may be given. Although mood and anxiety episodes are frequently associated with ADHD and increased risk of substance abuse, ADHD by itself is a significant risk factor in drug abuse disorders. 29 In children, ADHD often appears together with reading disabilities or dyslexia: reading disabilities affecting the cognitive domain, and ADHD affecting the behavioural field.30 Monozygotic and dizygotic twin studies point to two different disturbances but the possibility of a comorbid subtype should not be ruled out.31 The cognitive form of ADHD (20% of all cases) seems to share information processing deficits with dyslexia. 32 This cognitive impairment seems to continue into adult life, resulting in underachievement in academic and social contexts. The more disabling neuropsychological issues in adults are executive dysfunction and social imperception/ineptitude, the latter often attributed to personality traits or disorders and hence wrongly treated. In such cases, neuropsychological evaluation and subsequent cognitive treatment are indispensable.33 In the cases presented above, different associations of comorbidity frequently encountered in clinical practice are described. The various combinations call for different treatment strategies and therefore therapeutic programmes should be individualized. In Case 1 ± comorbidity of personality disorder, ADHD, and depression ± methylphenidate treatment was found to be effective in improving the patient’s academic performance. However, due to side-effects (appetite loss and insomnia), the treatment had to be interrupted, to be reinstated intermittently according to need. In Case 2 ± association between borderline personality disorder, ADHD and acute paranoid psychosis ± although methylphenidate caused side-effects, no exacerbation of the psychosis was elicited, and the ascription of many of the cognitive symptoms to ADHD opened up new possibilities for the
patient’s rehabilitation and resocialization. In Case 3 ± comorbidity of bipolar disorder, personality disorder and ADHD ± although lithium followed by carbamazepine proved to be effective in stabilizing the patient’s mood, his symptoms of inattentiveness persisted. Psychostimulant treatment proved effective but, due to fear of dependence, the patient stopped the treatment. In Case 4 ± concomitant borderline personality disorder, ADHD and drug abuse ± the effect of methylphenidate was dramatic: only when symptoms were correctly diagnosed as ADHD and appropriately treated by a psychostimulant (methylphenidate), did a significant improvement appear: the characteristics of the personality disorder lessened, academic achievement was attained, and drug abuse ceased.34
CONCLUSIONS The diagnosis of the adult form of ADHD calls for a broader perspective and understanding in both evaluation and treatment. Once the case is diagnosed, the physician should be prepared to consider other therapeutic modalities should first-line psychostimulants such as methylphenidate fail to improve symptoms. Furthermore, the patient’s awareness of the disorder may in itself assist therapy by allaying guilt for failure and concomitant low self-esteem. In cases of comorbidity with psychosis, mood disorders, personality disorders or drug abuse, it is important to ascertain which of the concomitant conditions is primary. If ADHD is diagnosed, then even if it is masked by other major psychiatric disorders, it should be treated promptly following alleviation of the major problem. Finally, as pharmacological treatment with CNS stimulants may be required indefinitely, there has to be close monitoring for response, side-effects and drug abuse. Moreover, in our experience, psychostimulants may provide much-needed stabilizing effects for the patients and, therefore, they may even be used, albeit with great caution, in treating drug abuse or psychosis.
KEY POINTS
· · · · ·
Adult ADHD with co-morbidity is frequently underdiagnosed or neglected Psychiatric comorbid conditions include: affective and anxiety disorders, personality disorders, alcohol and drug abuse and even psychosis Therapy of adult ADHD with comorbidity is complicated and both conditions should be treated Treatment strategy is multi-modal and individualized Psychopharmacological therapy requires a trial with psychostimulants alone or in combination with other medications, according to the comorbid condition
Adult ADHD
39
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of North Carolina on 10/31/14 For personal use only.
REFERENCES 1. Wender PH, Reimherr FW, Wood DR (1981) Attention deficit disorder (minimal brain dysfunction) in adults. A replication study of diagnosis and drug treatment. Arch Gen Psychiatry 38: 449 ± 56. 2. McCracken JT (1991) A two part model of stimulant action on Attention Deficit/Hyperactivity Disorder in children. J Neuropsychiatry 3: 201 ± 8. 3. Zametkin AJ, Nordahl TE, Gross M et al (1990) Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl J Med 323: 1361 ± 6. 4. Gur S, Granek A, Apter A (1996) Adult attention deficit hyperactivity disorder (in Hebrew). Harefuah 130: 851 ± 854. 5. Voeller KKS (1991) What can neurological models of attention, intention and arousal tell us about Attention Deficit/Hyperactivity Disorder? J Neuropsychiatry 3: 209 ± 216. 6. Mannuzza S, Klein RG, Bessler A et al (1993) Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 50: 565 ± 76. 7. Andrulonis P, Glueck B, Stoebel C et al (1981) Organic brain dysfunction and borderline syndrome. Psychiatr Clin North Am 4: 47 ± 66. 8. Pine DS, Klein RG, Lindy DC et al (1993) Attention Deficit/ Hyperactivity Disorder and comorbid psychosis: A review and two clinical presentations. J Clin Psychiatry 54: 140 ± 5. 9. Hooberman D, Stern TA (1984) Treatment of attention deficit and borderline personality disorder with psycho stimulants: case report. J Clin Psychiatry 45: 441 ± 2. 10. Manshadi M, Lippmann S, O’Daniel RG et al (1983) Alcohol abuse and attention deficit disorder. J Clin Psychiatry 44: 379 ± 80. 11. Glenn SW, Parsons OA (1991) Prediction of resumption of drinking and post treatment alcoholics. Int J Addict 26: 237 ± 54. 12. Wilens TE, Biederman J, Spencer TJ et al (1994) Comorbidity of Attention-Deficit Hyperactivity and psychoactive substance use disorders. Hosp Commun Psychiatry 45: 421 ± 3. 13. Biederman J, Munir K, Knee D et al (1987) High rate of affective disorders in probands with attention deficit disorder and in their relatives: A controlled family study. Am J Psychiatry 144: 330 ± 3. 14. Biederman J, Faraone SV, Keenan K et al (1991) Evidence of familial association between attention deficit disorder and major affective disorders. Arch Gen Psychiatry 48: 633 ± 42. 15. Milberger S, Biederman J, Faraone SV et al (1995) Attention Deficit Hyperactivity Disorder and comorbid disorders: Issues of overlapping symptoms. Am J Psychiatry 152: 1793 ± 9. 16. West SA, Strakowski SM, Sax KW et al (1995) The comorbidity of Attention Deficit Hyperactivity Disorder in adolescent mania: potential diagnostic and treatment implications. Psychopharmacol Bull 31: 347 ± 51. 17. Bellak LA (1976) A possible subgroup of schizophrenic syndrome and implications for treatment. Am J Psychotherapy 30: 194 ± 205. 18. Hechtman L, Weiss G, Perlman T (1984) Young adult outcome of hyperactive children who received long term stimulant treatment. J Am Acad Child Psychiatry 23: 261 ± 9.
19. Schubiner H, Tzelepis A, Isaacson JH et al (1995) The dual diagnosis of Attention Deficit/Hyperactivity Disorder and substance abuse: Case reports and literature review. J Clin Psychiatry 56: 146 ± 50. 20. Mannuzza S, Klein RG, Bonagura N et al (1991) Hyperactive boys almost grown up. V. Replication of psychiatric status. Arch Gen Psychiatry 48: 77 ± 83. 21. Kaplan HI, Sadock BJ, Grebb JA (eds) (1994) Synopsis of psychiatry (7th edn.) 1067 ± 8. Williams & Wilkins. Baltimore, MD. 22. Satterfield JH, Satterfield BT, Cantwell D (1981) Three-year multimodal treatment of 100 hyperactive boys. J Pediatr 98: 650 ± 5. 23. Levin GM (1995) Attention Deficit/Hyperactivity Disorder: the pharmacist’s role. Am Pharmacist 35: 10 ± 20. 24. Hunt RD, Minderra R, Cohen DA (1985) Clonidine benefits in children with attention deficit disorder: a report of a double blind placebo crossover trial. J Am Acad Child Adol Psychiatry 24: 617 ± 29. 25. Zametkin A, Rapoport JL, Murphy DL et al (1985) Treatment of hyperactive children with monoamine oxidase inhibitors. II. Plasma and urinary monoamine findings after treatment. Arch Gen Psychiatry 42: 969 ± 73. 26. Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 150: 885 ± 90. 27. Wozniak, Biederman J, Mandy E et al (1995) A pilot family study of childhood onset mania. J Am Acad Child Adol Psychiatry 34: 1577 ± 83. 28. Isaac G (1992) Misdiagnosed bipolar disorder in adolescents in a special educational school and treatment program. J Clin Psychiatry 53: 133 ± 6. 29. Biederman J, Newcorn J, Sprich S (1991) Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry 148: 564 ± 77. 30. Shaywitz BA, Fletcher JM, Shaywitz SE (1995) Defining and classifying learning disabilities and attention-deficit/hyperactivity disorder. J Child Neurol 1: 50 ± 57. 31. Gilger JW, Pennington BF, DeFries JC (1992) A twin study of the etiology of comorbidity: Attention-deficit hyperactivity disorder and dyslexia. J Am Acad Child Adol Psychiatry 31: 343 ± 8. 32. August GJ, Garfinkel BD (1989) Behavioral and cognitive subtypes of ADHD. Am Acad Child Adol Psychiatry 28: 739 ± 48. 33. Denckla MB (1993) The child with developmental disabilities grown up: adult residua of childhood disorders. Clin Neurol 11: 105 ± 125. 34. Durst R, Rosca-Rebaudengo P (1997) Adult attention deficit hyperactivity disorder as a possible underlying condition facilitating alcohol and drug abuse (in Hebrew). Harefuah 132: 618 ± 22.
