case report Neuropsychiatr DOI 10.1007/s40211-014-0103-0
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia Julia Huemer · Ingrid Sibitz
Received: 3 October 2013 / Accepted: 15 March 2014 © Springer-Verlag Wien 2014
Summary Background The comorbidity of attention deficit hyperactivity disorder (ADHD) and schizophrenia poses a considerable diagnostic challenge due to significant symptom overlap, and represents a highly debilitating condition for the patient. This case report aims to present the history of a 19-year-old patient suffering from these two diagnostic entities, and thereby seeks to elucidate diagnostic and therapeutic approaches for this condition. Methods The Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria for ADHD and schizophrenia were used to establish clinical diagnoses. Furthermore, an in-depth clinical interview with the patient’s mother was carried out. Finally, a clinical interview was conducted with the patient and the Wender Utah Rating Scale was applied to assess ADHD symptoms retrospectively. Results Outcomes of the mentioned diagnostic approaches confirmed the diagnosis of ADHD in the patient suffering from schizophrenia. As amphetamines would be contraindicated in the described patient, atomoxetine, a drug approved for the treatment of ADHD due to its efficacy as a selective norepinephrine reuptake inhibitor, was chosen. Following a 6-week interval after treatment initiation, a clinical re-evaluation was carried out, which showed an improvement of symptoms J. Huemer, MD () Department of Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria e-mail: [email protected] I. Sibitz Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
13
according to the International Classification of Diseases (tenth revision) criteria. Conclusion The present case report indicates that atomoxetine may be effective in treating symptoms of ADHD in patients with schizophrenia, without increasing psychotic symptoms. Results are discussed in terms of diagnostic and therapeutic implications. Keywords Adult ADHD · Schizophrenia · Symptom overlap
Diagnostik und Behandlung von ADHS bei einem erwachsenen Patienten mit Schizophrenie Zusammenfassung Hintergrund Die Komorbidität von ADHS und Schizophrenie stellt aufgrund von Symptomüberlappung eine erhebliche diagnostische Herausforderung dar und ist für den Patienten eine stark beeinträchtigende Bedingung. Der vorliegende Fallbericht setzt sich zum Ziel, die Anamnese eines neunzehnjährigen Patienten, der unter den erwähnten zwei diagnostischen Entitäten leidet, darzustellen und dadurch diagnostische und therapeutische Herangehensweisen darzulegen. Methoden DSM-IV Kriterien für ADHD und Schizophrenie wurden herangezogen, um die klinischen Diagnosen zu erstellen. Überdies wurde ein klinisches Interview mit der Mutter des Patienten durchgeführt. Schließlich wurde auch mit dem Patienten ein klinisches Interview durchgeführt sowie die Wender Utah Rating Scale angewandt, um retrospektiv ADHD Symptome zu erfassen. Ergebnisse Die Ergebnisse der erwähnten diagnostischen Zugänge bekräftigten die Diagnose von ADHD bei jenem Patienten mit Schizophrenie. Da die Verabreichung von Amphetaminen bei beschriebenem Patienten kontraindiziert ist, wurde Atomoxetin, ein Medikament,
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
1
case report
das für die Behandlung von ADHD aufgrund seiner Wirksamkeit als selektiver Noradrenalin-WiederaufnahmeHemmer zugelassen ist, verwendet. Nach einem sechswöchigen Intervall nach Behandlungsbeginn wurde eine klinische Re-evaluierung durchgeführt, die eine Symptomverbesserung nach ICD 10 Kriterien zeigte. Schlussfolgerung Der vorliegende Fallbericht beschreibt, dass Atomoxetin in der Behandlung von ADHD Symptomen bei Patienten mit Schizophrenie wirksam sein kann, ohne psychotische Symptome zu steigern. Die Ergebnisse werden in Bezug auf diagnostische und therapeutische Implikationen diskutiert. Schlüsselwörter ADHD beim Erwachsenen · Schizophrenie · Symptomüberlappung
Introduction Attention deficit hyperactivity disorder (ADHD), which is among the most common psychiatric disorders [1], has long been considered to resolve during adolescence, with no adverse effect on later adult life [2]. Yet, current research indicates a persistence of symptoms into adulthood in approximately two-thirds of patients [3]. Epidemiological studies provide prevalence rates of adult ADHD ranging from 2 to 5 % [4]. While hyperactivity and impulsivity are the most predominant and debilitating features in childhood, adult ADHD’s core symptoms refer to more subtle problems such as inner restlessness, inattention, disorganization, and impairment in behaviors associated with executive functioning [1]. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) criteria for ADHD define three subtypes based on the predominant symptom pattern: inattentive type, hyperactive–impulsive type, and the combined type. The revised DSM-V criteria stick to these diagnostic recommendations but aim to take age-dependent changes of the disorder over the course of a lifetime into account. Subsequently, changes of criteria include the following [1]. (1) For older adolescents and adults (aged 17 years and more), only four (instead of six) symptoms in either the inattentive or hyperactive–impulsive domain are necessary to establish the diagnosis. (2) The list of hyperactive–impulsive symptoms has been expanded to include “uncomfortable doing things slowly or carefully,” “being often impatient,” “difficulty resisting temptations or opportunities,” and “tending to act without thinking.” (3) Descriptions of symptom items have been elaborated to involve more specific descriptions of behavior, partly more applicable to adults. (4) The age-of-onset criteria have been extended by taking into account “noticeable inattentive or hyperactive–impulsive symptoms by the age of 12 years.” Recommendations on diagnosing ADHD in adulthood refer to the assessment of self-reported symptoms, along with significant impairment related to these symptoms. An in-depth diagnostic interview examining the
characteristic psychopathology by diligently questioning about childhood (and childhood onset of symptoms) and current behavioral problems is of utmost clinical importance. Furthermore, comparison with parent and/ or partner reports to provide more information on the nature and pervasiveness of symptoms is desirable [5]. There are many screening instruments and diagnostic interviews available, with a need for validating their translations throughout Europe. Commonly used rating scales for screening include the ADHD Rating Scale, the six-item World Health Organization Adult ADHD SelfReport Scale, the Brown ADD (Attention Deficit Disorder) Scale Diagnostic Form, the Conners’ Adult ADHD Rating Scale, and the Wender Utah Rating Scale (WURS; summarized in [1]). The WURS also involves symptoms of other, often comorbid disorders, and tries to establish a retrospective assessment of childhood ADHD symptoms. In terms of psychopharmacological approaches, ADHD symptoms can be treated effectively in both children and adults. Various studies in children have demonstrated the beneficial impact of stimulant medication and atomoxetine on the core symptoms of ADHD [6]. An increasing number of studies in adults demonstrate a similar clinical response to that seen in youth [7]. When evaluating treatment options, careful assessment of associated comorbidities should be strongly emphasized because these are highly prevalent [8]. Treatment recommendations suggest concentrating on treating severe mental health disorders, such as psychosis, first, and subsequently focusing on the therapeutic approach toward ADHD. One of the most understudied comorbid conditions is ADHD and schizophrenia [9, 10]. The comorbidity of ADHD and schizophrenia poses a considerable diagnostic challenge due to significant symptom overlap [11], and represents a highly debilitating condition for the patient [9]. This case report aims at presenting a history of a patient suffering from these two diagnostic entities, and thereby seeks to elucidate diagnostic and therapeutic approaches for this condition.
Case report Mr. L, a 19-year-old patient, was admitted to our day clinic because of increased impulsiveness and aggression toward his mother. The day-clinic treatment was intended to provide a therapeutic framework for establishing clinical stability and a day structure for the patient along with optimizing his long-term treatment.
Psychiatric history After long-lasting problems at school (with troubles keeping attention on tasks, failing to finish homework, and behavioral difficulties such as blurting out answers before the end of questions), which did not result in any further psychiatric evaluation, Mr. L’s family experienced
2 Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
13
case report
a non-normative life event. When Mr. L was 16 years old, his family home was the target of a burglary. Since this experience, Mr. L heard commenting voices along with the constant perception of birds twittering. These symptoms led to admission to a psychiatric hospital lasting 6 weeks. Part of this time was spent in a closed psychiatric unit due to aggressiveness toward others. Subsequently, he participated in two day-clinic programs. Eventually, the patient was re-admitted twice more in the course of the following year, firstly due to an exacerbation of psychotic symptoms, and secondly because of increased impulsiveness. Since the age of 15 years, Mr. L had been consuming tetrahydrocannabinol relatively frequently. In adolescence, he had also occasionally consumed speed. At the time of admission, he smoked 20 cigarettes a day.
Definition of problems at the time of admission With psychotic symptoms currently under control, at the time of admission, the patient described a feeling of constant nervousness, a permanent feeling of sleep deprivation, a high level of distractibility, and a lack of concentration as central issue. The patient reported feeling considerably impaired by these symptoms.
Medication at the time of admission and psychiatric history At the time of admission, Mr. L took amisulpride 200 mg, 3-0-2-0 tablets; prothipendyl 80 mg, 0-0-0-1½ tablets; and lorazepam 2.5 mg, 1-1-0-1 tablets. Psychiatric diagnoses so far included “drug-induced psychosis,” “paranoid schizophrenia,” and “suspicion of personality disorder.”
Mental status At the time of admission, Mr. L’s mental status was dominated by dysphoric mood along with a strongly provocative and boundless behavior. His affect was inappropriate. He reported auditory hallucinations in the sense of commenting voices. These voices were described as a symptom having accompanied the patient for several years now not causing relevant subjective distress. Furthermore, Mr. L reported paranoid ideas in the sense of delusions of persecution and control along with thought insertion and thought withdrawal.
Clinical observations during the course of treatment Mr. L had great difficulties participating in the structured day-clinic program. He often appeared inattentive and did not seem to listen when spoken to directly.
13
He had tremendous problems organizing activities and was easily distracted. Most importantly, Mr. L had a hard time participating in therapeutic group activities. He often fidgeted with hands or feet or got up from his seat when expected to remain seated. Additionally, he always seemed “on the go” and was rarely capable to stay calm by himself in periods of rest during the therapeutic program. Foremost, he talked excessively in groups, had troubles awaiting his turn, and frequently interrupted or intruded on others. His behavior was sometimes boundless and hypersexualized. When evaluating his social status, Mr. L, who was unemployed at the time of admission, described that he only had a few friends due to his own inability, as he put it, to maintain relationships. One of his central wishes was to establish a romantic relationship with a woman, a wish that stood in sharp contrast to his current psychosocial reality—living in an apartment with his mother, his most stable but also highly ambivalently connoted attachment figure. Recurring topics both in terms of clinical and psychotherapeutic evaluation and regarding prior psychiatric case histories involved the following: lack of insight, troubles adhering to treatment regimens, increased impulsiveness and lack of impulse control, boundless behavior, lack of social relationships, persistent wishes to be independent and have a steady employment contrasting with recurrent treatment and employment breakups, and hypersexualized behavior.
Diagnostic procedures Mr. L fulfilled DSM-IV criteria for schizophrenia. Due to the aforementioned clinical observation, a further evaluation of a possible comorbidity with ADHD was carried out. An in-depth interview with Mr. L’s mother revealed that, retrospectively, he fulfilled full DSM-IV criteria for ADHD from a developmental perspective. Psychological assessments revealed deficits in terms of selective attention. Finally, we conducted a clinical interview with the patient and also applied the WURS to assess ADHD symptoms retrospectively [12]. We chose this instrument because it was particularly designed for adults to describe their own childhood behavior [12]. Results from these further diagnostic approaches corroborated the diagnosis of ADHD.
Psychopharmacological approaches After establishing the diagnosis, we aimed at finding the most beneficial treatment for our patient. As amphetamines are contraindicated in schizophrenia and Mr. L’s prior abuse of speed, atomoxetine was chosen. Atomoxetine is a selective norepinephrine reuptake inhibitor approved for the treatment of ADHD. Dosage of atomoxetine was started at 40 mg daily and augmented to 80 mg after 2 weeks. Following a 6-week interval after treatment initiation, a clinical re-evaluation was carried out, which showed an improvement of symptoms according to the
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
3
case report
International Classification of Diseases (tenth revision; ICD-10) criteria.
Drug efficacy and symptom improvement During the 6-week interval, symptoms improved significantly. This was both reflected in clinical symptom observation according to ICD-10 criteria and reported by Mr. L and his mother. Some examples of this clinical symptom improvement were his newly gained ability to lead a conversation for more than 1 h without leaving the setting and his capacity to read a full article—an activity, which had previously been extremely negatively connoted. Apart from that, his attention level in group settings improved significantly, and his hypersexualized behavior was significantly reduced. This behavioral change was also reported by other patients. In addition, Mr. L was more structured in his daily activities and was able to keep appointments. His increased level of attention and his reduced nervousness also led to first steps toward a rehabilitative employment structure. Psychological re-assessment was conducted to objectify Mr. L’s clinical improvement. The patient provided informed consent, both for diagnostic and for therapeutic procedures. Apart from that, he consented to the publication of his case history in a scientific journal.
Discussion The present case history illustrates an example of a patient with schizophrenia who was diagnosed with ADHD for the first time in adulthood. Pondering on the present case raises the question why ADHD is often only diagnosed at a very late point in life in certain populations. First of all, this could be because the acceptance and recognition of ADHD as a clinical condition have only recently progressed worldwide. Thus, there are still many adults with ADHD who were never diagnosed with the disorder as children. Additionally, considerable reasons for underdiagnosis of ADHD include comorbid conditions, which in clinical practice may be identified as the primary or only diagnosis. This is particularly alarming when looking at recent figures revealing that ADHD is prevalent in approximately 10–20 % of people with common mental health problems according to epidemiological and clinical research [1]. Further studies reveal that this rate may be higher in some clinical populations, for instance, patients of forensic, addiction disorder, and personality disorder clinics. One of the most understudied comorbid conditions is schizophrenia and adult ADHD [9], with schizophrenia being the primary diagnosis. This comorbid condition does not only pose a diagnostic challenge due to significant symptom overlap [11, 13] and due to shared environmental risk factors between ADHD- and schizophrenia-spectrum disorders [14], but it is also of great interest due to its biological interactions, impacting psychopharmacologi-
cal treatment regimens: while dopamine is antagonized by antipsychotics, both stimulants [15] and atomoxetine cause dopamine increase. Atomoxetine, being the drug of interest for the present case report, was found to increase extracellular levels of norepinephrine and dopamine in the prefrontal cortex of rats, indicating a potential mechanism for its efficacy in ADHD [16]. Stimulants are generally contraindicated in psychotic disorders, although reports describe successful treatment of stable patients with schizophrenia maintained on antipsychotics [17]. For adults with ADHD, who have a condition in which a stimulant is contraindicated, the non-stimulant atomoxetine licensed for child and adult ADHD in the USA is considered to be an appropriate alternative [17]. The present case history illustrates the importance of screening for adult ADHD in patients with schizophrenia or other primary psychiatric diagnoses when they report problems such as inner restlessness, inattention, disorganization, and impairment in behaviors associated with executive functioning. Furthermore, it seems diagnostically relevant to include a developmental perspective also in adult psychiatric assessments to complete diagnostic evidence. Eventually, from a psychopharmacological viewpoint, our case report indicates that atomoxetine may be effective in treating symptoms of ADHD in patients with schizophrenia, without increasing psychotic symptoms. Clinical follow-ups at close intervals are of utmost importance to monitor psychotic and ADHD-related symptoms in these patients. Acknowledgments The authors thank the patient for allowing them to publish his case report. The authors are grateful for the proof reading of the manuscript by Anne Unger. Conflict of interest Julia Huemer and Ingrid Sibitz report no conflict of interest.
References 1. Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: the European Network Adult ADHD. BMC Psychiatry. 2010;10:67. 2. Hill JC, Schoener EP. Age-dependent decline of attention deficit hyperactivity disorder. Am J Psychiatry. 1996;153(9):1143–6. 3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med. 2006;36(2):159–65. 4. Simon V, Czobor P, Balint S, Meszaros A, Bitter I. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194(3):204–11. 5. Sandra Kooij JJ, Marije Boonstra A, Swinkels SH, Bekker EM, de Noord I, Buitelaar JK. Reliability, validity, and utility of instruments for self-report and informant report concerning symptoms of ADHD in adult patients. J Atten Disord. 2008;11(4):445–58.
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case report 6. Prince JB. Pharmacotherapy of attention-deficit hyperactivity disorder in children and adolescents: update on new stimulant preparations, atomoxetine, and novel treatments. Child Adolesc Psychiatr Clin N Am. 2006;15(1):13–50. 7. Meszaros A, Czobor P, Balint S, Komlosi S, Simon V, Bitter I. Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Int J Neuropsychopharmacol. 2009;12(8):1137–47. 8. Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2004;65(Suppl. 3):3–7. 9. Hallerbäck MU, Lugnegård T, Gillberg C. ADHD and nicotine use in schizophrenia and Asperger syndrome: a controlled study. J Atten Disord. 2012. Epub ahead of print. 10. Donev R, Gantert D, Alawam K, et al. Comorbidity of schizophrenia and adult attention-deficit hyperactivity disorder. World J Biol Psychiatry. 2011;12(Suppl. 1):52–6. 11. Karatekin C, White T, Bingham C. Shared and nonshared symptoms in youth-onset psychosis and ADHD. J Atten Disord. 2010;14(2):121–31. 12. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(6):885–90.
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13. Havik B, Degenhardt FA, Johansson S, et al. DCLK1 variants are associated across schizophrenia and attention deficit/ hyperactivity disorder. PLoS One. 2012;7(4):e35424. 14. Peralta V, de Jalon EG, Campos MS, Zandio M, Sanchez-Torres A, Cuesta MJ. The meaning of childhood attention-deficit hyperactivity symptoms in patients with a first-episode of schizophrenia-spectrum psychosis. Schizophr Res. 2011;126(1–3):28–35. 15. Kraemer M, Uekermann J, Wiltfang J, Kis B. Methylphenidate-induced psychosis in adult attention-deficit/hyperactivity disorder: report of 3 new cases and review of the literature. Clin Neuropharmacol. 2010;33(4):204–6. 16. Bymaster FP, Katner JS, Nelson DL, et al. Atomoxetine increases extracellular levels of norepinephrine and dopamine in prefrontal cortex of rat: a potential mechanism for efficacy in attention deficit/hyperactivity disorder. Neuropsychopharmacology. 2002;27(5):699–711. 17. Tossell JW, Greenstein DK, Davidson AL, et al. Stimulant drug treatment in childhood-onset schizophrenia with comorbid ADHD: an open-label case series. J Child Adolesc Psychopharmacol. 2004;14(3):448–54.
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
5
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia Julia Huemer · Ingrid Sibitz
Received: 3 October 2013 / Accepted: 15 March 2014 © Springer-Verlag Wien 2014
Summary Background The comorbidity of attention deficit hyperactivity disorder (ADHD) and schizophrenia poses a considerable diagnostic challenge due to significant symptom overlap, and represents a highly debilitating condition for the patient. This case report aims to present the history of a 19-year-old patient suffering from these two diagnostic entities, and thereby seeks to elucidate diagnostic and therapeutic approaches for this condition. Methods The Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria for ADHD and schizophrenia were used to establish clinical diagnoses. Furthermore, an in-depth clinical interview with the patient’s mother was carried out. Finally, a clinical interview was conducted with the patient and the Wender Utah Rating Scale was applied to assess ADHD symptoms retrospectively. Results Outcomes of the mentioned diagnostic approaches confirmed the diagnosis of ADHD in the patient suffering from schizophrenia. As amphetamines would be contraindicated in the described patient, atomoxetine, a drug approved for the treatment of ADHD due to its efficacy as a selective norepinephrine reuptake inhibitor, was chosen. Following a 6-week interval after treatment initiation, a clinical re-evaluation was carried out, which showed an improvement of symptoms J. Huemer, MD () Department of Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria e-mail: [email protected] I. Sibitz Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
13
according to the International Classification of Diseases (tenth revision) criteria. Conclusion The present case report indicates that atomoxetine may be effective in treating symptoms of ADHD in patients with schizophrenia, without increasing psychotic symptoms. Results are discussed in terms of diagnostic and therapeutic implications. Keywords Adult ADHD · Schizophrenia · Symptom overlap
Diagnostik und Behandlung von ADHS bei einem erwachsenen Patienten mit Schizophrenie Zusammenfassung Hintergrund Die Komorbidität von ADHS und Schizophrenie stellt aufgrund von Symptomüberlappung eine erhebliche diagnostische Herausforderung dar und ist für den Patienten eine stark beeinträchtigende Bedingung. Der vorliegende Fallbericht setzt sich zum Ziel, die Anamnese eines neunzehnjährigen Patienten, der unter den erwähnten zwei diagnostischen Entitäten leidet, darzustellen und dadurch diagnostische und therapeutische Herangehensweisen darzulegen. Methoden DSM-IV Kriterien für ADHD und Schizophrenie wurden herangezogen, um die klinischen Diagnosen zu erstellen. Überdies wurde ein klinisches Interview mit der Mutter des Patienten durchgeführt. Schließlich wurde auch mit dem Patienten ein klinisches Interview durchgeführt sowie die Wender Utah Rating Scale angewandt, um retrospektiv ADHD Symptome zu erfassen. Ergebnisse Die Ergebnisse der erwähnten diagnostischen Zugänge bekräftigten die Diagnose von ADHD bei jenem Patienten mit Schizophrenie. Da die Verabreichung von Amphetaminen bei beschriebenem Patienten kontraindiziert ist, wurde Atomoxetin, ein Medikament,
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
1
case report
das für die Behandlung von ADHD aufgrund seiner Wirksamkeit als selektiver Noradrenalin-WiederaufnahmeHemmer zugelassen ist, verwendet. Nach einem sechswöchigen Intervall nach Behandlungsbeginn wurde eine klinische Re-evaluierung durchgeführt, die eine Symptomverbesserung nach ICD 10 Kriterien zeigte. Schlussfolgerung Der vorliegende Fallbericht beschreibt, dass Atomoxetin in der Behandlung von ADHD Symptomen bei Patienten mit Schizophrenie wirksam sein kann, ohne psychotische Symptome zu steigern. Die Ergebnisse werden in Bezug auf diagnostische und therapeutische Implikationen diskutiert. Schlüsselwörter ADHD beim Erwachsenen · Schizophrenie · Symptomüberlappung
Introduction Attention deficit hyperactivity disorder (ADHD), which is among the most common psychiatric disorders [1], has long been considered to resolve during adolescence, with no adverse effect on later adult life [2]. Yet, current research indicates a persistence of symptoms into adulthood in approximately two-thirds of patients [3]. Epidemiological studies provide prevalence rates of adult ADHD ranging from 2 to 5 % [4]. While hyperactivity and impulsivity are the most predominant and debilitating features in childhood, adult ADHD’s core symptoms refer to more subtle problems such as inner restlessness, inattention, disorganization, and impairment in behaviors associated with executive functioning [1]. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) criteria for ADHD define three subtypes based on the predominant symptom pattern: inattentive type, hyperactive–impulsive type, and the combined type. The revised DSM-V criteria stick to these diagnostic recommendations but aim to take age-dependent changes of the disorder over the course of a lifetime into account. Subsequently, changes of criteria include the following [1]. (1) For older adolescents and adults (aged 17 years and more), only four (instead of six) symptoms in either the inattentive or hyperactive–impulsive domain are necessary to establish the diagnosis. (2) The list of hyperactive–impulsive symptoms has been expanded to include “uncomfortable doing things slowly or carefully,” “being often impatient,” “difficulty resisting temptations or opportunities,” and “tending to act without thinking.” (3) Descriptions of symptom items have been elaborated to involve more specific descriptions of behavior, partly more applicable to adults. (4) The age-of-onset criteria have been extended by taking into account “noticeable inattentive or hyperactive–impulsive symptoms by the age of 12 years.” Recommendations on diagnosing ADHD in adulthood refer to the assessment of self-reported symptoms, along with significant impairment related to these symptoms. An in-depth diagnostic interview examining the
characteristic psychopathology by diligently questioning about childhood (and childhood onset of symptoms) and current behavioral problems is of utmost clinical importance. Furthermore, comparison with parent and/ or partner reports to provide more information on the nature and pervasiveness of symptoms is desirable [5]. There are many screening instruments and diagnostic interviews available, with a need for validating their translations throughout Europe. Commonly used rating scales for screening include the ADHD Rating Scale, the six-item World Health Organization Adult ADHD SelfReport Scale, the Brown ADD (Attention Deficit Disorder) Scale Diagnostic Form, the Conners’ Adult ADHD Rating Scale, and the Wender Utah Rating Scale (WURS; summarized in [1]). The WURS also involves symptoms of other, often comorbid disorders, and tries to establish a retrospective assessment of childhood ADHD symptoms. In terms of psychopharmacological approaches, ADHD symptoms can be treated effectively in both children and adults. Various studies in children have demonstrated the beneficial impact of stimulant medication and atomoxetine on the core symptoms of ADHD [6]. An increasing number of studies in adults demonstrate a similar clinical response to that seen in youth [7]. When evaluating treatment options, careful assessment of associated comorbidities should be strongly emphasized because these are highly prevalent [8]. Treatment recommendations suggest concentrating on treating severe mental health disorders, such as psychosis, first, and subsequently focusing on the therapeutic approach toward ADHD. One of the most understudied comorbid conditions is ADHD and schizophrenia [9, 10]. The comorbidity of ADHD and schizophrenia poses a considerable diagnostic challenge due to significant symptom overlap [11], and represents a highly debilitating condition for the patient [9]. This case report aims at presenting a history of a patient suffering from these two diagnostic entities, and thereby seeks to elucidate diagnostic and therapeutic approaches for this condition.
Case report Mr. L, a 19-year-old patient, was admitted to our day clinic because of increased impulsiveness and aggression toward his mother. The day-clinic treatment was intended to provide a therapeutic framework for establishing clinical stability and a day structure for the patient along with optimizing his long-term treatment.
Psychiatric history After long-lasting problems at school (with troubles keeping attention on tasks, failing to finish homework, and behavioral difficulties such as blurting out answers before the end of questions), which did not result in any further psychiatric evaluation, Mr. L’s family experienced
2 Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
13
case report
a non-normative life event. When Mr. L was 16 years old, his family home was the target of a burglary. Since this experience, Mr. L heard commenting voices along with the constant perception of birds twittering. These symptoms led to admission to a psychiatric hospital lasting 6 weeks. Part of this time was spent in a closed psychiatric unit due to aggressiveness toward others. Subsequently, he participated in two day-clinic programs. Eventually, the patient was re-admitted twice more in the course of the following year, firstly due to an exacerbation of psychotic symptoms, and secondly because of increased impulsiveness. Since the age of 15 years, Mr. L had been consuming tetrahydrocannabinol relatively frequently. In adolescence, he had also occasionally consumed speed. At the time of admission, he smoked 20 cigarettes a day.
Definition of problems at the time of admission With psychotic symptoms currently under control, at the time of admission, the patient described a feeling of constant nervousness, a permanent feeling of sleep deprivation, a high level of distractibility, and a lack of concentration as central issue. The patient reported feeling considerably impaired by these symptoms.
Medication at the time of admission and psychiatric history At the time of admission, Mr. L took amisulpride 200 mg, 3-0-2-0 tablets; prothipendyl 80 mg, 0-0-0-1½ tablets; and lorazepam 2.5 mg, 1-1-0-1 tablets. Psychiatric diagnoses so far included “drug-induced psychosis,” “paranoid schizophrenia,” and “suspicion of personality disorder.”
Mental status At the time of admission, Mr. L’s mental status was dominated by dysphoric mood along with a strongly provocative and boundless behavior. His affect was inappropriate. He reported auditory hallucinations in the sense of commenting voices. These voices were described as a symptom having accompanied the patient for several years now not causing relevant subjective distress. Furthermore, Mr. L reported paranoid ideas in the sense of delusions of persecution and control along with thought insertion and thought withdrawal.
Clinical observations during the course of treatment Mr. L had great difficulties participating in the structured day-clinic program. He often appeared inattentive and did not seem to listen when spoken to directly.
13
He had tremendous problems organizing activities and was easily distracted. Most importantly, Mr. L had a hard time participating in therapeutic group activities. He often fidgeted with hands or feet or got up from his seat when expected to remain seated. Additionally, he always seemed “on the go” and was rarely capable to stay calm by himself in periods of rest during the therapeutic program. Foremost, he talked excessively in groups, had troubles awaiting his turn, and frequently interrupted or intruded on others. His behavior was sometimes boundless and hypersexualized. When evaluating his social status, Mr. L, who was unemployed at the time of admission, described that he only had a few friends due to his own inability, as he put it, to maintain relationships. One of his central wishes was to establish a romantic relationship with a woman, a wish that stood in sharp contrast to his current psychosocial reality—living in an apartment with his mother, his most stable but also highly ambivalently connoted attachment figure. Recurring topics both in terms of clinical and psychotherapeutic evaluation and regarding prior psychiatric case histories involved the following: lack of insight, troubles adhering to treatment regimens, increased impulsiveness and lack of impulse control, boundless behavior, lack of social relationships, persistent wishes to be independent and have a steady employment contrasting with recurrent treatment and employment breakups, and hypersexualized behavior.
Diagnostic procedures Mr. L fulfilled DSM-IV criteria for schizophrenia. Due to the aforementioned clinical observation, a further evaluation of a possible comorbidity with ADHD was carried out. An in-depth interview with Mr. L’s mother revealed that, retrospectively, he fulfilled full DSM-IV criteria for ADHD from a developmental perspective. Psychological assessments revealed deficits in terms of selective attention. Finally, we conducted a clinical interview with the patient and also applied the WURS to assess ADHD symptoms retrospectively [12]. We chose this instrument because it was particularly designed for adults to describe their own childhood behavior [12]. Results from these further diagnostic approaches corroborated the diagnosis of ADHD.
Psychopharmacological approaches After establishing the diagnosis, we aimed at finding the most beneficial treatment for our patient. As amphetamines are contraindicated in schizophrenia and Mr. L’s prior abuse of speed, atomoxetine was chosen. Atomoxetine is a selective norepinephrine reuptake inhibitor approved for the treatment of ADHD. Dosage of atomoxetine was started at 40 mg daily and augmented to 80 mg after 2 weeks. Following a 6-week interval after treatment initiation, a clinical re-evaluation was carried out, which showed an improvement of symptoms according to the
Detecting and treating adult attention deficit hyperactivity disorder in a patient with schizophrenia
3
case report
International Classification of Diseases (tenth revision; ICD-10) criteria.
Drug efficacy and symptom improvement During the 6-week interval, symptoms improved significantly. This was both reflected in clinical symptom observation according to ICD-10 criteria and reported by Mr. L and his mother. Some examples of this clinical symptom improvement were his newly gained ability to lead a conversation for more than 1 h without leaving the setting and his capacity to read a full article—an activity, which had previously been extremely negatively connoted. Apart from that, his attention level in group settings improved significantly, and his hypersexualized behavior was significantly reduced. This behavioral change was also reported by other patients. In addition, Mr. L was more structured in his daily activities and was able to keep appointments. His increased level of attention and his reduced nervousness also led to first steps toward a rehabilitative employment structure. Psychological re-assessment was conducted to objectify Mr. L’s clinical improvement. The patient provided informed consent, both for diagnostic and for therapeutic procedures. Apart from that, he consented to the publication of his case history in a scientific journal.
Discussion The present case history illustrates an example of a patient with schizophrenia who was diagnosed with ADHD for the first time in adulthood. Pondering on the present case raises the question why ADHD is often only diagnosed at a very late point in life in certain populations. First of all, this could be because the acceptance and recognition of ADHD as a clinical condition have only recently progressed worldwide. Thus, there are still many adults with ADHD who were never diagnosed with the disorder as children. Additionally, considerable reasons for underdiagnosis of ADHD include comorbid conditions, which in clinical practice may be identified as the primary or only diagnosis. This is particularly alarming when looking at recent figures revealing that ADHD is prevalent in approximately 10–20 % of people with common mental health problems according to epidemiological and clinical research [1]. Further studies reveal that this rate may be higher in some clinical populations, for instance, patients of forensic, addiction disorder, and personality disorder clinics. One of the most understudied comorbid conditions is schizophrenia and adult ADHD [9], with schizophrenia being the primary diagnosis. This comorbid condition does not only pose a diagnostic challenge due to significant symptom overlap [11, 13] and due to shared environmental risk factors between ADHD- and schizophrenia-spectrum disorders [14], but it is also of great interest due to its biological interactions, impacting psychopharmacologi-
cal treatment regimens: while dopamine is antagonized by antipsychotics, both stimulants [15] and atomoxetine cause dopamine increase. Atomoxetine, being the drug of interest for the present case report, was found to increase extracellular levels of norepinephrine and dopamine in the prefrontal cortex of rats, indicating a potential mechanism for its efficacy in ADHD [16]. Stimulants are generally contraindicated in psychotic disorders, although reports describe successful treatment of stable patients with schizophrenia maintained on antipsychotics [17]. For adults with ADHD, who have a condition in which a stimulant is contraindicated, the non-stimulant atomoxetine licensed for child and adult ADHD in the USA is considered to be an appropriate alternative [17]. The present case history illustrates the importance of screening for adult ADHD in patients with schizophrenia or other primary psychiatric diagnoses when they report problems such as inner restlessness, inattention, disorganization, and impairment in behaviors associated with executive functioning. Furthermore, it seems diagnostically relevant to include a developmental perspective also in adult psychiatric assessments to complete diagnostic evidence. Eventually, from a psychopharmacological viewpoint, our case report indicates that atomoxetine may be effective in treating symptoms of ADHD in patients with schizophrenia, without increasing psychotic symptoms. Clinical follow-ups at close intervals are of utmost importance to monitor psychotic and ADHD-related symptoms in these patients. Acknowledgments The authors thank the patient for allowing them to publish his case report. The authors are grateful for the proof reading of the manuscript by Anne Unger. Conflict of interest Julia Huemer and Ingrid Sibitz report no conflict of interest.
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