A dult - PowerPoint Presentation

Slide1

Adult attention – deficit/hyperactivity disorder and co-existing substance use disorder: epidemiology and clinical presentation

Mirjana Delić, MDSlide2

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by persistent patterns of inattention and/or hyperactivity and impulsiveness that can lead to severe disruptive behaviour

.1

Not only

a childhood disorder

.

2-3

APA. Diagnostic and Statistical Manual of Mental Disorders –

Text Revision. 4

th

Edn

. Washington DC: APA;

2000;

85–93.

Asherson

.

Expert Rev

Neurother

2005;5:525–39.

Elia

et al.

N

Engl

J Med

1999;340:780–8. Slide3

ADHD has an adult prevalence rate of 2–5%.1,2

There is an estimated 40–60% persistence into adulthood

(the full blown or in „partial remission“).

3

By adulthood there is a 1.5:1 M/F ratio of ADHD, and it is thought that females are likely to be underdiagnosed

.

1

A common reason for patient referral is that their child is diagnosed with ADHD first

(20% of parents of children with ADHD will have ADHD themselves).3

Kooij et al.

BMC Psychiatry

2010;10:67.

Fayyad et al.

Br J Psychiatry

2007;190:402–9.

Faraone

et al.

Psych Med.

2006;36:159

–

165Slide4

Worldwide Prevalence of ADHD in AdultsAccording to the 2007 WHO-WMH survey initiative, the estimated worldwide prevalence of adult ADHD is 3.4%

a

Upper end of 95% CI is below the prevalence estimate for total sample

b

Lower end of 95% CI is above the prevalence estimate for total sample

Country

Prevalence, % (SE)

n

Belgium

4.1 (1.5)

486

Colombia

1.9 (0.5)

a1,731France7.3 (1.8)b727Germany3.1 (0.8)621Italy2.8 (0.6)853Lebanon1.8 (0.7)a595Mexico1.9 (0.4)a1,736The Netherlands5.0 (1.6)516Spain1.2 (0.6)a960USA5.2 (0.6)3,197Total3.4 (0.4)11,422

Fayyad et al.

Br J Psychiatry

2007;190:402–9.Slide5

ADHD most likely has a multifactorial aetiology, including a combination of genetic and environmental risk factors:

-Approximately 80% of ADHD aetiology is linked to genetic factors

-

Various environmental factors

may also contribute

as secondary causes

Potential Aetiological Factors

Associated with ADHD

Group

Timing

Aetiological

Factors

Genetic

Mutations in the dopamine receptor and dopamine transporter genesEnvironmentalPrenatalDevelopmental cerebral abnormality, chromosome anomaly, virus, anaemia, hypothyroidism, iodine deficiency, exposure to drugs of abuse (e.g. nicotine) PerinatalPrematurity, low birth weight, anoxic-ischaemic encephalopathy, meningitis, encephalitisPostnatalViral meningitis, encephalitis, cerebral trauma, thyroid dysfunctionPotential Aetiological Factors Associated with ADHDMillichap. Pediatrics 2008;121:e358–65.Slide6

Impact of ADHD Beyond Core SymptomsFamily

Prone to emotional outbursts

6,11

Feels demoralized over constant

failure

6,11

Low self esteem

6,11

More chaotic personal and family routines11 Higher

rate of parental

divorce/separation

12,13

2-4 x

 sibling fights14Leibson et al. 2001. Hodgkins et al. 2011.Sobanski et al. 2012. Barkley et al. 1996. Searight et al. 2000. Weiss et al. 1999. Birnbaum et al. 2005. Biederman et al. 1998. Milberger et al.1997. Pomerleau et al.1995. Brown and Pacini. 1989. Manuzza et al.1997. Secnik et al. 2005. Slide7

Disorganisation (“doesn’t plan ahead”)

Forgetfulness (“misses appointments, loses things”)

Procrastination (“starts projects but can’t complete”)

Time management problems (“always late”)

Premature shifting of activities (“starts something but then quickly distracted by something else”)

Impulsive decisions (especially around spending, taking on projects, travelling,

jobs or social plans)

Criminal offences (speeding, illegal drugs)

Unstable jobs and relationships

Clinical Presentation in Adults

Kooij

&

Francken

. DIVA Foundation 2010.Slide8

Inattention

Over-activity

Impulsiveness

Ceaseless mental activity (distracted mind)

Mood lability / emotional dysregulation

Low tolerance of frustration

Low self-esteem

Variable performance

DSM

criteria

(core symptoms)

Associated

SymptomsCommon SymptomsAsherson. 1st European Network Adult ADHD Conference. London, 2011.Slide9

Inability to relax

Restless sleep

Excessively active lifestyle

Constant purposeless motion of extremities

Stimulus seeking or anti-social behaviours

Hyperactivity-related

p

roblems

Epstien

J, Johnson D,

Conners

CK.

Conners Adult ADHS Diagnostic Interview for DSM IV. North Towanda, NY: Multi-Health Systems; 1999)Slide10

Disinhibited behaviour

Alcohol, cannabis, cocaine, tobacco, caffeine abuse

Family violence

Speaking out or making decisions without considering

Impulsivity-related

p

roblems

Epstien

J, Johnson D,

Conners

CK.

Conners

Adult ADHS

Diagnostic Interview for DSM IV. North Towanda, 1999.Slide11

Disorganisation and inefficiency

Procrastination

Failure to plan ahead

Forgetfulness

Difficulty in multitasking

Misjudging how long it takes to perform tasks

Inability to complete tasks

Distractibility

Poor ability to follow long explanations

Inattention-related

p

roblems

Epstien

J, Johnson D, Conners CK. Conners Adult ADHS Diagnostic Interview for DSM IV. North Towanda, NY: Multi-Health Systems; 1999.Asherson. 1st European Network Adult ADHD Conference. London, 2011 Slide12

The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe

than is typically observed in individuals at a comparable level of development

Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years

Several symptoms are present in at least 2 settings

(e.g. home, work, school, with friends-relatives, other activities)

Symptoms interfere with social, occupational, and/or academic functioning

Symptoms not due to another mental disorder

Diagnosing ADHD: DSM-5 Criteria

APA. Diagnostic and Statistical Manual of Mental Disorders 5th Edn. Washington DC: APA; 2013;59–60. Slide13

Presentations:

-Combined

-

Predominantly inattentive

-

Predominantly hyperactive-impulsive

Inattention (at least 5 symptoms for age

>

17)Hyperactivity-impulsivity (at least 5 symptoms for age >

17)

-

ADHD in 'partial remission‘

-

Mild, Moderate, or Severe depending on few, intermediate, or many symptoms in excess of requirements, and minor, intermediate, or marked impairment, respectivelyClassifying ADHD: DSM-5 Criteria1APA. Diagnostic and Statistical Manual of Mental Disorders 5th Edn. Washington DC: APA; 2013;59–60Slide14

1: Clinical diagnostic interview:

Evaluate each of the 18 items (DSM/ICD) both currently and retrospectively,

and screen for comorbid disorders

2: Evaluation of impairments/needs:

Matching symptoms to impairments is key to the diagnosis

(developmental history important)

3: Screening instruments

Used to screen for ADHD and monitor treatment response

(Adult ADHD Self-Report Scale)

4: Psychometric tests:

Not sufficiently predictive, but a useful addition to the assessment (includes:

IQ-specific reading/mathematics difficulties, slow and variable responses,

response inhibition, working memory, choice

impulsivity)Diagnostic MethodsAsherson. 1st European Network Adult ADHD Conference. London, 2011.Slide15

Adult ADHD Treatments

Assess the relative severity of the substance use disorder (SUD)

, the symptoms of ADHD, and any other comorbid disorders. S

tabilizing

or addressing the

SUD should be the first priority when treating an adult with

SUD

and ADHD

.1. 1. Wilens TE. J Clin Psychiatry. 2004;65 Suppl 3:38-45Slide16

Multimodal Approach to Treatment Treatment should include:

- Pharmacotherapy

- Non-pharmacological treatment

Ps

ychoeducational

Psychological

PsychosocialSlide17

The clinician should begin pharmacotherapy with medications that have little likelihood of diversion or low liability, such as bupropion and atomoxetine, and, if necessary, progress to the stimulants.

Careful monitoring of patients during treatment is necessary to ensure compliance with the treatment plan.

1

1. Wilens TE. J Clin Psychiatry.

2004;65 Suppl 3:38-45Slide18

PharmacotherapyStimulantsAtomoxetineAntidepressants (bupropion, desipramine)Antihypertensive medications: clonidine and guanafacine (impulsivity and hyperactivity)

Antinarcolepsy medication (modafinil)Stimulants are effective in about 70% of patients with ADHD; their use in some parts of Europe is still controversial in both children and adults.Slide19

Does stimulant medications increase the risk of substance abuse in adulthood?

Stimulant

therapy in childhood does not increase the risk for subsequent drug and alcohol abuse disorders later in life.

Growing evidence has shown that stimulants, particularly long-acting formulations, can be given safely and are not routinely abused in substance-abusing populations

.

Mariani and Levin, 2006, 2007; Wilens et al, 2008Slide20

Non-pharmacological TreatmentEducation of patients and their families (psychoeducation)

Psychological interventions (cognitive-behavioural therapy, family therapy)

Psychosocial

interventions

Supportive coaching

Marital/family counselling

Career counselling

Technology

School/workplace accommodationsAdvocacySlide21

ConclusionsThe age-dependent change in the presentation of ADHD symptomsPeople suffering from ADHD are often stereotyped as lazy, bad or agressive, or considered to have a behavioral or special needs problem rather than a mental health disorder that requires treatmentIdentification of comorbid conditions: mood, anxiety, psychotic, organic and SUD (in addition to personality, tic and autistic spectrum disorders)

Diagnosis should include a detailed account of the developmental history; external validationMultimodal tretmentSlide22

Thank you!