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28.08.2014

Am i bipolar or adhd test, tinnitus causes and remedies - .

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I am going to spend a few minutes giving a little bit of an overview before I specifically talk about substance abusers with ADHD, so that I can set the platform for understanding why this comorbidity is important.
Substance use disorders are quite common in individuals with ADHD, and in fact, are overrepresented in individuals with ADHD compared to those without.
What is also true is the reverse; if you look at substance abusers who are coming for treatment, the prevalence rates of ADHD are overrepresented in these groups of patients, and that occurs whether you are looking at individuals with polydrug use, opiate use disorders, cocaine abuse or dependence, and alcohol use disorders. There are some general issues that make the diagnosis of ADHD difficult for all adults, and it may just be exacerbated when you are talking about substance abusers.
Similarly, individuals with late-onset ADHD, similar to the full ADHD group, had worse lifetime functioning in a variety of areas, but what is shown on this slide, is that there were more arrests, more driving tickets, and more driving accidents.
So what Faraone and colleagues conclude is that the subjects with late-onset and full ADHD have similar patterns of psychiatric comorbidity, functional impairment, and they also found similar familial transmission. When you look at ADHD versus depression, they share common symptoms of inattention and concentration problems and they may have psychomotor agitation or restlessness and sleep difficulties. The common symptoms you see in both ADHD and bipolar illness are hyperactivity, inattention, talkativeness, work dysfunction and impulsivity, but it seems to be much more extreme with bipolar I. If you see psychosis, suicidality, expansive mood or grandiosity, decreased need for sleep, and a lot of cyclical symptomatology, you should be thinking more bipolar illness.
Certainly with substance abusers, there are other factors that can also lead to the underdiagnosis of ADHD. I think that there are specific diagnostic challenges when trying to make the diagnosis of ADHD in both non-substance-abusing as well as the substance-abusing adult populations. Anyone asking "am I bipolar" can easily do a bipolar disorder self test to check their bipolar symptoms. However, any preconceived notions you have about bipolar symptoms and your diagnosis can distort the results. There are many dimensions to "being bipolar" and pop culture does not convey enough accurate info on bipolar for us to understand genuine bipolar symptoms. Or take our online test, and if you screen positive see a board certified expert in mood disorders.Finally, make sure you get educated.
ADHD exerts a substantial toll on the lives of its sufferers and their families.1,19 This article explores the social and personal impact of ADHD on the lives of adults with this disorder, and the clinical challenges and opportunities for improving patient care through appropriate diagnosis and treatment. ADHD has a wide-ranging impact on adult lives, manifesting as educational, interpersonal, physical, emotional, and work-related difficulties.
Adults with ADHD, especially those with comorbid conduct or oppositional defiant disorder histories, are more likely to engage in behaviors resulting in incarceration.
Because the DSM-IV-TR indicates that impairments from ADHD must have an onset during childhood, diagnosis involves establishing the presence of symptoms during childhood as well as assessing current impairment.22 The DSM-IV-TR requirement for manifestation of symptoms before 7 years of age relies on parental, peer, or self-memories of childhood occurrences or records for verification. Differences in ADHD presentation based on culture and gender pose another diagnostic challenge. Maintaining a high index of suspicion for the presence of ADHD in adults is a key aspect in making a correct diagnosis. After screening, accurate diagnosis of ADHD requires a multifaceted approach including assessments of history, present symptoms, and functional impairment (Table 4).15,40,51,53 An accurate diagnosis requires sufficient presenting symptoms from the patient, with a pervasive course since childhood, and confirmation of childhood symptoms by an outside informant. Complete evaluation of an adult with suspected ADHD should also include assessment of comorbid psychiatric diagnoses and underlying medical conditions.52 Some medical conditions may have symptoms overlapping those of ADHD or can themselves account for certain attentional symptoms. Once the diagnosis is made, patient involvement is a key element in the success of managing ADHD in adults.
Stimulants are the first line of treatment for ADHD.3 Stimulants, including methylphenidate and amphetamines, have been widely and successfully used in children for decades. The FDA has recently approved the use of two long-acting stimulants in adults with ADHD: a prolonged-release formulation of methylphenidate and lisdexamfetamine dimesylate, a long-acting prodrug.
In April 2008, the FDA approved the use in adults of a new once-daily stimulant, lisdexamfetamine dimesylate (LDX), the first long-acting prodrug indicated for the treatment of ADHD in children and adults. In addition to pharmacotherapy, nonpharmacologic interventions, such as helping the patient restructure their environment, develop organizational skills, and create better coping strategies, may be beneficial in adults with ADHD.16 Because ADHD affects the entire family, treatment interventions may involve the spouse and children in restructuring of task sharing, planning, and day-to-day functioning.
Adult ADHD remains under-recognized, underdiagnosed, and undertreated by clinicians in the US. Stimulants that have been used in the pediatric ADHD population for decades are effective and well tolerated in adults. The development of diagnostic tools and treatment guidelines, coupled with the use of effective and tolerable medications and effective management of comorbid conditions, should improve the quality of care for adult patients with ADHD. Medications proven effective in treating childhood ADHD are also successful in treating adult ADHD. In this expert roundtable supplement, Margaret Weiss, MD, PhD, presents a comprehensive overview of complications surrounding differential diagnosis in adults with ADHD.
Clinicians are now fully aware and in agreement that ADHD is common and treatable in all ages; however, most remain uncomfortable applying this information into practice. The objective of this discussion is to frame an approach to translating expertise in differential diagnosis and management of comorbidity in ADHD into knowledge translation for primary care physicians and psychiatrists. The National Comorbidity Survey Replication (NCS-R) was the first epidemiological study of adults to evaluate ADHD in the context of other psychiatric illnesses and disabilities.3 Kessler and colleagues3 demonstrated that the majority of adults with ADHD have a complicating clinically significant comorbid disorder, and up to 50% of patients with ADHD have a complicating mood or anxiety disorder (Slide 1). Patterns of comorbidity between children and adults with ADHD are similar.4 Developmental disorders such as learning disabilities or autism spectrum disorders are more readily recognized and assessed in young children. A common anecdotal comment in the empirical work on ADHD is that patients who screen positive for ADHD in non-ADHD clinics overlap with the patients who have been treatment resistant.
Barkley and Murphy9 recently published preliminary findings examining the extent to which the high levels of comorbidity seen in ADHD populations is specific to this disorder or common to psychopathology in general.
Education on ADHD in adults has attempted to simplify principals of differential diagnosis.
Both bipolar disorder and ADHD patients may experience racing thoughts, hyperactivity, talkativeness, impulsivity, and distractibility. Diagnosis of dysthymia as a distinct mood disorder requires evidence of chronic low mood and two other symptoms, most of which are problematic in ADHD.
There is a high rate of personality disorders in adults with ADHD.14 A personality disorder is a defined maladaptive and repetitive pattern of behavior and interaction with others. Certain comorbid conditions, such as depression and drug use, are interesting in that the lifetime prevalence of the comorbidity greatly exceeds the current prevalence.15 In practice, the majority of adults with ADHD have had a significant problem with one or the other of these two difficulties at some point in their life, but a much smaller proportion are in the midst of such an episode at the time of assessment. In the revised CADDRA guidelines that will appear in the Fall of 2007, two new knowledge translation tools will be made available to facilitate assessment of comorbidity and differential diagnosis in ADHD.
In the context of the raised expectations and tremendous enthusiasm for the therapeutic opportunity presented by adults with ADHD, it is important to understand that patients included in research data from clinical trials are a selected sub-sample in which significant comorbidities have often been excluded. Although the word treatment typically brings to mind medication or psychosocial therapy, treatment of ADHD really begins at the evaluation stage.
It is important to inform the patient of both what is currently known about ADHD and what is not known.
While there are several psychiatric comorbidities that are commonly associated with ADHD, there are also issues that result from having ADHD that are often mistaken for comorbidities. In terms of psychosocial treatments for ADHD, one must consider the fit between the patient, expectations, and the environment. There are several recommendations for psychosocial treatment that have not been evaluated specifically for ADHD, but are assumed to be helpful in that population because they are helpful to most other people. In a primary care setting or one where the practitioner has not had experience with ADHD, the challenge is to identify  someone with previously undiagnosed ADHD.
Some of the greatest clinical successes are patients who have ADHD and mild mood symptoms or demoralization, where the ADHD has not been previously treated. Another common presentation is when an individual reports ADHD symptoms but also has a very prominent personality disorder that clearly affects his relationships above and beyond the effects of the ADHD symptoms. A common clinical presentation is the individual who presents with a substance use disorder and a history of ADHD. There is now increased awareness of ADHD in adults and many more treatment options for ADHD.
ADHD is often treated with psychostimulant medications, which work by binding to dopamine transporters in striatum, and norepinephrine (NE) transporters in several brain regions. The nonstimulant atomoxetine, approved by the Food and Drug Administration for the treatment of ADHD, binds selectively to the NE transporter, thereby increasing NE diffusely and DA in the prefrontal cortex. In general, all medications that are useful in treating ADHD in children are also effective in adults.
Effect sizes of approved medications in adult ADHD are approximately half what they are in children. Some medications that are used off-label for ADHD are approved by the FDA for other indications in adults, including bupropion,4 guanfacine,5 and modafinil.6,7 Bupropion has the most supporting data of any of the non-approved treatments in adults. Medications that treat conditions other than ADHD can generally be used to treat those same conditions when they are present with ADHD. The efficacy of MAS XR was evaluated in 255 adults with ADHD in a 4-week, randomized, double-blind, placebo-controlled study.1 Treatment was associated with a statistically and clinically significant reduction in ADHD symptoms, as assessed by the ADHD Rating Scale at endpoint, with the greatest improvement in symptoms occurring in the 60-mg dose group. The current approach to treating adult ADHD with relatively higher doses dates to the mid-1990s, when a study utilizing MPH IR in adults with ADHD showed a robust drug response rate. Dexmethylphenidate ER was tested in 5-week parallel group design trial in adults with ADHD comparing placebo with 20 mg, 30 mg, and 40 mg doses under double-blind conditions.12 All three dosages were more effective than placebo, reducing mean ADHD-RS total scores by 36% to 46% versus 21% with placebo. The mixed dopaminergic noradrenergic agent bupropion is approved for depression in adults and used off-label for ADHD in children and adults.
Risk for substance abuse is a particular concern in adults with ADHD since stimulants are schedule II controlled substances and longitudinal studies of children with ADHD have found an increased risk for substance abuse.
A related question is whether it is possible to develop new medications for ADHD with low potential for abuse and diversion (ie, giving or selling the medication to others).
Understanding the relationships among ADHD and comorbid disorders is of particular importance in treating adults with ADHD.
The notion that anxiety symptoms could be secondary to ADHD would only apply if the anxiety were restricted to performance situations or other contexts in which impairment from ADHD is evident.
One study examined the rates of improvement in children with ADHD and anxiety disorders after treatment with stimulant medication (MAS XR).20 ADHD symptoms improved as would be expected without comorbidity. As a general rule, all treatments that are effective for ADHD in children are effective in adults as well, and all three medication classes which are approved for ADHD in children are also approved for use in adults. There has been an explosion of data regarding medication treatment of ADHD over the past 10 years, and this is especially true with regard to treatment of adults.
Q: Increasing publicity about ADHD treatment has raised expectations in many people who have long-standing failures, that the problem may be simple and responsive to a quick fix.
ADHD is a lifelong disorder; about 75% of children with ADHD continue to have symptoms into adolescence, such that the prevalence in the juvenile population ranges anywhere from 6% to 9%. What you see in individuals who have a substance use disorder as well as ADHD is that the ADHD confers an increased risk for an earlier onset of the substance use disorder. There is the late-onset ADHD in which they meet all the criteria in childhood, but you cannot seem to get that age of onset; they can not tell you that the symptoms began before the age of 7. So again, there seems to be a lot of similarity between the late-onset group and the full-onset ADHD group, which is different than the subthreshold ADHD.
Interestingly, most of the individuals that were diagnosed with late-onset ADHD, 83%, would endorse that the symptoms began before the age of 12. Representing a community sample, this slide shows the rates of psychiatric disorders commonly found in individuals with ADHD and non-ADHD.
What you again see is higher rates of a variety of psychiatric disorders, in individuals with ADHD than in those with non-ADHD, and clearly, this can complicate making the diagnosis. Although the sleep problems are not part of the diagnostic criteria for ADHD, many of us who treat people with ADHD find that they often have a lot of trouble falling asleep or their sleep is very restless, like you would see with someone who has depression. Whereas if you have a constant presence of core symptoms starting from childhood, that gives you more of a sense of somebody who might have ADHD. All of us may have problems at times with procrastination or being disorganized, but the difference is that, for people with ADHD, it is a chronic problem, and it really does impact their functioning.
For some clinicians, they may think if they cannot get symptoms before the age of 7 that they might just move on and not ask anything more about ADHD. Part of making the diagnosis of ADHD can be greatly enhanced if you can get old report cards or talk to older family members, and often this is quite difficult with substance abusers. This is why the checklist approach, as well as relying on self-reporting, can never yield a conclusive result.There is no physical test, such as a blood test for bipolar. They are guidelines that merely SCREEN for the POSSIBILITY, not definitive diagnostic tools, and CANNOT, in themselves, diagnose bipolar disorder in you or anyone else.


Preferably this would be a board certified expert psychiatrist with extensive experience in bipolar and other mood disorders.One reason for this is to get treatment, such as a prescription for a mood stabilizing medication. Lab work and other tests will be needed to rule out diseases such as thyroid conditions (looks like bipolar and often co-occurs with bipolar disorder), diabetes, Lyme disease, and quite a few others.My own bipolar diagnosis happened through pure chance.
This excellent summary from the University of Maryland will gives you an easy to understand but very accurate and insightful bipolar disorder overview. The symptoms, deficits, and consequences associated with ADHD have a profound negative impact on the lives of patients and their families. Controlled studies1,20 demonstrate that adults with untreated ADHD have poorer educational performance and attainment, significantly more marriages, greater likelihood of problems making friends, and a higher incidence of interpersonal problems than those without ADHD.
In a study at the Utah State Prison of 102 randomized male inmates 16–64 years of age, 26 received a positive diagnosis of ADHD (having significant symptoms both as children and adults).
Nonetheless, it is prudent to be alert for suicidality in all patients with ADHD regardless of the choice of treatment and, in particular, in those patients with comorbid mood, anxiety, and substance use disorders.
Its prevalence and the absence of relevant professional clinical training indicate a need to educate physicians and other healthcare providers who encounter the challenging task of diagnosing ADHD in adults.
Management of ADHD in adulthood requires the clinician to rule out fairly common medical conditions, such as hypertension, that may be exacerbated by stimulant treatment. Improved recognition and treatment of ADHD should result in improved productivity in academic, work, and home environments, and should enhance quality of life for both patient and family.
Adults with ADHD experience decreased productivity and underachievement in the form of chronic lateness, poor management of time and money, inattention to detail, and forgetfulness. Feedback from primary care focus groups from symposia on the assessment of ADHD in Canada suggest that efforts that have gone into knowledge translation of adult ADHD have been insufficient in dealing with assessment and treatment issues of differential diagnosis and comorbidity. While it is difficult to provide safe and effective treatment of ADHD without evaluating comorbidity, it is also difficult to provide such treatment for a comorbidity in an ADHD patient without identifying and addressing the ADHD. They found that adults with ADHD have significant comorbidities with depressive disorders, anxiety, alcohol use, cannabis use, other substance use, oppositional defiant disorder (ODD), conduct disorder, personality disorders, sleep problems, learning disabilities, and autism spectrum disorder.
It is thought that bipolar disorder can be distinguished by the prominence of mood symptoms, and that grandiosity, racing thoughts, decreased need for sleep, and hypersexuality are more specific to bipolar disorder.10 Adults with ADHD often have problems with anger and mood lability.
The clinical implications of lifetime diagnosis for current management is unknown, although some research indicates that lifetime depression may be a significant moderator of treatment response for ADHD. There is greater comorbidity in cross-sectional samples of adults with ADHD than there is in prospective cases followed over time, suggesting a referral bias in which those who present in adulthood have both persistent ADHD symptoms and other problems as well.
It is increasingly the case that people self-diagnose their own ADHD based on Internet information and popular books1 about the disorder; however, many of these sources propagate myths. For example, a patient with ADHD who is doing poorly academically and has been doing poorly socially for many years is likely to be demoralized and frustrated.
Examples of target outcomes for an ADHD patient include impulsivity at work or at school; a secondary target may be mood, sleep, or the effect on the family. There are numerous other medications that are effective in treating ADHD as well (Slide 3). While patients often request immediate-release agents, many clinicians are uncomfortable prescribing them to ADHD patients due to their difficulties with time management. Often, ADHD diagnoses are missed because the comorbid disorder is more prominent or is one that the practitioner is more accustomed to screening for based upon their own training. This is a difficult management situation because these patients are highly invested in ADHD treatment being the sole solution to their problem and have little motivation for changing their personality despite the obvious negative impact on their interpersonal relationships. Many adolescents and adults with undertreated or poorly treated ADHD develop substance abuse disorder.6 In this case, the critical question is which treatments to select given that there is some risk of abuse and diversion with stimulants.
This is supported by findings from neuroimaging studies that show differences in glucose utilization during positron emission tomography scans, and blood oxygen levels during magnetic resonance imaging (MRI) scans in adults with ADHD. Improvement in ADHD symptoms with MPH treatment was significantly different from placebo beginning at week 3. Several open studies and case reports but only a handful of controlled studies address the question of how to treat individuals with ADHD and comorbid substance abuse. The clinical presentation of ADHD and comorbid anxiety disorder is illustrative of this point. Unfortunately, there are few studies that provide empirical data regarding treatment of ADHD and comorbidity, as the large majority of research is conducted in non-comorbid subjects.
Stein: It begins with a careful evaluation, which results in a comprehensive diagnosis and treatment plan that describes the symptoms, impairments, and strengths of the individual, and whether the symptoms meet the profile of ADHD. Newcorn: One of the problems we have in identifying ADHD in adults as compared to children is that we do not know how to account for personality development. There is risk in providing improper treatment for another condition when one focuses on ADHD incorrectly, as well as in not treating ADHD properly. Clearly, recognizing and being able to treat ADHD in adulthood is an important new therapeutic opportunity.
Also, about 50% of children with ADHD will continue to have persistence into adulthood, such that the prevalence of adult ADHD ranges from 3% to 5%.
What becomes clear is that individuals with ADHD have higher rates of substance use disorders than those without ADHD.
So, by and large, looking at the older studies as well as the more recent rates, you could estimate that about 20% of individuals who are coming to substance abuse treatment will have adult ADHD. There is also a reduced likelihood of these individuals going into remission if they do develop dependence, and in fact, if remission is achieved, it seems to take these patients who have ADHD a longer time to reach remission. Or, a subthreshold ADHD in which they really cannot give you 6 symptoms of inattention or 6 symptoms of hyperactivity or impulsivity; they give you 3 or 4, but they cannot make the full criteria that they need for the symptom count. They compared these 4 groups and found that the full ADHD group and the late-onset ADHD group had similar rates of other psychiatric comorbidity, suggesting that there is a concurrent validity to the late-onset group which is different than what they found with the subthreshold ADHD group.
What they also found was that the subthreshold ADHD was milder and showed a different pattern of familial transmission, and in contrast to the late-onset ADHD, there seemed to be less evidence of the validity of the subthreshold ADHD. Here again, what you see are elevations in the rates of comorbid psychiatric disorders in addition to ADHD.
The 2 probably most common differential diagnoses to make with adults with ADHD is whether or not you are dealing with comorbid depression, or whether the depression is their only diagnosis.
With bipolar illness, you are more likely to see a lot more irritability, depression, and even substance abuse; whereas with ADHD, again, you are going to see a lot more improvement with structure. Another factor which may not be quite as common in adults but can occur is the desire to get special consideration with test-taking, that is, getting a longer time to take tests by carrying the diagnosis. Also, in substance abuse treatment settings, clinicians may not be familiar with or consider the diagnosis of ADHD. There are acute effects that are caused by cocaine or other stimulants that can look like ADHD, such as restlessness and agitation. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication.
Barriers to diagnosing ADHD in adults include diagnostic criteria developed and field-tested in children, nonspecificity of symptoms, high incidence of comorbid disorders that could mask or distract from the ADHD diagnosis, variation in presenting symptoms by gender and ethnicity, and lack of definitive diagnostic tools. An additional 22 inmates showed varying patterns of ADHD symptoms throughout childhood and adulthood, while seven had exhibited ADHD symptoms only during childhood, and seven showed ADHD symptoms only as adults.33 Of 129 inmates of a German prison for adolescent and young adult male prisoners, ADHD (using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition34 criteria) was diagnosed in 45%. Further, symptoms may become apparent only in more challenging situations, such as at home with its demands for multitasking, and be less prominent in a work environment chosen for its suitability for ADHD.16,54 Adaptive skills, intelligence quotient, and environmental demands may make it difficult to enumerate the six of nine symptom criteria or to validate the two-domain criterion of the DSM-IV-TR. A recent study identified a group of 79 adults who fulfilled all criteria for ADHD except for onset of symptoms before 7 years of age.
The critical factor in distinguishing many of these conditions from ADHD is the absence of childhood cognitive or behavioral symptoms consistent with ADHD.
Providing long-term support and encouragement at follow-up sessions is intrinsic to the treatment process and can also serve to significantly increase the often poor treatment adherence seen in ADHD. The selection of short-acting or long-acting ADHD treatments varied by specialty, with long-acting agents representing 56% of primary care prescriptions, 64% of psychiatrist prescriptions, and 79% of pediatric prescriptions.
Future research may demonstrate whether intervention for ADHD can reduce morbidity and mortality from tragic outcomes associated with ADHD such as increased rates of motor vehicle accidents, suicide, and substance abuse and dependence. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. Prospective study of tobacco smoking and substance dependencies among samples of ADHD and non-ADHD participants. The relationship between smoking and suicidal behavior, comorbidity, and course of illness in bipolar disorder.
Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members.
Stability of executive function deficits into young adult years: a prospective longitudinal follow-up study of grown up males with ADHD. A psychoeducational program for children with ADHD or depression and their families: results from the CMAP Feasibility Study. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. Long-term safety and effectiveness of mixed amphetamine salts extended release in adults with ADHD.
A double-blind, placebo-controlled, crossover study of osmotic release oral system methylphenidate in adults with ADHD with assessment of oppositional and emotional dimensions of the disorder. Lisdexamfetamine dimesylate and mixed amphetamine salts extended-release in children with ADHD: a double-blind, placebo-controlled, crossover analog classroom study. Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. Adults with ADHD benefit from cognitive behaviorally oriented group rehabilitation: a study of 29 participants. There are no psychological evaluations or laboratory tests that can confirm an ADHD diagnosis, and doctors familiar with childhood ADHD often have difficulty detecting adult ADHD due to its changed presentation. The first edition of the Canadian Attention Deficit Disorder Resource Alliance (CADDRA) practice guidelines2 addressed this issue by providing criteria to distinguish simple from complex cases of ADHD and recommended that only the latter be referred for consultation to a specialist. However, all of the available diagnostic interviews and rating scales have been either child based or adult based; what has never been tested is whether this migration of diagnoses with age is a function of the questions asked, changing environmental challenges across the life span, or actual age of onset. Similarly, just as it is cost effective to screen for comorbid disorders in an ADHD clinic, the same applies for ADHD screening in clinics treating other problems. It is easy to identify ADHD patients who have had hard lives but seem to keep fighting against all odds with an enthusiasm to keep trying.
Patients with ADHD live with a condition that annoys others, and they do not always see why.
These examples have been selected to illustrate that even for the experts, differential diagnosis in adults with ADHD presents a challenge.
This has significant consequences for our understanding of developmental outcomes and the burden of illness represented by untreated ADHD.
The Structured Clinical Interview for DSM-IV-TR (SCID-IV)17 does not include ADHD, ODD, learning disabilities, sleep disorders, autism spectrum, personality disorders, or Tourette’s syndrome. These patients are often disappointed to learn that for one or another reason they cannot take medication or that medication will not fix other more serious problems such as substance abuse, bipolar disorder, or personality disorder.
This discussion will focus on therapeutic management, including the implications of comorbidity on management of ADHD in adults, as well as some of the key treatment options. For example, some sources claim that people with ADHD are creative and fun to be around, but these sources often do not focus on the cumulative impairments and frequent comorbidity associated with the disorder. For example, it is very common to combine medication treatment of ADHD with CBT for comorbid anxiety or mood disorders, or with coaching, marital, or family therapy.
In addition, the populations selected for ADHD  studies may differ in several ways, including degree and presence of comorbidity, from patients who are treated in clinics. Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Adolescents with ADHD: patterns of behavioral adjustment, academic functioning, and treatment utilization. Bupropion could be a good choice for patients with ADHD and comorbid depression because it is approved for depression with has demonstrated activity in ADHD.
Findings have been mixed, with separation from placebo in some studies but not others.16,17 Some preliminary findings suggest that substance abuse improves when ADHD is successfully treated.


Individuals with ADHD, who often have impairments in performance and repeated experience of failure, might reasonably be expected to approach new situations with a certain degree of fear and trepidation.
As a corollary, it is important to consider whether ADHD is also present in adults with other psychiatric disorders, since these can often mimic or mask ADHD symptoms. Effect sizes for treatment of ADHD symptoms are approximately half of what they are in children, when approved doses are examined. If it is likely that the comorbid condition is a result of ADHD, or if ADHD is the most impairing condition, one should proceed with treatment of ADHD first. Important next steps are to more closely study the treatment of ADHD and comorbidity, with particular attention to presentation in adults, and to develop specific approaches relevant to this under-identified and under-treated population.
Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. There is emerging literature on personality disorders and personality styles in ADHD youths followed over time.
Some of them have another disorder that is worse than ADHD, but there is also a percentage of patients who do not meet the impairment criteria for ADHD.
But one also needs to consider possible psychological factors that could contribute to the enduring nature of ADHD in adults. There are specific issues related to substance abusers: the ADHD symptoms can be mimicked by alcohol and drug use, and there are specific difficulties when you are evaluating substance abusers in substance abuse treatment settings that I think lead to both under- and overdiagnosis. So, the results from this study suggest that late-onset ADHD may, in fact, be valid, and that the DSM-IV criterion may be too stringent. We have already talked about the fact that individuals with ADHD have higher rates of substance use disorders compared to those without, and here what I am showing is that the rates of other psychiatric disorders are more prevalent, as well. People with bipolar illness often do not have as great of a response if their world is structured for them. Similarly, if you have somebody coming in for an evaluation and they tell you their children have been diagnosed with ADHD, then you need to think that perhaps they have ADHD.
Often, clinicians were not trained during their residencies about the diagnosis of ADHD, or they just might not be thinking about it and therefore, they miss it. Somebody may say that they have all the symptoms of ADHD in order to get special consideration. In Withdrawal, a variety of drugs can also appear to look like ADHD; alcohol, sedatives, hypnotics, nicotine, and cocaine can produce restlessness and agitation, but you also see with certain drugs difficulty with concentration and irritability, and this can look like ADHD. They appear inattentive or impulsive in school, and this may be secondary to their difficulties at home rather than specific to ADHD, particularly if there was no structure, and that needs to be explored and can often be difficult to tease out. In other words, you cannot take a definitive, objective bipolar test, but must rely on experience and educated judgement instead. And as those of us who have lived with bipolar for a while know, there is that pesky (sometimes ruinous) bipolar behavior.
Given the relatively high prevalence of ADHD compared with other psychiatric disorders, clinicians should maintain a high index of suspicion and integrate screening for ADHD into all routine psychiatric evaluations. Recent data from Verispan13 indicates that prescriptions for ADHD medications for adults ≥18 years of age grew steadily from January 2003 through October 2007. Interviewing family members greatly improves the clinician’s ability to correctly identify ADHD, as others often remember impairments that the patient has forgotten or failed to recognize. When examined by patient age, long-acting agents accounted for 78% of ADHD prescriptions in pediatric patients (0–17 years of age), but only 49% of adult ADHD prescriptions.
Clinical trials of LDX in children have demonstrated significant improvements in ADHD rating scale scores compared with placebo and consistent times to maximum plasma LDX levels among the subjects.111,112 Similar results have been seen in adults. Meanwhile, clinicians can improve patient care and provide a better quality of life for these patients and their families by maintaining a high index of suspicion for ADHD, making screening for the disorder an intrinsic part of the standard psychiatric evaluation, and implementing a multifaceted approach to the diagnosis and treatment of adult ADHD. Psychosocial treatment, in conjunction with pharmacologic treatment or alone in patients with mild ADHD, is highly effective at controlling adult ADHD symptoms. Adults with ADHD show significant comorbidities with depressive disorders, anxiety disorders, substance use, oppositional defiant disorder, personality disorders, sleep problems, and learning disabilities.
This strategy has been in large part successful, but it has not solved the problem of addressing service needs because most ADHD adults are complex cases, and there are few psychiatrists providing back-up expertise in adult ADHD.
If ADHD is common but rarely diagnosed in specialized treatment populations at risk, the likelihood is that specialty clinics are failing to screen for or treat this condition.
Comorbidity of ADHD impacts compliance, treatment persistence, insight, self-regulation, attendance, and treatment response. There are several areas of differential diagnosis where the symptoms overlap between ADHD and another disorder is extensive, but treatment of the two disorders are distinct. The Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS) is not written for use in adults, although it has been used for adults.18 Diagnostic interviews developed specifically for ADHD in adults do not address differential diagnosis from other disorders.
Often, these individuals do not respond to antidepressants, which are typically tried first with adults with mood and ADHD symptoms. Other psychosocial treatments, such as coaching, are helpful to adults with ADHD, although these services are difficult to obtain in some areas. ADHD specialists typically see patients who have previously been diagnosed or treated for mild depression or dysthymia.
Stimulant treatment increases activation in brain regions implicated in attention and executive function in subjects with ADHD scanned with MRI while performing tests of inhibitory control. The idea that medications that are relatively rapid in their onset of effect may require more extended time before showing incremental improvement is intriguing, and speaks to the complexities in appreciating, tracking, and measuring treatment response in adults with ADHD. Hence, it stands to reason that some degree of anxiety may be secondary to the experience of having ADHD.
For example, we had a case of a first-year medical student who had taken an online questionnaire about ADHD symptoms and thought he had ADHD. Many patients have the mistaken impression that if they have ADHD, and it has not been diagnosed, then treatment may also cure their learning disability, substance problem, personality difficulties or mood disorder.
Thus, it is possible that psychosocial interventions will become increasingly important in treating adults with ADHD in the future, regardless of whether or not they are also taking medication.
Individuals who are substance abusers with ADHD seem to have higher rates of other psychiatric comorbidities, such as conduct or antisocial personality disorder, such that their treatment is even more complicated. What that means for clinicians is that we should be not be getting too preoccupied with when in childhood the ADHD symptoms began. However, a caveat to this is that individuals with long-standing ADHD often will also feel worthless or have feelings of low self-esteem because of the long-standing problems that they have had with having ADHD. If they are focused on a diagnosis that they think is of greater clinical concern, such as schizophrenia, depression, or bipolar illness, they might think that these psychiatric disorders take precedence, which, if it is an acute problem, may be the case, but then they may never get back to looking for or asking about the symptoms of ADHD.
Now, another factor that people always worry about is that perhaps substance abusers are feigning the symptoms of ADHD in order to get stimulant medication. The DSM-IV-TR would classify these patients as having a diagnosis of ADHD not otherwise specified (NOS) because they do not fulfill the age-at-onset criterion for ADHD.22 Gathering additional ADHD impairment data from family, friends, and school records from before 7 years of age can be helpful in many cases.
It can also be helpful to obtain school records to identify or corroborate childhood manifestations of ADHD.40 However, valuable supplementary information from family members or school records may often be somewhat difficult to obtain for adult patients no longer residing near their parents or schools. Longer-acting forms of stimulants and nonstimulants can improve convenience and extend control of ADHD symptoms in challenging adult environments and potentially may help decrease, but by no means eliminate, the likelihood of stimulant abuse and diversion. However, symptoms that result from ADHD, such as mood symptoms or lability, are often mistaken for comorbid disorders. Newcorn, MD, provides a discussion on the pharmacologic options available for adults with ADHD, considering dosages specific to adults and common comorbidities.
The thought disorder associated with ADHD is apparent to any skilled clinician who has to routinely take a history from these patients. The family doctor or psychiatrist in practice has to assess and manage ADHD without these advantages and often without easy access to expert consultation. There is no validated diagnostic interview appropriate to the spectrum of difficulties associated with ADHD in adults. In reality, many people do not outgrow ADHD, although often hyperactivity symptoms decline or become more subtle.2 Therefore, it is important to educate patients about what is and is not known about ADHD, including the limits of our current scientific knowledge about this disorder (Slide 1). Usually, contacting ADHD support groups such as CHADD or ADA is helpful in finding local professionals with this expertise.
For patients who present with a clear history of  ADHD, it is often best to treat the ADHD first, while monitoring the mood symptoms in response to the treatment. There are some data that suggest that one can treat the ADHD with stimulants without exacerbating the substance abuse,7 although there is need for further study in this controversial area. A related question is whether this anxiety improves if the ADHD is treated or whether it represents an independent problem. Often the people in charge are not clinical psychologists or psychiatrists, and therefore, the individuals who are running these programs may have little information or awareness of mental health issues, specifically adult ADHD, in their patient population.
Researchers at Rhode Island discovered that many patients diagnosed as bipolar actually had borderline personality disorder instead. It is often necessary to interview or obtain information from family, friends, coworkers, and old school or test records. It is important to remember that patients classified as having a diagnosis of ADHD NOS will also usually respond to approved treatments, as recently reported by Biederman and colleagues.58 In an open-label trial in 36 adults with late-onset ADHD NOS, an extended-release preparation of methylphenidate was associated with statistical and clinical improvement of ADHD symptoms. In a recent analysis96 of US prescribing patterns, long-acting medications were still being used more commonly to treat ADHD in children and adolescents (78%) than in adults (49%), though adults may have even greater problems with treatment adherence and drug abuse and diversion than those ≤18 years of age.
Anxiety disorders, depressive disorders, and substance use disorders are common among adults with ADHD.
Comorbidity with ADHD impacts treatment compliance, treatment response, and patient insight. When one informs these patients that they have ADHD, they are surprised to find their diagnosis includes the term hyperactivity. In cases like this, psychometric testing can be helpful in determining the extent of his learning disability.
At the same time, I am mindful that some patients respond better to one treatment for ADHD than another. And also, what is unique to ADHD is that usually people who are depressed are not extremely talkative and wanting to be constantly active.
At least most of the individuals that I see with ADHD who have used marijuana have begun before the age of 17. Also, computerized testing can sometimes lead to overdiagnosis because, even though computerized testing can provide very useful ancillary information for showing areas of dysfunction, it can also lead to false positives. Due to different presentation, comorbidities, and the need to establish long-term, continuous symptoms, many primary care physicians are hesitant to diagnose and treat adult ADHD.
Insufficient data on the interaction between ADHD and comorbidities impedes proper diagnosis and treatment.
Patients with ADHD may have episodic-like deterioration in functioning because living with ADHD is characterized by developmental hurdles, variable performance, and reactivity. The idea that there is actually a neurobiologically-based diagnosis that offers an explanation for a variety of these problems can be quite powerful, and this recognition can add a very important dimension to evaluating and treating adults with ADHD.
Once you get those 2 timelines, then you can look at the presence or absence of ADHD symptoms prior to drug use and during periods of abstinence.
Although the answers currently remain unknown, sleep research remains relevant to assessment and treatment of ADHD in adults. If the symptoms are not present during periods of abstinence or tend to come and go, then this is not consistent with an adult diagnosis of ADHD. Bipolar disorder is episodic, whereas borderline personality is a more pervasive and constant state.
Food and Drug Administration-approved pharmacologic treatments for adult ADHD include stimulants, dexmethylphenidate, and the nonstimulant atomoxetine. For example, data from long-term studies of treatment response in adults with ADHD suggest there may be incremental improvement over time. New treatments on the horizon may offer options better fitting the needs of adults with ADHD. Risk of abuse is a major concern; stimulant treatments are controlled substances, and children with ADHD show increased risk of substance abuse.



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