Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
www.mghcme.org
Diagnosis of Adult ADHD
Joseph Biederman, MDProfessor of Psychiatry Harvard Medical School
Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD
Director, Bressler Program for Autism Spectrum DisordersMassachusetts General Hospital
www.mghcme.org
Disclosures 2018-2019
My spouse/partner and I have the following relevant financial relationships with commercial interests to disclose:
– Research support: Genentech, Headspace Inc., Lundbeck, Neurocentria Inc., Pfizer, Roche TCRC Inc., Shire Pharmaceuticals Inc., and Sunovion.
– Consulting fees: Akili, Jazz Pharma, and Shire– Royalties paid to the Department of Psychiatry at MGH, for a
copyrighted ADHD rating scale used for ADHD diagnoses: Bracket Global, Ingenix, Prophase, Shire, Sunovion, and Theravance
– Financial interest: Avekshan LLC, a company that develops treatments for ADHD. My interests were reviewed and are managed by MGH and Partners HealthCare in accordance with their COI policies
www.mghcme.org
Paul Wender
“ADHD is probably the most common chronic undiagnosed psychiatric disorder in adults. It is characterized by inattention and distractibility, restlessness, labile mood, quick temper, overactivity, disorganization, and impulsivity. It is always preceded by a childhood diagnosis, a disorder that is rarely inquired about and usually overlooked.”
Adult ADHD28
www.mghcme.org
Is ADHD a Valid Diagnosis in Adults?
SYNDROMATIC CONTINUITY
Family-Genetic Studies
Treatment Effectiveness
Comorbidity and Neuropsychological Deficits
Impairments
Imaging Studies
Wender PH. J Clin Psychiatry. 1998;59(suppl 7):76-79. Spencer et al. J Clin Psychiatry. 1998;59:59-68.
www.mghcme.org
Adult ADHD Studied
1950 19801968 1970 1987 19941937
Minimal Brain
Dysfunction
Minimal Brain
Damage
Attention Deficit/Hyperactivity
Disorder (DSM-III-R)
Attention Deficit Disorder ± Hyperactivity
(DSM-III)
ADHD Residual Type (First Adult ADHD Dx
Attention Deficit/Hyperactivity Disorder (DSM-IV)
Efficacy of Amphetamine
Hyperactive Child
Syndrome
ADHD: Timeline of Definitions
1930
Hyperkinetic Reaction
of Childhood (DSM-II)
1902
First Description of ADHD by Still
www.mghcme.org
Changes in DSM-5 ADHD
• “Neurodevelopmental” - not “disruptive”• ≥ 6/9 inattentive or ≥ 6/9 impulsive/hyperactive
symptoms over last six months (>5 for adults)• Symptoms caused impairment by age 12 (no
longer 7)• ASDs no longer exclusionary• No more “subtypes”; Inattentive / Hyperactive-
impulsive / Combined are now “Presentations”• Restricted inattentive subtype: In Appendix,
worthy of further study
www.mghcme.org
Adult ADHD characterized by continuous lifelong
impairments and pervasiveness
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 2000.
Diagnosis of ADHD in Adults: DSM-V Diagnostic Criteria
Presentation: (1) inattention symptoms,(2) hyperactivity-impulsivity symptoms, or (3) both
Onset: some symptoms <12 years of age (childhood onset)
Chronicity: >6 months of disturbance (persistent)
Domains affected: cross-situational (home, work, school)
Functioning: evidence of impairment (can be relative)
12
www.mghcme.org
Reduced MPFC-PCC Coupling ReflectsCurrent Diagnostic State of ADHD
Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
Psychopharmacology Course 2017
www.mghcme.org
Neural Basis of Persistent ADHD
• Persistent ADHD alters intrinsic functional organization of the brain
• Findings supports the idea that adult ADHD diagnosis reflects a true brain difference
Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
www.mghcme.org
Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
Psychopharmacology Course 2017
www.mghcme.org
Inattention
Impulsivity/Hyperactivity
ADHD: Core Symptom Areas
Psychopharmacology Course 2017
www.mghcme.org
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 2000.
Diagnosis of ADHD in Adults: DSM-V Symptoms
Inattention
• Careless mistakes
• Difficulty sustaining attention
• Easily distracted
• Difficulty organizing
• Fails to finish tasks (frequently shifts activities)
• Seems not to listen
• Avoids tasks requiring sustained attention
• Loses things
• Forgetful
Hyperactivity/Impulsivity
• Unable to stay seated
• Fidgets
• Excessive movement (internal restlessness)
• “On the go”
• Excessive talking
• Blurts out answers
• Difficulty waiting turns (impatience)
• Interrupts or intrudes
32
www.mghcme.org
Symptoms of Inattention Often Manifest Differently in Adults
American Psychiatric Association. 1994. 83-85., ADHD in Adulthood 1999, Weiss, Hechtman and Weiss
DSM IV Symptom Domain Common Adult Manifestation
• Difficulty sustaining attention
• Doesn’t listen
• No follow through
• Can’t organize
• Loses important items
• Easily distractible, forgetful
• Difficulty sustaining attention
– Meetings, reading, paperwork
• Paralyzing procrastination
• Slow, inefficient
• Poor time management
• Disorganized
www.mghcme.org
Symptoms of Hyperactivity Can Manifest Differently In Adults
American Psychiatric Association. 1994. 83-85., ADHD in Adulthood 1999, Weiss, Hechtman and Weiss
• Squirms and fidgets
• Can’t stay seated
• Runs/climbs excessively
• Can’t play/work quietly
• “On the go” / “Driven by motor”
• Talks excessively
• Workaholic
• Overscheduled/overwhelmed
• Self-select very active job
• Constant activity
• Talks excessively
DSM IV Symptom Domain Common Adult Manifestation
Hyperactivity often changes to inner restlessness
www.mghcme.org
Symptoms of Impulsivity Often Manifest Differently In Adults
American Psychiatric Association. 1994. 83-85., ADHD in Adulthood 1999, Weiss, Hechtman and Weiss
• Low frustration tolerance
– Losing temper
– Quitting jobs
– Ending relationships
– Driving too fast
– Addictive personality
DSM IV Symptom Domain Common Adult Manifestation
Impulsivity in adulthood often carries more serious consequences
•Blurts out answers
•Can’t wait turn
•Intrudes/interrupts others
www.mghcme.org
AdulthoodChildhood
Hopelessness, frustration, giving up
Chronic failure
Unwanted pregnancy, sexually transmitted disease, divorce
Impulsivity, carelessness
Antisocial personality disorder, criminality
Oppositional defiant or conduct disorder
AddictionDrug experimentation
Car accidents/injuriesMultiple injuries
Job failure/underemployment
Becomes
Becomes
Becomes
Becomes
Becomes
BecomesSchool failure or underachievement
ADHD Impairment Persists
Courtesy of W. Dodson, MD.
29
www.mghcme.org
Patient attempts to compensate and time invested in the compensation is an important diagnostic indication.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 2000.
Diagnosis of ADHD in Adults: Patient Compensation Efforts
Patients usually:
• Set up rigid schedules
• Pursue areas of interest with extreme zeal
• Seek careers/situations with controllable stimuli
• Make use of organizational tools
• Impose own “time-outs” during stimulus overload situations (take walks/disappear)
33
www.mghcme.org
Course of ADHD Symptoms Over Time by Sex: A Growth Curve Model
Age by Sex Interaction: NS
Biederman et al. 2009Psychopharmacology Course 2017
www.mghcme.org
Age-Dependent Decline and Persistence of ADHD Throughout the Lifetime
Faraone et al. Nature Reviews Disease Primers 2015
www.mghcme.org
ADHD: Course of the Disorder
Inattention
Time
Hyperactivity
Impulsivity
Psychopharmacology Course 2017
www.mghcme.org
Inattention Drives Presentationof ADHD in Adults
0
10
20
30
40
50
60
70
80
90
100
Inattentive
%
Affected
Hyperactive/
Impulsive
Endorsed Symptom Clusters
N=149
P<.05
Millstein R et al. J Atten Disord. 1997;2:159-166.
90%
45%
www.mghcme.orgWilens T, Dodson W. J Clin Psych.
Diagnosis of ADHD in Adults:Common Clinical Histories
• Difficulties in elementary or secondary school
– Comments: “not living up to potential,” “spacey,” “hyper”
– Behavioral issues: “class clown”
• Difficulties in college
– Incomplete degree or longer time to complete degree
– Difficulty engaging in further education
• Difficulties at work
– Underachievement (mixed reviews)
– Low efficiency: Longer time to complete tasks
• Difficulties at home
– Poor organization, does not complete tasks
– Strained relationships with spouse and kids(who also may have ADHD)
34
www.mghcme.org
Diagnosis of ADHD in Adults: Examples of Adult ADHD Scales
Some Symptom Assessment Scales
• Brown ADD Scale
• Conners Adult ADHD Rating Scale
• Wender-Reimherr Adult Attention
• ADHD Rating Scale
• Barkley Current Symptoms Scale
• Adult Self-Report Scale v 1.1(18-item symptom assessment and screener)
• Adult Investigator Symptom Report Scale (AISRS)
Diagnostic Scales
• Conners Adult ADHD Diagnostic Interview
• Barkley Current Symptoms Scale (with supplemental Barkley scales)
• Brown ADD Scale Diagnostic Form
• Structured Diagnostic Interviews ADHD Module
Adler L, Cohen J. Psych Clin N Amer. 2004; 27:(2):187-201
14
www.mghcme.org
Murphy P, Schachar R. Am J Psychiatry. 2000;157:1156-1159; Conners CK. J Clin Psych.
1998;59(suppl 7):24-30; ASRS v1.1. Available at: www.adultADD.com/2_2_recognizing/screener.jsp.
Accessed November 26, 2003.
Diagnosis of ADHD in Adults: Validity ofSelf-Reports
• Self-report reliable and useful in diagnosisof ADHD in adults
13
www.mghcme.org
Spearman’s Rank Correlations Examining the Association between the AISRS (Clinician) and ASRS (SELF)
A. Whole Sample (N=54) B. Males (N=24) C. Females (N=30)
D. Age ≤40 Years (N=28) E. Age >40 Years (N=26)
rs=0.65, df=52, p<0.001 rs=0.68, df=22, p<0.001rs=0.69, df=28, p<0.001
rs=0.64, df=26, p<0.001 rs=0.70, df=24, p<0.001
Biederman et al JAD 2018
www.mghcme.org
Is ADHD Always a Childhood Onset Disorder?
www.mghcme.orgMoffitt et al. Am J Psychiatry 2015; 172:967–977.
www.mghcme.org
Adult ADHD
• Symptoms and impairment may emerge due to the accumulation of environmental and genetic risk factors
www.mghcme.org
Adult ADHD
• Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset with symptoms and impairment
• This multifactorial perspective allows for different risk factors to exert effects at different ages thereby influencing age of onset
www.mghcme.org
Adult Onset ADHD
• Because these effects are multifactorial, there is no clean separation of etiologic factors in people above and below the ages of 12 years set forth in DSM-V
Faraone and Biederman JAMA Psychiatry Editorial 2016
www.mghcme.org
70
80
90
100
110
120
130
140
150
0 10 20 30 40 50
Full
Scal
e IQ
Age at Initial Diagnosis
Age at Initial Diagnosis vs Full Scale IQ
IQ and ADHD
• IQ can compensate for the impairments of ADHD
• Can forestall diagnosis of ADHD
Horrigan J, et al. Presented at: 47th Annual AACAP Meeting; October 24-29, 2000; New York, NY.
11
www.mghcme.org
Shekim WO, et al. Compr Psychiatry. 1990;31:416-425.
Biederman J, et al. Am J Psychiatry. 1993;150:1792-1798.
Comorbidity in Adults With ADHD
Antisocial Disorder (10%)
Major Depressive Disorder (30-40%)
Bipolar Disorder (15-20%)
Anxiety Disorders (30-40%)
Substance Abuse Disorders (20-50%)
21
www.mghcme.org
Disorder ADHD Rate
Major Depression1 20%
Bipolar Disorder2 15%
Generalized Anxiety Disorders3 20%
Substance Abuse4 25%
Re-evaluate refractory patients for ADHD.
ADHD Comorbidity in Adults With Other Psychiatric Disorders
1. Alpert, et al. Psychiatry Res. 1996. 2. Nierenberg, et al. Presented at: APA; May 18-23, 2002; Philadelphia, Pa.3. Fones, et al. J Affective Dis. 20004. Wilens. Psych Clin N Am. 2004.
22
www.mghcme.org
1. Quick to get angry or become upset
2. Easily frustrated
3. Over-react emotionally
4. Easily excited by activities going on around me
5. Lose my temper
6. Argue with others
7. Am touchy or easily annoyed by others
8. Am angry or resentful
Deficient Emotional Self Regulation
Scoring: Never (0), Sometimes (1), Often (2), Very Often (3)
DESR: ≥ 95th percentile of total scores in Controls
Surman et al, AJP In Press
www.mghcme.org
Educational Impairment in High School
*
*
*
*
* p ≤.001
Percentage of Those Who Attended High School
52%
27%
37%
13%
37%
10%
30%
8%
"C" average or lower
Had a tutor
Had special classes
Had to repeat a grade
ADHD (N=464)
Non-ADHD (N=487)
Biederman et al. J Clin Psychiatry. 2006 Apr; 67(4):524-40
www.mghcme.org
Current Employment Status
*
*
*
*
* P≤.001
Percentage of Each Group
52%
72%
34%
57%
48%27%
14%
5%
Currently employed
Employed full time
Not currently employed
Looking for work
ADHD (N=500)
Non-ADHD (N=501)
www.mghcme.org
Workplace Impairment
* P≤.001, P≤.05, P≤.01
Easy to concentrate on work
Able to handle large work loads
Unless very interested, unable to pay attention for long periods of time
Organized at work
Sometimes have difficulty following instructions
One of the first that would be considered for a promotion
†
‡
*
*
*
*
Percentage of Those Employed Who "Strongly Agree"
33%59%
52%74%
46%20%
39%69%
5%
11%
31%45%
ADHD (N=261)
Non-ADHD (N=301)
† ‡
www.mghcme.org
Average Household Income by Education Level Attained
www.mghcme.org
Symptom domains
▪ Hyperactivity
▪ Inattention
▪ Impulsivity
ADHD: The Disorder
Psychiatric comorbidities
▪ Anxiety and mood disorders
▪ Disruptive behavior disorders
(conduct disorder and
oppositional defiant disorder)
+
Functional impairmentsSelf
▪ Low self-esteem
▪ Accidents and injuries
▪ Smoking
▪ Substance abuse
▪ Delinquency
School / Work
▪ Academic difficulties,
underachievement
▪ Employment difficulties
Home
▪ Family stress
▪ Parenting difficulties
Social
▪ Poor peer relationships
▪ Socialization deficit
▪ Relationship difficulties
Lead to