ATTENTION DEFICIT

HYPERACTIVITY DISORDER IN

ADULTSNURLIYANA BINTI DZULKARNAIN

ADHD-DEFINITIONBased on DSM-1V-TR criteria,defined as

developmentally inappropriate poor attention span or age-inappropriate features of hyperactivity and impulsivity or both

At least for 6 months, occur before 7 years old

Cause impairment in academic or social functioning

Considered a childhood disorder

ADHD-CLASSIFICATION The DSM-IV, or Diagnostic and Statistical

Manual of Mental Disorders, 2000 edition, defines three types of ADHD:

1) An inattentive type2) A hyperactive/impulsive type3) A combined type

ADULT ADHD-SYMPTOMS

Inattentive type (ADHD-I) Procrastination Indecision, difficulty recalling and organizing details

required for a task Poor time management, losing track of time Avoiding tasks or jobs that require sustained

attention Difficulty initiating tasks Difficulty completing and following through on tasks Difficulty multitasking Difficulty shifting attention from one task to another

ADULT ADHD-SYMPTOMSHyperactive/Impulsive-type (ADHD-H)

Chooses highly active, stimulating jobs Avoids situations with low physical activity or sedentary

work May choose to work long hours or two jobs Seeks constant activity Easily bored Impatient Intolerant to frustration, easily irritated Impulsive, snap decisions and irresponsible behaviors Loses temper easily, angers quickly

ADULT ADHD-DIAGNOSIS DSM-IV-TR criteria were developed for

children and adolescents-cannot always applied to adults-alteration to criteria to fit adult symptoms

Symptoms stated in criteria not appropriate in adults-rely on observations to childhood activities

Under report the severity of symptoms Impairment also include social and

leisure activities,parenting,and intimate relationships

ADULT ADHD-DIAGNOSIS Establishing whether the symptoms were also

present in childhood, even if not previously recognized

Combination of a careful history of symptoms up to early childhood, including corroborating evidence from family members, previous report cards, etc. along with a neuropsychiatric evaluation

Also screening tests,ruling out depression,substance abuse,anxiety,hyperthyroidism

ADULT ADHD-NEUROBIOLOGY Structural

differences(neuroimaging methods) Significant reductions in Total cortical

grey matter,prefontal and anterior cingulate volumes and right putamen/globus pallidus grey matter

Thinning of cerebral cortex in networks that mediate attention and executive fxRight hemisphere involving the inferior parietal lobule,dorsolateral prefontal anterior cingulate cortices

ADULT ADHD-NEUROBIOLOGY Neurochemistry Near infrared spectroscopy Increases oxygenated Hb in

ventrolateral prefontal cortex,indicating reduced activation of this area in task related actvtsmarked in working memory

Higher N-acetyl-aspartate/creatine ratios in the prefrontal corticosubcotical region and left centrum semiovale.

ADULT ADHD-NEUROBIOLOGY NeurochemistryPositron emission tomography (PET) Involvement of dopamine transporter Lower dopamine D2/D3 receptor activity

in caudate ,hippocampus and amygdalaMagnetic Resonance Imaging (MRI) Reduced activation of the ventral

prefontal cortex,anterior cingulate cortex and striatum

IMPACT OF ADULT ADHD Professional and economic impact-More likely to change jobs-Work productivity is lowerconcentration

difficulties,disorganization and reduced ability to cope with large workload

Social problems-Lack of friendships & poor relationship with

parents-Relationship difficulties-Problems adjusting after marriage-Parenting-more likely to have lack of parental

discipline,-ve parent child interactions

IMPACT OF ADULT ADHD Comorbidities-Mood disorders and anxiety disorders occur

with greater frequency in adults with ADHD-Bipolar disorder-Substance abuse disorder Sleep and activity disturbances-Difficulty in falling asleep and numerous

waking throughout the nightdaytime fatigue

-Driving accidents-attributed to impulsivity,inattention,loss of concentration and fatigue

ADULT ADHD-TREATMENT Current guidelines by AACAP,CADDRA and

BAP-combination therapy recommended:-• Psychoeducation,• An initial trial medication with titration to

an individual effective dose,• Assesment of residual symptoms• Long term community follow-up NICE Guidelines• Methylphenidate is first line drug• If ineffective or unacceptable-

Atomoxetine or Dexamfetamine

ADULT ADHD-TREATMENT First line-Pharmacotherapy-1st choice-

Methylphenidate(psychostimulant) Mechanism-Reuptake inhibition of

monoamine transportersincreases levels of dopamine and norepinephrine in the brain

Available as immediate release (IR),extended release (ER),OROS MPH

-2nd choice Atomoxetine(non psychostimulant)-inhibit norepinephrine transporter

ADULT ADHD-TREATMENT Pharmacotheraphy-Concerns Methylphenidate-Abuse-esp short acting prescriptions

risk of being injected or snorted-Risk of adverse cardiovascular events-MI

and hypertension-Amphethamine-better side effect

profile,better tolerated Atomoxetine(non-stimulant medications)-Rare-increase potential for liver damage

and suicidal ideation

ADULT ADHD-TREATMENT Psychosocial treatment As adjunctive treatment CBT(15 weeks)-Motivational interviewing and practice-Repetition and review of skills such as

organizing and planning,reducing distractibility,problem solving,adaptive thinking in times of stress.

Dialectic behavioural therapy(3 months)-Sessions discussing mindfullness,emotion

regulation and impulse control-Also undertake daily exercises and reading

educational materials regarding ADHD.

THANK YOU FOR YOUR ATTENTION