Hal Elliott, MD Associate Professor Residency Program Director Department of Psychiatry East Tennessee State University.
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Hal Elliott, MD Associate Professor Residency Program Director Department of Psychiatry East Tennessee State University Wake Forest University: Middle 50% of Students With SAT between 12501390 US NEWS and World Report: #25-30 Davidson College : Middle 50% of Students With SAT between 13101440 US News and World Report: #5-11 “A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically found in individuals at a comparable level of development” EXECUTIVE FUNCTIONING DISORDER ADHD: Neurobiologic Basis Attention Networks EXECUTIVE CONTROL ORIENTING (SELECTIVE ATTENTION) ALERTING Posner and Raichle. Images of the Mind. Scientific American Books; 1996. Neural Networks of Attention Prefrontal cortex Parietal cortex Cingulate gyrus Limbic structures (amygdala-hippocampus) Basal ganglia Thalamus Brainstem (reticular formation) Cerebellum Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272. Anterior Cingulate Cortex Cognitive Division Fails to Activate in ADHD Normal Controls y = +21 mm ADHD 1 x 10-2 1 x 10-3 y = +21 mm 1 x 10-2 1 x 10-3 Bush G et al. Biol Psychiatry. 1999;45:1542-1552. Heritability of ADHD ADHD Schizophrenia Panic Disorder Height Laarson( 2004) Rietveld (2003) Martin (2002) Kuntsi(2001) Coolidge (2000) Thapar (2000) Willcutt (2000) Hudziak (2000) Nadder (1998) Levy (1997) Sherman (1997) Silberg (1996) Gjone (1996) Thapar (1995) Schmitz (1995) Stevenson (1992) Edelbrock (1992) Gillis (1992) Goodman (1989) Willerman (1973) Matheny (1971) 0.0 0.1 0.2 0.3 Mean heritability of ADHD = .75 0.4 0.5 0.6 0.7 0.8 0.9 1 Heritability Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323. Variation in basal ganglia symmetry and in corpus collosum PET: Decreased brain glucose metabolism in basal ganglia of ADHD adults/adolescents (Zametkin et al) SPECT: Increased striatal availability of a dopamine transporter ( Krause et al) Genetic Studies: Twin and sibling studies most convincing biologic evidence Catecholamines and Brain Activity DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; A acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra. Lifetime Course of ADHD Symptoms: Inattention Domain Childhood Difficulty sustaining attention + Doesn’t listen No follow-through Can’t organize Loses important items Adulthood Difficulty sustaining attention (meetings, readings, paperwork) Paralyzing procrastination Slow, inefficient Poor time management Disorganized Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37. Lifetime Course of ADHD Symptoms: Hyperactivity-Impulsivity Domain Childhood Squirming, fidgeting Can’t stay seated + turn Can’twait Runs/climbs excessively Can’t play/work quietly On the go/driven by motor Talks excessively Blurts out answers Intrudes/interrupts others Adulthood Inefficiencies at work Can’t sit through meetings Can’t wait in line Drives too fast Self-selects very active job Can’t tolerate frustration Talks excessively Interrupts others Makes inappropriate comments Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37. Traffic Violations and MVA Among Young Adults With ADHD Negative Driving Outcomes From a Driving History Interview 70 P =.003 Subjects Responding Yes (%) 60 50 ADHD (n = 105) Control (n = 64) 40 30 P=.007 P=.001 20 P=.001 P=.002 10 0 Drove Before ≥12 Traffic ≥5 Speeding License ≥3 Vehicular Citations Licensed Citations Suspended Crashes or Revoked MVA, motor vehicle accidents. Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672. “ OFFICER, I AM NOT INEBRIATED…I AM JUST INEPT.” Britt Elliott ( 1988) Individuals With Substance Use Disorder (%) P<.001 100 75 80 60 40 20 0 18 Non-ADHD (n=137) 25 Medicated ADHD Unmedicated ADHD (n=56) (n=19) Biederman J et al. Pediatrics. 1999;104:e20 Spencer et al: 60% of children with ADHD meet criteria as adults Spencer, Biederman, Williams: 663/1700 meet criteria Borland and Heckman: 50% of ADHD kids meet criteria as adults as opposed to 5% of nonADHD siblings Distractibility Organizational problems Poor task completion Forgetfulness Careless errors/ trouble with details Sequencing problems Hyper-focusing/ Prioritization Problems “Deer in the Headlights” Authority Issues Stubbornness Intolerance of silly rules/ assignments Relationship problems ( peer and sig. other) Frequent changes in major/ schools Poor frustration tolerance Easily bored Poor or inconsistent academic performance despite adequate or even superior intellectual abilities Scattered Anxious/ “Scanning The Horizon” Irritable Chronically Late/ Poor Time Sense Procrastination Bored Easily/ Restless/ Impatient Trouble with Math/Directions Reading Comprehension Problems Compensatory OC Behavior Increase in distress/ anxiety/ disorganization when responsibility increases/ changes at work, home, or school. EXAMPLES: Birth of child Promotion Increase in academic workload Transitions: First of School Year, Starting College or Grad School, Moving Rooms, Changing Classes, Weekday to Weekend, Weekend to Weekday, Awake to Sleep, Sleep to Awake Anxiety Disorders (50%) Substance Abuse ( 27%-47%) Antisocial Personality Disorder ( 12%-27%) Affective Disorders (? %) NO COMORBID DX: 40% Copeland Symptom Checklist For Adult ADHD Brown Adult ADD Scale( BAADS II) Amen Scale While ADHD is a clinical diagnosis, consider psychometric testing if: Diagnosis is unclear Accommodations are needed More details re: exact deficits are needed or if LD is suspected. Childhood Prerequisite New Onset: medical work-up indicated Consider: endocrine, sleep apnea, drug interactions, hearing deficit, B12, head injury, heavy metal, seizure disorder. MRI/CT, EEG, BP, EKG, baseline labs, etc. Why? Childhood Onset – difficult to get accurate history, especially in individuals who have IQ in superior range. By adulthood comorbidity clouds diagnosis ADHD is a clinical diagnosis Schedule II medications/fear of prescribing Countertransference/Cultural Bias Many college students functioning in the intellectual ly superior range never had to study before college Many students had parents to manage all of their details, scheduling, deadlines, etc Some students attended exclusive private schools with very rigid day to day routines. External organization kept them structured and limited distractions. It isn’t compulsive checking behavior if you really might forget Anxiet y will increase catecholamines and can increase ability to attend Procrastination creates anxiety when the work is imminently due….and can increase ability to attend Classical conditioning model But…too many catecholamines cause a shut down effect. “Are you scattered because you are anxious or are you anxious because you are scattered” “Are you depressed because you can’t get your work done or are you not getting your work done because you are depressed” OC sxs as a compensatory mechanism. Ruminating. Lists. Excessive worry. Worst case scenarios. Not usually repetitive over time. Tend to be day to day worries as opposed to intrusive ego dystonic obsessions Thoughts jump from one thought to next as opposed to focusing on one obsession Compulsive sxs are less likely to be linked to obsessive thinking. Genetic overlap Hyperactivity vs. Mania/Hypomania Discreet episodes vs. ongoing symptoms Of pharmacologic options available for ADHD, stimulant medications are the: Most studied Most commonly used Most effective First-line agents for treatment Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S. DOPAMINE: mediates “verbal fluency, serial learning, vigilance for executive functioning, sustaining and focusing attention, prioritizing behavior, and modulating behavior based on social cues” (Stahl) NOREPINEPHRINE: plays role in “sustaining and focusing attention, as well as in modulating energy, fatigue, motivation and interest” ( Stahl) STIMULANTS: Methylphenidate (Ritalin, Ritalin LA, Metadate CR, Concerta) Mixed amphetamine salts ( Adderall, Adderall XR), Dextroamphetamine ( Dexedrine, Dextrostat), Dextroamphetamine long acting ( Vyvanse) d-methylphenidate ( Focalin) Pemoline ( Cylert)…LFT’s ANTIDEPRESSANTS/ OTHER Buproprion ( Wellbutrin) Venlafaxine ( Effexor) Duloxetine ( Cymbalta) Desipramine/ Imipramine Modafinil ( Provigil) Clonidine ( catapress) Atomoxetine (Strattera SSRI’s for comorbidity….not for core symptoms Problems with the stimulants Schedule II drugs (abuse liability, diversion, medicolegal concerns) 30% do not adequately respond or cannot tolerate stimulant treatment Short duration of action (compliance, embarrassment) Side effect profile adversely impacting sleep, appetite, mood, and anxiety Concerns about cardiovascular effects, growth suppression, and tic development Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432. Education Organizational Help (academic coaching) Learning Assistance Center @ WFU Individual and Couples Therapy CHADD SNL @ Davidson College Exercise Selection of occupation and need for novelty/ difficulty with change Leveling the playing field: Quiet Environment Extra Time UC Berkeley Study: Group Standard Time LD 13th percentile Non-LD 82nd percentile Extra Time 76th percentile 83rd percentile Accommodations for Resident Physicians with Attention Deficit Disorder Academic Psychiatry Elliott, Arnold, Brenes, Silvia, Rosenquist August 2007 Stimulants/ Schedule II drugs Alteration of sense of self/ blunting of creativity Non-linear thinkers in the academic environment. Myth of Laziness. Twice the work for half the result. “Left handed learners” Responsibility Square Pegs and Round Holes “My parents and I have different ideas about what I should do after graduation. I want to go to Florence and study Art History. They want me to move into their pool house and become a dental hygienist” Patient J, Senior at WFU I was a peripheral visionary. I could see the future, but only way off to the side. Steven Wright Attentiveness….does not characterize my brothers and me, all of whom were raised in SC and who have an air of abstraction and carelessness. None of us have a sense of direction. When something breaks, we fix it with duct tape…we tend to live in our own heads than in the actual physical world. We are more likely to get lost, to forget things, to stare blankly off in the distance for minutes at a time…at least part of the reason I resist ( taking something like Ritalin) is that I am not convinced the abstracted end of the mindfulness spectrum is such a bad place to be. In fact, I kind of like it here. Sometimes I wonder whether it is an accident that of the three abstracted Elliott brothers, two have graduate degrees in philosophy and the other is a psychiatrist. Carl Elliott, MD, PhD Better Than Well. American Medicine Meets the American Dream “One must still have chaos within oneself to be able to give birth to a dancing star” Nietszche “ You can dream the American Dream, but you sleep with the lights on and wake up with a scream” Warren Zevon ( Fistful of Rain) “ Walk with me out on the wire…” Bruce Springsteen ( Born To Run) Evaluation of Adult ADHD What to evaluate Current symptoms Impairment Establishing childhood onset How to evaluate Role of screening tools Role of scales (diagnostic and symptom assessment) Importance of prompts Who should evaluate Mental health professionals PCPs PCP, primary care physician. Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:8593; Wilens TE, et al. JAMA. 2004;292:619-623.