Adult Attention Deficit Hyperactivity Disorder

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Definition of ADHD: a condition marked by persistent inattention, hyperactivity, and sometimes impulsivity. It begins in childhood and often lasts into adulthood.

Many children diagnosed with ADHD recover completely but many of these children’s ADHD progresses to adulthood. Previously, it was believed that ADHD is a child’s disorder but recent studies hve proved that many people continue to suffer from this order even in their adulthood. 

Differences from childhood ADHD: adults with ADHD do share several symptoms with childhood ADHD e.g. general inability to focus on tasks, difficulty in completing tasks, remembering details, listening to instructions. But the main difference in the types of symptoms and difficulties experienced are;

a. rather than dealing with tests in school, the problems are more job related or relationship based.

b. instead of jumping around or running, adults face more of  fidgeting,  restlessness kind of a behavior. 

Classes of ADHD: are divided in 3 subtypes

1.Inattention.

2.Hyperactive/Impulsive.

3.Mixed.

Study showing shifting brain patterns in ADHD patients: study was conducted on 35 adults who were diagnosed with ADHD as children and 13 still had the disorder. Researchers used a technique called Resting State Function MRI (fMRI) to investigate that how do brain work when a person was not engaged in any particular activity. The patterns proved helpful in showing which parts of brain communicte with each other during such type of wakeful rest.

Results: a. In people without ADHD, when mind is unfocused, there ia a distinctive synchronization in brain’s activity at regions known as Default Mode Network ( a network of brain regions that are active when a person is not focused on the outside world).Whereas, in ADHD patients these networks… posterior cingulate cortex and medial prefrontral cortex – no longer synchronize.

b. In people without ADHD, when default mode network is in action, another network called Task Positive Network (is a network of areas in the human brain that typically responds with activation increases to attention requiring work) is suppressed.  When a person is involved in activities which require focus, the positive network dominates and reduces the activity of default network. If this reciprocal relationship degrades, then the ability to focus declines.

Diagnosis: “The psychiatric guidelines for whether a person’s ADHD is persistent or remitted are based on lots of clinical studies & impressions.This new study reveals that there is a real biological boundary between those two sets of patients” says MIT’s John Gabrieli, the Grover M. Hermann, Professor of Health Sciences and Technology, professor of Brain & Cognitive Sciences.

For diagnosis, symptoms must be present prior to age 12 years, should occur in 2 or more settings and symptoms may not be well explained by other mental disorders. Range of factors are observed in this case; 

a. scores on psychological tests.

b. employment history.

c. driving records

d.  whether illicit substances have been used.

e. social & emotional functioning.

f. details of past or current criminal behavior.

Differential diagnosis:ADHD can mimic other conditions which can complicate the diagnosis;

1. Generalized anxiety disorder… restlessness and difficulty in concentrating.

2. Bipolar disorder… distract ability, impulsivity.

3. Depression… psychomotor agitation & a diminished ability to think.

4. Emotional trauma.

5. Cocaine intoxication… hyperactivity,  impulsive acts, increased talkative behavior.

Signs you may have adult ADHD: 

a. feel edgy or restless.

b. facing relationship problems, being easily distracted or not being able to pay attention can sabotage a good relationship. 

c. you had academic problems as a child, e.g. had to work twice as hard as other children at that time to get through the school work.

d. you are a procrastinator. 

e. you are a thrill seeker.

f. frequently misplace your daily used items.

g. trouble at job.

h. have a quick temper.

I. act on impulse

j. not organized. 

Inhaling dirty air during pregnancy can increase ADHD risk: prenatal exposure to polycyclic aromatic hydrocarbons (PAH) can cause ADHD. PAH are toxic air pollutants, source is residential boilers, traffic, electricity generating plants etc. It is believed that PAH may be involved in damaging endocrine system, leading to DNA damage, oxidative stress & may interfere with placental growth factors which may result in decreased exchange of oxygen & nutrients.

Later in childhood, maternal malaise, caregiver emotional distance, criticism directed at the young child have been correlated with an increased risk of ADHD.  The justifying reason behind all this is the increased presence of human stress response in the young child, causing the developing brain to have a very intensive exposure to catecholamines & ADHD seems to be an adaptive measure to dampen the catecholamines response in a constantly stimulated brain.

Treatment: 

1. Stimulants: Methylphenidate & Amphetamines are being used for this purpose. These agents bind to presynaptic dopamine transporters & block reuptake mechanism, allowing the catecholamine deficit existing in ADHD a temporary remedy. As the long term use study of these drugs has not been done so caution is to be exercised, patients with CV risks factors in particular.

Methylphenidate IR… 10-60mg/day.

Methylphenidate SR… 10-60mg/day.

Methylphenidate ER… 10-60mg/day.

Amphetamine/ dexamphetamine IR… 5-40mg/day.

Amphetamine/dexamphetamine XR… 5-40mg/day.

Dextroamphetamine… 5-40mg/day

Methamphetamine… 5-40mg/day

Lisdexamfetamine… 30-70mg/day.

Tricyclic antidepressants: are also helpful in treating anxiety, depression & tic disorders, which are usually seen to co exist with ADHD. But these agents show a delayed onset.

Nortriptyline… 50-150mg/day

Imipramine… 100-300mg/day.

Atomoxetine: 40-100mg/day. It is a novel drug for the treatment of ADHD. It shows its action by selectively inhibiting the presynaptic Norepinephrine reuptake. But it has a poor response rate and a delayed onset. Its profile indicates that this drug is to be used as an adjunct or a second line agent.

Alpha 2 agonist: like clonidine can be used to treat ADHD in adults& children. It is used either as a monotherapy or as an adjunct. It stimulates alpha 2 receptors in prefrontral cortex and enhances the Norepinephrine flow and synaptic connectivity. The safety has not been established in adults, that’s why it is is placed as a last choice or an alternative choice category. 

Bupropion: 150-300mg/day. This drug has shown to decrease depression, aggression and to increase cognitive function but is not indicated for these uses. This drug may also increase anxiety, lower the seizure threshold, worsen tics, so is not to be used in such patients. This drug is given for smoking cessation, so can be used for this purpose as it is seen that a large number of such patients smoke.

Nicotinic agonists: are now being studied for this purpose. It was seen that smoking or nicotine exposure was improving the symptoms of ADHD. Researches are being conducted to find out nicotinic acetylcholine agonists which will have more tolerable side effects in order to improve the cognition in ADHD patients.

Ways to concentrate at work: 

1. by prioritizing the tasks. 

2. by specifying a time in a day to read emails.

3. by setting the time to check & answer voice mails.

4. by setting realistic goals one day at a time or one hour at a time. 

5. by finding a quiet place to work.

6. by organizing yourself, work place & work in a clean place.

7. by working in the same location, at the same time enhances the tendency to get the work done properly.

8. take notes, helps in remembering the things later.

9. surround yourself with organized people. 

Role of a Pharmacist: plays a very essential role in providing best and effective treatment for the adult ADHD because pharmacist has a complete understanding & knowledge of the pharmacology,pharmacokinetics, efficacy of available options of treatments, drugs & products.

Reference:

1. American psychiatric association.

2. Massachusetts Institute of Technology.

3. US Pharmacist.

4. Columbia center for Children’s Environmental Health.

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