Attention deficit disorder has been recognized as the most common underdiagnosed psychiatric disorder in adults and a major contributor to drug abuse, automobile and industrial accidents, and underachievement.
Characteristics of adult ADHD include:
- Difficulty concentrating.
- Inattention.
- Reading, repeat reading, and rereading again to understand the material.
- Difficulty initiating and finishing tasks.
- Disorganized behavior.
- Difficulty establishing a routine.
- Forgetfulness.
- Misplacing things.
- Shifting activities prematurely.
- Low frustration tolerance.
- Frequent daydreaming.
- Hyperactivity.
In my adult clinical practice, I have found inattentive ADD type to be much more common than the hyperactive type. The following characteristics may help identify the inattentive type:
- Quite, unassuming students work extremely hard to get into college
- At the university student’s grades drop incrementally. Many students present to my office on academic probation.
- Highly intelligent students fail to notice ADD symptoms until entering medical, veterinarian, or law school, etc. where they study an incredible number of hours to keep up.
- Older adults present with poor work performance or working much harder than others to get the job done. Often these patients present after their children have be diagnosed with ADD.
- I never prescribe more than 60 mg of Adderall daily. If needed I augment with guanfacine or Wellbutrin. If that fails, I refer to another psychiatrist.
ADD symptoms are extremely easy to fake. To alleviate this problem as much as possible students must show a marked improvement in grades. Older adults must have a job or get a job in 6-months or sooner. Almost all treated older patients soon get a promotion or a better job.
Considerable symptom overlap between bipolar disorder and ADD may lead to diagnostic confusion. Twenty-one percent of childhood ADD patients will develop bipolar disorder and 10 percent of ADD adults have a risk of developing bipolar disorder. Key distinguishing features of ADD include:
- Reading and rereading material.
- Shifting activities.
- Poor concentration.
Distinguishing diagnostic features of BPD include:
- Elation
- Grandiosity
- Racing thoughts
- Decreased need for sleep
- Severe mood instability
In my practice I have treated more than a few patients with bipolar spectrum disorder and ADD. In those cases, I begin with a mood stabilizer, usually lithium. After the mood is stabilized, I cautiously add Adderall.
Untreated ADD can lead to substance abuse as patients seek to relieve symptoms by self- medicating. If ADD is consistently treated, the risk of substance abuse is the same as in the general population. Psychostimulant treatment of ADD appears to protect against the development of substance abuse.
Medications used to treat ADD include:
Amphetamines, most commonly Adderall (dextroamphetamine + amphetamine) Amphetamines enhance the release of presynaptic dopamine and block reuptake of dopamine.
A study involving over 2600 subjects showed the efficacy of Adderall exceeding that of other medications.
Once the proper dose is reached response is almost immediate. Patients often report a feeling as if a spotlight has been focused on the task at hand.
Interestingly patients report less anxiety when taking Adderall because their anxiety about failure to get things done had diminished. If patients report increased anxiety the diagnosis is wrong, or the dose is too high.
Ritalin (methylphenidate) blocks the reuptake of dopamine. Methylphenidate is 50% less potent than amphetamines.
Strattera (atomoxetine)—a norepinephrine reuptake inhibitor that is the first nonstimulant approved by the FDA for treatment of ADD. Side effects include hypersomnia, nausea, dizziness, and GI distress. I have found this medication to be ineffective.
Wellbutrin XL—a multisite study showed efficacy. I never use it except in a few cases to augment Adderall.
Tricyclics—1000 subjects in 13 controlled studies showed TCAs effective in every study. Side effects limit their use.