Attention deficit hyperactivity disorder

Diagnosis

DSM Criteria: 52

• Must interfere with functioning or development, with symptoms of inattention and/or hyperactivity
  • Inattention: difficulty maintaining focus leading to missed details at work or conversation, easily side-tracked in tasks, difficulty with organization, misplaces objects, forgets errands/appointments
  • Hyperactivity: fidgeting, restlessness, excessive talking, interrupts others in conversation
• Symptoms were present before age 12
• Symptoms are present across multiple settings (school, work, home)
• Symptoms “interfere with or reduce the quality of social, academic, or occupational functioning.”
• Symptoms are not better explained by another psychiatric disorder (i.e. mood disorder, anxiety, dissociation, substance use)

Diagnostic considerations: though patients often present with symptoms of “attention deficit”, a variety of psychiatric and medical diagnoses may be contributing to symptoms of inattention, impulsivity, and hyperactivity

• Inattention / poor concentration is a core diagnostic criteria for generalized anxiety disorder and major depressive disorder 52
  • i.e. 90% of patients with depression in mental health clinics report difficulty with concentration 53 which often persist after remission of depressive episode 54; patients with borderline personality disorder can display impulsivity and deficits in problem solving 55
  • This can be especially tricky for patients with difficulty recognizing their own emotions
  • Patients with low self-esteem are especially vulnerable to being critical when self-appraising cognitive function, feeling they are not meeting others’ (or their own) expectations
• Patients with new-onset or significantly worsened symptoms should generally be considered as having an alternative etiology than ADHD, as adult-onset cases overwhelmingly do not meet criteria and/or are better explained by another psychiatric, substance, or medical disorder 56
  • Due to recall bias, retrospective symptom report from childhood is often not accurate when assessed longitudinally over decades 57
• ADHD rating scales typically have high sensitivity but low specificity, more appropriate for screening measures rather than sufficient for diagnosis 56, for example, the commonly used Conners Adult ADHD rating scale has been demonstrated to be invalid when assessing a patient with anxiety 58

Treatment

• Target inattention by treating existing psychopathology present (mood, anxiety, substance use, sleep disorders)
  • Patients with depression and predominant cognitive complaints may benefit from an antidepressant with pro-cognitive benefit, such as bupropion or vortioxetine 59,60
• Review current medication regimens for possible iatrogenic effects on attention (anticholinergic, sedative, or antipsychotic properties) 61,62
• Encourage nonpharmacologic and lifestyle modifications before pharmacologic intervention
  • A meta-analysis of CBT demonstrated moderate-large effect size for adult ADHD symptom treatment 63
  • Cognitive rehabilitation programs, such as goal management training, can be effective in improving executive function
  • Mindfulness meditation has been demonstrated to improve attention 64
  • Brief exercise has been shown to improve attention and motivation in ADHD 65
• Pharmacologically, stimulant (methylphenidate, dextroamphetamine) medication can improve sustained attention (though at times at the expense of cognitive flexibility) 66