Attention deficit hyperactivity disorder

Diagnosis

DSM Criteria (summarized)

• 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 (DSM-V)
  • i.e. 90% of patients with depression in mental health clinics report difficulty with concentration (Gaynes et al, 2005) which often persist after remission of depressive episode (Rock et al, 2014); patients with borderline personality disorder can display impulsivity and deficits in problem solving (Gvirtz et al, 2015).
  • 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 (Sibley et al, 2018).
  • Due to recall bias, retrospective symptom report from childhood is often not accurate when assessed longitudinally over decades (Moffitt et al, 2015).
• ADHD rating scales typically have high sensitivity but low specificity, more appropriate for screening measures rather than sufficient for diagnosis (Sibley et al, 2018), for example, the commonly used Conners Adult ADHD rating scale has been demonstrated to be invalid when assessing a patient with anxiety (Grogan et al, 2018)

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 (Verbeeck et al, 2017) or vortioxetine (Frampton 2016)
• Review current medication regimens for possible iatrogenic effects on attention (anticholinergic, sedative, or antipsychotic properties) (Bishara et al, 2017; McIntyre et al, 2018)
• Encourage nonpharmacologic and lifestyle modifications before pharmacologic intervention
  • A meta-analysis of CBT demonstrated moderate-large effect size for adult ADHD symptom treatment (Knouse, Teller, and Brooks, 2017).
  • Cognitive rehabilitation programs, such as goal management training, can be effective in improving executive function
  • Mindfulness meditation has been demonstrated to improve attention (Tang, Hozel, and Posner, 2015)
  • Brief exercise has been shown to improve attention and motivation in ADHD (Fritz and O'Connor 2016)
• Pharmacologically, stimulant (methylphenidate, dextroamphetamine) medication can improve sustained attention (though at times at the expense of cognitive flexibility) (Mueller et al, 2017)

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). (American Psychiatric Association).

Bishara, D., Harwood, D., Sauer, J. & Taylor, D. M. Anticholinergic effect on cognition (AEC) of drugs commonly used in older people: Anticholinergic effect on cognition. Int. J. Geriatr. Psychiatry 32, 650–656 (2017). PubMed link

Frampton, J. E. Vortioxetine: A Review in Cognitive Dysfunction in Depression. Drugs 76, 1675–1682 (2016). PubMed link

Fritz, K. M. & O’Connor, P. J. Acute Exercise Improves Mood and Motivation in Young Men with ADHD Symptoms: Med. Sci. Sports Exerc. 48, 1153–1160 (2016). PubMed link

Gaynes, B. N. et al. A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial. Gen. Hosp. Psychiatry 27, 87–96 (2005). PubMed link

Grogan, K. et al. Differential diagnosis and comorbidity of ADHD and anxiety in adults. Br. J. Clin. Psychol. 57, 99–115 (2018). PubMed link

Gvirts, H. Z. et al. Executive dysfunction in bipolar disorder and borderline personality disorder. Eur. Psychiatry 30, 959–964 (2015). PubMed link

Knouse, L. E., Teller, J. & Brooks, M. A. Meta-analysis of cognitive–behavioral treatments for adult ADHD. J. Consult. Clin. Psychol. 85, 737–750 (2017). PubMed link

McIntyre, R. S. et al. Characterizing, Assessing, and Treating Cognitive Dysfunction in Major Depressive Disorder: Harv. Rev. Psychiatry 26, 241–249 (2018). PubMed link

Moffitt, T. E. et al. Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am. J. Psychiatry 172, 967–977 (2015). PubMed link

Mueller, A., Hong, D. S., Shepard, S. & Moore, T. Linking ADHD to the Neural Circuitry of Attention. Trends Cogn. Sci. 21, 474–488 (2017). PubMed link

Rock, P. L., Roiser, J. P., Riedel, W. J. & Blackwell, A. D. Cognitive impairment in depression: a systematic review and meta-analysis. Psychol. Med. 44, 2029–2040 (2014). PubMed link

Sibley, M. H. et al. Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. Am. J. Psychiatry 175, 140–149 (2018). PubMed link

Tang, Y.-Y., Hölzel, B. K. & Posner, M. I. The neuroscience of mindfulness meditation. Nat. Rev. Neurosci. 16, 213–225 (2015). PubMed link

Verbeeck, W., Bekkering, G. E., Van den Noortgate, W. & Kramers, C. Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst. Rev. (2017) doi:10.1002/14651858.CD009504.pub2. PubMed link