Some patients with
Adult ADHD
Dr Rigo Van Meer
9/10/2013
Thanks to:
Catherine Flanagan
Innisfail Team
Tully Team
Goal
• Make doctors and mental health workers
more aware of adult adhd
• Make them consider adhd as a possibility
• Sharpen clinical acumen in diagnosing
adhd
• Especially in complicated cases
ADHD in adults can be from trivial to very severe
Severe cases can be compounded by depression, anxiety, angriness and
aggression, social deterioration, loss of meaning in life, illegal drug use and
incarceration.
Treatment of severe cases often gives spectacularly positive results that are life
changing. These successful treatments are in my experience one of the very
rewarding things a psychiatrist can do in his profession.
Adult ADHD lessons learned 1
I found reading about adult adhd treatment particularly unhelpful. Much general
statements and warnings, little practical guidance. I learned from experience in
around 150 adult adhd patients that:
Dose of Ritalin 10mg or Dexamphetamine 5mg is between 2 and 12 tablets daily,
with an average of 6.
Under-dosing gives many problems, as patients will use the dose they need, and
run out of their tablets too soon. Once the right dose is found, patients do not
want to increase the dose.
Dexamphetamine has fewer side effects and is felt as “softer” than Ritalin.
Dexamphetamine is therefore in general the better medication
Stimulant treatment:
As a rule reduces the urge to drink alcohol or to smoke dope.
Often will improve sleep dramatically.
Often has a general improvement in mood -> anti depressants can be stopped.
Adult ADHD lessons learned 2
Patients with adhd who seek treatment are often treated negatively and
condescending by doctors and pharmacists. Patient with adhd who seek
treatment are sometimes branded as “drug seeking”. When they try another
doctor they are “doctor shopping”.
Many patients with adhd use marijuana or alcohol to dampen their constant
feeling of stress and unrest.
Dexamphetamine and methylphenidate are not addictive. Patients who do not
have adhd find these drugs in general unpleasant.
Illegal use of amphetamines is often self medication for adhd. Proper treatment
of adhd decreases crime and keeps people out of jail.
Qualitatively different effect
• From my experience with successful and unsuccessful
treatments I have the strong impression that patients with
adhd have a qualitatively different reaction to stimulants
than most other people.
• Patients with adhd become relaxed and their sleep
improves
• Others become stressed and can't sleep very well
• Some illegal amphetamine users seem to know this, as
one of my patients was made fun of when he became
relaxed on speed in stead of high."Ha ha, you have adhd,"
another user told him
• I am not aware of research in this phenomenon, but I
would love to read about it
6
Common adhd problems
• Mood swings:
• aggressive outbursts
• Depressive feelings (not reacting to anti
depressants)
• Bad sleep (restless, waking up often)
• Feeling stressed, restless, on edge much
of the time
• Use of marijuana and alcohol (calms me
down)
Questions for ADHD screening
Have you ever been diagnosed with ADHD or has the diagnosis been
considered?
Did you have trouble concentrating most of your life?
(E.g. being easily distracted, not finishing things, getting easily bored, being forgetful,
acting chaotic)
Do you feel restless much of the time?
(E.g. feeling pressured, not relaxed, difficulty sitting still, fidgeting, moving all the
time)
If you ever used ritalin, amphetamines or speed, how did you react to it?
Minimal training
• Registrars should be trained to be
confident in diagnosing and treating adhd
in adults.
• During their training they should diagnose
and treat at least ten patients with adult
adhd, simple cases and cases with
psychiatric co morbidity
• Does this sounds reasonable?
ADHD
• Attention problems
– Can’t stay focused
– Easily bored
– Starts a lot, finishes little
– Can’t plan
– Can’t listen to instructions
But also…
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•
•
•
Often feels stressed or on edge
Easily irritated or angry
Emotionally more up and down
Feels out of control (and often is)
And socially…
•
•
•
•
•
•
•
Misses out on education
Runs with the wrong crowd
Problems heap up: can’t solve them
Drug use, alcohol
Offences (drugs, aggression)
“Depression”, anxiety
Life goes nowhere
Presentation to psychiatrist
• Young patient treated for adhd turns 18
• Adhd patient from other state seeks
continuation of treatment
• GP/psychologist/patient thinks of ADHD
• Depression/anxiety/social stress
• Schizophrenia/BPAD + adhd
Patient J, male, 48
Male, born 1955, Diesel fitter, Married. Four adult children.
Referral by GP July 2013
From letter of GP
Stopped Effexor-XR a week ago as he did not think they were helping his depression
Drove to Mt Carbine with his rifle yesterday >> drove home again
Police were called >> mate has now his rifle
No other firearms at home
Things seem a lot better with Dianne (wife) now
No benefit from Lexapro or Cymbalta in past
Assessment by CW of J
•
L was referred to MH services by his GP after he presented feeling
depressed, experiencing suicidal ideations, had a plan to shoot himself and
had access to means (gun). He also recently ceased his medication as he felt
they were ineffective. He has been treated with Lexapro, Effexor and
Cymbalta in the past with little improvement.
•
L believes he may have been experiencing depression for the past 30 years,
however, symptoms became worse after he had a heart attack in 2010.
•
Symptoms include low motivation, anhedonia, irritability, poor memory and
concentration, feelings of emptiness, poor sleep and suicidal ideations.
Denies any current suicidal ideations and is willing to seek treatment.
•
Ongoing relationship problems and financial stressors.
•
Drinks socially.
•
Identified a small group of friends and his boss as sources of support.
Medical review J
Casually dressed, well kempt
Friendly, cooperative
Comes across as nervous, is fidgety
Lifelong Hx of low mood, worsened since a heart attack.
Sleep: variable. Often not well rested in the morning. Tired during the day.
Appetite: not much of an appetite
He can't enjoy too much in his life. Has "thoughts" very often. Negative
ruminations, sometimes about suicide.
Not suicidal now.
Since his interview with CW, he feels better.
This is the first time he has really sought help.
Medical review cont’d J
• He hates being in busy places with many people. But he can go. No panic
attacks (no clear agoraphobia)
• He wants to quit his current job as a diesel fitter and wants to work on a
station. He has applied for a job on a station.
• He has used amphetamines in the past (at a party) Effect: made me feel
normal (!)
Medical review cont’d L
Probed adhd.
Always bad concentration, in school already.
Difficulty listening to instruction or reading them (when I put the paper down I
have forgotten them already).
Does not plan, but does prepare for things, as he does not want to do everything
the last minute.
Difficulty finishing things at home. On the job he finishes his tasks.
Procrastinates a lot.
Feels often stressed without a reason (butterflies in his belly)
Can't stop ongoing thoughts.
No drug use.
No problematic alcohol use
Medical review cont’d J
Conclusion
Very likely adult ADHD with co-morbidity (depression)
Plan
Start trial on Dex
Meds
Dexamphetamine 5mg 6 daily (on average)
Script dex #200
DDU OK
re 4 to 6 wk
S, male 40, amphetamine abuse and jail
From the referral letter GP:
PROBLEM: Anxiety, depression, OCD, recent release from prison
(convicted for manufacturing methamphetamine, 2 year in jail)
Tumultuous history: ADHD as a child
Anxiety, depression, OCD since late teens
Previous drug abuse mainly amphetamines including IVDU
Hepatitis C successfully cleared with interferon
He was on large doses of Aropax, Seroquel and benzodiazepines while in prison
but was keen to cease medications prior to his release. He has tried to cope
without medications as he does not want to get into drugs again. Is engaged with
ATODS.
I started him on Lexapro 10mg, today increased to 20mg.
S, male, amphetamine use and jail
Past diagnoses
Drug addiction
2010 (in Jail)
High anxiety and depression
Some antisocial traits evident
2012 (Community Health)
generalised anxiety
axis 2 : deferred
meds: Quetiapine started
Medical review S, male
Presents as very stressed, almost tortured.
Is tearful at moments.
Can’t sit still, fidgety
Has all the symptoms of adhd.
Used amphetamines for over 20 year.
Says they made him feel “normal”.
emotionally labile, desperate
Conclusion
Adult ADHD with co morbidity in crisis
Medications S, male
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Past Medications
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Lexapro 20mg mane
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Aropax 20mg
•
Xanax
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Present Medication
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Dexamphetamine 5mg 6 daily
Current Situation S, male, amphetamine use and jail
Report from CW
I talked to S and daughter on the 04/10/2013 and they reported that S has now
been living in Cairns with his daughter for the past 8 months. He has been
working fulltime as a scaffolder for past 8 months. He states he is happy, feels
normal and has no legal or illicit drug issues.
He believes that the treatment “saved his life”.
Patient L, 33, bipolar disorder
2003
Studies at Uni engineering
Taken to hospital by mother due to deterioration of mental state developing
gradually over several weeks and then rapidly in ten days
Somewhat dishevelled, guarded, elevated mood: he is confident, fatuous, FTD,
rhyming & punning, is undercover agent, mother involved with Osama Bin
Laden, he knows the Kennedy’s, etc. etc. Does not hear voices.
Presented during admission superficially well, but delusional when longer
engaged. No insight. ITO
Has used marijuana which is seen as the cause of his deterioration
L, male 33, bipolar disorder
Brother: depressive episodes
Two maternal cousins: psychotic episodes
Grandmother: Hx BPAD
2004
To Innisfail Team after admission in Brisbane for hypomania.
Settled on Lithium.
ITO
Schizoaffective disorder
DDx: BPAD
From then on:
Hx of relapses, ITO, non compliance with medication, admissions and good
periods. He is often obnoxious, but friendly at other times.
L, male 33, bipolar disorder
2013
Stabilised on
Lithium SR 450mg 3 daily
Aripiperazole 30mg
He works as a diesel fitter for 24 months now. Full time, completing mechanical
engineering apprenticeship.
He wants to study again
He is remarkably insightful and compliant
Discharged from mental health service, but still in occasional contact
L, 33, male, bipolar disorder
Then ....
His former caseworker talks with him about how his life and apprenticeship is
going.
He picks up on a raft of adhd symptoms.
He completes a full questionnaire and Luke “ticks all the boxes”
He asks me to review Luke
I agree. Clear ADHD.
Start trial with dexamphetamine.
Dose finding: 8 tablets daily (40mg)
L, male, 33, bipolar disorder
Very good effect:
Feels calmer. Thoughts are clearer
Can organize his day now
He watched a full movie. Never could do that before
Completes one task at a time
Generally feels better. Mood improved
No craving for alcohol, dope or cigarettes any more. Uses much less
Finds other people react much more positive towards him
He has still grandiose ideas at times, but he says with the dexamphetamine he
can put them in a much more realistic light. He feels the dex works as an antipsychotic (!!)
He is very happy with the changes
He says it is late in his life, but he feels he can now go on with his life
Reflection on L, 33, male, bipolar disorder
A very difficult patient with whom I worked for many years. The thought that he
(also) might have adhd never occurred to me.
It is very good to have an attentive and well trained team.
Treatment of his adhd has improved L’s quality of life significantly
Conclusion
BPAD
ADHD
Both well managed now
B, female, 50+, drugs and depression
Patient has been long known to the service with multiple problems:
Drug addiction (on Suboxone, seen by ATODS)
Depression
HepC
Anne developed Parasitosis delusion, needing a lengthy hospitalization.
Probably induced by drugs, possibly bad methamphetamine. She had never
been psychotic before.
She lived with a drug addicted and dealing partner.
B, female, 50+, drugs and depression 2
She was stabilized on:
Suboxone 32mg
Amisulpiride 600mg
Quetiapine 300mg
Venlafaxine 300mg
Diazepam 5mg tds
And ready for discharge from the service, although she felt stil depressed and
generally unhappy.
On presentation she had symptoms and a history of untreated adhd. I found her
unfocused and disorganized, emotionally unstable and unable to manage her life
Trial with stimulants indicated but:
•Had developed severe psychotic symptoms likely induced by drugs
•Lived with an amphetamine using & dealing partner
•Has a history of drug abuse herself
B, female, 50+, drugs and depression 3
Decided to trial dexamphetamine anyway because:
Could give her a big improvement in mental state
She was convinced she could keep the dex away from her partner
She was motivated to try
I have not seen any adhd patient developing psychotic symptoms under dex
(but I have seen a patient with acquired brain damage developing psychotic symptoms,
that stopped as soon as the dex was stopped)
B, female, 50+, drugs and depression 4
Result turned out to be very good (pfew!)
General concentration improved. Feels more in control of her life. Much more
settled and happier. Nil recurrence of psychosis. Amisulpiride and Quetiapine
stopped. Still on Venlafaxine, suboxone and prn valium, and Dexamphetamine
5mg 6 daily.
Report by CW on current Situation
Talked to B on the 04/10/2013 and she reported that she continues to work 2
days per week at Endeavour. She is no longer in a relationship with her abusive
drug dealer partner Shane. B is a new relationship with J who is not a user, nor
physical abuser. He is very supportive of B. Since commencing on
Dexamphetamine B has repaired her relationship with her parents. She is
presently attempting to reduce the Suboxone with the help of ATODS and
receiving counselling for people who were IV users.
B, female, 50+, drugs and depression 5
But….
Around a year later B developed again symptoms of parasitosis and was shortly
hospitalised
She admitted that she had used some Methamphetamine incidentally. Not clear
wether this was before or after the parasitosis started again insidiously.
She was restarted on anti psychotic medication
The dexamphetamine was stopped
Lessons?
Unclear. In hindsight it had been better to stay on anti-psychotics. But after a first
psychotic episode later in life, lifelong anti psychotics are not indicated.
Did the dexamphetamine play a role?
Further follow up will maybe learn us more.
P, male, 40+, stress
Building designer, works from home. Married, 4 children
April 2011
Self referral: “On the rocks”
Anger problems, no physical violence
Yelling at family
Financial stresses, wife threatens to leave him
Hx of drug addiction (pain killers after broken leg, 2003), stopped in 2004
Hx of depression after accident. Treated with antidepressant (which ?)
ATODS for 18 months for pain killer addiction
(Oxycontin, Endone, Panadeine forte, Voltaren, etc)
P, male, 40+, in 2011, stress
Assessed by psychiatrist (myself):
•No evidence of depression
•No psychiatric diagnosis
•Social stresses
•Patient declined tranquilizers
Referred to Tully support Centre for anger management counseling
CLOSED
P, male, 40+, in 2012, stress
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April 2012
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Self referred
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Marital issues: fears for marriage break up
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Kids (15, 13, 9, 7) not talking to me
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Unemployed now, but that is not the issue
•
Keen to seek help
•
Does not see himself as depressed
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Not suicidal
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NOT ACCEPTED
P, male, 40+, in 2013, stress
February 2013, Self referral
Relationship troubles
“always feeling angry”
feels like he is “constantly in trouble”
mood up & down all the time
major sleep problems: wakes ever ½ hour. Wakes up with headache
Feels tired/ exhausted
Reports a signifiant decline in mood
Flat, tearful during interview
Ruminating negative thoughts
Suicidal thoughts, no intent or plan
Consumed by self blame, fearful of marriage break down
P, male, 40+ in 2013, stress
Has been tried on different anti depressants in the past.
Ceased to use THC recently and recently reduced cigarettes
No practical issues: has full time job again (sugar mill), no financial problems,
stable accommodation
Scores high on Adult ADHD scale: disorganized, lacks ability to complete tasks,
lack of concentration
Provisional formulation: ADHD, depression?, sleep disturbance, marital problems
P, male, 40+, stress in 2013
Treatment
Started on Quetiapine for sleep 75mg (telephone consultation with consultant)
Encouraged to seek counseling
Full assessment & medical review planned
Med review
ADHD
Has reacted well to Quetiapine: sleeps again, calmer
plan
Continue Quetiapine
Trial on Dexamphetamine
P, male, 40+, stress, in 2013
First follow up
P does very well on the dexamphetamine
Concentration improved, work going well. He is been promoted!
Sleeps (too) well. Quetiapine stopped.
Feels more relaxed, not stressed or despondent anymore
Side effects:
Excess transpiration
On first day: felt “racing”.
P, male, 40+, stress, in 2013
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Further follow up
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Still goes very well
•
On 6 tablets (found 8 too much)
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Not moody anymore, thoughts “not so untidy” any more.
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Improved focus and concentration, even for boring tasks
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Eating breakfast for the first time
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Quetiapine stopped: after some initial problems with sleep now no sleeping
problems
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Wife is happy with the changes. She notices when he forgets to take his dex.
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Not angry anymore
•
Relationship is going well
P, male, 40+, stress in 2013
Collateral from family:
Massive change.
Kids, wife and in-laws say he is very different now.
Things go well at home.
Conclusion
Adult ADHD reacting well to psycho stimulant treatment
CLOSE