Have you ever experienced persistent symptoms of inattention or impulsivity that interfere with your daily functioning? Have you on various occasions tried to start projects at home or at work and not been able to complete them? Does your mind flit from one topic to the next and you have a hard time completing your thoughts? Do you open a novel or newspaper and find that you have read a page but cannot recall anything you just read? If any or all of these symptoms apply to you, you may be suffering from adult attention-deficit/hyperactivity disorder (ADHD). In North America and Europe, 3-5 percent of adults have ADHD, but only approximately 10 percent of those have been formally diagnosed. It is often found co-occurring with other disorders such as mood, anxiety and substance-abuse disorders. Adult ADHD is marked by persistent procrastination, inattentiveness, difficulty completing tasks as well as organizational problems. These difficulties affect multiple areas of an adult ADHD sufferer’s life, i.e., occupational, social and academic, resulting in financial loss, marital and relationship problems, and work-related issues. Often, these difficulties diminish one’s self esteem, leading to emotional shortcomings as well. The overall intelligence and learning potential of these individuals, however, is no different from an adult who does not have the disorder, but a 2004 study showed an income discrepancy of $4,334 lower for adults with ADHD versus their college-graduate counterparts. In addition, studies have shown that the total loss in work productivity in the United States alone is over $77 billion.
ADHD is a childhood-onset condition, requiring that symptoms be present from 7 years old and on. It is a neurological condition that is highly genetic. It is believed, however, that environmental factors play a role as well. A clinician will diagnose adult ADHD based on a client’s personal history, observing him or her during the sessions, observational evidence from family and academic reports going back to their years in school.
According to the DSM-5, the current standard for diagnosis of psychiatric disorders, there are three types of ADHD: predominantly inattentive type, predominantly hyperactive-impulsive type and combined type, which has features of both presentations. One must have at least six inattentive-type symptoms to be diagnosed as the inattentive type, i.e., the individual often fails to pay close attention to detail or makes careless mistakes at work, has difficulty sustaining attention in tasks or play, does not seem to listen when spoken to directly, loses things necessary for a task or is easily distracted by extraneous stimuli. One must have at least six hyperactive-type symptoms to be diagnosed as the hyperactive-impulsive type, i.e., often fidgets with hands or feet, leaves seat in a situation when sitting is expected, is often “on the go,” acting as if driven “by a motor,” often talks excessively and often interrupts or blurts out an answer before a question was completed. For the combined type, one must have features of both.
There is evidence that adult ADHD is due to problems in parts of the brain responsible for executive functioning, and difficulties can range from moderate to extreme between individuals. Often, they were stigmatized as children and experienced a degree of depression due to feeling different from their peers, which may play a role in depression, relationship problems and substance abuse as teenagers and adults.
The good news is we have excellent treatment options available today for adult ADHD that can drastically improve the individual’s life, greatly enhancing his or her performance at school, work and in relationships. Primary treatment for adult ADHD combines medication management with behavioral and vocational interventions. Medications are the first line and are tailored to the specific ADHD symptoms as well as the comorbid symptoms of depression, anxiety, etc. The first-line medications for adult ADHD are the stimulants, which can be immediate or long-acting. There is methylphenidate, such as Ritalin, which comes in immediate and long-acting (LA) preparations. It works to increase the quantities of the dopamine and norepinephrine neurotransmitters in the synaptic cleft. It is usually tolerated well in short stints, but there have been insufficient studies of long-term therapy in adults and there are some questions about long-term usage increasing blood pressure. Then there are the amphetamines, like Adderall, also available in short- and long-acting (XR) preparations. Amphetamines also act to increase the release of neurotransmitters into the synaptic cleft. The amphetamines are generally better tolerated than the methylphenidates and appear to have less cardiovascular side effects, such as elevated blood pressure.
There are also non-stimulant medications such as atomoxetine, otherwise known as Strattera, which has a delayed onset of therapeutic effect. It lacks abuse potential and is used for patients who can’t tolerate stimulants. It is effective for the inattentive type of ADHD due to the fact that it is primarily a norepinephrine reuptake inhibitor, increasing the concentration of norepinephrine in the synaptic cleft and boosting concentration. Rare side effects, however, are liver damage and increased suicidal ideation.
Desipramine, a tricyclic antidepressant, and bupropion (or Wellbutrin), another anti-depressant, which increases levels of dopamine and norepinephrine in the synaptic cleft, are also used in ADHD management, especially if there is a comorbid depression.
Finally, there is psychological intervention, such as CBT training, stress management, relaxation training and behavioral modifications to reduce the negative effects of the disorder. In most cases, psychosocial strategies alone are ineffective and must be combined with a medication regimen for one to achieve the ultimate remission of symptoms.
By Dr. Shani Stein
Shani Stein, MD, is a psychiatrist with a private practice in Teaneck. She specializes in treating adults with depression, bipolar, anxiety disorders and ADHD. She can be reached for a consultation at 201-591-5230.
