ADHD in adults Flavio Guzmán, MD

Overview Summary of DSM V criteria for ADHD Brief comparison with DSM IV Clinical features of adult ADHD

Introduction Children: 5.2 % Adults: 2.5 % Worldwide prevalence: Adult ADHD: 1:1 Children 4:1 Male / Female ratio Recognition that ADHD persists after adolescence Increase of diagnosis and treatment in adults Volkow, N. D., & Swanson, J. M. (2013). Clinical practice: Adult attention deficit-hyperactivity disorder. The New England journal of medicine, 369(20), 1935. Polanczyk, Guilherme, et al. "The worldwide prevalence of ADHD: a systematic review and metaregression analysis." American journal of psychiatry 164.6 (2007): 942-948.

DSM V Criteria

Diagnostic features Persistent pattern of Inattention: not due to defiance or lack of comprehension Hyperactivity / impulsivity Interferes with functioning or development More than one setting: Home School Work Informant confirmation Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Diagnostic features Symptoms were present prior to age 12 years Presentation Combined Predominantly inattentive Predominantlty hyperactive/impulsive Symptoms were present prior to age 12 years Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Diagnostic criteria Children: at least 6 of 9 symptoms Older adolescents (age 17 and older)and adults: at least 5 of 9 symptoms Inattention Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Often fails to give close attention to details or makes careless mistakes Details Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Difficulty sustaining attention in: Tasks Play activities Difficulty remaining focused during: Lectures Conversations Lengthy reading Attention / Focus

Inattention Does not seem to listen Mind seems elsewhere Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Unable to finish: schoolwork chores duties in the workplace Loses focus Easily sidetracked Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Start tasks

Inattention Difficulty organizing: Tasks Activities Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Avoids tasks that require mental effort Older adolescents and adults: Paperwork Reviewing papers Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Often looses things necessary for tasks or activities Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Is often easily distracted by minor stimuli Adults: unrelated thoughts Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Inattention Often forgetful in daily activities Adults: returning calls paying bills keeping appointments Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity / Impulsivity Diagnostic criteria Children: at least 6 of 9 symptoms Older adolescents (age 17 and older)and adults: at least 5 of 9 symptoms Hyperactivity / Impulsivity Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Often fidgets with or taps hands or feet or squirms in seat Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Leaves his/her place in: Classroom Office Other workplace Other situations Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Children: Run about or climb in situations where it is inappropriate Adults: May be limited to feeling restless Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Often unable to play or engage in leisure activities quietly Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Often “on the go” Unable to or uncomfortable being still for extended time Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Gives an answer before a question has been completed Cannot wait for turn in conversation Often talks excessively Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Often has difficulty waiting his or her turn (while waiting in line) Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Hyperactivity and impulsivity Often interrupts others Adolescents and adults: take over what others are doing Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013.

Summary of DSM V changes DSM IV DSM V Age of onset <7 yr <12 yr Number of symptoms Inattention Six of nine Children: six of nine Adolescents (≥17 yr) and adults: five of nine Hyperactivity - Impulsivity Other ADHD types ADHD presentations Feldman, H. M., & Reiff, M. I. (2014). Attention Deficit–Hyperactivity Disorder in Children and Adolescents. New England Journal of Medicine, 370(9), 838-846.

Diagnostic assessment for adult ADHD Patient interview: determine if ADHD symptoms Started in childhood Are severe enough Have been present throughout the patient’s life Have led to dysfunctioning throughout the patient’s life Interview an informant: partner, parent or other relative Kooij, JJ Sandra. Adult ADHD: Diagnostic assessment and treatment. Springer, 2013

Adult ADHD: Summary of symptoms Hyperactivity Excessive fidgeting Inability to sit still Impulsivity Spending impulsively Starting new jobs and relationships on impulse Sensation seeking behaviors Inattention Distractibility Disorganization Being bored Need for variation Difficulty making decisions Lack of overview Kooij, S. J., Bejerot, S, et al (2010). European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC psychiatry, 10(1), 67.

Adult ADHD: Summary of symptoms Mood lability Frequents highs and lows Short-fuse temper outbursts Kooij, S. J., Bejerot, S, et al (2010). European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC psychiatry, 10(1), 67.

Comorbidity in adult ADHD Comorbidity is the rule 75% of patients have at least one disorder Mood, anxiety, sleep, personality and substance use disorders Learning and other neurodevelopmental disorders Kooij, S. J., Bejerot, S, et al (2010). European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC psychiatry, 10(1), 67.

End of presentation