By Dr: Ibtihal Mohamed Aly Ibrahim

 Attention deficit hyperactivity disorder (ADHD) has primarily been considered a childhood condition.  Adults with the disorder were not recognized until the 1970s when diagnosis expanded to include ‘Adult Hyperactives’ and later ‘Attention Deficit Disorder leaving a residue’

difficulties with impulse control difficulties sustaining Attention

A. Either (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often makes careless mistakes. (b) often has difficulty sustaining attention. (c) often does not listen. (d) often fails to follow through on instructions or to finish tasks. (e) often has difficulty organizing tasks and activities. (f) often avoids tasks requiring sustained attention. (g) often loses things. (h) often is easily distracted. (i) often is forgetful.

(2) six (or more) of the following symptoms of hyperactivity- impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets or squirms (b) often leaves seat (c) often moves excessively (may feel restless) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" (f) often talks excessively Impulsivity (g) often blurts out answers (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others

B. Some hyperactive-impulsive or inattention symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings. D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder.

The DSM- IV, defines three types of ADHD 3) A combined type 2) A hyperactive /impulsive type 1) An inattentive type Coding note: for individuals (especially adolescents and adults who currently have symptoms that no longer meet full criteria “in partial remission” should be specified

ADHD 50% of ADHD children continue to manifest symptoms in adulthood ADHD Few Studies suggest that ADHD may arise de novo in adulthood

 50% of ADHD children continue to manifest symptoms in adulthood.  Estimates of the prevalence of ADHD in adulthood range from 1% to 5%.  adults with ADHD are twice as likely to be arrested, have a two-fold increased risk of being divorced, and a 78% greater risk of being unemployed.  50% of ADHD children continue to manifest symptoms in adulthood.  Estimates of the prevalence of ADHD in adulthood range from 1% to 5%.  adults with ADHD are twice as likely to be arrested, have a two-fold increased risk of being divorced, and a 78% greater risk of being unemployed.

Disorganization and forgetfulness ImpulsivityEmotional difficulties Hyperactivity or restlessness

 poor organizational skills (home, office, desk, or car is extremely messy and cluttered).  tendency to procrastinate.  trouble starting and finishing projects.  chronic lateness.  frequently forgetting appointments, commitments, and deadlines.  constantly losing or misplacing things (keys, wallet, phone, documents, bills).  underestimating the time it will take you to complete tasks.

 frequently interrupt others or talk over them  have poor self-control  blurt out thoughts that are rude or inappropriate without thinking  have addictive tendencies  act recklessly or spontaneously without regard for consequences  have trouble behaving in socially appropriate ways (such as sitting still during a long meeting).

 sense of underachievement  doesn’t deal well with frustration  easily flustered and stressed out  irritability or mood swings  trouble staying motivated  hypersensitivity to criticism  short, often explosive, temper  low self-esteem and sense of insecurity

 feelings of inner restlessness, agitation  tendency to take risks  getting bored easily  racing thoughts  trouble sitting still; constant fidgeting  craving for excitement  talking excessively  doing a million things at once

Hyperactive/Impulsive-type (ADHD-H) Inattentive-type (ADHD-I) Chooses highly active, stimulating jobs. Avoids situations with low physical activity or sedentary work. May choose to work long hours or two jobs. Seeks constant activity. Easily bored. Impatient. Intolerant to frustration, easily irritated. Impulsive, snap decisions and irresponsible behaviors. Loses temper easily, angers quickly. Procrastination. Indecision, difficulty recalling and organizing details required for a task. Poor time management, losing track of time. Avoiding tasks or jobs that require sustained attention. Difficulty initiating tasks. Difficulty completing and following through on tasks. Difficulty multitasking. Difficulty shifting attention from one task to another.

ADHD eating disorders substance use disorders depressive episodes bipolar disorder

Overlapping symptoms in ADHD and bipolar disorder. Bipolar disorder 1. More talkative than usual. 2.Distractibility or constant changes in activity or plans. 3.Increased activity or physical restlessness. 4.Loss of normal social inhibitions ADHD 1.Talks excessively. 2.Easily distracted/jumps from one activity to the next. 3. Difficulty sustaining attention 4.Fails to give close attention to details/makes careless mistakes. 5. Fidgets 6.Difficulty remaining seated restlessness 7.Runs or climbs about inappropriately 8. Difficulty engaging in leisure activities quietly 9. On the go as if driven by a motor 10.Interrupts or butts in uninvited. 11.Blurts out answers before questions have been completed 12.Difficulty awaiting turns

1- Comorbidity is a chance phenomenon. 2- Comorbidity is an artifact of overlapping criteria. 3- Comorbidity is due to a common diathesis that leaves patients vulnerable to separate illnesses. 4- Symptoms of ADHD that precede the onset of BD represent a prepubertal expression of illness antecedent to the development of a full affective episode.

"Protobipolar?"

1. Retrospective childhood diagnosis: A. Narrow criterion: met DSM-IV criteria in childhood by parent interview. B. Broad criterion: both (1) and (2) are met as reported by the patient: 1) Childhood hyperactivity. 2) Childhood attention deficits. 2. Adult characteristics: five additional symptoms, including ongoing difficulties with inattentiveness and hyperactivity and at least three other symptoms: A. Inattentiveness. B. Hyperactivity. C. Mood liability. D. Irritability and hot temper. E. Impaired stress tolerance. F. Disorganization. G. Impulsivity. 3. Exclusions: not diagnosed in presence of severe depression, psychosis, or severe personality disorder. 1. Retrospective childhood diagnosis: A. Narrow criterion: met DSM-IV criteria in childhood by parent interview. B. Broad criterion: both (1) and (2) are met as reported by the patient: 1) Childhood hyperactivity. 2) Childhood attention deficits. 2. Adult characteristics: five additional symptoms, including ongoing difficulties with inattentiveness and hyperactivity and at least three other symptoms: A. Inattentiveness. B. Hyperactivity. C. Mood liability. D. Irritability and hot temper. E. Impaired stress tolerance. F. Disorganization. G. Impulsivity. 3. Exclusions: not diagnosed in presence of severe depression, psychosis, or severe personality disorder.

Despite the relatively high prevalence of adult ADHD, only 11% of adult patients are treated due to multiple factors: Failure to seek medical advice. Misdiagnosis Treatment of the comorbid condition instead of ADHD

first-line therapy. increases in blood pressure methylphenidate block the uptake of dopamine and norepinephrine. better side-effect Amphetamines inhibiting the norepinephrine transporter. liver damage and increased suicidal ideation. Atomoxetin lower treatment effect than stimulant Antidepressants

 Tips for managing stress and boosting mood  Tips for getting organized and controlling clutter  Develop structure and neat habits—and keep them up  Tips for managing your time and staying on schedule  Tips for staying focused and productive at work

Other types of Psychotherapy Marriage and family therapy Cognitive-behavioral therapy Support groups for adult ADD / ADHD

Option 1. No change, i.e., use existing criteria, with no age-specific criteria. Option 2. Lower threshold for combined ADHD from 6 to 3 endorsed criteria from each element (HI or I).

Physical and mental health problems. compulsive eating. substance abuse. anxiety. chronic stress and tension. and low self- esteem. Work and financial difficulties. trouble keeping a job. following corporate rules. meeting deadlines. struggle with unpaid bills, lost paperwork, late fees, or debt. Relationship problems. fed up with constant nagging from loved ones to tidy up, listen more closely, or get organized