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Adult ADHD?!

Discussion in 'Psychiatry' started by Trismegistus4, Oct 11, 2016.

  1. Trismegistus4

    Trismegistus4 Worried Wellologist
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    I spent a year after residency working locums jobs in 3 different areas of the country, before taking a permanent job this past summer in yet another area. One thing I noticed is that there seem to be problems/complaints that are more common in some areas than others. Each locale had sort of its own "classic" issue. And where I am now, it seems to be adults wanting to get diagnosed with ADHD for the first time in adulthood.

    I had seen maybe 1 or 2 patients like this in all of residency. But here, it seems like I have at least 1 new patient every day on my schedule who scored some Adderall from their PCP, who is now sending them to me because of my... uh... expertise. Or who feels like they can't focus at work and just knows they have ADHD because they read a Facebook post about it. Or who took some of their friend's Vyvanse and suddenly it was like a cloud lifted and they were miraculously a new person! (Or who was diagnosed as a kid but is now 35 and has never tried being off stimulants, which also bothers me.)

    Has anyone here gotten good training on this in residency? It was a problem I was totally unprepared to deal with. I mean, people who insist that nothing works for their anxiety except Xanax are frustrating to deal with too, but at least residency gave me several years of experience doing so. I'm kind of blindsided by this. If you see patients like this, what do you tell them? We have 2 psychological groups in the area we refer people out to for testing, but I recall seeing a post from a psychologist on this very forum recently stating that the concept of psych testing for ADHD is bogus. But if you just run down the list of DSM-V criteria for ADHD, of course they just say "yes" to everything.

    I have a hard enough time believing in childhood ADHD, but in residency I got through the mandatory rotations in child/adolescent by keeping my head down, smiling and nodding, and doing what the attendings said. I didn't expect this to follow me into the adult population. I have half a mind to just grow a pair and flat out tell these people, "sorry, I don't believe in adult ADHD. You're going to need to see a different doctor."
     
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  3. TikiTorches

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    Give them straterra
     
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  4. Trismegistus4

    Trismegistus4 Worried Wellologist
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    They'll just say they already tried it and it didn't work, or they'll take it but come back and say it didn't work, or they'll protest that they already know what works (a stimulant) so they really need that.
     
  5. YumIsPeople

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    Not all of the psychological testing is like that. It also frequently includes neuropsychological testing that is hard to fake and has built-in measures to detect malingering: the T.O.V.A, the Conners Continuous Performance Test, the WAIS (for various reasons), various other Weschler memory scales, etc. Also, a lot of the time, the psychologist will ask the patient for report cards from childhood, accounts from parents, etc, since ADHD impairment must be obvious from childhood for the diagnosis to be valid. This all has at least a little theoretical backing from the literature, but it is also partially to try to weed out malingerers, in my opinion.
     
  6. TikiTorches

    Physician Classifieds Approved 7+ Year Member

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    I'm glad you posted this. I feel the same way op.
     
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  7. birchswing

    birchswing Patient/Interested in Psychiatry
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    You might not be aware, but there was a flood of news reporting on adult ADHD in the last year or so. A lot of information disseminated about how it has different symptoms than classic ADHD. I posted a thread here a while ago on a research study on this exact topic (recognition of a distinct adult ADHD phenomenon describing its characteristics).

    It seems like it's the medical community leading patients who then surprise another part of the medical community:

    http://www.mayoclinic.org/diseases-conditions/adult-adhd/home/ovc-20198864

    My thread:

    http://forums.studentdoctor.net/threads/late-onset-adhd.1200273/
     
  8. cookymonster

    Physician 7+ Year Member

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    Give them a sleep diary.
    Ask their wife or significant other to come to next appointment for collateral.
    Ask them to submit a urine drug screen that same day (consider alcohol biomarkers too).
    Make it clear you don't prescribe short-acting stimulants (or benzos).

    See how many come back the next visit after having done all those things. They may be ticked off they don't walk out the door with a stimulant, but if they've waited 35 years, they can wait another month. Hopefully you'll at that point have more subjective and objective data to know what you're treating, and at least feel pretty confident you're not causing harm.
     
  9. Jules A

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    My overall opinion is there are few adults, even with legit ADHD, who aren't able to function and I'm all for improving quality of life but at what cost? I have seen some who are as hyper and disorganized as a 6yo but that is rare in my experience. I don't treat most complaints of adult ADHD with stimulants because as the OP pointed out not only are, in my opinion/area/practices, a majority feigning, most aren't working, most have a history of substance abuse which I suspect will no longer exclude this population in the future but for now if the manufacturer is saying don't give this product to those with addictions history I'm abiding, many divert and at what point do they come off stimulants 50yo, 60yo, when they have a cardiac event in their 70s, never? I'll continue to treat them if they are willing to try the alternatives such as Wellbutrin, Strattera, Clonidine because in my experience even those with true adult ADHD seem to have some response to one or more of those offerings. If they aren't willing to try alternatives and/or continue working me for stimulants then they are free to find another provider. Don't even get me started on the providers who believe that an improvement in focus is evidence of diagnosis...
     
    #8 Jules A, Oct 12, 2016
    Last edited: Oct 12, 2016
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  10. erg923

    erg923 Regional Clinical Officer, Cenpatico National
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    Attention tests are very important for discovering what a person can and cannot do. However, for purely diagnostic purposes, cognitive tests of attention should at most play a very limited role, perhaps nudging a diagnostic decision one way or the other in cases that are on the threshold of diagnosis.For example, people with ADHD, on average, tend to score slightly lower on tests of working memory, processing speed, and verbal fluency than on tests of visual–spatial reasoning, fluid reasoning, and crystallized intelligence. However, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. In the end, a diagnosis of ADHD cannot be ruled in by any particular cognitive profile, nor can any particular cognitive profile rule it out. neuropsychy testing can help with assessing mimics, like LDs, however.

    I would recommend using the Wender-Utah scales to help/assist with historical presence of symptoms. Otherwise, its time intensive and requires collateral and careful thinking about the history and development of symptoms. Nothing in psychiatry should be checklist, much less attempting to determine the validity of AD/HD in adults with multiple secondary gain/ulterior motives.
     
  11. cookymonster

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    This is where the sob stories of C's and D's in sociology classes at Penn Foster and Southern New Hampshire online begin.
     
  12. birchswing

    birchswing Patient/Interested in Psychiatry
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    This is totally O/T, but may I ask for the back story behind your avatar @cookymonster ? I know the reference, but there must be a reason for it. My eyes dart away each time I see it because of the creepiness of that character.
     
  13. cookymonster

    Physician 7+ Year Member

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    Pornstache:
     
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  14. sluox

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    My research happens to have some overlap in this area:

    The gold standard diagnostic test is a longish structured interview. Something like Connors or DIVA, that would involve a degree of parental collateral. Cognitive testing is not generally useful. Structured interviews are well validated and are very specific (i.e. "faking" collaterals is rare).

    ADHD and substance use disorder (SUD) are often co-morbid. However, there's no convincing epidemiological evidence that there's an increasing liability with abuse or diversion in that group, except anecdotal, especially with longer acting stimulants. There is also no evidence suggesting that longer acting stimulants cause premature cardiac death used in long term. The data are sparse on this of course--so you should preempt this with patients. In patients with moderate to severe SUD, a failure to treat ADHD in pt with SUD often leads to increasing difficulty in controlling SUD. This is all well documented. However, the use of stimulants to treat SUD outcome is still an active area of research, and the current results are mixed (works at high doses for cocaine, but not for marijuana or opioids, etc.) i.e. the issue is not that treating SUD pts with stimulants get them "addicted" to another drug, it's that it's not efficacious (vs. say agonist maintenance), and stimulants do have side effects. In the meanwhile, at least their ADHD (if they have any) gets better. If you have a SUD pt who has relapses on agonist replacement, you should absolutely treat the ADHD, especially if it's bad. It's a very similar situation as any other psychiatric co-morbidity. You would give Leaxpro to a patient who's addicted to opiates who's also depressed, right?

    The pattern of misuse of stimulants is very different compared to the pattern of misuse with other drugs of abuse--patients generally use them to study for exams, etc. as opposed to "get high". This is not uncommon -- in fact stimulants are now the most commonly "abused" prescription drug in the late adolescent, but I think from a risk vs. benefit perspective the calculus is very different from say opioids or even benzos.

    There is some degree of faking symptoms, but generally speaking people don't really get highs from long acting versions, and certainly not highs like heroin or cocaine. Perhaps I just see more severe cases, but in my experience (and this corroborates with literature), if you genuinely have ADHD, and you use stimulants, you often get a very dramatic response. I usually tell patients that this is one of the most effective treatments in psychiatry, if not all of medicine. NNT ~ 3 or below.
     
    #13 sluox, Oct 12, 2016
    Last edited: Oct 12, 2016
  15. Shikima

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    Many adults are stressed out and are tired. They need a stim to help them out as they have poor boundaries.
     
  16. birchswing

    birchswing Patient/Interested in Psychiatry
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    Oh I knew it was Pornstache. I just thought maybe there was a story behind it. That show is arresting in how how the tone can shift 180 degrees. What I saw in that looks like it comes from a different TV show than say the final arc of the most recent season of the show. It's not like Oz where it's just dark consistently. It's a comedy that turns gutting out of the blue.
     
  17. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty
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    I constantly get these referrals and decline most of them because as others have said…testing is limited. The one exception is someone with a brain injury, which means it isn't *really* ADHD, but that is what the referrer writes because the symptoms have so much crossover in the adult population. I don't accept self-referrerals, I make it clear to the patient that I'm not a rubber stamp, and often I recommend a host of non-pharma options in addition to non-stimulant options first. All of these things have reduced the frequency of these types of referrals, at least amongst my regulars. Community referrals are a completely separate issue.

    That said, there is room for…"will this improve the patient's day to day functioning?" It's hard to argue that it wouldn't, but then there are the benefits/risks of using stimulants (the option the vast majority of patients choose). My personal (Libertarian) view make this an easy call for me, but my professional opinion is in contrast, and the latter is what they are seeking. Many of these folks have overlaying psych problems that are unaddressed, which combined with poor coping, increasing stressors (white collar workers mostly), and greater awareness via advertising….it's rarely actually ADHD. My recs focus on everything else and if they are still struggling after addressing those issues, then I can see supporting trialing a stimulant w. close supervision by their PCP/psychiatrist/etc. The cases that truly want help are fine with this approach, though most cases are just looking for a stimulant. /jaded but true
     
  18. Jules A

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    Sounds cynical but I agree and speaking only for myself having a cleaner house and smaller ass would be nice perks too.
     
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  19. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Cognitive testing is unnecessary unless there is a question of LD, low intelligence, or another neurological problem that could be underlying. The Connors/TOVA are also mostly useless. the effort/malingering scales don't really work all that well, they over-diagnose to a great degree. Self-reports don't do well, various studies have shown that self-reports essentially over-diagnose the disorder by a magnitude of 5-10 times the population base rate. All in all, it's difficult to get a good diagnosis of adult ADHD, it's really provisional at best in many cases. The gold standard is diagnostic interview, including parent and teacher reports, as well as a corresponding history. And, in the majority of my adult patients, I really can't get any of these collateral reports. Mostly I just try to educate other providers about the diagnosis and how they should treat the patient's high levels of anxiety and/or depression and see if the attention problems remain. Additionally, trying to combat the rampant misinformation that response to a stimulant is confirmation of the disorder. I still see that in provider notes.
     
  20. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    As a primary care guy, this is what I want when I refer someone for "ADHD eval" because I know that lots of things cause attention problems in adults and I want help sorting it out. Plus, there's the added benefit of "the specialist said this is likely your anxiety/depression/whatever and we need to get that taken care of before we address anything else".
     
  21. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Sure, but this just needs a psychological assessment rather than a neuropsychological assessment. Granted, some sites may not have both services delineated. May be good to check with the specialty services as to how they handle this. We occasionally meet with different groups of referring providers and present about what is and isn't a good referral for our service.
     
  22. sluox

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    You can figure this out easily with review of childhood history with parents. Differential isn't that hard...
     
  23. Shikima

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    50 year old guy shows up with his 80 year old mother to discuss history of childhood behavior as collateral for ADHD.
     
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  24. nitemagi

    nitemagi Senior Member
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    I think all too often adult adhd is something else -- anxiety (micro anxiety/avoidance moments), poor concentration training, etc. In general I won't use stimulants unless they're doing other executive functioning training/changes as well, and examining and treating any mimics.
     
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  25. clozareal

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    Current estimates of adult ADHD is 4-5%, which is about half of that of children. Despite acknowledgement in the sceintific community that ADHD does indeed occur in adults and and a plethora of studies to guide evidence-based clinical management, only 10% of adults who met criteria for ADHD are adequately treated. Two areas of controversy with properly treating adults with ADHD include a failure to diagnose ADHD, which can be confounded with other comorbidities, and apprehension about malingering, diversion, or abuse.

    Often times, a person can be intelligent enough to do well academically as a child and then not be identified as having ADHD when they're young, but when they need to get a job or continue higher education, their ADHD can manifest with increasing amounts of work that requires sustained attention in addition to intelligence. I do agree that a 50-60 year old who has problems with focusing and thinks they have new-onset ADHD might not have it, but this would be when I worry about dementia or depression.

    Here's a great paper by Dr. James McGough, who is an expert in ADHD, on how to work through the two barriers I mentioned above for adult ADHD:
    http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2016.15091207
     
    #24 clozareal, Oct 12, 2016
    Last edited: Oct 12, 2016
  26. sluox

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    Ha, you'd be surprised the people who are in their 50s that I diagnosed with collateral from their elderly parents, who after I explained what I'm doing, says OH YEAH HE DEFINITELY HAS IT.

    You do the best you can. When it's impossible obtain collateral, you document and weigh the risks vs. benefits. If someone may benefit tremendously from a trial of stimulants, it's a reasonable option to pursue (vs. a small risk of misuse).
     
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  27. SeniorWrangler

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    Sure there are lots of people with adult ADHD around.
    Whether it is a good idea to start them on stimulants is a whole other question. I would be more open to prescribing them short-term for somebody finishing grad school or other academic challenge than prescribing them open-ended to help people with their work tasks.
     
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  28. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty
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    Isn't that a slippery slope? I see the same rational with benzos. Both were meant to be a short-term intervention, but now the pt has been behaviorally reinforced to depend on the magic little pills to cope.

    There are no easy answers, thought I'm always weary of inadvertently setting up a patient for a potentially longer battle.
     
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  29. Jules A

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    I'm unable to imagine the overwhelming benefits or compelling reasons someone in their 50s suddenly needs a stimulant. Interesting timing and anecdotal but gripping none the less:

    http://www.nytimes.com/2016/10/16/magazine/generation-adderall-addiction.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news&_r=1
     
  30. sluox

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    It's not that suddenly they need a stimulant. It's that they have bad ADHD that was never properly diagnosed and treated, which is not rare at all in the community. This results often in a lifelong pattern of all kinds of symptoms. In fact, a lancet article recently suggests ADHD increases mortality http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61684-6/abstract

    There was a large cohort study that suggests stimulants do not cause excess cardiovascular events (Cooper et al NEJM 2011). Another large cohort study suggests treatment in particular reduces criminality in men (Litchenstein NEJM, 2012). If someone has bad ADHD and you don't treat it it can at times look vaguely like ASPD.

    I happen to be an addiction psychiatrist. I see a lot of people with bad bad SUDs, and there is without a question in my mind that for some of them if their ADHD isn't properly treated their SUDs don't get better. CBT is less effective with bad ADHD. This clinical intuition again corroborates with literature.

    Amphetamine use disorder is a real, if somewhat uncommon entity. The times article describes what sounds like a real use disorder...though I am not convinced the author genuinely does not have ADHD. Furthermore, it's yet unclear if the author is misusing immediate release or delayed release formulations. The abuse liability of vyvanae or daydrana is not even close to adderall IR. So I would say, as all existing literature suggests, for the 50 year old with untreated ADHD it is safe and effective to at least give a trial of a long acting stimulant.
     
    #29 sluox, Oct 12, 2016
    Last edited: Oct 12, 2016
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  31. NJWxMan

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    IMO, 90% of the time, we don't know the answer to the real question: why NOW? I always ask patients what made them come to the ED or IOP this week as opposed to last month or next week. Investigating that question will often make it clear to the patient that a stimulant is not necessary. Secondly, most times the patient has an underlying mood d/o which is not being appropriately treated. I see this in the ED all of the time; depressed patient with adhd now irritable and with racing thoughts, no sleep all due to stimulate cycling them. I almost always stop stimulants on admission.
     
  32. Shikima

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    Exactly, why now?
     
  33. AcronymAllergy

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    The most delayed ADHD eval request I've received was for an 80+-year-old whose son (a psychologist) thought his dad might've always had ADHD.

    RE: the last few posts, the most common "why now" reasons I've received for folks who are 40+ and requesting treatment are: switching jobs, going for or receiving promotion, and starting to experience more problems at work; had a friend/family member dx'd and now wondering if it's something they've always had and struggled with; returning to school. As someone previously mentioned, more times than not, there's also the issue of recently-increased emotional distress. Whether that's the primary cause of the attention problems, the person perhaps always had underlying ADHD-like symptomatology (either clinical or subclinical) that's now being exacerbated by the emotional distress, other factors affecting cognition are now in play (e.g., vascular or medication effects), or something else, is usually what our psychiatrists ask me to try and ferret out.

    It's almost an impossible mission much of the time, unfortunately, given the near-ubiquitous absence of childhood records. Typically, adults are fairly accurate at recalling childhood symptoms (at least when followed longitudinally and/or compared with parent recollection), but if they're struggling with other mental health issues presently, that can of course influence their retrospective report.
     
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  34. clozareal

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    Great discussion in this thread! I think adult onset ADHD is something that is new and that we will increasingly have to provide expertise now and in the future.

    There was a really interesting longitudinal cohort study recently that followed all children born in Pelotas, Brazil in 1993 up to the ages of 18 or 19 years. Three hundred ninety-three of the 5249 children were diagnosed with ADHD at age 11 and 492 were diagnosed with ADHD at age 18 or 19 years. Only 60 children with ADHD continued to have ADHD as young adults (17.2 percent) and only 60 young adults with ADHD had the disorder in childhood (12.6 percent). This is definitely challenging the idea that ADHD requires symptoms before the age of 12.

    Source: https://www.ncbi.nlm.nih.gov/m/pubmed/27192050
     
  35. Ceke2002

    Ceke2002 Purveyor of Strange
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    Unfortunately I think a big part of the problem is that a lot of the books regarding ADHD that have been written for lay people, and also segments of the media whenever there's an upswing in the popularity surrounding the debate about ADHD and Adult ADHD in particular, as well as the websites that have been set up as information portals for Adults with ADHD do have tendency to present stimulants as a kind of miraculous 'fix all'. Even those writings that include alternative methods of treatment will often talk about stimulants needing to be initially prescribed so that the person has the ability to engage in what's required for alternative treatment methods (which I can see as possibly being needed in children, but not necessarily in adults).

    And yeah, I fell for the hype surrounding stimulants as well. Having already been diagnosed with ADHD in childhood, and being fairly certain that I hadn't entirely grown out of it either, once I got my hands on some books and articles regarding ADHD in adults and saw a lot of myself in what I was reading, I was in the mindset for years that if I could only get a diagnosis and a prescription for stimulants that it would be the answer to everything. I was already self medicating as it was, but being prescribed stimulants was going to take care of that, it was going to care of everything - I'm probably some sort of Unicorn in terms of psychiatric patients, but despite having a history of substance abuse I honestly wasn't looking to be hooked up with stimulant medication to get high.

    So I did finally get a diagnosis, and yes the diagnosis was legit, I even had my case presented at one of those national Psychiatric symposium type things on the diagnosis and treatment of ADHD in Adults. So yay, awesome, now I have a diagnosis, and a prescription (dextroamphetamine), and life is about to be fantastic; except, well, no. The medication did what it was supposed to do, and for the first couple of weeks things were great (it was like my brain was finally able to breathe a sigh of relief, as corny as that sounds), but then, oh yeah medication has side effects. I felt so grungy, and jittery, and just all round blah, that I pretty quickly realised a cost vs benefit analysis wasn't exactly coming down on the side of benefit. This is something I wish more people understood, that the medication for ADHD isn't always going to be this sort of miracle in a pill it so often gets touted as, and that sometimes becoming too fixated on medication as a cure all can hinder you from looking at alternative treatments that may work just as well if not better. I know this was the case with me, I became so focused on the idea that a pill was going to fix everything that I didn't even really bother trying to work on any sort of symptom management sans medication -- not at least until I found out the medication wasn't the be all and end all that I thought it was going to be, and then it was like. "Wow, I wasted how many years trying to get a prescription that was supposed to fix me, when I could have been spending that time learning how to better manage things without medication? Seriously, how thick was I!" :smack:
     
  36. ahmedqman

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    I struggle making this diagnosis all the time. Part of me thinks that this Adult ADHD is a bunch of BS, and part of me thinks that I'm being too dismissive. Considering the ADHD and GAD symptoms overlap all the time, if someone has anxiety issues and tells me that they struggled with attention issues and distractibilty all through childhood but were able to compensate for it, I've seen some of my clinic attendings override my GAD diagnosis and do a trial of a stimulant. If the anxiety gets better, they go "the worry was secondary to ADHD as untreated ADHD can cause a GAD like presentation".

    So the question is, given that the literature actually suggests that most people don't abuse it, are you okay with accidentally dispensing PEDs (due to incorrect or nebulous diagnosis) instead of treating actual pathology?

    I've literally seen some of my colleagues say "hey, as long it isn't hurting them, what's wrong with it?"

    But one of the other clinic attendings (whom I deeply respect), stated "some people want us to turn a Ford Taurus into a Lamborghini".

    However, my brain rejects this "I need a quick fix to solve my problem" mentality.

    It's like benzodiazepines and GAD in my mind. I have clinic attendings that will start zoloft and scheduled benzodiazepines for 6-8 weeks to "restore functioning as quick as possible," (btw, if I'm going to use benzos, I'm more of a PRN benzo guy to assess control of anxiety and panic and the efficacy of the SSRI/SNRI/etc and therapy) yet we let depressed people sit around waiting 6-8 weeks for their SSRI to kick in at their therapeutic dose. We don't run around shooting depressed people up with stimulants or ECTing everything, to "restore functioning as quick as possible."

    Our goal should be to help people in the best way, and that may not be in the "fastest" way.
     
    #35 ahmedqman, Oct 14, 2016
    Last edited: Oct 14, 2016
  37. ahmedqman

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    If a stimulant calms someone down with a GAD like presentation, is it ADHD and not anxiety?

    I refuse to believe that it is that simple.
     
    #36 ahmedqman, Oct 14, 2016
    Last edited: Oct 15, 2016
  38. AcronymAllergy

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    I've yet to see compelling research that adult-onset ADHD is actually a thing. But the diagnosis can be tricky in adulthood because, as mentioned above, we're generally having to rely on retrospective self-report of childhood symptoms, possibly limited access to childhood assessment and treatment options (hence the absence of childhood diagnosis), influences from benefits of a diagnosis (medication, accommodations, etc.), and "interfering" effects from more recent emotional distress.
     
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  39. Trismegistus4

    Trismegistus4 Worried Wellologist
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    I'm thinking about this issue again because I've seen/will see several relevant patients last week and this one. Last week I saw a follow-up who described leaving stove burners on and getting into a car accident when she stopped her stimulant. She was really scatter-brained and hypertalkative. I almost believed her, and decided to give in and restart her stimulant. Then today I saw another follow-up who was started on a stimulant by another psychiatrist in our practice for what I believe are questionable reasons, but she's stable, not on a high dose, not doctor- or pharmacy-shopping, and not asking for an increase, so frankly it's just easier to continue it. And tomorrow I have a new patient on my schedule who's being referred by his PCP whom I can see in the chart he's been begging for stimulants because his alleged ADHD is impairing his job performance, and another follow-up I just saw a week ago, who actually called the office today and got himself on the schedule tomorrow after telling the MA he had a "panic attack all weekend" and that the doctor doesn't understand how dire his need for Ritalin is. (He's already on Klonopin.)

    I was hedging my bets in the OP and being a little diplomatic, but I'll come out and say it: deep in my gut, I don't believe in ADHD at all, in children or adults. I think it's a completely fake and phony condition. People who supposedly have it simply lack self-discipline and need to try harder. The fact that people can concentrate better and work harder while on meth doesn't mean doctors should prescribe meth to people. But then, I know some people here will refer me to scholarly journal articles supposedly proving that ADHD exists. And I'll admit to being closed-minded. I don't want to even read those articles because I don't want to believe it.

    But, because the medical community does accept ADHD, and I'm terrified of being accused of malpractice, I feel the need to play along to some degree.

    Just look at the DSM criteria for ADHD. They're so subjective, they're every bit as susceptible to the Forer effect as a mother convinced her child is an "Indigo child" because he's "empathic, curious, and strong-willed" and "possesses a clear sense of self-definition and purpose." Give me a break. "often fails to give close attention to details or makes careless mistakes?" How often? How close? How careless? What kind of details? Everyone could give more attention to details or make fewer mistakes than they do. "often has difficulty sustaining attention in tasks or play activities?" Again, how often? How much difficulty? Difficulty implies the person is trying, but is unable to accomplish the task. But how do we know whether he's really trying? "is often forgetful in daily activities?" How often? We've all misplaced our keys, or went to the supermarket without a written list only to find upon arrival home with our 5 bags of groceries that we forgot to get the one thing we originally went to the store for. Heck, I can easily claim I meet these criteria. Just today, I didn't leave the office until almost 7PM, because I had a full schedule, got behind on finishing notes, got a bunch of patient calls and refill requests, and then at 5:00 after the last patient left, the office manager and I spent what seemed like forever trying to figure out how to get a prescription to print on the right printer--and so, I was so stressed after all that that I wound up surfing the internet for half an hour before finishing my notes, even though I wanted to get out of there. Should I claim I have ADHD because I failed to just hustle and finish my notes and leave? Did I "need" Adderall to make myself not surf the internet for half an hour? No, I could have just done it. I simply didn't make myself.

    Weeding out malingerers would be great, but honestly I'm not even that concerned about malingering in most of these people. I don't get the impression most of them just want to get high off stimulants, or gain a leg up over their classmates on the bell curve, or sell the meds on the street, or whatever. I think they genuinely are like I was this afternoon--surfing the internet for half an hour before finishing their work, then getting ticked off at themselves for not making themselves finish it sooner so they could GTFO--and they feel there must be something wrong with them. If they've tried a stimulant and it "helped," that strengthens their suspicion. I think they read that subjective list of ADHD criteria, see themselves in them, and want relief. They want to be less lazy or lackadaisical and more like that type-A coworker they have who seems to have it all together. Even the guy I mentioned above who "needs" Ritalin despite paradoxically being on Klonopin, I don't get the vibe of an abuser from him. I think he's just a scatterbrained guy with a bunch of nonspecific symptoms who wants to just throw meds at them until he finds the right combination to help himself calm down and stay focused. Everyone would like to be able to concentrate better and work more effectively. But the psychiatric profession has created this named and identified "illness" which people can then identify with and feel as though they have an "answer"--and stimulants are a very effective treatment for this "illness." As MacDonaldTriad said in that thread birchswing linked, how many illnesses can you name where patients get angry at you when you tell them they don’t have that illness?

    I read your thread and it's describing something different. Most of these adult patients I'm seeing are older than college-aged, and not in school. They either feel their job performance is failing, or they feel they can't focus well enough on daily life.

    I would say in at least 50% of the cases, I've seen so far, the person is already on stimulants, or has taken them in the past, and the answer to "why now?" is that they recently ran out of the last stimulant prescription they had, because they moved from out of state, or their previous psychiatrist stopped taking their insurance, or their PCP isn't comfortable continuing stimulants so they put in a psych referral.

    That's sort of the problem for me. As I said, I'm getting these referrals from PCPs, whom the patient presented to first, complaining that they've recently realized they have ADHD and need a stimulant, and the PCPs are referring them to psych because we have "expertise." But how much "expertise" can I have if I learned zero about adult ADHD in residency and don't believe in it anyway? I'm struggling to decide what to do here, in a way that a) eases my own conscience, and b) doesn't harm patients.

    Most of us probably had a grave fear of controlled substances drilled into us by residency attendings, with some almost giving the impression that no controlled substances were ever indicated in any circumstances. I think it's inevitable as we get out in the real world, that we begin to question that. More and more, as I start cautioning against benzos and the patient starts getting all ornery, I find that small nagging voice in the back of my head going "you know, he's been on clonazepam 0.5 mg BID for a long time, he's not abusing it, he never requests early refills, he never requests an increase, you've checked the state pharmacy reporting database and he's not doctor- or pharmacy-shopping or going to the ED... would it really kill him if I just continued it?" And connected with that is the fact that giving in is much easier than constantly fighting with people. When it's been a long busy day, it's 4:59, and you just want to get the guy out of your office so you can go home, it's much easier to just renew the prescription than to have yet another pointless argument that only prolongs the inevitable. (I sometimes wonder if that's how some of these old docs get in trouble with the state board or the DEA. Not that they intended to set up a pill mill, but they just got sick and tired of fighting with every single patient who requests controlled substances.)
     
    #38 Trismegistus4, Nov 7, 2016
    Last edited: Nov 7, 2016
  40. TikiTorches

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    Worse are the cases of 3.4 who get 3.8 taking stims from friends.
    Oh hell no
     
  41. MrChance2

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    If the stims help them, they aren't abusing them, meet for ADHD, and don't meet for any other psych Dx then why not?

    An hour long interview can somewhat figure out who is just saying yes to every question you ask and who has some symptoms. Even better if they come by a few times and you get to know them better and can see their progress.

    I don't understand why a 7 year old needs these meds to learn spelling but a 30 year old won't benefit from them if he can't focus enough to work on spreadsheets at the office.

    Explain the risks to the patient and let them try them.

    Obviously there are tons of drug seeking patients that don't meet the criteria above but I don't see what's wrong with writing for stimulants in adults.
     
    #40 MrChance2, Nov 7, 2016
    Last edited: Nov 7, 2016
  42. cookymonster

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    ADHD is similar to mania and pornography in that it is ponderous and unreliable as hell to attempt to describe, but you know it when you see it.

    It is generally a lot easier to just take a pill than do things like eliminate distractions, devote extra time to practice and learning, or change lifestyle. However, there are occasions when it is obvious that ADHD symptoms are damaging a patient's life to the point that it is clear they have the motivation to do everything they can to overcome it. Such as when a patient is losing their business, facing home foreclosure, divorce, etc, when their spouses corroborate this, and when the MSE supports it. Usually these patients are already doing everything they can. Those are the few patients I have no reservations jacking up to 60 of Adderall, and I feel pretty gratified when they get better. The vast majority of the rest just seem to want performance enhancers.
     
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  43. TikiTorches

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    What non-pharmacologically based recs do you make?
     
  44. TikiTorches

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    Any citations or evidence-based guidelines for 60 mg?
     
  45. YumIsPeople

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  46. AcronymAllergy

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    There are a variety of books out there that cover recs in more depth (e.g., CBT protocols developed specifically for ADHD). But as a really brief and probably unhelpful overview: lots of structure, problem-solving, behaviorally-based contingencies, and suggestions regarding environmental manipulations (e.g., you may not always be able to limit how able a person is to "tune out" distractions, so you try to find ways to reduce or eliminate those distractions before they become a problem). This is primarily for adults. With children/adolescents, doing some parent training is also typically recommended.

    Research does of course suggest that meds (alone) are more effective in children and adolescents than psychotherapy and associated behavioral techniques (alone); in adults, the outcome research is much more limited.
     
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  47. smalltownpsych

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    If an adult states that they think they have ADHD and reports all the symptoms after reading them all online then they can have the diagnosis as far as I am concerned. Maybe the medication will help them with their work problem, maybe not. I really don't care that much. What worries me a lot more are the kids and the "epidemic" of ADHD. With kids and their families, I work very hard to find the best solution. With an adult ADHD referral, I ask them what they think the problem is and what the solution is and then give them the diagnosis and recommendation they have already researched online. I have way too many patients who need and will benefit from psychotherapy to spend too much time with these cases.
     
  48. AcronymAllergy

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    Problem with that is d/t stimulants being a controlled substance, there are production quotas. Mind you, I have no clue off the top of my head how often (if at all) that interferes with people's ability to find the medication, but it's something to keep in mind. Perhaps more of a minor point--if a person thinks they're having problems, I want to at least try to be able to tell them what I think is really contributing to their difficulties. Pipe dream, I know. But in my case, if someone's willing to come in to go through 4 hours of testing with me after they've waited a couple months following the referral from their initial MH appointment, I figure that says something. At least some of the time.
     
  49. hamstergang

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    Is this the only time you read the DSM? Your quoted text here isn't a criticism of ADHD, it's actually a criticism of a concrete reading of the DSM in the absence of clinical experience.
     
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  50. smalltownpsych

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    I hear ya and I do discuss alternative explanations and treatments but my experience has been that I am often just a hoop they have to jump through before they get the treatment they have researched and chosen. The whole thing makes me feel kind of icky and my problem isn't really with the patient. Has more to do with the system and the control issues that play out when dealing with controlled substances. Often with these and certain other patients (chronic pain springs to mind) I feel as though we are just caught up in one big unhealthy family system with major control issues.
     
  51. YumIsPeople

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    It actually does happen sometimes. http://www.reuters.com/article/us-adhd-adderall-shortage-idUSTRE80009E20120101
     

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