Attention impairment and early-childhood trauma: differentiating PTSD from PTSD+ADHD

[aim-agm]

Usually with patients that have symptoms of ADHD and a history of trauma the presence or absence of symptoms before the trauma is reliable in helping to determine the etiology of their attentional impairment. However, sometimes I have a patient for whom there is no real pre-trauma period because they were traumatized starting very early in life. How would you approach discerning the cause of the patient's attentional impairment in these cases?

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[Fan_of_Meehl]

Usually with patients that have symptoms of ADHD and a history of trauma the presence or absence of symptoms before the trauma is reliable in helping to determine the etiology of their attentional impairment. However, sometimes I have a patient for whom there is no real pre-trauma period because they were traumatized starting very early in life. How would you approach discerning the cause of the patient's attentional impairment in these cases?

Pay special attention to the pathognomonic (distinctive) sx's of PTSD, per se, to ensure validity of the dx in that individual...things like thematic fit between re-experiencing and avoidance symptoms specifically related to the index trauma(s) and then case-formulate and treat that pathology (the PTSD) with evidence-based treatment approaches and track progress on sx reduction over time. See if the other stuff also improves with reduction of PTSD-specific symptoms?

Do the same with respect to the pathognomonic (distinctive) sxs of ADHD, either concurrently or after trials of meds/EBP targeting the PTSD sxs?

Ignore all the symptoms PTSD/ADHD have in common (overlap)

 

[smalltownpsych]

This is a tough one because all the pressure will be to prescribe stimulants for ADHD and early childhood trauma is really tough to treat and manifests at different phases of development in different ways. The question really depends more on overall case conceptualization than this specific diagnostic question. Is the kid in stable secure environment right now? Are they doing well in school? Are they acting out in specific behavioral ways? How much behavioral and environmental intervention can be effected? As psychologist, are you in a primarily a treating role or an assessment role? What does the cognitive testing say? Do the caregivers want to use medication or are they reluctant?

 

[R. Matey]

Age is a critical factor here, but I presume the main difficulty is the 'difficulties with concentration' criterion? Similar to Meehl, I would look for signs of ADHD unrelated to inattention that are often associated with the phenotype that occurs across multiple settings (e.g., disorganization, dysregulation, reactivity). Also agree with smalltown, that functional impairment should be defined. I wonder if focusing treatment on PTSD to see if inattentive symptoms improve, prior to treating ADHD, would be a good path forward here? Provided the family is on board with it.

 

[aim-agm]

This is a tough one because all the pressure will be to prescribe stimulants for ADHD and early childhood trauma is really tough to treat and manifests at different phases of development in different ways. The question really depends more on overall case conceptualization than this specific diagnostic question. Is the kid in stable secure environment right now? Are they doing well in school? Are they acting out in specific behavioral ways? How much behavioral and environmental intervention can be effected? As psychologist, are you in a primarily a treating role or an assessment role? What does the cognitive testing say? Do the caregivers want to use medication or are they reluctant?

Sorry, I should have been clearer - I'm an adult psychiatrist so generally I'm usually not seeing these patients as children. So this is usually an additional confounder. Fortunately the stimulant question so far hasn't been too pressing - the patients have been on board with the plan of primarily treating the PTSD, that stimulants can exacerbate PTSD symptoms particularly if ADHD isn't present, and I have a medication regimen for PTSD that also should be reasonably effective for ADHD (sertraline, guanfacine and sometimes desipramine; former has Ki for Dopamine transporter as good or better than stimulants, latter has Ki for Norepinephrine transporter 1-2 orders of magnitude better than stimulants). Still, I suspect that if these patients do have ADHD they might be doing significantly better with a stimulant than without.

Pay special attention to the pathognomonic (distinctive) sx's of PTSD, per se, to ensure validity of the dx in that individual...things like thematic fit between re-experiencing and avoidance symptoms specifically related to the index trauma(s) and then case-formulate and treat that pathology (the PTSD) with evidence-based treatment approaches and track progress on sx reduction over time. See if the other stuff also improves with reduction of PTSD-specific symptoms?

Do the same with respect to the pathognomonic (distinctive) sxs of ADHD, either concurrently or after trials of meds/EBP targeting the PTSD sxs?

Ignore all the symptoms PTSD/ADHD have in common (overlap)

What would you say are the distinctive symptoms of ADHD in this case? I find myself questioning whether symptoms are due to ADHD or directly/indirectly due to trauma-related changes in mood and arousal/reactivity. It's more difficult with a lot of hyperactivity symptoms, but also comes up with inattentive ones (e.g. avoidance of tasks that require sustained mental effort might actually be a salient manifestation of diminished interest/participation in activities). I think I'm also more uncertain because I'm seeing the patients as adults, so in general ADHD symptoms would be less obvious and more difficult to differentiate from PTSD symptoms - I should put more effort into the history and description of childhood symptoms.

At least conceptually, I'd expect their attentional symptoms to get better with PTSD treatment whether or not they have ADHD, since the former would exacerbate the latter if present. But if the symptoms potentially attributable to ADHD are clearly having less improvement than the others then that would be suggestive.

 

[clausewitz2]

Sorry, I should have been clearer - I'm an adult psychiatrist so generally I'm usually not seeing these patients as children. So this is usually an additional confounder. Fortunately the stimulant question so far hasn't been too pressing - the patients have been on board with the plan of primarily treating the PTSD, that stimulants can exacerbate PTSD symptoms particularly if ADHD isn't present, and I have a medication regimen for PTSD that also should be reasonably effective for ADHD (sertraline, guanfacine and sometimes desipramine; former has Ki for Dopamine transporter as good or better than stimulants, latter has Ki for Norepinephrine transporter 1-2 orders of magnitude better than stimulants). Still, I suspect that if these patients do have ADHD they might be doing significantly better with a stimulant than without.

This is the wrong forum to hash this out at length, but you are conflating binding with actual activity. You are correct about the dissociation constants in this case but just because it binds to DAT doesn't mean it causes anything like the subsequent effects that, say, an amphetamine would. It's a bit more complicated than all that. Desipramine on the other hand has been a known and reasonably effective agent for ADHD since the 80s.

 

[Fan_of_Meehl]

Sorry, I should have been clearer - I'm an adult psychiatrist so generally I'm usually not seeing these patients as children. So this is usually an additional confounder. Fortunately the stimulant question so far hasn't been too pressing - the patients have been on board with the plan of primarily treating the PTSD, that stimulants can exacerbate PTSD symptoms particularly if ADHD isn't present, and I have a medication regimen for PTSD that also should be reasonably effective for ADHD (sertraline, guanfacine and sometimes desipramine; former has Ki for Dopamine transporter as good or better than stimulants, latter has Ki for Norepinephrine transporter 1-2 orders of magnitude better than stimulants). Still, I suspect that if these patients do have ADHD they might be doing significantly better with a stimulant than without.



What would you say are the distinctive symptoms of ADHD in this case? I find myself questioning whether symptoms are due to ADHD or directly/indirectly due to trauma-related changes in mood and arousal/reactivity. It's more difficult with a lot of hyperactivity symptoms, but also comes up with inattentive ones (e.g. avoidance of tasks that require sustained mental effort might actually be a salient manifestation of diminished interest/participation in activities). I think I'm also more uncertain because I'm seeing the patients as adults, so in general ADHD symptoms would be less obvious and more difficult to differentiate from PTSD symptoms - I should put more effort into the history and description of childhood symptoms.

At least conceptually, I'd expect their attentional symptoms to get better with PTSD treatment whether or not they have ADHD, since the former would exacerbate the latter if present. But if the symptoms potentially attributable to ADHD are clearly having less improvement than the others then that would be suggestive.

I would tend to think that the ADHD sxs are far LESS distinctive than certain of those for PTSD (especially properly specified intrusion/re-experiencing symptoms and avoidance symptoms. I also am a behavioral practitioner (I do not prescribe medications), so my instincts would generally be to focus on thoroughly assessing/treating the PTSD in cases of comorbid (or suspected comorbid) ADHD. A prescribing provider has perhaps more directly efficacious interventions to address ADHD.

 

[R. Matey]

At least conceptually, I'd expect their attentional symptoms to get better with PTSD treatment whether or not they have ADHD, since the former would exacerbate the latter if present. But if the symptoms potentially attributable to ADHD are clearly having less improvement than the others then that would be suggestive.

I would expect an adult who recovered from PTSD to continue to struggle with dysregulation, disorganization, etc., if they also had ADHD. This would be independent of mood/arousal symptoms, and again, occur in multiple contexts unrelated to the traumatic experience.

 

[smalltownpsych]

Sorry, I should have been clearer - I'm an adult psychiatrist so generally I'm usually not seeing these patients as children. So this is usually an additional confounder. Fortunately the stimulant question so far hasn't been too pressing - the patients have been on board with the plan of primarily treating the PTSD, that stimulants can exacerbate PTSD symptoms particularly if ADHD isn't present, and I have a medication regimen for PTSD that also should be reasonably effective for ADHD (sertraline, guanfacine and sometimes desipramine; former has Ki for Dopamine transporter as good or better than stimulants, latter has Ki for Norepinephrine transporter 1-2 orders of magnitude better than stimulants). Still, I suspect that if these patients do have ADHD they might be doing significantly better with a stimulant than without.



What would you say are the distinctive symptoms of ADHD in this case? I find myself questioning whether symptoms are due to ADHD or directly/indirectly due to trauma-related changes in mood and arousal/reactivity. It's more difficult with a lot of hyperactivity symptoms, but also comes up with inattentive ones (e.g. avoidance of tasks that require sustained mental effort might actually be a salient manifestation of diminished interest/participation in activities). I think I'm also more uncertain because I'm seeing the patients as adults, so in general ADHD symptoms would be less obvious and more difficult to differentiate from PTSD symptoms - I should put more effort into the history and description of childhood symptoms.

At least conceptually, I'd expect their attentional symptoms to get better with PTSD treatment whether or not they have ADHD, since the former would exacerbate the latter if present. But if the symptoms potentially attributable to ADHD are clearly having less improvement than the others then that would be suggestive.

Thanks for clarification. I have worked with quite a few adults with extensive childhood trauma and would tend to agree that treating the trauma and sequelae is typically the primary concern. The challenge is that the effects tend to be pervasive and difficult to treat and patients are in a lot of distress. I have been referring for ketamine treatment for a few of these patients as it seems to help alleviate distress while doing the treatment (CPT) and also helps to speed up the process a bit. Usually with these patients, trying to evaluate for ADHD would be like trying to determine if a match added to the heat of the whole house burning. I suspect that patient is just grasping for help a since the treatment is difficult and can get worse before ot gets better, a psychiatrist that helps alleviate some of that distress but also keeps clear that it is not going to fix it, is golden.

 

[cara susanna]

I err on the side of diagnosing in more ambiguous situations like that. I'd rather have a false positive than a false negative. So I will say that, while trauma may account for these symptoms, I cannot rule out ADHD. The only other thing would be looking at the course of symptoms to see if that gives any info, but in my experience that is often limited.