Diagnostic controversies in adult attention deficit hyperactivity disorder

OBJECTIVE: While it is increasingly recognized that attention deficit hyperactivity disorder (ADHD) persists into adulthood, there is no consensus on diagnostic criteria for adult ADHD. In this article the authors describe and contrast competing approaches for diagnosis of adult ADHD used in clinical and research practice. METHOD: The authors review the Wender Utah criteria, DSM criteria, and laboratory assessment strategies for adult ADHD. Advantages and disadvantages of each approach are described, and recommendations are made as a basis for clinical assessment and future research. RESULTS: Both the Wender Utah criteria and DSM-based approaches identify significantly impaired ADHD adults with neurocognitive, biological, and treatment response patterns similar to pediatric ADHD patients. The Wender Utah criteria established the need for retrospective childhood diagnosis and recognize developmental differences in adult symptom expression. The Wender Utah criteria fail to identify patients with predominantly inattentive symptoms, exclude some patients with significant comorbid psychopathology, and diverge significantly from the DSM conception of ADHD. The DSM criteria have never been validated in adults, do not include developmentally appropriate symptoms and thresholds for adults, and fail to identify some significantly impaired adults who are likely to benefit from treatment. There are insufficient scientific data to justify use of laboratory assessment measures, including neuropsychological tests and brain imaging, in diagnosing adult ADHD. CONCLUSIONS: Adult ADHD remains a clinical diagnosis. Clinicians should be flexible in application of the current ADHD criteria to adults. Additional research is required to validate adult diagnostic criteria.     

Temporal allocation of visual attention in adult attention deficit hyperactivity disorder

In two experiments, we examined the ability of adults with attention deficit hyperactivity disorder (ADHD) to process multiple targets appearing in a rapid serial visual presentation (RSVP) stream. Using a standard attentional blink (AB) task, subjects were required to both identify a target in the RSVP stream and detect a probe appearing in one of several posttarget serial positions. In Experiment 1, ADHD adults exhibited a protracted AB compared to controls, in that their probe detection did not improve as a function of increasing probe-to-target intervals (450-720 msec). In Experiment 2, the ADHD group performed as well as controls in detecting probes appearing immediately (i.e., 90 msec) after the target. Taken together, the results demonstrate that adults with ADHD exhibit a selective deficit in rapidly shifting attention between the target and the probe, when the two appear several hundred milliseconds apart. These results suggest that adults with ADHD can use automatic (reflexive) attention to detect items in close temporal proximity in the RSVP stream, but have difficulty allocating controlled attention to multiple stimuli separated by several hundred milliseconds.     

Psychostimulants, adult attention deficit hyperactivity disorder and morbid jealousy

OBJECTIVE: This paper aims to discuss the relationship between morbid jealousy, stalking behaviour, and psychodynamic issues. Comment will be made on the risk associated with diagnosis of adult attention deficit hyperactivity disorder (ADHD) and use of psychostimulants. CLINICAL PICTURE: A man born in the former Yugoslavia charged with stalking was referred for assessment. He presented with a history of treatment for ADHD with dexamphetamine and delusions regarding his wife's fidelity. TREATMENT: The patient was treated with neuroleptics and counselling for himself and his family. OUTCOME: The patient was returned to the community. He separated from his wife but retains the abnormal belief. CONCLUSIONS: The diagnosis of adult ADHD appears to be increasing in Western Australia. Treatment with stimulants is common. The misdiagnosis of ADHD and consequent misuse of stimulants, can lead to the development of morbid jealousy, stalking behaviour and arrest.     

H-MR-spectroscopy of cerebellum in adult attention deficit/hyperactivity disorder

Introduction

Neurobiological research has implicated the cerebellum as one possible site of neurophysiological dysfunction in ADHD. Latest theoretical conceptualizations of the cerebellum as core site of the brain to model motor as well as cognitive behavior puts further weight to the assumption that it might play a key role in ADHD pathophysiology.

Methods

30 medication free adult ADHD patients and 30 group matched (gender, age and education) healthy controls were investigated using the method of chemical shift imaging (CSI) of the cerebellum. The vermis, left and right cerebellar hemispheres were processed separately.

Results

We found significantly increased glutamate-glutamine (Glx) to creatine (Cre) ratios in the left cerebellar hemisphere. No other differences in measured metabolite concentrations were observed.

Discussion

To our knowledge this is the first evidence for neurochemical alterations in cerebellar neurochemistry in adult ADHD. They relate well to recent hypotheses that the cerebellum might control mental activities by internal models.     

Unaltered dopamine transporter availability in adult attention deficit hyperactivity disorder

OBJECTIVE: The authors examined whether patients with attention deficit hyperactivity disorder (ADHD) have altered striatal dopamine transporter levels, which may explain psychostimulant effects in this disorder. METHOD: Single photon emission computed tomography and [(123)I]2beta-carbomethoxy-3beta-(4-iodophenyl)tropane ([(123)I]beta-CIT) were used to assess dopamine transporter availability in nine adult patients with ADHD (eight of whom were stimulant naive) and nine age- and gender-matched healthy comparison subjects. RESULTS: Striatal [(123)I]beta-CIT binding did not differ significantly between the ADHD and comparison subjects. CONCLUSIONS: The findings suggest that a hypothesized dysregulation of dopamine function in ADHD does not entail altered dopamine transporter levels.     

Childhood attention deficit hyperactivity disorder features in adult mood disorders

A significant overlap between childhood mood disorders and many aspects of attention deficit hyperactivity disorder (ADHD) has been established. High rates of co-occurrence, familial aggregation, and more severe clinical manifestations of the illnesses when they are comorbid suggest that common genetic and environmental factors may contribute to the development of both disorders. Research on the co-occurrence of childhood ADHD and mood disorders in childhood has been conducted. We retrospectively investigated childhood ADHD features in adults with mood disorders. Childhood ADHD features were measured with the Korean version of the Wender Utah Rating Scale (WURS). The sample consisted of 1305 subjects: 108 subjects were diagnosed with bipolar disorder type I, 41 with bipolar disorder type II, 101 with major depressive disorder, and 1055 served as normal controls. We compared total WURS scores as well as scores on 3 factors (impulsivity, inattention, and mood instability and anxiety) among the 4 different diagnostic groups. The 4 groups differed significantly from one another on all scores. The group with bipolar disorder type II obtained the highest total scores on the WURS. The impulsivity and inattention associated with childhood ADHD were more significantly related to bipolar disorder type II than with bipolar disorder type I. The mood instability and anxiety associated with childhood ADHD seem to be significantly related to major depressive disorder in adulthood. In conclusion, multifactorial childhood ADHD features were associated with mood disorders of adulthood.     

Accuracy of adult recall of childhood attention deficit hyperactivity disorder

OBJECTIVE: Although reports of childhood status are necessary for making a diagnosis of adult attention deficit hyperactivity disorder (ADHD), systematic investigation of the accuracy of retrospective self-reports has been limited. This study examined accuracy of adult recall of childhood ADHD. METHOD: Participants were from a controlled, prospective 16-year follow-up of children with ADHD. At a mean age of 25 years, 176 probands (85% of the 207 subjects in the initial cohort) and 168 non-ADHD comparison subjects were interviewed by clinicians who were unaware of the subjects' childhood status. Subjects were asked about specific childhood ADHD behaviors, and the diagnosis of childhood ADHD was retrospectively established. RESULTS: Seventy-eight percent of the probands and 11% of the comparison subjects were identified as having childhood ADHD. Six symptoms demonstrated high discriminating power in differentiating the subject groups: distractibility, concentration difficulties, complaints of inattention, acting before thinking, being on the go, and fidgeting/squirming. When findings were adjusted for the prevalence of ADHD in the general population, the power of prediction was low. Positive predictive value was 0.27, i.e., of all adults retrospectively given a diagnosis of childhood ADHD, only 27% would be correctly identified. As expected, positive predictive value increased with increases in the estimated prevalence of ADHD. CONCLUSIONS: Retrospective diagnoses of childhood ADHD made on the basis of self-reports will in most cases be invalid in settings such as epidemiological surveys and primary care facilities. Greater accuracy can be expected in settings in which childhood ADHD is frequent. The results stress the importance of obtaining contemporaneous information on childhood symptoms in establishing a childhood history of ADHD. Future directions and implications for DSM-V are discussed.     

Differential reward processing in subtypes of adult attention deficit hyperactivity disorder

Objectives

Abnormalities in reward processing have been found in adolescents and adults with ADHD using the ‘Monetary Incentive Delay’ (MID) task. However, ADHD groups in previous studies were heterogeneous regarding ADHD subtype, gender and, in part, drug treatment status.This study sought to compare neural activations in the ventral striatum (VS) and prefrontal regions during reward processing in homogenous ADHD subtype groups and healthy adults, using the MID task.

Methods

In total, 24 drug-naïve, right-handed male adults with ADHD (12 subjects with combined type (ADHD-ct) and 12 subjects with predominantly inattentive (ADHD-it) type ADHD), and twelve healthy right-handed male control subjects were included.

Results

Compared to ADHD-ct and healthy subjects, ADHD-it subjects showed a bilateral ventral striatal deficit during reward anticipation. In contrast, ADHD-ct subjects showed orbitofrontal hyporesponsiveness to reward feedback when compared with ADHD-it and healthy subjects.

Conclusions

This is the first fMRI study that delineates dysfunctional and subtype-divergent neural and behavioural reward processing in adults with ADHD.     

Hyperfocusing as a dimension of adult attention deficit hyperactivity disorder

Patients with Attention Deficit Hyperactivity Disorder (ADHD) suffer not only from inability to focus but also from inability to shift attention for events that trigger their interests. This phenomenon is called “hyperfocusing”. Previous literature about hyperfocusing is scarce and relies mainly on case reports. The study aimed to investigate and compare the severity of hyperfocusing in adult ADHD with and without psycho-stimulant use. ADHD (DSM-IV-TR) patients either psycho-stimulant naive (n = 53) or on psycho-stimulants (n = 79) from two ADHD clinics were recruited. The control group (n = 65) consisted of healthy university students. A socio-demographic form, the Beck Depression Inventory, the Wender-Utah Rating Scale, the Adult ADHD Self- Report Scale and the Hyperfocusing Scale were applied to the participants. There was no difference between total Hyperfocusing Scale and Adult ADHD Self- Report Scale scores of two patient groups, but both have higher scores than controls (p < 0.001). Hyperfocusing is higher in adult ADHD and there was no difference between stimulant-naive patients or patients on stimulants. Hyperfocusing can be defined as a separate dimension of adult ADHD.     

Memory tests in subgroups of adult attention deficit hyperactivity disorder reveals simultaneous capacity deficit

Neuropsychological tests were used to evaluate different memory systems in the three subgroups of adult Attention Deficit Hyperactivity Disorder (ADHD) (n=105) using analysis of means, factor analysis, and GLM analysis with covariance of gender, estimated IQ, and level of anxiety and depression measured with the Hospital anxiety and depression scale. A higher IQ level was found in the neuropsychological background tests for the predominantly inattentive subtype (ADD). In the memory tests the dual-task memory/simultaneous capacity tests "Brown-Peterson" Consonant Trigram and Benton Visual Retention Test (BVRT) were the most sensitive and were severely reduced in all three subgroups, but only the BVRT revealed a difference between the three ADHD groups. In learning and delayed recall measured with Rey Auditory Verbal learning test and modified Diagnosticum für Cerebralsch?digung (mDCS), the Attention Deficit Disorder subgroup had the best learning and delayed capacity of the three groups. A good agreement was found between the interviewed DSM-IV-TR criteria, Conners CAARS S:S scale, and Wender WURS 25-item scales. Despite the difference in number of ADHD criteria for the three ADHD subgroups, the results in the neuropsychological memory tests indicate a severe reduction in all three subgroups of adult ADHD in simultaneous capacity.     

Neural response during anticipation of monetary loss is elevated in adult attention deficit hyperactivity disorder

Objectives: Risky behaviour seriously impacts the life of adult patients with attention deficit hyperactivity disorder (ADHD). Such behaviours have often been attributed to their exaggerated reward seeking, but dysfunctional anticipation of negative outcomes might also play a role. Methods: The present study compared adult patients with ADHD (n?=?28) with matched healthy controls (n?=?28) during anticipation of monetary losses versus gains while undergoing functional magnetic resonance imaging (fMRI) and skin conductance recording. Results: Skin conductance was higher during anticipation of losses compared to gains in both groups. Affective ratings of predictive cues did not differ between groups. ADHD patients showed increased activity in bilateral amygdalae, left anterior insula (region of interest analysis) and left temporal pole (whole brain analysis) compared to healthy controls during loss versus gain anticipation. In the ADHD group higher insula and temporal pole activations went along with more negative affective ratings. Conclusions: Neural correlates of loss anticipation are not blunted but rather increased in ADHD, possibly due to a life history of repeated failures and the respective environmental sanctions. Behavioural adaptations to such losses, however, might differentiate them from controls: future research should study whether negative affect might drive more risk seeking than risk avoidance.     

Sleep quality in adult patients with attention deficit hyperactivity disorder (ADHD)

Sleep disorders are common in adults with attention deficit/hyperactivity disorder (ADHD). Two sleep questionnaires; the Brown ADD Scale, the Symptom-Checklist-90-R, and a self-developed symptom questionnaire were administered in this study. In a sample of 61 patients without comorbidity, current substance abuse and medication intake, sleep problems were reported more often than in healthy controls. A lack of being refreshed in the morning was very closely associated with ADHD symptomatology whereas insomnia was related to the presence of comorbidity and depressive symptoms. In the total sample (N = 120), medication intake (mainly stimulants) was not related to any of the sleep parameters. It seems important to screen adult patients with ADHD for the presence of sleep disorders, especially insomnia, restless legs syndrome, and sleep-related breathing disorders (the last in conjunction with the body mass index). Since primary sleep disorders are associated with cognitive impairment, one might expect that ADHD symptomatology may improve if comorbid sleep disorders are adequately treated in addition to the specific ADHD treatment.     

注意缺陷多动障碍患儿的成人早期精神状况随访研究

Objective To investigate the psychiatric status in their young adulthood of children with attention deficit hyperactivity disorder (ADHD).Methods This was a prospedive study.The follow-up study of a cohort of clinic-referred ADHD children was conducted.At baseline, The consecutively referred children (n = 300) with DSM-Ⅳ ADHD, aged 7.5 - 17.0 years were assessed.At the 2.0 - 13.5-year follow-up, 116 ( 38.7% ) of them were reassessed ( aged 18.0 - 23.5 years ) using the structured psychiatric interviews to make DSM-Ⅳ diagnoses by trained clinicians, including the Conners Adult ADHD Diagnostic Interview for DSM-Ⅳ (CAADID), Structured Clinical Interview for DSM-Ⅳ Axis Ⅰ Disorders, Non-Patient Version ( SCID- Ⅰ/NP), and Structured Clinical Interview for DSM-Ⅳ Personality Disorders (SCID-Ⅱ).Results In the former 116 ADHD children, 50.9% (n =59) still met the ADHD criteria, in which 15.5% (n = 18) with pure ADHD, and 35.3% (n =41 ) fulfilled both ADHD and psychiatric/ personality disorders, 14.7% ( n = 17) met the criteria of psychiatric/personality disorders, but not ADHD,34.5% (n = 40) fulfilled none of the psychiatric/personality diagnoses at follow-up.Among 116 former ADHD children, 34.5% (n=40) had at least one DSM-Ⅳ axis Ⅰ disorders, in which 18.1% comorbid mood disorders, 10.3% anxiety disorders, 5.2% abuse disorders; and 32.8% (n=38) had at least one DSM-Ⅳ axis Ⅱ personality disorders, in which 5.2% type A personality disorders, 19.8% type B ( 17.2%anti-social personality disorders), 15.5% type C, and 6.0% others.Conclusion It indicates that ADHD youth be at high risk for a wide range of adverse psychiatric outcomes, and 2/3 of them have diagnoses of adult ADHD and/or psychiatric/personality disorders.     

注意缺陷多动障碍患儿的成人早期精神状况随访研究

Objective To investigate the psychiatric status in their young adulthood of children with attention deficit hyperactivity disorder (ADHD).Methods This was a prospedive study.The follow-up study of a cohort of clinic-referred ADHD children was conducted.At baseline, The consecutively referred children (n = 300) with DSM-Ⅳ ADHD, aged 7.5 - 17.0 years were assessed.At the 2.0 - 13.5-year follow-up, 116 ( 38.7% ) of them were reassessed ( aged 18.0 - 23.5 years ) using the structured psychiatric interviews to make DSM-Ⅳ diagnoses by trained clinicians, including the Conners Adult ADHD Diagnostic Interview for DSM-Ⅳ (CAADID), Structured Clinical Interview for DSM-Ⅳ Axis Ⅰ Disorders, Non-Patient Version ( SCID- Ⅰ/NP), and Structured Clinical Interview for DSM-Ⅳ Personality Disorders (SCID-Ⅱ).Results In the former 116 ADHD children, 50.9% (n =59) still met the ADHD criteria, in which 15.5% (n = 18) with pure ADHD, and 35.3% (n =41 ) fulfilled both ADHD and psychiatric/ personality disorders, 14.7% ( n = 17) met the criteria of psychiatric/personality disorders, but not ADHD,34.5% (n = 40) fulfilled none of the psychiatric/personality diagnoses at follow-up.Among 116 former ADHD children, 34.5% (n=40) had at least one DSM-Ⅳ axis Ⅰ disorders, in which 18.1% comorbid mood disorders, 10.3% anxiety disorders, 5.2% abuse disorders; and 32.8% (n=38) had at least one DSM-Ⅳ axis Ⅱ personality disorders, in which 5.2% type A personality disorders, 19.8% type B ( 17.2%anti-social personality disorders), 15.5% type C, and 6.0% others.Conclusion It indicates that ADHD youth be at high risk for a wide range of adverse psychiatric outcomes, and 2/3 of them have diagnoses of adult ADHD and/or psychiatric/personality disorders.     

Diagnostic profiles of adult psychiatric outpatients with and without attention deficit hyperactivity disorder

ObjectiveDespite growing recognition that attention deficit/hyperactivity disorder (ADHD) is a highly prevalent, impairing, and comorbid disorder that persists into adulthood, reports on the nature and extent of its psychiatric comorbidities have been mixed to date. This study compared the prevalence rates of all major Axis I disorders as well as borderline personality disorder in an unselected sample of adult psychiatric outpatients with and without ADHD.MethodsAs part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we administered a DSM-IV-based semi-structured diagnostic interview assessing ADHD and other psychiatric disorders to 1134 patients presenting for initial evaluation at an outpatient psychiatric practice. Logistic regression analyses were used to compare the rates of each disorder in patients with versus without an ADHD diagnosis (both overall and by Combined and Inattentive type).ResultsPatients with (versus without) any ADHD diagnosis had significantly higher rates of bipolar disorder, social phobia, impulse control disorders, eating disorders, and BPD, and significantly lower rates of major depressive disorder and adjustment disorder (all p < .05). Patients with (versus without) ADHD-Inattentive type had significantly higher rates of social phobia and eating disorders, whereas those with (versus without) the ADHD-Combined type had significantly higher rates of bipolar disorder, alcohol dependence, and BPD (all p < .05).ConclusionIn this novel investigation of the psychiatric profiles of an unselected sample of treatment-seeking adult outpatients with versus without ADHD, a distinct pattern of comorbidities emerged across subtypes, with implications for the accurate assessment and treatment of patients presenting for psychiatric care.     

注意缺陷多动障碍患儿的成人早期精神状况随访研究

目的 了解注意缺陷多动障碍(ADHD)患儿在成人早期罹患精神障碍的状况.方法 采用前瞻性设计方法,对就诊于北京大学精神卫生研究所精神科门诊的300例ADHD患儿进行随访,同意参加随访者116例(随访率38.7%),基线至随访为2.0～13.5年;患儿基线年龄为7.5～17.0岁,随访时年龄为18.0～23.5岁;采用以美国精神障碍诊断与统计手册第4版为诊断标准制订的定式会谈工具确定诊断,包括Conners成人ADHD诊断会谈量表(Conners Adult ADHD Diagnostic Interview for DSM-Ⅳ,CAADID)、DSM-Ⅳ-TR轴Ⅰ障碍定式临床检查(SCID-Ⅰ)和DSM-Ⅳ轴Ⅱ障碍定式临床检查(SCID-Ⅱ)工具.结果 随访时116例中符合成人ADHD诊断者共59例(50.9%),其中单纯符合成人ADHD诊断标准者18例(15.5%),同时符合成人ADHD及精神障碍/人格障碍者41例(35.3%);不符合成人ADHD诊断,但符合精神障碍/人格障碍者17例(14.7%);不符合任何精神疾病诊断者40例(34.5%),其中功能缓解29例(25.0%),功能未缓解11例(9.5%).116例中,40例(34.5%)至少共患1种DSM-Ⅳ轴Ⅰ障碍,其中21例(18.1%)共患情感障碍,12例(10.3%)共患焦虑障碍,6例(5.2%)共患物质滥用;38例(32.8%)符合DSM-Ⅳ轴Ⅱ人格障碍诊断,其中6例(5.2%)符合A组人格障碍诊断,23例(19.8%)符合B组人格障碍诊断,包括20例(17.2%)反社会型人格障碍,18例(15.5%)符合C组人格障碍诊断,6例(6.0%)符合其他人格障碍诊断.结论 ADHD患儿至成人早期预后较差,2/3左右罹患成人ADHD、精神障碍或人格障碍,其中50.9%符合成人ADHD.     

Alterations in the functional anatomy of working memory in adult attention deficit hyperactivity disorder

OBJECTIVE: The authors used a functional neuroimaging study with a working memory probe to investigate the pathophysiology of attention deficit hyperactivity disorder (ADHD). Their goal was to compare regional cerebral blood flow (rCBF) changes related to working memory in adults with and without ADHD. METHOD: Using [(15)O]H(2)O positron emission tomography (PET) studies, the authors compared the sites of neural activation related to working memory in six adult men diagnosed with ADHD and six healthy men without ADHD who were matched in age and general intelligence. RESULTS: Task-related changes in rCBF in the men without ADHD were more prominent in the frontal and temporal regions, but rCBF changes in men with ADHD were more widespread and primarily located in the occipital regions. CONCLUSIONS: These data suggest the use of compensatory mental and neural strategies by subjects with ADHD in response to a disrupted ability to inhibit attention to nonrelevant stimuli and the use of internalized speech to guide behavior.