Post on 18-Dec-2015
NorthShore ADHD Clinic
Creating Clarity
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Anthony M. OcanaMSc, MD, CCFP, ABAM
aocana62@wordpress.com
NorthShore ADHD Clinic
604-913-8183northshoreadhd.com
ADHDPractical Office Solutions
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DisclosuresDr. Ocana has received…
speaker honoraria from… Astra, Janssen, Lilly, Shire, Purdue and Wyeth…
consulting fees from… Lilly, Lundbeck, Shire and Janssen
educational grants from… Janssen, Lilly, Shire, Purdue, GSK
research funding from GSK and Shire
Some of the treatments mentioned in today’s seminar have not been approved by the Canadian HPB or American FDA.
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Practical Office Solutions Overview
ADHD…What does it look like?
What is it?
Is it real?
How do I make the diagnosis?
What are the treatment options/ benefits/ risks?
When should I refer?
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ADHD…What is it?
Overview Genetic differences… in dopamine circuits made dysfunctional… by changes in environment
Hallmark Symptoms Can’t focus Can’t get things done (on time) Can’t sit still Impulsive/ Impatient
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Dopamine Circuit Symptom Narrative
Attention Inattention Can’t focusMake mistakesCan’t stick to taskCan’t listenLoseForget
Executive Function Disorganization Can’t organizeCan’t prioritizeCan’t manage time
Motor Control Hyperactivity FidgetCan’t sit stillBusy mindTalk too much
Impulse Control Impulsivity Can’t foresee consequencesBlurts things outInterrupts
Reward Boredom ProcrastinateStart, but lose interestCan’t wait
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Stimulant Circuits
Reward
Executive Function
MotivationImpulse Control
Attention
Motor Control
ADHD is A Family Affair
Heritability genotype is 80% (Twin studies) phenotype is 40-60% (ADHD Parents will have ADHD child) Transmission is 25% (ADHD Children will have and ADHD parent)
Increased risk of ODD Correlates with family history of Addiction
Murray & Johnston, J Abnorm Psychol, 2006; Sonuga-Barke et al. Am Acad Child Adolesc Psych, 20028
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ADHD… Is it real?
Genetics Defective genes are dopamine associated D4, D5, DAT, DBH, SNAP-25, 5HTT
Anatomy Size/ activity reductions in dopamine-rich areas prefrontal cortex, basal ganglia, cerebellum
PhysiologyDegree of dopamine deficit predicts ADHD Symptoms distractibility, irritability, impulsivity, executive dysfunction
Pharmacology Symptom remission with dopaminergic agents Stimulants, Wellbutrin, Strattera
Co-morbidity Hypo-dopaminergic phenotype associated with other impulse control disorders
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ADHD… is it real?
Failed activation of cingulate gyrus in ADHD
Bush et al. Biol Psychiatry 1999;45:1542NorthShore ADHD Clinic
Current Standard of Care
Controversial
Do not diagnose
Do not treat
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Treatment Gap… not over-treated
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Only 50% with ADHD seek help…
Few MDs comfortable diagnosingOnly 25% receive an accurate diagnosis…
Even fewer MDs are comfortable managing ADHD Only 10% receive any treatment
Common medications have ++ side effectsOnly 5% are properly treated to full remission at 1yr
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Empathy Gap
Lack of empathy for suffering
Under-function is misunderstood
Stigma - moral/ ethical prejudice
(stupid, lazy, incompetent)
Extreme Implications
education/ vocation/ legal/ medical/ justice
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0% 10% 20% 30% 40% 50% 60%
Fired from job
Incarcerated
Arrested
Serious car accident
Accident prone
Substance abuse
STD
Teen pregnancy
< high school
Repeat a grade
Subjects (%)
ADHD
Non-ADHD
1. Barkley. Attention-deficit hyperactivity disorder, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al. JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.
Functional Impairment
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Attention
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Inattention
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ADHD Assessment…in four to five visits (not less)
Narrative
Clinician-administered ASRS
Review of Co-morbidity
Risk Assessment/ Exam
Treatment Options
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Narrative Assessment
What symptoms do you have?Have you had these all your life?
How much of a problem have they caused?
Who else in your family has these traits?
How do they affect your life?
ADHD Functional Enquiry
How do they affect your life?
Childhood
School
Home
Work
Financial
Career
Interpersonal
Family of origin
Intimate (partner, children)
Social
Health
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Cognitive / Executive
1. Easily Distracted2. Can’t stick to task3. Careless mistakes4. Difficulty listening 5. Forgets6. Loses/ misplaces7. Difficulty organizing 8. Avoid / procrastinate9. Fails to finish tasks (on time)
Hyperactive / Impulsive
1. Fidgets2. Leaves seat3. Busy Mind4. Difficulty unwinding/relaxing5. Talks excessively6. Lack of fore-sight / hindsight7. Speak out of turn8. Interrupts others 9. Difficulty waiting
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Adult Self Report Scale
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ADHD Diagnosis… it’s all about impairment
Narrative endorses impairment of function since childhood more than two domains
ASRS endorses 6/9 symptoms either cognitive/ executive or hyperactive/ impulsive associated with moderate/ severe or extreme impairment
Lifetime Impact is severe/ extreme or catastrophic
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ADHD and Co-morbid Disorders
Depression
Substance Use
Bipolar DisorderImpulse Control Disorder
Eating Disorder
Personality Disorder
Sleep Disorder
ADHD
Co-Morbidity
Mood DisorderAnxiety
Depression
Mood and Behavioural InstabilityBipolar
Substance Abuse
Impulse Control DisorderImpulsive Aggression
Gambling/ Shopping/ Eating/ Sex
Self Injurious Behaviour
Psychosis
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40
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20
30
Anxiet
y
Mood
Anti-Soc
ial
Bipol
ar
Learn
ing
Impul
se
Substa
nce
ADHD and Co-morbid Disorders
Biederman. Am J Psychiatry. 1993;150(12):1792. Biederman. Psychiatry Research 1994;53:13 Shekim. Compr Psychiatry. 1990;31(5):416. Kessler et al. Am J Psychiatry. 2006; 163:716-723
Prev
alen
ce (%
)
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Physical Exam
Family Hx sudden cardiac death cardiac defect pediatric cardiac surgery
Personal Hx cardiac Hx/ sx fainting during exercise
Other Hx Hx of seizure Hx of sleep apnea Hx of head injury
Exam
Ht/ Wt BP/ HR Cardio-pulmonary
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What can we do?
Assess
Support/ Validate
Educate
Activity/ Diet / Sleep/ LifestyleCoaching/ CounsellingStress Management
Medicate
Advocate
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Mechanism of Action of Medication
Dopamine
Dopamine
Dopamine
AtomoxetineBlocks re-uptake of dopamine in PFC
Methylphenidate blocks re-uptakeof dopamine
Amphetamine blocks re-uptake…and stimulates release of dopamine
Stimulant Protocol
Use long-acting stimulants
Biphentin®, Adderall XR®, Concerta® or Vyvanse®
Start at the lowest dose
Increase dose every 5-10 days until response
Review at 3 - 6 - 9 weeks
Slowly increase dose to complete remission of symptoms
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Stimulant Dose - Response Curve
Hyperactive
Increasing Dosage
Response
Valley of the Zombies
Remission
Agitation/ Anxiety
Mania / Psychosis
Time (weeks) 0-------1-------2 -------3-------4-------5-------6-------8-------9-------10
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Effect - Side effect
Time
Symptom Improvement
7 am 7 pm Midnight
Area of maximal side effectsFatigue, irritability, insomnia
Noon
Overstimulation, palpitations, loss of appetite
Stimulant Side Effects
Over-stimulation Hyper/ talkative Loss of appetite Dry mouth
Under-stimulation Fatigue Headache ADHD symptoms return Hyper-focus
Rebound Jaw tension Agitated Reward Seeking Insomnia
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Stimulant Risk Management
Over-stimulation/ agitation/ mania/ psychosis
Hx of mood instability, bipolar, active psychosis caffeine…cannabis …stimulants…cocaine…
Stop stimulants/ decrease cannabis Avoid meds if sleep deprived, sick or ++ stress Pre-treat with mood stabilizer (refer)
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Summary
Primary Care MDs Index of suspicion Take your time…to assess… manage
Validate ADHD Assess Co-morbidity… Manage risk Educate patient and family Treat to complete remission
Refer complicated cases Rewarding to treat – Large effect size – Dramatic improvement
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Anthony M. OcanaMSc, MD, CCFP, ASAM
604-913-8183 ext 2235
North ShoreADHD Clinic
Creating Clarity
northshoreadhd.com