ATTENTION DEFICIT DISORDER IN INTELLECTUALLY GIFTED ADULTS
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Transcript of ATTENTION DEFICIT DISORDER IN INTELLECTUALLY GIFTED ADULTS
ATTENTION DEFICIT DISORDER IN INTELLECTUALLY GIFTED
ADULTS
Hal Elliott, MDAssociate Professor
Residency Program DirectorDepartment of Psychiatry
East Tennessee State University
Wake Forest University: Middle 50% of Students With SAT between
1250-1390 US NEWS and World Report: #25-30
Davidson College : Middle 50% of Students With SAT between
1310-1440 US News and World Report: #5-11
DSM Definition of ADHD
“A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically found in individuals at a comparable level of development”
EXECUTIVE FUNCTIONING DISORDER
ADHD: Neurobiologic Basis
ALERTING
EXECUTIVE CONTROL
ORIENTING (SELECTIVE ATTENTION)
Posner and Raichle. Images of the Mind. Scientific American Books; 1996.
Attention Networks
Neural Networks of Attention
Prefrontal cortex Parietal cortex Cingulate gyrus Limbic structures (amygdala-hippocampus) Basal ganglia Thalamus Brainstem (reticular formation) Cerebellum
Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272.
Anterior Cingulate Cortex Cognitive Division Fails to Activate in ADHD
Bush G et al. Biol Psychiatry. 1999;45:1542-1552.
1 x 10-3
1 x 10-2 y = +21 mm
Normal Controls 1 x 10-2
1 x 10-3
y = +21 mm
ADHD
Mean heritability of ADHD = .75 Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323.
ADHD
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Matheny (1971)
Willerman (1973)
Goodman (1989)
Gillis (1992)
Edelbrock (1992)
Stevenson (1992)
Schmitz (1995)
Thapar (1995)
Gjone (1996)
Silberg (1996)
Sherman (1997)
Levy (1997)
Nadder (1998)
Hudziak (2000)
Willcutt (2000)
Thapar (2000)
Coolidge (2000)
Kuntsi(2001)
Martin (2002)
Rietveld (2003)
Laarson( 2004)
Heritability
Panic Disorder Schizophrenia Height
Heritability of ADHD
NEUROBIOLOGY Variation in basal ganglia symmetry and in
corpus collosum
PET: Decreased brain glucose metabolism in basal ganglia of ADHD adults/adolescents (Zametkin et al)
SPECT: Increased striatal availability of a dopamine transporter ( Krause et al)
Genetic Studies: Twin and sibling studies most convincing biologic evidence
Catecholamines and Brain Activity
DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; ACh, acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra.
Lifetime Course of ADHD Symptoms: Inattention Domain
+Difficulty sustaining attentionDoesn’t listenNo follow-throughCan’t organizeLoses important items
Difficulty sustaining attention (meetings, readings, paperwork)Paralyzing procrastinationSlow, inefficientPoor time managementDisorganized
Childhood Adulthood
Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC:
American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37.
Lifetime Course of ADHD Symptoms: Hyperactivity-Impulsivity Domain
+
Squirming, fidgetingCan’t stay seatedCan’t wait turnRuns/climbs excessivelyCan’t play/work quietlyOn the go/driven by motorTalks excessivelyBlurts out answersIntrudes/interrupts others
Inefficiencies at workCan’t sit through meetings
Can’t wait in lineDrives too fast
Self-selects very active jobCan’t tolerate frustration
Talks excessivelyInterrupts others
Makes inappropriate comments
Childhood Adulthood
Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American
Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37.
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Sub
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espo
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Drove Before Licensed
≥12 Traffic Citations
≥5 Speeding Citations
License Suspended or Revoked
ADHD (n = 105)Control (n = 64)
≥3 Vehicular Crashes
P =.003
P=.001P=.002P=.001
P=.007
Negative Driving Outcomes From a Driving History Interview
Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672.
Traffic Violations and MVA Among Young Adults With ADHD
MVA, motor vehicle accidents.
Driving Problems“ OFFICER, I AM NOT INEBRIATED…I AM
JUST INEPT.”
Britt Elliott ( 1988)
Substance Use Disorders in ADHD Teens Growing Up:
Overall Rate of Substance Use Disorder
Biederman J et al. Pediatrics. 1999;104:e20
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Non-ADHD(n=137)
Medicated ADHD
(n=56)
UnmedicatedADHD
(n=19)
Indi
vidu
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With
Sub
stan
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Use
Dis
orde
r (%
)
P<.001
1825
75
Childhood ADD into Adult ADD Spencer et al: 60% of children with ADHD
meet criteria as adults
Spencer, Biederman, Williams: 663/1700 meet criteria
Borland and Heckman: 50% of ADHD kids meet criteria as adults as opposed to 5% of non-ADHD siblings
ADD Symptoms In College/Grad Students:
Distractibility Organizational problems Poor task completion Forgetfulness Careless errors/ trouble with details Sequencing problems Hyper-focusing/ Prioritization Problems “Deer in the Headlights”
ADD in College/Grad Students (continued)
Authority Issues Stubbornness Intolerance of silly rules/ assignments Relationship problems ( peer and sig.
other) Frequent changes in major/ schools Poor frustration tolerance Easily bored Poor or inconsistent academic
performance despite adequate or even superior intellectual
abilities
What ADD College/GradStudents Report:
Scattered Anxious/ “Scanning The Horizon” Irritable Chronically Late/ Poor Time Sense Procrastination Bored Easily/ Restless/ Impatient Trouble with Math/Directions Reading Comprehension Problems Compensatory OC Behavior
OVERWHELMED
Increase in distress/ anxiety/ disorganization when responsibility increases/ changes at work, home, or school.
EXAMPLES:
Birth of child Promotion Increase in academic workload Transitions: First of School Year, Starting
College or Grad School, Moving Rooms, Changing Classes, Weekday to Weekend, Weekend to Weekday, Awake to Sleep, Sleep to Awake
COMORBIDITY IN ADULTS Anxiety Disorders (50%) Substance Abuse ( 27%-47%) Antisocial Personality Disorder ( 12%-
27%) Affective Disorders (? %)
NO COMORBID DX: 40%
Self Rating Scales Copeland Symptom Checklist For Adult
ADHD
Brown Adult ADD Scale( BAADS II)
Amen Scale
Psychoeducational Testing While ADHD is a clinical diagnosis,
consider psychometric testing if:
Diagnosis is unclear Accommodations are needed More details re: exact deficits are needed
or if LD is suspected.
CHRONIC vs. NEW ONSET Childhood Prerequisite
New Onset: medical work-up indicated
Consider: endocrine, sleep apnea, drug interactions, hearing deficit, B12, head injury, heavy metal, seizure disorder.
MRI/CT, EEG, BP, EKG, baseline labs, etc.
Controversy/ Skepticism Re: ADHD in Young Adults
Why? Childhood Onset – difficult to get
accurate history, especially in individuals who have IQ in superior range.
By adulthood comorbidity clouds diagnosis
ADHD is a clinical diagnosis Schedule II medications/fear of
prescribing Countertransference/Cultural Bias
WHY NOW?( If they didn’t have trouble as small children, doesn’t that
mean they are just lazy?)
Many college students functioning in the intellectual ly superior range never had to study before college
Many students had parents to manage all of their details, scheduling, deadlines, etc
Some students attended exclusive private schools with very rigid day to day routines. External organization kept them structured and limited distractions.
Compensatory Anxiety It isn’t compulsive checking behavior if
you really might forget Anxiet y will increase catecholamines and
can increase ability to attend Procrastination creates anxiety when the
work is imminently due….and can increase ability to attend
Classical conditioning model But…too many catecholamines cause a
shut down effect.
Cause and Effect “Are you scattered because you are
anxious or are you anxious because you are scattered”
“Are you depressed because you can’t get your work done or are you not getting your work done because you are depressed”
OCD and/vs ADHD OC sxs as a compensatory mechanism.
Ruminating. Lists. Excessive worry. Worst case scenarios.
Not usually repetitive over time. Tend to be day to day worries as opposed to intrusive ego dystonic obsessions
Thoughts jump from one thought to next as opposed to focusing on one obsession
Compulsive sxs are less likely to be linked to obsessive thinking.
BPAD vs. ADHD Genetic overlap
Hyperactivity vs. Mania/Hypomania
Discreet episodes vs. ongoing symptoms
ADHDStimulant Medications
Of pharmacologic options available for ADHD, stimulant medications are the: Most studied Most commonly used Most effective First-line agents for treatment
Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent
Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent
Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.
DOPAMINE/NOREPINEHRINE
DOPAMINE: mediates “verbal fluency, serial learning, vigilance for executive functioning, sustaining and focusing attention, prioritizing behavior, and modulating behavior based on social cues” (Stahl)
NOREPINEPHRINE: plays role in “sustaining and focusing attention, as well as in modulating energy, fatigue, motivation and interest” ( Stahl)
PSYCHOPHARMACOLOGYDopaminergic/ Noradrenergic
STIMULANTS: Methylphenidate (Ritalin, Ritalin LA, Metadate CR, Concerta)
Mixed amphetamine salts ( Adderall, Adderall XR),
Dextroamphetamine ( Dexedrine, Dextrostat),
Dextroamphetamine long acting ( Vyvanse) d-methylphenidate ( Focalin)
Pemoline ( Cylert)…LFT’s
PSYCHOPHARM ( cont.) ANTIDEPRESSANTS/ OTHER
Buproprion ( Wellbutrin)Venlafaxine ( Effexor)Duloxetine ( Cymbalta)Desipramine/ ImipramineModafinil ( Provigil)Clonidine ( catapress)
Atomoxetine (Strattera
SSRI’s for comorbidity….not for core symptoms
Why Nonstimulant Treatments for ADHD?
Problems with the stimulants Schedule II drugs (abuse liability, diversion,
medicolegal concerns) 30% do not adequately respond or cannot tolerate
stimulant treatment Short duration of action (compliance,
embarrassment) Side effect profile adversely impacting sleep,
appetite, mood, and anxiety Concerns about cardiovascular effects, growth
suppression, and tic development
Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S;
Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-
49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432.
Non- Medication Intervention
Education Organizational Help (academic
coaching) Learning Assistance Center @ WFU Individual and Couples Therapy CHADD SNL @ Davidson College Exercise Selection of occupation and need for
novelty/ difficulty with change
ACADEMIC ACCOMODATIONS
Leveling the playing field: Quiet Environment Extra Time UC Berkeley Study:
Group Standard Time Extra TimeLD 13th percentile 76th percentileNon-LD 82nd percentile 83rd percentile
Accommodations For Residents
Accommodations for Resident Physicians with Attention Deficit DisorderAcademic PsychiatryElliott, Arnold, Brenes, Silvia, Rosenquist August 2007
Thoughts Re: Gifted ADHD Adults
Stimulants/ Schedule II drugs Alteration of sense of self/ blunting of
creativity Non-linear thinkers in the academic
environment. Myth of Laziness. Twice the work for half
the result. “Left handed learners” Responsibility Square Pegs and Round Holes
Family Issues “My parents and I have different ideas
about what I should do after graduation. I want to go to Florence and study Art History. They want me to move into their pool house and become a dental hygienist”
Patient J, Senior at WFU
I was a peripheral visionary. I could see the future, but only way off to the side. Steven Wright
Mindfulness and Attentiveness Attentiveness….does not characterize my brothers
and me, all of whom were raised in SC and who have an air of abstraction and carelessness. None of us have a sense of direction. When something breaks, we fix it with duct tape…we tend to live in our own heads than in the actual physical world. We are more likely to get lost, to forget things, to stare blankly off in the distance for minutes at a time…at least part of the reason I resist ( taking something like Ritalin) is that I am not convinced the abstracted end of the mindfulness spectrum is such a bad place to be. In fact, I kind of like it here.
Sometimes I wonder whether it is an accident that of the three abstracted Elliott brothers, two have graduate degrees in philosophy and the other is a psychiatrist.
Carl Elliott, MD, PhD Better Than Well. American Medicine Meets the
American Dream
Creativity and Non-Linear Thinking
“One must still have chaos within oneself to be able to give birth to a dancing star”
Nietszche
Hearing The Beat of A Different Drum
“ You can dream the American Dream, but you sleep with the lights on and wake up with a scream”
Warren Zevon ( Fistful of Rain)
Pushing The Envelope
“ Walk with me out on the wire…”
Bruce Springsteen ( Born To Run)
Evaluation of Adult ADHD
What to evaluate Current symptoms Impairment Establishing childhood onset
How to evaluate Role of screening tools Role of scales (diagnostic and symptom assessment) Importance of prompts
Who should evaluate Mental health professionals PCPs
Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85-
93; Wilens TE, et al. JAMA. 2004;292:619-623.PCP, primary care physician.